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It was a case of 'no show' when health managers went to a Northern Ireland conference in the hope of getting a look at the devolved minister for health. What they got was John McFall, yesterday's man. Pat Healy was there

When senior managers were invited to a conference billed as explaining how the Northern Ireland Assembly would affect health and social services, there was a rush for places. Fifty hopefuls had to be turned away.

The key incentive was the prospect of the devolved minister for health outlining how the end of direct rule from Westminster would change things.

But with talks on the Assembly stalled, the conference was addressed by self-styled 'direct ruler' John McFall, still Northern Ireland's health and social services minister months after he expected to be 'away back to Scotland'.

'Do not lose heart,' he told a plainly disappointed and frustrated conference. 'The political process continues. Negotiations are taking place. You can be assured I will be replaced.'

This was little consolation for most delegates, who are keenly aware that vital decisions need to be taken on the future of acute hospitals and on reshaping services in line with the reforms taking place in the rest of the UK.

Mr McFall has already outlined his vision of how these changes could be achieved in Fit for the Future: a new approach, which tackles structural issues, and Putting it Right, on acute hospitals.

But decisions continue to await the Assembly.

The hiatus is being used by managers, civil servants and Mr McFall to meet as many assembly members as possible to ensure they are well briefed when responsibility for health and social services eventually passes to them.

Mr McFall offered several pieces of advice to his successor, including the need to keep to the level of health spending of the present government, which has added£732m to the budget over the next three years.

He urged the new minister to set up a public health group to tackle the health inequalities that have led to Northern Ireland's health being 'much poorer than it should be'.

Mr McFall cited the highest death rate from lung cancer in the EU, markedly lower life-expectancy rates, and substantial differences between the highest and lowest socio-economic groups.

His successor would also have to deal with the difficult political issue of the over-provision of acute hospitals.

'It is clear that 17 hospitals is too many for a population of 1.5 million, and it is also difficult to see how modern clinical standards for both treatment and training of staff can be achieved when the volume of cases is so low in some of these hospitals,' Mr McFall said.

The designate assembly has already had a debate on acute hospitals which left the impression that few of its members are willing to follow Mr McFall's advice.

One difficulty when the Assembly does finally take charge is that it will be a coalition government and, as Department of Health and Social Services permanent secretary Clive Gowdy explained, it is difficult to see where the opposition will come from.

All the main parties are guaranteed a seat in government, and the minister heading each department must be from a different party to the member chairing the departmental Assembly committee.

Mr Gowdy expects the committee to be more proactive than its Westminster equivalent, with a role in initiating and enacting new laws, and powers to get involved in policy development and budget allocation.

So, while the new health minister will want to develop policy ideas, produce new laws and allocate resources, the committee will be able to challenge all that. As Mr Gowdy said dryly: 'This could be an area of difficulty.'

For some delegates, the prospect of civil servants briefing both the minister and Assembly committee on matters of policy, giving answers to questions and getting involved in locally driven policy developments is a significant change.

William McKee, chief executive of the Royal Group of Hospitals, Belfast, said it meant 'the civil servants will be totally taken up running after their minister'.

He called for a regional body, separate from the civil service, to determine people's needs. He said afterwards that he saw such a body as an alternative to Mr McFall's suggestion of five health and social care partnerships to replace the present four boards covering the province.

Western health and social services board chief executive Tom Frawley was also concerned about how the partnerships would work.

Boards, he said, were being asked to manage change in conditions of maximum difficulty because there was uncertainty about overall objectives, conflicts of interest, role overload and role ambiguity.

There were also key questions that remain 'undefined, let alone answered'. These include whether the proposed primary care co-operatives would really control the proposed partnerships within an appropriate framework of corporate governance.

And if GPs had the majority and the right to chair co-ops, Mr Frawley asked: 'How can they be seen to fairly control themselves if they also control the partnerships?'

Would there be reserve powers, as there are for health authorities in England and Scotland, to intervene where standards failed or the strategic intent of the health system was not being adhered to, he asked.

Whatever change emerged, it was vital to lay to rest the false assumption that there was too much bureaucracy and that the system was over-managed.

'Clearly, it isn't,' he said. 'But it is overly complex because it has developed piecemeal in the last 10 years or so. Bureaucracy is not management. The key to the operation of any activity is high-quality effective management.'