Lisa Smyth: If Richard Pengelly can rubber-stamp changes to the 999 system on safety grounds, why can't he do the same for patients put at risk by nurses' strike?
The Department of Health says the RCN pay dispute is a matter for ministers, but is there really nothing more its high-profile permanent secretary can do, asks Lisa Smyth
The winter is never a good time of year for the health service. As temperatures begin to drop, GP surgeries, pharmacists, emergency departments (ED), community nursing teams, out-of-hours doctors, paramedics and minor injury units become a great deal busier.
There are a lot more coughs and colds and various strains of the flu virus begin to circulate, putting people with compromised immune systems at risk of potentially life-threatening complications.
The 41,000 people living with chronic obstructive pulmonary disease in Northern Ireland are also more at risk during the winter months. For such people, a simple chest infection can prove fatal.
The number of accidents increases as well, putting additional pressure on the health service.
In anticipation of an increase in ED attendance, GP consultations and hospital admissions, health bosses put in place a number of initiatives to cope with the additional demand.
Where possible, extra beds are made available and more staff are drafted in.
Even with this, however, it is not uncommon for elective operations to be cancelled at the last minute to free up beds and theatres when there is a spike in emergency cases.
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So, the ongoing industrial action by Unison and the Royal College of Nursing (RCN) could not have come at a worse time.
For years, both unions have been warning of growing discontent among members. Chronic underfunding, cutbacks, growing demand for services, a failure to implement much-needed reform and an almost complete lack of workforce planning have led to intolerable working conditions.
In the past 12 months, I have written stories about exhausted and stressed-out staff frequently being reduced to tears, the Northern Ireland Ambulance Service (NIAS) calling on paramedics from the Republic to cover shifts, spiralling waiting times, nurses who are terrified their patients will die before a hospital bed is found, a senior doctor speaking out about waiting times in the ED where he worked and a packed ED running out of portable oxygen.
The only reason why the health service has continued to function is down to the goodwill of staff working through their breaks, going without meals - and even toilet breaks - and staying well past their finishing time.
Most of them have done this in the knowledge that their colleagues in the rest of the UK are paid thousands of pounds more every year for doing the same job but in much better conditions.
It is little wonder, therefore, that the unions have said enough is enough.
However, the resulting industrial action seems to have caught those in charge of the health service by surprise.
The Belfast Trust implemented an almost blanket cancellation of outpatient appointments and non-urgent operations last week in a move that angered staff and the public.
The cost of cancelling so many appointments is sure to have run into hundreds of thousands of pounds.
Even the Secretary of State, Julian Smith, seems to have underestimated the strength of feeling among workers.
He posted an optimistic tweet last week, apparently hopeful that an increased financial package from the Department of Health would be enough to halt any further industrial action. It wasn't.
The unions, which have been clear that their members will not accept anything other than pay parity with the rest of the UK, described the revised offer as "insulting".
There has been some communication between the unions and the Department of Health since last Thursday but no meaningful negotiations.
Mr Smith appears to have all but washed his hands of the situation and is standing strong to his position that health is a devolved matter.
He has made a number of comments expressing his concern about the state of the health service and his commitment to finding a resolution, but he has also rejected any notion that he is the only person who can make a case for more money to the Treasury.
One has to wonder if he would take the same stance if it was his constituents in Skipton and Ripon facing 10-year waits for life-changing operations.
Northern Ireland does not have the luxury of waiting for much longer.
The industrial action is about to be ramped up and the disruption we have seen to date is only the beginning.
Thousands of outpatient appointments and operations have already been cancelled, and that is only when nurses have been working to rule - working the hours they are supposed to and not carrying out any non-clinical tasks.
In just five days, thousands of nurses and paramedics will strike. The impact of the planned action cannot be underestimated.
Unison paramedics will respond to immediately life-threatening 999 calls and will tend to patients who are dangerously ill.
These types of calls account for less than half of the cases they deal with on a daily basis, however.
At the same time, the RCN will stage a 12-hour strike, with only the likes of chemotherapy treatments, end-of-life care and intensive care units exempt from the action.
Even nursing cover in our EDs will be reduced. Patients whose lives are at risk will, of course, be seen, but there will undoubtedly be a significant impact on people with less serious conditions.
It is both startling and alarming that the situation has been allowed to deteriorate to this point.
So, where exactly does this leave us?
The Department of Health insists no more money can be found. It claims it cannot approach the Treasury for additional funding, maintaining that this can only be done by a local health minister or the Secretary of State.
Apparently, there is no mechanism for the permanent secretary to take such action, although he was able to approve changes to the way the NIAS responds to 999 calls earlier this year.
Normally, such a move would require ministerial approval, but Richard Pengelly was able to rubber-stamp the change because it was an issue of patient safety.
It is difficult to see how the impending strike action is not also a matter of patient safety.
Certainly, health officials have so far been at pains to stress that industrial action is putting patients at risk.
Local parties have expressed horror at what is happening in our health service but have so far failed to make any meaningful effort to get Stormont up and running again.
With just five days before the combined strike, both Sinn Fein and the DUP appear to be standing by their red lines.
The General Election and the UK's looming withdrawal from the EU are doing nothing to improve relationships between the parties.
So, the collapse of the health service in a matter of days appears inevitable. At this stage, the only thing that might stop the strike is the trusts declaring a major incident on Wednesday. If this happens, all staff on strike will immediately have to return to work.
NIAS bosses took this step four years ago to stop their staff from staging a round-the-clock walkout.
The unions will be well aware of this possibility and such a move would undoubtedly prompt a furious reaction.
As it stands, the Department of Health maintains it cannot afford to meet the demands.
However, the cost of not finding a resolution will ultimately be far greater.
- Lisa Smyth is a freelance journalist specialising in health issues