The promised land?

    Northern Ireland’s integrated services offer the government a
    model for England’s health and social care but, as Terry Philpot
    asks, is integration actually delivering?

    The government’s zeal for modernisation has caused it for once
    to cast its eyes not across the Atlantic but to the other side of
    the Irish Sea. There Northern Ireland’s much-trumpeted integrated
    health and social services are seen as a solution to the perennial
    problems of health and social services’ failure to work
    together.

    Last July’s NHS Plan mapped a future which leaned markedly
    toward the province’s arrangements. Initially this was greeted with
    relief by the Association of Directors of Social Services who,
    curiously, saw no reorganisation implications. Now, mature
    reflection and the Health and Social Care Bill giving flesh to the
    idea of care trusts under NHS control – by carrot or stick – the
    reality is starker and less agreeable. The association, some of
    whose members have in the past at least thought Northern Ireland
    worth more than a second glance, now wants more pluralist
    arrangements.

    Only those who take textbook descriptions for organisational
    blueprints can overlook the complicated nature and – now – the
    uncertain future of the Northern Ireland system. It is a system not
    only sometimes questioned from within but, in the light of the
    coming of the Northern Ireland Assembly, its future is being
    debated. Only last December Bairbre de Bruin, the health secretary,
    was talking about the strong possibility of an all-Ireland health
    service. Could integrated services remain intact in the face of
    that? There is also the review of local administration. Should
    democratic local government return to the province after nearly 30
    years (the present 29 local councils do not have major
    responsibilities)? And what would, then, be the chances of the
    boards and trusts being subsumed wholesale by new structures, when
    local government control in the rest of the NHS has never got
    beyond the starting post? One possibility would be to drop primary
    health care and social care into a new (democratic) system while
    acute hospitals were hived off into another quango of which
    Northern Ireland has now become so accustomed as a form of
    governance.

    In 1974 the suspension of the Stormont parliament and with it
    the end of elected, if deeply flawed local government, left an
    organisational gap into which were inserted centrally accountable
    joint health and social services boards.

    Set against the dual administrations of the rest of the UK, the
    boards might have looked innovative and even desirable, but
    internal structures included professional silos of directors of
    medicine, nursing, administration and social services and others.
    What the system suffered from was “too little collective vision and
    not enough shared culture”, says Hugh Connor, director of social
    services, South and East Belfast Community Trust and a member of
    England and Wales community care task force in 1994. However, in
    1980, the Department of Health and Social Security transplanted
    into the province Sir Roy Griffiths’ plans for general management
    in the separately run NHS elsewhere in England and Wales. Despite
    initial protests from some, the professional silos remained but
    were concerned with regional strategic planning, quality monitoring
    and professional standards; the directors lost operational and line
    management and executive responsibilities. Unit management followed
    soon afterward with the creation of acute hospital and community
    trusts shifting responsibility for services and commissioning
    considerably downward to create more variety and local
    responsiveness. The community trusts have social care, district
    nursing and health visiting under their belts.

    Significantly, what dramatically affected the management and
    delivery of social care stemmed from health reforms, just as the
    potentially enormous changes for English social services have grown
    from a national plan for the NHS. Roy Blair, director of social
    services, Southern Health and Social Services Board, points out
    that all reorganisations have been occasioned by health service
    needs. His predecessor, Terry Bamford, later executive director
    (social services and housing), Royal Borough of Kensington and
    Chelsea, in a paper for the ADSS last year, wrote: “There has been
    no recognition that the delivery of social care may require a
    different model. The needs of health care have dominated
    decision-making.”1 But almost everyone agrees that the
    structure has gone a long way to break down the traditional
    straitjackets of professional approaches. Multi-disciplinary
    working has become the norm. One offshoot of this is that
    inter-professional training has moved far more quickly in the
    trusts than in England and Wales. Unsurprisingly, training for the
    medical profession has kept its traditional distance.

    Andrew Dougal, chief executive of the Northern Ireland Heart,
    Chest and Stroke Association, says that “in recent years there’s
    been a lot more synergy and harnessing of different professional
    skills”. He also thinks that close inter-professional working
    allows doctors to see the validity of social work models of caring
    for people. “They tend,” he adds “to welcome the possibility of
    learning.” Hugh Connor believes that integrated structures, solving
    problems, assist health and social services, “march to the same
    drumbeat”.

    However, Mary Wilmont, director of social services, Northern
    Board, believes that social work has had a secondary place: much of
    her energy is taken up in defending its corner. She instances one
    of the most dramatic signs of social services’ status when two
    years ago the Eastern Board’s social care budget was raided to make
    up for an overspend by the acute sector.

    It is also Mary Wilmont’s opinion that integrated structures are
    confused with inter-disciplinary working. “If you are competing
    with other services for scarce resources it is more difficult to
    co-operate with them.”

    A major example of the budgetary primacy of health and acute
    care is perhaps the fact that there are still too many acute
    hospitals and beds for the province’s needs. Again, a higher
    proportion of adults in Northern Ireland are in institutional care.
    Long-stay hospitals still have their place. In 1999, 62 per cent of
    all packages of care for older people were in residential and
    nursing care, 10 per cent higher than 1995. The percentage of
    mentally ill people being supported at home has fallen in five
    years.2

    Even Hugh Connor, an unabashed enthusiast for the present
    arrangements, who was also critical of the Eastern Board
    experience, says: “Northern Ireland is no different from England in
    the sense that the first thing people think of is ‘Save our
    hospital’. GPs are just as powerful here as elsewhere. Being a
    community trust has, however, allowed us to keep an eye on that
    kind of provision. We have tried to create a common purpose and
    vision and a great deal of that is about social work values. People
    want cohesive services and in this trust we have led general
    practice, it hasn’t led us. We have nurtured it because our GPs
    didn’t work together and we have helped them to do so.” Individual
    trust directors of social services carry other responsibilities –
    some as heads of management performance, operations or planning,
    one as general manager of children’s services, another as deputy
    chief executive of a trust. This, says Hugh Connor, gives them a
    wider vision.

    Dominic Burke, director of social services, Western Health and
    Social Services Board, suggests that one benefit for social
    services is that because they are tagged to health
    organisationally, their spending has kept pace with it. His
    Southern Board colleague Roy Blair demurs. He believes that is open
    to question.

    Northern Ireland’s experience has been heralded as a possible
    promised land over the years. But only now, with the Health and
    Social Care Bill provoking serious thought about a world without
    social services departments, are we learning how little, in fact,
    we know about the province.

    The 1.6 million people of Northern Ireland are top heavy with
    boards, trusts, directorates and the paraphernalia of the quango –
    four boards, 19 trusts and one central department run health and
    social services. Until very recently, its public services have been
    governed day to day by civil servants. Lobbying has relied largely
    on its thriving voluntary sector. Politicians have for decades had
    their eyes on bigger issues than the delivery of home care or bed
    blocking. It still has no equivalent of Quality Protects,
    modernisation or joint reviews. Spending on children is £70
    per head per child behind England. There are proportionally more
    children in care in Ireland than in England and Wales.

    Curious, too, that the government has borrowed from a model one
    of whose most significant factors is “the democratic deficit”.
    Health and social services are two very different entities and
    Northern Ireland suggests that it takes more than placing them
    under the same roof to weld them together for effective
    delivery.

    And while the Department of Health is obsessed with health and
    social care working together, some councils have joined social
    services and housing, others have brought in education. No one is
    mentioning that in Northern Ireland housing and education – other
    key partners of social care – are separate and even have different
    boundaries. But Northern Ireland’s system does take in all services
    – adult and children. In the UK the future of children’s and family
    services is not even addressed as a consequence, so driven by adult
    services are the reforms. On paper, which is all Westminster
    ministers and most people know about Northern Ireland, things look
    hunky-dory. But are not the consequences of change for vulnerable
    young and old alike worth a more concentrated examination than
    this, the politicians’ latest panacea?

    1 T Bamford, Integrated Health and Social Care in
    Northern Ireland – Myth and Reality, paper for ADSS seminar,
    August, 2000

    2 T Bamford, ibid

    More from Community Care

    Comments are closed.