Members below a transcript of a letter to Mr Robin Swann MLA, Minister for Health from Maria Morgan, Assistant Secretary, on behalf of NIPSA Health Central Panel.

This is NIPSA’s initial response to the statement on the 9 June 2020 in relation to Rebuilding Health and Social Care – Strategic Framework and the proposed structures in relation to this. We send without prejudice to any further comment that we may need to make about this consultation process.

I must begin this correspondence by making clear that NIPSA’s leadership at every level across the HSC, understands the scale and intensity of the challenges that have impacted upon virtually every aspect of society because of the COVID 19 crisis.

As Minister for Health, your department and the HSC services they support, have of course found themselves at the very eye of the storm that has overtaken us all.

NIPSA acknowledges that Leaders across the HSC, working alongside civil servants in the department, have done the very best that they could, within the time that they have had, to put in place plans and arrangements to support the services we have all relied on across the last few months. However,

  • Does it mean that the planning and arrangements have been good enough across the system, including in the Department of Health (DOH)? No, it does not.
  • Does it mean that everything planned has been delivered, as it should, by all HSC organisations including by the DOH? No, it does not.
  • Does that mean that there aren’t questions of the utmost seriousness to answer for all organisations including the DOH? No, it does not.

NIPSA as a key stakeholder will set out its broader view on these matters in time. We will of course play our role in whatever processes are put in place to maximise learning, scrutinise shortcomings and attribute potential responsibilities, in due course.

However, the importance of maximising learning from the events of the past number of months must, in NIPSA’s view, take precedence over all other considerations at this point. Introducing any change in organisational frameworks at this critical moment must be judged solely on whether it helps or hinders the actioning of this learning.

This is central to best supporting the concurrent planning frameworks necessary to re-establish some level of ‘normality’ in services, while also enhancing preparedness for the potential COVID scenarios that lie ahead.

It is only right that faced with the immensity of these challenges that you as Minister should interrogate the fitness for purpose of the planning frameworks and levers available to you as the leader of the HSC. Our initial view is that the approach you have announced is flawed in a number of regards.

In particular, NIPSA is deeply concerned about the lack of reference to HSC workers across the documents. Given the huge efforts put in by staff and their Trade Unions at all levels, in the joint endeavour to suppress the impact of the virus, this is troubling.

It remains NIPSA’s view that nurturing this sense of common effort should be central to all rebuilding plans, given the sacrifices and future efforts that may be needed in the months ahead. This makes the absence both of a dynamic role for Trade Unions in relation to a wide range of initiatives in the framework document, as well as in their established role in departmental advisory structures, all the more inexplicable.

In particular, the announced approach appears to show the hallmarks of the well-known, top down managerial views of a number of your advisers rather than the broader view of the HSC itself. Alongside this, it deviates widely from the frameworks laid out as existing policy in “Health and Wellbeing 2026 - Delivering Together” without appropriate preparation, or mandate.

In NIPSA’s view, an apparent DOH focus on command and control type approaches to the arrangement, commissioning and delivery of services has been a consistent thread in every review of Health Service structure from ‘Fit for the Future’ to the ‘Hayes review’ to ‘TYC’ to the Bengoa report.

The language this focus is presented in, shifts and changes, but it is NIPSA’s settled view that this outdated agenda has been a constant across this timeframe. The outworkings of this focus has, we feel, impacted upon Permanent Secretaries and Ministers alike, across both devolved mandates and Direct Rule interludes for twenty years.

NIPSA would suggest on the basis of the above, that the fitness for purpose of the advice from this command and control lobby, who provide much of your immediate advice and support is problematic. It has been a factor in both the serial failure of previous ‘reform’ initiatives and the serious planning deficits alluded to earlier in this correspondence.

NIPSA as an organisation is therefore not convinced that grafting what appear to be the same long held departmental objectives, this time onto the language of emergency response, will lead to any difference in outcomes.

We urge that as Minister while your announcements focus on the pressures the HSC undoubtedly faces, that you should emphasise continuity and action within both the letter and the spirit of the existing ‘Delivering Together’ policy framework in meeting these pressures.

NIPSA believes that a concurrent planning process, at this stage, should utilise the sense of shared purpose and commitment at all levels of those able to contribute to plans and actions to re-establish fully functioning, properly funded Health and Social Care services. We say this in the context of an exhausted workforce who have experienced numerous failed reform approaches that have not yielded the kind of HSC that is required, because too often their views have not been listened to.

NIPSA believes that there can be no viable rebuilding process that does not address safe staffing, Agency spend and the vacancy problems that have so undermined service to date. These are points that we will develop more fully in our formal consultation response.

Such an approach provides the foundation for much needed honest conversations on both improvement and preparedness. These conversations should use existing collaborative evidence and co-production based tools. These are already outlined in existing policy and would be key in helping us all deal with the immense challenges ahead in a timely manner.

Perhaps the points above have already been dealt with within the Bronze, Silver and Gold command structure already established. However, NIPSA and its members have little evidence of such self-reflection, critical thinking and joint ownership of problems as well as solutions, emanating from this structure. Given the overlap in membership, the current lack of transparency risks being repeated in the proposed Management Board structure.

NIPSA is fundamentally concerned that the introduction of what in essence appears to be a command and control governance framework, onto already stressed HSC structures, will contaminate and confuse much-needed emergency responses, that have been worked on locally and regionally over the last period. There is a danger that a sense of ownership and decisions made with a knowledge of local strengths and weaknesses will be lost and NIPSA views this as a key deficiency in the proposed approach.

Co-mingling the emergency response and the pre-existing reorganisation and transformation agendas, will inevitably graft on layers of difficulty and a legacy of suspicion into an emergency response scenario that requires a clear sense of common purpose from all concerned.

This runs the very real risk of squandering much of the good will and common purpose in evidence in each Health Trust, as the departments proposed approach will all too easily distract from, not enable, the urgent need to learn and rebuild in as fraternal an atmosphere as possible.

So NIPSA urges caution before committing to a Departmental approach to the current crises based on a command and control based model. Not only because we believe this approach to be outdated and inflexible, but because we are of the view it is likely to fail. It will fail both to deliver on building the sense of shared purpose and common goals needed to deal with COVID’s impact across HSC stakeholders and beyond. While most importantly it will also likely fail to deliver on the planning and delivery goals you as Minister will expect it to deliver.

NIPSA accepts putting in place effective regional frameworks that enable and support the development of effective local delivery are complex and tricky. Frameworks that end up being perceived as confusing, ineffective and limiting are unfortunately a more frequent result of the command and control approach we feel this approach represents.

It is therefore NIPSA’s view that the proposed “Management Board” and the associated Memorandum, as currently outlined, do not represent an optimum response.

In particular, NIPSA is struggling to reconcile how the assumption of such wide-ranging powers by the DOH cannot fundamentally affect the various schema for the delegation of statutory function these structures are currently designed around.

This is a position that seems to assert, ‘that with great power comes no responsibility.’ Given the powers being assumed and the scope of the agenda outlined across the strategic framework document, NIPSA is not convinced such an approach will survive prolonged contact with the realities on the ground.

NIPSA acknowledges that emergency measures may well demand some centralised planning of some aspects of service delivery and other changes in the way we do things. Equally, devolving power and enabling key local approaches will be the optimum approach in many other circumstances, and it is on this point NIPSA is of the view both the Memorandum and TOR for the Management Board fall short.

In particular, where leadership or planning have been felt to be deficient, the responsibility to address shortcomings and deficits, wherever they may be, lies with your leadership team. This NIPSA believes, should be the bedrock of the Department of Health’s approach, informed by open and honest conversation and evidence, at all levels, not the distraction of another rearranging of the organisational deck chairs.

Current departmental policy in “Delivering Together” talks of decision making that will be designed ‘by and with people and communities not by organisations and services’. There is little evidence of this approach in the planned Management Board structure.

NIPSA believes that the Memorandum should be substantively amended to reflect the function of Trade Unions as the key representatives of the ‘experts in service’ so that this can be integrated into your approach. Co-production and co-design are key roles in a re-invigorated structure to rebuild from COVID for a sustainable HSC. This should be a key pillar to the departmental approach, which if properly resourced, would in NIPSA’s view support emergency and service delivery planning not as an addendum to the existing advisory structures.

Reframing the Management Board document and Memorandum to give a clearer focus on the encouragement of local leadership delivering within the context of a clearly understood set of Ministerial directives is the key recommendation NIPSA is making.

This should sit alongside a departmental approach that focusses on the delivery of the resources and supports requested to enable successful local delivery wherever possible, rather than on building a single regional employer structure, which currently does not exist. We restate our long held position that all communities require a fully funded NHS that is accountable and that policy going forward reflects the failures of market led approaches.

In conclusion, NIPSA’s view is that to adopt a Departmental approach that has the inherent risk of co-mingling long set Departmental planning and delivery agendas with the responses to a public health crisis of an unprecedented scale, would be ill advised. NIPSA believes this cannot be your intent in moving to tackle the critical problems we are confronting.

Clearly, these are NIPSA’s initial views in relation to your proposals and we would intend to provide a more comprehensive response at the conclusion of the consultation period. If it would be useful to engage on any of the matters covered in this correspondence, both myself and lay representatives within NIPSA would be happy to do so at any stage.

Yours sincerely

Maria Morgan
Assistant Secretary

On behalf NIPSA Health Central Panel