The absence of ministers since the collapse of Stormont’s power sharing in early 2017 hasn’t stopped health service leaders in Northern Ireland from pushing forward their transformation agenda. Health department perm sec Richard Pengelly tells Suzannah Brecknell about driving change through shared leadership, hard work, and difficult discussions
Nerve centre The control hub at Antrim Area Hospital
In Northern Ireland, an ageing population and chronic under-funding are creating twin pressures on a healthcare system in crisis. Hospital waiting times are high and rising, as is pressure on GPs and urgent care, where a lack of doctors is compounding the challenge. All this is familiar to healthcare providers and patients across the UK, but in Northern Ireland there’s an additional challenge. There’s a shortage not just of doctors, but of ministers.
When CSW meets Department of Health permanent secretary Richard Pengelly he has been without a political master for over two years. There’s a widespread belief that the crisis in Northern Irish healthcare is festering without ministers in place to co-ordinate reforms. “I would hate to be the next minister coming in, because a narrative has evolved that all we need is a minister [to drive transformation],” Pengelly tells CSW. “The problems that minister will face are no different and, in many ways, much, much deeper than the problems I face,” he continues. “The basic problem is we have a flawed configuration of services and we don’t have enough money. Just the presence of a minister isn’t going to change that.”
Still, Pengelly is bullish about the change that is happening even without ministers – he’s chosen to meet CSW at Antrim Area Hospital so we can see some of the work already under way to improve services. As well as visiting two units enabling patients to receive care more quickly without unnecessary admissions to hospital, we sit in on a fast-paced meeting in the hospital’s “control hub”.
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A team of professionals from across the hospital, supported by three discharge managers, work their way through a list of patients who are ready for discharge but have complicated needs, trying to ensure those needs are met as quickly as possible. Two large screens display a dashboard showing how many people are waiting in A&E; how many people are expected to be admitted today; how many beds are free in each ward – there’s data galore, but also a very sharp focus on the individual cases which make up that data. Keeping an eye on who is coming in and out of hospital to manage capacity is not unusual, but what is rare is the presence of colleagues from social and community care in this meeting. Their input means that the hospital can work more effectively with care homes and GPs, for example, to make sure people are discharged as soon as possible. Where people are ready to leave hospital but not able to go home – as in the case of one patient who now requires oxygen cannisters and is waiting for a new electric cooker before they can go home safely – the hospital can arrange for them to move into a bed at a care home as an interim measure.
Creating this integrated health and social care team has improved the care that patients receive and means the hospital is better placed to face times of high demand. It might seem that such an approach would be common in Northern Ireland, where health and social care have sat in the same government department since the 1970s. But, as with the return of ministers, Pengelly says structural integration is not a magic bullet for system reform. “Don’t fool yourself into believing that because you call it integrated that’s going to solve your problems,” he says. “An integrated approach provides you with a stronger tool set to try and address the challenges of both health and social care, but you still need to manage those challenges.”
He adds that in big and complex systems there’s “always a tendency to try and push problems along to be someone else’s problem, the thought that ‘If we fix our bit of the system, we are a high performance organisation [never mind the others]’,”. To address this tendency, he thinks healthcare leaders need to act like the professionals in that control hub and make sure the patients are always at the centre of discussions so “the conversation isn’t how do we make the organisation perform better but how do we make things better for the user. I would say that’s the part of our transformation journey where we have made the most progress,” he adds. “We’re starting to behave like a system.”
Pengelly also believes that although the lack of ministers is a challenge, the health service is in a better position than some parts of the public sector because it has a clear road map for reform. In October 2016, a few weeks before power sharing collapsed in Northern Ireland, his department published Delivering Together: Health and Wellbeing 2026 – a 10-year plan for reform which had support from all the political parties. The plan was produced following a review carried out by former surgeon and World Health Organisation adviser Professor Rafael Bengoa, which called for care to be re-designed around community needs rather than existing buildings and structures. The essence of the new system – moving more care into the community and creating specialist treatment centres – is a model that most health services are moving towards. But being well-evidenced and widely supported by experts does not mean such a change is easy, or fast.
“With a 10-year transformation document, the first couple of years are largely getting your sleeves rolled up and starting to do the hard graft,” Pengelly says. “[That work] is not going to require big meaty ministerial decisions. So we’ve been doing a huge amount of work in that space.”
“Don’t fool yourself into believing that because you call it integrated that’s going to solve your problems”
He lists several key achievements, though he concedes that some – such as a new workforce strategy or a collective leadership statement – aren’t necessarily things the public would see as concrete progress. But there has been real change. Alongside all the reviews and task forces, a new network of elective care centres has been created for procedures like cataract and varicose vein surgery; and new care pathways are being established so that, for example, patients can go straight to a physio for back problems rather than needing to see their GP first.
Patients who still value the old models of care sometimes resist changes of this sort, believing them to be driven by cuts or other motives rather than being designed to give them better treatment.
This view is demonstrated during our hospital visit: in one of Antrim Area Hospital’s new units, which allows patients to receive treatments that previously required an overnight stay over a series of day visits, one patient CSW speaks to is very pleased with the new service but thinks it has been driven only by bed shortages. In fact, treating patients as outpatients wherever possible can improve outcomes and reduce risks for the individual. The unit was set up to improve care; freeing up beds is a by-product.
As Pengelly discusses the challenge of getting buy-in from the public, he puts responsibility squarely on those leading reforms. “It’s not [patients’] fault. we’ve got to explain that this is a better pathway for them.”
He cites “the big shining success” of previous reforms, the creation of two specialist centres which treat STEMIs, the most serious type of heart attack. “If you have a STEMI in Northern Ireland you’ll be taken to one of these two centres,” he says, even though there may be a general hospital closer to you. “We’re now outperforming anywhere else in the UK [in relation to treatment of STEMIs] so that model, to create real centres of excellence, works.”
“The public want healthcare facilities close to them,” he continues, “We understand that. But I want people to have access to excellent healthcare. Many doctors will tell you that, apart from cases when there’s blood gushing out of you, in the vast majority of cases it’s more important who you see as opposed to how quickly you see them.”
If public acceptance is one challenge, another is the ingrained ways of working which result from trusts acting as stand-alone organisations rather than thinking of themselves as part of a wider healthcare system. In the long term, creating a more system-wide approach will require a different way of planning care across the country. Under the current system, the DH sets policy and its arm’s-length body – the Health and Social Care Commissioning Board – then commissions care from local trusts. But this, Pengelly says, is a model more suited to larger populations such as England, where it can stimulate competition between care providers and thus improve services. In Northern Ireland, as the Bengoa report and previous reviews have argued, improvement would better driven by collaboration and integration, with a partnership-based approach to planning and managing care across the region.
In the long term this means abolishing the HSCB – something only ministers can do, of course – and the department taking on more of a role in helping to design services in partnership with local providers. Pengelly also suggests the DH could take on a management role, overseeing networks of specialist care which would be based in trusts across the region. But until such structural changes are made possible by ministers (with the caveat that a minister would be free to set a new direction), Pengelly is positive about the progress being made to develop more integrated and collaborative ways of working.
He sees this developing particularly through the regular meetings of the Transformation Implementation Group which brings together trust chief executives with representatives from the DH and the HSCB. Pengelly says putting all the chief executives together in a group and saying “you’re not here to represent your organisation, but you’re here as a senior leader with a specialist knowledge of that organisation” has driven change.
The group of leaders has also helped to address a perennial issue when running a big system – how to spread innovative ideas from one part to another. Meetings are held at a different trust each time, and the host organisation is asked to kick the meeting off with a presentation about a change they’ve made and are proud of. “When that finishes I go round to each chief executive and say, ‘Do you think that’s good?’,” Pengelly explains. “They say ‘Yeah’ and I ask: ‘Why aren’t you doing it?’ It’s desperately uncomfortable… so now before the meeting they’re finding out what’s happening [in the host trust] and finding out if they can copy it.”
That “flawed configuration” which Pengelly mentioned means that Northern Ireland currently has too many hospitals, which presents workforce challenges as well as affecting the way specialist care is delivered. “If you open the doors of any healthcare facility, you need a certain level of safe staffing, so if have too many [facilities], you’re not going to be able to recruit staff,” he explains.
Some specialisms may be particularly hard to recruit for, and hospitals often end up relying on more expensive locum staff to keep their departments running. But as Pengelly points out, this doesn’t just mean there is a shortage of doctors in Northern Ireland (though in some cases there will be). “A locum consultant is as much of a doctor as a consultant,” he says. “We’ve got to understand: why will an individual not take a full time job?” So the workforce challenge is in part about making the health and social care service a more flexible and desirable employer, as well as considering how to develop and recruit new doctors.
“The public want healthcare facilities close to them. We understand that. But I want people to have access to excellent healthcare”
In the meantime, he has been “heartened” to see trust chief executives thinking of the impact on other trusts as they recruit for their own specialists – for example one leader offered to cancel a recruitment drive after all the applicants came from a nearby trust which would have been destabilised had he chosen to appoint one of their consultants. Pengelly believes that leaders had previously wanted to act in this collegiate way, but feels it has been important for him to “permit” this behaviour. “That meant me saying to individual trusts: it’s acceptable for your performance to dip if it means at a system level we stabilise and address the bigger issue,” he says. “You will not be held to account for that performance. Everyone’s bought into it.”
Another challenge for any major reform is “dual rolling” – need to keep an old system going while the new one is being set up, but then also being able to stop those old services when the new ones are ready. “Over the years we have been quite good at putting in place new services; we’re not great at stopping old services,” Pengelly says.
This time there may be a direct motivation to do so. A number of transformation projects setting up across Northern Ireland are being funded with money from the £1bn confidence and supply funding given to the Democratic Unionist Party in 2017. Between them, the projects willl receive £100m over two years, but in year three, that funding will be gone and trusts will need to ensure that any new services are sustainable on their own.
“We need to be willing to look at it from a system perspective,” Pengelly says. “Some of the transformation projects are about meeting need that we were meeting in the past but meeting that need in a completely different way. Some of the transformation is about meeting need that in the past we weren’t addressing. So for some of them it will be additional services, but in the round there’s got to be some savings. So it’s not going to come down to each organisation having to wash its own face.”
In the long term, there will need to be new funding allocations and budgets for the transformed services, which requires ministers. The absence of an executive shouldn’t be downplayed; life without ministers is not an easy one. But a period without political interference – and therefore the breathing space for leaders to drive the foundational work of a ten-year transformation? That’s something for which many senior civil servants might be grateful, and something of which Northern Ireland’s health leaders are taking full advantage.
Duty of Candour
In December last year, the long-running Hyponatremia Inquiry into the deaths of five children in Northern Ireland the early 2000s concluded that four of these deaths had been avoidable. Among the report’s many recommendations was the introduction of a duty of candour for healthcare professionals.
By calling for this duty to apply to individuals, the report went further than other parts of the UK, where the duty applies to organisations – and it has caused concerns for doctors’ groups such as the GMC. “Ultimately that will require legislation, but we’re doing the preparatory work,” Pengelly says, adding that this will mean they can proceed quickly if a minister does agree to implement it.
But addressing the failings in the report will also require cultural change. “We can’t just say that a legislative answer is going to fix your problem if the organisation isn’t up for the open debate,” he says, and he draws out the careful balance to be struck between a legalistic approach and cultural shifts.
“There’s very strong anecdotal evidence that a significant number of clinical negligence claims have their origins in the family just wanting to know the truth. It wasn’t about the pursuit of money or being in court,” he explains. “But the difficulty we have and any system has is that when there is talk of a claim, the first thing you do is you go to seek legal advice. The first thing your legal advice does is tell you to say nothing.”
He also reflects on the balance between holding individuals to account and encouraging an open culture. He is quick and sincere in his admission that the health system “got this badly, badly wrong”. “Our system let these families down, and the focus that we have is making sure that something like that never happens again,” he says.
“For the families, understandably and rightly, one of their big concerns at the moment to hold to account people who were part of the system that led to the loss of their children.
“The balancing act that I have is I genuinely want an open and candid culture where people readily put their hand up and say ‘I think I got this wrong’. If the pendulum swings too far one way and you seek to serve justice to quickly, everyone else in the system watches that and they’re going to retreat into their shells.”