A fresh, new strategy for the Northern Ireland health and care system?

Following Northern Ireland’s Assembly elections in May, Dr Lourda Geoghegan – a Health Foundation GenerationQ Fellow – shared with us her optimism for a fresh start for the country’s health and care system. The political hyper-complexities of the preceding years had just been simplified. Instead of being an ‘unhappy coalition of five parties’, the Northern Ireland Executive had become a coalition of just two – the Democratic Unionist Party and Sinn Fein – with the latter taking responsibility for the Department of Health (DoH), under new Health Minister Michelle O’Neill.

Talk of health system reform is a constant in all parts of the UK. Northern Ireland’s current journey began in 2014, with Sir Liam Donaldson’s review of quality and safety, followed by Professor Rafael Bengoa’s review of service configuration, which was commissioned by the former Health Minister at the beginning of 2016. The Bengoa report – Systems not Structures: Changing Health and Social Care – and the DoH’s subsequent strategy or ‘outworking’ of Bengoa’s recommendations – Health and Wellbeing 2026: Delivering Together – were both published a few weeks ago.

So just how fresh is the fresh start for Northern Ireland?

The Triple Aim of better health, quality and value is now well-accepted throughout the UK. It is explicitly referenced in Scotland’s 2020 Vision for Health and Social Care and the Quality Delivery Plan for the NHS in Wales, as well as underpinning the Five Year Forward View in England. But Northern Ireland goes one step further. Bengoa and his expert panel advocate the ‘quadruple aim’ by adding ‘improving the work life of those who deliver care’. And in turn, the DoH’s strategy reflects a very high regard for, and the crucial role played by, the workforce. Verdict: pretty fresh.

Some expected Bengoa to make specific recommendations about which hospitals or services should close. However his report concludes that these decisions are best made by clinicians and service users. Instead Bengoa and his expert panel recommend criteria against which service sustainability should be assessed across the whole country. It includes considerations around patient outcomes, minimum volumes of activity, the use of clinical pathways co-created with patients, acceptable training provision for junior doctors, the viability of maintaining a permanent workforce and cost. The DoH will be consulting the public on the criteria shortly and, while not a silver bullet, this approach has the potential to take some heat out of service reconfiguration discussions as they progress. Verdict: very fresh.

The DoH’s strategy does not steer clear of making proposals about the structure of the health service, however. New ‘Ambulatory assessment and treatment centres’ and ‘Elective care centres’ are to be established across the country. Where, how many and the service specification will be decided in partnership with clinicians and patients over the next 12 months. And acute inpatient care will need to change in response to these new facilities. But will this approach prove too directive and put clinicians off from really engaging with the debate about the detail of the new centres? After all, local ownership of these facilities will be key to their success and assimilation with the existing NHS infrastructure. Verdict: possibly not so fresh.

It’s also unclear how these new centres fit together with one of Bengoa’s main recommendations – for Accountable Care Systems (ACS) to emerge across the country in the form of integrated, provider partnerships. This is one proposal that the Health Minister does not seem to have fully embraced. The DoH’s strategy talks about empowering local providers and communities to work in partnership and ‘to plan integrated and continuous local care for the populations they serve’. But the emphasis is on partnerships for planning, rather than for providing care. That said, insiders say that the ACS model is still being actively discussed in Northern Ireland, but that for the DoH to have made it a central tenet of its strategy may have been premature. So for ACS, it may be a case of wait and see. Verdict: hopefully fresh.

Finally, the language used and culture described in both reports engenders a very mature and positive approach to the transformation of the health and care system in Northern Ireland. In the DoH’s strategy the Health Minister says ‘I am committed to achieving the change required using a process of co-production’ with patients, service users and staff, adding that ‘This Executive is united as never before in its commitment to take the right, perhaps difficult, decisions’.

The scale of this challenge is not underestimated. Nor is the timeframe for achieving this level of transformation (10 years). The announcement of a new Improvement Institute ‘to fully integrate quality improvement into the work of every HSC organisation’ appears to be another indicator of a genuine commitment to supporting, rather than merely stating, the need for change. Reactions to the DoH’s strategy have been largely supportive. Given the history of devolution in Northern Ireland – it’s been suspended four times since 2000 – this is an achievement in itself. Verdict: impressively fresh.

So my overall verdict on the new strategy for the Northern Ireland health and care system is that it does, without a doubt, look like a very fresh, fresh start. Hopefully it will stand the test of time – 10 years to be precise – as well as the tricky politics and public debate that will inevitably come with it.

Sally Al-Zaidy is a Senior Policy Fellow at the Health Foundation