To trust or not to trust?

Trusts in Northern Ireland worked better when they included hospitals and community services within the one legal entity, management consultant George Nixon told the HMI South Forum in Waterford Regional Hospital. Maureen Browne reports.

Many of the new healthcare trusts in Northern Ireland are now being organised along the lines of major service clusters such as acute hospital services, specialist hospital services, primary care services and child care services, according to management consultant, George Nixon, who has worked for many years on the organisation and development of the N.I. Trusts,  There was a decreased emphasis on institutions and an increased emphasis on the services, he told this month’s HMI Forum held by HMI South in Waterford Regional Hospital.

George Nixon
George Nixon

Opening the forum, HMI President, Richard Dooley, said that today more than ever there was a greater need for managers, at whatever level they were working, to recognise that they were part of a professional grade, and the Institute was there to support them and to provide them with opportunities for networking and learning.

Breda Kavanagh, Chair of HMI South said the new government had advocated a hospital trust system and the Minister had described it as a system which would allow hospitals to determine their own future with members of the public having a say in how hospital services developed.  Therefore HMI was very anxious to hear of the experience with trusts in Northern Ireland.

The story of hospitals trusts started with Margaret Thatcher in the 1980s and sprang from her belief that public service providers were intrinsically inefficient and could only be improved by the introduction of competition

George Nixon said that the story of hospitals trusts started with Margaret Thatcher in the 1980s and sprang from her belief that public service providers were intrinsically inefficient and could only be improved by the introduction of competition. That text had been broadly continued by subsequent governments in the UK to this day.  Bringing in private providers was possibly a step too far for Thatcher, so instead she pursued the idea of the internal market, on the basis that if you established organisations which would compete with each other you would get greater efficiency.  Thatcher was also interested in comparing spending and looking at efficiency and outcomes.

There were two main elements of the changes brought in initially. The first was that health authorities, which used to be at the top of the bureaucratic heap, took on the role of commissioners, looking at population health needs, deciding the quantum of services required and then getting organisations to compete for the provision of these services.  This resulted in hospitals becoming more self sufficient.

The second main element was that money should follow the patient, which is also part of the plan of the new Minister for Health, Dr. James Reilly.  “In many ways, the idea that citizens should be empowered to decide where they wanted to go and the money would go with them and the institution rewarded for services provided and numbers treated, didn’t really work very well,” said Nixon.

“Of the 19 trusts most were hospital based, there were some community based, a few were delivering hospital and community services and there was one ambulance trust. There were four commissioning organisations, dealing with north, south, east and west. There was an amazing concentration of hospitals in Belfast, all competing for services.”

Nixon said that trusts in the UK are legal entities, with governance through a board with both executive and non executive directors.  The hospital CEO, Director of Nursing, Medical Director, Director of Social Services and the Director of Finance were on the Board and there were also at least six non executive directors drawn from the community, business, professional and political areas.  Initially these had been appointed by the Minister through a nomination system, but now they went through a public appointment process.

There were some limitations in the internal market – competition was not realistic if there was just one big hospital in an area

The Boards were responsible for meeting service delivery standards and quality and safety targets.  They met in public once a month and also had committees (the members of which were normally non executive) dealing with areas such as audit, clinical governance and risk.

Nixon said that as time went on the thinking was that there were too many trusts and in the past ten years there had been lots of change and realignment.  There were some limitations in the internal market – competition was not realistic if there was just one big hospital in an area.  There had also been weakness in commissioning.  For example, contracts tended to be commissioned for one year, with no assurance that the volume of service would continue for two or three years and in these circumstances it was very hard for a provider to invest significantly.

It had been decided that the number of organisations needed to be rationalised and that services should work much more in clinical networks (that led to trouble with politicians opposing any closures in their constituencies).  The authorities began to look at how cancer services and then critical care and a host of other programmes should be delivered and the commissioners decided that they would purchases integrated services across the system.

Nixon said the changes had resulted in more clinical involvement and in more accountable services.  The trusts encouraged enterprise and innovation and doctors and nurses felt for the first time they had a real say.   The trusts also led to increased performance management and job planning and clear accountability between the trust and the commissioning organisation and with the Department.

There were now just five very large trusts in Northern Ireland plus an ambulance trust, one commissioning authority (the Health & Social Care Board), one public health agency, one business support trust and a regulation and quality improvement authority.  Collectively these organisations spent 40 per cent of the entire Northern Ireland budget.

Trusts enabled a clear delivery point of accountability predicated upon working within national service and other policies and clarity about the quantum of service to be provided within agreed financial envelope.  They worked better when they included hospitals and community services within the one legal entity.