Managing healthcare without a government: it’s time to step up, says NI chief nurse

When Charlotte McArdle was appointed as CNO in Northern Ireland she never imagined she would have to do the job without a health minister. Now she wants nurses to help to transform the care service

• Absence of government at Stormont for the past two-and-a-half years has stalled plans to transform the health and social care service 
• RCN warned in April that there were 2,500 nurse vacancies across the system – around 12% of the workforce
• Professor McArdle says nurses have the right skills to play a leading role in reforming healthcare

Charlotte McArdle, Northern Ireland’s chief nursing officer, can’t remember a time when she didn’t want to join the nursing profession.

‘My mother tells me I’ve always wanted to be a nurse. She says I used to play with dolls and syringes, and practice doing injections into oranges,’ says Professor McArdle. ‘I don’t come from a particularly medical background or family, so it’s not in my genes.’

Genes or not, she took to nursing as a career with focus and vigour, working her way up from her first job as a staff nurse in trauma and orthopaedics in the Dublin hospital where she trained, to her current role at the Department of Health in Belfast.

‘The chief nursing post doesn’t come up very often and it was a real opportunity to show leadership to the profession at a very difficult time’

But, much as she obviously still loves nursing, there have been challenges along the way. Not least of these is the political situation in Northern Ireland. 

Professor McArdle and her colleagues have been working without a health minister, or a legislative assembly, since the breakdown of devolution in early 2017. Although talks aimed at a return to power-sharing resumed this spring, there is, at the time of writing, no real sign of a breakthrough.

Making a difference

It was a very different picture back in 2013 when Professor McArdle decided to apply for her current role. At the time she was director of nursing at the South Eastern Trust (one of five health and social care trusts in Northern Ireland) and was enjoying making a difference at a local and regional level.

‘It was a difficult decision, because I absolutely loved being director of nursing in the South Eastern Trust, and we were doing some really creative and innovative things,’ she says. ‘Leaving was a big step. But the chief nursing post doesn’t come up very often and it was a real opportunity to show leadership to the profession at a very difficult time.’

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By ‘difficult time’, she means that Northern Ireland, like the rest of the UK, was in economic decline, with health services trying to make savings at the same time as demand for care was rising. Nursing placements at undergraduate level had been cut, exacerbating the shortage of nurses that persists today. 

‘Everything was being cut, not just nursing,’ says Professor McArdle.

The political situation at the time, however, appeared stable. ‘We have very local politics in Northern Ireland, and at this stage we had a very well-functioning devolved assembly,’ she says. ‘The health minister would come out to my trust and he knew me by name. I thought to myself, where else in the world would the minister know people in my position by their first name?’

She felt that in order to work with politicians it was important to ‘get into their world a bit’. ‘I’d had a clinical career of around 20 years at this stage, but very little understanding of politics,’ she says. ‘If I’m going to try and show leadership and influence health policy for Northern Ireland then, I thought, I need to understand how to do that better.’

Different skill sets

It was an unfamiliar work environment for her, she says. ‘Civil servants have a very different skill set and operate differently; their perspective is always about serving the minister. And the minister can take advice from lots of different places. 

‘So, I’m the professional adviser to the minister in nursing and midwifery but they have different priorities and perspectives and party manifestos that have to be considered. When you understand that, it makes this easier. But most times, to be honest, ministers do take your professional advice.’

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She has worked with four ministers in her time at Stormont (even with the absence of a minister for the past two-and-a-half years). This is a high turnover by any reckoning, and it has not always been easy.

‘Every minister has their own personality, and their own way of doing things,' she says. 'Some like a lot of detail, and others don’t. Some want to be involved in every decision and others don’t. It takes a while to work all that out and build a relationship. So, when it happens in quick succession as it did here, it’s challenging.

‘But what I’ve learned is that everyone wants the same thing. The political system and the civil service and the public health system – we all want better outcomes for the population. We just have different ways of getting there.’

‘Crisis point’

Nobody could deny that there are deep and serious challenges in Northern Ireland’s health and care system. For example, waiting times are consistently the worst in the UK, with around a quarter of patients waiting more than a year for treatment, according to figures for March 2019.

There is also a lack of nurses, with the RCN warning in April that there were 2,500 vacancies across the system – around 12% of the workforce. It is estimated that there is a similar number of vacancies in the care home sector.

The RCN has also pointed out that nurse pay in Northern Ireland lags behind that in England, Scotland and Wales. Indeed, RCN Northern Ireland director Janice Smyth has gone so far as to say that nursing services are ‘at crisis point’.

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Added to that, the lack of government at Stormont for the last two and a half years has, to an extent, stalled plans to transform the health and social care service that were promised following a review led by international health services expert Rafael Bengoa. Professor Bengoa’s report recommended radical changes, including rationalising acute services and shifting more care into the community.

Turning the ship

The health minister at the time, Michelle O’Neill, acknowledged that the health and care service was ‘at breaking point’ and pledged to take the transformation plans forward. That was in the autumn of 2016, just a matter of weeks before devolution was suspended.

Professor McArdle does not shy away from the issues, but she insists that progress is being made. 

‘Things are really hard, which is why we need a transformation plan,’ she says. ‘Thankfully the minister Michelle O’Neill left us with her transformation plan for ten years, called Delivering Together in 2016, so we’ve been working at that; putting the foundations and infrastructure in place to make that a reality, recognising that ten years isn’t going to happen in three years.

‘One in five people here will have mental ill health at some point in their life and mental health carries a socioeconomic burden because people can’t work’

‘A lot of the population maybe haven’t seen the change, and there may be times, when the waiting lists come out and they’re no better than at the last quarter, when they get a bit frustrated, but healthcare’s a big organisation and turning that ship, even a little bit, takes a lot of time.’

Professor McArdle says that what Northern Ireland needs now is a new, forward-looking model of care. ‘Nursing and midwifery is integral to all of it happening because we’ve got 33% of the overall healthcare workforce.

‘Nursing and midwifery are, for me, still the professions that stretch out to all four corners of the health and social care system because they have the ability to work in communities, with people and at that level. My message to nurses is that we need to step up and lead this, and show that nursing can lead this – that we have the skills to do it.’

Out of conflict

One of her key priorities is about reorganising primary care into multidisciplinary teams (MDTs). ‘Multidisciplinary teams are, for me, centred around the GP and the district nurse as the core, supported by the wider team with more input from, say, physiotherapy. You can potentially cut 30% of the GP workload through musculoskeletal work, for example.’

'If we can get that multidisciplinary team working well and right, it will change the lives of people who need to use our services'

Northern Ireland’s relatively recent history, which saw decades of the Troubles followed by a peace process culminating in the signing of the Good Friday agreement in 1998, has also left its mark on health services, including primary care. ‘We particularly need mental health workers [as part of the MDT] because we are a society coming out of conflict,’ she says.

‘One in five people here will have mental ill health at some point in their life and mental health carries a socioeconomic burden because people can’t work. Getting people back to work is a huge boost for them in terms of improving their mental health but it also means they can look after their family and contribute to society. So mental health is key, AHPs (allied health professionals) are key – GPs and nursing need to be strengthened.’

There is work going on to look at how the relationship between the district nurse, health visitor and GP can be made stronger and there are two pilot sites, one in the west and one in the south east, developing MDTs. ‘As part of that we are investing in additional district nursing support,’ she adds.

Safe staffing

She also points to work to take forward a safe staffing policy launched in 2014. ‘There are a number of phases to that, and we have done work on what safe care in district nursing looks like.’

This is happening despite a lack of functioning government in Northern Ireland, she says, adding that the money for transformation was agreed as part of the confidence and supply deal between the DUP and the Conservative government at Westminster. The deal, which kept the Conservatives in power after they lost their majority in the 2017 general election, may have been controversial but it certainly provided a boost for health.   

‘This gave us £200 million transformation money and we’re in the second year of that. We’ve been drawing that down to make some of these changes a reality and to test a lot of these new models,’ says Professor McArdle.

It’s a fantastic opportunity with great potential to make a difference, she says. ‘I think if we can get that multidisciplinary team working well and right, it will change the lives of people who need to use our services, but also our staff.’

‘I know it is very challenging for staff at the moment but there is light ahead. I hope we will get to a position where we have no nursing vacancies’

The team includes health visitors, she stresses, adding that there has been investment in reducing the ratios of health visitors to patients. ‘We’re also looking at a prototype for neighbourhood nursing, using the Buurtzorg approach, but adapted for Northern Ireland.’

Positions vacant

These initiatives are all very well, but where will the nurses come from to fill these posts?

‘We’re no different to anyone else – there are huge challenges with nurse vacancies,’ Professor McArdle says. There are a couple of reasons for that – one is that our [student] numbers were cut during the really difficult financial years, and obviously it takes a bit of time to wash through the outcome of that, so we’re experiencing the problems with that now. Also there have been changes to the pension scheme and some people have decided to take early retirement.

‘What we find is that young people tend to want to go and work somewhere else, but then they come back to Northern Ireland. I think what we have to do is get more flexible about how we allow that to happen,’ she says.

Men in nursing

Back in January, Northern Ireland became part of the global Nursing Now campaign, which aims to raise the profile and status of nurses worldwide.

In Northern Ireland, the focus is on tackling homelessness and, perhaps more controversially, on improving the equality and diversity of the nursing profession. This includes efforts to attract more men into the profession.

At last year’s RCN congress, held in Belfast, some young male nurses from Northern Ireland put forward a motion calling on council to develop a strategy to attract more men into nursing.  It was defeated but Professor McArdle said she would be prepared to help them take this forward.

‘The young guys want to encourage more men to go into nursing – that’s all they want to do, to go into schools and say, “look guys, I’m a nurse; it’s a great opportunity for you”.

‘They’re not interested in the career progression [issue] and how men get to the top more quickly, all that sort of stuff. They are looking at it from their perspective and I think that’s a good thing to do.

‘I’ve worked with them and I’ve set up a group, co-chaired by one of the young male nurses and a senior female nurse – and she is mentoring him to explore the wider issues in nursing, so it’s now called the equality and diversity group. They’re doing really great work.’

The Nursing Now work is perhaps a logical extension of Professor McArdle’s own interest in looking internationally as well as at Northern Ireland. In 2017, she studied with the International Council for Nurses’ Global Nursing Leadership Institute. 

‘This really encouraged me to look up and out of my own environment,’ she says. 

‘It has helped me connect policy here to a bigger strategic context and we now link nursing policy to WHO priorities and, indeed, the UN sustainable development goals. I believe this is an important aspect of professional leadership and strategic influencing,’ she adds.

‘Light ahead’

‘I know it is very challenging for staff at the moment but there is light ahead. We will have this year the first increase in the nursing students coming out of university and there will be a steady increase from this year on. I hope we will get to a position where we have no nursing vacancies through our own means of growing our own nurses over the next five years.'

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Professor McArdle’s enthusiasm for nursing remains undimmed. ‘I think it is a fantastic career,’ she says. ‘It is what you make of it. It’s very rewarding, it’s very challenging, and it’s different every day. I’ve loved it and I’ve given of myself to nursing and I think it has paid me back tenfold over.’