WEBVTT 00:00:00.000 --> 00:00:02.940 Welcome to the Deep Dive. I'm your host, and 00:00:02.940 --> 00:00:05.980 joining me to unpack today's topic is our resident 00:00:05.980 --> 00:00:08.160 health policy expert. Glad to have you here. 00:00:08.320 --> 00:00:10.240 Thanks for having me. Always good to be here 00:00:10.240 --> 00:00:14.160 for a deep dive. So I want to start you off, 00:00:15.099 --> 00:00:16.879 well, start the listener off really with a little 00:00:16.879 --> 00:00:20.199 thought experiment. OK, I'm right. Imagine you're 00:00:20.199 --> 00:00:23.960 walking down a street in Belfast or Derry. Right. 00:00:24.190 --> 00:00:26.789 And it's raining because, well, it's Northern 00:00:26.789 --> 00:00:29.530 Ireland, so of course it's raining. And you stop 00:00:29.530 --> 00:00:32.229 a local to ask them about their health care. 00:00:32.490 --> 00:00:35.469 I can guess where this is going. Right. Because 00:00:35.469 --> 00:00:37.789 nine times out of ten, maybe even ten times out 00:00:37.789 --> 00:00:39.810 of ten, they're going to talk to you about the 00:00:39.810 --> 00:00:42.210 NHS. They'll, you know, complain about NHS waiting 00:00:42.210 --> 00:00:45.869 lists or praise the NHS nurses. The logo on the 00:00:45.869 --> 00:00:48.270 hospital even looks like the NHS logo. It does, 00:00:48.329 --> 00:00:50.850 yeah. It's free when you walk in the door. It 00:00:50.850 --> 00:00:53.289 cracks like a duck. It walks like a duck. And 00:00:53.289 --> 00:00:55.810 here is where we have to basically shatter the 00:00:55.810 --> 00:00:58.189 illusion right away. It's technically not the 00:00:58.189 --> 00:01:00.409 NHS. No, it isn't. And it's honestly the most 00:01:00.409 --> 00:01:02.770 common misconception about the region, even for 00:01:02.770 --> 00:01:04.569 the people who actually live there. Which is 00:01:04.569 --> 00:01:07.049 wild to me. Yeah, it is. I mean, while it sits 00:01:07.049 --> 00:01:09.390 under the broad umbrella of the UK's National 00:01:09.390 --> 00:01:11.950 Health Service, the system in Northern Ireland 00:01:11.950 --> 00:01:15.209 is legally and structurally a completely different 00:01:15.209 --> 00:01:17.530 beast. Right. It's called Health and Social Care, 00:01:18.170 --> 00:01:22.019 or HSC for short. HSC. Which, let's be honest, 00:01:22.299 --> 00:01:25.500 sounds a bit like a rebranding exercise some 00:01:25.500 --> 00:01:28.299 consultant came up with to justify a massive 00:01:28.299 --> 00:01:30.480 fee. It really does. But you're telling me this 00:01:30.480 --> 00:01:33.239 isn't just an acronym change, right? The social 00:01:33.239 --> 00:01:35.579 care part of that title is actually doing some 00:01:35.579 --> 00:01:37.959 heavy lifting. Oh, absolutely. It is the defining 00:01:37.959 --> 00:01:40.459 feature. In fact, for public policy nerds, and 00:01:40.459 --> 00:01:42.819 I definitely count myself among them, the Northern 00:01:42.819 --> 00:01:45.540 Ireland model is often viewed as the holy grail. 00:01:45.709 --> 00:01:48.109 The holy grail of health care, that's a big claim. 00:01:48.250 --> 00:01:50.129 Well, think about how it works in England or 00:01:50.129 --> 00:01:52.510 the US. You have your medical care, right? Doctors, 00:01:52.909 --> 00:01:56.069 hospitals, surgeries. That is one silo. Then, 00:01:56.609 --> 00:01:58.150 completely separately, you have social care. 00:01:58.349 --> 00:02:01.430 So that's nursing homes, home help for the elderly, 00:02:01.790 --> 00:02:04.230 social workers. In England, those are run by 00:02:04.230 --> 00:02:06.569 local councils. Right. Different budgets, different 00:02:06.569 --> 00:02:09.310 bosses. Exactly. Different IT systems, different 00:02:09.310 --> 00:02:13.039 everything. Which is the classic bureaucratic 00:02:13.039 --> 00:02:15.500 nightmare. You know, you hear those stories where 00:02:15.500 --> 00:02:17.639 you're stuck in a hospital bed, medically fit 00:02:17.639 --> 00:02:19.979 to leave, but you can't go home because the local 00:02:19.979 --> 00:02:22.520 council hasn't signed off on a wheelchair ramp 00:02:22.520 --> 00:02:24.900 for your front door. Precisely. The left hand 00:02:24.900 --> 00:02:27.080 has no idea what the right hand is doing. That 00:02:27.080 --> 00:02:29.500 is the global standard of inefficiency. Yeah. 00:02:29.780 --> 00:02:32.580 But in Northern Ireland, way back in the 1970s, 00:02:32.620 --> 00:02:35.340 and then it was formalized later in 2009, They 00:02:35.340 --> 00:02:37.379 did what everyone else dreams of. They combined 00:02:37.379 --> 00:02:40.719 them. Medical and social. Yes. Medical pair and 00:02:40.719 --> 00:02:43.000 social services are integrated under one roof, 00:02:43.219 --> 00:02:46.280 managed by the exact same organizations. On paper, 00:02:46.360 --> 00:02:49.099 this is the absolute dream. OK, so it's a unique 00:02:49.099 --> 00:02:51.479 health care experiment that should theoretically 00:02:51.479 --> 00:02:54.199 offer this seamless coordination between, say, 00:02:54.259 --> 00:02:57.159 your heart surgeon and the social worker arranging 00:02:57.159 --> 00:02:59.759 your home. Oh, that's the idea, yeah. So today, 00:02:59.939 --> 00:03:01.599 our mission for this Deep Dive is to explore 00:03:01.599 --> 00:03:03.639 this. Because let me get this straight. We have 00:03:03.639 --> 00:03:06.710 a system. that was designed to be the Ferrari 00:03:06.710 --> 00:03:09.009 of healthcare, integrated, streamlined, efficient. 00:03:09.550 --> 00:03:11.830 But looking at the stack of research we have 00:03:11.830 --> 00:03:14.930 for today, reports from the Nuffield Trust, the 00:03:14.930 --> 00:03:17.990 outcome stats, the waiting lists, this Ferrari 00:03:17.990 --> 00:03:20.250 seems to be sitting on cinder blocks in the front 00:03:20.250 --> 00:03:24.430 yard, missing an engine and like three wheels. 00:03:24.849 --> 00:03:26.930 That is exactly the tension we need to explore 00:03:26.930 --> 00:03:29.360 today. The performance statistics in Northern 00:03:29.360 --> 00:03:32.060 Ireland are currently significantly worse than 00:03:32.060 --> 00:03:33.979 the rest of the UK. Wait, worse than England? 00:03:34.319 --> 00:03:36.219 Because England isn't exactly having a great 00:03:36.219 --> 00:03:38.240 time with health care right now. Significantly 00:03:38.240 --> 00:03:40.919 worse. And that is what we're digging into. We 00:03:40.919 --> 00:03:43.860 need to figure out why this integrated system, 00:03:44.139 --> 00:03:46.139 which makes so much sense on paper, this perfect 00:03:46.139 --> 00:03:48.439 structure, hasn't been the magic bullet that 00:03:48.439 --> 00:03:50.979 experts hoped for. Why the only fully integrated 00:03:50.979 --> 00:03:54.020 system is performing the poorest. Exactly. OK, 00:03:54.039 --> 00:03:55.740 before we get to the why, I need to understand 00:03:55.740 --> 00:03:57.780 that what you mentioned is called HSE. How is 00:03:57.780 --> 00:04:00.780 this machine actually built? Is it just like... 00:04:00.599 --> 00:04:03.979 one giant office block in Belfast running everything? 00:04:04.139 --> 00:04:06.300 Not quite. The history actually started back 00:04:06.300 --> 00:04:09.180 in 1948, separately from the NHS, but parallel 00:04:09.180 --> 00:04:11.819 to it. But the modern version really comes from 00:04:11.819 --> 00:04:15.120 the Reform Act of 2009. They did this massive 00:04:15.120 --> 00:04:18.920 slimming down exercise. They went from 19 different 00:04:18.920 --> 00:04:22.680 trusts. 19. Yeah, which is a lot for a population 00:04:22.680 --> 00:04:24.920 of less than 2 million people. That's a lot of 00:04:24.920 --> 00:04:27.740 management. Exactly. So they took those 19 and 00:04:27.740 --> 00:04:30.019 brought them down to just six. OK, six trusts. 00:04:30.100 --> 00:04:32.139 That seems a lot more manageable. You have five 00:04:32.139 --> 00:04:34.740 geographic trusts. So that's Belfast, Northern, 00:04:35.120 --> 00:04:38.319 Southeastern, Southern, and Western. And then 00:04:38.319 --> 00:04:40.480 one ambulance trust that covers the whole region. 00:04:40.660 --> 00:04:43.649 Got it. But here is the key difference. Unlike 00:04:43.649 --> 00:04:46.370 in England, these trusts hold the purse strings 00:04:46.370 --> 00:04:49.170 and the staff contracts for absolutely everything. 00:04:49.389 --> 00:04:51.689 Everything. If you work in a mental health clinic, 00:04:51.870 --> 00:04:54.350 you work for the trust. If you are a surgeon, 00:04:54.350 --> 00:04:56.949 you work for the trust. If you are a social worker 00:04:56.949 --> 00:04:58.730 checking on at -risk children... You work for 00:04:58.730 --> 00:05:01.329 that same trust. Exactly. Okay, so if I'm a patient 00:05:01.329 --> 00:05:04.269 in, let's say, the Southern Trust, the guy fixing 00:05:04.269 --> 00:05:06.610 my broken hip and the person helping me wash 00:05:06.610 --> 00:05:09.230 my dishes when I get home are ultimately answering 00:05:09.230 --> 00:05:11.790 to the same corporate boss. That is the theory. 00:05:12.370 --> 00:05:14.949 And that brings us to what we call the integration 00:05:14.949 --> 00:05:17.790 paradox. I like that term. You would assume, 00:05:17.790 --> 00:05:20.029 logically, that this integration would make the 00:05:20.029 --> 00:05:23.410 system vastly more efficient. If you control 00:05:23.410 --> 00:05:25.550 the whole chain of care, you should be able to 00:05:25.550 --> 00:05:29.029 move people out of expensive hospitals and into 00:05:29.029 --> 00:05:32.750 cheaper community care instantly. Right. No arguments 00:05:32.750 --> 00:05:34.610 between the council and the hospital about who 00:05:34.610 --> 00:05:36.389 pays for the bed. Just move the patient where 00:05:36.389 --> 00:05:39.360 they need to go. And yet... Terry Bamford's analysis 00:05:39.360 --> 00:05:42.300 from 2015 showed the exact opposite happened. 00:05:42.839 --> 00:05:45.279 Despite this integration, Northern Ireland has 00:05:45.279 --> 00:05:47.740 actually failed to reduce its reliance on hospitals. 00:05:48.000 --> 00:05:50.500 Really? Yes. In fact, reliance on institutional 00:05:50.500 --> 00:05:53.100 care, so keeping people in hospital beds or nursing 00:05:53.100 --> 00:05:55.879 homes, is higher in Northern Ireland than elsewhere 00:05:55.879 --> 00:05:58.360 in the UK. That feels completely counterintuitive. 00:05:58.480 --> 00:06:00.939 Why would an integrated system cling to the most 00:06:00.939 --> 00:06:03.500 expensive way of treating people? Bamford highlights 00:06:03.500 --> 00:06:05.800 three main blockers, and they are fascinating. 00:06:06.100 --> 00:06:08.930 The first one is cure politics. Of course it 00:06:08.930 --> 00:06:11.720 is. To move resources into the community, you 00:06:11.720 --> 00:06:14.699 usually have to close or downgrade hospital buildings. 00:06:14.699 --> 00:06:17.399 You have to say, look, we don't need this acute 00:06:17.399 --> 00:06:19.980 wing in this rural town anymore. Oh, I can see 00:06:19.980 --> 00:06:23.100 that going down well. In a small town, the hospital 00:06:23.100 --> 00:06:25.500 is basically like the church or the local football 00:06:25.500 --> 00:06:28.360 club. You try to close it and you lose the next 00:06:28.360 --> 00:06:31.379 election. It is politically toxic. So the building 00:06:31.379 --> 00:06:34.360 stay open and the money stays tied up and keeping 00:06:34.360 --> 00:06:36.699 the lights on. That makes sense. But the second 00:06:36.699 --> 00:06:39.430 issue is even more interesting. It's a culture 00:06:39.430 --> 00:06:41.990 clash. We have to remember that health services 00:06:41.990 --> 00:06:44.769 are free at the point of use. Right. That's the 00:06:44.769 --> 00:06:47.470 sacred cow of the whole UK system. You walk into 00:06:47.470 --> 00:06:50.089 A &E, you get treated, you walk out, you never 00:06:50.089 --> 00:06:53.189 see a bill. Exactly. But social care is means 00:06:53.189 --> 00:06:56.209 tested. It's a paid culture. Ah, I see where 00:06:56.209 --> 00:06:59.029 this is going. Imagine you have an elderly patient. 00:06:59.269 --> 00:07:01.930 Let's call her Mary. Mary is in a hospital bed. 00:07:02.089 --> 00:07:03.990 She is medically fine. She's totally ready to 00:07:03.990 --> 00:07:06.670 go home. Now, the hospital bed is costing the 00:07:06.670 --> 00:07:10.110 system maybe 500 pounds a night, but it's completely 00:07:10.110 --> 00:07:13.029 free to Mary. To move her home, she needs a care 00:07:13.029 --> 00:07:15.670 package. That care package might only cost the 00:07:15.670 --> 00:07:18.170 system 20 pounds a day. But because it's social 00:07:18.170 --> 00:07:21.689 care. Mary has to undergo a financial assessment. 00:07:21.930 --> 00:07:24.050 She has to prove she can't pay for it herself. 00:07:24.149 --> 00:07:26.269 And I'm guessing that assessment isn't exactly 00:07:26.269 --> 00:07:28.629 speedy. Not at all. It takes time. There might 00:07:28.629 --> 00:07:30.870 be a dispute over her savings or her pension. 00:07:31.410 --> 00:07:34.089 So you have this perverse situation where Mary 00:07:34.089 --> 00:07:38.029 sits in a hyper -expensive hospital bed for three 00:07:38.029 --> 00:07:40.269 weeks. Walking a sick patient from getting in. 00:07:40.490 --> 00:07:42.550 Exactly, while the bureaucrats argue over who 00:07:42.550 --> 00:07:45.449 pays for the chief home care. That is maddening. 00:07:45.629 --> 00:07:47.069 The whole point of the integration was supposed 00:07:47.069 --> 00:07:49.310 to remove the walls, but the financial rules 00:07:49.310 --> 00:07:51.649 just built them right back up again. Bamford 00:07:51.649 --> 00:07:54.449 noted that the greatest difficulties lay in these 00:07:54.449 --> 00:07:57.189 differing values. The free culture and the means 00:07:57.189 --> 00:07:59.910 -tested culture just didn't mesh. It's like oil 00:07:59.910 --> 00:08:02.769 and water. And then just to add insult to injury, 00:08:03.410 --> 00:08:06.490 the tech was a disaster. Oh, government IT projects. 00:08:06.730 --> 00:08:09.730 Always a favorite. For a long time, the IT systems 00:08:09.730 --> 00:08:12.350 for health and social care weren't even compatible. 00:08:13.410 --> 00:08:16.750 Plus, patient confidentiality rules often prevented 00:08:16.750 --> 00:08:19.170 the sharing of info that the system was theoretically 00:08:19.170 --> 00:08:21.490 designed to share. Wait, so the doctor couldn't 00:08:21.490 --> 00:08:23.829 even email the social worker? Essentially, yes. 00:08:23.990 --> 00:08:26.089 So, you have the outward structure of integration, 00:08:26.430 --> 00:08:29.230 but the skeleton inside the tech and the culture 00:08:29.230 --> 00:08:32.190 was completely fractured. It's like buying a 00:08:32.190 --> 00:08:34.210 top -of -the -line smartphone, but not having 00:08:34.210 --> 00:08:37.470 a data plan. I mean, it looks great, but it doesn't 00:08:37.470 --> 00:08:39.809 actually connect to anything. That is a very 00:08:39.809 --> 00:08:41.990 good way to put it. Okay, so the machine is jammed. 00:08:43.489 --> 00:08:45.929 And this brings us to the really heavy stuff 00:08:45.929 --> 00:08:50.070 in the sources, the performance crisis. I was 00:08:50.070 --> 00:08:52.210 looking at a report from the Nuffield Trust in 00:08:52.210 --> 00:08:54.769 2017, and honestly, the numbers are hard to wrap 00:08:54.769 --> 00:08:57.009 your head around. They are very stark. My first 00:08:57.009 --> 00:08:58.610 thought was, well, maybe they just don't have 00:08:58.610 --> 00:09:00.549 enough money. That's the first place everyone 00:09:00.549 --> 00:09:02.970 looks, but the Nuffield report completely debunks 00:09:02.970 --> 00:09:05.909 that. Really? Yeah. It showed that spending per 00:09:05.909 --> 00:09:08.850 head in Northern Ireland was roughly 2 ,200 pounds 00:09:08.850 --> 00:09:11.580 a year. which is pretty much exactly on par with 00:09:11.580 --> 00:09:13.980 the rest of the UK. So they aren't drastically 00:09:13.980 --> 00:09:17.039 underfunded compared to England. No. But the 00:09:17.039 --> 00:09:19.639 output, the result of that money, much, much 00:09:19.639 --> 00:09:22.360 worse. Let's talk about those waiting lists because, 00:09:22.500 --> 00:09:24.120 you know, we hear about waiting lists all the 00:09:24.120 --> 00:09:26.299 time. People say, oh, the list is up. But we 00:09:26.299 --> 00:09:28.639 need to contextualize the scale here for the 00:09:28.639 --> 00:09:30.860 listener. It is a different magnitude entirely. 00:09:31.100 --> 00:09:33.179 Let's go back to 2015 just to set the scene. 00:09:33.659 --> 00:09:35.539 The waiting list target in Northern Ireland, 00:09:36.059 --> 00:09:39.110 the actual goal they were trying to hit was 52 00:09:39.110 --> 00:09:42.029 weeks. A year. Their goal was to make you wait 00:09:42.029 --> 00:09:45.250 a whole year. Yes. And just for context, England's 00:09:45.250 --> 00:09:49.029 target at that same time was 18 weeks. Wow. So 00:09:49.029 --> 00:09:51.370 the ambition in Northern Ireland was nearly three 00:09:51.370 --> 00:09:53.669 times worse than the ambition in England. And 00:09:53.669 --> 00:09:55.450 they weren't even hitting that 52 -week target. 00:09:55.529 --> 00:09:57.710 That's unbelievable. The sources mentioned that 00:09:57.710 --> 00:10:00.409 around 16 % of the entire population of Northern 00:10:00.409 --> 00:10:02.909 Ireland was on a waiting list. Wait, one in six 00:10:02.909 --> 00:10:05.039 people? That's not a waiting list, that's just, 00:10:05.039 --> 00:10:07.759 that's the population. It creates a state of 00:10:07.759 --> 00:10:11.220 permanent limbo for the entire society. And it's 00:10:11.220 --> 00:10:13.700 not just elective surgeries like getting a new 00:10:13.700 --> 00:10:17.440 knee, it's emergency care too. Right, A &E. The 00:10:17.440 --> 00:10:19.919 standard target for A &E is to see people within 00:10:19.919 --> 00:10:23.320 four hours. In Northern Ireland, over 20 % and 00:10:23.320 --> 00:10:26.200 sometimes up to 30 % of patients were waiting 00:10:26.200 --> 00:10:28.940 longer than that. But there was a scarier stat 00:10:28.940 --> 00:10:32.519 in there. The 12 -hour wait? Yep. 12 hours in 00:10:32.519 --> 00:10:34.919 a plastic chair. You arrive at breakfast, and 00:10:34.919 --> 00:10:37.419 you're literally still there at bedtime. In February 00:10:37.419 --> 00:10:42.659 2022, 16 .3 % of attendees waited more than 12 00:10:42.659 --> 00:10:44.860 hours. And we aren't talking about sitting in 00:10:44.860 --> 00:10:47.480 a comfortable lounge watching TV. No, this is 00:10:47.480 --> 00:10:50.379 a crowded, stressful, noisy emergency department. 00:10:51.019 --> 00:10:52.879 Exactly. And this isn't just about being uncomfortable 00:10:52.879 --> 00:10:55.320 or bored. I mean, this kills people. It does. 00:10:55.740 --> 00:10:57.820 We really have to talk about the human cost here 00:10:57.820 --> 00:11:00.000 because the stats can sort of hide the tragedy. 00:11:00.399 --> 00:11:03.240 In 2019, Heather Monteverde from McMillan cancer 00:11:03.240 --> 00:11:06.159 support highlighted this devastating statistic. 00:11:06.279 --> 00:11:09.320 I remember reading this. One in five cancer patients 00:11:09.320 --> 00:11:11.620 in Northern Ireland received their diagnosis 00:11:11.620 --> 00:11:13.899 in an emergency department. Let's just pause 00:11:13.899 --> 00:11:15.980 on that for a second so the listener really grasps 00:11:15.980 --> 00:11:19.500 it. One in five. That means they didn't get caught 00:11:19.500 --> 00:11:21.799 by a routine screening. They didn't get caught 00:11:21.799 --> 00:11:24.500 by a GP referral. Right. It means the system 00:11:24.500 --> 00:11:27.250 failed them at every prior step. They likely 00:11:27.250 --> 00:11:29.269 had symptoms, maybe they were even on a waiting 00:11:29.269 --> 00:11:32.009 list to see a specialist, but they waited so 00:11:32.009 --> 00:11:34.730 long that the cancer grew until it became an 00:11:34.730 --> 00:11:38.210 acute, life -threatening emergency. They collapsed, 00:11:38.409 --> 00:11:41.129 or the pain became unbearable. They went to A 00:11:41.129 --> 00:11:43.289 &E, and that is where they were told they had 00:11:43.289 --> 00:11:45.470 cancer. And by that point, your options are incredibly 00:11:45.470 --> 00:11:48.190 limited. Exactly. Patients diagnosed in A &E 00:11:48.190 --> 00:11:51.129 have the lowest survival rates. It's a systemic 00:11:51.129 --> 00:11:53.690 failure that is literally costing lives. And 00:11:53.690 --> 00:11:55.789 it wasn't just cancer, was it? We saw a grim 00:11:55.789 --> 00:11:57.830 pattern with homelessness, too, in the sources. 00:11:58.009 --> 00:12:01.350 Yes, the death rates. In a specific 18 -month 00:12:01.350 --> 00:12:05.629 period reported back in 2019, 205 homeless people 00:12:05.629 --> 00:12:07.710 died in Northern Ireland. And again, to give 00:12:07.710 --> 00:12:10.289 context, Northern Ireland is small. Very small. 00:12:10.370 --> 00:12:13.769 It has about 2 .8 % of the UK's total population. 00:12:14.210 --> 00:12:17.070 But those deaths accounted for more than 25 % 00:12:17.070 --> 00:12:20.509 of the total UK homeless deaths. That is disproportionate 00:12:20.509 --> 00:12:23.639 on a massive scale. It suggests a fundamental 00:12:23.639 --> 00:12:26.019 breakdown in the safety net. Remember, this is 00:12:26.019 --> 00:12:28.480 supposed to be the integrated system. Social 00:12:28.480 --> 00:12:30.500 care and health care are supposed to be working 00:12:30.500 --> 00:12:32.740 hand in glove. Right. If a homeless person is 00:12:32.740 --> 00:12:35.220 at risk, the health side and the social side 00:12:35.220 --> 00:12:37.679 should be coordinating to save them. But the 00:12:37.679 --> 00:12:39.990 data suggests that simply isn't happening. You 00:12:39.990 --> 00:12:41.669 know, when you read these reports, it's really 00:12:41.669 --> 00:12:43.950 easy to get numb to the numbers. But there was 00:12:43.950 --> 00:12:46.350 one story in the BBC sources that really grounded 00:12:46.350 --> 00:12:49.309 this for me. It was about a woman moving from 00:12:49.309 --> 00:12:52.289 County Armagh to Wales. Ah, the Swansea case, 00:12:52.350 --> 00:12:54.870 yeah. So she moves to Swansea. She has a condition 00:12:54.870 --> 00:12:56.889 she's been managing or trying to manage back 00:12:56.889 --> 00:13:00.990 home. She goes to her new GP in Bristol, or Swansea, 00:13:01.009 --> 00:13:04.230 I believe, and hands over her medical file. And 00:13:04.230 --> 00:13:06.149 the reaction of the doctor was very telling. 00:13:06.389 --> 00:13:09.259 Yeah. The doctor was shocked, visibly shocked 00:13:09.259 --> 00:13:11.039 at the standard of care she had been receiving 00:13:11.039 --> 00:13:13.779 in the Southern Trust. And the really heartbreaking 00:13:13.779 --> 00:13:16.039 part was that the patient herself didn't realize 00:13:16.039 --> 00:13:18.600 how bad it was. That's the scary thing, isn't 00:13:18.600 --> 00:13:20.919 it? Normalization. If everyone you know waits 00:13:20.919 --> 00:13:23.179 three years for an operation, you just assume 00:13:23.179 --> 00:13:25.240 that's how long operations take. You don't realize 00:13:25.240 --> 00:13:26.860 that a short flight away, people are getting 00:13:26.860 --> 00:13:30.440 it done in four months. Right. When you are inside 00:13:30.440 --> 00:13:32.399 the bubble, you just accept the dysfunction. 00:13:32.899 --> 00:13:35.690 It takes an outsider. or actually leaving the 00:13:35.690 --> 00:13:39.549 system to realize, wait, this isn't normal. It's 00:13:39.549 --> 00:13:43.070 a classic frog in boiling water scenario. So 00:13:43.070 --> 00:13:45.669 if the hospitals are overwhelmed and the waiting 00:13:45.669 --> 00:13:49.629 lists are a mile long, the logical fix, the textbook 00:13:49.629 --> 00:13:53.389 fix is primary care, right? The GPs. If we can 00:13:53.389 --> 00:13:56.110 catch things early with a GP, we save the hospitals. 00:13:56.830 --> 00:13:59.110 How are the GPs holding up in this storm? They 00:13:59.110 --> 00:14:01.970 are drowning just as fast. They are facing a 00:14:01.970 --> 00:14:03.990 massive crisis of resources and recruitment. 00:14:04.549 --> 00:14:07.070 Back in 2017, it got so bad that the British 00:14:07.070 --> 00:14:10.110 Medical Association, the BMA, actually took a 00:14:10.110 --> 00:14:12.289 vote to start collecting undated resignations 00:14:12.289 --> 00:14:15.250 from GPs. Explain that to me. What exactly is 00:14:15.250 --> 00:14:18.230 an undated resignation? It's basically the nuclear 00:14:18.230 --> 00:14:21.070 option. Every GP signs a formal letter saying, 00:14:21.070 --> 00:14:23.789 I quick, but they leave the date at the top blank. 00:14:24.039 --> 00:14:25.820 They hand them all over to the union leaders. 00:14:26.200 --> 00:14:28.220 It's essentially saying to the government, we 00:14:28.220 --> 00:14:31.539 have a loaded gun. If you don't fund us, we write 00:14:31.539 --> 00:14:35.120 in today's date and the entire primary care system 00:14:35.120 --> 00:14:39.240 collapses overnight. That is dramatic. That's 00:14:39.240 --> 00:14:41.139 like writing a breakup letter to your partner, 00:14:41.519 --> 00:14:43.360 leaving it on the kitchen counter and saying, 00:14:43.399 --> 00:14:45.940 I'm not leaving yet, but if you don't do the 00:14:45.940 --> 00:14:48.799 dishes, I'm signing this. It really shows the 00:14:48.799 --> 00:14:50.679 level of desperation. Now they didn't hand them 00:14:50.679 --> 00:14:53.750 in, thankfully. but the threat was very real. 00:14:53.909 --> 00:14:56.399 But amidst all this, There was an attempt to 00:14:56.399 --> 00:14:58.740 fix things, right? I read about them pushing 00:14:58.740 --> 00:15:01.600 for something called MDTs. Multidisciplinary 00:15:01.600 --> 00:15:04.759 teams. Yes. Is this the Cookstown model? Yes. 00:15:05.019 --> 00:15:07.559 Launched in 2018. It actually goes right back 00:15:07.559 --> 00:15:09.500 to that original integration dream we talked 00:15:09.500 --> 00:15:12.059 about. OK. How does it work? The idea is that 00:15:12.059 --> 00:15:14.039 you shouldn't just go see a GP for everything. 00:15:14.139 --> 00:15:16.679 You should be able to see a physiotherapist or 00:15:16.679 --> 00:15:19.220 a mental health specialist or a social worker 00:15:19.220 --> 00:15:21.200 right there in the local practice. Oh, that makes 00:15:21.200 --> 00:15:23.720 total sense. If I have a bad back, I don't really 00:15:23.720 --> 00:15:26.309 need a doctor. Physio, keep me out of the hospital 00:15:26.309 --> 00:15:30.090 entirely. Exactly. The Cookstown Hub had scanning 00:15:30.090 --> 00:15:33.289 facilities, minor surgery, a pharmacy, all in 00:15:33.289 --> 00:15:36.490 one place. It's a brilliant model. But, and I 00:15:36.490 --> 00:15:38.549 feel like there's always a but in this story. 00:15:38.970 --> 00:15:42.559 Always. You cannot roll out a major reform like 00:15:42.559 --> 00:15:44.980 that across a whole country without strong political 00:15:44.980 --> 00:15:47.779 leadership. And this is where Northern Ireland's 00:15:47.779 --> 00:15:50.419 unique political situation completely wrecks 00:15:50.419 --> 00:15:52.960 the party. The political vacuum. Right. We have 00:15:52.960 --> 00:15:54.779 to explain this briefly for the international 00:15:54.779 --> 00:15:57.600 listener. Northern Ireland's government is based 00:15:57.600 --> 00:16:00.820 on mandatory power sharing. If the two main political 00:16:00.820 --> 00:16:03.259 parties don't agree to form a government together, 00:16:03.519 --> 00:16:05.200 there is no government. The whole thing just 00:16:05.200 --> 00:16:07.539 collapses. It's not like the U .S. or the U .K. 00:16:07.539 --> 00:16:09.450 where if the leader quits a new one just steps 00:16:09.450 --> 00:16:12.190 in, the lights literally just go out. Correct. 00:16:12.549 --> 00:16:16.710 And from February 2022 to January 2024, the DUP 00:16:16.710 --> 00:16:19.409 boycotted the executive over Brexit protocols. 00:16:19.570 --> 00:16:21.450 And obviously we aren't taking a stance on the 00:16:21.450 --> 00:16:23.529 politics of that, but the practical reality is... 00:16:23.529 --> 00:16:25.049 For two years, there was no health minister. 00:16:25.149 --> 00:16:27.950 Two years. Right on the heels of COVID. Right 00:16:27.950 --> 00:16:31.570 when the system was on its absolute knees. And 00:16:31.570 --> 00:16:34.309 crucially... Because there was no minister, there 00:16:34.309 --> 00:16:36.669 was no proper budget. So you can't hire staff. 00:16:36.769 --> 00:16:39.269 You can't sign off on multi -year building projects. 00:16:39.350 --> 00:16:41.669 You can't roll out these Cookstown models because 00:16:41.669 --> 00:16:44.049 there is nobody with the legal authority to sign 00:16:44.049 --> 00:16:46.789 the check. Tom Black, the BMA chair, said the 00:16:46.789 --> 00:16:49.549 crisis boils down to workload and workforce. 00:16:49.669 --> 00:16:52.230 Yeah. But you can't fix the workforce if you 00:16:52.230 --> 00:16:54.850 don't have a minister. Exactly. It's like... 00:16:54.559 --> 00:16:58.000 trying to drive a bus from the backseat. You 00:16:58.000 --> 00:17:00.220 can yell directions all you want, but you can't 00:17:00.220 --> 00:17:02.399 turn the wheel. And while the politicians were 00:17:02.399 --> 00:17:04.680 arguing about Brexit, those waiting lists we 00:17:04.680 --> 00:17:07.519 talked about just grew and grew. Okay, we have 00:17:07.519 --> 00:17:10.220 painted a fairly bleak picture here. We have 00:17:10.220 --> 00:17:12.799 a system that is fighting itself culturally, 00:17:13.259 --> 00:17:15.779 drowning in demand, and headless politically. 00:17:16.619 --> 00:17:18.759 Is there any glimmer of hope? Is there anything 00:17:18.759 --> 00:17:20.980 on the horizon that might actually turn this 00:17:20.980 --> 00:17:25.450 ship around? There is one major technological 00:17:25.450 --> 00:17:27.670 glimmer, if you want to call it that. It's called 00:17:27.670 --> 00:17:30.869 the Encompass program. Encompass. It's very corporate. 00:17:31.009 --> 00:17:32.930 What is it? Remember how we said the IT systems 00:17:32.930 --> 00:17:34.910 didn't talk to each other? The skeleton was broken, 00:17:35.230 --> 00:17:38.950 yeah. Encompass is the fix. It's a massive rollout 00:17:38.950 --> 00:17:43.009 involving Cloud21 and Tegria, which is a US company. 00:17:43.529 --> 00:17:46.829 The goal is a fully integrated electronic health 00:17:46.829 --> 00:17:49.230 and care record across absolutely everything. 00:17:49.329 --> 00:17:51.109 Hold on. I have to be a little skeptical here. 00:17:51.190 --> 00:17:53.930 Yeah. We have seen government IT projects in 00:17:53.930 --> 00:17:56.650 the UK before. They usually involve spinning 00:17:56.910 --> 00:17:59.369 billions of pounds and then completely abandoning 00:17:59.369 --> 00:18:01.210 it five years later because the software doesn't 00:18:01.210 --> 00:18:03.730 work? That is a very fair question to ask. Why 00:18:03.730 --> 00:18:05.710 is this one different? The main difference here 00:18:05.710 --> 00:18:07.950 is that they are buying an off -the -shelf system 00:18:07.950 --> 00:18:10.670 called Epic, which is already used by top hospitals 00:18:10.670 --> 00:18:13.470 globally, rather than trying to build a custom 00:18:13.470 --> 00:18:15.950 one from scratch. OK, that's smart. And the scope 00:18:15.950 --> 00:18:18.869 is unprecedented. It covers acute physical health, 00:18:19.269 --> 00:18:21.589 mental health, community care, and social services. 00:18:21.890 --> 00:18:24.779 So if I see a social worker about my housing 00:18:24.779 --> 00:18:27.420 situation, and then three days later I end up 00:18:27.420 --> 00:18:29.779 in A &E with a stress -induced heart condition, 00:18:30.259 --> 00:18:32.759 the A &E doctor can actually see the social worker's 00:18:32.759 --> 00:18:35.700 notes. That is the goal. If it works, it creates 00:18:35.700 --> 00:18:38.440 the second fully integrated system of its kind 00:18:38.440 --> 00:18:41.490 in Western Europe. It attempts to finally solve 00:18:41.490 --> 00:18:44.470 that information silo problem Terry Bamford warned 00:18:44.470 --> 00:18:47.430 about. So it brings the digital reality in line 00:18:47.430 --> 00:18:49.950 with the structural theory. Yes. It seems like 00:18:49.950 --> 00:18:51.769 such a basic requirement for the modern era, 00:18:51.849 --> 00:18:53.650 doesn't it? Doctors should be able to see your 00:18:53.650 --> 00:18:56.109 notes. But I guess in this context, it's a revolution. 00:18:56.390 --> 00:18:58.589 It is. It's the digital infrastructure that should 00:18:58.589 --> 00:19:00.890 have been there from the very start. Now, will 00:19:00.890 --> 00:19:03.730 it solve the political gridlock? No. Will it 00:19:03.730 --> 00:19:06.269 solve the funding parity issues? No. But it removes 00:19:06.269 --> 00:19:08.309 one of the biggest friction points in the system. 00:19:08.569 --> 00:19:11.829 Exactly. So where does this leave us? We started 00:19:11.829 --> 00:19:14.750 by talking about a unique experiment, a place 00:19:14.750 --> 00:19:17.509 where health and social care are one and the 00:19:17.509 --> 00:19:20.049 same. It is a fascinating case study in the gap 00:19:20.049 --> 00:19:23.309 between theory and reality. Northern Ireland 00:19:23.309 --> 00:19:25.450 has the structure that health policy experts 00:19:25.450 --> 00:19:27.910 around the world argue for. They have the integrated 00:19:27.910 --> 00:19:31.390 model. Right. But as we've seen, structure alone 00:19:31.390 --> 00:19:33.650 just isn't enough. It has been bogged down by 00:19:33.650 --> 00:19:35.650 the difficulty of culture, the legacy of old 00:19:35.650 --> 00:19:38.230 buildings, and political instability. It's a 00:19:38.230 --> 00:19:41.369 warning, really, for any listener whose local 00:19:41.369 --> 00:19:43.910 government is proposing this. You can't just 00:19:43.910 --> 00:19:46.069 merge two departments, change the letterhead, 00:19:46.529 --> 00:19:48.910 and expect magic to happen. Absolutely. The lesson 00:19:48.910 --> 00:19:51.829 here is that integration is hard. You can merge 00:19:51.829 --> 00:19:53.950 the organizations, but merging the cultures, 00:19:54.390 --> 00:19:56.809 the free versus the means tested is the real 00:19:56.809 --> 00:19:59.329 battle. If you don't fix that, you just create 00:19:59.329 --> 00:20:02.630 a larger, more complex bureaucracy that is even 00:20:02.630 --> 00:20:05.509 harder to steer. Precisely. That makes you wonder. 00:20:06.210 --> 00:20:08.470 We always hear that breaking down silos is the 00:20:08.470 --> 00:20:10.410 answer to everything in corporate and public 00:20:10.410 --> 00:20:13.029 life. It's the buzzword of the century. But if 00:20:13.029 --> 00:20:15.130 Northern Ireland, the only place in the UK that 00:20:15.130 --> 00:20:17.490 actually did it, has the worst waiting lists 00:20:17.490 --> 00:20:20.690 and the worst performance stats. Maybe the silos 00:20:20.690 --> 00:20:22.950 aren't the biggest problem. Maybe we need to 00:20:22.950 --> 00:20:25.390 stop assuming that integration is the automatic 00:20:25.390 --> 00:20:28.210 magic cure for modern health care. That's the 00:20:28.210 --> 00:20:30.009 uncomfortable question that nobody really wants 00:20:30.009 --> 00:20:32.369 to answer, but looking at the data we went through 00:20:32.369 --> 00:20:34.430 today, we really can't ignore it. Definitely 00:20:34.430 --> 00:20:36.269 something for you to think about the next time 00:20:36.269 --> 00:20:39.450 you hear a politician promising a seamless new 00:20:39.450 --> 00:20:42.250 system. Thanks for joining us on this deep dive 00:20:42.250 --> 00:20:44.150 into the health and social care system of Northern 00:20:44.150 --> 00:20:45.170 Ireland. We'll see you next time.