How the new Northern Ireland health structures work

The emphasis of the reorganised healthcare structures in Northern Ireland was on care pathways rather than professionals or institutions, Mr. Colm Donaghy, Chief Executive, Belfast Health & Social Care Trust told the HMI West Forum in Manorhamilton, Co. Leitrim, when he explained how the new structures worked.  Maureen Browne reports.

The emphasis of the reorganised healthcare structures in Northern Ireland was on care pathways rather than professionals or institutions, Mr. Colm Donaghy, Chief Executive, Belfast Health & Social Care Trust told the HMI West Forum in Manorhamilton, Co. Leitrim, when he explained how the new structures worked.

Colm Donaghy
Colm Donaghy

He said new Directorates had been created, which for the first time were not based on doctors managing doctors or nurses managing nurses, but on multi-disciplinary team working. For example, the Directorate of Specialist Hospitals was managed by a Director with a social work background, who managed doctors and nurses.

“We believe this puts us in a much stronger position to deal with issues like obesity and to co-operate with the local community.  Our focus is on care pathways that patients follow rather than on institutions they use or the professionals who deliver care. At the same time we believe that effective change can only be led by people who deliver the services, particularly the professionals.  Effective change is probably 10 per cent about structures, 20 per cent about process and 70 per cent about behaviour.”

We are always conscious to see what we can do to minimise some of those health inequalities.

Mr. Donaghy said that the first phase of the change in Northern Ireland in 2007 reduced the number of Trusts from 19 to six. The result was that they went from fairly small organisations to fairly large organisations, even when compared to the Trusts in England. The Belfast Trust, of which he is Chief Executive, employs over 20,000 staff and has a turnover of over €1.3 billion.

“In making the changes, we were very keen to have a different emphasis on delivery.  In the future we wanted a much more integrated approach and we wanted to take full advantage of health and social care.”

The second phase was the creation of the Health & Social Care Board, which meant that the four existing Boards (East, North, South and West) were reduced to one Board, with the responsibility to performance manage, commission and manage finances operationally on an annual basis, with the strategic finance still managed by the DHSS. The DHSS is the overriding authority which sets policy and strategic direction.  The Minister gives commissioning directions (priorities) to the Health & Social Care Board.

“The Patient & Client Council provides a powerful independent voice on behalf of patients and clients and has a direct practical role in assisting people with complaints.

The reorganised service also has a number of other agencies.  A Public Health Agency focuses on public health in the context of protecting, improving and monitoring outcomes of commissioning.

A Business Services Organisation provides organisatonal, legal services and manages all procurement services as well as doing quite a bit of work around the payments function for all the Trusts.

Services are commissioned locally, nationally and from other countries, including the Republic.  The Belfast Health & Social Care Trust is the main provider of tertiary services in Northern Ireland, providing cardiac surgery and renal transplant services.

“As Chief Executive, I have the responsibility to provide the services commissioned from our Trust and I have a duty of quality to ensure services meet required standards and regulations. We are continually improving those services.  We also have a responsibility, as far as we can, to review health inequalities. For example, we know that in Belfast, like in many cities, the more affluent people live eight or nine years longer than those who live in socially deprived areas and in delivering health and social care, we are always conscious to see what we can do to minimise some of those health inequalities.

It has a direct line to the Minister, keeping him informed on how providing organisations are delivering on quality.

“The Patient & Client Council provides a powerful independent voice on behalf of patients and clients and has a direct practical role in assisting people with complaints and taking them through the complaints system.  It also provides lots of information and advice to the public on how services perform.

“The Regulation Quality & Improvement Authority has responsibility for the regulation, inspection and improvement promotion. It has a direct line to the Minister, keeping him informed on how providing organisations are delivering on quality.  The Authority also has a role in regulating the private and independent sectors and domiciliary care providers.”

Mr. Donaghy said that the Trusts work on a three year planning cycle – there is a comprehensive spending review every three years.  This is driven from Westminster in terms of treasury and the Northern Ireland Executive also has a comprehensive spending review.

“Six years ago, for the first time, our Executive decided that the top priority in Northern Ireland was to grow the independent or private sector jobs to assist the economy.  Health and education, which had always got quite generous budgets, did not get quite such a generous allocation and that meant that we had a new dynamic. We were set pretty stringent targets in terms of cash release programmes. In Belfast, our budget was cut by 130 million pounds between 2007 and 2010 and that drove organisations in particular directions to ensure we could deliver quality of care while at the same time delivering efficiencies.  The approach we took in Belfast was to ensure we put in place a financial strategy that allowed us to deliver reform, as opposed to reform that delivered a quantum of savings.  The difference is in the mindset. Our focus was reform and the financial strategy was the enabler.  We have agreed with our Commissioner that we have a reform period over the next three years and the Commissioner has agreed with us that because we won’t get full year effect of these reforms in terms of finance they will provide bridging to allow the full effect of reform to kick in. Our financial strategy is enabling reform to take place as opposed to the other way around.

“In line with the DHSS strategic plan and commissioning directive, the Board has produced a three year commissioning plan. The first year is more detailed than year 2 and 3. As organisations we produce our quality improvement and cash release plans/corporate plans, which take account of directions from the DHSS and the commissioner.

“In any one year we would have a series of priorities given to us by the Board and the Minister and we would produce a Trust Delivery Plan saying what we believe we can do with the money and to deliver services to required standards.  We finally come up with an agreed Trust Delivery Plan.

“If you think of a triangle, the top of our triangle is quality and safety, which has to be the apex, the right hand angle is income and expenditure, on the left government priorities and in the middle patients.  Quality and safety are the most important. In Belfast recently we had to close our A & E, because not to do so would have been unsafe. It is a constant battle between quality safety and improvement, income and expenditure and government priorities to balance what we can do to deliver government priorities and we deliver safe services.

“Our vision in Belfast is to be a leading edge organisation where we set the standard of excellence for others to follow. We are doing a lot of work in partnership with Queen’s University.  One example is the newly opened molecular diagnostic service in co-operation with Queen’s, which is seen as one of the leading edge developments in cancer care on the island and has got a considerable amount of interest from Europe.  It is important that research and development is translated into better outcomes for patients.

We want to do more of this. We want to be innovative and creative within our organisation and have launched an Innovation & Leadership Academy, which will be an outward as well as an inward looking part of our organisation. We are using the Academy to draw in methodologies that other organisations are using. We have fantastic expertise within our own organisation. We employ over 800 doctors and we need to be using their fantastic expertise to help us deliver innovation. We are identifying people within and outside our organisation as associates to work with us in the Academy. Our plan is to work on small incremental improvements in performance that will deliver transformational change over time.

“There is also a new dynamic for us in working with the local community in planning, delivering and implementing change. They have so much to offer and we are working with them to ensure their voice is heard in the design and delivery of new models of care such as Social Enterprises.”