Northern Ireland's streamlining of its public sector promised to be a less brutal process than England's. But some big holes in performance measurement brought challenges of its own, writes Daloni Carlisle
For those in England recovering from the hectic reforms of 2005-06 and hoping against hope that it is all over for a while, spare a thought for colleagues in Northern Ireland, where reform is only just now beginning in earnest.
It is, depending on your point of view, either a time of great excitement and opportunity or one of immense unrest and risk.
The reforms have been a long time coming. It was in November 2005 that Northern Ireland secretary Peter Hain announced a radical restructuring of public administration in the province. It would bring in not just health but also social services, local government and education.
The aim was, as elsewhere in the UK, to reduce the number of public bodies and make the public sector more streamlined and economically efficient. The number of health and social care bodies would fall from 47 to 18. But it would take place relatively slowly compared to the breakneck speed in England.
Health would go first, with major reforms to the provider side in April 2007 and to commissioning and performance management in 2008. The other public sectors would start later, with their major reforms completed in 2009. The result would be a completely new health and social services structure. From the top, the Department of Health, Social Services and Public Safety would be slimmed down, have responsibility for developing strategic policy and set long-term targets, lead the drive for better performance and performance manage a new Health and Social Services Authority.
The new HSSA - the equivalent of a strategic health authority in England - would replace four local health and social services boards, taking responsibility for commissioning and performance managing health and social services.
The next tier would be seven local commissioning groups with responsibility for local commissioning of services, working with GPs and other health professionals as well as the public and voluntary sector.
All of this is scheduled for April 2008, requiring new legislation that is due to go forward this month.
Changes to the provider side, meanwhile, did not require new laws. The merger of 18 health and social care trusts into five new super trusts integrating acute hospital care, community services, mental health and learning disabilities as well as social care went ahead earlier. Along with a new ambulance trust, these were established on 1 April 2007.
This, if you like, is the front story. There are several back stories to do with the effects of uncertainty on 71,000 staff working in the NHS in Northern Ireland, the wisdom of reforming health ahead of the rest of the public administration, political uncertainty as the province moves from direct rule to self-determination as well as the past performance of the NHS in Northern Ireland and how, exactly, the powers that be ended up with the current structures.
When it comes to the last of these stories, there is one man whose name keeps coming up: Professor John Appleby, chief economist at the King's Fund. In 2004 he was commissioned by the health and finance ministers to do a mini-Wanless for the province.
'Clearly we did not have the resources to do the same sort of job,' says Professor Appleby. 'But we were able to look at the sort of ball-park figure Northern Ireland would need for its future health and social care spending.'
The problem he encountered was that no-one was really measuring anything. Waiting times were horrendous - over 18 months for some elective procedures. It was widely acknowledged at senior level that quality, safety and performance were disastrous in many places. But measures of performance and productivity were sparse.
'The information systems were very weak,' says Professor Appleby. 'We pieced together some measures for performance and productivity and concluded broadly that the Northern Ireland productivity was lower than in England and potentially significantly lower in certain areas.'
When his report came out in August 2005, there was the inevitable quibbling over whether his figures were right to every decimal point but he dismisses this as largely irrelevant to the conclusions that must follow his general conclusion.
'What,' he asks, 'does Northern Ireland have to promote performance? Given that it is a public service and there is no market, what are the mechanisms other than pure public spiritedness by doctors and managers?'
His general conclusions were: almost nothing. 'Performance management was pretty poor,' he says. 'There was notionally a sort of split between those organisations with money and those with services. But it seemed to me - and we interviewed 100 people to draw this conclusion - that the split was more in name than anything else. There was no real significant pressure by boards on providers to improve productivity.'
In the period after the report's publication, he went to speak to various groups of managers. 'When I told them that in England managers had lost their jobs over failure to meet targets, I was met with stunned silence, then: 'You're not going to recommend that, are you?' from the audience.'
Clearly, Professor Appleby was not in the business of telling Northern Ireland how to run its health services and comparisons are always invidious. He did, however, suggest they explore ways of creating a commissioning/provider split; they should look at the English finance reforms and what could be learned from payment by results and think about how choice might be re-engineered for the context.
Now comes a happy coincidence. Officially, it was the ministers of health and finance that commissioned Professor Appleby; in reality the permanent secretary at the finance department, Andrew McCormick, had a big hand in the job. Just after the report was published, Dr McCormick moved to the health department, where he is still permanent secretary today.
First, the DHSSPS tackled waiting lists, contracting with the old Greater Manchester SHA to bring in their expertise to set up integrated clinical assessment and treatment services (ICATS), using private sector capacity. By April 2007, waiting lists for elective surgery were down to six months and on target.
Even the British Medical Association agrees grudgingly that this has worked well. 'We had patients waiting two-and-a-half years for their first outpatient appointment and a year and a half for their elective surgery after that,' says Dr Brian Dunn, chair of the BMA's GP committee in Northern Ireland.
'We felt we had no option but to support the ICATS and they are making a difference. Trusts have been pushed extremely hard and clinicians have worked hard.'
Next, the DHSSPS set about designing a new health structure. Much of what Professor Appleby recommended is apparent in the reforms now being implemented.
There is a clear purchaser-provider split. There will be a form of payment by results and a tighter financial regime. Choice is putting in a guest appearance in the form of direct payments and individual budgets as an empowering tool. But practice-based commissioning is off the agenda, as is greater involvement of the private sector. There will be no foundation trusts, which are felt not to be right for the province.
It is pretty early days and the resurrection of the Northern Ireland Assembly means a new health minister. At the time of writing this was expected to be one of the Official Unionist MPs and they were expected to back the Review of Public Administration reforms already in train.
But as Dr McCormick points out: 'The model [for health services] has been agreed with Peter Hain but it is not universally agreed here. It is the greatest hesitancy.' If the new assembly does not back the law changes, it will be back to square one.
In the meantime, the DHSSPS has opted to act as though it is full steam ahead and set up shadow organisations with designate chief executives. It is, says the NHS Confederation's Northern Ireland director Alan Gilbert, the only sensible opion.
Dr McCormick fought - and won - a battle to recruit the designate chief executive for the new HSSA from an open pool (rather than within the Northern Ireland public sector). In August last year he brought in David Sissling, former chief executive of Leicestershire, Northamptonshire and Rutland SHA.
Mr Sissling's plans for the new body are advancing. It will, he says, have five main areas of responsibility: strategic leadership; performance improvement; commissioning; public health and well-being; and workforce planning.
He is keen to import some of the lessons learned the hard way in England, notably over consultation with staff, patients and public, and then there is the issue of clinical leadership. 'We have to make sure professionals are at the front of these changes and leading it,' says Mr Sissling. 'We are planning programmes of involvement and leadership and this will be a real hallmark of what we do.'
Given that commissioning is probably even less developed in Northern Ireland than it is in England, he is keen to develop capability in this area and is working on a novel model. 'It is deliberately different from practice-based commissioning,' says Mr Sissling. 'We plan to have seven local commissioning groups and we have already appointed designate chief executives to a number of these. Then at local level will be community commissioning associations bringing in GPs, other health professionals and community groups.'
These local groups will hold a delegated budget and commission for a minimum of 30,000 people. 'It's a community-based membership approach that will commission on true priorities based on understood needs,' says Mr Sissling, who envisages local groups forming a management group and establishing a membership to carry out the work.
The BMA is urging its members to get involved. 'We would probably have preferred to have practice-based commissioning,' says Dr Dunn. His reservations are that PBC rewards good practices; community commissioning associations reward the collective, including practices that do not do so well.
GPs are reportedly getting together to bid to form management groups and Dr Dunn adds: 'My latest advice is that you may not have everything you want but it's time to become enthusiastically involved and make them work.'
Professor Appleby is sceptical. PCTs in England were recognised as too small to work effectively and were therefore amalgamated to create the new PCTs in 2006. Northern Ireland, with a population of 1.6 million, is around the size of greater Birmingham and proposes to have seven local commissioning groups and who knows how many smaller community commissioning associations. 'There is a problem with going too small,' he says. 'If you go too low with your budgets they are simply too small and the provider side ploughs over them.'
Bear in mind that the reforms have created five supertrusts, the largest of which - Belfast Health and Social Care trust - employs 22,500 people, has a budget of£1.1bn, is the largest employer in Northern Ireland and the largest trust in the UK.
Mr Gilbert, of the NHS Confederation, makes another point about the uncertainty. 'The local commissioning groups were supposed to be coterminous with the new local authority boundaries. But some of the political parties are taking exception to the seven local authorities and will propose 11 instead.'
Northern Ireland has tried to be more humane in its handling of staff than was England. In April 2007 Dr McCormick announced that the NHS would shed 1,700 staff to save£50m a year. The plan is to do this without compulsory redundancies. Applications for new jobs is restricted to staff working within the public sector and there is a support programme for people who have to make significant changes. Good for staff who will feel less threatened, not so great for a health service looking for fresh ideas.
Nevertheless, the unions are unhappy. There has been a bit of a game of hokey-cokey as they walked out of talks and walked back in again. But on 8 March the DHSSPS issued its HR framework without the agreement of the unions.
For Jo Cooper, national officer for Managers in Partnership, one of the hottest issues is what happens to staff who lose their NHS job and might not apply for jobs in other public sectors as they undergo reform. 'The spectre of unemployment and redundancy are hanging over everybody and have been for such a long time,' she says. 'It causes confusion and depression.'
Unison head of bargaining Lily Kerr adds: 'All the jobs are open to all the RPA-affected staff. But because health has gone first, health staff are in double and triple jeopardy.'
- Northern Ireland's public sector has been slimmed down in line with similar moves around the UK.
- A study into future spending needs for health and social care found performance measurement lacking.
- Elements of the English NHS reforms are being taken on board - but still require the vote of the Assembly.
The new look
The five new provider trusts created on 1 April are joint health and social organisations that encompass an enormous range of services.
Pat McCartan, chair of Belfast Health and Social Care trust, and chair of the NHS Confederation in Northern Ireland, thinks this brings enormous benefits. 'Because we are joined up we can exploit the synergies in developing new services,' he says,
One example in Belfast is seven new health and well-being centres, containing not just health services such as GPs and community health workers and minor surgery facilities but also leisure services such as libraries and sports facilities.
'It's one door for three major public services, all of which can promote health and well-being.' The challenge for the trusts will be to create management structures that bring the different parts together and a board strong enough to challenge.
'The key will be having a good board with some strong appointments.'
Rise of the regulator
Another aspect of the reforms has been regulation, with the birth in 2005 of the Regulation and Quality Improvement Authority (RQIA), a super-regulator responsible for health and social care.
RQIA has just completed the first clinical and social care governance review across all boards, trusts and agencies in Northern Ireland, with the results expected in May. The reviews are likely to lead to improvement plans being developed in partnership with the new organisations, assisting with the smooth transfer of control on issues of corporate leadership and accountability and safe and effective care.
The RQIA is also planning a number of thematic reviews in the area of mental health and learning disability.
Meanwhile the DHSSPS this year signed an agreement with the National Institute for Health and Clinical Excellence which means its guidance can now be used.