Belfast Telegraph

Monday 21 April 2014

Poots must use carrot and stick approach to drive health reforms

Health Minister Edwin Poots has some big decisions to make over the health service
Health Minister Edwin Poots has some big decisions to make over the health service

Edwin Poots has ambitious plans for Northern Ireland's biggest personal service provider: a better and improving health service.

His logic for better business efficiency, as argued on paper in ‘Transforming Your Care' (TYC), is hard to fault.

The delivery plans are awaited and a cause for concern. Consultation has ended. Now there must be a mixture of (mainly) persuasion, backed by incentives and, ultimately, through new behavioural requirements. There are some ‘carrots' but some ‘sticks' will also be needed.

In an important coincidence, Edwin Poots has given extra impetus to his consultation on TYC when, only days earlier, the Government Audit Office calmly took the health service to task for several key weaknesses in the current delivery processes.

First, in a reassuring comment, the Audit Office commended each of the various health service trusts and other separately accounting bodies on the ability in 2011-12 to live within their financial budget allocations.

However, to live within a budget is not the same as making the best use of a budget allocation! The Audit Office report makes uncomfortable reading on some of the normal performance indicators. The essential tension is between the assessment of current performance and the stated ambitions of TYC.

Not only are there questions about organisational methods, there are also the more difficult questions of how organisational performance can be incentivised to deliver better results.

If the health services were organised on a payment for service delivered mechanism there would be a confident expectation of improvements.

A system of financial incentives to encourage results at an appropriate unit level has proved elusive and divisive.

The Audit Office evidence on the efficiency of the health services at the point of need is well documented and, for a potential user, not reassuring.

The critical concerns on A&E are:

  • In accident and emergency cases, 95% of patients should wait for four hours or less;
  • No patient in A&E should wait longer than 12 hours for treatment.

These targets are poor enough but are far from being reached.

Trusts average nearer to an 85% outcome and the number of people in A&E who waited for longer than 12 hours increased in 2011-12 by 2,832 to an annual total of 10,211.

Appointments with consultants:

  • No out-patient appointment should take more than 21 weeks: in March 2012, 5,903 patients were still waiting;
  • No in-patient appointment should take more than 36 weeks: in March 2012, 775 patients were still waiting.

Noticeable failure to meet targets that are themselves modest is again in evidence. The pathways in the health service continue to produce bottlenecks and waiting lists.

Another critical performance, not included in the Audit Office review, is the poor performance of the health service in delivering appropriate care for patients after their needs following an acute admission have been met and/or to avoid inappropriate admissions to acute hospital units.

An effective system of residential and/or nursing care, with reshaped financial under-pinning, is not yet on the drawing board.

If Mr Poots is to maintain credibility, then behavioural professional changes must be specified and delivered:

  • Some deterrence to universal walk-in access to A&E is needed;
  • Incentives to make better use of specialised GP services, reducing hospital referrals;
  • Direct access to nursing and/or residential care for some frail people needs to be more accessible;
  • Across the health and social services, policies to improve the supply of service and to constrain inappropriate demand are a requirement.

Mr Poots will fail if he cannot make the concept of Integrated Care Partnerships work, and work effectively. Much of the unsatisfactory performance of the health services lies, somewhat obscured, in the poor organisation of primary care.

That points to the benefits of a major review of contract terms and salaries in financing primary care services.

Is the Executive prepared to back radical contractual changes from Mr Poots to make his transformation plans effective?