HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health & Social Care Reform
(Northern Ireland Local Government Association)
19 June 2008
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Rev Dr Robert Coulter
Dr Kieran Deeny
Mr Alex Easton
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Mr John Matthews ) Northern Ireland Local Government Association
Ms Heather Moorhead )
Ms Suzanne Wylie )
The Deputy Chairperson (Mrs O’Neill):
I welcome Heather Moorhead, chief executive of the Northern Ireland Local Government Association (NILGA), John Matthews, vice-president of NILGA, and Suzanne Wylie of the chief environmental health officers’ group.
Mr John Matthews ( Northern Ireland Local Government Association):
I thank the Committee for receiving us. This is an example of how the relationship between local and central government is growing.
We welcome the Programme for Government and the changes that are happening. NILGA wants to contribute to those changes and play its part in the whole range of services that are being delivered to the community. I am standing in for Arnold Hatch, who, at the last minute, had to go to England on business.
We think, and very much hope, that our vision for local government accords with your own in that we want an innovative, modern approach that is supported by the partnerships and relationships in Northern Ireland’s new dispensation between local and central government on modern, citizen-centred public services and greater efficiency and effectiveness. We want to see the breaking down of the silo-type management of services, and very much support the hub-of-the-wheel model in community and health services and other service delivery. We see local government representatives playing a key part in that. NILGA believes that that should be at the core of the changes.
We have met Health Minister McGimpsey on this issue, and he assured us that his vision is for greater democratisation of local health bodies in the delivery of services. We believe that he agreed with us that local government representatives should account for at least 50% of the membership of those bodies. In that way, the local community will have ownership of the services, feel more involved, have better feedback, and enjoy an improved sense of well-being.
There must be a clear understanding of the roles of board members and of public and council representatives. Members who are working on health bodies must be properly supported and briefed in order that they can give responsible and rational answers to the press and public.
Reporting structures are central to communication between central Government, local government and service deliverers. They are at the heart of the image of politicians, both local and in the Assembly. All of us — in this respect, we are all in the same family — receive criticism and a rough press. However, if the issue of reporting structures is properly addressed, that will be to everyone’s benefit — good for services, for citizens, and for those sectors of Government that are delivering the services. In addition, we want wider emerging arrangements across central Government.
NILGA is producing a paper for the strategic leadership board, which has been set up by the Minister of the Environment to deal with the implementation of the review of public administration (RPA) and bringing the 26 councils into 11 councils. The paper, which deals with community health issues, is expected to be ready in about eight weeks’ time, and we will forward it to the Committee.
Ms Heather Moorhead ( Northern Ireland Local Government Association):
A lot of people are involved in local authorities, and the RPA has taken about five years, with various ups and downs. One of the prizes of the RPA was coterminosity, in order that services could be streamlined. Many of our colleagues are running three or four partnerships that have different arrangements. A lot of time is required in order to develop those relationships, which distracts from getting a key plan for service delivery.
Four councils are somewhat out of step with the health trusts: Limavady, Newry and Mourne, Dungannon, and Castlereagh. If it is in the gift of the Department to examine that situation, we would welcome that. If that is not possible at this stage, there should be some negotiation and discussion with NILGA on how to implement community planning and develop suitable arrangements. Part of progressing community planning is streamlining the approach to create fewer partnerships. We want to work with the Committee to consider how to do that in a way that does not involve lots of staff running around to different kinds of organisations.
Ms Suzanne Wylie ( Northern Ireland Local Government Association):
I emphasise the need to explore the opportunities for working in the new community planning process that will come into operation under the review of local government and the advantages that it will bring by streamlining and integrating services locally. It will also provide greater public engagement and local accountability.
Community planning of health improvement and preventive health measures has a fundamental role in addressing health inequalities and focusing on integrating health improvement, protection and promotion. It also has a role in ensuring that the health impacts are taken into consideration in every public policy and by all public services. We welcome the establishment of a regional public health agency with a central role in co-ordinating the integration that, according to the consultation document, will be both regional and local. We welcome the local support for local government that the document suggests.
Local government should be regarded as civic leaders and agents of delivery, as that is where the community planning framework creates the hub to ensure integration of services, including those that have an impact on health improvement. However, local government should also be seen as an organisation that, in conjunction with partners, can deliver health improvement. It has responsibilities for environmental health, health improvement through the provision of leisure and open spaces, community development, good relations, economic development, and so forth. After 2011, local government will also have regeneration and planning powers, et cetera.
Local arrangements must include good and balanced two-way communication and joint working in community planning. Rather than the one-way consultation process that the consultation document suggests between the community planning organisations and the regional public health agency, we want a two-way communication process; that should be included in the legislation.
The local community plan must also be influenced and established in the light of regional policy — none of us would argue against that. The community plan can help to strike a balance between regional policy and local need. We would welcome the exploration of innovative delivery approaches at local level and the concept of local joint public health units or teams that would have joint ownership with the regional public health agency and local government. Those could be physically co-located, with the possibility of joint appointments. I am happy to take questions from the Committee on how that would pan out in the future.
I am keen that best practice from other regions be considered — many joint working arrangements exist in England, Scotland and Wales. All have slight variations, and each has disadvantages and advantages. We recommend that those arrangements should be considered and that the best should be adopted.
During the past several years, there has also been considerable partnership working on health improvement, which should be built on. There is lots of good practice from which to learn. It should be built on in a way that links with the regional public health agency and the community planning process at a local level. Integrated health and well-being partnerships that are aligned to the community-planning framework should be developed on an appropriate geographical basis. We want to highlight the need to involve local commissioning groups and patient/client councils in that process to develop and deliver community plans.
Finally, local government wants to see the development of some community planning pilots from 2009, which is, obviously, when the health structures change. Local government structures will not change until 2011, but we would like some pilots to be introduced during the interim in order to test some of those models and arrangements for integrated working and also to build the capacity of local government during that period. We suggest that the health structures design team should work closely with the local government modernisation task force on order to take some of those arrangements forward.
One benefit of local government is that it can think about health in its widest sense. A problem that we have found is that thinking on health ends up with the health profession — it is about sickness. In fact, health is about economic development, social cohesion, fuel poverty, crime, and so on. The language that is used and the way that business is done are important. If health remains simply a matter for the health profession, then it is somebody else’s job. Our belief is that if that were co-located with councils, and informing community plans, those plans would have a “health wedge”. The added value, or “big win”, from that is that the wedge — the thinking on health — would begin to influence all of the other areas, such as economic development, parks and leisure, and all of those kinds of strategies.
We welcome the regional public health agency, because it will bring about better intelligence and information. We will be able to see how our policies make people’s health and well-being better or, indeed, worse. Sometimes, work can be done on health strategies when, in fact, the economic development policy has a bigger impact on people’s health than anything else. Hopefully, community plans will have a focused approach on health, with health professionals working with environmental health officers in an influencing role and an added, innovative way of working.
Another advantage is that councils are innovative and close to citizens. They find ways to work together to bridge gaps, and find resources to plug those gaps, when other agencies cannot. The genesis of health action zones throughout Northern Ireland was based on where there was co-location and shared thinking between the health sector and local government. Lots of creative things happened. In fact, the health action zones created a culture for that, and innovations began to be piloted throughout the rest of Northern Ireland. We have, therefore, learnt from others and we are pushing at the right doors in order to try and find a more integrated approach.
Another advantage of having that within councils is that we would get all the things that we have discussed — economies of scale, back-office services, and so on. They provide the support structures, but we also get the intellectual philosophy right. Therefore, we welcome proposals for a much stronger and closer role for local government. We have begun to experience that relationship. Instead of there being a stand-off, which is usually the case, there is a realisation that everybody is responsible and that we must work together in order to make progress.
We do not want to usurp in any shape, form or fashion the strategic direction that will be set by the Assembly. It is good to have the opportunity to have dialogue in order to determine how services can be delivered and measured on the ground. One thing that will make a difference to our ability to make improvements and to interface with central Government is the power of well-being in that legislation. There are other features of the legislation, such as the clean neighbourhood agenda, which are more pertinent to what we do. However, it all feeds into the better lifestyle of the citizen. We are grateful for the opportunity to discuss that. Hopefully, we will have more opportunities to interface with the Assembly and to lay out the thinking of local government.
The Deputy Chairperson:
I agree that more integration, co-operation and focus are needed in order to tackle health inequality, which can be done locally. You talked about the benefits of community planning. However, there is no legislative requirement on councils to consult. The main aim of community planning is to engage with people in communities. The absence of that legislative requirement will cause problems and disparity, depending on where one lives and how focused councils are on encouraging co-operation. Will that be a problem, or will we see improved outcomes?
The style of community planning is happening all over Northern Ireland and it is beginning to show benefits, although it is frustrated by the fact that there are so many stakeholders. Some are coming to the table and some are not, and we are trying to move forward. We will see a massive difference when we get the statute and there is a better understanding and a framework. These issues are massively important. We must understand how to target things locally. We want to provide an even level of service for equality purposes, but we must also be clever about how that is done locally. The things that are happening in Strabane are not necessarily the same as those happening in Belfast; that is why we need community planning. We will have 11 new councils and there will not be the same problems throughout each borough: some towns may be quite wealthy and others not, so we will need community plans to tackle those differences. We hope that community planning will provide a level of flexibility.
The modernisation agenda for local government will address the issue of mechanisms for community engagement. Neighbourhood delivery structures have been put into play by many local authorities in Great Britain, and they join up neighbourhood service delivery with other agencies. That is the direction that we see local government moving in.
The Deputy Chairperson:
I welcome your suggestion of a pilot scheme. There are some good and bad examples of neighbourhood renewal, which involves several agencies coming together. Some councils have divorced themselves from that altogether. We must learn from good and bad practices and move forward.
Minister Foster’s statement, when she was Minister of the Environment, was very pertinent in that the changes taking place are not an event but a process. We are all subject to that process, and the target is an improvement of the way in which we live and work together.
As a GP, I am greatly interested in this subject. The old days of waiting for diseases to occur and treating them are disappearing rapidly. That is good to see. It is about health promotion and disease prevention, and that is where local government comes in. I am delighted to see that happening. Ms Wylie referred to facilities for young and elderly folk to encourage them to exercise, which, in turn, encourages mental well-being.
In your submission you referred to local government having a function of scrutinising the delivery of health services, and I could not agree more — that would be wonderful. Coterminosity will come into effect in 2011, and we should be thinking about our local commissioning groups (LCGs) being coterminous with our councils, not our trusts — and I mentioned that to the Minister the last time he came to the Committee. I would like to see six LCGs eventually, one in Belfast and five others, each with two councils. The Minister told the Committee that the plan is for four local councillors, which would be two from each of the new councils. That, to me, would make more sense as there would be an overlap of trusts and it would introduce competition. If doctors felt that their patients were not getting the service from one trust, they could go and commission from another trust.
I agree with you in one sense. You said that the Minister gave a commitment that local councillors would make up over half of the LCGs, but that is certainly not what he said to the Committee.
The Minister did not give a commitment, but there did not seem to be any area of disagreement. That is something that we aspire to.
He has given a commitment to more democratisation. This is our view.
I am currently on the West Local Commissioning Group — although I know that those groups are changing. There are 16 members, and four of those are local councillors and four are GPs. It is quite right that that should be geographically correct in each of the areas.
The regional health and social care board in Belfast is to have 400 staff, yet we have only 16 in each of the five local commissioning groups. There is no need for those 400 people in Belfast; I would have no problem with taking away half of those 400 and bringing the local commissioning groups up to 20 or 22 members. Then we could certainly have 50% councillors.
We are talking about commissioning going out to the local communities — bottom-up from the patient. You said that the health sector has always been in the hands of the professionals but believe me it has not. I know that you did not mean it like that. Commissioning was in the hands of the health boards, many members of which were managers or administrators and did not have qualifications in health. Many of those board members did not know the local communities, nor did the communities know them; commissioning was done in a top-down way. This whole idea of local commissioning is bottom-up.
There are a lot of councillors in my area who are committed to health, but I am told that on some councils there are not as many. There are reasons why many councillors in our area are involved in health, and it is a good thing. There are other people who are involved in their communities — for example, GPs such as me, pharmacists and optometrists. With the current proposal of 16 members, there is a danger of having no dentist, or no lay members, or not enough GPs. All of the people who I work with are committed to their local areas. As with elected councillors, there are people in health and the allied professions, and lay members — optometrists, dentists, people in childcare — who are very committed to their own areas and look at it in that way.
Is that the future? Do you think that eventually we should be coterminous with the councils — if we have 11 — rather than the trusts? There are still hundreds of people in the Department of Health, never mind the 400 people working for the regional commissioning board; that is bureaucracy dominating when we do not have enough commissioners in the community. If LCGs had 22 members, then I would accept your view that 10 of those should be councillors — there needs to be enough room for everybody who is interested.
We have our own house to look at; one of the big items in the review of public administration is the reduction in the number of councillors and the necessary change that will come when a lot of those councillors do not stand at the next elections. Capacity-building was one of the things writ large in that review. It is in all our interests to up the game and raise the standard of people who are aspiring to get involved in local and central government.
Capacity-building in local government is one of our big targets, but we have to change that culture. Currently, we have a few oul fellas going to a meeting of an evening to have a wee bit of an argument with their mates across the table — it cannot be that way in the future. I look forward to more professional people sitting on boards, bringing intelligent and rational comment to the various outside bodies. I look forward to the whole change that we are committed to, and to being able to sell that to the public.
The rationale among elected members is that the health sector is run too much by professionals. The concern is that one or two elected members cannot make that much of a difference on those boards, as they would be overridden all the time by the professionals. The main point that we are making is that it is important to have public representatives — not just professionals — giving a public view of what people think is important; that is the ethos of what we are trying to say.
Our view is that commissioning should be as local as possible. We want coterminosity. Something similar to what you have described would be a best fit with local government, and we would support that.
What do you think of this situation? All of us, even local GPs, are accountable. The patients know who we are, as does the electorate. What you are proposing is a different model. Previously, no one knew who was on the health boards. The boards could commission and make decisions and people did not know who to go to if they had grievances. Now the plan is that everything will be locally controlled, and that is the good thing. However, to me, having 400 people in Belfast overseeing what the rest of Northern Ireland is doing makes a mockery of the whole situation. The Committee needs to know how many staff each of those bodies will have.
The Deputy Chairperson:
The point about capacity-building for councillors is a key one. I sat on the RPA capacity-building subgroup, and the issue of the needs of councillors has been strongly highlighted by that subgroup.
There is also the issue of confidence. The general public need to have the confidence that the councillors representing them on the various bodies are capable, and that they are attending the meetings of those bodies.
That is why we make the point about support. We currently have elected members on European monitoring committees, and the papers that they receive can be quite voluminous. If those councillors are carrying out five or six other jobs, that amount of paperwork is not manageable.
To assist with that, we received funding to appoint a European officer. That officer analyses the papers, prepares the briefings, sits with the members and agrees the key points that local government wants to make, and reports back. While we want elected members to be on the bodies, we also want appropriate arrangements. It would be inappropriate to ask public representatives to do a professional’s job. However, we do not want to undermine individual members. Often it is not the members’ fault, but the fault of the system. We have found that our members are much more confident and better briefed, and can report back and articulate their views so long as they get appropriate support.
It is important that you are here today to express the views of local government. Many of us have a background in local government. Local government must be closer to the ground and the people if health inequalities are to be tackled and if people are to be supported in changing their lifestyles. There should be so much more going on in local government, particularly through the leisure centres and parks that we already have. If more is to be taken on — in a broader health sense — much will depend on how meaningful a role local government has within these bodies.
You talked about having sufficient numbers of elected representatives on the different bodies. That, I feel, must be balanced by the inclusion of other people and the community. A lot of it has to do with the role that councillors have. They must have something to contribute, not be sent there as a nodding dog with a large volume of paper that no one has time to get through.
The way that committees are set up in local councils can also make a difference. It is not just the chairperson who needs the briefings. We find in our own Committees that everyone needs to be kept informed of what is going on. That may mean cutting a great deal of less relevant matters from committee business, but that creates time for councillors to feel more confident and informed if they are attending meetings elsewhere.
We are in the midst of very exciting times, as the Committee has discussed with the Institute of Public Health in Ireland. Particularly in the case of the public health agency, where the more meaningful role is, how much contact have you had with the Department as to how meaningful the role of NILGA will be? Will it be a formal role rather than a consultative or box-ticking position?
It is important that NILGA should have a tangible role to play. It would be worth having some sort of pilot to help build capacity and see if it works. This is all about making things better for people, and it is only worth doing it if it will achieve that.
There has been disappointment in local councils with the responses given by some of the Departments during the review of public administration. It was not intentional, but meaning can get lost in the way that things are written. It is most important that there be a partnership between local government and everything else that goes on.
We have a big piece of work to do to tease out exactly what these bodies are going to do, and to make sure that they work together. The healthcare body must work with the public health agency; otherwise, it will not work at all. These bodies are so huge, as Kieran Deeny said. Decentralisation and moving services to other parts of the country have been mentioned, but we still have huge bodies in Belfast. The Committee must work with the Department to consider what the functions of those two big bodies will be. If this is to work, there must be a formal relationship between those bodies and local government and the communities. That is the bottom line for me, and I suspect that it is the bottom line for everyone. The proof of the pudding will be in the eating, but we cannot wait until it is all eaten. We must get it as right as possible before it gets off the ground.
It is our health and our community, not the bureaucrats’.
I do not know how much contact you have had with the Department on what your role will be and how formal that role will be. It must be a meaningful role.
We have had quite a bit of contact with the Department, both officially and through some of the stakeholder engagement exercises that were carried out around the consultation document, which were all without prejudice. Belfast City Council has had contact with the Minister and the Chief Medical Officer. The chief environmental health officers group and NILGA have also had those contacts. We have worked closely together in local government so that we are giving one message about how the reforms could work and how the relationships should be formalised at a local level.
I have been impressed. The Department has been open and engaging in wanting to have genuine talks. In such situations, a stand-off can develop as people seek to keep what they have. The Department has been open to the view that something closer is needed.
You made the point that Strabane and Belfast have different requirements. Carmel Hanna and Kieran Deeny mentioned inequalities, and that issue must be addressed. Inequalities can only be addressed at a local level — I support that position entirely.
I agree with the Deputy Chairperson and Mr Matthews about capacity-building; that is critical at this stage. However, your description of councils is not a reflection of what happens at Strabane District Council.
I have one further point. The commissioning groups will be located locally. Local government is exploring options for subregional structures. For example, planning services will be with local government. NILGA’s prerequisite will always be to empower the statutory bodies, which will be the 11 councils. We want the councils to have as much of the services and to be as autonomous and locally accountable as possible. We suspect that, when we examine the services, some areas of work will need to be delivered on a shared basis. There are perhaps three or four areas in Northern Ireland that do not have technical services and planning. We would welcome a discussion on that, because we do not want separate health and planning subregional structures.
As you suggested, a shared service might allow the local commissioning groups to serve two councils. In the short term, a relationship with the regional public health agency might work on a two-for-one basis for community planning, and that might also work for planning and other arrangements in a group or other shared service, or in some other way that provides for the council something that could not be done across 11 councils. Our prerequisite will be to have as many services in the 11 councils as possible.
The Deputy Chairperson: