Northern Ireland: super health and social services trusts set to replace existing structures. What do professionals think?

Once regarded as a model for the UK to follow, the system of integrated health and social services in Northern Ireland is to be completely rebuilt. Directors and managers see some advantages but others aren’t so sure, reports David Callaghan

“If it ain’t broke don’t fix it” is the saying, and many feel it is a pertinent one when it comes to health and social services delivery in Northern Ireland.

Integration between agencies in the province has for some time been lauded as a template for their UK counterparts. Sector conferences were told they should learn from the close working relationships developed in Northern Ireland.

Joint health and social services boards, with a system of 19 community and acute health care trusts developed in the 1970s and 1980s, helped to break down barriers between professionals and promote multi-disciplinary working.

At present the four boards plan, purchase and commission services, and the trusts actually deliver services by managing staff and controlling their own budgets. There are also four health and social services councils – one covering each board area – which monitor services and advise on improvements.

These arrangements have won many admirers over the years as they appear to represent an effective way of making professionals from different workplace cultures work alongside each other.

So why is the whole thing being torn up and recreated? Under the review of public sector administration, which ministers have
claimed is the most significant shake-up of public authorities for 30 years, the boards and all but one of the trusts are going. (The existing ambulance trust will remain intact.)

New authority
The existing trusts will be replaced by five “super” health and social services trusts (combining acute and community health with social services) and a new health and social services authority. New trusts, which will deliver services, are due to become fully operational next April, and all the new organisations will be overseen by the Department of Health, Social Services and Public Safety as before.

The new authority will cover the entire province and replace the four boards in commissioning services using seven new local
commissioning groups as its district arm. The groups will match a reduced number of district councils – down from 26 to seven.

David Sissling, who was chief executive of Leicestershire, Northamptonshire and Rutland Strategic Health Authority, has
taken up the role of chief executive, ahead of the new authority’s live operational date of 1 April 2008.

Northern Ireland minister David Hanson said earlier this month: “The aim is simply to cut back on excessive bureaucracy
and bring services closer to people.” But Patricia McKeown, Northern Ireland regional secretary for Unison, says: “It is a cynical Treasury act to save money. They consider we cost too much per capita.”

She also predicts there will be between 700 and 1,000 job losses. The province’s Unison branch is set to join protests in England against cuts in health services.

McKeown also accuses the government of imposing an English model of health care on Northern Ireland: “It has caused  considerable problems in England, and it will damage our health services.”

On this point, Mary Anderson, who is deputy chair of the British Association of Social Workers in Northern Ireland, agrees.
“We have always been integrated, and this is the modernising agenda from England that doesn’t fully fit and there are difficulties.”

Anderson also believes that many people will lose their jobs.

“There are an awful lot of senior managers out there who aren’t going to have jobs, and their personal assistants as well. And instead of three directors of mental health we will have one. But it looks as if there won’t be an impact on social workers.”

But Anderson does agree that change is needed because there are too many organisations, and says the province is “ridiculously small” for such a large number of trusts and boards.

She warns that directors of services in the new regime will have “hellish” jobs trying to cope with such a big department, and she questions whether there is enough investment to make the switch to the new regime work.

Morale is low among health and social services staff because of the uncertainty, she says. Pressure to implement the new pay structure in the health service, Agenda for Change, is not helping. Health managers, though, are positive about some of the changes. Alan Gilbert, director of the Northern Ireland Confederation for Health and Social Services, says: “Integrated trusts are a better model than the split of acute and community trusts.”

He admits there is some uncertainty about how the boards and trusts will relate to each other. The local commissioning groups
will have power devolved from the new health and social services authority, but exactly what that means is still unclear, Gilbert says.

This uncertainty characterises the way many people feel.

A voice of calm comes from Cecil Worthington, who chairs the Northern Ireland branch of the Association of Directors of Social Services and who says the integrated model for which the province is famed will remain intact.

He admits the pace of change is challenging, but he believes the new larger organisations will pull services closer together. He does not foresee large-scale job losses, with voluntary redundancies accounting for any cut in numbers.

Power-sharing
One major factor that could come into play is the creation of a new power-sharing assembly in Northern Ireland. Talks ended last week with positive noises from politicians about the prospects of the assembly reforming after a gap of more than four years next March.

Worthington says: “The assembly will be coming out of cold storage at the earliest in March and by then we will be moving into these new structures.”

Only one political party, Sinn Fein, has backed the planned number of seven district local authorities from 2009. There might be some change there if the other parties press for it, which would have a knock-on effect on the number of local  commissioning groups as they are designed to mirror councils.

But health and social services seem set on a course of no return, with opinions divided over whether they will lose their halo of model integration.

PHASES OF EVOLUTION
1972-73: Health and Personal Social Services (NI) Order 1972 paved the way for four health and social services boards
to be created taking over welfare functions from defunct county and county borough councils and Northern Ireland Hospitals Authority with 26 local Hospital Management Committees, which were also abolished. New Central Services Agency took over functions of former Northern Ireland General Health Services Board.

1989: UK government white paper Working for Patients led to Health and Personal Social Services (Northern  Ireland) Order
1991. This order created new health and social services trusts, which were given responsibility for delivering services. The existing boards adapted to a commissioning role through contracts with the new trusts. New health and social services councils were also created to monitor actions of boards and take up complaints.

1994: Health and Personal Social Services (Northern Ireland) Order was needed to remedy flaw in law which had prevented trusts fully exercising statutory social services functions.

2007-8: New health and social services authority to cover whole of Northern Ireland and take on functions of boards from April 2008. It will commission services using seven new local commissioning groups. Five “super” health and services trusts will replace 18 existing trusts from April 2007.

This article appeared in the magazine on the 26th October, under the headline Super for some