Missed targets and a rise of 15 per cent in people waiting for treatment. . The minister is blaming years of underfunding, but is she right? Jonathan Traynor reports

Published: 21/03/2002, Volume II2, No. 5797 Page 14 15

Trust and health authority chief executives - and politicians - casting a fearful glance at figures for 18 month-plus longwaiters in England will alight on the figure nine. Nine too many, as anyone might say. And indeed supposedly deemed 'illegal' by next month.

It is hardly surprising, then, the news that in Northern Ireland the figure has reached almost 7,000 has appalled ministers, patient groups - indeed almost everyone involved in NI's health economy.

The only point of contention is the cause - and the cure.

The latest figures released by the Department of Health, Social Services and Public Safety - for December - represent an increase of nearly 15 per cent on the same time the previous year, with almost 58,000 queuing for treatment.

The announcement comes nearly exactly a year after the minister set a target for boards and trusts to reduce the numbers waiting to 48,000 by March 2002.

NI's health service is in a cash and organisational crisis according to pressure groups - and health minister Bairbre de Brun can only agree. The minister has adopted a mantra of 'years of underfunding', the Assembly's health committee issues increasingly desperate recommendations for action while pressure groups, lobbyists and professional bodies cry for action on multiple fronts.

Senior officials in trusts across the province are torn between delight at the upsurge in interrogation of officials from the DHSSPS by Assembly members and dawning awareness that the same questions are being asked of them.

For the past six months, newspaper headlines have become increasingly dominated by strident headlines declaring that there is a 'meltdown' in NI's health service and describing ongoing crises.

While occasional voices praise 'good work' that continues and commend staff at all levels, it is clear that many believe that NI's health service is in a continual state of crisis.

Cash - or the lack of it - is said to be the root of the ills for the service. Ms de Brun told the Assembly's health committee that direct rule from London had left an inheritance of under-funding.

At the root of many concerns is the Northern Ireland Executive's block grant from the Exchequer - set under the Barnett formula which is meant to provide an equation to allow equal distribution of money between disparate parts of the UK.

'There had been chronic underinvestment in delivering service and in renewing and modernising buildings and equipment. There had been a policy of imposing cash savings, none of which were returned for further investment in health and personal social services;

some£190m has been lost in this way, ' says Ms de Brun. But there is a growing lobby claiming that allegations of past neglect are a smoke screen. Earlier this year, the minister announced proposals for replacing GP fundholding with a network of local health and social care groups beginning next month.

The plans drew fury from professional bodies, prompting a coalition of medics, nurses and midwives. The British Medical Association's GP committee angrily dismissed the inherent 'quangoism' in the proposals.

Committee chair Dr Brian Patterson said: 'The LHSCGs will not be empowered to influence either commissioning of secondary care services or primary care development. Bearing in mind the composition of the LHSCG management boards, which will be health and social services board/trust top-heavy, there is little the primary care team will be able to effectively influence, making a nonsense of the 'bottom-up' approach. The quangoism of these bodies is because of the lack of infrastructure and adequate resourcing.'

At a joint press conference last month, the BMA, Royal College of Nursing and Royal College of Midwives claimed that even management budgets for the LHSCGs were nonsensical. The proposal to fund the groups at£3 per patient is believed by the three organisations to be totally inadequate if a primary care system of prescribing, plus elective care, plus community nursing and other services is to be provided. They compare the management allowances within the service with the department allowance set at£21 per patient; the health and social services boards at£11.50 per patient; and trusts at£40 per patient.

Breedagh Hughes, NI board secretary for the RCM, is concerned at the lack of recognition given to midwives: 'We are profoundly dismayed to find that the word 'midwife' does not appear in the new guidance for the establishment of the LHSCGs. Most women nowadays spend only one or two days of a pregnancy in hospital, with the remainder of their care being provided by midwives working in primary care.'

And lobby groups are even more frustrated. Janet Montgomery, chair of NI's Registered Homes Confederation, which represents independent sector homes, despairs of the situation for elderly people. 'There is a growing sense of frustration among statutory providers, voluntary providers and private care and nursing homes, ' she says. 'More and more health service managers are struggling with absurdities like elderly patients blocking beds that are readily available in the independent sector.'

And she says budgetary blocks are hampering innovative solutions that could save money and produce positive patient outcomes in areas such as orthopaedic rehabilitation. 'It seems that the chaos is spreading to such an extent that the minister will be unable to come up with any solution that will benefit the growing despair of providers and patients.'

But what seems to be most frustrating to many in the service is the tardiness in decision-making.

Ms de Brun claims that decisionmaking in key areas such as cancer services (see box) are moving as quickly as possible.

In other areas the public sees delays as ludicrous. Last week the Assembly's public accounts committee issued a report on pathology services which showed that reforms agreed in 1983 have not yet been implemented.

There are currently 14 laboratories providing 6 million tests a year, despite the fact the proposals in the 1980s were to reduce the number of laboratories to six.And the slow pace has been compounded by under-staffing, with 10 consultant posts currently vacant.

With waiting lists soaring, cancer developments running behind schedule and dismay expressed by managers, patients and politicians, the minister presented her 2002-03 budget to the health committee. Ms de Brun was not able to present an optimistic picture. She told members that while there were some cash increases available, there was limited money for new developments.

Committee member Professor Monica McWilliams summed up the confusion and frustration felt by many when she said the service was 'going to be facing never-ending crises for the next year'. l Not a brick in the wall: an unbuilt cancer centre Within the next six months, Belfast will host a major cancer conference at which specialists from Dublin, Washington DC and further afield will share information about treatment, care and innovative community and nursing practices.

But Northern Ireland's new regional cancer centre remains unbuilt - six years after chief medical officer Dr Henrietta Campbell produced a report calling for its establishment.Assembly health committee chair Dr Joe Hendron says: 'The cancer centre is the key missing link to a modern, fully integrated patient-centred cancer service.This centre of excellence was a major recommendation of Dr Campbell's report, and it is a matter of increasing concern that, some six years later, not a brick has yet been laid.'

Bairbre de Brun told the NI Assembly last week that there has been no undue delay in proceeding with the centre's business case.She said: 'I inherited a planned investment of some£32m, and a private finance initiative process in train.Last year, the trust and clinicians involved made the case that we needed a state of the art facility incorporating new and emerging technology, and building on advances in patient care and treatment.They stressed the centre needed to be designed and equipped to serve the community well into the century.'