Transformation - Health Blog by DoH Permanent Secretary Richard Pengelly

Date published: 05 April 2019

“I would like to cover two key issues in this health blog – why we need transformation; and where we are at now.

DoH Permanent Secretary Richard Pengelly

“The latter aspect is much easier to deal with – and I hope I can illustrate that we are making excellent progress, particularly over the last few weeks.

“But first let me turn to why we need transformation.  This is a simple question, with – I believe - an equally simple answer. 

“However, I also believe we have yet to properly convince the public that this simple reality is true.

“Our answer is that we have a system that continues to underperform and is heading towards collapse.

“There are two key reasons for that:

  • Firstly, as Rafa Bengoa said, we have a 20th century model seeking to meet the challenges of delivering care in the 21st century. And within that model, we currently spread our resources and expertise too thinly, and across too many sites, for it to be resilient and sustainable.
  • Secondly, the demands upon our system continue to grow at a rate we simply cannot keep pace with. Our population is getting older, and people are living longer with more long term health conditions. This presents a huge, and growing, challenge.

“These two factors comprise what has been dubbed “the burning platform” for change.  But I believe that we are still some way from achieving wider acceptance of that proposition.

“Again, I believe that there are two reasons for this:


  • There is still a view across society that a health and social care system can only be effective if it is close to you. The reality is that health care is becoming more and more complex, and it is simply not possible to replicate the required level of expertise in all locations. 
  • This is not a money issue, but more a people issue – to maintain expertise, individual clinicians need to be continually exposed to both volume and complexity of case mix.  And without that expertise, patient outcomes will not be as good as they could or should be.  We can already see that that is the case in some areas.
  • So we need to better explain that at least as important as how quickly you are seen, is the skills and experience of the person seeing you; and that there is a tradeoff between proximity and quality.


  • Society does not accept the burning platform is due to our staff.  Despite the flawed model, staff continue to work miracles within it - this is a testament to their dedication, professionalism and compassion.
  • And, to be very clear, I refer here to all staff who work across health and social care – not just those in the fabled front line.  Everyone in our system makes a vital contribution to patient care.
  • Without all of them, none of them could perform the work they do. 

“One of the real joys of my role is getting the opportunity to get out to speak to colleagues across the system.  And as much as I am continually hugely impressed by those I meet, the stark reality is that those same colleagues cannot continue to carry the load that they do - they are simply worn out.

“Our system survives at the moment due to their efforts, and we must change that.

“We can only do so through transformation.

“So, having set out the case for change, I wish to make an ask of clinicians.

“This ask recognises the reality that the public will most readily accept an alternative proposition from those they trust.  In the context of healthcare, this means clinicians.

“In this context, all HSC staff are the key to making change happen. Your engagement, your input, your innovation, your commitment and your leadership will make or break transformation.  So please help us with the important debate on these issues.

“Just to be clear - this is not about spin or creating a narrative.  This is about changing the focus of the debate to the issues that really matter in terms of the quality of care we offer.

“Turning now to what we have achieved, I’m pleased to say that, just over two years into the Transformation journey, we are making headway and we are pushing forward. Change is happening.


“As part of a long term approach to tackling long waiting lists, Delivering Together outlined a requirement to transform our approach to elective care surgery.

“Prototypes for day case elective care for varicose veins and cataracts are now operational and taking patients.

“These prototype centres will mean up to 2,000 additional treatments annually for cataracts, and 500 more annually for varicose veins.

“We are planning to do more, and have announced that day case surgery hubs will be rolled out across a wide range of specialities:

  • General Surgery and Endoscopy;
  • Urology;
  • Gynaecology;
  • Orthopaedics;
  • ENT;
  • Paediatrics; and
  • Neurology.

“Work is being taken forward in each speciality, including identifying preferred sites for the centres, and will inform a regional model for day case surgery across Northern Ireland.  This will ensure people get their surgery faster.

“We have also undertaken a review to look at the Population Health Needs for Urgent and Emergency Care.

“This work will help establish a new care model for Northern Ireland, giving specific consideration to the most appropriate arrangements for the assessment and admission of older people.

“Significant progress has also been made to provide more support in primary care.

“Key to this is a new model for Primary Care through Multi-Disciplinary Teams - this will see local GP practices focus not just on managing ill-health, but also on the physical, mental and social wellbeing of communities.

“To support this approach, physiotherapists, social workers and mental health practitioners, will be based in GP practices.

“The creation of these new multi-disciplinary teams will also be supported by increased investment in District Nursing, Health Visiting, training, and access to appropriate specialist advice.

“Down and Derry/Londonderry GP Federation areas were chosen as the first two areas for the roll-out of this new model.

“In terms of the reconfiguration of services, a range of reviews have been launched to identify the optimal, safest and most sustainable configuration in some important areas:

  • Two public consultations were launched last week – one on the reconfiguration of hospital-based stroke services; and one on a review of breast assessment services.
  • Work is ongoing to determine the new service model for cancer services.  Currently new treatment pathways are being developed, involving both staff and those with lived experience of cancer services.  We also recently announced our intention to commission a new cancer strategy for Northern Ireland.

“These reviews, alongside those on plastic surgery and burns, imaging, diabetes, paediatrics, pathology, and neurology will make a significant impact on how we better meet the needs of those who access our services.

“Significant work is also underway to build capacity in communities, and in prevention. Key to this is linking strongly to social care, with a focus on improving and safeguarding the wellbeing of individuals, families and communities.

“To this end, a programme of work is currently underway to reform services which support some of the most vulnerable families and children in Northern Ireland. This work includes a regional roll-out of a new social work model called ‘Signs of Safety’. This will see 2,500 social workers trained in this new approach by the end of the year.

“Further work to build capacity in our communities is being brought forward through the Community Development Framework. This work is progressing well in partnership with staff, the voluntary and community sectors, and service users, with a report produced and work is now underway to procure a delivery partner for support services.

“A central plank of our Transformation strategy is to design and implement new models of care that have the potential to harness the strengths of different parts of our system, working and delivering together.

“In this context, a new pathfinder project has begun a root and branch review of the current service provision in Fermanagh and West Tyrone.

“In a similar space, the recommendations from the Daisy Hill Pathfinder are now being implemented with significant progress made in providing a stable Emergency Department workforce, stronger links with local GPs, enhanced services for the sickest patients, and improved patient flow.

“We’re also making better use of technologies and data to support the development of an HSC which meets the needs of the 21st Century. 

“These are all concrete examples of transformation taking place. But there is also other, less visible, but equally important work being taken forward.

“An HSC-wide Collective Leadership Strategy was launched near the start of the transformation journey. The implementation and embedding of the strategy is ongoing. This includes a set of core values and behaviours that have been developed for the whole of the health and social care system. 

“An HSC Workforce Strategy has also been developed – this provides a detailed look at the workforce challenges we face. It focuses on ensuring that health and social care is a rewarding and fulfilling place to work and train.

“One particular project as regards workforce is that work is well underway to have a single lead employer for doctors and dentists in training by 1 August 2019.  This will address some significant issues for that group.

“Our transformation strategy is based on the principles of staff and user engagement – or co-production

“We have developed and published a Co-production guide – this is not the end point, but one stage on a continuing journey towards embedding partnership working within health and social care.


“I think that it is necessary to properly illustrate that the transformation agenda is well on its way.  It’s certainly not gathering dust on a shelf, as some like to say.

“That said, we have much, much more to do.  And the task that lies ahead is not easy.  But we travel with confidence - staff across the HSC continue to work together positively, to look for new ways to make things happen and to get things done.

“I want to finish with two brief messages.

“Firstly, to people thinking of pursuing a career in health and social care – please do!  We need bright ambitious people to refresh our system, and to continue to move it forwards.  I hope, if nothing else, this blog gives you sense of our ambition and capacity for change. 

“For my part, I have no doubt that we will see this through and transform Northern Ireland into a world leader in this area.

“Finally, the focus of my comments, and many other debates on this topic, are necessarily on the challenges we face and the need to change.  But let’s not forget that every moment of every day, fantastic care is being provided across Northern Ireland.  We are generally not comfortable talking about success – but our staff have much to be proud of.

“As I have already said, our system only survives because of everyone’s commitment to it.  And what will drive us forward is our desire to be better, and to do better, for the public we serve."

Notes to editors: 

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