Health and social services in Northern Ireland are seriously inadequate. The deficiencies can be found in many parts of the system but, for simplicity, lie in two main areas: the delivery of acute hospital care and inadequate social care services with particular relevance to elderly people.
nhappily, we know what could be done. We are dithering about doing it.
To her credit, the last health minister, Michelle O'Neill, took steps to focus on how both these services are delivered. Professor Bengoa reported on health services and, now, an expert report on proposals for adult care and support, essentially in a caring environment away from acute hospitals, has been published.
The experts acknowledge that plans must be made to transform the services.
The experts on social care, Des Kelly and John Kennedy, offer conclusions that constitute a loud overdue wake-up call. Their report understates the urgency and scale of the problems, relies too heavily on laudable voluntary and community responses, and is inadequate in the setting of explicit priorities where, inevitably, ministers and officials must decide on how to deliver change.
The need is to prioritise key developments, ensure fairness in funding and rationalise the wider expectations on what levels and forms of adult care can be provided and funded.
The starting point is health and social care services are managing on tight budgets which are at lower levels than ideal. The continuing budgetary constraint has important implications for the setting of priorities. It also points to a shortcoming in the expert assessments now available to official decision makers.
The expert report on proposals to reboot adult care and support has been written from a starting point where a radical review is outlined but without regard to their financing. Questions of how to finance changes have not been specifically considered. That is deliberately left for the next stage in the consultative debate. This expert report is, therefore, an unconstrained review of a large number of possible changes and this dilutes the targeting of the conclusions.
The absence of a review of the allocation of funding leaves two major questions unexamined.
First, are the principles underpinning the allocation of official funding fair and acceptable? Second, in the provision of adult social care, is there clarity on the degree to which families have responsibility both morally and legally in being the first line of response when care needs emerge?
In Northern Ireland there is a notable degree of family involvement as carer in the immediate response to needs.
That leads into a discussion of the need to design the social care system so that there is an improved sense of fairness in the delivery of services. The present systems, partly by historical accident, allow some services to be provided free of charge whilst other services are moderated by the introduction of means testing.
Social care supported 'at home' (if available) may be free at the point of need. However, full-time care in residential or nursing home environment is usually subject to means testing and/or limits on official finance.
A growing feature of adult social care is the availability of 'self-directed support' payments which allocates funding to an individual, or family, so that they can buy social care from non-Government providers. This has become a critical (and potentially sensible) mechanism.
Northern Ireland is drifting into plans for social care which cannot hope to have big enough budgets that avoid priority setting. Needs, fairness and equity are all being missed.