The turmoil in Northern Ireland's health service over the past week is not an isolated problem. It is a symptom of something much bigger: our inability to make and deliver difficult decisions about public service reform.
Some observations and ideas from Pivotal:
1. Everyone agrees in principle that transformation in health is needed. Politicians and clinicians have known for years what needs to be done. But this consensus comes apart when specific changes are proposed - so although political leaders know what is needed, they haven’t done it on anywhere near the scale required. So far we have not had the difficult conversations, including with the public, about what service reconfiguration looks like in practice. The result has been a piecemeal, reactive approach where change only happens when services reach crisis point.
2. Many of the public remain completely unconvinced that changes in where health services are delivered will lead to improved services and better outcomes overall. They only see the loss of a service locally and the risks that this might involve. No convincing vision has been presented for how change would be good for all of us.
3. There is little recognition of the scale and urgency of challenges in health. Good quality, sustainable health services will not be possible unless difficult choices are made about where and how services are delivered. The status quo is not sustainable and further delays will mean services for the public get worse - it’s “Change or collapse” as Professor Bengoa said.
The challenges in Health are mirrored across other public services. We are nowhere near having adequate plans in place to address many long-standing policy challenges. Our heads are in the sand about the scale of problems. We fail to acknowledge that difficult decisions will involve trade-offs and opposition. As well as health, there is a similar pattern in the absence of a realistic plan for wastewater infrastructure, unresolved tensions between water quality and agriculture, the reluctance to accept that choices are required in our public finances, and many other areas.
In health and elsewhere, doing nothing means further deterioration in service quality and increased costs in the future. Every year that difficult decisions are delayed, waiting lists grow, infrastructure deteriorates, costs increase and public confidence declines.
So what needs to happen? Three recommendations for the new Health Minister and the Executive as a whole:
Politicians need to provide vision and leadership about how change will result in better health services. This includes being honest and realistic about the scale of the challenges and the choices needed, and stopping pretending current services can all be maintained as they are. The public need to be given opportunities to scrutinize, challenge and understand this vision; knowing the destination will help dispel fears about changes needed now. Proper public consultation and communication will be key - but at its core is bold and courageous leadership from politicians that promotes the vision even in the face of opposition.
Specific actions plans should set out what change will happen in practical terms. We need to stop talking about transformation as an aspiration and spell out what it means in detail. As one politician once said, “Don’t tell me what. I know what. Tell me how.” So no more reports or reviews - detailed action plans instead. These should be based on evidence and expert advice about what will give us the best health service, not on political interests.
Politicians need to unite around the delivery of transformation in practice. The last ten years have shown the parties committed to the principle of transformation, but this has unravelled when specific changes were proposed. Improvements will never happen if every change is opposed locally. This links back to the need for a compelling vision for how transformation will be better for everyone - we need a vision that everyone can endorse, that makes the case for the difficult choices that will be needed along the way. Once we have that vision, our politicians must collectively unite behind what delivering it means in practice.
Northern Ireland does not lack reports, reviews or diagnoses of its problems. What it lacks is the political courage and collective leadership to implement solutions. Until that changes, transformation will remain a promise rather than a reality.
