Integrated services to improve health and well-being

William McKee is Chief Executive of Belfast Health and Social Care Trust which was formed in April this year following the Review of Public Administration in Northern Ireland. One of five ‘super trusts’ which have replaced eighteen across Northern Ireland, Belfast Trust is the biggest trust in the UK. Interviewed by Catherine Couvert, he explains the role and priorities of the new trust.

What is your role as head of the new Belfast Trust?

We have to do three things at once. We have to build capacity into the new organisation. We have to deliver government mandates, mostly around access targets, waiting times and the very demanding financial regime that we have. We have to set out a clear future direction.

My personal target is to demonstrate to nearly 23,000 staff and to users of the services that Belfast Trust is more than the sum of the six previous trusts that formed it. It is my clear view that these organisations were all very successful by objective standards. So it’s quite a demanding target I’ve set myself.

Is the transfer to the Belfast Trust effectively complete?

I was appointed in July 2006 and did not know whether to laugh or cry to find that there was no plan on the stocks from the previous year saying how the Department of Health wanted trusts to be established. I started from a standing start; we were still trying to put on our running shoes, never mind a standing start.

It has been a very short time from my appointment to beginning to appoint directors in November 06 to 1 April 07 when we were fully operational with only about 20 staff appointed. In the first four months of full operation, we made remarkable progress but to say it is finished is way short of the mark. We’re completing the appointment of about 200 staff to the most senior positions.

What is happening in the interim?

There is no interim. Patients still need to be treated; children are still in care. Responsibilities were simply transferred. In reality, for 22,000 of the nearly 23,000 staff, life goes on as before. Reorganisation is confined to a senior cadre of people, not at purely managerial background but senior clinical and professional staff. The trust has been given a remarkable amount of goodwill from staff. Staff by and large overwhelmingly see the advantage of a merged integrated organisation.

What do you see as the advantages of a merged trust?

Belfast Trust is very big, it spends a billion pound a year, that’s three million pounds a day, about one eighth of the total Assembly budget, it impacts on the lives of millions of people every year directly. How do you bring added value to an organisation that is larger than previous organisations that might have been more flexible and more responsive? The six previous trusts were all around institutions or sites like the Royal and the City, Green Park and the Mater or geographic, North and West Belfast, South and East. We have chosen to organise around client or service groups.

We have one director responsible for all the children’s services from the Regional Children’s Hospital, the two obstetric units, and all the community based support for families and protection of children.

Similarly, for older people, the director who reports to me has services for older people in their own homes in the community, but also the three A&E departments, and the three medical and surgical units in the Central Belfast hospitals.

If we are asked to improve waiting times in the A&E departments, we can only fix it by looking at the whole system. Almost everyone who is admitted through an A&E department is an older person with a chronic condition and they have an acute episode of that. We can only fix it by looking at the whole patient’s journey, the whole system for supporting older people and giving them as much independence and autonomy as possible.

Same with mental health services, we can now take a system wide approach rather than focus on institutions and some sterile debate about one institutional setting versus another. We can leapfrog that and talk about what is the best service for people with mental illness. We need a crisis intervention service that deals with really acute episodes of mental illness, we need some primary care services and we need some continuing care services. So, we focus on bigger teams of mental health professionals and multi-disciplinary teams that focus on related groups of services.

The new structures are designed to encourage a more radical approach, more focused on the user. They are also designed to universalise best practice across the whole of Belfast rather than one trust inventing some new idea but it not being copied by another.

Is there a similar approach in all the new super trusts?

To a greater or lesser extent. Belfast is twice as big as any of the others but very compact, whereas the others have big geographical coverage, so they tend to have a more geographic approach to services.

Is Belfast Trust moving towards a shrinking of acute services and the development of more services in the community?

We are working in the context of a clear government policy that has a preference for whole or community based solutions over institutional solutions. Older people prefer not to go into hospital if they can avoid it. Institutional settings would not always be the best setting in which to deal with someone with a mental illness.

The way I have organised services facilitates that. For example, the director with responsibility for services to older people can take money out of institutional settings and use it to reinvest in community based settings to support older people closer to their home.

Would it be a reasonable target to say that we will shift five per cent of work from institutional setting into community settings over the next five years or so? I think it would be reasonable.

Will it involve job losses?

It will be handled through natural wastage, voluntary severance and creating new jobs from the money saved. There is no clear evidence whether community based settings are more or less expensive, they are better in many cases. The reorganisation is meant to result in job losses that can release money to the frontline. We have been set an overall target that the managerial cost and direct support cost of organisations should shrink by 25% and while my Minister has not ruled out compulsory redundancies we are doing all that we can to avoid it.

What is the impact of reorganisation on user involvement?

The creation of the trust in itself does not affect user involvement and yet on the other hand it does because it is a clear objective of the Belfast Trust to engage with users and other people more closely.

Our business is to provide cost effective, timely and relevant health and social care. Our purpose is to improve health and well-being. Health and well-being is not entirely or even mostly about health and social care but why else do we have health and social care if not to improve health and well being?

We can only improve health and well being by working in partnership with users, with the voluntary and community sector, the independent sector, the City Council, education, housing, the justice system etc.

We have begun work on a partnership approach to do user engagement, community development and a health improvement strategy. It is being done in an open way with a wide range of stakeholders including users. For example, the director for mental health and learning disability, Brendan Mullen, is going to appoint a user to take responsibility for user involvement and quality.

Can you summarise your vision for the trust?

The mission of the trust is to improve health and well being by working in partnership in its delivery of a comprehensive and integrated range of health and social care to a population of 340,000 in the Belfast and Castlereagh District Council areas, to Northern Ireland and beyond for specialist services.

We are currently asking staff, at different levels and of different backgrounds, what they think the values and ethical standards of the Belfast trust should be. That piece of work will be completed in late Autumn and will become part of our vision document. Then we want to set out maybe five basic themes to pursue over the next three or five years.

An important target is to demonstrate to users and others, and to our political masters that our services are safe, that they are improving and modernising.

Is it difficult to set out targets at a time of political restructuring?

Yes, but isn’t it all the more important that you do so?

Mr McKee ended by saying how grateful he was for the high calibre and dedication of the staff he is working with at all levels, and that he looks forward to the challenges ahead.