HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health & Social Care Reform
6 March 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister
Ms Sue Ramsey
Dr Michael McBride
Dr Miriam McCarthy
Dr Andrew McCormick
Mr Michael McGimpsey (Minister of Health, Social Services and Public Safety)
The Chairperson of the Committee for Health, Social Services and Public Safety (Mrs I Robinson):
I apologise for the delay in inviting the public and the Minister into the Committee; we had some housekeeping matters to attend to. I welcome the Minister and his officials and those in the Public Gallery.
Minister, I regret that your time has been cut short. When the Deputy Chairperson and I met you some time ago, you said that you would be happy to discuss any issues that we might raise. However, we will not have time to discuss those matters today. The main evidence session will be on the proposals for health and social care reform, which you announced on 4 February 2008 and which are now subject to consultation.
I welcome Dr Andrew McCormick, the Department’s permanent secretary; Dr Michael McBride, the Chief Medical Officer; Dr Miriam McCarthy, deputy secretary from healthcare policy; Bernard Mitchell from the modernisation directorate; and David Bingham, the director of human resources.
As our time is limited, I will hand over immediately to the Minister.
The Minister of Health, Social Services and Public Safety (Mr McGimpsey):
Thank you for the welcome; I am delighted to be here. I will get through my opening remarks as quickly as possible, as I know that you are anxious to ask questions and I am keen to answer them.
First, restructuring is guided by the need to modernise the health estate — several hospitals are more than 50 years old and will need to be replaced at considerable capital cost. Secondly, we need to be efficient; I recognise that the Health Service is inefficient, and we must drive out inefficiencies. Thirdly, we must engage the local population in taking responsibility for its own health. Those are the three overarching strategic aims to which I work.
When I came into office I was faced with a proposal for a health and social care authority, and when I examined the proposals I felt that some opportunities had been missed. I went back to square one and began with a blank sheet of paper. I worked on proposals that presented the best opportunity for administering health for the future and began by looking at the three core functions that were proposed for the health and social care authority.
The first was to determine need in various areas and to commission health provision to address it.
Secondly, we considered performance management and improvement. Much of that is included under targets and ensuring that we deliver as efficiently as possible without affecting quality and patient safety.
The third aspect is finance. We deal with a very large budget and some very large organisations, and those organisations must stay within budget and exercise financial discipline.
Those were the three core elements that I looked for in a new regional health and social care board to replace the four existing health boards. It will have a maximum of 400 staff and will focus on commissioning performance management, improvement and financial management.
The next step involved engaging the population. Direct rule Ministers proposed to abolish the Health Promotion Agency, and its functions would be subsumed in that giant authority. I thought that that was a missed opportunity. Having taken advice from Dr Michael McBride, the Chief Medical Officer, and a very wide range of opinion from Northern Ireland and further afield, it was decided that the agency was the best way forward. A health promotion and improvement organisation was proposed — which would include the Health Promotion Agency — but which would have several other functions, including health promotion, health protection and public health.
We will engage the population, particularly on health inequalities: men living in inner south Belfast will live five years less than those who live in outer south Belfast; women will live three years less. That is as a result of health inequalities. We must look at how we drive forward health promotion, health protection and the public-health agenda.
Furthermore, I talked about the need for democratisation. Local government has a major role in public-health and in working closely with the new public health agency. There are some problems with local government as we do not know how many councils there will be, but we are fastened to the present five trusts, and we can be largely coterminous with whatever emerges, with some small adjustments. There is a focus on local government working on local community planning with local community and volunteer groups; initiatives such as health action zones and healthy cities will also be important. Responsibility for those functions will be removed from the trusts and given to the new agency, which will work closely with local government.
As part of the democratisation agenda, I have examined the commissioning function of the regional health and social care board and have decided that local public representatives should sit on the commissioning groups. I also expect to see local government representation on the board of the new agency as well.
I have also considered the proposal for a patient client council. As the Committee is aware, there are four health and social service councils, whereas the proposal under direct rule was to abolish them and to replace them with a single patient client council. However, we do not want to miss an opportunity to allow local representatives to play an important role in representing their communities. Those councils should not be abolished but should be reinforced and strengthened. We are considering proposals for a regional council with five sub-councils or perhaps one for each trust. That is covered in the consultation document. It is important that the local population has a voice.
A common services organisation will take over functions such as financial payments, recruitment, estates management, and information and communication technology that are not core to the board, the agency or the Department. That will reduce the size of the Department. The Department will focus on policy, legislation, standards and priorities, and on supporting and advising the Minister. The original proposal was for human resources to be dealt with by the new authority. However, as I do not believe that to be a sensible move, I will retain human resources in the Department.
That is a brief synopsis of the Department’s direction. The time frame is very tight, but it is achievable, and the 12-week consultation period is already under way. My target is to have the legislation ready for Second Stage by the summer.
The efficiencies that were set out under the review of public administration — a reduction of 1,700 administrative jobs to save £53 million per annum — will be achieved under that arrangement, and we will hit all the targets that we said we would. However, the major efficiencies will be achieved through the working of the new structures. As colleagues are aware, the five trusts were in place when I took up office in May, and I felt that it would be a mistake to alter those structures fundamentally or to tamper with them. At that stage, the new structures were just starting out and needed to be built up rather than put into reverse. Thus those structures will largely stay the same. As I said, it is my intention that responsibility for public health will be taken from the trusts and given to a new regional health promotion agency.
I am happy to leave it there and answer colleagues’ questions.
When will the regional health and social care board come into being?
I anticipate that it will come into being in April 2009. The target date is 1 April in the next financial year, which is tight but achievable. There is sufficient time for a full consultation period and the consideration of its findings. As in the run-up to the Budget, I will visit boards and trusts throughout Northern Ireland because the establishment of the new board poses many questions.
Through the consultation process, I will be keen to hear what others have to say and to consider any additional feedback. I am at pains to emphasise that nothing is written in stone. I have created a broad outline, but I am keen to hear from everyone, including the unions and staff. A great deal of wisdom is gained simply by listening.
I have a question for the Minister, although it may not be particularly relevant to today’s meeting. Given that the Department of Health, Social Services and Public Safety has been treated differently from all the other Departments, have you calculated what further savings can be made over and above the 3% efficiencies that can be returned to the Department over for use in front-line services? Have you come up with any figures?
The review of public administration states that 1,700 jobs must be cut to save £53 million, and that will be achieved.
Minister, I want to tease out more of your thoughts on local councils. How will local councils help in promoting health?
My second question is probably more for the Chief Medical Officer: will the agency do as much to promote and improve health as it will do for those who already suffer from long-term conditions?
Michael, you and I attended a stroke strategy event yesterday. Is that the type of condition that the agency can help to prevent? Is the agency as concerned with preventing the further deterioration of poor health as it is with health promotion?
Many Committee members have been local government representatives. My experience, as a member of Belfast City Council for the past 15 years, is that Departments are good at devising policies and plans. However, I am not so sure about their ability to deliver and implement those policies, and I envisage that local government will play a crucial role in that. Local government would be good at implementation. There is an opportunity for local representatives, who work closely with communities, to provide local representation and implementation.
Local government will have a strong role to play in delivering initiatives such as health action zones and healthy cities, and particularly in Investing for Health and the tackling of health inequality. As I do not yet know how many councils there will be, it is difficult to determine to what extent local government will be represented on commissioning groups, the public health agency, and patient and client councils.
However, I will reserve places for local government representatives, and there must be a drive for representation across the board. How that is done is a matter for discussion with the Northern Ireland Local Government Association (NILGA), local councils and others. Peter Hain proposed seven councils, the present number is 26, and the assumption is that the final number will be neither of those but somewhere in the middle.
I do not know where that middle will be. We may have our own views on the proposals, but whatever the council structure may be we will accommodate it coterminously.
You are determined, Minister, to move forward —
The member will address his remarks through the Chair.
Minister, through the Chair, are you determined to move forward and let the Department of the Environment — and whatever is finally decided in relation to councils — catch up with you?
I am on the ministerial subgroup on the review of public administration. As for the Department of the Environment, the planning proposals are at an advanced stage, although discussions still need to be held on other areas. The new local-government structures offer us a brilliant opportunity, since decisions on the promotion of health will no longer be just a matter of the Assembly exercising its powers regionally. We have a tremendous opportunity, through local government, to redress the difficulties of the past 30 wasted years in which local councils had no powers. Councils will have an important role in the new regional health promotion agency. I will let Michael talk about health protection and public health and the input that we hope to get from local government.
Dr Michael McBride (Department of Health, Social Services and Public Safety):
There has been much discussion about public health, and it is important that we remind ourselves that public health is about what society does to improve and protect its health and that everyone has a part to play. As the Minister said, improving public health must happen at a variety of levels. There is a strategic level across Government, under the framework that is outlined in Investing for Health and through the ministerial group on public health, which is chaired by the Minister. There is also the local level, because public health is about delivery in communities.
The proposals, particularly those for strong involvement from local government, provide a unique opportunity to ensure that we build on the projects that have been working well, such as the local Investing for Health partnerships. District councils have already been actively involved in that and in bringing about meaningful change for communities. Through the consultation exercise on the Minister’s proposals, we now have a unique opportunity to further embed local government in tackling health inequalities and in improving the health and well-being of the population.
Ultimately, public health is a matter of where people work, learn and live. It is about urban planning, such as local government decisions on the licensing of premises or about fast-food outlets; it is also about how we plan our environment, such as planning cycle paths and pedestrian precincts. Therefore local government has a vital, vibrant role to play. Public health must be put into the hearts of communities and local government, and we must build on the successes that we have undoubtedly had under the Investing for Health strategy.
Thank you, Michael. I hope that that answers your questions, John.
Yes. Thank you, Chairperson.
Minister, you and your officials are more than welcome. Wearing my GP hat, I have a particular interest in local commissioning. That is a new concept, and I could not agree more with the idea of local and bottom-up involvement.
I have some questions on practicalities. This morning, I spoke to a couple of GPs who are on present local commissioning groups, and they are concerned about practical issues. For example, some GPs have made arrangements in their practices for taking on locums. I know of one practice that has taken on a partner on what it understood to be a four-year contract. What will happen in such circumstances?
Having spoken about the proposals in my area and with other GPs, I know that people would welcome council representation on local commissioning groups, as GPs are particularly concerned about commissioning. Some years ago, in what might be described as a water-testing exercise on fundholding, GPs almost got their hands on commissioning and the ability to use finance for services for their patients. Will there be devolved commissioning with the necessary finance and the power to make decisions?
If that was the case, my GP colleagues and I would more than welcome that proposal. You said that the Department is involved in legislation; we believe that it is involved in strategies and planning, but not commissioning. If the proposal is genuinely about the devolution of commissioning — with the necessary finance and decision making and a bottom-up approach involving GPs, health professionals, the public and council representatives — we would be very interested.
If the proposal ends up as an exercise that needs a rubber stamp from the Department, my worry is that the GPs involved might walk away from it. The Health Committee does not want that to happen, because there is a great deal of GP interest in it.
Can you give me an assurance that that will be the case? I know that the local commissioning groups will be part of the regional health and social care board. GPs must be made aware that they will have real commissioning power that will be backed up by financial measures. With the help of councillors, patient representatives and allied health professionals, GPs having the power to determine the needs of primary care will be good news for the future of local commissioning groups.
I can give you that assurance, Kieran. We began with a blank sheet on this proposal. I sat down with officials — Dr Andrew McCormick, David Sissling and others — and one of the first issues to arise was the agreement that David Sissling came to with the British Medical Association (BMA). The Department will stand over that, as it is very much a part of the proposal.
A public health medical professional, along with GPs, will be part of a commissioning group and will help to determine need. There were four GPs in each group, and that number should stay the same. You can take comfort from that, as the BMA has done. If you wish, Andrew can go through the technical details and what has already been discussed with the BMA.
The proposal for seven groups was made because Peter Hain said that there would be seven councils; there will not be seven, although I do not know how many there will be. It seems to work with five groups; as 15 multiplied by seven would result in 105 commissioners for Northern Ireland. I wanted to change that. I also wanted to give the groups extra weight by reducing the number to five.
In addition, it seems that there was a missed opportunity for local representation in the make-up of the groups. I propose that there should be four locally elected representatives in each of those groups as well a public health medical professional and other professionals. That will be subject to consultation, and other proposals will be made.
There will be a transition, and the Health Department will seek to manage those GPs who have given undertakings or made commitments. Andrew will deal with that crucial issue because one of the building blocks is GPs being involved in commissioning for their areas.
Dr Andrew McCormick (Department of Health, Social Services and Public Safety):
The proposal always included a framework within which the questioning process would work. There will be a continuation of regional targets, standards and service frameworks as the basis for commissioning. However, decision making — which is the critical point — will be increasingly devolved. That will allow for consideration of targets and standards at regional level.
In that context, it is for the commissioning groups to make plans for the services that are appropriate to the needs of their populations, and that will enable the devolved process to work.
We get the best of both worlds: decision making is devolved while infrastructure and bureaucracy is kept to a minimum. The handling of money, for example, will not be the responsibility of the local commissioning groups; that minimises the need for administration and bureaucracy, but it delivers exactly what is decided at local level.
The Minister remains in control and his approval for commissioning plans will be required; but any plan that is based on a local assessment of need and in response to that need will be considered. That is the best of both worlds.
What happens to a GP has who has made changes to his or her practice and is not reselected to serve on a local commissioning group?
That issue will not arise until July at the earliest, so we have some time to work through the detail. During direct rule we decided not to set local commissioning groups up in shadow form, as we did not want to ask GPs to commit for a year when we were unsure what would happen. Therefore the decision was made that appointments would last for four years, which meant that some GPs made the kind of decision that you talked about. We now have to manage the consequences of that.
The seven groups remain, and their contribution continues to be beneficial. The consultation on the proposals is ongoing, and we will proceed only after a primary decision has been taken by the Assembly. However, the transition will have to be handled sensitively. We are grateful for the adjustments that some GPs made, and we will respect and honour those.
I welcome the Minister and his team and thank them for the presentation. Most people will welcome the steps that are being taken to improve structures. It is important that what is mapped out runs concurrently with the setting up of the new councils, which is supposed to happen by 2011.
Does the Minister agree that, with each passing day, it becomes more likely that we will have 26 councils until 2013? If that is the case, does the Minister agree that there is a danger that the process will be messy, confusing and frustrating for those who use the service?
We all want inequalities to be removed. Practically every stroke sufferer who spoke at the event that John McCallister referred to said that treatment is often a postcode lottery. For example, the availability of occupational-therapy services in the west is much poorer than in the east of the Province. Is there anything in the structures that will tackle such problems?
Living within budgets was talked about. The Western Trust has to deal with debts of £3·3 million. I am not questioning how that debt was accrued, but it is difficult to understand how inequalities of service can be tackled while some trusts have to deal with significant debts as well as other problems.
It is coming to the end of the financial year, and trusts are expected to live within their budgets. At this time of year things become concentrated. I am not aware of there being a deficit in any of the trusts, and I would expect them to inform us if there were. Last year’s deficit has been recovered, and I expect all trusts to meet their targets this year.
As far as the 26 councils are concerned, I remain optimistic that we can get agreement. If we do not get agreement, things will be very messy. The Department of Health will accommodate whatever number of councils there are, whether that be 15 or some other number. Although we may be stuck with the existing structure for another while, I will deal with that and with the discussions with local government officials. However, I will not allow that to derail the key issues for the future structure of the Health Service.
We expect much of the inequality of provision to be addressed through commissioning based on local need. Another key element is the capitation formula for financial resources in each area. That should be done equitably and fairly, and it should be based not simply on population but on need.
Will the Department still carry out the capitation exercise?
Yes, it will. The budget will flow from the Assembly to the Department. You mentioned the introduction of the service frameworks, which will set the level and quality of service that patients anywhere in Northern Ireland are entitled to expect. Some of those frameworks have been introduced and more will follow. The issue of stroke services will be addressed through one of those service frameworks.
It is a well-known fact that, every year, 4,000 people in Northern Ireland suffer a stroke. Unfortunately and tragically, 1,300 of those people will die in the first month, and a further 1,300 will be left permanently disabled. Indeed, some of us heard the views of those affected by strokes and their carers at a very compelling workshop, which was sponsored by the Northern Ireland Chest, Heart and Stroke Association and by Speech Matters.
With regard to the point about the inequity in service provision, we are consulting on the draft stroke strategy. Thanks to the agreed budget settlement, there is significant investment to ensure that we improve the inequity in service provision. The consultation period finishes at the end of March.
We are, as the Minister indicated, developing a raft of service frameworks. There will be a section on stroke in the cardiovascular health-and-well-being service framework. That will set the optimal standards that we should attain for all patients, irrespective of whether they live in Strabane, Strangford, Ballymena or Ballycastle. The standard of service provision should be the same everywhere. Therefore, the service frameworks will set explicit standards and outcomes that we would like to achieve. As Dr McCormick said, those frameworks will then form the basis of our commissioning of services from providers, and they will inform how we will benchmark ourselves against achieving that quality of service.
Dr Miriam McCarthy (Department of Health, Social Services and Public Safety):
We are in the process of consulting on the stroke strategy, and we invite comments from Committee members. We asked Speech Matters to produce a user-friendly, shortened document, which has been very useful in workshops for people who do not want to sit and read a lengthy textual document and for people who have suffered a stroke and for whom sight is a problem. There is a real opportunity with this strategy to make a difference.
I know that the Committee is interested to hear more about it at a future date, and I will facilitate that.
Ms S Ramsey:
It is crucial that this be tied in with Investing for Health because, at that time, that document was a vision for the future. If the Assembly implements this strategy correctly, there are exciting times ahead. I do not want to seem too negative; however, having gone through the Committee’s work and having dealt with issues in my constituency, it is clear that staff, service-users and families must be informed as quickly as possible. It is important to avoid confusion during the transitional period.
The Minister indicated in his statement on 4 February that he had examined other models. It would be interesting to know if he has incorporated any areas of best practice into his own proposals. I am eager to ensure that no potential conflict of interest arises on commissioning groups between the provider and the commissioner.
I take on board the Minister’s point about local government and increasing the input of local councillors; however, considering that those councillors know the issues in their own constituencies, will the community and voluntary sector’s contribution to health and social care be negatively affected by the reform?
The community and voluntary sector plays a key role, which will be enhanced by the establishment of a regional public health agency. In my experience — and probably in the experience of anyone has who been a local councillor — local government plays an important part, through local knowledge, in delivering information and service on the ground. Furthermore, local councillors will play a key role, because they are in close contact with their communities. That is a strong reason for local government to work together with the community and voluntary sectors. Rather than compete, each should complement the other and strengthen the system.
The Department examined other models. For example, the Irish Republic has the Health Service Executive, which is essentially a super health-and-social-care authority, similar to what was proposed here under direct rule. However, there are mixed views about how successful that has been. The Scottish model provides that the trusts commission for their areas, depending on what they determine the needs to be. That is dangerous because the providers could commission simply what they can provide, rather than deliver provision based on need. Therefore, I believe that a separation is necessary. The Department has effectively stripped away the outer layers of the proposed health-and-social-care model to the three core functions of commissioning, performance management and financial management, and there are very strong reasons for those. That is the best way forward.
This is potentially a very exciting time for health, and the first time that this has happened in 30 years. If the Assembly establishes the new health and social care body correctly, it can tick a box, and — as long as the model is flexible enough to evolve and change without having to break up and start again — that body can serve its purpose for the next 30 years.
At the time of the launch of Investing for Health. in 2002, Sir Donald Acheson, former Chief Medical Officer of England, referred to it as the best public-health document that he had seen in the English language.
That was a product of genuine cross-Government and cross-party co-operation under the leadership of the Minister in the Ministerial Group for Public Health. It has delivered in the short term by improving life expectancy. However, we have not been as successful in closing the inequality gap between rich and poor.
As you outlined, crucial factors are coming together: we have, again, a strong, local Government, and a policy review of Investing for Health will commence next year, for which we are doing the preparatory work. We are happy to keep the Committee updated on that. Furthermore, we are reviewing the fundamental structures of the Health Service to improve the health of the population, improve life expectancy and reduce health inequality. Therefore, I agree — this is an exciting time.
Ms S Ramsey:
I do not want to sound negative, but can there be a conflict of interest between the provider and the commissioner?
No. We are trying to get the right balance. The commissioning groups are designed so that there is no provider involvement; there is, therefore, no conflict of interest. Furthermore, we do not regard commissioning as a confrontational process or something that is designed to cause dispute or difficulty. On the contrary, the power — the financial resources and the decision-making power — is on that side of the system. However, we must build on the successful collaborative approach that works well in this region, because trusts and commissioners can — and should — work together, particularly clinicians and other professionals. The structure and systems can deal with the hard edge of final decision-making, but the nature of the system is more collaborative and constructive, and we must build on that strength.
It is also important to stress that, although there are five commissioning groups tied to five trusts, that does not mean that each commissioning group is tied to one trust for provision — they can go to any trust. The commissioning groups have the freedom to go to any one of the five, which strengthens the commissioning function.
I welcome the Minister and his colleagues. I am grateful for the presentation.
Although there is a fair bit of detail on the issue, I will concentrate on the headlines. You talked about the local focus; however, you spoke about the health inequalities in the individual patient’s journey. The other inequality is in long-term illness, which you referred to when you mentioned strokes. We have all been to presentations with patients and carers, and it is humbling to listen to what goes on in their heads and to how little their voice is heard. We focus on cancer and heart disease; however, many people, such as those with arthritis and multiple sclerosis who do not have those diseases still suffer quality-of-life problems. It is important to improve the details and quality of their care, even if that is only flexibility in appointments or not having to wait for six months to go to a pain clinic following a flare-up. I put it on record that it is important to do that. Many people, particularly the long-term sick, do not feel that they have a voice in a big organisation, because they are spoken to but not listened to.
You mentioned health promotion and the Health Promotion Agency, which is covered by the commissioning functions. Do you have any details about that? Will the Health Promotion Agency per se be incorporated into a new regional public health authority? How do you picture the strategies for disease prevention and health promotion?
Miriam will respond to your remarks about long-term illnesses and the patient journey.
I see the new agency as reinforcing, strengthening and enlarging the whole health-promotion agenda about promotion, protection and public health. Michael McBride can deal with the detail better than I can.
You raise a very important issue on chronic-disease management.
Management of chronic disease is crucial to the future of services. There has been a move away from isolated incidents of disease. Most people, as they get older, are now more likely to have a chronic disease, and live with it rather than die from it. During the CSR period, the Department has identified a significant amount of money — over £10 million — to improve the management of chronic disease. Some of that is based on trying to keep people in their own homes, and maintaining their independence and dignity, rather than their being hospitalised. You are absolutely right: often, it is humbling to listen to people’s stories about how they must manage, and how their chronic disease affects not only them as individuals, but their entire families.
Therefore, it is important to maintain patients in their own homes, with independence and dignity. An example of how that is achieved is through the introduction of specialist nurses — heart-failure nurses and specialist respiratory nurses — who visit people in their homes. Patients love that and it makes a difference. It helps patients on a personal level and significantly improves the management of their disease. That has real potential, which must be further explored in the next couple of years.
Moreover, there is the potential to monitor patients at home. Rather than bring them to outpatient clinics or to GPs, they can monitored without having to leave their homes. For years, diabetics have monitored their own blood-sugar levels at home. There is huge scope to expand that area through telemedicine and other technological advances. The Department is committed to exploring those possibilities and now has funding to do so. It will look to working with professionals in achieving its objectives.
The first part of the question referred to functions of the public-health agency. Clearly, there are three large elements of that. The first is public-health support and expert advice from the multidisciplinary public-health team to the board that will commission services, so that commissioning will be about transformational changes and services that achieve better, more equitable outcomes for all patients and service users, irrespective of where they live.
The second important element is that of health improvement and of bringing together the critical mass of staff and expertise from the existing boards, the Health Promotion Agency, and the health-action zones, to move forward that work agenda in a way that has always been envisaged in the investment strategy’s objectives and goals for health.
The important third element is health protection, which covers, as the Minister mentioned, childhood immunisation, cervical screening, breast screening, emergency planning and preparation for pandemic flu, as well as the important issue of surveillance for infections, including healthcare-associated infections. Recent events have emphasised the importance of ensuring that there is a strong, centralised function that can rapidly co-ordinate the Department’s response.
Many areas have been covered. I welcome the pledge from the Minister and the Department to set the wheels in motion to deliver a more effective, efficient and better Health Service for patients, and to set in place the framework, strategies and targets that are long overdue. Input from local councillors will be a move in the right direction towards helping to eradicate health inequalities. Serious inequalities in the current health system must be addressed.
Two issues that always come to the fore are the efficiency savings of £53 million by 2011 and the 1,700 reduction in staff. I want an assurance from the Minister that those staff will come from the already overbureaucratic management-administration system, rather than from nursing and front-line staff who deal with patients; and that there will be no detrimental effect to patients. I am concerned that patients will still have a service that is delivered to the highest standard during the transitional period. Perhaps the Minister will provide clarification.
Yes, I can give that assurance. The 1,700 reduction in jobs will, primarily, be from the boards’ administrative staff and not from such staff as nurses. Dr McCormick will provide the details.
The first phase, the merger of the trusts, has happened. The unfolding of the job reductions will happen through to 2011; the numbers will be achieved and the savings secured by that date. The process will involve filling the posts by competitive processes as the new organisations form. There will be a process of early retirement or voluntary redundancy so that delivery of the objective of streamlined administration is achieved as smoothly as possible.
The majority of savings will come from the reduction of the 18 trusts — all of which have their own finance divisions, HR divisions and other support — to five organisations. Approximately 1,300 of the 1,700 job reductions will come from the merger. The new proposals on the structures for the rest of the sector, which affect the existing boards and agencies, must secure around 400 job reductions. Those will not be achieved by staff redundancies but by suppressed posts. We have had a process of vacancy control for two years, which means that the process can be managed. Although that involves a substantial cost, we are seeking to manage and minimise it to achieve long-term savings. The costs are one-off, but the savings will last for the rest of time. That works as a justifiable value-for-money process, and it delivers the objective of streamlined administration.
Some Committee members touched on commissioning. Minister, you said that effective commissioning is the link between policy development and delivery on the ground. Given that research shows that healthcare improvement starts from the ground up, have you considered other ways, in addition to the health and social services councils, to ensure that the patient voice is heard at all levels, including commissioning and regional-board levels?
Do you think that the new regional health agency could contribute to renewing the focus on protecting the funding of such key public-health strategies as Protect Life, which is part of the suicide strategy?
The four elected local representatives will pay an important part in representing local communities. That element was missing before, and it is an important element because those representatives are in a position to represent the views of local communities. Furthermore, the patient-client councils will have an important role. Places will be set aside for local councillors, as well as for the councils representing their particular areas. There will be five organisations; the question of whether that will be one organisation with five subsets or five separate organisations is out for consultation. I am in favour of there being one organisation because a strong regional voice is needed, as well as a local voice.
A council and sub-councils seems to be the best solution. However, patient client councils are another important way of enabling people to express their views and to ensure that there is accountability, not merely through the Assembly but through local councils as well.
Does the Minister envisage the new public health agency giving a renewed focus to the protect life strategy and the suicide strategy?
Those strategies aim to reduce need and demand for Health Service resources by encouraging local health engagement. The strategies will benefit greatly from that approach.