Health and social care planning is an extremely complex multi-dimensional matrix. It calls for exceptional management skills serving 1.8m people and affects over 70,000 employees.
The Northern Ireland health and social care budget (excluding the civil servants in Castle Buildings) will have an annual current expenditure budget of £4.15bn in 2014-15. Health and social care is not a commercially motivated business: it does require an organisational structure that delivers in a business-like manner. Efficiency, productivity, technical change and customisation to people's needs are critical.
The parameters of health and social care provision must be assessed against a background of scarce resources in the face of nearly limitless potential demand.
The report, prepared under the chairmanship of John Compton, deserves one large compliment: in 142 pages he has laid out a convincing and ambitious strategy outlining answers to unavoidable pressures.
Compton and his team have met the challenge set by the minister. Unkindly, the argument can be advanced that their report was the easier piece of architecture. The more difficult tasks lie in the challenge to deliver a complex inter-related series of changes within available resources. Many jobs will move and many job descriptions will change, often incrementally. People in over 2,000 jobs may face redundancy.
The report convincingly demonstrates that a 'no change' agenda would generate serious crises. Growing demand pressures would leave some people with unacceptably poor services.
The most telling feature of the Compton plan is that service improvements, through re-organisation, can be delivered 'within the constraints of the current level of funding' to 2014-15 supplemented only by extra transitional funding of £70m to ease the changes.
Compton gives only sketchy details of the likely (still awaited) business plan. An implementation plan will be ready by mid-2012, in only nine months! There will be many conservative voices and many interest groups making protective reservations.
There are numerous sensible proposals for realignments, more ambitious services based on extended contact for patients at (and from) their own homes, wider responsibilities for GPs and integrated care teams, functional rationalisation of medical specialists and related support services (including broader ambulance services), and wider scope for contracting with community and voluntary organisations.
One analytical feature stands out. The arithmetic of the Compton team relies on changes to divert significant numbers of patients away from entry to acute hospitals to appropriate or better services either at home or for example, nursing homes.
The proposed change in the clinical profile of acute hospital services is not a new concept.
However, the concept has been converted into an estimate that acute hospitals (whether 5 or 7) will release £83m in the next four years, equivalent to 5% of their current budgets.
This is critical to the Compton budgeting. It sits alongside the current rubric that hospital budgets must increase by 2% pa because of demographic change, 2% pa to allow for medical and surgical progress, which are only offset by an extra cash input of 2% pa. To move to a 5% reduction depends on success in changing the numbers and profile of patients being admitted to acute hospitals.
Compton hopes to have an implementation plan next summer. That would be a serious challenge even for a coherent management team. It is much less reliable given the complex professional groups that are to produce operational plans. The integrated care partnerships will advise the five local commissioning groups (LCG) as they make proposals alongside the Trust Boards.
The hierarchy to implement the reforms is, unhappily, too cumbersome.
A good start has been made. Now the operational plans will be the hard part.