Friday 12 October 2001

MINUTES OF EVIDENCE

Crisis in the Health Service

Members present:
Dr Hendron (Chairperson)
Mr Gallagher (Deputy Chairperson)
Ms Armitage
Rev Robert Coulter
Mr J Kelly
Mr McFarland
Ms M McWilliams
Mrs I Robinson

Witnesses:

The Chairperson:

Thank you for attending this morning, especially at such short notice. I acknowledge your letter relating to the £2 million that the Ulster Hospital has received and we will hear more about that later.

The Committee is concerned that the Health Service across Northern Ireland seems to be disintegrating. We appreciate the massive problems you face as regards funding. The Health Service is underfunded in comparison with levels of demand. It is important to compare the funding situation here with that in England because the bulk of our costs are driven by developments in pay, drugs, clinical and other professional standards there. We must maintain comparable budget levels with England or we will see deterioration in the level local service.

Although there is greater need and demand here - and we have a strong case for higher levels of resources - there are lower funding allocations. You and your Colleagues will be aware that the amount of moneys promised over the next few years is frightening; there will be a shortfall of many millions of pounds.

The Minister of Health, Social Services and Public Safety (Ms de Brún):

I am grateful for the opportunity to discuss the overall state of health and personal social services (HPSS) and I thank you for your kind opening remarks.

In your invitation you identified a range of issues which you wish to discuss this morning and at the outset I would briefly outline some of the steps I have started to put in place to tackle these issues and the challenges that lie ahead. My approach has been based on three main strands. First, I have been working on a planned strategic way to build a stronger and more efficient HPSS, embracing developments in primary care, regional hospital services, community services and quality. Secondly, my officials have been working daily with the service's staff to provide solutions to the immediate problems that affect our services in each of our areas. Thirdly, my Colleagues and I have continued to press for recognition of the importance of providing additional resources to deal effectively with the difficulties and challenges we face.

The draft Budget for 2002-03 throws into sharp relief the extent of these difficulties and challenges. In July, I advised the Committee that we needed an extra £122·6 million just to meet inescapable commitments and top priority developments. If I had obtained that amount or something close to it then I could have maintained access to critical services and would have been in a position to debate today how best to improve and develop services next year. I am not in that position. The draft Budget offers me an additional £31 million, some £6 million short of what I need just to maintain existing levels of service.

When I assumed responsibility for the Department of Health, Social Services and Public Safety in December 1999 I took over a dedicated, skilled workforce focused on looking after the sick and vulnerable in our community. I also found a service, which, under direct rule, had not been given the priority it deserved. As you stated, Mr Chairman, there had been chronic under-investment in delivering service and in renewing and modernising buildings and equipment. There had been a policy of imposing cash savings, none of which were returned for further investment in health and personal social services; some £190 million has been lost in this way.

The service has not been able to match development elsewhere, and its attitude and behaviours reflected the internal market. There was no long-term investment in the workforce to guarantee availability of skilled, trained staff to meet the increasing demands across the whole spectrum of services. There was still a major emphasis on dealing with illness rather than prevention.

In my term as Minister I have aimed to address those deficiencies. I recognise that it will take time to put things right as regards people skills and infrastructure, even if the money were available. These represent long term investments. I cannot stress strongly enough that there are no immediate solutions. No easy savings can be made which will compensate for such a situation.

Despite the fact that, since the early 1980s, the equivalent of £190 million in today's terms has been removed from the HPSS baseline budget, 10% more patients have been treated in the last five years. During the same time there has been a 27% increase in the number of community care packages. Additionally, the service plans to achieve savings of £12 million by the end of 2002-03. All of this demonstrates that the service will continue to set the pace in pursuing efficiency and value for money. However, no one should think that greater efficiency is a substitute for major public investment. Restructuring the HPSS will not deliver a higher level of resources either.

As the Committee knows, I am keen to see an efficient organisational infrastructure with a shift of resources from administration to care. That is something that we have discussed in the past. I will pursue that aim in the context of the Executive's consideration of the issues arising from the review of acute hospitals and their wish to review public administration. It would be wrong to think that organisational restructuring, however radical, will offer more than a modest contribution to ease the pressures that I face.

Those factors underpin my insistence that we cannot resolve the present serious situation in HPSS without addressing the fact that additional resources are needed. The Committee and I had a constructive discussion about the Budget position report when we met in July. I am grateful that the Committee supported the case for significant investment in services.

I have established a range of measures and initiatives designed to provide the strategic management and direction that is required. I have put in place clear co-ordination arrangements for tackling winter pressures. I have started to institute critical, additional intensive care and high dependency provision. I have moved to remedy the under-investment in the nursing workforce. I have embarked on a strategic analysis to identify future workforce needs. I have introduced radical changes in planning and accountability. I have brought forward important legislation with the help of the Committee and the Assembly. I have established the Northern Ireland Social Care Council and the acute hospitals review. I have led the development of the investing in health strategy. I have proposed new standards for quality in governance in best practice and best care and accelerated the modernisation of the ambulance fleet.

An action plan on cardiology and cardiological surgery has been set out for consultation. I have announced new arrangements for senior pay levels in HPSS. Soon, I will announce the way ahead in primary care, and I will propose further enhancements of the ambulance services. Other initiatives are underway. The review of community care is well advanced, and work is progressing on the development of the carers' strategy. A review of renal services aims to identify what additional provision is needed, what the configuration of services should be and the balance between the different methods of treatment.

The resources I sought recently reflected the need to continue to start these initiatives and to meet a range of critical pressures on existing services. The Committee has discussed those with me on several occasions.

The settlement that emerged from the draft budget will not even enable me to stand still. In order to meet part of the gap, several of the Programme for Government's targets may have to be postponed. As the Executive acknowledged, under that scenario it will be impossible to introduce free nursing care from 1 April 2002.

I must make it clear that in order to address the present state of health and social services a range of investments must go ahead for which there is no provision in next year's figures. The first priority will be the reinstatement of the Programme for Government targets that were deferred. Beyond this, I still need the £91 million that the Committee supported, and which Members referred to in discussing the £122·6 million figure during the statement on the Budget. However, I recognise that there is no possibility of that sort of increase at present. It will make a difficult situation worse in many services, including those mentioned in the invitation that the Committee sent to me.

There is critical need to maintain momentum in the residential child-care strategy and to increase our level of adoption and foster care. I must also develop our mental health services, particularly for children and adolescents. Services for the elderly are facing a crisis. We need to build up our capacity to care for the elderly in the community and I am aware that resources have not kept pace with the increasing costs faced by the residential and nursing home sector. We urgently need to improve key regional services such as the renal, cardiac, cancer and neurosurgery aspects.

Hospital capacity is at breaking point. Reports of unacceptable trolley waits are now commonplace and the increasing emergency admissions continue to squeeze out the capacity available for waiting list work. Expanding capacity in providing adequate provision to deal with winter pressures is a key priority. We also need to put on a permanent footing the advances made in our drug and alcohol strategy.

These are important issues and I will continue to press for the resources needed to allow my Department and the HPSS to deal with them. I can also assure the Committee that my officials, the Department and the HPSS will work with whatever resources are available to us to do the very best we can for the people who depend on us for health and social care services. I know that the Committee appreciates the nature of the problems and the difficulties facing the HPSS, and I am grateful that that was made so clear in your opening remarks. I hope that I can continue to rely on the Committee's support in my efforts to build a stronger and more effective service.

The Chairperson:

Thank you, Minister. As you have said, the Committee appreciates the funding problem. We are worried about the regional cancer centre. Dr Etta Campbell, the Chief Medical Officer, produced a report in 1995 that followed a similar report in England and Wales. There was a lot of opposition to the closure of the Belvoir Park Hospital at the time. However, as people began to understand the situation, support gradually increased for one large cancer centre at the City Hospital with four units elsewhere.

The Committee met with the Campbell Commission not long ago. The situation is desperate. We recently visited Belvoir Park Hospital and like you, Minister, we have great admiration for the staff there. Out-of-date equipment is breaking down, and patients attending from various parts of Northern Ireland sometimes have to leave and come back again.

The costs for the new centre are rising on a daily basis. The figure is now almost £57 million. The Committee understands the financial constraints and the need for prioritising or reprioritising. However, the money has to be found. The number of people dying of cancer in Northern Ireland is now almost equal to the toll for heart disease.

Bids have been made to the Executive programme funds under infrastructure/capital renewal in respect of roads and gas because of their regional nature. The cancer centre will provide a regional service. Have you considered a bid given the centre's regional nature? Executive programme funds are also available under the headings service modernisation and new directions. The Committee has given this matter serious consideration. My central point is that we need to prioritise.

My second point is about Knockbracken Healthcare Park, formerly known as Purdysburn. There is a lot of land there - possibly 100 acres - which could be sold. The same could happen at Muckamore Abbey and at many other places. I am not a financial expert, but I understand that the more properties that you have not used, in some way, makes it difficult to get extra funding from the block grant. It should be in your interests, and that of the Department, to look at that.

Money must be found to fund cancer programmes. I am not pointing the finger at you, Minister, because if I were put in a corner I would have great difficulty with the matter also. You will have the support of the Committee and I do not know of any Minister on the Executive who would say that that could not be done.

I have already mentioned bids for funding in respect of roads and gas, and they are necessary. However, the funding for the cancer centre must be found. Yesterday, I spoke to Prof Patrick Johnston and Prof Roy Spence, a cancer surgeon, and the Committee spoke recently to Action Cancer. Our constituents and Assembly Colleagues agree that this is a major issue and it has to be dealt with urgently. I may be overstating the case, but I feel it is important.

Therefore, as bids for roads and gas have been made to the Executive programme funds under infrastructure/capital renewal, service modernisation, and new directions, a precedent has been set as regards bidding for a regional centre.

Ms M McWilliams:

Where are we going to get the money? The Minister has pointed out that we have lost £118 million, and that is going to have serious repercussions. Having looked at the Executive programme funds I am concerned that under the heading 'infrastructure', health does not seem to be a priority. Given that we have our bids in front of us under service modernisation, new directions, and social inclusion, the total bid is over £42 million. The total funds available are only £37 million. Therefore it is unlikely that we will get all of them.

There are questions to be asked, such as how did the bid in respect of the brain injury unit end up under Executive programme funds? There is confusion when bids are being made. First, it would be nice to see them in advance, and secondly, why do they ending up where they are? Is it because there has been some jiggling around to make them fit under certain criteria?

More importantly, if we are not going to find the funding for new capital projects such as the cancer hospital, where is the bid for that under the Executive programme funds? What about the purpose built maternity hospital that we were promised and which was not mentioned in the lead-in to the discussion about plans for the future?

In your budget statement you said that some planned developments will now have to be deferred. You outlined to the Committee a number of Programme for Government actions that are starting to fall behind; waiting lists received the most attention. You mentioned the adolescent and psychiatric beds that are not likely to be in place; but we had predicted that for some time. At the end of its letter to us the Department make the point that there will be a deferral of some planned commitments rather than service reductions. People working in the service already feel that they are experiencing service reductions. Trolleys are stacking up and people are waiting longer and longer. They are asking staff what is going to happen. Staff feel that reduced services are staring them in the face.

The Committee must gain a sense of what deferred commitments means. Nursing care has been mentioned. In the last paragraph of the press release you highlight community care and mental health services. People in those services are concerned about why they are always deferred. Therefore there are a number of points with regard to the budget as it currently stands.

Mrs I Robinson:

We are annoyed that we have not seen a package for the new cancer hospital at the Belfast City Hospital site. The equipment at Belvoir Park is in a dilapidated state and unable to cope with the demands put upon it. Can the Minister guarantee that she will, in the interim, find the moneys to keep the equipment running smoothly as breakdown leads to cancellations of appointments?

Ms de Brún:

As regards maintaining equipment, people know that some of the bids put in last year to the Executive programme funds were not covered. Members knew at that time some of the things that we hoped to do. The cancer centre is a top priority for us; we will find the money even if it means re-prioritising other things.

The business case has to be properly evaluated. Members will understand that where trusts signal developments in the service which mean that the previous assessment of the amount of money needed is not sufficient, the level of money needed goes up significantly and another business case has to be requested. Members want to see resources being used properly, and that we do not take short cuts with the process in the interests of the patients and the taxpayer.

Therefore it is important that we get it right. The £56 million estimate now reflects the consensus among service interests. I hope that the business case can be cleared urgently. There will be a need to conclude the private finance initiative (PFI) process to reach decisions on what other form of procurement there will be and, because the sums are significant, the decisions are not for me alone. There has to be a proper process, but it is a priority for me.

There has been investment in the Belvoir Park site for the provision of services. Thirty thousand pounds was allocated in 2001 for the maintenance of equipment. In July last year I made £300,000 available for the treatment-planning computer. As you know I closely look at what else needs to be done at Belvoir. I assure the Member that it is something that we are actively looking at, and I hope to be able to make an announcement shortly. That investment is not to underpin services but to provide an opportunity for staff to be trained in new technology in preparation for the cancer centre.

I understand the points you make about the priority of cancer services; there is no doubt about that. No-one would say that this cannot be done, but I must say that my Executive Colleagues and I have had to agree on a draft Budget in which many priorities cannot be done. That is the position we are in.

As regards maternity hospitals, you will know from the Department's letter that it is one of the major issues facing us in the near future, and I will point out what work is being taken forward. I can return to the present situation as regards the work on the maternity hospital and I can also address the generality of how money is made available for capital programmes if Members wish.

I am concerned that mental health services and work in the community should not suffer. However, I have to be realistic about some of the decisions I may have to take and where they impact. Final decisions have not been made, but I thought it right to be honest with Members about some of the difficulties we may face. When I talk about service reductions, I refer to laying-off staff. I am trying to avoid cutting back on what we are doing at present.

Ms M McWilliams:

It concerns the Committee that you are constantly talking about re-prioritising within a budget that is so limited; I made this point on the Floor of the House. Is there much concern among the other Ministers that there needs to be an attempt to re-prioritise the Executive programme funds? It seems to me that if there is any give in the current system, that is where it is. The Health Service has not done very well out of it to date.

You must go back to the Ministers and address this issue. You are having to re-prioritise within an amount of money that is already so small that the people are screaming about what is happening yet there is an infrastructure budget of £100 million, of which £69 million is still unallocated. I know there are issues concerning roads, rail and telecommunications. However I am concerned that that is the largest amount on the Executive programme funds for next year and for 2003-04. Why have we not done better from that?

Ms de Brún:

For the first time the Executive has stated that health, education and roads are a priority. It named health as a priority. I hope that that will carry through to the examination of the Executive programme funds and that it will carry through to the way resources are allocated against priorities.

The Executive programme funds are new, but this is not extra money. These funds come out of the same block that would have been allocated. Health forms such a large part of that block, and a priority within that block, that money being allocated in a different way has an impact. It can potentially reduce and potentially increase the amount in the health budget depending on the allocation.

Ms M McWilliams:

The Health Service in England seems to get money all the time for certain priorities compared with the service here. In our case money coming here goes into the block grant. Subsequently, you, as Minister, try to bid for money from the block grant. The Executive programme funds sit alongside the block grant. I would argue we have not done very well out of the Executive programme funds. How can you justify that situation?

Ms de Brún:

My Department has not done well out of some allocations from the Executive programme funds. Another point worth making is that although money may come here with a health or education tag it has been decided that it will not go to any particular area automatically. The requirement is that money comes here as a block grant and is allocated by the Executive.

The Chairperson:

You and your Department are strongly pushing for funding for the cancer centre. Everyone agrees how urgent and necessary that is. Will your Executive Colleagues support the bid? Do they understand how desperate the situation is?

I believe that the business case was made three times. On the second occasion experts were brought over from the UK Government. Their decision was that the figure arrived at was too low and that you would have to look at the business case again. That exercise was carried out in June and it is now October. What is the situation now?

Ms de Brún:

I cannot break confidentiality in order to tell the Committee how my Executive Colleagues have responded. However, I can say that the difficulties and choices have been made to them in detail.

Mr J Kelly:

It strikes me as we talk that health is such a broad issue. It is not a Castlereagh issue; a west Belfast issue, or a west of the Bann issue; it affects everyone throughout the north of Ireland. There is merit in our asking for a meeting with Reg Empey and Seamus Mallon to discuss our views on the very critical nature of the Health Service. We need to press upon them, at face-to-face level, the critical necessity of finding money from some source to help us get out of the state we find ourselves in.

Mr Gowdy:

The issue of funding is not a block to progress on the cancer centre. The centre is a top priority for us in protecting patients' interests. It has to be delivered as quickly as possible.

Our problem is that we must also square off the taxpayers interests. That is why the business case is so critical. We cannot write a blank cheque. If we did, I would be facing the Public Accounts Committee in a few years' time. It is critical for us to ensure that we get the expenditure profile right.

In comparison with the Executive programme funds, the cancer centre will be a major capital project from which significant amounts of money will be spent in about a year. That will be phased over the couple of years subsequent to that. It is not easy for us to bid against the Executive programme funds, which tend to be worked on a one-year horizon. We have a project that spans a number of years, so phasing is important. We are determined to deliver this, so not getting programme funds is not a block for us. We would like extra money, as it is critical for us to deliver everything that we need to do. However, that money has such primacy that we will prioritise to make sure that it is delivered.

Mr Hill:

In Annex 1 of the position report we gave you at the last meeting, we set out what had been gained from the Executive programme funds. Forty-two million pounds, out of £154 million, was allocated - 24% of the Executive programme funds. This was inadequate and did not reflect the proportion of the block that we represent.

The bids you have been looking at this week represent this year's second tranche of Executive programme funds. At the beginning of the year it was decided that the complete allocation process for four of the funds should not be in February and that there should be a second bidding process later in the year. The children's fund was taken out of that process because it was decided that the voluntary organisations were not in a position to bid properly from it, so proper machinery needed to be in place to allow those organisations to bid. Therefore that money was deferred until February.

The bids relate to three funds. Even if we had a business case, none of those funds would be sufficient for the cancer centre. A justified business case would put the cancer centre into an infrastructure fund bid. That is our single biggest fund. Last year, we got a 33% share of the infrastructure fund bid, and the biggest element of that was for the Ulster Hospital. We did not do as well as we should have, but we got a reasonable share of that.

In February, we will have an opportunity to bid again for next year's allocation from the Executive programme funds. Depending on the progress of the business case, we could put a bid in for the cancer centre. However, we cannot submit a bid without a fully supported business case.

Ms M McWilliams:

Under what heading would you submit the bid?

Mr Hill:

It would be submitted under the infrastructure fund. The other funds are too small.

The Chairperson:

The main heading is infrastructure/capital renewal. However, the other two funds could be part of a topping-up exercise.

Ms de Brún:

The only three funds available on this occasion were service modernisation, social inclusion and new directions. Those are the only ones that the Executive are considering.

Mr Hill:

There is no mileage in trying to get resources under those three funds. We must proceed with a bid under the infrastructure heading.

The Chairperson:

Will next February be the time to do that?

Mr Hill:

Yes - if we have a business case.

The Chairperson:

As I understand it, the business case was submitted in June.

Mr Simpson:

We have been working closely with Belfast City Hospital in developing the business case, and there have been informal exchanges. A first version of the revised business case was submitted in June. There were problems with it, and we asked staff from Belfast City Hospital to continue to work on it. We did not get the revision in a form with which our economists were happy until the end of September - it is important to note that. We are now working urgently on that, and the next step is to put it to the economists in the Department of Finance and Personnel and look for their agreement. It is important to note that that is our position on the business case.

Mrs I Robinson:

Can we have a guarantee that that the bid will be ready for February, given the importance of cancer services?

Mr Simpson:

Yes, we are pretty sure that the processes will be cleared by the Department of Finance and Personnel fairly quickly.

The Chairperson:

I understand that but I hope that the bids will be included in the next tranche in February. I hope that everything will be in order so that finance can be agreed. It will take three years to build the cancer centre but it cannot start until the finance has been agreed.

Mr Gowdy:

The critical aspect of the business case is that we need to submit bids against the phased expenditure we will need. We need to know exactly how much we are asking for each year.

Mr Simpson:

We also need to be clear about the public-private partnership versus public sector choice. It is very important that the business case rehearses that argument fully and that it is clear which route we are going to take.

Ms M McWilliams:

Is it right to say that regardless of whether the money comes from the Executive programme funds you are currently prioritising the cancer centre in your budget? I hear you saying that you will be submitting a bid for Executive programme funds under the infrastructure/capital renewal heading. If that is so then that bid will release a lot of money from within your budget. What are your plans in relation to that money?

Mr Gowdy:

The cancer centre is such a high priority that we will not let the absence of money from the Executive programme funds stall it. Other items will have to be removed from our priority list so that we can deliver on the cancer centre. If we get money from the infrastructure/capital renewal fund then we will all benefit.

Mr Simpson:

We have a long list of very deserving capital schemes waiting. We have more schemes than the amount of money likely to be made available to us will fund.

Mr Hill:

It is likely that the fund would only make a contribution to the cancer centre - just as with the Ulster Hospital project. The best we can hope for is a significant contribution.

The Chairperson:

I will write to you, Minister, on the points we have discussed.

Ms de Brún:

I welcome that. I stress that this is the time when people throughout the service should begin the debate on what bids should be made from the funds. I welcome the Committee's views on this proposal and on anything else that the Committee would like to draw to our attention to.

Ms I Robinson:

It would be churlish not to welcome the announcement of the early release of the £2 million capital funds for the Ulster Hospital to open the 20-bed Jaffa ward. However, will the Minister assure the Committee that the £1 million required to staff the ward annually will be in place before summer 2002 when the ward should be up and running. A consultant, a junior medical team, three senior house officers, and 28 full-time nurses will be needed. What is being done to attract new nursing recruits to the Health Service?

Waiting lists affect all disciplines in the Health Service and there is great concern at the lengthening of these lists. The Programme for Government published in February 2001 contained a target to reduce waiting lists from 51,000 to 39,000 by the year 2004, with the immediate aim of reaching 48,000 by March 2002. Unfortunately the latest figures show that the numbers have risen to 54,000. What has gone wrong, and why has the target in the latest draft Programme for Government been changed to,

"by March 2003 to have constrained hospital waiting lists to the March 2002 level"?

How can we agree to a target when we have no idea what the waiting list will be in March 2002? What has been achieved as a result of the investment of £8 million to specifically tackle waiting lists?

Ms de Brún:

I will come back to the specific question on the Ulster Hospital. The question on waiting lists was general, but they cannot be seen in isolation. Hospitals cannot maintain their capacity for elective surgery if medical admissions are running at such a rate that patients must be accommodated in surgical beds. In the last year alone, for example, there has been a 9% increase in medical admissions in the Eastern Board area. Such increases cannot be absorbed by a hospital service that is already running close to full capacity.

I have consistently made the point that two things are needed. One is to put money specifically into waiting list initiatives already in place, and I can tell you what we have done on that. The other is the significant additional investment in capacity. That has been successful and has made a difference in the South and in England.

It is not just a question of money. A comprehensive planning framework, which I set out last year, will work over the next three years. We have very ambitious plans for reducing waiting lists. In addition to last year's £5 million, £3 million was allocated to tackle waiting lists. That was made recurrent. It must be remembered that it is being put into a system with capacity difficulties. Some of it is being used to buy additional elective procedures. The Eastern Board plans to buy extra cardiac surgery procedures, and has set aside £400,000 for that. Resources are also paying for additional nursing staff in hospitals. It is being put towards better management in the system, and I will address some of those points.

One point regarding the framework concerned management systems, one of which was computerised waiting list management systems. The range of measures that the service has put in place to improve the management of hospital admissions and discharges is having an effect. The aim is to make the system more efficient and thereby treat more people. Were it not for that, given the capacity difficulties, the situation would be even more difficult. People are being offered the opportunity to have their operation at a different hospital if they have been waiting a long time. Patients have travelled to Scotland, for example, for cardiac surgery.

Scheduling more routine work earlier in the year was one of the plans when pressures were less likely to disrupt admissions. That has not been totally successful given that the pressures, which were in wintertime only, have, in the last year, spread over a greater part of the year.

Improving communication and information will mean that if a person cannot attend at an appointed time, someone else can have that slot. Mr Gowdy can give you more examples of the specifics. The Boards' action plans in response to the framework for action have put in place a range of managerial, clinical, planning and efficiency measures. I mentioned the computerised management system.

The Eastern Board has set up a team to look improving the linkages between hospital and primary care, building on the lessons it has learnt in tackling winter pressures. A number of pilot studies started. One at the Royal Victoria Hospital is to reduce waiting times in oral surgery. The waiting times for magnetic resonance imaging (MRI) have been considerable. A mobile MRI unit was brought in to provide a scanning service for the Northern and Western Board areas to help reduce waiting lists. Additional scanning capacity is also continuing at the Royal Victoria Hospital. It will impact on other areas as MRI is rolled out.

The validation of waiting lists improves their accuracy. Departmental officials meet with specific designated waiting list managers every two months, and a considerable amount of money has been made available for specific waiting list initiatives. That is beginning to make an impact, but against the background of a service that is running far too close to full capacity. Any difficulty, either staff illness or the illness of a clinician, or any difficulties in the hospital's capacity, such as delayed discharge, will have a disproportionate knock-on effect.

Mrs Robinson:

What about the Ulster Hospital?

Ms de Brún:

In addition to everything I have mentioned at the outset, the £1 million are contingent on the outcome of the draft budget proposals, when I will be in a better position to inform you.

Mr Simpson:

The £2 million are now available as part of the phase 2 development, and we can spend it as and when the contractors arrive on site. We expect that the refurbishment of Jaffa Ward will be complete by mid-summer 2002, therefore the revenue requirements will begin to kick in from that point. As the Minister said, whether or not that can be made available depends on the outcome of next year's budget and the Eastern Board's ability to meet that.

Mr Gowdy:

Mrs Robinson asked about what had gone wrong as regards waiting lists and about the target in the Programme for Government. It is important to take into consideration that the service has had to face pressures, and there were some interesting problems during the last year. The first is the significant rise in emergency admissions across the board. Figures from the Eastern Board area show an increase of 9% in emergency admissions during the past year.

People live longer, which is a good thing, but they need more care and treatment, and that imposes additional pressures on the system. The pressures of modern living also have an impact, causing more accidents and health problems; and the system has to cope with that as well.

A particular issue that arose during the year, which had an impact on the waiting lists, was the advice that we should use instruments only once for tonsillectomies and some other procedures because of the risk of transmission of BSE. That had a significant effect on tonsillectomies and caused an increase of 60% in the waiting list in the ear, nose and throat speciality.

Medicine can do much more to keep people alive, so we see people in intensive care beds and the high dependency unit beds for longer periods of time. It means that the turnover of people who have had surgery and need to be cared for is slower. Bed space in the intensive care units has been a part of the problem.

We are aware that the system does not only relate to hospitals; people also need help to get into the community again, and we need to invest more in the community to speed up the flow of people through the system.

Given the significant rise that we faced, we did not want to be unrealistic about the Programme for Government. It seemed sensible to commit to maintaining or improving waiting lists in order to have an impact on the rate of growth by March 2002.

Mrs I Robinson:

There is not a single answer to the problem of waiting lists, and I presume that people who do not turn up for appointments also have a considerable impact on waiting lists. As regards the £1 million revenue, an inaccurate comparison would probably be that opening the ward without the staff in place and without 20 new beds would be like opening a pub with no beer. I would put pressure on you to come up with that £1 million or opening the unit will be a waste of time.

Mr Simpson:

The Department and the Eastern Board acknowledge that.

Rev Robert Coulter:

Thank you, Minister, for coming today. I assure you that we are fully behind all your efforts to improve the Health Service. We appreciate working closely with you on that.

I want to make a point on delayed discharge, or bed blocking. That has been a problem in our area for some time. Last night I made some checks, and I discovered that in two of the hospitals that make up the United Hospitals Group Trust there are 96 elderly people occupying beds while waiting to get out into the community. Mr Gowdy mentioned this as being part of the problem. There are 50 such elderly people in the Ulster Hospital. I did not go any further than that, because I was beginning to get scared that the figures might be too large to gather.

What specifically is being done to eliminate bed blocking? Secondly, what is being done to make use of the spare capacity in some residential homes? It is my understanding that it is cheaper to look after the elderly in the community rather than in hospitals. The perception is that not enough is being done to get people out into residential homes, thereby freeing up beds in hospitals. On the other side of the coin, what is being done for the long-term care of the elderly? Perhaps I should declare an interest in that.

When we are told that there is no money for this, and then we hear of certain people getting huge salary increases of around £500 per week on top of an already good salary, the perception in the community is one of disbelief and cynicism. What is the Department doing to ensure that those residential homes that are closing because of a lack of funding are being looked after, and that, on the other side of the coin, the perception is not given that there are people on a gravy train?

The Chairperson:

I presume that Rev Robert Coulter is talking about executive salaries. The Minister's statement yesterday on that issue was welcome, although, through no fault of hers, it only applies to new people coming in. That is because of the statutory arrangement of boards and trusts. That argument is for another time. Before the Minister answers those questions, perhaps John Kelly could ask his questions on a related subject.

Mr J Kelly:

I want to reiterate Rev Robert Coulter's support for the Minister and her colleagues and the way that they have attempted to redress the imbalance in our Health Service. Looking at the topics for discussion - waiting lists; trolley waits; bed blocking; community care packages; winter pressures; health service structures; primary care; and the regional cancer centre - gives us some idea of the immensity of what faces the Health Service. Underlying all of that is the funding issue. I want to emphasise again my suggestion that we seek an urgent meeting with Sir Reg Empey, Séamus Mallon, Mark Durkan and, perhaps, the Health Minister to express our views on the current critical status of health. While roads and education are important, if we do not have a healthy society, those things take second place.

I have a question for the Minister on winter pressures. Minister, what plans are in place to deal with winter pressures? Are trusts aware of whatever funding will be available to deal with winter pressures? Do all trusts have contingency plans in place, or will we be facing a similar critical situation to last winter?

Ms de Brún:

I thank both members for their restatement of the Committee's support for the service, its needs and the commitment of people at every level in the service in endeavouring to deal with the problems. When I am visiting staff in the Health Service, I make a point of letting them know that, although it does not always come through in the Assembly when Members are highlighting difficulties in their areas, it is always specifically mentioned that there is no reflection on the dedicated staff in the service. Staff have voiced their appreciation for the Assembly and Committee members' comments.

In relation to delayed patient discharges, it is clear that that is a major issue. Not only is it being considered as part of the planning processes for the winter and the waiting list strategy, but it is also a major component of the initial stage of the current community care review. It has also been brought to our attention that the arrangements with carers for patient discharge need to be addressed in the carers strategy. The problem is being examined from various angles and is being cross-referenced.

The core elements of winter planning include co-ordination of services. That addresses the problem of demonstrating that systems are in place to maximise links between the voluntary and independent sectors as regards primary community hospital services. We managed to improve on last year's performance by learning from the difficulties of the previous year through partnership working. Boards, trusts, GPs and other health and social care providers are working closely together in developing plans to make the most of our integrated service.

Another factor to be included in the plans this year will be best practice. Where some trusts made an impact last year in showing best practice, those elements have been imported into the plans of other trusts and board areas. One result will be that contingency arrangements will be in place should demand outstrip supply anywhere.

Mr Kelly asked whether trusts are aware of what funding is available. Funding has been made available in the context of a service faced with the outcome of the draft Budget proposals. The service has also been asked to put in place contingency plans, as well as the winter service planning, to ensure that the rigorous financial situation that the Executive have demanded of us all is met.

Some of the work that helps with winter planning does not necessarily get charged to that heading. When dealing with waiting lists, for example, the Department recognises the need to tackle the capacity in the community as well as the capacity in the hospitals. That planning will also impact on winter planning.

Mr Gowdy:

Rev Robert Coulter made a point about bed blocking and getting people into spaces in homes. Don Hill and I had a meeting yesterday with the Homefirst Community Health and Social Services Trust at which we discussed those issues about getting people into the community. Those things are not as straightforward as they seem. Understandably, people want to go to nursing homes that are convenient for their families, and therefore they cannot be put into the first available space. People have a preference as to where they want to go, and they know where they do not want to go. They want to wait until a space becomes available in their preferred nursing home. One can understand that, because that is where they will be living.

There have been other cases where the individual could have been released back to his or her own house if care and support were provided, but their partner or other family member was not fit enough to cope with that. Therefore, there was a question of trying to get a package of care support for the carer. All those issues proved difficult to resolve. There is some spare capacity in some places, but it is not appropriately situated to solve the problems of those who are blocking the beds in the hospitals that Rev Robert Coulter mentioned.

The Minister wants to see a lot of money going into the development of this community infrastructure. She has identified several million pounds from the waiting list money to go into community care services. The Department recognises that it must build that capacity if it is going to solve the problem.

The Chairperson:

Hospital statistics for 2000-01 show that an average of 9% of outpatient clinics were cancelled. One major problem is that sometimes patients are not turning up for their appointments. Some trusts had cancellation rates as high as 12% or 14%, while others were slightly lower. That is a major problem. Perhaps, Minister, you can write to the Committee about that. The rate for the Royal Group of Hospitals was 10%, and for Belfast City Hospital 12%. That is a big variation. The Committee would appreciate some comment - or written correspondence - on that subject.

Ms de Brún:

A number of factors contribute to those statistics. One of the temporary factors in the rise in waiting lists in the last quarter has been staff absences due to illness, et cetera. Another contributory factor was the move to the Causeway Hospital and the disruption that is to be expected during a move to new premises.

Health trusts are doing many things to help patients keep their hospital appointments. The appointment letters stress the importance of either attending for the appointment or notifying the inability to attend in good time. Advisory posters in GP surgeries and hospital waiting areas illustrate the impact on waiting times for other patients of a patient's non-attendance, and reminder letters are issued to patients in the week prior to an outpatient appointment. Appointment letters that request the patient to confirm their intention to attend and which include a direct point of contact to the patient's clinic are also sent out. The trusts are very aware of the importance of the matter, and work is going on to tackle the problem.

The Chairperson:

Perhaps, Minister, you will write to the Committee on the subject of cancellations and waiting lists.

Mr Gallagher:

The Chairperson pointed out that the Northern Ireland average for the cancellation of outpatient clinics is 9%. However, at Erne Hospital in Enniskillen the figure is 14·5%, and at South Tyrone Hospital it is 14%. Those figures are probably the highest in Northern Ireland, and, because they are so much higher than the average, they must be examined carefully. We have mentioned that patients cancel their appointments, but consultants cancel appointments too. We must look at the problem from all angles.

The Chairperson:

We would like the Minister to write to us on that issue.

Ms de Brún:

Perhaps the Clerk of the Committee can let me know about any specific topics that the Committee would like me to address by letter, above and beyond the topics have been dealt with today?

The Chairperson:

There is a huge variation in the figures. Some hospitals have a low cancellation rate of 4% or 5%, while others have a much higher rate - for example, the mental health clinic at Alexandra Gardens. We would like an overview of the situation.

Ms Armitage:

Health Service structures are important - they are the very foundation of the Health Service. Do you agree that four health boards and 19 trusts are excessive, given the size of Northern Ireland? Why did you not include that issue in the acute hospitals review? It was included at the request of this Committee.

There is a perception that the trusts look after their own interests and compete for the same staff. I think you said that that would create modest savings. I would have thought that, given the Department's bank balance, even modest savings would be quite useful. Has your Department considered the savings that could be made if the number of trusts and boards were reduced, or if they were closed down altogether and another system put in their place?

Finally, can the health service structures review be carried out before the public administration review?

I was pleased with the announcement this week about the new salary arrangements for senior executives in the Health Service. The Minister may not have the details here, but perhaps she can inform the Committee in writing. I am not sure whether the new arrangements will be effective immediately. Will they come into effect when contracted staff renew their contracts?

Ms de Brún:

The Executive are examining the issue of public administration across the board. Now that the Executive has been established, we must look at whether the structures that were previously in place, which were suited to a particular form of administration, are still suitable today.

The issue of the wider structural change in the Health Service is firmly on my agenda. It is not only a matter of costs, but also of the most efficient structures for the service. I can assure you that officials have examined both issues. It is important that we ensure that the organisational structure is appropriate for the efficient and effective delivery of services.

I will bring forward proposals for primary care shortly, and they will necessitate the development of structural arrangements that will give primary care professionals, and others in the community, a genuinely effective role in commissioning and delivering services. We need to develop such structures.

The question raises two points. Trusts are competing for staff. The spirit of competition that used to exist in the internal market created difficulties for the service. We have been gradually trying to develop a service that replaces some of the competition with co-operation, closer working and integration. Staffing is of particular concern, given that there are so few specialist staff available. That is the case here and in the South, and elsewhere in the NHS.

The acute hospitals review addressed the question of structures. I will address the issues in the course of the Executive's consideration of acute hospitals and in the context of the Executive's wish to review public administration, as well as other issues concerning the development of acute hospital services. Those will provide the wider context in which any proposals for organisational change must be developed. However, it is important to keep one other point in mind. Proper integration between health and social services is central to the efficient working of the services. Furthermore, whatever new arrangements may emerge must support the close working of all parts of the service, not only with each other but also to facilitate the interconnection between health and social services - especially social services - and education, housing and other key public services.

Social services personnel work closely on several issues. Those who have worked on inter-sectoral forums will understand the close links that exist there. That is why it is important to look at these issues within the wider context of whether they are, for example, coterminous, or whether the existing structures facilitate working with education, probation services, housing or any other key service. Those are the ways in which we will be looking at the links when we address the question of structures.

Ms Armitage:

Did you say "modest savings", Minister?

Ms de Brún:

I did.

Ms Armitage:

I take it that you know that the Department has calculated how much money could be saved if the trusts and boards were reduced in number. What does "modest savings" mean?

Ms de Brún:

The saving is modest when one looks at the impact that it would have on the overall organisational structures. To give you a particular figure would imply that I had decided on a particular number of trusts.

Ms Armitage:

Have you not?

Ms de Brún:

No. It is something that is under consideration and consultation at present. I hesitate to speak about it, but it is not a large sum. It is nothing like the figures that I have heard in past discussions on the savings that would be achieved.

Ms Armitage:

How soon will you have an end product? When will you be able to tell us that you have made your decision? Will it be a long-term decision? I would have thought that you would have looked at it earlier.

Ms de Brún:

I intend to make suggestions on how to move forward in primary care soon - possibly next week. One point about primary care is that, because part of the debate around the structures was commented on in another consultation, there was a need to check what impact my actions might have on that other consultation. There was a need to look closely at some of the financial issues around the emerging situation. Those are issues that I will be commenting on shortly.

In view of the wish of the Executive to review public administration, I will take the wider organisational issue forward as well as the issues around the development of acute hospital services. Those will go to the Executive following the end of the initial consultation period on the acute hospital review. That is due to happen at the end of this month. It is then up to the Executive to decide whether they wish to move forward on this earlier than on other phases of the public administration review.

I will be making a very clear point to the Executive. There is the issue of the proper working of health and personal social services, but there is also the question of their working with other services. We need to look at the timing of all this. Whether that means delaying one matter or bringing another forward more quickly is not for me to say, but the two things need to be looked at very closely together.

The Chairperson:

In several meetings with Dr Hayes, the Committee stressed that the acute hospital situation cannot be looked at without bringing in the issues of primary care and structures. We welcome what you have said, Minister, and at least you will be looking at these matters prior to a review of public administration. We will move on to primary care.

Mr McFarland:

I also want to comment on the last topic. The Minister will not be surprised that I should introduce a note of discord. We are looking at a disaster area. At the top, we have £2·4 billion coming in, and at the bottom, we have overworked staff and patients on trolleys. There is clearly something wrong.

I understand the argument about a lack of funds. We hear it regularly when the Department comes in front of us. It is a constant complaint, and it is clear that there is underfunding. However, I wonder whether there is also a distinct lack of proper management of the NHS. I am thinking of a system here - we have had it during the debates on the Budget - where we are discussing what happens to the money. The Department gives it to the boards and the boards give it to the trusts. About six months ago during the discussion on the Budget, we heard that the Department had no system in place to monitor what happened to that money at trust level, although I understand, Minister, that you are now putting a system in place to do that.

I am somewhat amazed that you have been able to run a Department for years without having a clue - certainly since the trusts were set up - as to what happened to the money down at the bottom end. That is a concern. There is a certain hands-off attitude there. I am sure you have seen the latest report from the Northern Ireland Audit Office, on the Fire Service. Millions of pounds' worth of computers are sitting in stores. The whole thing is an administrative shambles. Was no one from the Department curious about what was going on?

We recently visited Musgrave Park Hospital to look at orthopaedics, and discovered that there is a substantial surplus of general surgeons. We are well above our quota of general surgeons and well below our quota of orthopaedic surgeons. How has the Department allowed this to get to the stage where there are far too many consultants for one discipline and far too few for another?

[The Deputy Chairperson in the Chair]

This all smacks of a hands-off attitude, a lack of management, and a lack of interest in what is going on. That worries me, and I wonder whether there needs to be a detailed examination of the system that you operate.

I also wonder if, in the reluctance to address the issue of the boards, there is a desire to protect the status quo. This has all been presided over in a comfortable way. I described it earlier as a disaster area. Is there a marked reluctance to interfere with people's employment here? Are we looking at the NHS as an employment agency? I have heard anecdotal evidence that in the dark days of direct rule, when the Secretary of State wanted to improve the unemployment list, because it was useful to do so, he asked the Department to employ a number of people, and the Department simply absorbed them. Is the Department a sort of politburo, doing things in the old style? Perhaps what we need to do is to become a lean, mean machine, dealing with and putting money down for patients, rather than operating at board and Department level.

I will move on to primary care. We have been discussing this for around 18 months. We are aiming for a seamless robe of medical care that produces a new system for primary care, takes the Hayes review into consideration and produces a new system for acute care, all married together in a single sensible unit.

We had a row with the Department last year over GP fundholding. The Assembly decided that it would give the Department a year to sort this out, so that by 1 April next year we would have a primary care system in place and, with the Hayes review, an acute system that was married together and put in place so that the whole thing worked. We would not lose the expertise in GP fundholding, because it would move forward into the new system.

I have the distinct impression, Minister, that we are treading water. You will tell us that it is not possible to do this in the time available, and that the boards have to stay because they have to take over GP fundholding. In other words, we will end up in the position you were in last year, because I see from the budget that Hayes will not be addressed until December 2002. Why, if we are trying to produce this seamless robe, does everything here seem to be on the long finger?

There are two questions. Where are we with primary care and the plans? Why is it being delayed? Why is it not being married up with Hayes? Why have you not wisely used the time that was given to you to sort yourselves out as a Department between last March and 1 April next year?

Ms de Brún:

I will address both of those. You are absolutely right - you have introduced a note of discord. I have appealed to you at every meeting to try to word your questions in a slightly less negative manner.

Mr McFarland:

Our job, as I keep saying, Mr Chairman, is as a watchdog on the Department. Our job is not to cosy up to you, Minister. Our job is to examine what you are doing and whether you are doing it in the best way on behalf of the people of Northern Ireland. This is a democratic system and I must be allowed to point out your errors as I might see them, without being accused of being objectionable or awkward.

The Chairperson:

You have made that point clearly.

Ms de Brún:

If I answered you using the kind of terminology that you used in your questions, there would be an objection. I am simply logging that; of course I will answer you in the professional manner in which I have answered all the questions to date.

I indicated where we are on the question of primary care in my answer to Mrs Armitage. I hope to be able to tell you within the next week what the plans are. I have indicated why the plans are being brought forward in this timescale. They had to be married with the recommendations of the acute hospital review. Therefore, it was not possible to advance them without some consideration of how we would look at that, or the financial situation or the question of how we will address the structural matters. We have done that. I will be bringing those points forward soon.

There was a suggestion that deferring the ending of GP fundholding bought the Department a year: that is not the case, and I made it clear at the time that that would not be the case. It is not just time that the Department needs to set up structures; it also needs money. It is not possible to pay for GP fundholding and other structures simultaneously. Therefore, while the work can be done on the development of some of these structures, I cannot have official new structures and GP fundholding at the same time within the money available to me; I simply cannot pay for both. That is a difficulty that I face, and that is the effect that deferring the ending of GP fundholding will have.

I can assure you that we are moving forward on the question of primary care. Considerable work has been done, and the question of the links with other aspects of the service and the question of the structures have been looked at. The question of the development of primary care itself has also been looked at. I have made it clear that, even given the enormous difficulties that we face due to the draft Budget proposals, I had to, and did, signal to Executive Colleagues that the question of financing the new structures would be one of the things that I would have to examine in terms of possible deferment given the Budget position. Primary care and the development of new primary care structures are so important to me that that is not something that I want to do. It is something that we have quickly moved forward with, and I will be able to signal to you the detail of some of this in the coming week.

Mr Gowdy:

I want to pick up on Mr McFarland's colourful description of our lack of management of the system. As I have done before, I refute that; I do so by saying a couple of things. The first point relating to planning is that we have had annual plans for many years. The former Health and Social Services Executive produced plans to determine how money would be related to the activity that we needed to see in place. Each of the boards has been responsible for producing commissioning plans each year, again determining the activity that would be possible with the amount of money that was available, so there is a clear linkage there.

In terms of how that is used, we have had a clear monitoring of what has been happening at the activity level for many years, and it has concerned the financial performance of the organisations. We have been getting details of financial performance, and also detailed information on the volumes of activity, quarterly and monthly. So we are not sitting back and watching the system do its own thing. We have clearly been keeping a close eye on it, so much so that when we were recently subject to a review by outside consultants, we got a clear indication that we were impressing them by the amount of activity that we had been doing in managing the system.

As we have moved from the old internal market, with the substantial degree of freedom that the then Government wanted to see, we have been increasingly adding to the measures of monitoring and control. We have instituted a number of things over the last couple of years that have given us an even tighter grip on the activity of the various bodies. There is no question of us leaving these bodies to get on with things themselves.

We are not in an industry that produces "x" million widgets every year. We are providing services to meet need as that need arises in the community. Much of it is emergency need; it is driven by what happens out there, and the system must respond. We must build in a degree of flexibility that allows the system to respond immediately to what happens. The major problem for us is our inability to provide the funds that are needed and to provide the quality of service. That is why, when we get down to the bottom end, we are seeing the trolley waits and so on. If we had the ability to buy more capacity in the system, we would be able to avoid some of those problems.

I want to make it clear that we do not have a hands-off attitude, and we are not determined to protect the status quo. We want to be seen to reassure the Minister, the Committee and the Assembly that the money that is voted to us is used properly.

[The Chairperson in the Chair]

Ms de Brún:

I would like to make one more point. Alan McFarland suggested that I was reluctant to address the boards issue. I assure him that I have no such reluctance. I am addressing the boards issue within the context of the Executive's wish to review public administration. Also, I have indicated that I want to raise the issue in the course of the Executive's consideration of the acute hospital review. I am addressing the question. There are some aspects that my Department cannot work on without reference to others in the Executive. I have a context in which I can address this. I have made no decisions, and no private conclusions, about boards; that is something that is open to future discussion.

The Chairperson:

Thank you very much, Minister. I apologise for having had to leave for two minutes. I missed the exchange between you and Alan McFarland, but I will look at it later.

We are coming close to the end of our meeting, but I want to ask about primary care. The words "seamless transition" have been used over and over again. We sincerely hope that there will be a seamless transition on this matter. I am not going to rehearse last year's arguments. I know that you and your colleagues understand that primary care is the basis of the Health Service. That is why we asked Maurice Hayes to widen the review. His initial remit was acute hospitals, but we asked him to include primary care because the two things are linked, as is the issue of structures.

Mr Gallagher:

I have had to wait for quite a while to ask my question about the Ambulance Service, and the Minister made a pre-emptive move by saying that she will soon make an announcement about the enhancement of the Ambulance Service. When will we hear about that? Will it be directed at, or include attention for, areas where ambulance cover is poorest, such as the west of the Province?

Will it meet the 2002 target of replacing 10 accident and emergency ambulance vehicles? Will it do something about poor response times, for example, where it takes 45 minutes for an ambulance to reach a patient? Will it take account of the ambulance report's recommendation about locating bases for ambulance services so that the distance factor will be overcome in the future?

Ms de Brún:

There are two aspects to this matter. One aspect concerns the enhancements that have already been brought in, and the other concerns the further enhancements of the service that I hope to announce soon. In the past three years my Department has managed to provide an additional £6 million for ambulance modernisation. That has been used to address some of the significant deficits in the fleet with the purchase of over 100 new vehicles - approximately 45% of the fleet. Last year, when I made my initial announcement on the findings of the strategic review of the Ambulance Service, that was a priority.

The money has also allowed us to modernise the entire stock of defibrillators, and to bring in other essential medical equipment. It has also enabled the Ambulance Service to purchase the necessary equipment to pilot a medical priority dispatch system in the Eastern Board area by March 2002. It has allowed it to increase staffing levels and do some essential work to ensure that levels of staff skills are maintained to appropriate standards.

Members will know that I made earlier bids to the Executive programme funds for the Ambulance Service. In my latest set of bids for Executive programme funds, I have again submitted bids for support to modernise ambulance communications technology and pilot rapid response schemes in each board area. I want to assure you that, as with other aspects of the service, the Ambulance Service will, in the interim, continue to take whatever measures are possible within the available resources to improve the quality of service it delivers. There were specific points taken last year. You had raised questions about ambulance times in Fermanagh and other areas of the Western Board, and measures were taken at that time. The Ambulance Service is aware of the areas needing attention.

Mr Hill:

One of the main problems that faced the Ambulance Service was dealing with four boards, each with their own independent service level agreement. The provision of care services in the Eastern Board is organised at individual trust level, and that is not a sound basis for developing a regional Ambulance Service. That is a key element of the new proposals and one that has already been agreed with boards. We are beginning to operate new arrangements whereby there will be a single partnership commissioning arrangement. That will permit a regional strategy to be developed for the Ambulance Service for the first time. That is an important part of the progress already made.

Another element of progress relates to priority dispatch arrangements: in other words, directing or trying to reach a decision on the priority to be accorded to individual calls. That is an important part of managing response times. It is being piloted in one board area, and will be rolled out to all board areas next year.

The Minister referred to digital trunk radio, and that is a major exercise involving both the police and the Fire Service. It has taken a lot of planning and it is only because we have the business plan in place that we were able to submit the detailed bid.

On the specific question of what the announcement will do, we will have to wait until it comes out. It will certainly show that the target for 10 vehicles has been met, because that is part of the monitoring of our programme for action targets. It will also major on two issues: response times and call times. With regard to response times, it will automatically major on those areas where we are unable to meet existing targets. It will look at and develop detailed proposals on rapid response, and first response, to help address the problems of isolated rural areas. In the case of where ambulances should be located, the Ambulance Service has drawn up a programme under which it will locate individual ambulances at 11 additional areas, so that the response times are significantly quicker.

Ms de Brún:

I made the point last year that some things could go ahead immediately, but that working groups had to look at other things. The review group had not fully costed its recommendations, and some further work was needed to analyse more fully the implications of taking forward a number of the proposals. I am currently considering that. When it is possible, as it will be shortly, to move on this, we will publish a consultation package on some of those detailed proposals.

Mr Gallagher asked about specific areas of need, and I am aware, for example, that the Ambulance Service has been replacing the vehicles that are in use across the North. The service got 10 new vehicles in the past year, and two of those were deployed in Omagh and Strabane. More vehicles will be brought into service if we have the funding. The bid for rapid response crews and vehicles in each of the four board areas has been made to the Executive. That will identify Newtownhamilton, for example, as a base for the Southern Board area. People have seen specific difficulties and have tried to address those.

The Chairperson:

I do not want a discussion on the research and development element of the Department of Health, Social Services and Public Safety, but we did not give you notice of the retirement of the pathologist Prof Ingrid Allen, who was involved in research and development. Prof Bob Stout is now in post. I sometimes wonder how that group decides where funds go, and as far as I know, none of its funds have gone towards primary care. That is a great bone of contention in primary care professions. Could that be looked into, Minister?

A letter from Dr Ian Carson of the Royal Group of Hospitals has been sent to every GP in Northern Ireland in the past few days, and doubtless to others involved with regional neurosurgery services. I spoke to Dr Carson yesterday, and I have carefully studied his letter. I understand why he has done what he has done. There was a review of neurology services - neurology is related to neurosurgery. That review finished a year ago. When will we hear about that review, because it is related to this matter? What is happening with that? Time is moving on and we need to wind up soon.

Ms de Brún:

Paul Simpson will deal with the point about neurosurgery and the neurology review. We have the costings and the bids for the resources to take us where we have all recognised that the service needs to be. We have a strategic overview of where we want to go, and officials are in daily contact with those in the service and are dealing with specific aspects and difficulties that arise. Paul Simpson and Brian Grzymek, the director of secondary care, have been in contact on a number of different issues.

Mr Simpson:

We are concerned about the difficulties that the Royal Victoria Hospital has been experiencing with nursing and anaesthesiology. We have asked the hospital for an urgent report. I received an informal response from the Royal indicating the steps that it is now taking to relieve the situation and bring it back from the position that Ian Carson described. This is a regional service, and the Royal is working closely with the four boards to put urgent steps in place to try to remedy the situation.

The first step that it is taking is the recruitment of additional anaesthetists, and it is working closely with the Eastern Board on that. At our level, we recognise the need to increase the number of anaesthetists in training; we are currently looking at proposals from the Speciality Advisory Committee (SAC) on anaesthetists.

The hospital is also looking to appoint additional nurses, because one of the difficulties was on the nursing front. The intention is to try to quickly appoint an additional 10 nurses so that the hospital can reopen some of the beds. The Royal hopes to be in the position to reopen 10 beds by 1 January. I hope that we will then begin to see some remedy.

The Chairperson:

The conditions that are named in the letter do not stop GPs from referring patients to related professionals in the hospital.

Ms de Brún:

We talked earlier about the whole-system approach to working. The trust wishes to urgently arrange for the Regional Medical Services Consortium and GP representatives to meet with the neurosurgeons in the next two weeks to discuss the way forward.

The Chairperson:

That makes sense. You are referring to the regional medical people who represent the four boards.

Mr J Kelly:

Minister, what progress has been made by the trusts on the introduction of TSN action plans? Are you satisfied that the new capitation formula properly addresses the inequalities in health provision in different areas? Has the Department taken into account the new measures of deprivation in the North of Ireland that were published by Oxford University's social disadvantage research group?

Ms de Brún:

A departmental representative worked with the Noble review team, and Mr Hill will address that. Each board and trust has its own TSN action plan, and they have been discussing that work. The Department of Health, Social Services and Public Safety has worked successfully with the trusts and boards on several initiatives, such as the 'Investing for Health' document, which plays a major part in addressing inequalities, and the Sure Start scheme.

The Department has also looked at the development of the two existing health action zones and has put in place two new health action zones. The local trusts and boards have been working closely and have been supportive in those areas. Mr Hill would be better at explaining how the systems are put in place to monitor the way in which those action plans are impacting on inequalities in a way that delivers the new TSN priorities that the Executive have set.

It is a long-term approach. It will address social need by putting particular focus on tackling the inequalities, and the way that the capitation formula, which has been revised, will impact is also monitored. I am confident that the process is there to cope with any modifications that are needed. I also know, from my visits to some of the boards and trusts, that they have looked closely at how to monitor the way in which their allocation of resources is meeting new TSN targets, as well as their statutory equality duties.

Mr Hill:

The trust plans are formally due next April. We have had a couple of workshops with the trusts and detailed meetings with the boards. We are collectively trying to ensure that the new TSN agenda is taken forward corporately across all the boards and trusts. It is pointless for the Department of Health, Social Services and Public Safety to have a TSN agenda if it is not reflected in the boards and trusts. That is moving forward well, and there will be consultation on the trusts' new TSN plans in the next six weeks.

You mentioned the Noble research team's report. The Department now has expertise on its professional side that has a good reputation both in the Province and across the island. That is why we had representation on the project board. The report, which replaces the Robson indicators, is proving useful; for example, we used it to address where best to place community pharmacies. It is not ideal for resource allocation, but it is an excellent and updated method of identifying where the key areas of deprivation are. It ties in closely with our capitation exercise. The last major capitation exercise took needs weightings forward quite a stage. Eighty-five per cent of our programmes of care now have needs weightings. The last report had 40%. That is a significant forward leap. However, there is still quite a bit to be done, particularly in areas where need has not been met. It is an ongoing agenda, and most people will recognise good progress.

The Chairperson:

Thank you. Minister, you have been very patient and you have been generous with your time. We are all in the business of trying to get a better health service for the people.

2 July 2001 / Menu / 23 January 2002