New analysis: The long view

There must be times when senior civil servants – and trust and commissioner leaders – wish they were left to get on with the job of delivering the best possible health and care, with no ministers telling them what – or what not – to do. In Northern Ireland, health and care leaders have the latter, but are increasingly frustrated as their hands are tied when it comes to making major changes to services.

Northern Ireland has been without a ruling power-sharing executive since January 2017, with the two most popular parties (the Democratic Unionist Party and Sinn Féin) in dispute. This has dealt a number of blows to the already struggling integrated health and personal social care system.

Like the three other national health and care services in the UK, transforming delivery and moving more care out of hospital are seen as key to tackling surging demand and long waiting lists. A number of reports and strategies over recent years have backed this approach and there appears to be political consensus behind it.

Without a minister in place, senior civil servants have been running public services at departmental level, making changes where they feel they have a mandate from the previous executive. However, their ability to make decisions was curtailed in the summer when a judicial review determined that a civil servant did not have the power to grant planning permission for a waste incinerator in County Antrim. Only ministers should decide, the ruling said – a verdict widely interpreted as applying to all departments and all major decisions.

Northern Ireland secretary Karen Bradley has promised to bring forward legislation to give departmental secretaries the power to make big decisions in the absence of a government.

Initially, a lack of an executive meant health and care and other public services were without a budget in 2017/18 – the 2016/17 allocations were then rolled on into 2017/18, but extra funding was added in year through the monitoring round system of reprioritising budgets.

With little hope for a deal between the two parties, Ms Bradley intervened in March this year to set departmental budgets for 2018/19. This gave health and care a 2.6% uplift, including an additional £60m for activity pressures and £10m for mental health services, plus a non-recurrent £100m transformation fund (a further £100m will be available in 2019/20). She also consented to the transfer of up to £100m from capital funding to revenue.

While they welcomed the setting of a budget, health leaders remain concerned, as evidenced by witnesses in a Commons Northern Ireland Affairs Committee inquiry in September. The committee is looking into the effects of the absence of a government on health and care funding and heard the service was starting from a difficult position. Witnesses told the committee that cost pressures this year are likely to be between 5% and 6%.

Waiting times were also highlighted. Northern Ireland has some of the longest waiting times in the UK. At the end of the last financial year, almost 31% of patients had been waiting more than 52 weeks for a first consultant-led appointment. And 62% were waiting longer than 13 weeks for inpatient or day case admission – the previous executive set the maximum at 55%.

No room for manoeuvre

One witness, Paul Cummings, finance director of the Health and Social Care Board – the commissioning body – and Public Health Agency, told the inquiry that he had received an extra £207m in this year’s allocation. But this left little financial headroom to develop services.

‘We went into this year with a significant deficit because we are relying on, and have relied on, increasing mid-year and end-year monitoring rounds,’ he said. ‘Our system went into this current financial year in deficit because we required £140m of non-recurrent funding last year through the monitoring round just to break even. The £207m [additional income] was set against an opening deficit of £236m.’

Mr Cummings, a former HFMA UK chair, went on: ‘We are not in a position to procure extra services in the current financial year. We are just about standing still and meeting inescapable pressures, some demography, a bit of NICE drugs. We are extremely challenged financially, and service development is not something we have been able to pursue in the current year.’

Valerie Watts, chief executive of the Health and Social Care Board and interim chief executive of the Public Health Agency, outlined how the £100m transformation fund would be spent this year.

‘Roughly £30m is targeted at stabilising the system by stemming the increase in waiting times for both diagnostic and elective care,’ she said. ‘Some £15m has been identified for investment in primary care, and that includes £5m for the initial roll-out of an operating model for multidisciplinary teamworking within GP practices. Some £15m has been identified for workforce development right across the whole health and social care system, with up to approximately £30m of investment in reforming hospital and community services. That includes investment in the establishment of new elective care centres.’

Additionally, she told MPs that £5m would be invested in building capacity in communities and in health prevention approaches, and a further £5m in the enablers for transformation, including co-production and quality improvement initiatives.

Health and Social Care Board commissioning director Miriam McCarthy said the £30m being spent on improving elective care this year would help reduce waiting times, but ‘it would be unrealistic to think that will sort the problem completely’.

Other initiatives will help, particularly with outpatient waits, Dr McCarthy added. Demand management projects were looking at stemming the flow of hospital outpatient appointments by offering alternatives such as virtual clinics or advice to GPs from hospital doctors, for instance.

Cancer specialties had reduced ongoing follow-ups by discharging patients into the care of their GPs and there was room to replicate this across other specialties.

Mrs Watts acknowledged that a lot of the transformation work to date had been preparatory in nature and the MPs wondered if this would be different with a minister in place.

The witnesses reiterated that, at the moment, significant structural transformation could not happen. In terms of closing or reproviding services, the officials’ hands are tied – they could not close services as there was no mandate to take such decisions. They could develop services, but funding was tight.

To illustrate the limitations they face, Dr McCarthy said a guidance paper on maximising the cost-effectiveness of varicose vein surgery was being written. Surgery for clinical reasons – bleeding or pain – would be recommended, but not for cosmetic reasons. However, she accepted that once the paper is completed, it could be delayed, as a minister would be needed to consider it before issuing it as a consultation.

Mr Cummings added: ‘There are things we want to be doing to bring our service offering in line with some of the changes that have happened in England and Wales that we are not able to take forward or we are not able to pursue.’

He singled out the Power to people review – an expert panel review of social care, which made a number of recommendations including making the better-off pay for their care. Mr Cummings said that without a minister, officials could not address the review’s recommendations. ‘We have no [ministerial] view on charging, which is one of the proposals we may want to examine to come into line with the rest of the UK.’

Care at home

Care at home was one of the areas of focus for the transformation programme and funding, Mr Cummings said. But domiciliary workers should no longer be paid minimum wage – the job required skills that should be paid at a higher level. ‘We need to re-examine whether we as a society are prepared to pay and contribute to that, because we are the only part of the UK where domiciliary care is free. The rest of the UK contributes to that cost.’

Longer term budget allocations will help the planning of transformation schemes. Asked about her priorities for an incoming minister, Mrs Watts said three-to-five-year budgets were needed. ‘We need to be not limping along from year-to-year, just hearing what we’re getting to provide health and social care services sometimes late in the day. We need to be forward planning, and over longer periods of time.’

Even with ministerial direction, the challenge facing Northern Ireland’s health and care service is tough. Senior executives hope transformation programmes will reduce demand currently running at up to 6%, but it will be challenging to do so in just two years – they believe sustained transformation over five to 10 years is needed.