Lisa Smyth: Northern Ireland's health service has been on the critical list for years... but offering hard-pressed staff ill-disguised bribes is not the cure
Goodwill alone is not a lasting solution. The political class here need to step up to the plate, says Lisa Smyth
When the Systems, Not Structures report was published in 2016, it made a compelling case for a radical overhaul of the way the health service is run.
Just a few pages in, it made the ominous warning that change was necessary or Northern Ireland would "see services deteriorate to the point of collapse over time".
It continued: "This report presents an opportunity that must be seized and acted upon."
Certainly, it was obvious to anyone involved in the health service at the time that things could not continue on without some kind of intervention.
Waiting times were already becoming a significant issue, health unions were warning of an impending workforce crisis, and the NHS was beginning to struggle to meet the demand of a growing ageing population.
In response to the report, the then health minister, Michelle O'Neill, released a blueprint for the future of health and social care over the next decade.
The Delivering Together document contained a series of wide-ranging proposals to create a sustainable health service and was met overwhelmingly with cross-party support.
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Released to much fanfare, there was a sense of hope - particularly among health professionals - that the changes necessary to ensure the future of the NHS were within our grasp.
Sadly, however, Delivering Together was probably the last significant policy about which our politicians agreed.
Within three months of its publication, the relationship between the DUP and Sinn Fein reached rock bottom and Northern Ireland's power-sharing government ceased to exist.
And as the Assembly collapsed, it wiped out the optimism that the health service might be saved from collapse.
Health bosses are at pains to stress that work is ongoing behind the scenes to implement the recommendations contained in Delivering Together.
It is true that practice-based pharmacists can now be found working in GP surgeries in Northern Ireland.
Meanwhile, work is under way to open new regional elective care centres around Northern Ireland which will help reduce waiting times for operations including procedures to treat varicose veins and cataracts.
Both of these schemes are to be welcomed.
But the fact of the matter is, the sweeping changes that will truly make a difference - think reduction in the number of acute hospitals or emergency departments - are still as far off today as they were three years ago when Ms O'Neill released Delivering Together.
The reasons for this are very simple - firstly, such changes require a level of funding that has simply not been available, and secondly, they need a health minister and functioning Executive to sign them off.
In the meantime, as predicted by the authors of the Systems, Not Structures report, the health service has stumbled closer to collapse.
In fact, given the events of recent weeks, it is difficult to argue that we have not reached that point already.
In the weeks running up to Christmas, thousands of healthcare workers staged crippling strike action in their fight for better pay and conditions.
Public service unions Nipsa, Unison and Unite were joined on the picket line by colleagues from the Royal College of Nursing, whose members had voted in favour of industrial action for the first time in the organisation's 103-year history.
The walk-out came just weeks after the latest official figures revealed there are more than 300,000 people waiting for a first outpatient appointment across Northern Ireland.
The situation has become so serious that the Health and Social Care Board has said it is analysing statistics to establish how many people on a waiting list may have died because of the delay for treatment.
Amid all of this, an increasing number of staff - exhausted and burnt out - are warning they cannot guarantee the safety of their patients.
Some have even claimed they are being pushed to the brink of suicide as a result of their working conditions.
It is a damning indictment of the state of our health service.
So, it's little wonder that the unions rejected out of hand the last pay offer made by the Department of Health after it failed to meet the demand of parity with colleagues in the rest of the UK.
It is also not surprising that comments made by the chair of the Systems, Not Structures report just two days before Christmas have been met with equal disdain by health workers.
Speaking to the BBC earlier this week, Professor Rafael Bengoa, who headed up the 2016 review of the health service, suggested that performance related pay could be used to drive up standards.
The former Basque health minister - who acted as an advisor to the Obama administration and the World Health Organisation - said he supported the demand for pay parity.
However, in the interview on the Stephen Nolan programme, he continued: "One needs to be thinking of a much more flexible system, this is not a privatisation, it is trying to make the public system much more flexible.
"We are all trying to do that with our different health services across Europe.
"The important thing is that one can identify how to measure different teams doing different work according to the results they are getting. You can measure results.
"I think the unions have to be thinking about this type of alternative and not try to standardise everyone on everything."
He used the example of nurses being financially rewarded if they reduce the number of discharged hospital patients having to be readmitted after developing complications.
"If one is to consider putting more resources into the system, one has to think about how to use those resources in a new way, not necessarily use them in the traditional way," he said.
Unsurprisingly, the unions were horrified at the suggestion.
Patrick Mulholland from Nipsa said: "Frankly in the context of where we are today with industrial action in heroic struggle with health workers trying to defend staffing levels and improve them, it is insulting that Mr Bengoa would come off with comments like that.
"It is quite useful, because what it does reveal to public sector workers, the health service workers and to the trade union movement in all its glory, is the direction of travel that some people would like to take our health service - a health service which is grossly understaffed, staff not properly paid and then having to beg for pittance from their bosses - this is not an acceptable future.
"Mr Bengoa is on the wrong track and frankly Mr Bengoa does need to butt out."
Certainly, in the current climate, it does appear inappropriate to propose performance related pay for some of the lowest paid NHS staff.
Such a system does already exist for the most senior doctors - the Clinical Excellence Awards scheme provides substantial financial rewards to consultants who are deemed to have made a valuable contribution to the health service.
But to propose the introduction of financial incentives for the staff embroiled in the current strike action is entirely different.
Not only are they fighting for a fair and equitable wage, but they are already at the forefront of efforts to improve patient safety.
Frustrated by the conditions in which they are working, they are the ones who are putting their careers at risk to speak out publicly about their concerns over the state of the health service.
They are the people who work countless of unpaid hours, putting their own health on the line, just to ensure patients get the best care possible.
The fact is, as it stands, despite their best efforts, patients are coming to harm and furthermore staff already feel aggrieved they are not getting proper recognition for the work that they do.
Meanwhile, the politicians who are the people who have the power to make the changes that will enable staff to drive up standards and who continue to rake in their MLA salaries, have so far failed to deliver.
The health service needs more than the goodwill of its staff to keep it running, what it does need are elected representatives making crucial policy decisions and putting in place a proper budget.
Until this happens, staff will always be fighting an uphill battle when it comes to their efforts to provide the best care possible.
Lisa Smyth is a freelance journalist specialising in health issues