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SESSION 2002/2003 COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY Evidence Given in Relation to the MINUTES OF PROCEEDINGS, MINUTES OF EVIDENCE Ordered by The Committee for Health, Social
Services and Public Safety to be printed 9 October 2002 POWERS AND MEMBERSHIP POWERS The Committee for Health, Social Services and Public Safety is a Statutory Departmental Committee established in accordance with paragraphs 8 and 9 of Strand One of the Belfast Agreement and under Standing Order No. 46 of the Northern Ireland Assembly. The Committee has a scrutiny, policy development and consultation role with respect to the Department of Health, Social Services and Public Safety, and has a role in the initiation of legislation. The Committee has the power to:
MEMBERSHIP The Committee was established on 29 November 1999 with eleven members, including a Chairman and Deputy Chairman, and a quorum of five. The membership of the Committee is as follows:
NOTE The Department of Health, Social Services and Public Safety's consultation paper 'Developing Better Services-Modernising Hospitals and Reforming Structures (June 2002)' followed from the review of acute hospital services commissioned by the Minister of Health, Social Services and Public Safety, Ms Bairbre de Brún, in August 2000. It sets out proposals for the modernisation of hospital services in the context of new technologies and skills, improved standards, specialisation of medical practices, and the increasing healthcare needs of an ageing population. The paper also outlined the need for organisational reform and set out options for structural change that takes account of the Executive's recently announced Review of Public Administration. The Minister's proposals envisage a radical change to the way in which hospital services are delivered, including their configuration, range of services and accessibility, which is particularly relevant to rural communities. In light of the significance of the document, the Health, Social Services and Public Safety Committee undertook to conduct its own consultation exercise on the Report to assess the robustness of the proposals and their ability to be implemented effectively. Areas for examination included the enhanced local hospital model and the equality assessment, the proposals for maternity services, linkages to primary care and improved communications, and the availability of resources. The Committee agreed on 19 June 2002 to write to a wide range of relevant bodies to seek their views on the proposals for acute hospital services. The Committee agree to examine in detail the options for reform of health and social services administrative structures at a later date. The original deadline for responses was extended to 31 October 2002, in line with the Department's amended consultation end date. The Committee agreed on 09 October 2002 that it should publish the responses received to help inform the public. As the Northern Ireland Assembly went into suspension from 14 October 2002, only those responses received before that time are included in this publication. The Committee would like to thank all those organisations that responded for their submissions, which will help inform the final decisions on the future of hospital services for Northern Ireland into the 21st Century TABLE OF CONTENTS List of Organisations that provided Written Submissions WEDNESDAY, 12 JUNE 2002 at 2.00 pm Present: Dr J Hendron (Chairman) Apologies: Mrs P Armitage In Attendance: Mr P Hughes (Committee Clerk) Dr Hendron took the Chair at 2:03 pm. Public Session 5. Acute Hospitals Review: Modernising Hospitals and Reforming Structures Departmental Officials: Mr Clive Gowdy, Permanent Secretary The entire proceedings are recorded separately in verbatim minutes of evidence. The main points covered by the Officials are summarised as follows:
Agreed: The Committee agreed the draft press release, as amended, on its response to the review of acute hospital services. Agreed: The Clerk will write to the Department to request clarification on the numbers of business cases for the various hospitals already made and awaiting decisions, and those cases still to be completed. A date will also be sought for the decision on the new Regional Maternity Centre, on completion of the specification process. DR J HENDRON [Extract] MINUTES OF PROCEEDINGS Present: Dr J Hendron (Chairman) Apologies: Mrs P Armitage In Attendance: Mr P Hughes (Committee Clerk) Dr Hendron took the Chair at 2:05 pm. Public Session 9. Developing Better Services: Consultation Paper on Acute Hospital Services Agreed: Members agreed the draft paper on 'Developing Better Services', which sets out proposals for the Committee's examination of the Department's above consultation paper. The Committee will undertake an examination of the Report and its conclusions and recommendations, with assistance from Research Services, to assess the robustness of the proposals and their ability to be implemented effectively. Areas for examination will include the enhanced local hospital model and the equality assessment, the maternity proposals, linkages to primary care and improving communications, and the availability of resources. Evidence will be sought from a range of relevant bodies, to gauge the degree of support for the proposals. DR J HENDRON [Extract] WEDNESDAY, 09 OCTOBER 2002 AT 1:30 PM Present: Dr J Hendron (Chairman) Apologies: Mrs P Armitage In Attendance: Mr P Hughes (Committee Clerk) Dr Hendron took the Chair at 1:40 pm. Public Session 6. AOB (iii) Developing Better Services In order to inform the public of the range of views and concerns received in response to the Committee's consultation on 'Developing Better Services', the Chairman recommended that the Committee order the responses to be printed. Question put and agreed to: That the minutes of proceedings, minutes of evidence and written submissions received in relation to the Committee's consideration of the Department of Health, Social Services and Public Safety's consultation document on 'Developing Better Services' be printed. DR J HENDRON [Extract] MINUTES OF EVIDENCE MINUTES OF EVIDENCE Wednesday 12 June 2002 Members present: Witnesses: 1. The Chairperson: I welcome Mr Clive Gowdy, Mr Paul Simpson and Mr David Finnegan from the Department of Health, Social Services and Public Safety to the Committee. We were grateful for your presentation and help yesterday, Mr Gowdy, in relation to the document that the Minister presented this morning, and we will not ask you to repeat that briefing. I will make a few points first, and then ask my Colleagues to pose their questions. 2. I have studied the document carefully and appreciate that the Downe Hospital and the Tyrone County Hospital in Omagh are to be enhanced local hospitals. Is the new build at Downe to be cancelled? I did not hear the Minister's comments this morning, and the point is not covered in the document. 3. Mr Gowdy: The Minister clearly recognises that the fabric of the Downe Hospital needs to be replaced. The announcement this morning was primarily to set out the framework, and the implementation features will follow the consultation. There is a commitment to make investment at the Downe Hospital, but until the Minister's full implementation plan is put out, towards the latter part of the year, I cannot be more precise. 4. Mr Simpson: We are asking Down Lisburn Health and Social Services Trust to update its business case, and to have it ready to go in time for the Minister's decision at the end of the year. 5. Mrs I Robinson: As we were unable to attend this morning's meeting, will Mr Gowdy go through the announced timescale to help Members? 6. Mr Gowdy: The Minister launched the document today, with a consultation period up to 30 September for responses. As soon as possible after the conclusion of the consultation period, we will put together an implementation plan setting out the phasing of the work to be done and the transition we must make. It is the Minister's intention to publish that before the end of this calendar year. 7. The Chairperson: In relation to the decision on Enniskillen, you mentioned yesterday the discussions held with health authorities south of the border. My impression was that developments on hospitals just over the border, such as Sligo General Hospital, would be insufficient to provide services in the Fermanagh area. At what level did those discussions take place? Were the two Ministers and the North/South Ministerial Council involved? 8. Mr Gowdy: Mr Simpson and I discussed this with Michael Kelly, the secretary general of the Department of Health and Children, and some of his departmental colleagues in Dublin. We subsequently exchanged correspondence, and the Minister has spoken to Micheál Martin, the Minister for Health and Children in the South. It has been done at that level. 9. The Chairperson: Yesterday we discussed the White Paper and the Green Paper. I am sure my colleagues understand the difference between the two. For absolute clarification, however, perhaps you might explain those aspects with regard to the Minister's document. 10. Mr Gowdy: The proposals on hospital services have been subject to considerable consultation. We received advice from the acute hospitals review group. Their report has been consulted on, and we received many responses. At present the Minister is laying out her proposals, which set out the direction she believes she should take on hospital services. She is now seeking further reaction. That is the White Paper element, which has firm proposals for action. 11. The second part covers structure and organisation, and contains proposals that have not yet been consulted on to any great extent. We must give people the opportunity to let us know their opinions and where they feel the emphasis should be. We need to produce something similar at the end of that process. It will be published towards the end of 2002 as the Minister's proposals, based on consultation responses. It falls into those two slightly different categories. 12. Mrs Courtney: The Chairperson has already asked you about cross-border ministerial contacts. Did such contact take place to plan co-ordinated provision of hospital services along the border? Has Minister de Brún discussed co-operation on acute services with Minister Martin? Does your Department intend to ensure that future patients are hospitalised as close to home as possible, regardless of which side of the border that hospital is on? 13. Mr Gowdy: Since the establishment of the Executive, we have been working on five areas for co-operation as part of the Good Friday Agreement, aspects of acute hospital services being one. The hospital working group has been discussing how services have been developed in border areas. We also have the co-operation and working together group, which has done much work on co-operation on services. We have regular contact with the Department in Dublin to discuss such issues. 14. This issue has featured at some of the North/ South Ministerial Council meetings, and there is a very clear understanding of what is happening to build up services. If we can co-operate in providing services, particularly in areas where they might be lacking on one side of the border, we should do so. There is clear recognition that we can act for the benefit of patients by working together. 15. One area for co-operation is emergency planning, and another is accident and emergency services. If a plane crashed on the border, there is very clear understanding that we need to mobilise the Ambulance Service, the Fire Service, get the hospitals ready and so on. That planning takes account of people having to travel in either direction in case of emergency. 16. Mr Simpson: An individual needing emergency treatment as a result of a road traffic accident or a fall, for example, will already be hospitalised in the nearest hospital, no matter which side of the border it is. The patient will be stabilised there and, when capable, transferred. That is a long-standing arrangement. 17. Mr Berry: The consultation period will last until 30 September, and will be followed by the implementation time. How will people be assured that implementation and action will take place before the end of the year? There is much concern that the document will be shelved if resources are not there. You know as well as I do, and Committee Members who visit hospitals time and again will support me in this, that people want changes made and decisions taken. We do not want the document to be shelved; we want action. Mr Gowdy said that it is hoped that there will be action by the end of the year, but that can easily slip into next year. Assembly elections will take place next year, and all Members will want to ensure that they are batting the right way, which could result in a serious situation in the Health Service. Like many in the Health Service, we fear that decisions could slip and we could be the same position this time next year. As Assembly Members and public representatives, how can we be assured that action will take place sooner rather than later? 18. Mr Gowdy: This is a very major set of changes, both in the hospital sector and the structure and organisation of the health and social services sector. The changes must be properly planned, which is why an implementation plan is needed over a 10-year period. We realise that the changes cannot be made overnight; some changes will need to be implemented early, and others will have to be deferred. That is why an implementation plan, produced after the consultation period and before the end of the year, is absolutely critical. 19. We are determined, and the Minister has made it clear to us that she is also determined, to get the implementation plan out by the end of the year. The Minister has made public statements saying that the implementation plan will be complete by the end of the year, so there is a clear commitment on the part of the Department and the Minister to produce an implementation plan. 20. The implementation plan will detail how we propose to take all the proposals forward, and will indicate the timescales, which will be important for the Department in obtaining money. The Government budgeting system works on a three-year rolling basis, so we cannot be certain what money we will have in five years. The Department must plan its bids over the next ten years. We need a clear understanding that we can give in public so that everyone knows how we propose to make the changes work. I assure you that we are determined to produce the implementation plan by the end of the year. 21. Mr Berry: The figures on page 42 of the document state that the Department hopes to secure a 30% increase in the number of consultants. How confident are you that those figures will be achieved? 22. Mr Simpson: The proposed staffing increases apply not just to medical staff, but also to nursing and other staff. A combination of activities will be necessary to achieve the increases over the 10-year period. Probably over the next four or five years, we will have to rely heavily on importing doctors from elsewhere. Given the timescale that is necessary to increase the intake of students into medical school until they qualify as doctors, they will not be available for consultancy posts until the end of that period. In the short term, we will have to look elsewhere to recruit people. 23. The vision for the development of hospital services that is set out in the document will greatly improve our chances or attracting people from elsewhere. Personnel in the Health Service keep telling us that, because of the current blight in some hospitals, it is difficult to attract people. Once that uncertainty has been removed and people are clear on the direction, we hope that there will be an improvement. We are currently in active discussions with Queen's University about increasing the intake in the medical school from the current 177 places to 250. That will require quite a steep increase - in fact, a step change - in the medical school. 24. The nurse-training intake has been increased significantly, and we will continue with that increase over the next year or two. We are also working with the University of Ulster on several of the health professional intakes. It is a combination of measures, and we are reasonably confident that if the money is there, we could have the people to meet the needs. 25. Mr Gowdy: The nursing and medical courses are oversubscribed. There are not sufficient places for the applicants. We are confident that we can step up and still have people coming forward. 26. Mr Berry: I have concerns about importing. The figures must be met, but would that not have long term implications? How do you cater for the young people who want to join the medical profession in Northern Ireland, and find that there are no places available? How would you deal with that in the long term? 27. Mr Simpson: There will be a phased increase in the number of posts, and we will continue to add additional posts. When local people qualify, there will be posts for them. 28. Mr J Kelly: I welcome the document, which is a positive contribution to halting the decline in our Health Service. Could you elaborate on the two pilot midwifery-led schemes, and also what you see in the document that relates to west of the Bann? 29. Mr Gowdy: There was a substantial amount of interest in the midwife-led units as a result of the consultation process on the acute hospitals report. It gives women greater choice, and we are keen to explore midwife-led units as a new approach. Potentially it offers an innovative and interesting way to develop maternity services. However, there are several issues that must be explored first. The current model is that maternity services should be located close to other consultant-led services. Anaesthetists, paediatricians and other services are needed if things go wrong. However, if we can screen out high-risk pregnancies and direct them to the consultant-led services, there is no reason why we should not have midwife-led units in place. 30. We need to ensure that those issues are resolved so that we know what would happen in particular circumstances if we located these in certain places. We feel that it should be tried in a heavily populated area in the east of the Province and in a less heavily populated area in the west. We will be inviting expressions of interest for those two pilots soon. 31. The Chairperson: Does the Royal College of Midwives totally support this? 32. Mr Gowdy: It has consistently said that we should be going in that direction. 33. The Chairperson: I take that this is just as long as the at-risk cases are sifted out. 34. Mr Gowdy: Absolutely. 35. Mr J Kelly: To clarify this, we are talking about pilots. They will be expanded if we see the need for them in the wider community. We are not just talking two units, but a pilot scheme that will expand. 36. Mr Gowdy: Yes. We need to test these pilot schemes and learn from them. We need to see what degree of support there is for them, and whether women really want to have them. After that the door opens. We could see expansion if there is a positive outcome. 37. Mr J Kelly: What about the situation west of the River Bann? 38. Mr Gowdy: We have been careful to recognise that there are access problems in rural areas. We take that very seriously, which is why we have done extra work on travel times and access to acute services in remote areas. A new hospital is required for the south-west, and based on the figure work that we have done, the Enniskillen area is the preferred location. However, we do not want to leave a big gap for people in the Tyrone area, which is why we are talking about enhanced localised services at Tyrone County Hospital. 39. The process began a few months ago with the Downe Hospital, when the Eastern Health and Social Services Board and the Down Lisburn Health and Social Services Trust explored the sort of services an enhanced hospital would need. They had already developed some thinking on the matter, which we were able to build on. That is why we were able to define in the document what the Downe Hospital needs. That work has not been done in the west of the Province for Tyrone County Hospital. The Western Health and Social Services Board needs to undertake that work before we can define exactly what services would be needed. We expect Tyrone County Hospital to follow the model of the Downe Hospital. 40. Altnagelvin Hospital is a major player in acute care. Along with the new hospital in Enniskillen in the west of the Province, it is very important. The Mid-Ulster Hospital must be linked to those acute hospitals and the enhanced one in Omagh to create a network that covers the west of the Province. 41. Mr J Kelly: Is the outworking of this that no rural area will be isolated from acute services? 42. Mr Gowdy: That was a deliberate policy objective. 43. Rev Coulter: Congratulations on producing a very good report. With regard to the reduction of the health and social services boards, will there be redundancies amongst the administration staff, or an increase in numbers? How will the community trusts be amalgamated? Will that be based on geographical boundaries? What is the raison d'être for the amalgamation? 44. Mr Gowdy: This part of the consultation will gather views on the direction that we should take. We do not have the same sort of firm proposals for this project. We want to hear from the public and service users on several issues. The Committee is also an important player. 45. Mr Simpson: I remind the Committee of what Mr Gowdy said earlier about the timescale for any changes to the structure of the health and social services boards. The document is clear that, with regard to chapter five on structures, this is a Green Paper. It states that further consultation on definitive proposals will have to be done in line with the review of public administration. We have made a commitment to take account of the emerging criteria and principles from that review when determining the final configurations. That should give the Committee an idea of how far away we are from making changes. 46. Having taken account of the review of public administration, when the Minister is in a position to produce her definitive proposals and structures, the Department intends that that document will set out the rules of engagement with regard to the whole human resources dimension. This will cover how we deal with people - their rights, and protection arrangements. We fully intend to engage with all the relevant trade unions in agreeing those. Generally, we are not talking about redundancies. There is no general feeling that we have an over-managed service. If anything, we have an over-structured rather than an over-managed service. All the skills and talents of management will be needed for whatever new structures we devise. 47. Regarding the amalgamation of community trusts, the chapter simply identifies for the reader several possible ways in which trusts could be changed, including the possibility that we would no longer have trusts. We are now open to the views of the public and the Health Service on whether we would still regard integrated health and social care trusts as being a cardinal principle that we do not want to give up on. Depending on the importance you attach to that, you can take different approaches to the structures. At this stage, it is very much open to discussion. 48. The Chairperson: There are no firmed up proposals for structures, which is the Green Paper that we referred to earlier. 49. Mr Simpson: Exactly. 50. Ms McWilliams: I want some clarification about the Mater Hospital before I go into the details of the projects' finances. We are told that there will be nine acute hospitals, with 24-hour accident and emergency services, and a range of in-patient, outpatient and day procedures. What does the Mater Hospital have? 51. Mr Gowdy: The Mater Hospital has all the services that a local hospital would have, plus maternity services. 52. Ms McWilliams: What will it lose? 53. Mr Gowdy: It loses accident and emergency services and in-patient medical beds. 54. Ms McWilliams: It does not state that clearly in the document. 55. Mr Gowdy: We tried to focus on what we will build up in local hospitals. We want to build up the Mater Hospital. However, it shifts some of the services that are acute in nature to the acute hospitals. 56. Ms McWilliams: The next sentence says that eight out of the nine will have consultant-led in-patient maternity services. A tiny footnote explains that the Mater Hospital will not have that, but will be tied in to where a decision is made about a centralised maternity hospital. 57. Mr Gowdy: The Mater Hospital will retain consultant-led maternity services. 58. Ms McWilliams: That will be in conjunction with the Royal Group of Hospitals. I understand that. However, it is not counted, as the document speaks about only eight of the nine. 59. Mr Gowdy: It is not counted as one of the acute hospitals. We are saying that eight of the acute hospitals will have consultant-led services, plus the Mater Hospital will be a ninth. 60. Ms McWilliams: That could lead to some confusion in working out the numbers, which is my next question. Maternity services at Downpatrick Maternity Hospital and Lagan Valley Hospital will close until decisions are made about pilots, which I asked you about yesterday. Since those midwife-led decisions have not been made, those mothers will have to come into the Belfast region. Currently, we have provision for a merged Jubilee Maternity Hospital and Royal Maternity Hospital site on the Royal site, but no decision has been made about the centralised maternity unit. How long will that take? I foresee enormous pressure. You have already sent out a message of what is going, but not what is replacing it. 61. Mr Gowdy: We are not talking about closing hospitals. They will stay open, and we will try to build up the their services. We will be moving services such as maternity to bigger centres. There is also the question of a midwife-led unit. 62. Ms McWilliams: Let us not get into semantics. 63. Mr Gowdy: That is an important distinction. 64. Ms McWilliams: For people using those two hospitals, moving the services is the same as not having the current services. 65. Mr Gowdy: We are trying to continue to provide access. 66. Ms McWilliams: Yes, in one site at the Royal Maternity Hospital, which is currently under pressure. 67. Mr Gowdy: It is providing services to people in these areas. We are conscious that there are travel time issues, and we want to ensure that we avoid creating problems for people. It is not a case of us closing something and turning it off. We are trying to make sure that we provide services that are accessible for people. There is a question about where the midwife-led units might be located, and the Downe Hospital might be one site to take on that role. 68. Ms McWilliams: I am concerned about midwife-led centres when no decisions have been made. You and I had a discussion yesterday about the word "pilot". However, I am more concerned about what is going to happen. Where a consultancy-led service is required, all those responsibilities are going to pile up on overpressured hospitals, either in the Ulster Hospital or in the Royal Maternity Hospital. I appreciate that because of judicial reviews no decision has been made on the centralised maternity unit. We have had a decision on acute hospitals, with something else kicked into touch further down the line. I foresee serious problems in relation to that. 69. Mr Gowdy: That is the point that I was making to Mr Berry. A planned approach is required, as we are conscious that there is much to do. If we try to do that piecemeal, what you have described might well become a problem for us. There must be a phased sequence and a transition. We need a clear articulation by the end of the year of how we will deliver on the document. The points that you have made are going to be very important to us. 70. We cannot exercise unilateral control over the location of the central maternity unit. We must go through the process that we are currently engaged. We are at the point where we have a specification. 71. Mr Simpson: That has gone to the trusts so that they can come back to us with proposals. 72. Ms McWilliams: I had hoped that that would have been before the summer, which is what we were promised. We still do not have that. I assume that the costings I have here do not include a business case for a centralised maternity unit. 73. Mr Simpson: We need to go away and think about that. There is a long list, amounting to around £1·2 billion, and I cannot recall whether the maternity unit is included. 74. Ms McWilliams: So you do not know whether or not the costings I have for capital funding include that business case? 75. Mr Simpson: I will be able to tell you very quickly whether or not they do, but I do not have that information with me. 76. Ms McWilliams: I would appreciate that. 77. We have here a list of capital funding projects for the next 10 years, and you have told us what the estimated requirements are going to be. The estimated requirement for this year is £38·2 million. Should we not be looking at the projects' estimated financial profile? You may not have the information to hand, but it is crucial for the Committee. To work out that capital funding figure, you know where to start and how to phase it. Is it best to look at the project costs, which are to be found on page 55 of the 'Developing Better Services' document? The project costs will increase to £52 million next year, to £87 million the following year, and to £122 million in the year after that. Can you give us some idea of what will start next year? Will this increase to £52 million next year, and then to £87 million and then to £122 million? Is it possible for you to do that? 78. Mr Gowdy: The list of schemes is a long one, and we would have to go back and consult the list. We would be happy to give that information to the Committee in writing. 79. The Chairperson: That would be helpful. 80. Ms McWilliams: Since you have to go back to document, may I suggest that you supply the information for the whole 10 years, as I have only asked about commitments up to 2005? 81. Mr Simpson: In our reply to the Committee we will include the caveat that all of this is built on assumptions about the availability of capital. The list simply comprises what we intend to do if the money is available. It must not be assumed that it is a definitive list and an implementation plan. 82. Ms McWilliams: I appreciate that. 83. Mr Gowdy: The result of the consultation will feed into that as well. 84. Ms McWilliams: Since you have already done a great deal of work to get to the stage of having project costs and capital costs, it would assist us greatly to be able to understand exactly what is meant by that. 85. Mr Gowdy: Yes, we will do that. 86. The Chairperson: Please write to the Committee with clarification. 87. The centralised maternity service in Belfast is not sorted out yet and there is overcrowding at the Royal Maternity Hospital. Can I assume that the Downpatrick Maternity Hospital and the Lagan Valley Hospital maternity unit will not be cut down until the centralised maternity at Belfast is sorted out? 88. Mr Gowdy: The Minister is keen to continue providing services at those hospitals for as long as they are needed. There is an issue about when services should be stopped at one location and shifted to another. Some of that will be determined by the responses on such matters as midwife-led units, et cetera. There are some decisions to be made following the consultation. 89. Mrs I Robinson: As I said yesterday, I am concerned that Lagan Valley Hospital might lose its maternity unit, especially since Lisburn received city status and considering the geography of the area. The Mater Infirmorum Hospital has been rubber-stamped to continue with maternity services, even though a time ago it did not have a high enough number of births to allow it to continue. As there will also be a maternity unit at the Royal Group of Hospitals, people have been telephoning me expressing their concern at it being chosen rather than the Belfast City Hospital site. Such a selection of sites is detrimental to many women from the Unionist community. It would be preferable if Lagan Valley Hospital maintained its maternity services for women from the Unionist community who do not want to travel to the Mater or the Royal. 90. Mr Gowdy: That point will be considered in the consultation process. Women from both communities have their babies delivered in the Mater. A decision has not been made yet on the location of the Belfast maternity hospital, so there are a couple of imponderables in what Mrs Robinson says. 91. Mrs I Robinson: I am not criticising the nurses, doctors or other staff of the Royal Group of Hospitals or the Mater Infirmorum Hospital. I am going by the results of a survey that revealed that Protestant and Catholic women felt comfortable and secure going to the old Jubilee Hospital. Some people will not feel comfortable going to the Royal or the Mater, if that is where the maternity services will be located. The maternity unit should be at the Belfast City Hospital site, but if it is not, then the maternity service at Lagan Valley Hospital should be retained. 92. The Chairperson: I understand that. 93. Mr Gowdy: I also understand what Mrs Robinson is saying, but until we see the outcome of the consultation we do not know what site will be chosen. I should add that there is still a maternity unit at the Ulster Hospital. 94. The Chairperson: There is still some important work to be done in sorting out the maternity service. 95. Mr Gallagher: Thank you for the presentation. I can recall looking at a document some years ago that outlined the way forward for acute hospital development as being based on six centres. When the results of the document are translated on to a map, it will be obvious that the arrangements will be fairer to all communities. I am interested in how the costs of the capital development will be covered. Do you have any idea how much the new hospital at Enniskillen, for instance, will cost? How does the Department intend to raise the costs? Will it be through normal methods, or are there likely to be some private interests involved? 96. The document states that some local hospitals will have additional services, and it goes on to mention the Downe Hospital, Lagan Valley Hospital and others. However, it does not mention South Tyrone Hospital. Does that mean that it will not have any additional services, or are things unlikely to change there? I raise that because people from that area have made sensible comments when they see Craigavon Area Hospital under pressure while there is space at South Tyrone Hospital, and they see how busy the accident and emergency department is at Craigavon Area Hospital while the local accident and emergency department in Dungannon is closed. 97. You said that you hope to have the implementation plan by the end of the year. Will that pick up on details such as who implements aspects of the plan, because the structures involve boards and trusts and they are part of the change? Therefore, if boards and trusts are going to change and there is going to be rationalisation, will they also have responsibility for implementing parts of the plan? 98. Mr Simpson: The definitive costs for the new hospital north of Enniskillen can only be worked out in the context of the preparation of a business case. It depends, to a degree, on the chosen site. There are various possibilities such as the cost of purchasing a greenfield site or the cost of building on the Erne site. In our planning we are assuming that the all-up costs will be similar to the updated cost of the Causeway Hospital, which is between £70 million and £80 million. 99. South Tyrone Hospital is listed as being a local hospital in the document, so it will have the range of features that are described in the document as those belonging to a local hospital. The Southern Health and Social Services Board has been working well with the local trust to identify additional activities, in the short to medium term, that South Tyrone Hospital could carry out. A service development plan for the hospital is currently under consideration. The hospital is already doing some interesting things, such as developing ophthalmology day services, and there are other interesting possibilities. The Minister quite rightly said that the precise detail of what every local hospital will do in the broad core list of services in the document would be configured depending on local circumstances. Therefore, South Tyrone Hospital will be able to do other things in addition to those listed, but principally it will be a local hospital. 100. Mr Gowdy: The Department will continue to oversee the implementation plan, which will be under our overall control. Initially, boards would be responsible for implementation, because even if there is to be a change in structure with the boards to go, that requires legislation to make it happen - it cannot happen overnight. Therefore, we will initially guide it from the Department, expecting the boards to do some of the initial work, and when the change is finally agreed and takes place, the responsibility will move to whatever successor bodies there may be. 101. Mrs I Robinson: You said that Lagan Valley Hospital and another hospital west of the Bann would have protected elective surgery as a service provision. Can you guarantee that their work will not be interrupted because of bed blocking or insufficient beds in other hospitals? 102. Mr Gowdy: That is the concept, and the driving force behind the initiative. If we are to make any real impact on the waiting lists, we must put dedicated facilities in place. To develop Lagan Valley Hospital as a dedicated, elective centre, we must protect it from the vagaries of the winter pressures and other crises that may occur. 103. Mrs I Robinson: I do not want the hospital to be an overspill facility. 104. Mr Gowdy: It will have clear status as a centre in which such things will be done, and to ensure that it delivers the right volume of elective work, we will build up its capacity. 105. Mr J Kelly: Catholic and Protestant mothers did not opt for the maternity facilities at the City Hospital for sectarian reasons. They did so because that was where they felt comfortable having their babies. They wanted to keep the maternity services at the City Hospital, but not because they wanted to sectarianise them. Has the Executive approved the document? 106. Mr Gowdy: The Executive has discussed the document extensively. The Minister is responsible for the proposals, and the Executive has agreed that she should put the document out for consultation. 107. Mr J Kelly: Is the Executive aware of the financial projections? 108. Mr Gowdy: The Executive knows how much money is required. However, they have not given a guarantee that we will get all that we require. Given that the timing for normal Government budgeting is three years, they have not been able to give us a guarantee of money over the full 10-year period. They are aware of the financial projections and they know the extent to which we will bid. 109. Mr J Kelly: On a more positive note, will you expand on the impact of the two protected elective facilities on issues such as waiting lists? 110. Mr Gowdy: They are designed to overcome a major obstacle that we face. Emergency cases block the beds in our hospitals and limit elective work. We must find a way to protect the elective opportunities by making them invulnerable to such external pressures. Therefore, the idea is to have two centres in which the beds, the theatres and the staff would be dedicated to elective work all year round, and would not be required to put it aside to cope with emergency pressures. That brings us to the capacity issues, which is why we must build acute hospital capacity and ensure that we have enough beds to allow for a regular flow of cases through the two elective centres. Other hospitals will do elective surgery, but they will not have the same protected status. 111. Mr J Kelly: Therefore, barring a national catastrophe, those facilities will be protected for elective surgery only? 112. Mr Gowdy: Yes. 113. Ms McWilliams: I am interested in the development of consultant-led fracture clinics in all acute hospitals and full inpatient fracture services at Antrim Hospital and Craigavon Area Hospital. Does the Department intend to phase in such provision? There are no fracture services at some of the acute hospitals. The proposals will release the pressure and address the current backlog. 114. Mr Simpson: There is a clear distinction between the fracture clinics and an inpatient fracture service. The intention is for there to be consultant-led fracture clinics at every acute hospital to deal with the walking wounded. The document refers to extending the current provision with regard to serious fractures such as long-bone fractures and neck-of-femur fractures, which is only available at the Royal Hospitals, the Ulster Hospital and Altnegelvin Hospital, to include Antrim Area Hospital and Craigavon Area Hospital. 115. Ms McWilliams: That does not include the Causeway Hospital. What do you mean, therefore, when you refer to "all acute hospitals"? 116. Mr Simpson: All acute hospitals will have consultant-led fracture clinics. My latter point was in relation to in-patient consultant services. A neck-of-femur fracture would be operated on in Antrim or Craigavon hospitals, rather than transferred to Belfast, Derry or the Ulster Hospital. 117. Ms McWilliams: The Department has said that steps will be taken to enhance services at Musgrave Park Hospital, which has a huge waiting list. 118. The Chairperson: It has an elective orthopaedic waiting list. 119. Ms McWilliams: What is the time frame on that enhancement? 120. Mr Simpson: The Department currently has a business case for an increase in theatre capacity. Assuming that that business case is agreed and endorsed by the Minister, the Department expects that additional theatre capacity will probably become available during the next two years - maybe sooner. 121. Ms McWilliams: The business case has been included in the costings. Has the Department already put in a bid in the current round? 122. Mr Gowdy: The Department already has a clear capital expenditure profile. We would have been doing this anyway. 123. Ms McWilliams: Therefore, double costing is not taking place? 124. Mr Simpson: The answer to that question is no, and you will see that when the Department sends the Committee the total list. I am sure the list that the Committee will receive will include not only things that were already programmed, but also additional things. 125. Ms McWilliams: That will avoid confusion about decisions that have already been taken, and future decisions. 126. Mr Simpson: A decision will not be made until the business case is approved. The Department is optimistic, and we want to make the provision available. However, it cannot say formally to the Committee that the business case has been agreed until it is signed off. 127. Ms McWilliams: Given the consultation on this, I am concerned that it may be held up. 128. Mr Gowdy: It will not be held up for that reason. 129. The Chairperson: Many orthopaedic surgeons whom I have spoken to felt that there could only be two places of excellence with regard to orthopaedic surgery. One is the Royal Hospitals - although the Ulster Hospital has a tradition of orthopaedic surgery - and the other is Altnegelvin Hospital. They said that if there were a third place, there would not be three places of excellence. I support what has been proposed in the document. The Department is saying that in addition to the Royal Hospitals/Ulster Hospital and Altnegelvin Hospital, Antrim Hospital and Craigavon Area Hospital will be able to deal with all severe fractures, and the other acute hospitals will deal with fractures to a lesser extent. Is that correct? 130. Mr Gowdy: Yes. 131. The Chairperson: Have lesser fractures been defined? We all know that a fracture of the finger is a simple fracture. Orthopaedic surgeons have asked where the cut-off line is between fractures that are referred to the main orthopaedic centres, and those that are not. 132. Mr Simpson: As you know, different surgeons are presently taking different views about what they are prepared to do themselves, and what they will refer elsewhere. You will get a different picture from someone such as Crawford Bell in Downpatrick, as you might from a surgeon in Craigavon, regarding what they will treat and what they will refer elsewhere. I cannot give a straight answer to that question at the moment. 133. However, the Department aspires to a situation in which any fracture, whether it is of a minor or major nature, will be seen by an orthopaedic consultant in consultant-led orthopaedic clinics. That is why the Department wants each of the nine acute hospitals to have such a clinic. No longer will the general surgeon have to make a judgement call. The orthopaedic surgeon will make a decision, and will either treat the fracture - if it is minor - there and then, or refer it to an in-patient centre for further attention. 134. The Chairperson: I accept your point. If someone with a fractured neck-of-femur were brought to the Causeway Hospital, for example, would they be stabilised and transferred to Antrim Hospital or another main hospital? 135. Mr Simpson: It would depend on the severity of the fracture. The patient may need specialist treatment. 136. Mr Berry: I mentioned fracture services to Mr Gowdy yesterday. The document states that full in patient fracture services in Antrim Area Hospital and Craigavon Area Hospital will also be established. There is no timeframe mentioned, so what is happening with those? We have lobbied for a long time to get those services. 137. Mr Simpson: The Northern Health and Social Services Board and the Southern Health and Social Services Board have had proposals in the pipeline for some time to develop in patient fracture services at those hospitals. On the foot of this document, we will now invite them to bring those proposals to us, along with the usual business case that should be prepared. The timescale for implementing those proposals will depend on the Minister's conclusions on the overall implementation plan. At the end of the year tough decisions will have to be made on priorities, depending on the amount of money that the Executive is prepared to make available. 138. The Chairperson: As Rev Coulter said earlier the report is excellent, and I agree with him. However, that does not mean that I would not get into the arguments about the Erne Hospital and the Tyrone County Hospital in Omagh. I appreciate the complexities of those discussions. It is obvious that people living in certain areas will worry about the impact of delivery at a later stage. The Committee would like to thank you for your excellent report. Belfast City Hospital Trust Causeway Health and Social Services Trust Down Lisburn Health and Social Services Trust Eastern Health and Social Services Board Fermanagh District Council Homefirst Community Health and Social Services Trust Magherafelt/Cookstown District Councils Mater Hospital Trust Mater Hospital Community Action Group Northern Ireland Ambulance Service Northern Ireland Multi-Disciplinary Primary Care Forum Northern Ireland Practice and Education Council for Nursing and Midwifery Omagh & District General Practitioners' Association Omagh District Council and The Hospital Campaign for the Rural West Steering Group Rural Development Council South & East Belfast Health and Social Services Trust Sperrin Lakeland Health and Social Services Trust The Royal Hospitals and Dental Hospital Health and Social Services Trust Ulster Community and Hospitals Trust UNISON United Hospitals Health and Social Services Trust Western Health and Social Services Council WRITTEN SUBMISSION BY: 6 September 2002 I refer to your letter dated 26 July seeking comment from the Trust on the benefits to be achieved or problems arising from the reshaping of hospital services. With regard to the specific policy areas highlighted in your correspondence we would make the following comments:
Patients requiring acute hospital services should be provided with the highest possible level of clinical, technical and scientific expertise. This requires a highly skilled workforce which can be achieved only by the concentration of skills in a reduced number of locations. The implementation of European Directives will make this even more essential. The designated acute hospitals will have a vital role in supporting and linking together other services which are more appropriately delivered locally. The aim must be to enable each patient to expect a seamless network of care, which guarantees easy access to the highly technological services of the acute hospitals when necessary and equally easy access to a wide range of appropriate local facilities.
The proposed role of local hospitals is central to the strategy. They can be tailored to provide many aspects of the wide range of local diagnostic, treatment and supportive services. They will also need to develop strong linkages with the acute hospitals and to primary care. It will be important for the local hospitals to attract and retain a workforce appropriate for their purpose. Some members of clinical teams will have to work across the acute/local hospital interface and, in other cases, into primary care situations.
This is the biggest challenge for the HPSS. Health promotion, screening, early diagnosis, many clinical treatments and supportive care services are all provided most effectively in the primary care situation. The ongoing development of these services needs to be carried out in close liaison with the clinical teams based in hospitals. The new Local Health & Social Care Groups will need time and support to effectively develop primary care in the first instance and their commissioning expertise in the longer term.
The goal of a modernised hospital service which truly meets the needs of the community will be realised only with a properly funded regional and local ICT strategy. Realistic timeframes are required to ensure integrated implementation. Improved ICT provision should include regional systems for radiology, pathology and the Unique Patient Identifier. These would reduce clinical risk and make a signification contribution towards improved efficiency.
We agree with the need to support rural communities through a range of initiatives. These should be developed on the evidence of successful models elsewhere.
The Trust gives full support to the development of midwife-led maternity units associated closely with consultant-led units. We would recommend a visit to the midwife-led unit at Craigavon Area Hospital.
It is clear that there is a need for additional elective surgical capacity if we are to eliminate unacceptably long waits for treatment. Our own performance in this respect has been hampered by totally inadequate and outdated day surgery facilities in the Gardner Robb and Dufferin Buildings at Belfast City Hospital. These need to be replaced as a matter of urgency. The Trust would welcome the provision of new specialist centres although this would not avoid the crucial need to update existing facilities in the acute hospitals. The concept should be developed in association with clinical teams providing emergency, urgent and complex surgery in acute hospitals, so that there is a clear definition of the particular role of the new centres and the expected benefits.
The Trust's experience of cross-border co-operation has been of benefit to patients, to staff and to service development. We would be pleased to brief the Committee on our cross-border initiatives and other important links with services in GB and elsewhere. We would also highlight our pivotal role in the valuable link between the two governments and the National Cancer Institute of the United States.
The Trust welcomes the indication in the document that a number of Belfast hospital specialties will be relocated in line with the recommendations of the report: Taking forward the Pattern of Acute Hospital Services in the Eastern Board Area (December 2000). There is strong clinical support for the development of the central focus for these services at BCH. This would result in important benefits for patients and the services themselves. Again, we would be pleased to brief the Committee accordingly. I hope these comments will be of assistance to the Committee. We will be responding in greater detail to the Department in due course. J QUENTIN COEY WRITTEN SUBMISSION BY: 4 September 2002 I refer to your letter of 26th July 2002 in respect of the above matter and your request for comments on key issues pertaining to the above document. The Trust particularly welcomes the refocusing of acute services within nine sites, and is encouraged by the inclusion of Causeway Hospital as one of the nine. The Trust believes that, given the investment there has been in a modern hospital in the Causeway area, and recognising our geographical location, we have a unique opportunity to ensure the development of future acute services to meet the needs of the local population. The Health and Social Services and Public Safety Committee may, however, wish to bear in mind how Causeway Hospital, Daisy Hill and the new hospital in Enniskillen (if this is the eventual location) will contribute to the future network of acute hospital care. Given the economy of scale associated with the size of these hospitals it would seem appropriate that a profile of services should be developed for these sites which would secure their viability. The Trust would also wish to point out that in addition to the envelope of service provision, consideration should also be given to the continuing involvement and training of junior medical staff and other health care professionals. We would also wish to point out that given the economy of scale associated with hospitals the size of Causeway, recognition must be given to core funding issues and the fact that unit costs for services on sites such as these may seem comparatively high. In this context, consideration might be given as to how Causeway Hospital might absorb current workload of other smaller neighbouring hospitals. With regard to the establishment of new local hospitals, there is of course, no Local Hospital located geographically within the Causeway area, but the Trust does have two community hospitals, one in Ballymoney and one in Ballycastle which support primary and secondary care. In this context, the Trust believes that the issues to be considered here are:
With regard to improved communications and information technology links, the Trust will fully support and respond positively to any initiatives to improve communications including IT should additional resources become available. The telemedicine and teleconferencing facilities have already been tested in Causeway Hospital and work very effectively. These developments are not necessarily limited by technology but by the financial resources available. The commitment to improve ambulance/transport services and fast/rapid respond schemes is welcomes by the Trust. An improved and adequately resourced ambulance service, with a thinking control arrangement, is essential to the implementation of a new effective pattern of acute hospital care. This Trust would be particularly interested in entering into discussions on the most appropriate model of providing mobile cardiac services in geographical areas such as Causeway with a large rural population. Causeway Trust is committed to providing an integrated acute/community midwifery service and would envisage a midwifery provided service as an integral part of the consultant led unit in Causeway Hospital. The Trust is still developing its thinking on this matter but we would ensure that any model that is developed will be compatible with the thinking in the report. The Trust would have some concerns regarding the location of the 2nd of the two specialist centres for planned elective surgery. As it is suggested that it would be somewhere west of the Bann, serious consideration will have to be given to the population corridor that might exist between Lagan Valley Hospital as one location and any second location west of the Bann. Given the geographical isolation of Causeway population from these centres there needs to be assurance that the local population in Causeway areas is not disadvantaged. The Trust would see it as essential that planned elective surgery continues to be provided for the local population at Causeway Hospital. This is currently proving very difficult due to the high numbers of blocked beds as a result of inadequate investment in Community Care to facilitate timely discharge. In relation to co-operation between Northern Ireland and the Republic of Ireland the Trust will respond positively to any appropriate opportunity to participate in seamless health care arrangements and in this context would envisage a role in support of Altnagelvin Hospital, which is the closest hospital geographically aligned to both ourselves and the nearest border point. The Trust would also wish to comment on a number of other general points not included in your specific questions. We would wish to make your committee aware of the absolute necessity of having intensive care beds in Causeway Hospital to support emergency and complex surgical cases. Maintenance of intensive care beds would ensure safe patient care and alleviate the need for patients to travel in excess of 30 miles for intensive care to the nearest larger acute hospital. In the planning of the new Causeway Hospital, the Trust was able to take the opportunity to rationalise a range of acute services which were delivered internally. The Trust recognises that this rationalisation had to take place as part of the commissioning of the new hospital, but would have some concerns that there would appear to have been little rationalisation in other Trusts and particularly across Trust boundaries in respect of acute services. The Trust believes that there is now an opportunity through this process to take an overview of the entire provision of acute services which was difficult in the past because of the management structures and the configuration of Trusts as competitive entities not collaborative partners. On a more general note, we would wish to point out the potential difficulties faced by Causeway Hospital in the interim until the new pattern of services is in place and appropriately resourced. The increasing demand for services, compounded by increasing standards emanating from Royal Colleges and other sources, will create service delivery issues and subsequent financial and funding problems associated with maintaining Causeway as a viable acute hospital in the interim period. While the Trust is working collaboratively with the Northern Health and Social Services Board on this matter we believe that the risks associated in this interim period should be brought to your attention. I trust that these observations may be useful to your committee and in this context I would extend an invitation to the committee to visit Causeway Hospital and meet with Senior Clinical and Managerial staff. Given the likely development of a new hospital west of the Bann, Causeway could provide a useful opportunity to members of the Health Committee to see a similar sized new hospital. MS NORMA EVANS WRITTEN SUBMISSION BY: 9 September, 2002 Thank you for correspondence requesting comment from the Trust on the proposals outlined in 'Developing Better Services'. The Trust is currently in the process of compiling its response to the consultation document and as part of this process meetings are being held with staff throughout the organisation and with other local bodies. The full response from Down Lisburn will be discussed at the Trust Board meeting in October, but in reply to your letter I have outlined below some comments that indicate the Trusts initial views on the Minister's proposals.
The Trust has a particular interest in the service models outlined for the Lagan Valley and the Downe Hospitals and some initial comments on these are detailed overleaf. Downe Hospital
Lagan Valley
Maternity Services The consultation document has outlined that consultant led maternity services would no longer be provided at either the Downpatrick Maternity Hospital or the Lagan Valley Hospital. In relation to the Downpatrick Maternity Hospital, the Health Committee may be aware that a number of measures have had to be put in place by the Trust to ensure the continued provision of maternity services from the facility. This had not been without some significant difficulties and the Trust would welcome a final decision from the Minister on the future of consultant led services for the area. This must also allow for any change to be taken forward in a timely, planned and coherent manner. Equally, the mothers in the area must be engaged to ensure if there is an alternative model, it is designed to minimise difficulties for them. The Trust is however disappointed that the document proposes the removal of consultant led maternity service from the Lagan Valley Hospital. The Trust believes that due to its location, ie proximity to Belfast, the hospital should be afforded the same opportunity as that outlined for the continued provision of maternity services from the Mater Hospital. The Trust is confident that robust networking arrangements could be established with Belfast Units to enable safe, high quality maternity services to continue to be delivered from Lagan Valley into the future. However, the Trust acknowledges that when a new central maternity facility is available in Belfast, this will create a new paradigm for obstetric services within the EHSSB area. Midwife led units The Trust is currently gathering details on midwife led units to enable it to develop a properly informed view on the proposed establishment of pilots within Northern Ireland. This information gathering has taken the form of staff visits to such units in England and Wales and research presentations. The initial information presented has outlined the opportunities that midwife led units provide in terms of offering a safe local choice for some women who are in a low risk category for delivery. However, the Trust expects to express an interest in piloting one of the units, however, the issue is to be further discussed with staff. I would emphasise that the above comments are an outline only of the Trust' initial views of 'Developing Better Services'. A more detailed and comprehensive response will be forwarded to the Department by the end of October. I hope however the details are helpful to the members of the Health Committee and naturally if you thought it appropriate, I would meet with the Committee to discuss these comments in more detail. JOHN COMPTON WRITTEN SUBMISSION BY: 1.0 Introduction 1.1 The Eastern Health and Social Services Board, along with other consultees, will be responding to the consultation paper "Developing Better Services" prepared by the Department of Health and Social Services and Public Safety (DHSS&PS). The paper deals with proposals in respect of modernising hospital services and making changes to health and social care structures. Consultees are asked to respond to the paper by the end of October 2002. 1.2 The Board considers that it would be helpful if we adopted a 2-phase approach to the consultation response. We feel that we should prepare this paper in relation to Modernising Hospital Services as Phase 1 of our response, because the Board has already done a lot of thinking about how it sees the pattern of hospitals emerging within its area and because we feel it might be useful for other consultees to have seen our proposed response as a way of helping them to think about their own response. 1.3 The consideration of potential future Health and Social Care Structures is at a less advanced stage and the Board would propose to conclude its views at its meeting in October for submission together with the Phase 1 response by the end of October. 2.0 Summary of the Main Recommendations of "Developing Better Services" as it relates to the Eastern Board Area 2.1 The Developing Better Services document as it relates to hospital services, discusses the background to the need for change:- "...Pressures for change are coming from many and varied directions - new patterns of illness and disease, new medicines and treatments, new technologies, new skills and changes in how doctors, nurses and other health professionals train and work. These changes, combined with years of under-investment, are placing sustained pressures on hospitals and their staff". It describes the challenges and opportunities provided by these trends which should allow for two apparently divergent things to happen:- on the one hand, the ability to make use of the developments in technology to allow things to be done locally which in previous times would have only been done more centrally e.g. sophisticated diagnostics and elective procedures on a day case or outpatient basis; and, on the other, the gathering together into larger teams of health professionals who want to sub-specialise in areas of care or disease while still having sufficient numbers of patients to treat so that they maintain and improve their skills. 2.2 The paper supports the concept of "managed clinical networks" which would link these services across a number of sites and provide a range of specialist and more routine services to a population in a clinically appropriate and convenient way. These services would be closely linked also to the services provided in primary care and community care settings. 2.3 Two types of hospital are described in the Developing Better Services paper:- New Local Hospitals A Local Hospital would "provide a local base for expert clinicians, specialist nurses and other health professionals, who will relate to populations rather than to individual facilities and provide a range of services including:-
2.4 In the case of the Eastern Board area, the Downe, Lagan Valley and Mater Hospitals would be Local Hospitals. The paper also described variations to the standard profile for each of these Local Hospitals as follows:- 2.5 Downe would be an Enhanced Local Hospital because of its geographical and time distance from acute hospitals, so in addition to the facilities described above it would have a 24-hour A&E Unit linked to an acute hospital network and capable of providing resuscitation and emergency coronary care and a consultant-led inpatient medical service. The hospital would not have consultant-led inpatient maternity services. 2.6 Lagan Valley was envisaged as needing "to continue to provide a wide range of acute services for much of the period leading to the establishment of a new pattern of hospital services, pending its transformation to a modern Local Hospital". Over and above the standard profile of a Local Hospital, Lagan Valley is envisaged as being a specialist centre for planned (elective) surgery for Greater Belfast. This would be a centre which allowed elective surgery to proceed on a year round basis, without the interruptions which are often currently experienced as a result of surges in demand for emergency medical admissions. 2.7 The Mater hospital, like Lagan Valley, is envisaged as needing to "continue to provide a range of Acute Services for much of the period leading to the establishment of a new pattern of hospital services, pending its transformation to a modern Local Hospital". In addition to its standard profile as a Local Hospital, the Mater is distinguished from its peers in regard to two issues:- the recognition of its long history as a teaching hospital "ideally placed to play an even more significant role in contributing to training of doctors, nurses and other health professionals of the future"; and, the fact that close proximity to the new centralised maternity hospital (which will be sited on either the Royal Group or Belfast City Hospital sites) may make it possible to continue with inpatient consultant-led obstetric services provided these are closely networked with the major maternity hospital service. 2.8 Modern Acute Hospitals The Developing Better Services paper proposes that there will be nine Modern Acute Hospitals in Northern Ireland and in respect of the Eastern Board area these would be the Belfast City Hospital, the Royal Group and the Ulster. The clinical profiles for each of the Acute Hospitals would vary according to history and location but each would have a 24-hour A&E service and a wide variety of inpatient, outpatient and day procedures services. Eight of the nine Acute Hospitals would have consultant-led inpatient maternity services. (There would be one centralised maternity service based on either the Belfast City or the Royal Hospitals site depending on the results of consultation which is currently underway). 2.9 In terms of changes to the clinical profiles of these hospitals, Developing Better Services proposes that certain specialties should be relocated "in line with the recommendations of the Eastern Health and Social Services Board's report : Taking Forward the Pattern of Acute Hospital Services in the Eastern Board Area, (December 2000). These specialties are Plastic Surgery, Dermatology and Rheumatology". It is also recognised that Paediatric and Adult ENT services should be reorganised as between the Royal and City Hospitals sites with appropriate account being taken of work by the Board, the Trusts and the clinicians on the best approach to siting aspects of these services. 2.10 In addition to describing the general profiles of a Local and an Acute Hospital and describing the specific variations relating to each of the current hospital sites, Developing Better Services sets out a position in respect of Maternity services. It proposes that inpatient consultant-led maternity services should not be part of a Local Hospital profile (except in relation to the Mater Hospital - as described above). Inpatient consultant-led obstetric services would, therefore, be provided on eight of the nine Acute Hospitals plus the Mater and it is also proposed that there should be development of midwife-led units adjacent to consultant-led maternity units. 2.11 The paper also suggests that stand-alone midwife-led maternity units should be piloted on two sites, one in the East of Northern Ireland and one West of the Bann. 3.0 How the proposals in Developing Better Services compare with those made by the Eastern Board in December 2000 3.1 During the year 2000, the Eastern Board conducted a review of hospital services within its area and produced a paper "Taking Forward The Pattern of Acute Hospital Services in the Eastern Board Area". Before making the final recommendations to the Department and Minister in December 2000, the Board had carried out consultation on its original proposals, modified them and conducted an assessment of any adverse impacts of the recommendations, from an Equality (Section 75 of the NI Order 1998) point of view. 3.2 The Eastern Board's paper contained 24 recommendations which dealt, inter alia, with the profiles of each of the hospitals currently providing acute services in the geographical area and also made specific recommendations in relation to the relocation of particular specialties so that they could be in close proximity to other specialties already on these sites. 3.3 If we compare the Eastern Board's position in 2000 with the Ministers position in Developing Better Services in 2002, the situation is as follows:- 3.4 Roles of the Belfast City, Royal and Ulster Hospitals
3.5 Relocation of a Range of Specialties As to specific specialty dispositions between the hospitals, the Eastern Board recommended the following:-
3.6 It is these recommendations in relation to the appropriate location of specialties that are taken up and endorsed in paragraph 4.50 of Developing Better Services. 3.7 In its initial consultation paper in 2000, the Eastern Board had discussed the advantages of children's ENT services being located in the two Paediatric inpatient environments within the Board i.e. the Royal Belfast Hospital for Sick Children (RBHSC) and the Ulster Hospital. This is in line with the widely accepted and expected policy that children should be treated in a "children's environment". 3.8 The Board also proposed that the adult ENT service at the Royal and City hospitals should be amalgamated onto the City site and, together with head and neck surgery, should be located in close proximity to the Plastic Surgery service which was being proposed for relocation to the City Hospital site. 3.9 During the consultation process the ENT (Otolaryngology) clinical professionals were unanimous in the view that the services for adults and the majority of children should be maintained together with only the very specialist children's services being located in the RBHSC. The clinicians did accept that the City and Royal adult services should be amalgamated but did not have a consensus as to where that amalgamation should take place. 3.10 In the intervening period since 2000, the clinicians have agreed that in future, children's ENT services should be located in a specialist children's environment. In relation to services at RVH and BCH, the logical location would appear to be to have these services located in Phase 2 of the RBHSC development. We understand that they are still of the view that the Belfast City and Royal adult ENT services should be amalgamated as soon as possible, in view of the poor quality of accommodation on both sites. 4.0 The Eastern Board's recorded position in relation to the other Hospitals covered in Developing Better Services Downe Hospital During 2000, when the Board was developing its ideas on recommendations for the future of hospital services in its area, it was asked by the then Minister to chair a group which consisted of representatives of the Eastern Board, the Down Lisburn Trust, the hospital consultants in Downpatrick, a number of consultants from hospitals in Belfast and a representative of the Down Community Health Committee. 4.1 That group developed a model for services in Downpatrick in the future which would allow patients with life threatening conditions to be resuscitated if necessary and stabilised in an A&E facility in Downpatrick and transferred as necessary to hospitals in Belfast. The model also proposed that the hospital should have consultant-led inpatient medical services as well as a range of outpatient, day case, ambulatory and diagnostic services. 4.2 This model for Downpatrick is essentially that which has been described in Developing Better Services as Enhanced Local Hospital status for Downe. 4.3 At the time of its work in 2000, the Eastern Board was specifically asked by the Minister not to plan for the future inclusion in a Downpatrick hospital of inpatient consultant-led obstetric services. In its document, the Board recognised that, in the event of inpatient obstetric services being removed from Downpatrick site, there would be a need to take action to mitigate the impact of the loss of these local services on women who would normally use them. We suggested that arrangements might be put in place for women to have a midwife known to them, to accompany them to an inpatient obstetric service, assist with the delivery of their baby and then return with them either to the local hospital facility or to their home where appropriate follow up support for the immediate postnatal period could be put in place. 4.4 The Developing Better Services document suggests that it would like to see a full exploration of the possibility of a stand alone midwife-led maternity unit in the East of Northern Ireland and, if this is something which the population of Downpatrick and the local Down Lisburn Trust would like to investigate, the Board would be ready to facilitate. Lagan Valley Hospital 4.5 The Eastern Board's work in 2000 did not envisage a significant change in the Lagan Valley hospital profile although work was already underway then and has continued, with reshaping the distribution of facilities within the hospital and modernising care pathways etc. 4.6 The Lagan Valley hospital has remained busy in medical terms (Appendix) and we in the Board cannot envisage a time within the 10-year planning period, when sufficient alternative inpatient acute medical services would be available elsewhere which would allow for replacement of that necessary capacity. 4.7 A further issue, which is not discussed in Developing Better Services, is the benefits for hospitals such as Lagan Valley and the Mater, which have inpatient psychiatry on site, to have close clinical relationships between general medicine and psychiatry services because of cross referral between these specialties. This must be a factor favouring the retention of general medical services at Lagan Valley. 4.8 We would envisage that, over time, it may be possible through close networking with other hospitals such as the City and Royal Hospitals, for emergency surgery not to be done in Lagan Valley. This would permit the surgeons there to concentrate on the development of the 'protected elective' service proposed in Developing Better Services. 4.9 The Board can identify with the rationale in Developing Better Services in relation to a consistent approach to inpatient obstetric services across Northern Ireland but (as will be discussed in the Mater section to follow) we recognise the obvious anomaly between the proposals for the other small maternity units (including Lagan Valley) and the proposals for the Mater obstetric service. 5.0 The Mater Hospital In its work in 2000, the Board recognised that the Mater hospital was consistently under pressure in terms of the volume of patients from its 'natural catchment' and this level of pressure has been sustained over the intervening period (Appendix). 5.1 The Mater has been undergoing a programme of redevelopment with significant new facilities to replace the surgical and medical facilities from the original hospital, having been opened within the last year. 5.2 The Mater serves a particularly deprived area of the Eastern Board where levels of mortality and morbidity are significantly higher than in other parts of the area. While, over the next 10 to 15 years, the population of the inner city is set to fall further, we do not envisage a situation where either the health of the local population would be so radically changed or alternative capacity would be available elsewhere, to allow the Mater hospital to withdraw from the acute services which it provides currently. In these circumstances, we would see no advantage in signalling a profile for the Mater which would take it out of the provision of acute medicine or Accident and Emergency services. 5.3 While for all hospitals in the Eastern area we see opportunities to arrange Emergency Surgical services to limit the number of sites where these are provided, especially at night, and we see advantages in developing larger rotas of surgeons to deal with out-of-hours cover, the Mater hospital can, in the Board's view, contribute significantly to the provision of elective surgical services to help reduce and sustain a reduction in, the numbers of people waiting for these procedures. 5.4 The Board also recognises that the Mater hospital has a role, with all hospitals which are not designated as Cancer Units, in the Cancer network in terms of diagnostics, local treatment where appropriate and referral onwards as part of multidisciplinary treatment. The Mater currently provides the specialist service for Hepato-Biliary Cancer and, for as long as the particular expertise remains on the site, it would seem appropriate to retain this specialist service. 5.5 The same arguments pertain for the Mater as for the Lagan Valley in relation to the mutually supportive links between the psychiatry services which are on site and a general medicine service. 5.6 In terms of inpatient obstetric services, the Board has, in its response to the report of the Acute Hospitals Review Group ('Hayes'), pointed up the inconsistency of that report advocating the retention of inpatient obstetric services in the Mater but the removal of the services from Lagan Valley. The position taken in Developing Better Services is again similar to that proposed by the Acute Services Review Group. The Board would recognise, however, that the most difficult issue for smaller obstetric units is getting appropriate support from neonatologists and, simply because of the closer proximity of the Mater to the central Belfast major maternity hospital, it must be easier to make a neonatology service more sustainable for the Mater than for any of the other smaller maternity hospitals which currently provide consultant-led obstetrics. It would only be in the circumstances where the Mater obstetric facility was very closely networked with this central Belfast service in terms of neonatology support and the appropriate transfer of more complex cases, that the Board could advocate a different approach being taken to the Mater hospital than to the other smaller units (Lagan Valley and Downe) in its catchment area. 6.0 Conclusion The Eastern Board sees a great deal of consistency between its own recorded position and that of Developing Better Services in terms of hospital profiles within its area and recommendations about consolidation and appropriate location of particular specialties. 6.1 In this regard, we would not take issue with the documents conclusions and recommendations in relation to the roles and clinical profiles of the City hospital, the Downe, the Royal or the Ulster hospital. We also welcome the affirmation that the specialties of Dermatology, Plastics and Maxillo-Facial Surgery and Rheumatology should be relocated in line with the Eastern Board's proposals and we welcome the recommendations in relation to ENT services. 6.2 We endorse also the recommendations which are made throughout the document in relation to networking of hospitals and services and the recognition given to the factors which are leading to the need for changes in service. 6.3 The primacy also given to the need for investment in both infrastructure and the training, recruitment and retention of staff is very welcome. 6.4 The concerns we have with Developing Better Services are in relation to the clinical profiles and roles of the Mater and Lagan Valley hospitals which the Developing Better Services document sees moving out of the provision of A&E services and acute medicine in the latter part of the planning period. Our difficulties arise from our practical experience over the last number of years. We have found the emergency medical system throughout the Eastern area to be under pressure on an all year round basis and we do not envisage a situation where sufficient capacity and resource will be devoted to provision of emergency medical services or alternatives in a way which would allow the capacity provided by the Mater and Lagan Valley to be removed. Pressure on central Belfast hospitals, (Mater, Royal and Belfast City), in terms of the flow of emergency patients, would also be increased should the changes proposed in Developing Better Services, in relation to Whiteabbey Hospital, come about. 6.5 The overall emergency medical system in the Eastern area seems to us to operate within such a tight capacity that we have little room for manoeuvre and this is exacerbated each time we lose capacity because of an outbreak of infectious illness in any of our hospitals. 6.6 We would also have concerns that there has not been sufficient recognition given to the inter-dependence of the acute psychiatric services which are on site in both the Lagan Valley and the Mater and the other general medical services. 6.7 It is our view, that it would be better to sustain the confidence of the current and potential staff and the community in the Lagan Valley and Mater as locally important institutions providing valuable links in the emergency service chain since we have no realistic alternatives to this capacity and service for as long forward as we can see. Anne Lynch WRITTEN SUBMISSION BY: October 2001 A NEW ACUTE HOSPITAL FOR THE SOUTH WEST OF NORTHERN IRELAND TABLE OF CONTENTS 1. Introduction 1.1 Structure of Report 2. The Hayes Report 2.1 General Findings 2.2 Acute Hospital Provision - Principles 2.3 Acute Hospital Configurations 2.3.1 Option 1: Acute Services on 15 Sites 2.3.2 Option 2: Acute Services on 6 Sites 2.3.3 Option 3: Acute Services on 9 Sites 2.4 Location of the New Hospital for the South West 2.5 Conclusions 3. Accessibility 3.1 A Geographical Information System Approach 3.1.1 Distance Band Analysis for New Hospital in Enniskillen 3.1.2 Distance Band Analysis for New Hospital Located in Omagh 3.2 Average Distances to Acute Hospital Services 3.3 Conclusions 4. Sustainability 4.1 Catchment Areas - Static Sustainability 4.2 Dynamic Sustainability 4.3 Site & Location Issues 4.4 Conclusions 5. Equity 5.1 Age Analysis 5.2 Other Indicators of Deprivation/Health Disadvantage 5.3 Conclusion 6. Conclusions 1. INTRODUCTION 'Everyone has a right to timely, quality care based on clinical and social need' This Report is concerned with analysing the implications of the simple statement set out above, which was included in the draft Programme for Government published by the Northern Ireland Executive in September 2000. In particular, this Report to Fermanagh District Council analyses the issues of timely access to quality acute health care in the South West of Northern Ireland. The wider issues of access to acute health care were dealt with in the Report of the Acute Hospitals Review Group which was published in June 2001. The Report - widely known as the Hayes Report after the Group's Chairman, Dr. Maurice Hayes - is now the subject of a consultation process. It is expected that the Northern Ireland Executive will take decisions in the course of 2002 on the main recommendations of the Hayes Report. This Report focuses on a sub-set of complex issues considered in the Hayes Report, those relating to the location of a new acute hospital for the South West of Northern Ireland. While there has been a great deal of rhetoric surrounding the controversial issue of the location of the new acute hospital for the South West, this Report takes a logical, evidenced-based approach by reviewing the evidence which the Hayes Group considered, confirming its validity and, where appropriate, extending the analysis to deal with additional issues. The overall conclusion, based on the evidence in the Hayes Report and the additional evidence gathered for this Report, is that 'Hayes got it right' and that the location of the new acute hospital for the South West in Enniskillen provides the only accessible, sustainable and equitable solution to the provision of acute hospital services for the South West. 1.1 Structure of Report This Report considers the evidence relating to these complex and controversial issues in five further Sections
2. THE HAYES REPORT In August 2000 the Minister for Health, Social Services and Public Safety, Bairbre de Brún, appointed the Acute Hospitals Review Group drawn from medical professionals, community and health service user backgrounds under the Chairmanship of Dr. Maurice Hayes to 'review the current provision of acute hospital services and, taking account of the issues of local accessibility, safety, clinical standards and quality of services, to make recommendations to the Minister on the future profile of hospital services.' 'We were left in no doubt that what concerned people most was access to accident and emergency, coronary care, medical emergency and maternity services' - Hayes Report The Group's Report, published in June 2001, has been widely welcomed as a comprehensive and authoritative analysis of the complex issues of the location and provision of acute hospital services. In particular, the Report's recommendations were built upon a meticulous process of local consultation based on over 300 submissions received and 200 group or individual meetings. The Review Group recognised the commitment of the Northern Ireland Executive to ensuring access to public services, including hospitals, to those in rural areas. 2.1 General Findings Some key general findings of the Review include
' a person should not have a worse prospect of recovery from a medical emergency, whether in a remote rural area or the centre of a city' - Hayes Report 2.2 Acute Hospital Provision - Principles After a detailed review of the context for the provision of hospital services, the Hayes Report sets out a vision for the future of hospital provision and proposed means of delivery of hospital services in Northern Ireland. The Report sets out to achieve a hospital provision for Northern Ireland which is
Reviewing evidence on emergency care services, the Hayes Report finds 'Accessibility is an issue of over-riding importance in relation to emergency medical care, and in particular the need for A&E services to be within a minimum distance or travelling time of where people live. We believe that a period of one hour represents a reasonable benchmark of accessibility. Indeed, we recommend that Northern Ireland should have a configuration of hospitals providing emergency care services which ensures that the whole population can normally expect to access those services within one hour.' 'Our vision aims to build on what we currently have: to adapt hospitals rather than close them; and to improve rather than reduce access to services' -Hayes Report In reviewing maternity services, the Report concludes that the entire population of Northern Ireland should be within one hour of the nearest consultant-led maternity unit, that all units should have 24 hour consultant paediatric and anaesthetic cover and a sufficiently large caseload to justify an full consultant team, either on its own or in conjunction with another unit. The overall conclusion reached by the Report is that 'the entire population of Northern Ireland should normally expect to be within one hour's travel time of emergency care services and a consultant-led maternity unit.' 'There is clearly substance to people's concerns about being able to access emergency care services within a reasonable timescale.' - Hayes Report 2.3 Acute Hospital Configurations The Hayes Report then considers the implications of alternative configurations for delivery of acute hospital services. In considering alternative configurations access was the most important consideration but the Report also gave weight to
A transport model was used to estimate the percentage of the population under each option which lived outside 45 minutes and 60 minutes travel bands from acute hospital services. 2.3.1 Option 1: Acute Services on 15 Sites This Option is the status quo with acute service provision in the 'Golden Six' hospitals and 9 other sites including both Enniskillen and Omagh.
All of the population would fall within 60 minute travel time to acute hospital services and just 3,000 (0.2%) would have to travel for greater than 45 minutes to reach acute hospital services. However, this option failed in terms of affordability and sustainability of services and in terms of the quality and safety of services. 2.3.2 Option 2: Acute Services on 6 Sites This Option would concentrate acute services in the so-called 'Golden Six' hospitals - the Belfast City Hospital, the Royal Group of Hospitals, the Ulster Hospital and the Antrim, Craigavon and Altnagelvin Hospitals.
This Option would clearly score highly on affordability and sustainability and the safety and quality of services but fails the accessibility criterion - 245,000 (14.5% of the population) people would live more than 45 minutes from an acute hospital and 58,000 (3.4%) more than 60 minutes travel time from acute services. 2.3.3 Option 3: Acute Services on 9 Sites Under this Option acute services would be provided in the 'Golden Six' hospitals and, in addition, at Newry (Daisy Hill Hospital), Coleraine (Causeway Hospital) and at new hospital for the South West. Under this Option, the travel time model used by the Hayes Group found that all of the population would be within one hour's travel time of acute services and just 35,000 (2.1%) would have a travel time in excess of 45 minutes. 'We therefore recommend this configuration of services as the minimum necessary to provide acceptable access to emergency care and inpatient maternity services to all the people of Northern Ireland. The nine hospitals . . . will be the key anchorage points for our proposed Health and Social Care Systems and every effort must be made to ensure their long term viability.' - Hayes Report
Hayes found this Option to be 'the minimum necessary to provide acceptable access to acute hospital services' and suggested that management of the hospital services should be part of a wider restructuring of health and social care based around 3 clusters of activity
The Report envisaged a hierarchy of hospital services with
While Hayes found that this Option was the minimum necessary to provide acceptable access to acute services, the Report acknowledged that the issue of sustainability of the Option had to be addressed. The Report suggested that day surgery and routine elective work might be transferred to smaller hospitals from neighbouring larger hospitals, that the increased workload of Craigavon Hospital might be shared by adjoining smaller hospitals and that opportunities might exist to service cross-border health needs. Hayes also recommended that on 8 of the 9 acute hospital sites (the exception being Belfast City Hospital) a consultant-led maternity unit should be provided with 24 hour consultant paediatric and anaesthetic cover. 2.4 Location of the New Hospital for the South West Finally, the Hayes Report turned to the location of the proposed new hospital for the South West. It rejected the option of maintaining both sites as being not viable and it rejected the 'one hospital on two sites' model as a long term solution because of the inevitable duplication and the questionable sustainability of both hospitals under that model. Having eliminated the other options, the Hayes Report then had to face up to where a single site new hospital for the South West would best be located. The options considered were Enniskillen, Omagh or a new 'green field' site located between Enniskillen and Omagh. The green field site would be located at or close to the population centre of gravity. Studies published with the Hayes Report1 showed that such a centre of gravity would be located well outside any significant town and the Hayes Report rejected this option because, situated away from a significant town, the new hospital would require significant physical and economic infrastructure provision and would have difficulty in assembling the staff to support its work. Such an investment outside an existing town would also run contrary to the Regional Development Strategy. The Hayes Report set out the considerations in deciding whether Enniskillen or Omagh would be the better location for a new hospital. Sites were available at both locations, each town could offer the necessary economic and physical infrastructure. Omagh would provide a 'slightly larger' catchment area for the new hospital but Enniskillen would provide better access for the population to the west of Lower and Upper Lough Erne - which cannot reasonably be served by Sligo General Hospital, in the South, because of the poor road network. 'We strongly believe . . . that a new hospital on a single site, linked with others as part of a larger Southern Health and Social Care System, represents the best way forward for sustaining the safe delivery of the necessary range of high quality services for the population of the South West' - Hayes Report 'In the shorter term the Board and Trust should spare no efforts in securing arrangements for the maintenance of acute services across the two sites, drawing on assistance from both Altnagelvin and Craigavon Hospitals, as appropriate.' - Hayes Report Using the principles they had established for future provision of hospital services (summarised in Section 2.2, above), the Hayes Report 'conclude(d) that Enniskillen offers the better location for a hospital providing emergency care and inpatient maternity services. .we believe that a location in or around Enniskillen provides cover for a wider geographic albeit thinly populated area and ensures that the people to the West of Lough Erne are not disadvantaged through impaired access to services.' The Hayes Group, therefore, recommended that
a modern local hospital facility should be provided at Omagh to provide the population in and around the town with access to a wide range of local services. This new Omagh hospital would link into the new hospital for the South West at Enniskillen, thus contributing to the sustainability of the new hospital in Enniskillen, but might also develop links with Altnagelvin. The new local hospital in Omagh would be a modern state of the art facility providing a wide range of local services and a local emergency unit. It is clear from the Hayes Report that what is envisaged for Omagh is not a community hospital but a modern advanced hospital of a type new to Northern Ireland. The Hayes Report recommended that the new hospital for the South West at Enniskillen should be put in place by 2006, with work on the new modern local hospital facility for Omagh commencing thereafter. 2.5 Conclusions The Hayes Report is an impressively comprehensive and well informed analysis of a highly complex and controversial subject. Implementation of the Hayes recommendations would provide the South West of Northern Ireland - both Counties Tyrone and Fermanagh - with high quality, accessible and sustainable acute health care services involving
This is a prize worth having for both Fermanagh and Tyrone. But are the recommendations of the Hayes Group right, are they based on good evidence and do they represent the best possible outcomes for the people of Northern Ireland as a whole as well as those of the South West? The next three Sections of this Report consider those issues in terms of how far the Hayes Review Group recommendations represent the best outcome in terms of
'The changes are manageable if handled with skill, care & urgency'. 'It is important that things are seen to happen.' - Hayes Report 3. ACCESSIBILITY The Hayes Report placed considerable weight on the accessibility of acute hospital services to the local population, describing accessibility as 'an issue of over-riding importance' and 'the most important consideration'. The weight given to accessibility as a criterion is justified in the case of emergency treatment by the concept of the 'golden hour' following injury during which patient outcomes improve considerably if they can receive hospital treatment. This consideration, together with the obvious need for accessibility to maternity services, led the Review Team to conclude 'We believe that a period of one hour represents a reasonable benchmark of accessibility. Indeed, we recommend that Northern Ireland should have a configuration of hospital providing emergency care services which ensures that the whole population can normally expect to access those services within one hour.' Accepting that criterion, it is then necessary to consider whether the Hayes recommendations do best serve the needs of Northern Ireland as a whole and of the South West in particular. In addressing these issues, we have not taken a narrow Fermanagh or South West approach. Instead we have considered how the configuration of acute hospital services in the South West contributes to the achievement of the aims for the overall Northern Ireland acute hospital system. 3.1 A Geographical Information System Approach The Hayes Report provides brief summaries of the implications in terms of travel times of 3 options for the future configuration of acute hospital services (See Section 2.3) but it does not provide a detailed statement on these issues and it does not model the effect of locating the new hospital for the South West in Omagh, rather than Enniskillen. More detailed results of the traffic model used by the Hayes Review Group are available online but they related to clusters of local government wards and are difficult to relate to particular communities and their populations. To address these issues more satisfactorily, we have carried out our own sophisticated Geographical Information System (GIS) study of the issues of accessibility to acute hospital services. While we have modelled alternative provisions in the South West of Northern Ireland, we have presented our results to show the overall impact on the Northern Ireland acute health care system, rather than taking a narrow, local approach. In rural areas and in particular those without motorway or dual carriage roads, allocating a time to a particular journey is difficult. In Enniskillen itself journey times are particularly unpredictable. For these reasons we have based our GIS analysis on distance, rather than estimated journey times. However, we relate this distance-based approach to the concept of the 'Golden Hour' used in the Hayes Report. The GIS methodology is complex but in essence, we plotted the location of each existing or proposed acute hospital referred to in the Hayes Report and generated road distance bands around each hospital. The software then identified which of Northern Ireland's 3,729 enumeration districts fell within each band of road distance. Estimates by the Northern Ireland Statistics and Research Agency of the mid-1999 population of each enumeration district were then applied to the enumeration districts in each distance band to generate estimates of the total population (and the population broken down by age) living
By running the model with different configurations of hospital services (e.g., new hospital for the South West in Enniskillen or Omagh) we were able to assess the appropriateness of the Hayes recommendations in terms of accessibility of hospital services to the Northern Ireland population. The models were run for a number of hospital configurations but the most relevant related to
The GIS analysis produced both graphical and statistical outputs. 3.1.1 Distance Band Analysis for New Hospital in Enniskillen The map on the following page shows the distance band analysis for the Option
recommended in the Hayes Report, i.e., acute hospitals in the 'Golden Six'
at Newry, Coleraine and the new hospital for the South West located in Enniskillen2. In rural areas an average point to point speed of 40 MPH would represent a good journey in many cases. Any person living 40 or more miles from an acute hospital would be likely to be outside the 'Golden Hour' criterion set by Hayes. However, when the journey involves going through an urban centre, such as Enniskillen, which does not have a by-pass or through-pass arrangement, average speeds decline substantially, in this case persons living 30 or more miles from an acute hospital could also well fall outside the 'Golden Hour' criterion. We have, therefore, taken as our criterion that a person living between 30 and 40 miles from an acute hospital is at risk of failing the golden hour test while a person living 40 miles or further away will fail that test. Distance Band Analysis for New Hospital for South West located in Enniskillen The map shows a good coverage of Northern Ireland with most areas of population being less than 20 miles from an acute hospital. Areas between 20 and 30 miles from an acute hospital include parts of County Tyrone, the Glens of Antrim and South Down. Small areas in County Tyrone to the west of Castlederg and in the central Sperrins fall in the range 30 - 40 miles from an acute hospital, however, these areas are sparsely populated. These results can also be stated in a tabular format. Distance Band Analysis for New Hospital for South West located in Enniskillen
The table shows that under this Option, with the new hospital for the south west located in Enniskillen, 5,079 people, just 0.3% of the population of Northern Ireland, would live at a distance by road greater than 30 miles from an acute hospital and 0.1% - representing 118 people, would live at a distance greater than 40 miles. This represents a high degree of achievement of the golden hour criterion and if one takes a point between 30 and 40 miles distance by road as representing one hours' travel time, depending on the road system, is consistent with the findings of the Hayes Report on this option. 3.1.2 Distance Band Analysis for New Hospital Located in Omagh The Hayes Report did not carry out an analysis of the impact on accessibility if the new hospital for the South West were located in Omagh, instead of Enniskillen, as recommended. We have used our GIS system to model that situation, using the same approach as in the case where the new hospital is located in Enniskillen. We will first describe the results of the Omagh case and then compare the Enniskillen and Omagh results. The map on the following page shows the distance band analysis which would result if the new hospital for the South West were to be located in Omagh, rather than Enniskillen.
Distance Band Analysis for New Hospital for South West located at Omagh The table shows the results of the analysis in a tabular format.
As in the Enniskillen case, the map shows a good overall coverage of Northern Ireland with most areas of population being within 20 miles of an acute hospital. However, there are significantly greater areas which are between 20 - 30 miles from an acute hospital, including many in County Tyrone and most of County Fermanagh, while West and East Fermanagh lies between 30 and 40 miles from an acute hospital service, together with a small area of West Tyrone. The results show that in this analysis 14,721 people would live more than 30 miles from an acute hospital (compared to 5,079 if the hospital were to be located in Enniskillen as recommended) and that 680 people would live more than 40 miles from an acute hospital (compared to just 118 if the hospital was located in Enniskillen). The results of the two options are summarised in the following table which shows the number of people living between 30 and 40 miles and between 40 and 50 miles from an acute hospital under each option. Comparative Analysis: Number of Persons at Risk of Exclusion or Excluded from the 'Golden Hour' under each Option
If the new hospital for the South West were to be located in Omagh, a total of 14,721 would be at risk of exclusion from the Golden Hour or excluded from the Golden Hour. This number is 2.9 times greater than would occur if the new hospital were located in Enniskillen, when just 5,079 persons would be at risk of exclusion or excluded from the Golden Hour criterion. While these differences are not large in terms of the overall population of Northern Ireland, when considered in terms of the numbers of persons at risk of failing to meet the golden hour test (living 30 - 40 miles away from a hospital) and those which would fail to meet the test on our assumptions (living over 40 miles away) it is clear that option of locating the new hospital for the South West in Omagh fails to meet the requirements of a very significantly larger number of residents of Tyrone and Fermanagh than if the hospital was located in Enniskillen as recommended by the Hayes Review Group. The analysis of the Hayes Report is therefore shown to be well based on the evidence available and its conclusion that the new hospital for the South West should be located in Enniskillen has been shown to be sound. 3.2 Average Distances to Acute Hospital Services The GIS analysis has clearly shown that the location of the new hospital for the South West in Enniskillen will achieve a significantly higher degree of compliance with the criteria set out in the Hayes Report in terms of access than if the hospital were to be located in Omagh. However, it is worth noting that the Omagh option does achieve marginally higher percentages of the population living closer to hospitals, for example 90.06% of the population would live within 20 miles of an acute hospital if it were located in Omagh whereas an Enniskillen location would give a result of 89.0% of the population living within 20 miles. Using the GIS data it is possible to estimate average travel distances to an acute hospital under each option. This is done by multiplying the mid point of each distance range (0 - 10 miles, for example) by the number of people in each range under each of the options. The table summarises the result of this analysis.
While the average travel distance to an acute hospital is less in the Omagh option, the difference is trivial, equivalent to 176 yards. Clearly there is no material difference between the options in this respect. 3.3 Conclusions On the principal and most important consideration set out by the Hayes Review, the location of the new hospital for the South West in Enniskillen is clearly preferable to location of the hospital in Omagh in that the Enniskillen location involves significantly fewer persons being beyond one hour's travel time from an acute hospital. 4. SUSTAINABILITY The Hayes Report identified accessibility as the most important consideration, but it is not the only consideration. Current hospital services in the South West are not sustainable because the sub-optimal case load they carry does not permit training or sub-specialisation while the uncertainty about the future of each hospital makes staff recruitment and retention even more difficult than it would otherwise be. There would be little point in re-configuring hospital services in the South West if the resulting pattern of work would not be sustainable in the long term. There are a number of aspects to sustainability. On one hand the sheer scale of a catchment area can make a hospital sustainable. That is difficult to achieve in rural areas. However, a hospital may also be sustainable as part of a larger network of hospital and other health services. In that situation caseload can be managed between the individual sites and the training and development of medical and other staff can also be a group effort. In addition, a hospital can be sustainable as a matter of policy, through the transfer of case work from a busy, large, often urban, hospital to other hospitals. Finally, hospitals can be sustainable by providing specialist services which are not available elsewhere - including in the case of the new hospital for the South West the provision of services which are not available, or which are under stress, in the adjacent 5 Southern Border Counties. Sustainability through sheer scale of catchment area can be thought of as 'static sustainability'. On the other hand, sustainability through active management processes represents a form of 'dynamic sustainability'. Wherever the new hospital for the South West is located will require active management processes to achieve and sustain dynamic sustainability. The need for this approach - and for a political commitment to the success of the hospitals established - was fully recognised in the Hayes Report. 4.1 Catchment Areas - Static Sustainability The concept of static sustainability can be addressed by measuring populations in particular catchment areas. However, there are significant limitations to catchment area analysis as citizens are active consumers of health services and do not always choose to attend the service which is geographically closest. Despite these limitations, which we discuss below, we used our GIS data to carry out a catchment area analysis of the alternative configurations of acute hospital services in Northern Ireland. For this analysis, the same data set was used as for the distance bands analysis but we asked the software to identify which hospital each of the 3,729 enumeration districts was closest to by road. We then aggregated the populations of those enumeration districts to work out the total population in each catchment area. In other words an enumeration district and its associated population was included in the catchment area of a particular hospital only if that hospital was nearer to the enumeration district by road than any other hospital. The map below shows the catchment areas of the acute hospitals in the Hayes recommended option, i.e., the Golden Six hospitals, Coleraine and Newry and the new hospital for the South West located in Enniskillen.
The results of the GIS analysis of hospital catchment areas are summarised in the following table. Catchment Area Analysis for New Hospital for South West Located in Enniskillen
It is obvious on this analysis that the smallest hospital in terms of its static catchment area would be the new hospital for the South West in Enniskillen with a 'natural' population of 105,368, accounting for 6.23% of the Northern Ireland population somewhat less than the other Level Three hospitals in Coleraine and Newry. We then repeated the catchment area analysis for the situation in which the new hospital for the South West was located in Omagh, rather than Enniskillen. The map on the following page shows the boundaries of the catchment areas which would result in that situation. The more northerly location of the hospital has the effect of pushing back the catchment areas of the Altnagelvin, Antrim and Craigavon hospitals appearing to create a larger, 'natural' catchment area for the hospital in Omagh. The tabular information spells this out in more detail. Catchment Area Analysis for New Hospital for South West located in Omagh
On this basis the new hospital at Omagh would appear to have a natural catchment population of 154,441, accounting for 9% of the Northern Ireland population. In terms of other hospitals, the main impacts would be
These 'edge effects' would be much less marked if the new hospital at the South West were located in Enniskillen. By way of illustration, if just ½ of the additional population covered by an Omagh location were to be subject to these edge effects, the differential between an Omagh and Enniskillen location would be much reduced - to just 14,078 more persons in the catchment area than if the hospital were in Enniskillen. On that basis, a more realistic estimate of the catchment area population for a new hospital in Omagh would be 119,446, accounting for 7% of the Northern Ireland population compared to an estimate for the hospital's location in Enniskillen of 105,368, accounting for 6.2% of the Northern Ireland population. In this regard, it is also worth noting also that road improvements currently being implemented in Omagh, Newtownstewart and Strabane will improve the accessibility of Altnagelvin to the Omagh catchment area. 4.2 Dynamic Sustainability In interpreting the estimated catchment areas of alternative locations for the new hospital, there is a need to recognise that the hospitals from which a new hospital for the South West in Omagh would appear to draw population are large, established and sophisticated Level Two hospitals whereas the new hospital for the South West, wherever it is situated will be a new Level Three hospital offering a lesser range of services and a lesser depth of coverage. Thus, for example, the boundaries on the GIS map relating to a new hospital at Omagh suggest that it would draw patients from Strabane District Council area but it is likely that many citizens of Strabane District would elect to travel to Altnagelvin Hospital to benefit from the more sophisticated services available there. In addition, it is envisaged that the new hospital for the South West will be part of an actively managed clinical network, working in association with the Level Two hospital at Craigavon. In that context, a managed process of transferring caseload to the new hospital in Enniskillen can be established, as recommended by the Hayes Report. Indeed, as the case load of the Craigavon Hospital would be greater if the new hospital was in Enniskillen rather than Omagh, it an be seems very much more likely that such a transfer process would occur under this option than if the new hospital for the South West were to be located in Omagh. In addition, staff training and experiential development can also be managed in the context of the clinical network approach. Further factors include the greater likelihood of significant cross-border work being developed at Enniskillen, which borders Donegal, Leitrim, Monaghan and Cavan and is adjacent to Sligo. Unlike Omagh, which is effectively cut off from border traffic by the terrain of the adjacent area, Enniskillen is already a focus of border roads and communications and it has a reputation as a pleasant town in which people from across the border would be more likely to accept treatment. In addition, Enniskillen is the centre of a substantial tourism industry, unique to Fermanagh, which accounts for 273,000 staying visitors. The current Erne Hospital provides the acute medical services for these visitors which would represent a significant extension of the catchment of the new hospital for the South West located in Enniskillen. All of these factors suggest that the apparent gap between the population which the new hospital in the South West located in Enniskillen would serve compared with an Omagh location would be substantially eroded in practice. In addition, there is increasing evidence that hospital economies of scale are realised at quite small unit sizes and that diseconomies of scale set in quickly. With the ability to transfer caseload and to manage staff training and development in the context of a managed clinical network with Craigavon, there is no objective evidence to suggest that an Enniskillen location would not be sustainable and the population to be covered by an Enniskillen location is of the same order of magnitude as those at the other proposed Level Three hospitals in Coleraine and Newry. At a more strategic level, a new hospital for the South West in Enniskillen would have strategic distance from other, larger hospitals. This would make the hospital, in itself, more sustainable than a hospital in Omagh, which would be in the shadow of other, larger hospitals. 4.3 Site & Location Issues The Hayes Report recommended that the new hospital for the South West should be located in Enniskillen, either at the site of the present Erne Hospital or on a new site to the North of the town. Studies carried out by the Western Health and Social Services Board indicate that a greenfield site would require some 30 - 40 acres at a site yet to be identified to the North of Enniskillen. The capital cost of the new build hospital is estimated at £72.5 million but this does not take into account, roads, water, sewerage, electricity or telecommunications infrastructure costs. Offsetting this, the disposal of the present Erne Hospital site is estimated to generate income to the Board of approximately £1 million. If the new hospital was constructed on the site of the present Erne Hospital, some of the existing buildings could be re-used and/or extended and considerable new build would also be required. The necessary infrastructure is already in place at the Erne Hospital and the estimated capital cost on this site would be £66 million. The Erne site is relatively cramped and provision has been made in the capital costs for multi-storey patient and visitor car parking. However, concern which had been expressed at one point about the ability of the Erne site to accommodate the new hospital for the South West has been allayed. In a letter to the Chairman of Fermanagh District Council dated 7 August 2001 the Chairman of the Sperrin Lakeland Health and Social Care Trust wrote 'With the purchase of the former bakery site by the Trust and given the accommodation which will become available in the current buildings with the new health centre and the acquisition of land currently held by the Rivers Agency we continue to be satisfied that there is sufficient land to enable the longer term development of the new hospital to take place.' In addition the Private Secretary to the Minister of Health, Social Services and Public Safety wrote to the Chairman of the Council on 25 September 2001 stating 'Departmental officials have looked closely at the proposed developments on the Erne site and are satisfied that it would still be feasible for the Erne Hospital to provide the future requirements for the south west as identified in the Acute Hospitals Review Group.' 4.4 Conclusions The Hayes Report recommended the location of the new hospital for the South West in Enniskillen on the basis of achieving accessibility within one hour to acute services. The analysis in Section 3 has shown that recommendation to be well-founded - alternative locations such as Omagh would fail to meet the accessibility criterion for the configuration of hospital services. However, a new hospital has to be sustainable. Commitment to a new hospital at Enniskillen would restore confidence in the health structures in the South West and would ease the current recruitment and retention difficulties affecting medical staff in both Enniskillen and Omagh. Participation of the new hospital in a managed clinical network with Craigavon Area Hospital would enable other staffing and training issues to be tackled and would allow for the managed transfer of caseload between the sites. There is, therefore, no reason to believe that a hospital for the South West would not be sustainable, whichever location is chosen. However, whichever site is chosen will require medical, managerial and political commitment to achieve a dynamic sustainability of the type which has been outlined earlier in this Section, as was recognised in the Hayes Report. 5. Equity Section 3 of this Report reviewed the evidence in relation to the accessibility of acute services and concluded that the location of the new hospital for the South West in Enniskillen, as recommended, by the Hayes Report achieved the over-riding accessibility requirement in a way which could not be achieved by location of the hospital in Omagh. The previous Section reviewed the issues relating to the sustainability of hospital services in either Enniskillen or Omagh and concluded that a new acute hospital in either location could achieve sustainability through active processes of management and through commitment at medical, managerial and political levels. The remaining issue which we intend to explore is the equity of alternative locations for the hospital. One aspect of the equity issue is the equality impact of the proposed location. Section 75 of the Northern Ireland Act 1978 requires all public authorities to have regard to the need to promote equality of opportunity between
It is the duty of the public authority to carry out Equality Impact Assessments and it would not be appropriate to examine all of these issues in detail. However, our GIS data does enable us to assess the impacts of alternative locations for the new hospital for the South West on
This Section uses that data to consider whether one location or another benefits particular age groups and uses recently published deprivation indicators to examine whether other effects prejudicial to equality of opportunity would arise. It also sets these arguments in the context of the very considerable gains which implementation of the Hayes recommendations would have for all of the people of the South West of Northern Ireland. 5.1 Age Analysis As explained in Section 3.1 of the Report, the population data relating to each enumeration district which was fed into the GIS model was broken down by the age groups indicated above. This enables us to model the impact on different age groups of the location of the new acute hospital for the South West. The age based data in relation to the option in which acute hospital services are provided at the Golden Six hospitals, Newry, Coleraine and a new hospital in Enniskillen are summarised in the following table. To facilitate comparisons the data is presented in cumulative percentage terms. Age & Distance Bands Analysis for New Hospital in South West located in Enniskillen
As can be seen from inspection of the table, the younger population and the elderly population have a slightly more favourable outcome than the population of working age or the total population but the differences are small. The following table repeats the analysis on the same assumptions except that on this occasion it is assumed that the new hospital for the South West is located in Omagh, rather than Enniskillen. Age & Distance Bands Analysis for New Hospital in South West located in Omagh
In this case the younger people have a slightly more favourable outcome than the general population or the population of working age, but the 60+ age group has a marginally less favourable outcome than the general population. To facilitate comparison between the Enniskillen and Omagh locations, the following table shows the absolute numbers of people in each age band living 30 - 40 miles from an acute hospital (at risk of breaching the golden hour test) and those living 40 - 50 miles from an acute hospital (assumed to breach the golden hour test) when the new hospital for the South West is located at either Enniskillen or Omagh. Comparative Age & Distance Band Analysis: Those at Risk of or Excluded from Golden Hour
The table shows that both for the total population and for all age bands the location of the new hospital for the South West in Enniskillen would provide a very significantly better equality of outcome for people of different ages than would its location in Omagh. It is not possible to replicate this degree of analysis for the other categories recognised in equality impact assessment but an age analysis is particularly important because it is in children and amongst the elderly that acute medical episodes occur most frequently. 5.2 Other Indicators of Deprivation/Health Disadvantage There are a number of indicators of relative health deprivation in Fermanagh which can build to a picture of a deprived population which would be considerably disadvantaged if it did not have access to high quality acute hospital services within a reasonable travel period. A significant indicator is the relatively high rate of infant mortality in Fermanagh. The following figures compare Northern Ireland and Fermanagh infant mortality rates.
Unemployment captures a number of dimensions of economic disadvantage. The September 2001 claimant count unemployment rates for Fermanagh and Northern Ireland are shown below.
Housing disadvantage is also a telling indicator of economic and health deprivation.
5.3 Conclusion This Section has shown that in terms of two of the principal client groups for acute hospital services - young people and the elderly - location of the new hospital for the South West in Enniskillen, rather than Omagh, would provide a more equitable outcome. Our GIS based approach is more difficult to apply to the other groups identified in the equality procedures. However, we have indicated across a range of indicators that the population in Fermanagh is significantly more disadvantaged than the Northern Ireland average. There is a close inter-relationship between our accessibility and equity analyses which has not yet been explored. The discussion of equity and equality issues is usually conducted in terms of comparative degrees of disadvantage. This is appropriate when the question is which group in society should have preferential access to services. However, - as our analysis has shown and as the Hayes Report recognised - if the new hospital for the South West is not located at Enniskillen, but instead located at Omagh, a significant proportion of the total population of Fermanagh will be excluded from access to acute hospital services during the crucial golden hour period. In this situation the issue is not about relative disadvantage but about exclusion from essential services and this then becomes an issue not of equality of impacts but of basic human rights to the provision of vital services from the national and regional government. This illustrates the degree of the starkness of choices facing the people of Fermanagh, particularly those to the West of Lough Erne. These people will, literally, have no choice of services available to them if the new acute hospital is located in Omagh, rather than Enniskillen. On the other hand, if the new acute hospital is located in Enniskillen, as recommended in the Hayes Report, residents of Tyrone will have access to a modern local hospital in Omagh and acute services provision in Altnagelvin, Antrim Area Hospital, Craigavon Area Hospital or the new hospital for the South West in Enniskillen. 6. Conclusions This Report has focused on the complex issue of how to provide timely access quality acute hospital care in the South West of Northern Ireland. The present system for the delivery of acute care is not sustainable, the quality of service is being eroded and degraded. A new configuration of acute hospital care for the South West of Northern Ireland is needed. The Acute Hospital Review Group recommended that acute care in the South West of Northern Ireland could best be provided by the provision of a new hospital for the South West located at Enniskillen. That new hospital would, however, not exist as an island. It would be part of a managed clinical network with Craigavon Area Hospital and with a new, modern local hospital which the Hayes Report recommended should be provided in Omagh. Implementation of the Hayes recommendations would provide the South West of Northern Ireland - both Fermanagh and Tyrone - with high quality, accessible and sustainable acute health care. This is a prize worth having for both Fermanagh and Tyrone. However, consideration of the Hayes recommendations for the South West has produced considerable controversy. This Report has taken a logical and evidence-based approach to considering the complex and controversial issues involved. It has reviewed the evidence considered by the Hayes Group and, where appropriate, extended the analysis to deal with additional issues. It has done so by examining whether the Hayes recommendations offer best outcomes in terms of the
The overall conclusion, based on the evidence in the Hayes Report and the additional evidence gathered specifically for this Report is that 'Hayes got it right' and that the location of the new acute hospital for the South West in Enniskillen is the only accessible, sustainable and equitable solution to the provision of acute hospital services for the South West. 6.1 Accessibility The Hayes Report found that 'Accessibility is an issue of over-riding importance in relation to emergency medical care, and in particular the need for A&E services to be within a minimum distance or travelling time of where people live. We believe that a period of one hour represents a reasonable benchmark of accessibility. Indeed, we recommend that Northern Ireland should have a configuration of hospitals providing emergency care services which ensures that the whole population can normally expect to access those services within one hour.' We examined the issue of accessibility of acute hospital services for the South West principally by using a sophisticated Geographical Information System (GIS) model based on distances by road from hospitals. This enabled us to examine the implications of alternative acute hospital configurations in the South West. We found that if the new hospital for the South West was located in Enniskillen, just 5,079 people across the whole of Northern Ireland would be at risk of exclusion or excluded from access to acute hospital services within the 'Golden Hour' identified in the Hayes Report. However, if the new hospital for the South West was located in Omagh the equivalent number rises to 14,721 - almost 3 times greater than if the new hospital was located in Enniskillen. We, therefore, concluded that on the principal and most important consideration set out by the Hayes Review, the location of a new hospital for the South West in Enniskillen is unambiguously preferable to its location in Omagh. 6.2 Sustainability Our GIS model was used to generate estimates of the catchment areas of hospitals in Northern Ireland - the areas and the associated populations which would be nearest by road to particular hospitals. We found that if the new hospital for the South West was located at Enniskillen it would have the smallest catchment of the Northern Ireland hospitals (6.2% of the Northern Ireland population), somewhat smaller than the other Level 3 acute hospitals to be provided at Coleraine and Newry (both of which would serve 7.3% of the Northern Ireland population). If the new hospital were located at Omagh it would serve 9.1% of the Northern Ireland population. However, this is a very static analysis which does not take account of the fact that a new hospital in Omagh would be surrounded by well-established Level 2 hospitals which patients would be likely to prefer for acute health care. These 'edge effects' could reduce the apparently larger catchment area of an Omagh location to just 0.8% of the Northern Ireland population. In addition, the Hayes Report recommended that the new hospital for the South West at Enniskillen should be part of a managed clinical network with Craigavon Area Hospital, which would share its workload with the new hospital as well as providing new opportunities for staff training, development and experience. On this basis either an Enniskillen or Omagh location could be made sustainable. Further factors favouring an Enniskillen location are the need to serve the acute hospital needs of over 273,000 staying visitors - a factor unique to Fermanagh - and Enniskillen's much better position for serving cross-border health service markets. The greater distance between a hospital in Enniskillen and other, larger hospitals would also contribute to the sustainability of an Enniskillen site which would not be operating in the shadow of, or potentially in competition with other larger and established hospital sites. We also confirmed that the site of the existing Erne Hospital is capable of accommodating the new hospital for the South West. We found that commitment to a new hospital for the South West at Enniskillen would restore confidence in the health structures in the South West and ease the current recruitment and retention difficulties affecting medical staff in both Enniskillen and Omagh We concluded that the new hospital for the South West can be sustainable, whichever location is chosen. However, whichever site is selected will require medical, managerial and political commitment to achieve a managed sustainability, as was recognised in the Hayes Report. 6.3 Equity We considered whether location of the new hospital for the South West at Enniskillen or Omagh would provide a more equitable outcome. It is for public authorities to carry out a full Equality Impact Assessment but our GIS model enabled us to examine the impacts of alternative locations on two of the groups most frequently requiring timely access to acute medical services - children and older people. We found that locating the new hospital for the South West at Enniskillen would mean that just 1,437 people under the age of 16 would be at risk of exclusion or excluded from the 'Golden Hour' criterion. If the hospital was, instead, located at Omagh the number of young people at risk of exclusion or excluded would rise to 3,667 - more than 2.5 times the figure for the Enniskillen location. In relation to people of 60+ just 776 would be at risk of exclusion or excluded from the 'Golden Hour' criterion if the hospital was located in Enniskillen. If the hospital was located at Omagh this number would rise to 2,720 - more than 3.5 times the figure for the Enniskillen location. While other indicators of deprivation and disadvantage were not amenable to analysis by the GIS model, Fermanagh remains a disadvantaged county relative to Northern Ireland average figures across a range of key health, economic and social indicators. The analysis of equity issues reinforces the findings of our analysis of accessibility. If the new hospital for the South West is not located in Enniskillen, as recommended, but is instead located in Omagh a significant proportion of the total population of Fermanagh will be excluded from access to acute hospital services during the crucial 'Golden Hour' period. This exclusion will disproportionately affect children and elderly people who have more frequent needs for acute medical services. 6.4 Overall Conclusions The location of the new hospital for the South West in Enniskillen best fulfils the Hayes recommendation that all of the population of Northern Ireland should normally be able to gain access to acute hospital services within 1 hour. The analysis of sustainability has shown that a hospital located in either Enniskillen or Omagh would be sustainable, particularly in the context of a managed clinical network with Craigavon Area Hospital. Location of the hospital in Omagh would be inequitable particularly for children and elderly people, who have the most frequent recourse to acute medical care, many of whom would be excluded from access to acute health services within the crucial 'Golden Hour' period. This illustrates the absence of choice facing the people of Fermanagh, particularly those to the West of Lough Erne. These people will, literally, have no choice of services available to them if the new hospital is located in Omagh, rather than Enniskillen. By contrast, if the new acute hospital for the South West is located in Enniskillen, as recommended in the Hayes Report, residents of Tyrone will have access both to a new, modern local hospital in Omagh and alternative acute hospital facilities in Altnagelvin, Antrim Area Hospital, Craigavon Area Hospital and the new acute hospital service for the South West in Enniskillen. In this context, the argument becomes one about the potential exclusion from essential services of a significant part of the population of Fermanagh, an issue of basic human rights to the provision of, literally, vital services from the national and regional government. Our analysis of existing and new evidence has confirmed that 'Hayes got it right' and that the location of a new acute hospital for the South West in Enniskillen is the only
solution to the provision of acute hospital services to the South West of Northern Ireland. WRITTEN SUBMISSION BY: 13 August 2002 Thank you for your letter of 26 July 2002 requesting comments on a number of policy areas in regard to the reshaping of acute hospital services. In our response to the Department, we do not intend to comment extensively on the proposed way forward. Rather we want to highlight the fact that the new arrangements will have a significant impact on community care, including mental health services. We feel that the absence of any comment on community services would give the impression that the existing services will be able to cope with new acute hospital arrangements. However, we will be pointing out that community services will need to be enhanced appropriately to be able to cope with:
Given that our existing funding falls short of that available to other community trusts, on a per capita basis, we will emphasise the need for parallel investment in community services in order to support the change programme in hospital adequately. I trust this is helpful. CHRISTIE COLHOUN JOINT WRITTEN SUBMISSION BY RETENTION OF ACUTE HOSPITAL SERVICES AT THE November 2000 CONTENTS Section I Executive summary II Background and terms of reference III Contextual review IV Equity V Capacity VI Accessibility Appendices A Bibliography SECTION 1 EXECUTIVE SUMMARY Background 1.1 In April 1998 the Northern Health and Social Services Board ("NHSSB" or "the Board") published its strategy for the development of acute services within the Board's area entitled "Towards a better future - a strategy for developing acute services into the next century". 1.2 In short this document sets out the Board's case for change, namely a move towards having acute services focused at the Board's two new hospitals in Antrim and Coleraine, complemented by local non-acute hospitals and facilities. 1.3 After a consultation process which included a joint response to these proposals by Cookstown District Council ("CDC") and Magherafelt District Council ("MDC") the Board confirmed their decision in October 1998 to transfer certain core acute services from Mid Ulster Hospital to Antrim Hospital. 1.4 A number of policy statements endorsing the policy of increasing centralisation of acute services have been issued by Government since October 1998. However, it has been made clear that any final decisions will be made by the Northern Ireland Assembly. 1.5 In response to the concerns raised by numerous groups and individuals over the impact of proposed changes in hospital provision on local services, the Minister for Health, Social Services and Public Safety, Bairbre de Brun, announced the establishment of an independent review group in August this year. 1.6 The terms of reference for this review group are: "To review the current provision of acute hospital services and, taking account of the issues of local accessibility, safety, clinical standards and quality of services, to make recommendations to the Minister on the future profile of hospital services". 1.7 This document, which draws on results of the extensive consultation process completed in the course of the compilation of the original submission to the NHSSB discussed above, constitutes the joint submission by CDC and MDC to the Acute Hospitals Review Group. Response 1.8 Both CDC and MDC believe that the proposed transfer of acute services from the Mid Ulster Hospital is incompatible with a number of Government's core strategic objectives in the delivery of health care which are:
1.9 In addition, a number of other factors pose significant questions over the benefits of a move to centralised provision of acute care. These include:
1.10 These factors are explored individually below. Equity 1.11 The statistical analysis set out in Section III of this submission provides a compelling case that both the CDC and MDC areas perform poorly under virtually every one of the main causal factors associated with social exclusion. 1.12 The proposed transfer of acute services from the Mid Ulster Hospital will exacerbate existing levels of deprivation through:
1.13 In addition, it is accepted that hospital usage declines as the distance to hospital services increases. Consequently, it is probable that the proposed transfer will provide a significant deterrent to many individuals who should be exploiting acute services, exacerbating the poor health and increased level of illness associated with social exclusion. 1.14 These impacts are clearly inconsistent with Government's aim to reduce inequality and ensure that changes do not increase variations in availability or access to health care. Accessibility 1.15 Both the Government and the NHSSB have made it clear that quality and safety of care must have primacy over geographical accessibility. 1.16 It is accepted that treatment and medical attention for a number of special acute conditions are best provided from "centres of excellence". However, for a large number of common acute conditions (e.g. heart attack) speed of access to medical assistance is a key factor in survival rates, and consequently a key consideration in determining the "quality and safety of care". 1.17 The additional journey time to Antrim will almost certainly increase mortality rates. This risk is exacerbated by:
1.18 In addition, journey times for many residents of the CDC and MDC areas will be significantly in excess of the acceptable journey time defined by the NHSSB as 40 minutes. Indeed, many of those using public transport will face a journey of several hours as a result of multiple connections and an infrequent service. Capacity 1.19 Implementation of the NHSSB proposal will result in a 28% reduction in both acute and total bed availability (300 and 288 beds respectively) in the Board area. This reduction assumes that the planned expansion at Antrim to provide 125 additional beds is completed. 1.20 Notwithstanding the trend of reducing lengths of stay for acute inpatients, there is a significant body of evidence to indicate that hospitals throughout Northern Ireland are operating at capacity and consequently are unable to respond to short term medical emergencies. 1.21 This concern is aggravated by reports from local general practitioners of increasing capacity issues at Antrim Hospital with patients regularly faced with long "trolley waits" or referrals to other hospitals. Quality of service 1.22 There does not appear to be any compelling evidence to support the thesis that services centred on large hospital units represent the optimum delivery channel in terms of quality. Indeed, in many instances the key factor in determining the quality of service is the ability for patients to rapidly access medical assistance (e.g. severe trauma). Diseconomies of scale 1.23 Although it is widely accepted that larger hospitals are more cost effective, there is also evidence to indicate that diseconomies of scale can arise when hospitals increase beyond an optimum size. Conclusion and alternative proposal 1.24 CDC and MDC consider that the proposed transfer of acute services from the Mid Ulster Hospital will compound the high levels of deprivation and social exclusion already faced by a large proportion of the local population. This is incompatible with Government policy and the Board's own stated aims. 1.25 Whilst the case for the centralisation of certain specialist disciplines is accepted, arguments for improved quality of care seem irrelevant where poor roads infrastructure, severe traffic congestion, inadequate public transport and prohibitive transport costs will effectively deny these services to large sections of the community in the CDC and MDC areas. 1.26 Consequently, both CDC and MDC believe that the transfer of acute services from the Mid Ulster Hospital as currently proposed should not be allowed to proceed. 1.27 However, both Councils accept the need for change in the face of increasing demands on hospital services and the need to operate within budgetary constraints. Consequently, after careful consideration both CDC and MDC have developed a proposal which would see the development of the Mid Ulster Hospital as one of perhaps two or three hospitals servicing the communities of South Armagh, South Down, South Londonderry, Tyrone and Fermanagh. 1.28 This would achieve the overall objective of a significant reduction in the number of hospitals delivering acute services, whilst minimising the adverse impact of centralisation on the most vulnerable sections of the community within areas which are already amongst the most deprived in Northern Ireland. 1.29 It is anticipated that these hospitals would provide a minimum level of acute services to include:
1.30 These services have been highlighted as critical requirements by the public in both District Council areas, on the basis that in each of these disciplines speed of access to medical care is deemed to be the key factor in securing "quality and safety of care". 1.31 In addition, each of these hospitals should be established as a "centre of excellence" for a limited number of other acute disciplines (for instance the Mid Ulster could host a dedicated orthopaedic unit which would service a much larger catchment area). 1.32 This proposal performs significantly better against Government's core strategic objectives of equity, accessibility and targeting social need.
SECTION II BACKGROUND AND TERMS OF REFERENCE Background 2.1 The Northern Health and Social Services Board ("NHSSB") is the second largest of the four Boards in Northern Ireland, representing an area of approximately 4,000 square miles and a population of approximately 415,400 people. 2.2 The NHSSB area covers the following council boundaries: Antrim Coleraine Moyle Ballymena Cookstown Newtownabbey Ballymoney Larne Carrickfergus Magherafelt 2.3 There are three trusts within the Northern Board area:
2.4 Mid Ulster Hospital is managed by the United Hospitals Health and Social Services Trust. NHSSB proposals for consolidation of acute services 2.5 In April 1998 the NHSSB published its strategy for the development of acute services within the Board's area entitled "Towards a better future - a strategy for developing acute services into the next century". 2.6 This document sets out the rationale behind the Board's strategy of a move towards having acute services focused at the Board's two new hospitals in Antrim and Coleraine, complemented by local non-acute hospitals and facilities. 2.7 In the strategy document the Board recognises that "there is no definitive vision of how care can best be delivered - the issue is one of balance: balance between centralised and local services; quality; access and cost; and, acute, community and primary care services". 2.8 Notwithstanding the recognition that there is no definitive solution the document sets out a number of givens:
2.9 On the basis of these "givens" and the assertion that "no change is not a realistic option" the Board set out three options for consultation which were: Option 1 2.10 Under this option potentially all inpatient/daypatient/outpatient/accident and emergency (A&E) and professions allied to medicine ("PAMS") presently provided at the Mid Ulster, Whiteabbey, Braid Valley and Moyle Hospital sites would be provided by hospitals in Antrim and Coleraine or other nearby acute hospitals. 2.11 Inpatient continuing care and respite care would be secured from local community settings rather than hospitals. Psychiatry and social services currently provided at Whiteabbey would be transferred to a new location in that area. Community care and primary care services in the area would be improved and ambulance services would be enhanced. 2.12 This option would require an additional capacity at Antrim hospital comprising additional theatres and 190 additional beds. Option 2 2.13 Under this option Antrim and Causeway hospitals become the focus for acute inpatient care services while local hospitals would be developed at Whiteabbey and Magherafelt. These local hospitals would provide other community health and social services and certain aspects of services at Larne and Ballymena would also be reorganised. 2.14 This option would require additional capacity at Antrim hospital comprising additional theatres and an additional 130 beds. 2.15 Whiteabbey hospital would offer a range of outpatient clinics with approximately 45 beds available for the assessment and rehabilitation of older people. X-ray, ECG and both psychiatric inpatient and day hospital services could also be provided. 2.16 The local hospital in Magherafelt would offer a range of outpatient clinics, a paediatric day assessment unit and approximately 30 beds for assessment and rehabilitation of older people. X-ray and ECG services could also be provided. Option 3 2.17 This option is as option two with additional investigative and surgical day procedures and minor injury units provided at the local hospitals in Whiteabbey and Magherafelt. 2.18 The Board concluded by stating that "the proposals set out in this document are positive, balanced and meet the challenges presented. Their realisation will require capital investment in the region of £30m - £40m which will give people a coherent and comprehensive pattern of acute and local services equal to that anywhere in the United Kingdom or Ireland". CDC/MDC response to proposals 2.19 Following the publication of the Board's consultative document Cookstown District Council ("CDC") and Magherafelt District Council ("MDC") jointly engaged KPMG Management Consultants to develop a comprehensive and representative response to the Board's proposals. 2.20 This response, which was submitted in July 1998, highlighted a number of critical arguments for the retention of acute services at the Mid Ulster Hospital which were:
2.21 KPMG concluded that on the basis of the critical arguments set out above the proposed withdrawal of acute services from the Mid Ulster Hospital is:
2.22 The Consultants concluded that "on the grounds of equity alone the proposals run counter to stated Government policy. In addition, arguments, if proven, in relation to improved quality of care are valueless if the people of the two council areas cannot properly gain access to the service". 2.23 Based on this analysis both Cookstown and Magherafelt District Councils rejected the Board's proposal to remove acute care services from the Mid Ulster Hospital. 2.24 The NHSSB responded in writing in October 1998, stating that after careful consideration the Board had decided to adopt option three, as set out above, with the addition of oral surgery services being retained in the Mid Ulster area and the provision of minor injury services in the Larne and Ballymena areas. Acute Hospital Services Review 2.25 On 8 August 2000 Bairbre de Brun, the Minister for Health, Social Services and Public Safety, announced the establishment of an independent review group, under the Chairmanship of Dr Maurice Hayes, to examine acute hospital services in Northern Ireland. 2.26 The terms of reference for this review group are: "To review the current provision of acute hospital services and, taking account of the issues of local accessibility, safety, clinical standards and quality of services, to make recommendations to the Minister on the future profile of hospital services". 2.27 The Group is currently consulting with a large number of individuals, organisations and groups and as part of this process has written separately to CDC and MDC asking for submissions. 2.28 This document, which draws on results of the extensive consultation process completed in the course of the compilation of the KPMG response document discussed above, constitutes the joint submission by CDC and MDC to the Acute Hospitals Review Group. Terms of reference 2.29 ASM Horwath have been engaged jointly by Cookstown and Magherafelt District Councils to develop a document for submission to the Acute Hospitals Review Group setting out:
2.30 In light of the extensive consultation carried out in the development of the Council's response document to the NHSSB the consultation for this engagement was restricted to: Primary research
Secondary research
2.31 Both Cookstown and Magherafelt District Councils would like to thank all those who assisted in the development of this submission including statutory bodies, community representatives and individuals. SECTION III CONTEXTUAL REVIEW 3.1 This section sets outs the contextual background to the options set out in the NHSSB strategy document and the proposal to transfer acute services from the Mid Ulster Hospital. Definition of acute services 3.2 It is clear from a review of the consultative and strategy documents released by the Department of Health, Social Services and Public Safety ("DHSSP"), [formerly the Department of Health and Social Services ("DHSS")], the Health Boards and the Trusts that there is considerable confusion over the definition of acute services. Indeed, very few of these documents provide any details of the services described as acute. 3.3 In their strategy document "Facing up to Change - a review of acute hospital services in the Southern Health and Social Services Board" the Board provides a definition of the term "acute inpatient hospital service" as: "Acute hospitals will need to be able to attract a sufficiently large case load in order to support the provision of a range of specialities and to justify the high level of investment in equipment and manpower. - An acute hospital should be expected to offer high quality care 24 hours a day and to provide: - general medical and surgical specialities; - an Accident and Emergency Department led by a consultant in A&E Medicine with adequate supporting staff and facilities; - a capacity to develop specialities and services currently provided on a regional basis; - an Intensive Care or High Dependency Unit; - Anaesthetics; and - a range of investigative facilities, including Pathology and Radiology." " In addition to the above specialities an acute hospital would also normally provide obstetrics and gynaecology services, with readily available neonatal care, except where the workload of the other surgical specialities is sufficient to allow viable anaesthetic cover." Overview of government strategy 3.4 In 1997 the Government published two main consultation documents in relation to the Health Service in Northern Ireland:
3.5 These documents set out the Government's proposals for the future of the Health and Social Services in Northern Ireland incorporating the policies in relation to the provision of acute hospital services. 3.6 A recurring theme within these documents is the intention to reduce the number of acute hospitals in Northern Ireland in order to:
3.7 In 1998 the Government issued a further consultation document: "Fit for the Future" which marked the 50th anniversary of the National Health Service and offered the public a chance to express their views on the Government's proposals. 3.8 In 1999 the Minister for Health and Social Services, Mr John McFall, published a document "Putting it Right. The case for Change in Northern Ireland's Hospital Service" which sets out a vision of the future actions required to improve the quality of the hospital service in Northern Ireland. Mr McFall stresses that this document is an analysis of what needs to be done; the decision of what to do is for the new Assembly. 3.9 There have been no Government policy documents published in the last two years. However, as discussed in Section II of this document, the provision of acute hospital services in Northern Ireland is currently under review by the Acute Hospital Services Review Group ("AHSRG"), and a report is expected within the next six months. 3.10 The documents mentioned above will inevitably influence this review process and therefore each document is discussed in further detail below. Health and Wellbeing: Into the next Millennium 3.11 Chapter two of this document states that the overall aim of this Government strategy is "to improve the physical and mental health and social well being of the population" with the following specific objectives:
3.12 One of the key areas identified in the strategy is "the need to tackle inequalities between groups within the population and to target services and resources to those most in need" which is discussed in Chapter four of the document. It states a commitment to "minimise inequalities in population health and social well being and in need for, and access to, health and social care in Northern Ireland". 3.13 In Chapter 6 of the document the Department sets out the strategy to be adopted to secure the specific objective set out above of "improving acute care", and the Department's overall aim "to provide the highest quality of care appropriate to the needs of the patient". In pursuit of this aim the priorities for action during this period are listed as: (1) move increasingly towards the purchasing of acute services based on evidence of clinical effectiveness; (2) secure further improvements in the quality of service to patients; (3) provide locally accessible services for more routine procedures through enhanced co-operation between primary and community based and hospital care teams; (4) concentrate specialised services on fewer acute hospital sites in order to secure optimum levels of clinical effectiveness, quality of care and value for money; (5) continue to move from inpatient to day and outpatient investigation and treatment; (6) ensure that patients continue to have access to high quality regional medical services; and (7) secure greater efficiency in the use of resources. 3.14 Priority number four clearly states the Department's commitment to a policy of increasing consolidation of acute services, indeed the document highlights the expectation of "progress towards a future pattern of significantly fewer acute hospitals serving larger populations." 3.15 This vision is tempered by the acceptance that "concentration of specialised services onto fewer sites raises issues of accessibility, and purchasers will continue to have to balance ease of access to services against consideration of clinical effectiveness and quality standards". 3.16 However, the Department makes it clear that it remains committed to a policy where "quality and safety of care should have primacy over geographical accessibility, and purchasers will be expected to reflect this when securing the provision of acute services". 3.17 The Department cites a number of key reasons for the commitment to increased consolidation, which include:
3.18 The Department also highlights the restrictions on availability of resources and the increasing competition for funds from new capital developments and enhanced services. This is encapsulated in the statement that "cost effectiveness must be a priority for acute services and any unnecessary duplication of services, or the inappropriate provision of services which fail to meet recognised quality standards, must be eliminated as far as possible". 3.19 The document identifies 19 hospitals providing acute services in 1997 (this has now been reduced to 17 with the removal of acute services from Banbridge and South Tyrone), and goes on to name six hospitals (namely Altnagelvin, Antrim, Belfast City, Craigavon, Dundonald and Royal Group) that will "provide the main focus for future investment in inpatient facilities". 3.20 It is also stated that if "the ratio of acute hospitals to population which currently obtains in England were applied to Northern Ireland, there would be no more than 10 acute hospitals in Northern Ireland". However, no reason is given for the further reduction from 10 to 6, which would result in a ratio in England of almost twice that in Northern Ireland. Well into 2000: A positive agenda for Health and Wellbeing 3.21 The purpose of this document is to set out:
3.22 The Government's vision includes the assertion that "Government is committed to economic, health and social policies which promote good health and wellbeing for all on an equitable basis", and repeatedly stresses the importance of social inclusion and social justice. Social inclusion 3.23 The Government is dedicated to the prevention of social exclusion, which can be caused by poverty, illness, disability, low educational achievement, ethnic background, lone parenthood or unemployment. It is recognised that socially excluded groups suffer more ill health and poorer social wellbeing. 3.24 The document states that the Government "wants to see greater pace and focus on the promotion of social inclusion, leading to a fairer, more participative and socially healthy society" and establishes the following goals:
Social justice 3.25 The Government's vision stresses a commitment to social justice, which will underpin all policies and programmes. It will instigate a renewed effort in addressing the inequalities in health and wellbeing and promises "commitment and a co-ordinated approach at every level." 3.26 The goals in relation to social justice are set in the document as follows:
3.27 Chapter 3 of this document sets out the areas on which Government would like particular attention to be focused. Once again, social inclusion and social justice are high on the list of priorities. 3.28 The following specific objectives were set out in the 1997-1998 Department's annual Business Plan:
3.29 The Government recognises that good health and wellbeing are not evenly distributed across the population and states that "those who are less well off suffer higher levels of illness, more difficult access to services and earlier death". The Government pledges a commitment to improving this situation despite the obvious complexity of the issue. 3.30 The Government also recognises the recommendations of the Standing Advisory Commission on Human Rights set out in the Targeting Social Needs (THSN) Initiative. The THSN stress the importance of directing resources to those most in need in each Board area. The Health and Social Services Boards are required to:
3.31 Chapter 7 of the document sets out Government's proposals for acute hospital services and states that a balance must be struck between community care provided locally and specialised services provided at "fewer sites". The document refers to the Regional Report, which identifies six hospitals as acute service providers for the future as discussed earlier in this Section. 3.32 The Government has commissioned the Health and Social Services Boards in each area to review critically the pattern of hospital services in their areas to ensure that specialised services are maintained at the highest quality and as wide a range of services as possible is available locally. Fit for the Future 3.33 This document was issued by Mr Tony Worthington, Minister for Health and Social Services, in 1998 inviting the public to comment on the Government's proposals for the reformation and modernisation of Health and Personal Social Services (HPSS) in Northern Ireland. The consultation period was scheduled to end on 31 August 1998 following which the Government would publish its proposals for the way ahead. These proposals have never been published. 3.34 "Fit for the Future" reinforces Government's emphasis on overcoming inequalities in Northern Ireland. The new HPSS will be built on 7 principles:
3.35 Equity has been stated as the number one priority in the Government's proposals and is defined as "providing a consistent standard of service for everyone with equal access for equal need". Government has also expressed a commitment to reducing inequalities as a matter of urgency. Putting it Right 3.36 The Minister for Health and Social Services, Mr John McFall published this document in 1999 to assist the new Assembly in making decisions regarding the provision of hospital services in Northern Ireland. 3.37 At the date of this publication the number of acute hospitals in Northern Ireland had already been reduced to 17 and plans were underway for a further reduction to 16 by 2000. The report states that a number of hospitals in Northern Ireland do not have sufficient facilities to provide adequate care and are hence unsafe. 3.38 Mr McFall identifies four options for the way forward:
3.39 The first two options have been dismissed on the basis of lack of available funding and appropriately skilled staff. The third option suggests a reduction in the number of hospitals to 3, which would be likely to be located in Belfast and Derry. This option has been dismissed on the basis of discrimination against people in rural communities, in terms of accessibility to hospital services. 3.40 Option four is stated as the preferred option and proposes the development of new care networks which incorporate the following stages:
3.41 Mid Ulster Hospital has been included in the list of local hospitals to be supported by the Causeway hospital as "Area hospital", and Antrim hospital as "Regional hospital". Department of Health and Social Services (DHSS) 3.42 The DHSS published a Corporate Strategic Plan 1998/99-2002/03 stating that the Department aims "to minimise inequalities in population health and wellbeing and in the need for, and access to, care services". The DHSS will provide overall direction for reducing inequalities and is responsible for "ensuring that those inequalities are identified, that needs are accurately assessed, that available resources are targeted where health and social need are greatest, and that action to reduce inequalities is initiated, monitored and evaluated". SECTION IV EQUITY Introduction 4.1 The contextual review set out in Section III of this report clearly establishes Government's commitment to reducing inequalities in health and well being in Northern Ireland. 4.2 Indeed the DHSS state clearly that "the effectiveness of targeted resources, programmes and services must be assessed to ensure that they are succeeding in reducing, and not inadvertently perpetuating or increasing, variations in health and social wellbeing or in the availability of, or access to, health and social care". 4.3 This message is reinforced in "Fit for the Future" where the principle of "equity" is identified as one of seven principles which will "underpin any proposals for change and everything the HPSS will do". For the purposes of this principle, equity is defined as the requirement for the HPSS to provide a consistent standard of service for the whole of Northern Ireland, with equal access for equal need. 4.4 Government policy is based on the premise that people who are "socially excluded" suffer more from illness, and aims to overcome social injustice and ensure that all people in Northern Ireland have equal access to a comprehensive range of high quality health and social services. 4.5 A number of policy documents include a recognition that social exclusion can be caused by "poverty, illness, disability, low educational achievement, ethnic background, lone parenthood or unemployment". 4/6 Approximately 90% of the patients using the Mid Ulster Hospital are from the CDC and MDC areas. This section sets out a body of evidence to demonstrate that residents in these areas already lag behind the Northern Ireland average in many of these causal criteria. Deprivation 4.7 The CDC and MDC areas are two of the most deprived areas in Northern Ireland as reported in a study of deprivation ("Relative Deprivation in Northern Ireland") published in 1994 by Manchester University. 4.8 The table below sets out the ten most deprived districts in Northern Ireland:
Source: Policy Planning and Research Unit - Occasional Paper No 28 Relative Deprivation in Northern Ireland, Brian Robson, Michael Bradford and Iain Deas 4.9 This position is exacerbated by:
Unemployment 4.10 Unemployment in the these areas remains relatively high albeit slightly less than the Northern Ireland average as demonstrated in the table below:
Source: T&EA October 2000 DETI Statistics Research Branch 4.11 However, the economically active population in both Council areas is lower than the Northern Ireland average as demonstrated in the tables below:
Source: Northern Ireland Census 1991 4.12 The key features are:
4.13 Any rationalisation of existing services at the Mid Ulster Hospital is likely to exacerbate the unemployment levels set out above (the hospital currently employs 547 staff the majority of whom live within the CDC and MDC areas) through a loss of direct and indirect employment. Sources of income 4.14 The main sources of income in the CDC and MDC areas are set out in the table below. Employment Categories 1997
Source: Northern Ireland Census of Employment, Employee Jobs, District Council Areas September 1997 & September 1995 4.15 The table above excludes numbers employed in farming. These can be obtained from the table below. Agricultural Census Farm labour force
Source: The Agricultural Census in Northern Ireland - Results for June 1999 Department of Agriculture for Northern Ireland 4.16 The key features of the above tables are:
4.17 Farm incomes are already well below the Northern Ireland average, and this position is likely to deteriorate as a result of the poor economic outlook for the sector. Disability 4.18 CDC and MDC areas have high levels of disability with a larger proportion of the population currently receiving disability benefits than that obtained in Northern Ireland as a whole:
Source: Department of Social Development, Statistics and Research Branch 4.19 Cookstown District Council area has a particularly high proportion of its population currently receiving disability living allowance and incapacity benefit. Educational achievement 4.20 Educational attainment levels in both the CDC and MDC areas are lower than the Northern Ireland average in virtually every education category as illustrated in the table below:
Housing 4.21 A high proportion (60% higher than the Northern Ireland average) of the housing stock in the CDC and MDC areas is considered to be unfit as reported by the Northern Ireland Housing Executive in 1996:
Source: Northern Ireland House Condition Survey 1996, Statistical Annex The Housing Executive Long term/chronic illness 4.22 A high proportion of the population in both the CDC and MDC (11.9% and 8.2% respectively) areas suffer from long term and chronic illnesses as demonstrated in the tables below: Dependant residents in households with long term illness
Source: Magherafelt District Council Area profile for Magherafelt District Council Area Taken from 1991 Census (NI)
Source:Cookstown District Council 4.23 In addition, it is understood that both areas have a high incidence of coronary attacks, although we have been unable to obtain statistical data to support this. Conclusion 4.24 The statistical analysis set out above provides clear evidence that the population in the CDC and MDC areas perform poorly under all of the main causal factors associated with social exclusion. 4.25 Existing levels of deprivation in the area are likely to be exacerbated by:
4.26 Both CDC and MDC consider that Government's commitment to promote policies which "reduce ...variations in health and social wellbeing or in the availability of, or access to, health and social care" are incompatible with a decision to transfer acute services from the Mid Ulster Hospital.section v CAPACITY Introduction 5.1 In their strategy document "Towards a better future" the NHSSB concede that implementation of their proposals to transfer acute services from the Mid Ulster Hospital to Antrim would require "significant development at Antrim Hospital". However, there is widespread scepticism of this commitment within both the CDC and MDC areas given the failure to deliver the previously promised expansion at Antrim. 5.2 This section provides a detailed review of existing capacity and details a number of trends which evidence a critical shortage of hospital beds in the Board area, and Northern Ireland generally. Review of hospital services 5.3 Hospital statistics 1 April 1999 - 31 March 2000 Volume 1: Programme of Care provides the following statistics in relation to hospital attendance in Northern Ireland:
5.4 Approximately 10% of total inpatient activity was accounted for by the United Hospitals Group exceeded only by Belfast City Hospital (21%) and the Royal Group of Hospitals (15%). 5.5 Based on the 1991 census and births and deaths records for the past nine years, we have estimated the current population of Northern Ireland at approximately 1.67 million. 5.6 The British Medical Association (BMA) carried out a survey on Northern Ireland hospitals in January 1999 with the following results:
5.7 The following graph illustrates the decrease in available hospital beds in Northern Ireland over the last eight years.
Source: The Northern Ireland Annual Abstract of Statistics 1999 5.8 The BMA concluded that the hospital service was in an extremely worrying situation due to problems which had been highlighted to the Government in 1998. The BMA states that Government "instead of stopping the reduction in year round bed availability by investing in additional beds for our major acute hospitals, .attempted to deal with the problems by using a sticking plaster when major surgery is needed". 5.9 The BMA attended a conference in Carrickfergus in April 2000 where the Vice Chairman, Mr Panesar announced that "Northern Ireland now lags almost three years behind the rest of the UK in terms of health service reforms." He continued to make the following points:
5.10 A report published in February 2000 by the Royal College of Nursing showed that Northern Ireland has one of the longest waiting times for hospital treatment with waiting times in Accident and Emergency units running into more than a day. A lack of beds was stated as the main reason for the delays in services. 5.11 It is clear that the provision of hospital services in Northern Ireland is far from ideal and that the quality of services provided are at an unacceptably low level. 5.12 The table below sets out capacity and occupancy levels for all hospitals in Northern Ireland for the year ended 31 March 2000:
5.13 Each trust listed above provides at least one hospital. The Mid Ulster Hospital is operated by the United Hospitals Trust which is managed by the NHSSB. 5.14 The current and proposed bed capacity for hospitals in the NHSSB area is summarised as follows:
*estimated on the basis of local hospital capacity at Mid Ulster Hospital. 5.15 As illustrated above, implementation of current NHSSB proposals would result in the total number of available beds in the NHSSB area decreasing by 330 (approximately 28.1%). This assumes that the proposed expansion at Antrim to provide for an additional 125 beds is in place before the planned reductions at other hospitals. 5.16 The demand for this reduced number of beds will have been exacerbated by the recent closure of acute services at the South Tyrone Hospital in Dungannon which the Board has confirmed to have resulted in an increased work load at the Mid Ulster Hospital. Acute service provision 5.17 The current and proposed acute hospital bed provision in the NHSSB area is summarised as follows:
5.18 As illustrated above, the total number of acute hospital beds in the NHSSB area will decrease by 287.6 (approximately 28%) if the NHSSB proposals proceed. 5.19 The widely reported growth in demand for acute services in Northern Ireland and the growth in population will result in even more demand for the reduced number of beds. 5.20 The demand for acute beds is also evidenced by a high proportion of patients in both the Causeway HSS Trust and the United Hospitals Group HSS Trust waiting significant periods for operations:
5.21 At 31 March 2000 there were 3,007 people waiting for acute inpatient services in the regions serviced by these trusts. Recent capacity problems 5.22 Northern Ireland's Health and Social Services were placed under significant strain in the winter of 1999/ 2000 when normal winter pressures compounded by a flu epidemic resulted in many hospitals struggling to cope and many patients faced with significant waits on trolleys while beds were found for them. 5.23 These problems are clearly documented in the Department of Health, Social Services and Public Safety document "Facing the Future - Building on the lessons of winter 1999/2000" which was published in April 2000. Indeed the document states that "acute bed occupancy is running too close to full capacity throughout the year". 5.24 The NHSSB encountered many of the problems experienced across Northern Ireland and was forced to reopen a number hospital wards including Ward 5 at the Mid Ulster which we understand has remained open since. 5.25 In addition, we understand that both the day surgery and gynaecology wards are currently in use to facilitate "over flow" from Antrim Hospital. 5.26 The effectiveness of actions taken in light of the crisis in 1999/2000 will become apparent over the next few months, however there are widespread reports of bed shortages throughout the summer months with "trolley waits" becoming a regular experience for many patients being admitted to hospital. 5.27 This experience is supported by reports from general practitioners in the NHSSB area who have stated that the inability to get a patient admitted to Antrim Hospital because of lack of capacity has become a regular occurrence. Conclusion 5.28 The review of existing and proposed bed capacity in the NHSSB area, and Northern Ireland as a whole, raises the question: where do the patients currently occupying acute beds go if the current proposal goes ahead ? 5.29 It is suggested that the demand for acute beds will reduce as a result of a decrease in the time patients spend in hospital and an increasing number of cases being dealt with at the primary care level. 5.30 These trends are supported by HPSS statistics, which indicate that beds have been used more intensively with a 21% increase in patient throughput for acute specialities between 1990/91 and 1994/95. 5.31 However, increasing demand for new services and the ageing population (elderly population projected to increase from 11% to 20% over the next 20 years) will place ever increasing pressures on hospital beds. In addition, there is already irrefutable evidence that hospitals throughout Northern Ireland are running at or approaching capacity. 5.32 It would appear that the Boards are attempting to reduce bed numbers faster than efficiency gains alone are able to justify. SECTION VI ACCESSIBILITY Introduction 6.1 The NHSSB has stated that independent research commissioned by the Board concluded that, "whilst people value local access to acute care, they place greater importance on the quality of care they receive, particularly for more serious illnesses, and are prepared to travel in such instances". 6.2 This message is repeated in the HPSS regional strategy where the Department's policy was clearly stated to be "that quality and safety of care should have primacy over geographical accessibility, and purchasers will be expected to reflect this when securing the provision of acute services". 6.3 Both these policies are predicated by the presumption that quality of care is enhanced by the centralisation of acute services. However, whilst this argument is generally accepted for specific acute illnesses or conditions, where treatment is best provided by teams of specialists, there are a number of conditions (e.g. heart attack) where speed of access to medical assistance is a key factor in survival rates. 6.4 CDC and MDC consider that centralisation is the best option for a range of specialist conditions, where patients need to access specialist equipment or medical skills. However, patients should not be required to accept significant journey times or distances to access acute care. 6.5 This section provides a detailed review of the accessibility issues arising from the planned transfer of acute services to Antrim Hospital and in particular, questions how these can be justified in the context of Government's commitment to achieve "equal access for equal need". 6.5 This section provides a detailed review of the accessibility issues arising from the planned transfer of acute services to Antrim Hospital and in particular, questions how these can be justified in the context of Government's commitment to achieve "equal access for equal need". Journey times By car 6.6 The following towns are within the Mid Ulster Hospital catchment area. The table below sets out the journey distances and times (by car) from each of these towns/townlands to Magherafelt (Mid Ulster Hospital) and to Antrim Hospital based on an estimate of travel times provided by the Automobile Association ("AA"). However, Magherafelt District Council contend that the AA estimates of travel times do not take account of local travel conditions and have provided, for comparative purposes, what it considers to be realistic travel times for the journey to Antrim Hospital during off peak and peak time traffic volumes.
Source: Automobile Association Route Planner 2000-http://www.theaa.com and Magherafelt District Council. NB: 'Rush Hour' timings relate to the periods 7am to 9.30am and 4.30pm to 6.30 pm. 6.7 As illustrated above the transfer of acute services will, in all cases, involve significant additional journey time for residents from virtually every town within the CDC and MDC areas travelling to Antrim Hospital. 6.8 It should also be noted that journey times will be longer than the realistic travel times noted above due to:
By public transport 6.9 Census statistics show that 73.9% of people in the CDC and MDC areas are vehicle owners and hence, the remaining 26.1% are reliant on public transport. The following table sets out the journey times and costs by bus from the same towns to Antrim.
*journey times do not include connection time Source: Ulsterbus Magherafelt and Cookstown Local Bus Timetable Nov 1999 - May 2000 6.10 The table shows that the people in the towns and villages listed above will have to spend an additional 73.5 minutes on average each way on a bus to access Antrim hospital. 6.11 The NHSSB report "Development of Hospital Services" published in 1974 establishes the acceptable journey time to access acute services as 40 minutes. On the basis of the table above it is doubtful if anyone travelling by public transport will be able to travel to Antrim Hospital within an acceptable journey time. 6.12 A number of factors will mean that in practice journey times will be significantly longer than those indicated above. These include:
Travel costs By car 6.13 Based on the table set out above residents within the CDC and MDC areas will have to travel an extra 15.7 miles on average to reach Antrim hospital. This would result in an extra cost of approximately £5.50 per journey based on a mileage rate of 35 pence per mile. By public transport 6.14 The average additional journey cost on a bus to Antrim Hospital is £7.66 per return journey. 6.15 In the year ended 31 March 2000 the average length of time spent in hospital in Northern Ireland was 7.8 days. If we assume the average family would visit a relative on at least five occasions during this time the average additional costs incurred by the family would be as follows: By car
By bus
6.16 This represents a significant financial penalty for residents who, as demonstrated in Section IV of this report, are already among the most deprived in Northern Ireland. 6.17 In summary, the transfer of acute hospital services will result in longer journey times for people living in the CDC and MDC areas, which will in turn result in increased costs incurred by an already disadvantaged community. This directly contravenes the Government policy of equity and equality. Traffic congestion 6.18 The car and public transport journey times discussed above take no account of potential delays on the roads in the CDC and MDC areas. The quality of the road infrastructure in both the CDC and MDC areas is relatively poor with mainly single carriageway roads and a complete absence of ring roads around towns in the region. 6.19 These problems are exacerbated by the proportion of the population in the area engaged in farming activities, with agricultural vehicles and livestock on the roads regularly causing additional delays. 6.20 However, the principal issue arising from the planned transfer of acute services to Antrim Hospital is the severe traffic congestion on the A6 route through Toomebridge village. The A6 is the only access route from Magherafelt to Antrim, and severe queues build up on the Magherafelt approach to Toomebridge during the morning peak from 7:00 to 9:00 am, and on the Belfast approach during the evening peak from 5:00 to 7:00 pm. 6.21 The queues can stretch for up to 1.5 miles and average speeds vary between 7 and 14 miles per hour over the queuing length. 6.22 The NHSSB made direct reference to the particular difficulties around Toomebridge and committed to "continue to press for urgent action by relevant government departments to remedy inadequacies in certain parts of the road network...in particular.the A6 at Toomebridge". 6.23 The DOE have conducted a number of surveys of traffic in the area and have confirmed that the village experiences serious traffic congestion at the following times:
6.24 DOE Roads Service has provided the following information regarding the volume of traffic passing through Toomebridge village :
6.25 The Department of Social Development (DSD) has responded to this problem and has been planning a £13 million dual carriageway bypass of Toome for some time subject to funding. 6.26 The 3.5 kilometre long dual carriageway bypass will be constructed around the northern periphery of Toomebridge with a new bridge located 550m downstream from the existing bridge to carry the bypass over the Lower River Bann. There are no plans however, for the improvement of the A6 out of Toome to the M2 which is a single carriageway already carrying a significant level of traffic including tractors and heavy goods vehicles. 6.27 Work on this new bypass was planned to commence by the end of 2001 with the completion date expected to be approximately 18 months later. However, on 16 November 2000 the Minister for the Department for Regional Development (DRD) stated that the difficulties with the Treasury over the planned privatisation of the Belfast Port mean that the start date has been suspended. 6.28 The DSD are also currently carrying out a review of the roads in the Cookstown and Magherafelt District Councils areas however, this report will not be available until January 2001. 6.29 There are also significant delays reported on the A26 between Ballymena and Antrim. The third stage of major road works is currently underway in order to complete the dualling of the road. In August this year Mr Gregory Campbell of the Department for Regional Development (DRD) stated that "everyone is working to keep traffic disruption to a minimum, but with 21,000 vehicles using the route every day there is bound to be significant delay". The work is scheduled for completion by May 2001. Traffic accidents 6.30 Traffic congestion is further exacerbated by the number of road accidents in the CDC and MDC areas. The following statistics were provided by the RUC for fatal and injury road traffic accidents:
Source: The Royal Ulster Constabulary Recorded Crime Statistics for Northern Ireland, Cookstown and Magherafelt sub-divisional areas 6.31 As illustrated above, the number of accidents in these areas has increased significantly over the last three years. 6.32 In the two years ended 31 March 2000, there were 23 injury accidents on the road from Toome village to the M2 in which one person was killed and 35 people injured. 6.33 These statistics exclude minor accidents and breakdowns, which, because of the single carriageway, can cause significant disruption. Ambulance service 6.34 The following map shows the density of population in Northern Ireland.
Source: "Mapping the Road to Change" A Strategic Review of the Northern Ireland Ambulance Service January 2000 6.35 The Mid Ulster Hospital catchment area consists largely of the Magherafelt and Cookstown District Council areas. This area is described as "sparsely populated" by the Northern Ireland Ambulance Service, which leads to accessibility issues in relation to hospital services. 6.36 These issues are exacerbated by the poor roads in many outlying regions within the CDC and MDC areas and the absence in many parts of any road signage. This results in additional delays where ambulance crews and medical personnel are forced to stop to ask directions. 6.37 "Mapping the Road to Change" was published by the Northern Ireland Ambulance Service (NIAS) in January 2000. This document summarises the results of a strategic review of the NIAS and provides the following information. 6.38 In 1998/99 NIAS managed a fleet of 243 vehicles, employed over 700 staff and responded to almost 67,000 emergency and over 38,000 urgent calls. 6.39 The following table summarises NIAS activity per station in the Northern Division during 1998/99.
Source: Mapping the Road to Change A Strategic Review of the Northern Ireland Ambulance Service 6.40 There are 56 ambulances employed in the nine stations listed above. This represents 23% of the total number of ambulances used by the NIAS which appears dangerously low considering that the Northern Division has the second highest number of urgent calls in Northern Ireland as illustrated by the graph below: The key features are as follows:
6.41 The Northern Ireland Health and Personal Social Services "A Charter for Patients and Clients" states that if an emergency ambulance is called "it should arrive within 14 minutes if you live in an urban area, 18 minutes if you live in a rural area, or 21 minutes if you live in a remote area". 6.42 A review of the Northern Ireland Ambulance Service (NIAS) was commissioned in October 1998 by Mr John McFall, the then Minister for Health, in order to "identify opportunities and resources required to improve patient services provided by the Ambulance Service". 6.43 The report proposed the design of "an improved emergency ambulance service" with the introduction of call prioritisation. New proposed performance standards were set as follows:
1. Additional hours of ambulance cover required each day to meet the targets. Hours of cover were calculated using an interactive modelling tool.; 2. Depending on types of vehicles used Source: Review of the Northern Ireland Ambulance Service 6.44 As part of their strategic review the NIAS reviewed current performance in terms of the new "eight minute standard". The results are illustrated by the graph below. 6.45 As demonstrated above the ambulance service in the NHSSB area is currently unable to achieve
the minimum standards set down in the recent review. 6.46 The following graph shows the number of calls where the ambulance reached the scene within eight minutes. 6.47 The NIAS strategic review states that the following emergency conditions
"are or may be immediately life threatening within 10 minutes of recognition" but can be effectively treated by ambulance staff:
6.48 As discussed in the paragraphs above, over fifty percent of urgent calls answered by the Northern Division were not at the scene within 8 minutes. We can reasonably assume that most of these cases would not have received treatment within ten minutes and can hence, conclude that in over fifty percent of urgent ambulance cases in the Northern Division catchment area, people are at a higher than average risk of losing their lives. 6.49 If plans for all acute hospital services to be transferred to Antrim and Causeway hospitals go ahead, cardiac ambulances will have to travel from the Antrim or Causeway hospitals to treat patients in rural areas suffering from heart attacks. As discussed above, cardiac cases fall into the "emergency condition" category and require treatment within ten minutes. Given that journey times will increase by up to 26 minutes without accounting for traffic congestion or accidents on the road, as discussed in paragraph 5.5 above, the risk of fatalities is extremely high. 6.50 Furthermore, all ambulances will face an extended travel time on the return journey to the hospital. This extra journey time will only further heighten an already dangerous situation. 6.51 The NHSSB recognise the difficulties in ambulance cover in their strategy document and note that there is "an absolute requirement to ensure that the ambulance service is adequately resourced and expanded to deal with increased need". 6.52 However, it is clear that a careful examination of the proposed structure and resources to be applied in this improved ambulance service will be required before any decision can be made on the transfer of acute care services. Conclusion 6.53 It is clear that the transfer of acute services to Antrim Hospital will result in significant increase in journey time and journey cost for virtually all residents within the CDC and MDC areas. 6.54 These problems will be particularly acute for those without access to a car, which are likely to be among the most deprived groups, who face prohibitive journey costs and journey times (including connections) of anything between four and eight hours. 6.55 It also probable that these additional journey costs and time will pose a significant deterrent to those planning to visit relatives in hospital. Given that patient visits are accepted to be a key factor in accelerating recuperation from illness this could result in an increasing feeling of isolation among patients and an adverse impact on overall lengths of stay. 6.56 In addition, the inability of the ambulance service to meet basic response performance standards is particularly worrying. It appears highly unlikely that the service will be able to meet the improved performance standards set out in their recent review without significant investment in additional ambulances, staff and training. WRITTEN SUBMISSION BY: EXECUTIVE SUMMARY It is the view of the Mater Hospital Trust having considered the best evidence, available that to implement the proposals in Developing Better Services pertaining to the Mater Hospital would:
The Mater Hospital Trust welcomes change - change that is based on the best evidence available, change which maximises efficiency and the prudent use of scarce public money and change which improves services to our communities. It is the opinion of the Mater Hospital Trust that Developing Better Services does not meet these demands. INTRODUCTION 1. The Mater Hospital Trust welcomes the opportunity to contribute to the discussions of the Committee on the proposals within the consultation document, 'Developing Better Services'. 2. The Trust has addressed the areas specifically identified by the Committee but has also included a range of issues that the Trust feels the Committee should consider in greater detail. 3. The Trust wishes at the outset to make clear its continued and ongoing commitment to providing the full range of acute hospital services to the community of north Belfast and south Antrim, adapting to the changing needs of the community and the requirements of increasing professional standards. 4. The response to the Committee is divided into two sections:
SECTION A Refocusing Of Acute Services Within Nine Sites From The Current 15 To Achieve The Concentration Of Expertise And Experience Required To Deliver The Highest Possible Levels Of Clinical Care. 5. While the report highlights the need for change, it generally focuses on the needs and requirements of professional standards in training and practice and very little on patient and community need. 6. There is no discussion in the report about the changing or growing health
and social care needs of populations or communities, nor the relationship between
social and economic deprivation and poor health, bar a single reference to an
ageing population345. 7. The report in 3.3 and 3.5 suggests that, 'larger facilities are considered better able to use sophisticated diagnostic and support services efficiently and economically, and support the number of clinicians necessary to provide 24 hours cover.' However, the authors of the report provide no evidence to support this statement. 8. The Nuffield Institute and University of Leeds have completed a significant
volume of work in this area. This extensive piece of work concludes that the
best research suggests there is no general relationship between volume
and quality. The authors fine no evidence that cost savings can be secured merely
by increasing the scale in acute hospitals beyond 200 beds and that it is likely
that large hospitals (600 beds) display diseconomies of scale6.
It has also been suggested that many medical patients are probably best
managed by general (internal) medical specialities practising in medium to smaller
hospitals78. 9. Where there is evidence,
as in the management of some cancer patients, for the concentration of services
to improve patient care, the Trust is wholly in support of this, with the proviso
that where services can be provided locally they are.9 SUMMARY 10. There is no substantial evidence to suggest that the concentration of services, as described in Developing Better Services, will provide the highest levels of clinical care. Establishment of new local hospitals, which will network with acute hospitals and local primary and community care to provide services that do not need to be delivered in a large acute hospital. 11. Developing Better Services suggests that hospitals are changed into a range of new organisations, New Local Hospitals, Enhanced Local Hospitals and Modern Acute Hospitals. 12. Before examining the detail suggested in the report, it is important to emphasise the confusion and potential misrepresentation created by the use of these terms. To describe, for example, the Mater Hospital as a Local Hospital for many people suggests that the hospital will not change, which is clearly incorrect. It could be suggested that the emphasis on titles in the report would be misleading. 13. The report describes Local Hospitals as an important new concept, yet fails to provide any evidence for their development. It is suggested that Local Hospitals will provide 70% of the services people need in hospital, but as in other areas of the report this suggestion is made with no evidence to support it. 14. The range of services to be provided is described in 4.16.
Intermediate Care 15. The Report also suggests that intermediate care should be provided in Local Hospitals yet the Report fails to define intermediate care or illustrate how and by whom that care would be given. This lack of information makes it impossible to assess that impact on the Communities needs. The Kings Fund defines intermediate care as care, 'for those people who, through timely therapeutic intervention may be diverted from acute physiological crisis and hence admission to an acute care bed.' 16. The 'Review of Community Care - First Report14' suggests that intermediate care schemes could lead to more cost effectiveness in the long term by:
17. There appears therefore a disparity of views between Developing Better Services and Review of Community Care - First Report, with the former suggesting intermediate care belongs in the institution which is a hospital and the latter suggesting it belongs in community and home based settings. It is the view of this Trust that intermediate care should be focused on the patient's home and community, not in a hospital setting. It is this Trusts belief that this would ensure better outcomes for the patient and be more cost effective for the service. Rehabilitation Beds 18. The Report suggests that local hospital should have 'Rehabilitation Beds' these beds would, 'support people who require less intensively supported care as they complete their recovery from an inpatient treatment. Again as in the area of intermediate care there is no indication of volumes of activity, evidence base for the development for this model or suggested workforce profile for those who would care of these patients. 19. The suggestion that rehabilitation should be based in an institution such as a hospital is also at odds with the DHSSPS 'Review of Community Care - First Report.' These views of users reflected in this Report suggests that 'Institutional environments are often de-habilitating in that they actually lead to increased dependency, loss of individual resilience and ability to cope independently. (Paragraph 23) The Report goes on in paragraph 24 to use an illustration of rehabilitation in the home as an example of best practice. Step Down Beds 20. Developing Better services also suggests that local Hospitals should provide services for 'step down beds'. In the absence of any detail, it is assumed that 'step down patients' are for example, post operative patients, who are unfit for home but over the initial acute recovery period. Patients can develop post-operative complications, both of a minor and major nature, following the initial few days post surgery. 21. The Report does not indicate who would be caring for these patients, as these Local Hospitals would not have any acute inpatient beds there would be no junior, middle grade or senior medical staff caring for inpatients. However, the Trust is unaware of any discussions that the DHSSPS may have had with local General Practitioner colleagues about the significant commitment that would be required in this regard. 22. It is suggested that Local Hospitals would also not have any theatre staff, it must be assumed that should a complication be observed and diagnosed by a professional, who has yet to be defined or described. The patient would then have to be transferred to a larger hospital to receive the required intervention and then transferred back to the Local Hospital for the recovery period. 23. If the authors are suggesting that these step down patients are so stable as to not require any significant input from medical staff, the Trust would suggest that they should be discharged home with support in the community or home if required. Local Circumstances 24. In 4.19 the Report suggests that the authors have 'taken account of local circumstances, a number of these (Local hospitals) will have some additional services'. While the Report goes on to describe a range of services associated with particular areas of the province, none refer to the actual health and social care needs of the populations they service. They only reference is to distance travelled. It is difficult therefore to see where the authors have linked 'Local circumstances' to 'additional services'. 25. In relation to the Mater Hospital, the report suggests that because
of the current 'capacity problems' the use of the acute services at the
Mater hospital will continue. It then suggests it should undergo a 'transformation'
into Local Acute Hospital. While in 4.19 the report indicates that this
'transformation' will be based on local circumstances, there is
no reference at all to the local circumstances of the people of north Belfast
and south Antrim whose health and social care needs are well documented.15,16 26. The Trust considers that Developing Better Services fails to acknowledge the health and social care needs of the communities of north Belfast and south Antrim and consequently fails to consider their impact of the design and delivery of services. This omission could suggest that the authors have their focus on institutions and buildings, not on populations and community need. SUMMARY 27. The Trust considers the model suggested for Local Hospitals fails to address the health and social care needs of communities. The Trust considers that the suggested template of services for the people of north Belfast and South Antrim is wholly inadequate to meet their needs. As described the Trust does not consider the template suggested for the Mater Hospital as acceptable. Enhancement Of Primary Care To Work Closely With The Local Hospitals And Form The Bridge Between Acute And Primary Care 28. The Trust is disappointed at the limited reference to primary care and the importance of the interface between primary, secondary and tertiary care. The authors appear to be constrained by organisational and professional boundaries. This is most apparent in the emphasis the Report has on 'large hospitals' and lack of acknowledgement of natural population flows as opposed to Board boundaries, something which was more ably represented in the Acute Hospital Review Group Report (AHRG). 29. The AHRG Report acknowledged the reality that many people in Newtownabbey and Carrickfergus gravitate towards Belfast and the Mater Hospital in particular, acknowledging that people doe not move according to Board boundaries. It could be argued that the authors of this Report are doing what they challenge the population and staff not to do - that is focusing on current bureaucratic arrangements. 30. This Trust considers that an alternative model would have been to take the patient journey as an approach starting and ending in their home, wherever that is. This approach has been more ably represented in the Review of Community Care, the content of which is often at odds with the recommendations in Developing Better Services. 31. The Mater Hospital Trust has a long history of close working relationships with local General Practitioners. In partnership with local General Practitioners, the first 'Out of Hours Scheme' on a hospital site was developed. This close working relationship has resulted in a reduction of the numbers of patients attending A&E with primary care conditions, that is the Mater Hospital treats a significant number of patients coded 'red' and 'orange' utilising the Manchester Triage Scale when compared to most other A&E departments, an example of partnership working to improve efficiency and care. SUMMARY 32. The Trust believes that the report has ignored natural populations and population movements and focused on current organisational boundaries. The Trust also feels there has been a missed opportunity to strengthen the relationship between hospital and primary care as one part of the continuum of care that begins in primary care and the patient home and ends there, with the hospital playing an often vital but short part of that journey. Improved Communication And Information Technology Links 33. This Trust is wholly in support of maximising the use of technology in support of care, wherever that care is delivered. Supporting Rural Communities Through Measure Such As Improved Ambulance / Transport Services And First/Rapid Responder Schemes. 34. The Trust supports the development of any mechanism that ensures the provision of a high quality service to all in Northern Ireland. While the Trust is mindful of the significant difficulties faced by rural communities, the Trust also feels that all communities should have their services developed, to meet their local health and social care needs, particularly in relation to the relationship between social and economic deprivation and disease indices, not journey times alone. 35. Investing for Health, suggests that a key target of the DHSSPS, HSS Boards and Trusts is to reduce health inequalities. The evidence suggests that those who are have high levels of deprivation and associated high levels of health and social care need, do not currently access services at the same level of those in less deprived areas, with less health care needs. For example the more affluent population of South Belfast, while having less health care needs, would potentially access more services than those of the populations of north Belfast. SUMMARY 36. The Trust suggests that removing significant hospital services from communities who have quantifiable health and social care needs and high levels of deprivation will have a detrimental impact on their health and well-being. Development Of Midwife Led Maternity Units Alongside Consultant Led Units 37. The Trust while supportive of the concept of midwifery led care and improved choices for women feels the evidence for units to be developed and sustained in isolation of an Obstetric Unit is limited. The issue of how to manage the unexpected emergency remains unresolved. 38. The report suggests that the Mater Hospital should retain its maternity unit conditional on the Mater Hospital working with the centralised Belfast Hospital. If the basic standards required for a Maternity Unit to exist are considered;
Within the context of the Local Hospital that the DHSSPS propose for
the Mater Hospital, none of these minimum stipulations would be met regardless
of links with other Hospitals17.
39. The Trust is also concerned about the detail of an answer given by the Minister of Health Social Services and Public Safety to the Mr Alban Maginness, Member of the Legislative Assembly, with regards to the maternity unit. In this response the Minister says, ' it will be for the Mater Hospital Trust, working with the new centralised Belfast Maternity Service to show that these arrangements can be put in place and sustained.'18 While the suggested model of service has been suggested by the DHSSPS, they have given no suggestion as to how to make this work. Given the standards described in the previous paragraph, it could be suggested that the DHSSPS is asking the Trust to complete a task they know to be impossible, with no assistance or guidance from the authors of the suggested model. SUMMARY 40. The Trust feels it is disingenuous of the authors to suggest that the presence of a Maternity Unit is possible within the template of services they suggest. Development Of Two Specialists Centres (East And West Of The Bann) For Planned Elective Surgery. 41. The development of Elective Centres is a relatively new concept in service provision. While it appears to be used as an example of how the authors have reflected local need in enhancing the status of some hospital, the provision of an elective unit bears no relation to local need. The development of facilities such as this may serve the needs of clinical staff but will not serve the needs of communities, unless they are developed and delivered within the communities they serve. 42. The Trust has recently been awarded additional capital and recurrent funding from the Eastern and Northern Health and Social Services Board and will be opening the first Protective Elective Unit in the Eastern and Northern Board areas. This significant development is at odds with the proposals in Developing Better Services. Enhanced Co-Operation Between Northern Ireland And The Republic Of Ireland On A Range Of Healthcare Issues. 43. This Trust feels however, if the people of Northern Ireland are to receive the best care possible links should be established with colleagues in Europe and beyond. SECTION B 44. This section reflects some of the other issues that this Trust feels require either clarification or challenge. Recruitment of Medical Staff 45. Developing Better Services indicates that some change is required as many hospitals are having difficulties recruiting medical staff and therefore are failing to meet the working time requirements set for Junior Doctors Hours. In Northern Ireland the Minster has established an Implementation Support Group to oversee the implementation of the working time arrangements for junior medical staff. 46. The Mater Hospital Trust has an enviable record of meeting the requirements of junior Doctors hours. The Mater Hospital Trust has achieved 100% compliance for Pre Registration House Officers, (PRHO) and the Trust is aware some larger units have been unable to achieve such compliance. SUMMARY 47. The Mater Hospital has successfully recruited and retained medical staff to meet the needs of the local community. The Trust has also achieved 100% compliance for PRHO's rotas, has currently approximately 70% of all medical rotas compliant with action plans to address the small shortfall. Teaching Role of the Hospital 48. The report in 4.35 to place a significant emphasis on the teaching role of the Mater Hospital and suggests that, ' the Mater will be ideally placed to play an even more significant role in contributing to training of doctors, nurses and other health professionals in the future'. Given that the Mater Hospital will have no acute inpatient services, no intensive care unit, no gynaecology ward, no accident and emergency department, no theatres, no surgical beds, no medical beds and no coronary care unit, the ability of the Trust to provide any significant teaching is in question. 49. The profile of the hospital will be such that Pre Registration House Officers, that is newly qualified Doctors receiving the final year of their under graduate education, would no longer receive their core training in the Mater Hospital, ending a long and distinguished history of Medical training in the hospital. 50. Some middle grade staff may be able to receive some training based only in outpatients and day surgery however this would be subject to the Post Graduate Council giving permission for junior medical staff to work across a number of sites, something which they have been reluctant to accede to in the past. 51. While it is implied in Developing Better Services that there are difficulties with educational and training standards in units other than the largest this is not the case at the Mater Hospital. Royal Colleges and the Post Graduate Council have acknowledged the quality of pre and post registration medical education on numerous visits to the hospital. In its most recent report, the Joint Committee on Higher Training in Accident and Emergency Medicine commented,' The Mater is in an area of social deprivation and trainees gain experience in care of a wide range of acute medical problems. Last year 63 patients with gun shot wounds were treated at the hospital. The department is very highly spoken of as a training site by Specialist registrars with a varied and challenging case mix, dedicated medical and nursing staff and very supportive speciality colleagues and hospital management.' 52. This commentary is reflected in previous Royal College Visits for example:
53. The Trust understands that A&E Committees reports in other Belfast Hospitals may not have been so favourable. The standard of education and support in the A&E department of the Mater Hospital reflects the standards and quality of medical education throughout the Trust. 54. In addition, there are significant numbers of nursing staff from both Queens University and the University of Ulster receiving clinical placements in the Mater Hospital. Given the proposed changed profile of the unit the majority of these placements would be unavailable. This will inevitably have an impact on the ability of the DHSSPS to train the additional nursing students planned in the future. 55. In addition the Trust has been working with local educational and other bodies to provide opportunities to staff to access student nurse training while remaining in employment and is currently in discussion with colleagues about providing distance learning pre registration programmes. This provides much needed educational, career and life opportunity to members of our local community where educational opportunities have not always been available. Should the changes happen in the future this would be significantly curtailed. 56. The reference to 'other health professionals' has been made without any suggestion of which professionals. However, the arguments made in the previous paragraph of this report would hold true in this scenario, without the range of services there are very limited training opportunities. SUMMARY 57. The Trust considers that the template of services suggested for the Mater Hospital would result in the removal of undergraduate medical education and significant elements of under graduate clinical placements in nursing. The Trust also feels that opportunities to provide members of the local community with greater educational opportunities would be significantly curtailed. Development of Psychiatry Services 58. Psychiatry services for north and west Belfast patients are currently
provided in a 55 acute inpatient unit on the acute hospital site. While there
is no discussion in Developing Better Services about the future of acute
mental health services the AHRG did recommend that, acute inpatient psychiatric
services should be co-located with other acute services'19. 59. While this statement has been made without any reference to evidence, the Trust is concerned that the model whereby it is suggested that acute services are removed from the Mater Hospital, combined with increasing clinical standards, may undermine the long term viability of the inpatient mental health unit, at a time when the need for such a service is increasing, not decreasing. The Need for Change in Structures 60. This section of the report focuses a way for the provision of clinical services to the management of these services. It is suggested (5.5) that the current arrangements, 'do not reflect the new emphasis in partnership and co-operation. Nor do they readily support the objectives of empowering local communities, targeting social needs and removing inequalities, which feature strongly in the Executive's Programme for Government'. 61. It is the view of this Trust that had social care need, inequalities and the health needs of the communities of north Belfast and south Antrim, been considered, the proposals for the Mater Hospital in Developing Better Services would not have been made. 62. While the report suggests in paragraph 5.16 that the case for reform is clear, it then fails to illustrate this. The report in page 35 goes on to ask for a view on abolishing the Boards. This Trust feels that any change and reform should be based on evidence of performance. There is currently little evidence to suggest that any of the proposed models of commissioning are any more or less efficient than the current system. 63. The authors of the report have asked for a view on the establishment of a single Regional Authority. This Trust supports this suggestion, with two provisos;
The Trust feels that the key to the success of any Regional body is a real involvement of communities in the design and delivery of services. 64. With regards to the organisation of Trusts, as with the commissioning organisations, the Trust feels that organisational structures should be based on the best evidence of effective performance in meeting local needs. This may result in a variety of models. It is this Trusts experience that devolving local management and decision making to Trusts when combined with a strong community involvement in the design and delivery of these services has ensured that the Trust remain effective and efficient in meeting patient needs. 65. This view can be reflected in the issue of community representation through the HSS Councils. In attempting to flatten structures, the DHSSPS must be careful not to centralise the patient / community voice so much so as to make it silent. SUMMARY 66. The Trust suggests that reform in structures and organisations should reflect evidence of effective management performance and the best evidence available. A Model for Hospital Services 67. The report outlines in 4.5 the principles that the authors used in guiding the outcome of the report. While these sentiments are laudable, they fail to address in any way the health and social care needs of the community. The Trust would suggest that the authors look to the Scottish Review of Acute Hospitals which had two guiding principles;
68. It is disappointing that the only reference in the Northern Ireland principles to communities or people is the reference to travelling times. The Scottish Review was underpinned by key assumptions many of which would have contributed to our local report, for example:
Performance 69. The Mater Hospital has, over the eight years since it was formed as a HSS Trust, grown in financial, activity and capacity terms. The following paragraphs demonstrate clearly that any decision to downgrade will have significant impact on the provision of services in the Belfast area and beyond. It also dispels the belief that some may have that the Mater is a small hospital on the periphery of the two "big" Belfast hospitals serving only a small population in a limited way. It also would lead one to question the logic and associated costs of stripping modern state-of-the-art facilities down to a rehabilitation service and imposing a further burden on the population of North Belfast and the South Antrim areas served by this Trust. Financial Performance 70. The Mater Hospital has achieved or exceeded its financial targets set by the Department in each of the years since it attained Trust status. In an era of continual pressure on healthcare organisations to manage costs within budget, the Hospital has also created many opportunities to develop and expand services. This has resulted in the Trust income increasing by almost 115% over eight years, which is probably unique among Northern Ireland Trusts. 71. From an income base of just under £16 million in 1994/95, the Trust is anticipating an income in excess of £34 million in 2002/03. (Table 1 illustrates) Table 1
72. This additional income is a measure of the support the Trust has generated over several years, and continues to enjoy, from its commissioners, GP's and the public. 73. The Trust whilst continuing to grow has also ensured that its services are delivered in a cost effective manner. For example, the DHSSPS publishes performance data on the costs of surgical procedures in Trusts. These are known as Healthcare Resource Group costs (HRG's). The latest available figures for the year 2000/01 bear out the performance of the Mater Hospital. The Departments own figures confirm that the Mater Hospital remains one of the most cost-effective units in the whole of Northern Ireland for these types of procedures. The Mater Hospital unit costs are the lowest in:
74. The same publication also contains an index of the relative cost efficiency of the Acute Trusts in Northern Ireland. In this index, the Mater hospital is ranked as 20% more cost efficient than the average for Northern Ireland. Capacity 75. The Mater Hospital has continued to grow in physical size and capacity also over the last number of years. The bed capacity of the hospital has increased from less than 250 beds in 2000/01 to almost 300 by the end of 2002/03 with a further 26 to be opened in 2003/04. This will take the Mater Hospital bed complement to a total of 325 beds across the full range of specialities. (Table 2 illustrates) Table 2
76. These increases have resulted from the well-documented needs of the population served by the Mater Hospital both in North Belfast and beyond. The addition of 20 Medical beds added in February 2002 reflected the demand placed on the Accident & Emergency Department by the increasing attendances resulting in increasing numbers of trolley waits. 77. A further 14 beds are being opened in the Autumn of 2002 to become the first Protected Elective Unit in the Eastern and Northern Board Areas dealing with the acute waiting list problem in the province. It is expected to put around 1000 additional inpatient cases and an additional 400 - 600 day cases through the unit per year. The Trust has also secured a further £3.2 million of capital to create a 42-bedded unit in the new hospital, opening in 2003 and 2004. 78. The physical size and environment of the Hospital has also changed dramatically over the last few years. The Trust has experienced huge investment in the last three years as a result of the YP Trustees who invested over £16 million of their funds in the hospital to create a modern state-of-the-art facility including modern fully equipped wards and a high-performance Day Procedure Unit (DPU). Service Performance 79. The DHSSPS publishes its hospital performance statistics annually. The latest statistics for 2000/01 demonstrate that the Mater Hospital scores highly against all acute Trusts but particularly against the other Belfast Trusts in many important indicators:
80. The Mater Hospital is also shown as having:
The Trust anticipates that these results will be demonstrated again in the 2001/02 year. 81. It is against this background of increased capacity and efficiency that the Mater Hospital has continued to attract high levels of demand for its services. The tables below illustrate a hospital that continues to grow in response to the needs of the populations of Eastern and Northern Boards.
Potential Impact of downgrading the Mater Hospital 82. Whilst the Developing Better Services document contains some financial figures, it does not set out in any detail the likely full cost implications of the changes proposed in any detail. Undoubtedly this will be a key part of any further plans issued by the Minister and will also describe how individual hospitals will be invested or dis-invested in. It is essential, whatever the outcome of the consultation process, that a financial strategy is developed to support the changes and importantly to ensure financial control and stability in the process. 83. In the absence of the detailed analysis of impact, it is possible to make some judgements based on the indicators in the table above, about the likely impact of the removal of the inpatient beds from the Mater Hospital Trust. 84. For example applying the Royal Group Hospital throughput rate to the Mater Hospital bed capacity at present would indicate that:
£2.09 million in BCH; £1.78 million in RGH. 85. Whilst this analysis is by no means complete, it does demonstrate that the rationale for transferring Mater Hospital activity and services without examining the detailed performance and costs is flawed. Equality 86. The Trust is concerned that the focus of the preliminary equality impact assessment concentrated solely on the configuration of either 15 or 9 acute hospitals based on travel time. Other valid and significant equality of opportunity considerations across the Section 75 categories in North Belfast have not been assessed. 87. The Trust is the single major employer within North Belfast, an area that is already recognised as having high levels of social and economic deprivation. The communities in North Belfast have witnesses some of the highest level of social conflict, unrest, unemployment and polarisation throughout the history of the Troubles in Northern Ireland. The area has also been identified for particular attention under the New Targeting Social Need initiatives, due to the deprivation levels and poor uptake of healthcare and immunisation. 88. In order to access the other Belfast hospitals, residents would be required to undertake two bus journeys and for communities who are suspicious about crossing into the 'other' community's areas, this could lead to further reductions in those who need healthcare the most accessing services. SUMMARY 89. The Trust considers that it is difficult to understand how reducing healthcare services in North Belfast does not have a significant adverse impact on equality of opportunity. The Trust in its formal response to the Department will highlight potential adverse impacts across the nine categories in detail. Employment 90. The Hospital is the largest employer in North Belfast employing over 1000 staff. At present 63 % of staff working in nursing support, administrative and clerical, works and maintenance and support services grades live in the local community of North Belfast. 91. Removal of acute services from the Trust will result in significant change of the staffing profile within the Hospital and reduce the need for current numbers and type of staff. This will have a direct impact on those members of staff who live in the local community, taking account of the relatively low earning levels of staff, their access to private and public transport, and the increasing polarisation of communities. 92. When asked, many staff who live in North Belfast have clearly stated to the Trust that they do not have access to private transport, they cannot afford the additional public transport costs and that in the on-going situation of social unrest and conflict between communities, have serious concerns regarding working in other Hospitals or Healthcare facilities. SUMMARY 93. The Trust considers that the impact on employment in the north Belfast area, if the proposed model is implemented would be significant, particularly for those already in lower paid employment who do not have the resources to travel widely for employment. A New Way Forward 94. The Mater Hospital Trust recognises and welcomes the challenges faced today and tomorrow. The Trust feels however that there is an alternative model of care to that suggested in Developing Better Services, building on the principles of, a service led by patient need and with standards of service provision determined and audited nationally, but how best to meet these standards decided locally. 95. The Trust considers the variations in geography and health and social care need mean that there is no single solution. One proposed solution is to reverse the model suggested in Developing Better Services, place the local hospital at the front line of all but very specialist services and organise the services around the patient rather than the professional. With the right support, infrastructure and back up the numbers of patients that would require transfer to the central unit might well be in the minority21. The potential advantages would be a closer relationship with primary care and the patient's home and reduced levels of transfers while maintaining high standards of care. 96. The Trust considers that to meet the significant and growing health and social care needs of the communities we service the Trust should continue to provide the full range of acute hospital service in partnership with local General Practitioner, Community Trusts and Community leaders and Community and Voluntary Groups. SUMMARY 97. It is the view of the Trust having considered the evidence available that the proposals in Developing Better Services would:
98. Mater Hospital Trust values the time and commitment the Health Committee has given to debate and discuss the proposals in Developing Better Services. 99. Trust considers that the report lacks the voice of the communities we serve, the evidence to substantiate recommendations and the vision to create a new sustainable future for patient care and treatment with our hospitals as one part of our total service. The Mater Hospital Trust welcomes change - change that is based on the best evidence available, change which maximises efficiency and the prudent use of scare public money and changes which improves services to our communities. It is the opinion of the Mater Hospital Trust that Developing Better Services does not meet these demands. WRITTEN SUBMISSION BY: As you may be aware the Minister for Health, Social Services and Public Safety published her proposals for the future of health services in Northern Ireland on 12 June 2002 - "Developing Better Services: Modernising Hospitals and Reforming Structures". It has been proposed that the Mater Hospital Trust should become a Local Hospital. This proposal would effectively end the Mater's proud tradition of providing a wide range of acute hospital services to its local community - a community whose health care needs are clear. All medical, surgical, intensive care and gynaecological beds would be removed. This would mean patients requiring immediate treatment for heart attacks or breathing difficulties would no longer be able to attend the Mater. The 24-hour Accident and Emergency Services would become a minor injuries unit dealing with cuts and bruises which would leave totally inadequate local provision given the continuous civil unrest. Because of these proposals there has been a ground swell of opinion which is clearly saying 'Hands off the Mater'. A cross community group representative of Northern Belfast and the Greater Shankill Mater Hospital Community Action Group are leading a campaign to oppose these proposals and to provide a voice for all the people who will be effected by these changes. The Action Group is strongly opposed to the proposals. We wish to present our case for retaining acute services at the Mater Hospital. We are writing to you requesting that we make a presentation to the Health Committee and have this listed as an agenda item. Over the past few weeks a petition has already been widely circulated within our local community and throughout Northern Ireland and while the consultation period for these changes is short we are now receiving thousands of signatures in support of our campaign. We also request that we could present copies of this petition to the Health Committee. On behalf of the community, the Act Group would also welcome the opportunity to obtain your views on the Minister's proposals. We recognise that we have given short notice in making this request, but as the consultation period for such radical change is short, too short, ending on 31 October 2002 we must meet prior to this. Thanking you in anticipation. M HOLMES WRITTEN SUBMISSION BY: 10 September 2002 We welcome the opportunity to respond specifically to the Health Committee on the document "Developing Better Services" as requested in your letter of 26 July 2002. As you are aware the Northern Ireland Ambulance Service (NIAS) has been the focus of a Strategic Review which identified major resource implications both capital and revenue, not only for the Service to deliver improved response times but also to take account of the planned rationalisation of acute hospitals and the re-profiling of acute care in Northern Ireland. "Developing Better Services" emphasises the need for long-term planning. We wish to ensure that the Ambulance Service is seen as an integral part of healthcare and that any proposals within the Strategic Review coincide with the longer-term plan of this document. Para 4.69 of the document and the bullet points that follow outline some of the initiatives, which are considered to be required within NIAS. We would have preferred to have seen a much more comprehensive recognition of the pivotal role of NIAS in relation to this whole acute hospital change agenda and a recognition of the need for fundamental investment in core services rather than simply highlighting supporting measures. In relation to your specific policy areas, as identified in your letter, we could comment as follows: 1. We recognise the professional arguments in favour of refocusing acute services into fewer sites and indeed the requirements laid down by the Royal Colleges in relation to professional standards which support this approach. However, as we have stated on many occasions such a rationalisation requires an investment in the Ambulance Service on two fronts: 1.1 in relation to actual resources on the ground in order to maintain emergency cover as ambulances travel further to receiving hospitals and are out of their "area" for longer; and 1.2 the greater clinical skills and training required of ambulance staff that will have to care for patients over a greater length of time. There is also the very strong element of public perception that ambulance staff will be trained to higher standards. 2. The detail of the Services that will be available or indeed expanded in the new local hospitals is not apparent in the document. In principle we welcome the increase in services at local hospitals as this should reduce the journey times for patients and in consequence in some cases the need for ambulance transport. 3. NIAS is a very valuable part of the bridge between primary and acute care. This is not explicitly recognised within the body of the document. Functions such as the Patient Care Service bringing patients in the community to and from hospital and doctors' urgent admissions into hospital are not considered. The Emergency Admissions Co-ordination Centre (recently visited by the Health Committee) based at Ambulance Control Belfast, has the potential to expand the relationship between primary and acute care. 4. The Service awaits a decision on the proposals to rationalise the four communication centres to one Regional Emergency Control and one Patient Care Service Control Centre. The Service would aspire to have automatic vehicle location and advanced mapping systems, tools which the Service believe are essential to effectively co-ordinate pre-hospital care across Northern Ireland. The transmission of ECG's from a patient's home to hospital is already being piloted within the Service. The advancement of this and similar technology requires new ways of working and additional investment and training of staff. 5. Paragraph 4.69 states that supporting measures will be put in place. NIAS view is that this statement requires to be strengthened and state explicitly that these supporting measures as outlined in the following paragraphs will be led by NIAS. These initiatives must be totally owned and led by the Ambulance Service as specialists in this area. We welcome the Department's plans to improve ambulance response times for many rural areas. Reference is made to thrombolysis. We feel this should be broadened to include initiatives such as paediatric and obstetric training, trauma life support and other nationally recognised clinical developments in pre-hospital care. 6. We have sought clarification in relation to whether the "midwife led units" will be physically adjacent to the consultant led units. If they are not there are implications for inter-hospital transfers. 7. The Northern Ireland Ambulance Service and the Ambulance Services in the Republic have enjoyed excellent working relationships for many years. We welcome the opportunity to expand on this work with particular reference to major incident responses and are co-operating with the current review of the potential for a Joint Air Ambulance. P McCORMICK WRITTEN SUBMISSION BY: BACKGROUND The Northern Ireland Primary Care Forum (NIPCF) was formed in June 2000 to consider emerging local policies for primary care. The Forum is one of the few NI-wide multi-disciplinary groups within the HPSS. Forum members have worked with the DHSSPS and other agencies to try and improve patient care through effective development and deployment of primary care - the care professionals (family doctors, community-based nurses and others) who are the first point of contact with the HPSS for you and your constituents. INTRODUCTION The NIPCF appreciates the Assembly Health Committee's request for a response of our collective views regarding the consultation paper, Developing Better Services, however are disappointed in having to respond to yet another consultation document. Patient services are rapidly declining due to the lack of decisions relating to policy and strategy. Consultation is useful but repeated consultation leads to unacceptable delay, inertia and loss of staff morale. The proposals published in this document, on the future of the health services in Northern Ireland, will clearly have a major impact on healthcare workers and service users across the province. It is therefore vital that clear, definitive radical decisions, which are necessary, are not only taken but are supported both managerially and financially to provide excellent care to patients. Considerable investment is needed to ensure that patients do not suffer by being caught in the middle of a shrinking acute sector and an under-funded primary care system (which is currently the case). It appears that 'Developing Better Services' is a unique document in being part White Paper and part Green Paper. The reorganisation of secondary care has been delayed for too long and the plan outlined, although not to everyone's liking, is a least a beginning to address some of the problems endemic in our hospitals. Speed is of the essence and further consultation unnecessary. KEY RESPONSE POINTS The NIPCF supports the view of the Acute Hospitals Review Group Report (AHRG, 2001), that primary care provides a pivotal role in addressing growing pressures in acute hospitals. Dr Hayes (Chair of AHRG) stated that "it rapidly became clear to us that although we were asked to conduct a review of acute hospitals, we could not perform that function without also considering the role of primary care and its interface with secondary care". The 'Developing Better Services' paper is the first part of a response to the AHRG report which contained proposals relating to primary care that were mainly well-received by NIPCF. The report also contained a wide-ranging framework for reform of the whole HPSS system and set time-scales for change that underscored the urgency of the task. A key lesson developed in the work of the AHRG was the need TODAY to begin to work with the whole HPSS system and not just with the acute sector in isolation. It is unfortunate that the current consultation document does not seem to develop that "whole systems" approach, except in a purely nominal way. There is no development of the AHRG's primary care centred service concept evident within this document. Support outside the primary care arena for this policy direction is, understandably, guarded but if that policy is to be effective it must be developed in all policy contexts in much the same way as the Equality policy is addressed. If we continue simply to develop acute services with little or no reference to the changing position of primary care then we will miss a significant opportunity for developing better services - a costly mistake for NI patients. The idea of developing a network of centres that support universal access within a defined timescale is supported as a rational basis for service planning. We would however remind planners that rural communities are not the only situations where access times are at risk - traffic congestion and other problems in city locations may affect an even larger population. We are disappointed to note that existing primary care arrangements for 24-hour cover are not considered worthy of a mention (para 4.69/70) and would recommend that pre-hospital care in its totality should retain a primary care focus with LHSCG leadership. The paper proposes increases in consultant medical staff, allied health professions, qualified nurses and doctors undergoing GP training (even though the paper seems to be proposing training more doctors as GPs but then not actually using them as partners in practices). The difficulty is that while Developing Better Services has recommended significant increases in the number of aforementioned professionals, the recent workforce reviews carried out by the Department of Health appropriates funds for a more modest increase in numbers of professionals. These are actually less than would happen as a result of a natural expansion in the workforce. There is obviously no evidence of co-ordinated thinking in relation to Developing Better Services and the Departments' Human Resources Strategy. Also we would like to know how these increases would be obtained considering the current recruitment and retention problems that exist, particularly amongst the nursing profession. The NIPCF strongly disputes the accuracy of the definition of a LHSCG (p46) and its comments about the way in which LHSCGs would operate (p34/35). The paper confirmed our fears that the LHSCG function is nowhere nearly as certain or secure as some DHSSPS officials would have had us believe. The paper raises questions about commissioning that the NIPCF would have previously taken as resolved. Had the NIPCF been asked to describe our general direction it would have said LHSCGs are the start-point in a structure that would allow Health and Social Services Boards to disappear. Now it seems that LHSCGs will be transformed either into a three-headed commissioning body or as some sort of combined body, with or without acute services. CONCLUSION Chapter five 'The Green Paper' is both inchoate and incoherent to the NIPCF members. The NIPCF has repeatedly presented its suggestions for improving primary care and its interface with secondary care. This document does not meet any of the requirements proposed. It appears to the NIPCF that the DHSSPS are visibly still completely unclear about the sort of arrangements that are to be employed operationally to manage the HPSS - this was, in short, the lack of vision that was and is one of our major concerns.
WRITTEN SUBMISSION BY: 24 September 2002 DELIVERING BETTER SERVICES - MODERNISING HOSPITALS AND REFORMING STRUCTURES 1. Introduction The above document was issued for consultation in June 2002 with an invitation to respond by 31 October 2002. NIPEC is pleased to provide the following response. The overall aim of NIPEC is to support the professional development of nurses and midwives to enable them play a proactive and responsive role in the delivery of high quality health and social care services for now and into the future. NIPEC will particularly support practice, education and performance and this response places particular emphasis on the issues that have most relevance to its remit. 2. Comments on Analysis and the Need for Change 2.1 NIPEC welcomes the proposals to establish a modern hospital system capable of delivering a quality service to meet the current and future needs of the public in Northern Ireland. NIPEC supports the development of the hospital service as a dynamic, integral part of the total health system, working effectively with primary and community care services, to deliver appropriate care and treatment to patients and re-integrate them back into the community. 2.2 Whilst NIPEC welcomes the proposals outlined in the consultation paper, it considers that they fail to give sufficient emphasis to the role of nurses and midwives (and professions allied to medicine) in bringing about the change. 2.3 NIPEC acknowledges the need for structural reform, and strongly advocates a partnership approach to reinforce the efficient and effective delivery of acute and other vital services. (Chapter 5). 2.4 NIPEC would support the following issues addressed within the document:
3. Comment on Model for Future Hospital Services 3.1 NIPEC is supportive of the proposed network of acute hospitals and local hospitals but would add that successful implementation depends on an adequate infrastructure. However, NIPEC believes that an opportunity may have been missed to further enhance the overall care experience of patients, through the development of Nurse Led Units, e.g. Minor Injuries Units, Assessment and Rehabilitation Units for the elderly medical patient and Nurse Led Mobile Coronary Care Units. The benefits of such Units include accessibility, availability of 24 hour care and the provision of an integrated service to patients where and when required. 3.2 The document appears to reflect cognizance of the challenge that structural changes will present to the provision of medical education. NIPEC would wish to emphasise that a similar challenge may be experienced by providers of nursing and other health professional education. 4. Specific Comments on Proposals The following comments are made in relation to specific aspects in the consultation paper. 4.1 NIPEC would advocate that the successful implementation of the proposals, and the effective delivery of services in the future, will require the equal engagement and resulting ownership of all professions. 4.2 The increasing demand for care and treatment from the growing elderly population with chronic illness, will present opportunities for services to be delivered close to where the person lives. These may effectively be provided through nurse-led initiatives in a partnership approach such as Hospital at Home Schemes, Rapid Response Schemes and Intensive Home Treatment Teams. These types of services are designed to care for the person in their own home, eliminating the need for admission to hospital, or to support the person in their home following early discharge from hospital. Nursing roles that focus on the care of people with chronic illness such as diabetes or respiratory problems have a valuable role to play here also. (Paragraph 2.6). 4.3 NIPEC would accept that sub-specialisation has contributed to role development for nurses and midwives. However, there is a risk that specialisation may result in the deskilling of non-specialist staff, thereby reducing their ability to provide holistic care. NIPEC recognises the need to work with Trusts to identify further development opportunities. (Paragraph 2.13 and 2.14). 4.4 NIPEC advocates the integration of clinical practice and theory. It also acknowledges the significant contribution that effective mentorship makes to the clinical practice education experience and will continue to promote its value to the providers of clinical placements. (Paragraph 2.20 and 2.21). 4.5 NIPEC acknowledges that robust clinical and social care governance arrangements will have resource implications. NIPEC would emphasise that nurses and midwives, together with other health professionals, will require support and effective facilitation to embrace this challenge adequately. Practitioners will also require support to meet their individual continuing professional development needs. (Paragraph 2.25) 4.6 NIPEC, in driving evidence based nursing and midwifery, supports the aspiration to improve standards and the dissemination of good practice alluded to in Paragraph 2.26. 4.7 NIPEC welcomes managed clinical networks and would emphasise that the full involvement of all health care professionals is critical to effective network development and ownership (Paragraph 3.15). NIPEC believes that patient and client care may be enhanced within an integrated service network as alluded to in paragraph 4.4. The nursing and midwifery professions have proved to be creative and ideally placed to provide seamless care across boundaries. Many nursing roles have a hospital and community remit such as in discharge co-ordinator, cardiac rehabilitation and palliative care. 4.8 NIPEC welcomes the development of a flexible health care workforce to support the delivery of services to meet the needs of local communities, it also values the potential for individual practitioner's to enhance their clinical knowledge and skills. There are positive examples within nursing and midwifery to illustrate the value of a flexible workforce. (Paragraph 4.8). 4.9 NIPEC wishes to emphasise that Local Health and Social Care Groups present a valuable opportunity to include nurses and midwives, working within community and primary care, in the commissioning of services based on local need. (Paragraph 4.10). 4.10 NIPEC welcomes the proposal to develop midwife-led care where there is evidence to suggest added value. NIPEC would be pleased to work in collaboration with the service and education providers to ensure that nurses and midwives are adequately prepared and supported to provide safe care for patients. (Paragraph 4.66 and 4.67). 4.11 NIPEC accepts the Department's assessment that current services are under-staffed and that this impedes the necessary improvements in quality and performance. NIPEC acknowledges the actions already taken by the Department to address the deficit in the numbers of qualified nurses and it endorses the proposal to develop the role of health care support staff to enable them make a greater contribution to care and treatment. The efficient use of the role of qualified nurses and midwives within the wider health care team requires further exploration. (Paragraph 7.11). 5. Conclusion NIPEC looks forward to receiving the outcome of the consultation process. Meanwhile, any correspondence regarding this response should be addressed to:- Mr. Brendan Mc Grath Tel. (028) 90238152 WRITTEN SUBMISSION BY: 9 August 2002 As Chairman of the Omagh and District General Practitioners' Association (approximately 60,000 patients), I felt I should write to your Committee on our Association's behalf. Our views are best illustrated in the two attached letters/statements which were printed in our local press. We should also add that the figures/tables shown in the "Developing Better Services" (eg pages 23 and 24) are factually wrong. Indeed, we can prove this and show that there will be many more people "inaccessible" in Tyrone/Mid Ulster if Enniskillen is the chosen site than there would be South of Lough Erne if Omagh was to be chosen and this is the case even when hospitals across the border are taken into consideration - as they should and must be and as stated by the Minister in the document > paragraph 13, page ix. As a Major Primary Care Association in this area we are keen to meet with the Minister and/or your Committee before 31 October deadline. I go on holiday to USA on 12 August 2002 returning on 27 August 2002 and we are presently in the process of arranging a "Post-Summer Holiday" meeting of Omagh and District GP Association during the first week of September. I look forward to your reply. DR C K DEENY Printed in Local Press on Thursday 4 July 2002 TRUST HAS FAILED OUR PATIENTS - GP'S After a meeting of the Omagh & District General Practitioner's Association on Tuesday 23 June 2002 the following statement has been released: "We the General Practitioners of Omagh & District and responsible
for the primary health care of approximately 60,000 patients, now state publicly
that the Sperrin & Lakeland Trust by:- With acceptable & modern-day quality and standards utmost in our minds we wish also now to state categorically that we will continue to refer & admit our patients to the appropriate hospital(s) and that we will not under any circumstances refer or admit our patients to the proposed new hospital in Enniskillen just to help sustain or make viable this proposed new hospital, which every one of us feels is doomed to failure in the medium to long term. Regardless of pressure from senior medical administrators or indeed politicians, we will always refer our patients to the hospital(s) where they will receive the best possible treatment with the best possible outcome and, in acute situations, we will admit our patients to the appropriate hospital(s) absolutely & entirely with patient safety and survival paramount in our minds. The inaccurate, irresponsible & totally misleading public statements by our trust have our patients believing that we will have an Enhanced Local Hospital in Omagh (24 hour A&E, Coronary Care, Medical Inpatient beds) and a good chance of the one protected elective centre earmarked for West of the Bann. On reading Minister Bairbre de Brun's document "Developing Better Services .", nothing could be further from the truth. Such an Enhanced Local Hospital (as described in the document - paragraph 4.22) will of course undermine the proposed new hospital in Enniskillen and, as stated in this document, this cannot and will not be allowed to happen (paragraph 4.28). Surely, our trust can see this or is this due to incompetence? Or is this a policy of deliberate misinformation? Our patients should not forget that this proposed new hospital needs them as patients for it to be viable and sustainable - the more patients treated in Enniskillen and the less treated in Omagh - the better. Also, our trust needs our patients to accept this document's recommendations in their entirety so as they are implemented. But to encourage our patients to accept this unjust recommendation by having them believe that they will receive medical services, that the trust must surely know cannot be provided, is really unforgivable. Is it not about time that this un-elected group of people that make up our trust are held accountable to the public they represent and are responsible for - our patients - the people of Omagh & District? It is the duty & responsibility of Doctors and Nurses to provide community health care for people and it is the duty & responsibility of trusts to provide community health and social services where our care, as medical professionals, is rendered. In Omagh & District our trust is failing miserably in the provision of these essential & life-saving services. The consensus among our members is that our patients through uncertainty & trepidation and in hope & desperation are asking ourselves, their GP's, to not only "see to" their health care needs (which is our duty) but also to act as their advocate in "looking out for" the very services (the duty of the trust) in which to deliver this care. Having no alternative, it seems, we will try & undertake this added responsibility. Finally, to all of our patients, we believe that your health care needs and rights will be denied you if this recommendation is implemented and we urge you not to accept it. Why should you accept 2nd or, more correctly, 3rd rate health services? We promise now that we, your General Practitioners in Omagh & District, will make every effort and explore every avenue to secure the same standard & quality of health care services for you as provided for the rest of the Northern Ireland population." DR KIERAN DEENY Printed in Local Press on Thursday 1 August 2002 THE CASE FOR AN OMAGH SITE - NOW MUCH STRONGER Everyone that I have talked to that has read Bairbre de Brun's document can clearly see that a so-called Enhanced Local Hospital (ELH), as described, cannot develop or be allowed to develop in Omagh. Sperrin Lakeland Trust have publicly refuted that they have been misleading the public by their statements? These are some of the words made public by Mr Richard Scott, Chairman of our (?) local trust: "to identify the range of services to be provided at the new hospital in Enniskillen and at the enhanced local hospital in Omagh." "An immediate priority for us will be to continue to manage and maintain existing services in Omagh and Enniskillen until the new and the enhanced local hospital come into operation." So sure, it seems, that this important matter is already "done & dusted" Mr Scott also states: "We strongly believe that the enhanced local hospital in Omagh must be developed first"!! In our statement (Omagh & District GP Association) of Tuesday 23 June 2002 we posed an either/or question, ie either these statements were made to deliberately misinform people or they were made as a result of incompetence on the part of the trust. I know our public are well able to make up their own minds on this but, in either case, it is a rather serious & worrying situation given the privileged position that Mr Scott holds as Chairman of a body of people "trusted" to provide vital health care services for all of us. It should also be stated that there are a lot of very positive, sensible & forward - thinking proposals in Bairbre de Brun's document. To dismantle these ever increasing layers of bureaucracy is one of them. We have a growing administrative monster in the NHS which "leech-like" is draining away whatever little financial resources are provided and all at the expense of the sick, suffering & dying patients. Another is in fact the whole concept of an ELH which I now believe is part of the overall solution. An other, as far as we are concerned locally, is the much publicised paragraph 4.28. Looking at the whole matter more closely 4.28 is not to be in some way despised - it is actually an extremely important paragraph because in it, I believe, lies the answer. By closing the hospitals in Dungannon & Magherafelt, a much larger population mass will become part of the problem and so therefore, it is only right & just, that they should become part of the solution. Folk in Cookstown and west of it would use an Acute hospital in Omagh being 26 miles away but with no towns, villages or even a traffic-light in between. Similarly, patients in Dungannon and west of it would travel to Omagh rather than having to virtually queue for hours trying to get in to Craigavon. Paragraph 4.28 states: "The model will need to demonstrate that any proposals are viable, sustainable and will not undermine the new acute hospital in the area." Because of its very small population catchment area (preventing viability & sustainability) and the fact that an ELH in Omagh would certainly undermine it, the present proposal with Enniskillen as the new acute hospital will fail on all 3 counts. However, because of a much larger area available to Omagh (attracting patients from East, South, North & West of it) a new Acute hospital in Omagh would be both viable & sustainable and an ELH in Enniskillen would not undermine it (again because of Omagh's large population catchment area). This proposal (an Acute hospital in Omagh and an ELH in Enniskillen) would meet all 3 criteria & I firmly believe that it is the only fair and just solution for all of us in this part of Ulster. Indeed, if paragraph 4.28 is read without any preconceived ideas, it literally is pointing to an Omagh site for the new Acute hospital. I believe now that, largely due to Department of Health guidelines and Minister De Brun herself in ceasing acute services in Magherafelt & Dungannon and writing in paragraph 4.28, the evidence for an Omagh site as an Acute hospital serving the people of the South-West of our province (extending into Mid-Ulster & helping out beleaguered Craigavon) is now even stronger and, indeed, it is becoming harder & harder to argue against it. DR KIERAN DEENY GP WRITTEN SUBMISSION BY VB/23/3 9 September 2002 DEVELOPING BETTER SERVICES - MODERNISING HOSPITALS I refer to your letter of 26th July 2002 seeking views on the Department's proposals. I am responding to you on behalf of:
1.0 Health Committee Scrutiny Role We welcome the decision by the Health Committee to scrutinise the Department's proposals. We believe that the failure of the Committee to seriously examine the Acute Hospitals Review Group Report (the Hayes Report) and challenge the rationale on which the Hayes recommendations were based, has contributed to the flawed thinking and lack of an evidence-based approach which is evident in the Department's proposals. We now consider that the Health Committee must carry out a root and branch examination of the Department's proposals, taking into account the earlier recommendations of the Hayes Review and the wider government policy context in which these proposals sit. 2.0 Impact on the Rural West (Tyrone/Fermanagh) You will appreciate that the Department's proposals on the future profile of acute hospital services will have a particular impact on the Rural West (Tyrone/Fermanagh). In these circumstances, I request that we have the opportunity to give oral evidence to the Health Committee to allow us to expand the arguments presented in this paper and present supporting evidence and information. Throughout the remainder of this paper, I have provided an initial response to the issues highlighted in your letter of 26th July 2002. You will appreciate that it is not possible to consider the key elements in the Department's proposals without access to the information which was used to support the conclusions reached. It is regrettable that three months into this consultation process, the information promised by the Department relating to access times has still not been made available. It is now probable, taking into account the limited resources available and the complexity of the issue that we will not be in a position to provide a considered response to the consultation by the closing date of 31st October 2002. This should be an issue of significant concern to your Committee. 3.0 Refocusing Acute Services on 9 Sites The 'Developing Better Services' proposals by the Department represent a major policy initiative which will shape the provision of acute hospital services for the next 50-60 years - we must, therefore, get it right. It is clear that in the past we have not got it right and major investments have been made in the wrong places. The Department seems committed to compounding past failures by investing up to £100m of public money in a new acute hospital on an Enniskillen site - a proposition which is unsustainable in the longer term and will not provide equitable, high quality, accessible services to which the people of the Rural West (Tyrone/Fermanagh) are entitled. This results from the failure of the Department to adopt objective and evidence based criteria (Appendix 1) and to take proper account of the opportunity to develop a seamless system of cross-border health care to the mutual benefit of communities north and south of the border. In response to an earlier report by the Acute Hospitals Review Group (the Hayes Report), the Hospital Campaign for the Rural West commissioned an independent assessment of the recommendations by the internationally recognised York Health Economics Consortium. The York Report, as it became known, clearly identified that an objective consideration of all of the evidence clearly identified that Omagh was the right location for a new acute hospital to serve the needs of the people of the Rural West (Tyrone/ Fermanagh). A copy of the report is attached for your consideration (Appendix 2). In such circumstances, we cannot endorse the proposal by the Department to focus services on 9 sites including a site in or around Enniskillen. The Hospital system which emerges from this consultation is one that will be with us for at least the next half century. It is one where traditional provision in Omagh, Dungannon, Strabane and Magherafelt - all major centres in the West - will have been removed. The new improved provision has to reflect the geography of the West and be located at its centre, not on its periphery. 4.0 The Local Hospital It is important that the range of services included in 4.16 of the 'Developing Better Services' document are available within easy reach of all communities. However, it is totally misleading to refer to such a facility as a 'local hospital'. It is reasonable for the general public to expect that if they arrive at a 'local hospital' in the case of an emergency, that it will be open and staffed at an appropriate level. That is certainly not the case in the 'local hospital' concept proposed by the Department - a concept which is wholly unproven in a rural context such as that found in the Rural West. The Department also proposes an enhanced local hospital status for the Downe and has requested the Western Health and Social Services Board to develop a model for enhanced services at both the Tyrone County Hospital and the Erne Hospital sites, within the limitation that such enhanced services do not undermine the new acute hospital in the area. We have serious concerns regarding the viability of the enhanced local hospital concept and would request the Health Committee of the Assembly to establish the viability and sustainability of the concept. 5.0 Enhancement of Primary Care Primary care teams at a local level are the first point of contact and play an increasingly important role in sustaining vulnerable and chronically ill people in the community and managing their access to appropriate levels of acute care. The role and funding of primary care, particularly taking account of the development of local Health and Social Care Groups, has been given totally inadequate attention in the Department's Consultation document. In fact, its consideration occupies half a page (4.0-4.12) in a 62 page document and the Department is totally unspecific in its proposals as to how it intends to enhance Primary Care. Additionally, Department officials have confirmed that they have not taken into account GP referral patterns or evidence in 'patient choice' when determining the future profile of the acute hospital provision. The failure of the Department to consider such key evidence has resulted in the wrong conclusions being reached on the siting of a new acute hospital in the Rural West. It is essential that the Health Committee clearly establishes the Department's proposals for primary care provision including the costing and funding of such proposals. 6.0 Improved Communication and IT Links We must ensure that any new arrangements are resourced in terms of highly trained staff, modern buildings and equipment and state of the art technology and communication systems, to provide people in Northern Ireland with health services comparable to the best in Europe. Reference is then made to the importance of such systems within the concept of managed clinical networks. The concept of managed clinical networks is still in its infancy, untried and untested, and while in theory it may provide the solution to meeting the access difficulties of rural communities to acute hospital services, it must be approached with considerable caution - after all the Department has clearly indicated that the Sperrin Lakeland Trust one hospital, two sites model, which included many of the features of a managed clinical network, has failed. 7.0 Supporting Rural Communities It is clear that the Department of Health, Social Services and Public Safety has based its proposals for this future profile of hospital services on 'access within the golden hour'. This is a highly questionable foundation on which to build a pattern of acute hospital provision designed to provide safe, high quality and sustainable services over the next 50-60 years. The Hospital Campaign for the Rural West will provide evidence which will undermine the very basis on which the Department has constructed its model for provision. It is, however, accepted that early action in emergency care situations, by getting expert attention to patients, is effective and it is accepted that quality ambulance services and other forms of intervention including those proposed in the 'Developing Better Services' document, can result in improved outcomes. It must also be recognised that such services can not be limited to rural areas. They must be accessible in our towns and cities and could, if properly designed and adequately resourced, have a significant impact as part of balanced health care provision. 8.0 Midwife Led Maternity Units This is not the first time that such a proposal has been tabled. When maternity services were withdrawn from the Tyrone County Hospital (in the early 1990s) and consolidated on the Erne site, it was proposed that action would be taken to develop midwife led maternity services. However, there was inadequate commitment by the Department, Board and Trust to the concept and the proposal never materialised. It is difficult to see the current proposal as anything more than a repeat of this earlier commitment and a possible attempt to provide a 'sop' to the withdrawal of maternity services from the Mid Ulster Hospital in Magherafelt. This belief is reinforced by the fact that the Department has failed to identify a site for a midwife led unit either in the east or the west of the province. In examining maternity services, the Health Committee should also look closely at the issue of sustainability of quality services and the issue of 'patient choice'. There is very clear evidence in Tyrone/Fermanagh that women have clearly voted with their feet and have chosen to have their babies in Altnagelvin and Craigavon rather than the Erne. As a result, the Erne is operating at a level of approximately 50% of the 2000 births recommended as necessary to provide a sustainable service. This is further clear evidence that acute hospital services based in a new acute hospital in or around Enniskillen will not be sustainable in the longer term. 9.0 Planned Elective Centres The Department, in 'Developing Better Services', proposes two new elective centres; one at the Lagan Valley Hospital and one west of the Bann. Regrettably, the Department failed to identify a location for the new centre in the West, leading many to conclude that the Department was cynically playing vulnerable communities in Tyrone, Fermanagh and South Derry off against each other. There is a need for a serious evidence based approach to determine the right pattern of service provision for the people in the Rural West. Current proposals will result in a 'black hole' in acute service provision in the heart of rural Northern Ireland with further reinforcement of service provision around the periphery. The Hospital Campaign for the Rural West is not interested in developing an 'Omagh versus anybody' agenda; our sole aim is to achieve, for the people of Tyrone and Fermanagh, health services provision which is appropriate to need and sustainable into the future. The Health Committee must examine closely the approach being adopted by the Department and request the Department, as a matter of urgency, to clarify its proposals to ensure that any consultation is meaningful. 10.0 Enhanced Co-operation between Northern Ireland and Republic of Ireland The Department, in developing its consultation proposals, has singularly failed to take proper account of the scope for hospitals on each side of the border to complement each other in the provision of services. Only now, three months after publishing its proposals, is the Department proposing to access the scope for hospitals in Cavan and Sligo to complement a hospital in Omagh in the provision of services for dispersed populations in south and west Fermanagh. Additionally, there is concern that the Department is continuing to 'move the goalposts' in this matter. Initially, Hayes rejected the use of Sligo General Hospital on the basis that the condition of the road from Blacklion to Sligo was such that it involved journey times in excess of one hour. Now the Department has abandoned that argument and replaced it with a requirement that these hospitals will be required to provide services of the level of Craigavon or Antrim, well in excess of the level of service which the Department itself proposes for the new acute Hospital in Enniskillen. 11.0 Review of Structures You have indicated that the Health Committee wishes to concentrate on the proposed changes to acute services at this stage. It is important that your Committee carefully considers the implications of the options included in 'Developing Better Services' for new administrative structures. There is also clear evidence of a historical imbalance and eastern bias in Northern Ireland's acute hospital system, which lies mainly within the Greater Belfast area. Any new arrangements must address this problem and the need for the west to have its own discrete arrangements for health care management and planning. 12.0 The Wider Policy Context Public services must be organised and delivered on an equitable basis. The Department has included a preliminary assessment of equality implications of proposals for 9 Acute Hospitals in its consultation proposals. This assessment purports to analyse the impact of proposals for 9 acute hospitals on the designated equality groupings. However, the assessment and the proposals fail to address the wider policy context as spelled out in the Programme for Government and the Regional Development Strategy. In addition, Targeting Social Need has to become much more than just empty rhetoric. It is clear that the Department's proposal to locate a new acute hospital in Enniskillen will result in reducing access to services for those communities which already suffer the highest levels of deprivation in Northern Ireland. This is perverse and illogical. 13.0 The Way Forward The Department's proposals are illogical and are not evidence based. The Health Committee failed to examine the Hayes recommendations and as a result the Department has developed its own proposals with no serious debate on the issue. The Committee must not repeat that mistake and must ensure that the proposals are rigorously tested against a range of appropriate and evidence based criteria including quality, accessibility, sustainability, value for money and socio economic considerations. I look forward to having the opportunity to meet your Committee to further consider these matters. D McSORLEY DEVELOPING BETTER SERVICES - MODERNISING HOSPITALS The Hospital Campaign for the Rural West believes that the Minister's proposals are fundamentally flawed and not sufficiently evidence based. Specifically:
WRITTEN SUBMISSION BY: 9 August 2002 I refer to your invitation of 26 July 2002 to comment on the Department of Health's paper "Developing Better Services - Modernising Hospitals". The RDC has recently produced a report "A Picture of Rural Change: 2002" which is our first attempt to produce a comprehensive Rural Baseline for Northern Ireland (I have enclosed a copy of the report). The report identifies five themes of which two would be particularly relevant to your consultation process. Most relevant would be theme three, Service Provision, which concludes that the presence or absence of any service greatly affects the sustainability of a local community and as an increasing number of services become centralised to improve cost efficiencies, there is a subsequent increased requirement for population mobility. Our report presents spatial data on the location of GP practices in relation to settlement size (map 3.3) which suggests that significant portions of the rural population must travel larger distances (than their urban counterparts) to their GP surgery. This contrasts with the relatively good levels of GP provision in rural areas when considering the ratio of persons to GP practices (map 3.9). Additionally in theme four Social Wellbeing, we conclude that rural areas are as prone if not more prone to key health problems as their urban counterparts, however the irregular patterns of identified cases of heart disease (map 4.5) emphasis that provision of health and social services is a complex issue which requires detailed assessment of need at local level. NIGEL FLYNN WRITTEN SUBMISSION BY: 9 August 2002 I refer to your letter of 26 July 2002. We wish to comment as follows:
Having the right spectrum of services across hospital and community will help ensure that acute hospital care that is sensitive and appropriate is available for those who need it. Continuation of the present system will, in our view, continue to give a poor quality service and put people at risk of hospital acquired infection as well as adversely affecting their cognitive state.
The development of these Centres will require a considerable investment of finance.
R S FERGUSON WRITTEN SUBMISSION BY: 3 September 2002 I refer to your letter dated 26 July 2002 inviting the Trust's comments on Minister De Bruin's Developing Better Services - Modernising Hospitals document, for the health care committee's consideration. Subsequent to receiving your correspondence on 30 July 2002 the Minister formally advised Trusts of her intention to extend her consultation period to the 31 October 2002. In view of this extended consultation period the Trust is taking the opportunity for some extended examination of the proposals in the Minister's document before concluding its deliberations and making a formal response in advance of the end of October deadline. In this regard therefore, given the deadline that you have set for 9 September, it is not possible at this stage to share with the Health Care Committee the Trust's formal position. However we did feel that it may be of interest to the committee to be advised of a range of specific pieces of work which have been commissioned by the Trusts Acute Services Steering Group. These pieces of work are designed to provide an analysis of those recommendations and proposals within Developing Better Services which particularly impinge upon services here in the Southwest. I have spoken with David Gordon of your office who is aware of the level at which we are able to respond at this stage. Before dealing with the aforementioned work in progress specifically, it may be helpful to share with the Committee the Trust's initial reflections and early response to the receipt of the Minister's report. Prior to the formal launch, the Trust Board had taken the opportunity, through a workshop, to consider the possible issues that may arise dependent upon the Minister's decision particularly in respect of the issues surrounding the acute hospital in the Southwest. In essence the Trust response reinforced the strategy adopted by us at an earlier stage which emphasised the need for an early decision; the need to recognise the importance of, and secure, the stability of existing services in the interim; the need to secure investment in staff and equipment; the need to build public confidence; and the need to begin to prepare for future changes in configuration of service provision. The Trust welcomed the Minister's paper as a positive step towards concluding the long and much debated issue of the new acute hospital for the Southwest within the Trusts area. Whilst the Trust will be taking the opportunity to comment more generally on the Minister's proposals in their totality, the focus for our initial analysis has centred around four particular aspects of the Minister's proposals. These are: the profile of services for the proposed acute hospital in the Southwest, the potential for, and profile of services within a local enhanced hospital; the potential to bid for the development of a protected elective centre for the west of the province; and the potential to consider the development of a pilot midwife led unit. Under the auspices of the Trust's Acute Services Steering Group, which is chaired by the Chief Executive and involves clinicians and other senior Managers, four small working groups were established to develop the Trusts thinking in respect of the aforementioned models. This work is being taking forward in an inclusive manner and has been subject to further consideration by the Trust Board members at a workshop organised for 10 September 2002. The Minister has requested the Western Board to test the model for the enhanced local hospital at either Tyrone County Hospital, Omagh or Erne Hospital, Enniskillen. Our clinical staff are directly involved in developing this model which the Western Board are sharing with locally elected representatives. As I said at the outset given the extended consultation period it is not possible for me to provide you with a final position in respect of the issues cited within your correspondence at this point. I trust however that this brief letter gives you a sense of the focus of our attention during this earlier stage of our deliberations. Certainly once the Trust Board is in a position to advise of its formal position I would be very happy to share this with the Committee and indeed, if it is of assistance would be happy to facilitate a meeting with key officers within the Trust and committee members. MR HUGH MILLS WRITTEN SUBMISSION BY: Ref: 100-1-1 4 October 2002 DEVELOPING BETTER SERVICES We appreciate the invitation to submit comments about this consultation document to the Health Committee. On behalf of our Board of Directors, I have enclosed a paper setting out our views and suggestions. Like many others, we continue to be deeply concerned about the problems of ill health within our society, and the problems faced by our Health and Social Services in addressing those needs. We need to press on quickly to modernise our hospital services. We fully agree with the emphasis placed on developing clinical networks, linking acute hospital services across sites, and spanning primary and secondary care. Though some services may need to be concentrated, other services can be decentralised and made more locally accessible. We have a concern, however, that the constraints of the European Working Time Directive may make it impractical to maintain 24 hour emergency services at all the hospital sites proposed in Developing Better Services; for this reason, we are recommending that a careful analysis of the potential impact of the Working Time Directive be undertaken while finalising the model for hospital services. In the attached commentary, we have responded to some specific issues relating to the future model for hospital services. There are a number of areas where service reconfiguration within Belfast has been proposed, and we would ask that the clinical, financial and social implications of all available options be taken into account in reaching a decision. For example, in regard to the relocation of plastic and maxillo-facial surgery (currently at the Ulster Hospital), there are strong clinical reasons for considering the Royal Hospitals as a possible future site - an option which has not yet been given adequate consideration. The current organisational structure of the Health and Personal Social Services is largely a legacy of the internal market; it is not best suited to the delivery of integrated services through clinical networks, based on the principle of collaborative working. We will welcome the early introduction of a new structure, reflecting service needs over the next decade. We need to move to a form of service commissioning based on the development and implementation of health improvement plans through collaboration, avoiding reliance on the bilateral contracts or agreements which characterised the inconsistencies of the internal market. There is an important role for a new regional health authority, in leading this process and in fostering the development of managed clinical networks. Substantial investment in our health services is long overdue, both in terms of staff and infrastructure, and the proposed increase in resources is very welcome. The total requirements for resources may well prove to be higher than anticipated in Developing Better Services - other factors such as our ageing population, and the implementation of measures in response to the European Working Time Directive, will create additional demands. At the same time, we need to introduce more rigorous mechanisms for performance management, to ensure resources are used efficiently and consistently to good effect throughout the Health and Personal Social Services. I hope these comments are helpful to the Committee. If you would like us to comment further on specific issues, we will of course be pleased to do so. Evan Bates THE ROYAL HOSPITALS AND DENTAL HOSPITAL A COMMENTARY ON "DEVELOPING BETTER SERVICES: MODERNISING HOSPITALS AND REFORMING STRUCTURES" For convenience, we have cross-referenced our comments to the structure of the Developing Better Services report. 1. INTRODUCTION We appreciate the opportunity to make comment on the proposals set out in Developing Better Services. 2. THE NEED FOR CHANGE Many of the points made in this chapter resonate with us. We are very conscious of the increasing pressures on health services, the delays that many patients face when receiving treatment, and the vulnerable nature of many clinical services. The chapter could be extended in certain respects: 1) We need to tackle the persistent and probably increasing health inequalities within our society - developing a wider package of measures to improve health standards, managing chronic ill health more effectively (and thereby reducing the likelihood of acute crises), and improving access to acute care when necessary. 2) Developing Better Services did not identify how quickly change will be necessary. We have no doubt that changes are needed urgently:
3) Developing Better Services described the role of information and communications technology in positive terms. It does not point out, however, that the Health and Personal Social Services have been comparatively slow to introduce new information and communications technology - we have a much weaker technological base than neighbouring regions and countries. Major changes to the way we introduce, manage and use information and communications technology have become essential. We must address these matters with alacrity - we will very quickly find that the current service arrangements are no longer workable. 3. WHAT KIND OF CHANGE? Developing Better Services recognised the need for radical reshaping of acute hospital services. Some hospital services - particularly those needed on an emergency basis - will inevitably become more centralised, but it will be possible to make other services more locally accessible - ideally in a patients home or in community health and treatment centres. We fully agree about the need to develop managed clinical networks - linking acute hospital services across sites, and spanning primary and secondary care. Effective and adequately resourced clinical networks will enable patients to receive seamless care, to consistently high standards throughout the region. Integration of services spanning primary and secondary care will be of most advantage to patients with a chronic disease - probably half of all elderly people will have one serious chronic disease; perhaps a fifth of all elderly people will have two or more chronic diseases. Issues of accountability (both financial and clinical) at managed clinical network level have yet to be resolved in the UK context. It is interesting that Kaiser Permanente, one of the largest and most successful providers of health care in the United States of America, have found it helpful to bring primary and secondary care doctors into common teams, with shared resources. There could be benefit, pending the wider reform of organisational structures within the Health and Personal Social Services, from identifying clinical leaders for a number of managed clinical networks, with roles extending across both primary and secondary care. The shape of acute services will need to alter substantially during the next decade. The European Working Time Directive, skill shortages, and likely changes in medical training arrangements, will oblige us both to develop new staff roles and to adopt new ways of working within hospitals (particularly in the way that we provide emergency and other night-time services). 4. A MODEL FOR FUTURE HOSPITAL SERVICES We are eager that a new model for hospital services be implemented as soon as possible. We look forward to new opportunities for working in partnership with others to improve health services across wider networks. We endorse many of the principles and concur with many of the proposals in this chapter. We agree that there must be a network of acute and local hospitals, and better linkages with primary care. We have a concern, however, that the constraints of the European Working Time Directive may make it impractical to sustain 24 hour emergency services at all the hospital sites proposed in Developing Better Services. As a minimum, we strongly recommend that a careful analysis of the potential impact of the Working Time Directive be undertaken while finalising the model for future hospital services. We note the proposal to develop a number of hospitals as local hospitals. Focusing on Belfast, there are severe capacity problems within the acute sector. We need to find mechanisms that will allow us to reconfigure clinical services, quickly, while maintaining or expanding overall capacity. The Mater Hospital is close to areas of severe health and social deprivation, and we would be particularly keen that a substantial range of acute services, such as emergency medical services and elective surgery, should continue at that site. Turning to some specific points: 1) The success of a new model for hospital services more focused on working together within networks will depend not only on the commitment and enthusiasm of staff, but also on the provision of appropriate infrastructure. We will need to be able to share information, and to transfer patients in safety between sites. Information and communications technology (and telemedicine) services within the health service require extensive reorganisation and investment - beyond the extent envisaged in the recent consultation document on the regional information and communications technology strategy. In terms of patient transfer, specialist patient retrieval teams are needed for babies and children, and the adult service requires further strengthening. 2) Maternity services must be safe and of high quality, offering women real choice about their care. The development of a new centralised maternity hospital in Belfast is long overdue. We are convinced that for clinical and social reasons the Royal Hospitals site will be the ideal location for the new hospital. If this is the eventual decision, we will be eager to develop maternity services as part of a wider, accessible network. We would welcome the opportunity to participate in the pilot of midwife-led stand alone units, particularly in relation to the development of protocols, and support arrangements. 3) Developing Better Services proposed the relocation of a number of Belfast-based hospital specialties in accordance with earlier recommendations by the Eastern Health and Social Services Board. The Eastern Board had sought the transfer of several services to Belfast City Hospital, driven by a concern about the cost-effective use of expensive infrastructure at that hospital. We agree that sometimes we must accept a suboptimal solution to achieve better overall use of resources, but the merits (and costs) of alternative options still need to be explored. In regard to the relocation of plastic surgery and maxillo-facial surgery (currently at the Ulster Hospital), and the centralisation of adult dermatology and ear, nose and throat surgery, we anticipate that there would be little to choose between the Royal Hospitals and Belfast City Hospital sites, in cost terms; but in clinical terms the Royal Hospitals would have significant advantages:
genito-urinary medicine, paediatrics, oral medicine and infectious diseases (including HIV/AIDS) are available only at the Royal Hospitals. We provide a full service for complicated skin cancers, with input from dermatosurgery, plastic surgery and oncology. This analysis by the Royal College of Physicians (published after the Eastern Health and Social Services Board recommendations) reinforces the case for centralising dermatology at the Royal Hospitals. Dermatology is well established here; transfer to the Belfast City Hospital would weaken clinical linkages and inhibit network development.
Drawing on our mixed experiences of the project during the 1990's to reconfigure services between the central Belfast hospitals, we have recommended on several occasions that these hospitals should be brought into a single organisation. This would create an opportunity to develop a commonly shared and coherent vision of how services can best be provided in future. The starting point would be to create larger clinical teams that span existing hospital sites. The outcome could involve proposals for a radical reconfiguration of clinical services across the central Belfast hospitals - a reconfiguration which might for the first time gain widespread support from both staff and local communities. We continue to favour this approach, or indeed any approach which would explore the clinical, financial and social implications of all available options. 4) We believe that there is considerable potential for working in partnership on a North/South basis, not only in border areas, but also at a regional level. We have formal linkages with two hospitals (the Beaumont Hospital and Castlebar General Hospital/Western Health Board), and we are confident that collaboration will be of mutual benefit. 5. THE NEED FOR CHANGE IN STRUCTURES At other occasions, we have emphasised that major organisational changes are very disruptive in the short-term, and that the full benefits (linked with professional staff training and capital development programmes) may only emerge over a ten year period. The current structure of the Health and Personal Social Services is largely a legacy of the internal market; it is not best suited to the delivery of integrated services through clinical networks, based on the principle of collaborative working. We will welcome the early introduction of a new structure, reflecting likely service needs over the next decade. On specific points: 1) We welcome the development of local health and social care groups as a mechanism for increasing sensitivity to local service issues. Commissioning should focus on assessing local needs and priorities, within a wider planning and service delivery framework - "commissioning" must not become "contracting" under another name, reliant on bilateral (and potentially inconsistent) agreements between commissioners and health care providers. The best mechanism for effective communication is through full involvement of local groups and acute service providers in regional and sub-regional health improvement planning. 2) We support the development of a regional health authority, at arms length from the Department of Health, Social Services and Public Safety. While the focus would primarily be strategic, it seems inevitable that the authority would also have a role in approving operational plans and monitoring operational performance - not least because resource allocations impact directly on operational services. From a public perspective, the authority would have little credibility if it seemed to disassociate itself from major operational issues. The authority would provide the channel for empowering managed clinical networks spanning other Health and Personal Social Service organisations, and for ensuring their accountability. 3) We believe that a strong regional authority, working with local health and social care groups, would obviate the need for the current tier of four health boards. 4) The responsibilities of Trusts will gradually be supplanted by developing clinical networks. For several years, we have encouraged the merger of the Royal Hospitals and Belfast City Hospital, either as part of a wider group of hospitals within Belfast, or as part of a wider health system spanning primary and secondary care. We believe that such a merger, though initially disruptive, could create many opportunities for realigning and strengthening clinical services, facilitating network development. 5) We agree that the four Health and Social Service Councils should be replaced by a single statutory Health and Personal Social Services consumer body, complementing the establishment of a regional health authority. 6. EQUALITY The analysis in Developing Better Services is narrowly focused on the location of a new acute hospital in the southwest. Clearly there are many health and social inequalities within our society, and our health and social services have an important role in tackling the causes and consequences of these inequalities. However, further delays in modernising our hospitals and reforming organisational structures will also have detrimental consequences, particularly for those people in greatest need and with few resources. 7. RESOURCES AND TIMING The proposed increases in resources for the Health and Personal Social Services are very welcome, and long overdue. We appreciate the difficulties in projecting the need for resources, and the impossibility of any guarantee that the resources will be made available. Presumably the total requirement for additional resources for the Health and Personal Social Services will be higher - perhaps substantially so - than indicated in Developing Better Services. Other factors such as our ageing population, and the implementation of measures in response to the European Working Time Directive, will also have substantial resource implications. The implementation of Agenda for Change could lead to a significant step increase in staff costs. Additional costs will also arise during periods of transition, both in clinical areas and in management (particularly for services such as human resource management). At the same time, we need to introduce more robust mechanisms for performance management, to ensure resources are used efficiently and consistently to good effect throughout the Health and Personal Social Services. WRITTEN SUBMISSION BY DEVELOPING BETTER SERVICES - MODERNISING HOSPITALS Introduction The Ulster Community and Hospitals Trust welcomes this opportunity to offer views in relation to the planning, organisation and delivery of Health and Social Services in Northern Ireland in the 21st Century. The involvement of the Health Committee is extremely welcome in terms of the careful consideration which needs to be given to the forward management and organisation of Health and Social Services. There is full acceptance that the Developing Better Services - Modernising Hospitals consultation presents an important opportunity to ensure that Hospital and related community Health and Social Services and Primary Care provision are given priority in political debate and discussion. Background to Better Services The Hayes Report on Acute Hospitals created a framework to radically examine how acute hospital services are delivered. Managed clinical networks and well-managed linkages with primary care services were viewed by Maurice Hayes and his team as elements crucial to a modern Health Service. However, the later document, Developing Better Services, distils many of the key issues raised by Hayes very much in a hospital-only context with clear and explicit emphasis on the acute sector. Whilst acknowledging that the subject in hand is a future hospitals framework in Northern Ireland, hospitals themselves cannot be viewed in isolation from the extra-mural service structures which already exist in primary care and in the community, extra-mural services which need further development in order to compliment and fundamentally deliver the acute sector agenda. To this extent Developing Better Services has imposed limitations upon itself. Health, Social (Community) and Hospital Services have been developed to a high level of interdependence in the region, driven in particular by the extremely successful People First initiative launched in 1993. Today the position is that there is close fusion particularly within combined acute/community Trusts in terms of the actual, on the ground management of pathway services for patients. Integrated Health and Social Services Adjustments, changes and modifications to acute hospitals will impact directly and indirectly on related Health and Social Services for patients. It is to be regretted that this critical actuality of service integration is not accorded the prominence it deserves; the effect, intended or not, is to give the perception that integrated delivery of services is coincidental to overall care rather than crucial to the coherent delivery of modern Health and Social Services. It is felt that much more could be achieved by amplifying the uniquely integrated structure of Health and Social Services in Northern Ireland rather than concentrating almost exclusively on acute hospital services, with the subsequent inclusion of other allied services as a seeming after thought. Northern Ireland's integrated Health and Social Services structure should be viewed as a unique strength to be developed further rather than be viewed as a potential impediment to progress and service modernisation. Our integrated health and social services structure is an enabler of care pathways and provides solution to difficulties in delivering good quality services. As such the concept is now being replicated in many other parts of the UK where, despite different agencies, unitary management arrangements are being established to provide for smooth flow and seamlessness. Integrated delivery systems would seem to be the basis of a wider UK health modernisation agenda. Much more could have been achieved in terms of analysis and debate if appropriate attention had been afforded to the critical and inextricable linkages between acute hospital services and allied community Health and Personal Social Services. Both the Hayes Report and Developing Better Services are substantially incomplete in that they fail to embrace fully the benefits of integration of Health and Social Services in Northern Ireland. Acute Hospital Services The proposals within Developing Better Services reflect those set out in the earlier Hayes Report. It is considered that the concentration of major acute hospital services on nine sites is an understandable and predictable response to an analysis of service provision which has been in place for more than ten years. To some extent the proposals contained in the Developing Better Services document could be construed as ten year old solutions to issues raised in the early 1990's. There would appear to be an emphasis on acute hospital services inadvertently detached from other Health and Primary Care Services. This analysis in a vacuum, it appears, has resulted in the proposed new model for hospital services. Patently, hospitals detached from localities and naturally occurring communities would not be consistent with a more up-to-date analysis of health care and health care provision. It is accepted that the principle of developing acute hospital services by ensuring that there is a concentration of expertise at specific sites is not contested. Increasing clinical effectiveness linked to expertise, quality standards and performance is viewed as the correct direction of travel in delivering acute hospital services. The model of nine major hospitals is recognised as a functional response premised on as noted previously, a historical rather than current analysis of Health and Health care. Increased specialisation, higher clinical standards, working time directive and the new consultant contract would apparently question the validity of a nine hospital model. The sustainability of nine hospitals has to be a factor for careful consideration. The momentum of clinical change and service regulation may result, in the long term, in the number of major acute hospitals having to be re-visited. The Trust would acknowledge that the thrust of proposed acute hospital development is consistent with the emerging health agenda premised on the current needs of the Northern Ireland population. Accessibility to acute provision in geographical terms is a vital element in the consultation document. This position is endorsed by the Trust with the qualification that the principle of accessibility to hospital services should be applied to all Health and Social Care Services. The Committee should note that there is no reference to acute Mental Health Services in the consultation document. Mental Health Services, particularly acute in-patient provision, is a critical element of acute hospital care. The absence of Mental Health Services from the consultation document should not allow Mental Health Services to be overlooked in the proposed modernisation of hospital services. Local Hospitals The envisaged model of local hospitals merits further analysis. The idea of local hospitals forming a framework of provision, and a bridge to acute services, is desirable. However, in contrast with the more detailed treatment of major acute hospitals it is not clear what precisely should be included in a "local hospital". Local hospitals and enhanced local hospitals networked with community health and social care provision is an important construct? in the development of the continuum of care. There is scope, however, in the context of networked services to develop a more precise understanding of the sort of bridge which needs to established between primary care and secondary care services. To that extent local hospitals are likely to and should vary substantially in profile based on specific locality needs. Earlier interventions, increased community support with increased support from and for general practice, will make the particular vision of a local hospital more a reality. The linkage between local hospitals and acute hospitals, premised on a robust model of Community Care and Primary Care, is patently desirable. Funding Community and Primary Care Services adequately and consistently would allow appropriate services to be externalised from acute hospitals. A cautionary note which must attach to the central underlying premise in Developing Better Services is that all other support services - Primary Care, Community Health and Social Services - will need to be funded and developed concomitantly for the envisaged model of hospital services to operate effectively. Only by retaining and further improving the productive synergy between primary and secondary care sectors can secondary care successfully deliver the acute hospital agenda. Primary Care The importance of Primary Care Services to the envisaged integrated system of Health and Social Care Services, incorporating the proposed model of acute hospital services cannot be overstated. Critical to the provision of good secondary care services is primary care. The emphasis on acute provision has not provided for the same attention to be given to Primary Care Services. The development of LHSCGs will contribute to the comprehensive provision of primary care services. Essentially, the development of robust links with secondary care will be contingent on local networks and primary care provision being adequately resourced. Resourcing adequately the primary care services will ensure that only those people with secondary care needs will arrive at acute hospitals. At present, acute hospitals have to pick up work which could have been addressed outside an acute setting. Further, the involvement and commitment of primary care, and general practice in particular, is essential to the delivery of effective local hospital services. Improved Information and Communications Technology The importance of ICT in the provision of Health and Personal Social Services cannot be overstated. Central to developing better services with improved outcomes for patients and carers is the provision of ICT which delivers robust Electronic Care Records and Electronic Care Communication. Patently, existing systems within HPSS are, in many instances, past their useful life. This Trust fully accepts the position set out in the consultation paper in relation to ICT development and would add that a comprehensive system, as envisaged in the HPSS ICT Strategy, requires investment. This investment itself should not be viewed as being in any way separate to good clinical care and thus subsumed under an administrative initiative. It needs to be seen in the light of the services to be delivered - essential to promoting and sustaining the quality and effectiveness of patient care. There is a recognition that Health and Social Care processes should be simplified and that ICT should make available to patients and their carers relevant and timely information. Vital to an enhanced ICT Strategy is the question of staff training and development. Similarly, the dissemination of and access to "E-Information" is viewed as essential in developing better patient and/or client care. To reiterate, ICT is essential in the design and delivery of HPSS. Funding for ICT should be an agreed priority. Supporting Rural Communities The consultation paper recognises the complexity of delivering good Health and Social Care Services to many of the dispersed populations and rural communities in Northern Ireland. Measures to support the provision of Hospital Services to rural communities are considered to be essential, particularly in terms of innovative planning and the provision of improved ambulance and transport services. Perhaps understated in the consultation document is the importance of good access to Primary Care and Community Health and Care Services, which are inextricably linked to the provision of secondary care and acute hospital services. The consultation document argues the case of access for rural populations to hospital care and a range of pre-hospital support services to ensure that provision to rural communities is as good as that available to people living in communities in close proximity to hospitals. This position is fully supported. It should be noted that the new model for hospital services set out in the consultation document, if applied in a prescriptive manner, will militate against locality and community specific pre-acute hospital provision. The "one size fits all" approach must be avoided. There needs to be scope to develop community and locality specific services which are designed to meet the identified needs of particular populations within a flexible framework for hospital services. This position is not suggesting a carte blanche but rather advancing the view that the new model of hospital services should be viewed as illustrative and not definitive. Clearly, funding for services will be a major determinant of the quality and extent of provision. Rural communities should not be disadvantaged or treated inequitably in the provision of services. Developing of Midwife-Led Maternity Units It is widely acknowledged that access to local Maternity Services is an issue which has generated considerable debate. Consistent with the idea of primary care and ease of access to maternity care the model of midwife-led maternity care for low risk mothers is an acceptable proposition. Risk Management and Clinical Governance would be factors to be taken into account in the design of midwife-led maternity units. Supervision and linkages with consultant-led facilities will require the design and monitoring of specific protocols to govern the operation of detached midwife-led maternity units. Development of Specialist Elective Centres It has been established that acute hospital services in Northern Ireland have fundamental capacity problems. This has resulted in major continuing difficulties, for example, in relation to waiting lists, waiting times and A&E pressures. The proposed development of 2 new elective centres in the province, it could be argued, may present a somewhat over simplified solution to a much more complex problem. While the proposed new elective centres in the East and West of the province are to be welcomed, it is considered that the issue of acute hospital capacity will not be comprehensively or adequately addressed simply by their creation. There is need to review capacity issues in a number of hospitals and the Ulster Hospital is a case in point. To be fit for purpose in terms of dealing with the acute hospital agenda, particularly as noted in the consultation document, with an aging and increasingly frail population, further capacity must be developed to match the demographics of local populations and communities. Accelerated development of acute in-patient capacity is vital to address the emerging health needs of the population at present and into the future. Enhanced Cooperation between Northern Ireland and the Republic of Ireland on a range of Health Care Issues The proposals contained in the consultation document are to be welcomed and make excellent sense. Patently, there is much room for cooperation in the provision of acute hospital services. Similarly, it has been established there are many opportunities to further cross-fertilise between both jurisdictions in Ireland. Specialist services may be better organised on an inter-jurisdiction basis. The Trust would support the view that collaboration on a North-South basis is essential, particularly to maximise resource utilisation for specific high tech services. Résumé The Trust, in responding to the consultation document, has sought to address the major themes which are set out in Developing Better Services. While the committee has not asked for views at this juncture in respect of organisation and structures within HPSS, it is imperative not to reduce the importance of connectivity between high achieving organisations and the services which are provided by such organisations. Structural change which introduces instability must be clearly premised on a clearly specified outcome which justifies the potential dismantling or re-aligning of organisations and structures. The Health Committee will assuredly arrive at a balanced view in terms of the change needed to secure preferred service outcomes. In doing so consideration will need to be given to the impact on staff recruitment, retention and morale which will be significant and adverse if there is a perceived threat to organisations and structures. Finally, The Trust would be pleased to provide a further, more detailed response in relation to the questions raised about organisations and structures in the consultation document. WRITTEN SUBMISSION BY: 10 September 2002 Our full response on this critical issue will be submitted by the end-October deadline after consultation with our Branches. We have noted however, your request for briefings for the committee to be available by 9 September, and we attach a note of key issues that have arisen in our work to date. We would be delighted to give evidence to the committee if the opportunity arises. PATRICIA McKEOWN Key Issues: UNISON analysis of Developing Better Services We would identify the following as critical issues for consideration by the committee: 1. This is not a single unconnected initiative. It forms part of a list of Health and Executive initiatives including;
In addition, we understand that the publication of a Regional Health Strategy is imminent. The 'fit' between Developing Better Services and these initiatives needs to be tested and examined. 2. In addition the document is focused on process and output issues. The critical test should be the extent to which the 'pain and gain' in the proposals can be justified as producing better health outcomes for our society. 3. The Hayes Review of necessity went outside its formal boundaries to address the crucial link between acute and community provision, and the predicted shift of care from the acute to the community sector. Developing Better Services has a more restricted scope. The published 'Phase I' of the Community Care Review is generally acknowledged to be weak, and fails to challenge the fundamental weaknesses in current provision. Again the 'fit' between Developing Better Services and the Community/Primary care agendas needs examination. 4. The proposals in the document should also be tested and examined on the extent to which they support the key values statement in Investing for Health;
5. The core principle of economies of scale for acute services needs careful testing and examination. It needs to be established that this will lead to clear and demonstrable clinical gain, not just managerial convenience, preferences on the location of work, or outdated approaches from the Colleges. 6. We are not proposing at this stage to comment on issues for specific sites or location or configuration of services. However, the core modelling approach in the document uses a '45min/1hour' travel time approach. The report does not comment on the impact on location or configuration decisions of the '30min' parameter recommended in the Hayes Review by Professor Osborne (p44, footnote). The rationale behind this, and its impact on location/configuration decisions, could well be examined by the committee. We would be concerned if any artificial funding consideration had been used to restrict analysis of Professor Osborne's recommendations, which might well amend some proposals which are clearly creating significant public and employee disquiet. 7. Between Hayes and the Department's Review, there has been a clear shift in thinking over maternity provision. We welcome the commitment to parallel and stand alone mid-wife led units. We would urge the committee to insist that these proposals be fleshed out as a matter of urgency. Again, we welcome in principle the move to commissioning protected elective work. 8. The A&E issue is clearly causing substantial public difficulty. No evidence has yet been produced to demonstrate what proportion of cases currently presenting would still be treated in a nurse-led unit (fully staffed, and with at least the same hours of availability). This evidence will be crucial to convincing people of the merit of changes proposed. Our instinct is that the percentage who would present with and need comparable treatment is high, but the case needs to be demonstrated. The most important contribution the committee could make to current and future A&E issues is to examine and endorse the 48 hour GP access Target (included in the English NHS Plan for implementation by 2005). 9. Structures;
In principle we would endorse Model B; Commissioning integrated with all Delivery. Particular attention should be paid to experience to date with reform proposals developed by the Scottish Executive. 10. Reconfiguration and reduction of Trusts needs to be based on demonstrable health gain. The recent King's Fund Study shows that 'savings' are far lower than those anticipated, and that health initiatives can easily be compromised. 11. The Equality Assessment in Developing Better Services - based on travel times only - is profoundly limited and disappointing. It is a caricature of the requirements of the legislation. The committee should take specialist evidence and advice on how an effective Final Assessment can be delivered. 12. We are profoundly disappointed with the 'targets' in the report; in particular the timing of the 3 month targets for outpatient appointments and elective procedures. These are listed for implementation 'when the new pattern of services is established'. On the time scales in the report, are we looking at 2010-2012? The contrast elsewhere is stark. Both the English National Plan and the Republic of Ireland's National Plan for Health, target these entitlements for 2005. We appear to be creating a 'poor relation' future for Northern Ireland here. 13. Hayes targeted 500 bed reductions. The Department appears to be silent on this issue. Clarity on future targets for bed provision is essential. 14. The island-based approach in Hayes to treatment of eg rare cancers has also been diminished or avoided in the Department's Report, and the merits of the Hayes proposals on this issue should remain in focus. 15. The committee should rightly expect to be presented with a far more precise, targeted and accountable implementation plan than the vague 'sketch' in the Department's report. Additionally, consideration needs to be given to the 'drag' on implementation created by existing Trust deficits, and the Scottish Executive's approach to removing debt from the system. 16. Workers in the Health Service are committed to improving healthcare. For change to go forward, there needs to be a framework for change. The heart of this will be real delivery of the Department's commitments to strategic partnership working in 'The Employer of Choice'. Early signals are also essential on
Critically, these protections need to extend to contracted-out workers, in particular in support services and homecare. They must be seen as part of the 'NHS family' in this process of change. The support of the Committee on these issues would be appreciated. WRITTEN SUBMISSION BY: 5 September 2002 Thank you for your letter of 26 July 2002. The Trust intends to make a full response to the Department's consultation process, and has already held a series of meetings with senior clinical staff and managers to discuss what that response should be. I am therefore happy to share with the Committee the views which we intend to express to the Department on their proposals for hospital services. The broad thrust of the proposals is consistent with the Trust's previously expressed views in response to previous strategic documents considering the future profile of acute hospital services. This includes the Northern Health and Social Services Board's Acute Review in 1998, Putting it Right, which described John McFall's vision of services, and the Acute Hospital Review Group Report produced by Dr Hayes and his colleagues. 1. Nine Acute Hospital Configuration The Trust is supportive of the principle that acute care should properly be focused on a smaller number of sites. This is necessary to ensure that key acute specialties can be appropriately staffed and that the volumes of patients treated at each location are sufficient to maintain the specialist skills required to ensure the best quality of care and optimum patient outcomes. It is important, however, that the nine acute hospitals have sufficient capacity to deal with the increasing number of emergency medical admissions that have caused such difficulties, particularly in the Greater Belfast area, in recent years. Antrim Area Hospital has borne more of this burden than most of its peer hospitals, as can be evidenced by the records maintained by the Emergency Admissions Control Centre, and will require development of significant additional bed capacity to address additional workload. It should be remembered that infrastructure development in areas such as Accident and Emergency, Outpatients, X-ray, Laboratory, and health records storage will also be required in support of this development, as well as office and ancillary accommodation for increased clinical staff and the associated additional support staff. Concentration of acute facilities is, of course, only acceptable in the context of an adequate transport infrastructure and local facilities for non-acute care, and I have commented on this below. 2. New local hospitals The Trust has consistently argued that the concentration of acute services must be accompanied by a strong local hospital network, both to provide local access for non-acute services and in support of acute hospitals. We believe that as many services should be provided locally as is consistent with safety and effectiveness. This should include enhanced diagnostic facilities, Minor Injuries Units, step-down and/or intermediate care beds, possibly ante- and post-natal Obstetrics, and an appropriate range of elective surgery. The Trust has some concerns regarding the equity and distribution of the proposed 'enhanced' local hospitals. The decision on the range of services to be provided at a local hospital should be based solely on need and viability. While the Trust is supportive of the local hospital concept, it recognises that there may be operational difficulties in maintaining professional cover for these hospitals, including maintenance of professional skills. Nurse-led wards could be appropriate for management of the limited range of procedures, with access to consultant support. This would require a two-tier rota for consultants, but with a larger team working across the acute and local facilities, this may be professionally acceptable. To prevent isolation, local hospitals will need a supportive infrastructure for staff within the wider organisation. They will require a sophisticated communications system including telemedicine links with the acute hospital, and consideration would need to be given to rotation between the acute and local hospital to help staff maintain their skills and professional development. The Trust is concerned that the Report again makes no reference to services provided at Braid Valley Hospital, Ballymena and Moyle Hospital, Larne, despite this omission having been highlighted in our response to the Acute Hospitals Review Group Report. Services such as Care Of the Elderly, Palliative and Stroke Care interrelate closely with the operation of the acute sector, and offer valuable support to community services and GPs. In its response to the NHSSB review, the Trust expressed the view that acute inpatient services for the elderly within its area would be better provided at Antrim Area Hospital. It also noted that inpatient rehabilitation along with a small element of continuing and respite care should be sited locally, and this should be supplemented with consideration of outpatient, day hospital and minor injuries services. This continues to be the view of the Trust, and services at these sites should be considered as part of the review. 3. Enhancement of Primary Care Primary and Community Care is an essential support to the acute sector. Some of the problems currently being experienced by hospitals could be eased with improved investment in these services, resulting in reduced admissions and earlier discharge. It is likely that professional staffing of local hospitals will rely on the support of Primary Care, particularly of GPs. Development of Primary Care into areas such as minor injuries and minor surgery may need to be considered, and they may have an important role to play in pre-hospital coronary care. 4. Improved communication and information technology links Sophisticated communications will be vital to support local hospital services. This should include telemedicine, which will enable local hospital staff to seek immediate consultant advice, and teleradiology, which enables remote reading of x-rays, ultrasound scans and CT/MRI scans by Consultant Radiologists. Consideration will need to be given to the adequacy of the current communications infrastructure before this can happen. There will need to be substantial investment in Information and Communications Technology as outlined in the draft Regional Strategy to compensate for years of underinvestment. The case for an electronic care record, which can be accessed at any time by clinical staff in any location, is emphasised by the Report's recommendations, under which a patient may attend three or more hospital locations for different aspects of care. 5. Improved ambulance/transport services If acute services are to be concentrated on a smaller number of sites, access to the core nine hospitals either by car, public transport or ambulance (emergency or non-emergency) needs to be properly facilitated. The Trust's concerns regarding the potential bottleneck for patients travelling from the Mid Ulster area to Antrim Area Hospital have been eased by commencement of the Toome Bypass, while the planned upgrade of the Larne Road should improve access for residents of the Antrim Coast. However, completion of the direct road access from Antrim Area Hospital to the M2 motorway is also important in this context, particularly for emergency ambulance and cardiac car access. Funding of additional Patient Transport Services by the Northern Ireland Ambulance Service is important, as is development of more frequent minibus services between Antrim and local communities. Improved emergency ambulance services, both for direct admissions to core hospitals and for emergency transfers from local hospitals, especially those with midwife-led maternity units or elective surgical centres, and specialist training for ambulance crews in pre-hospital coronary care and in Paediatric Advanced Life Support will be an essential prerequisite for the changes proposed. The Trust has consistently supported the development of supporting measures such as Rapid Responder/ First Responder schemes for pre-hospital coronary care. These should involve not only paramedical staff but also local people and possibly GPs, and will be essential as Cardiac Car services from the core hospitals could not respond in a timely way to a wider catchment population even if they could be adequately staffed. 6. Midwife-led maternity units The Trust's research has shown that these units are operating successfully in other parts of the UK, and that with proper selection, and regular review / transfer protocols, they can be a safe alternative to consultant-led care for some mothers. The Trust has considered the model with relevant clinical staff, and intends to express interest in developing the second pilot midwife-led unit 'west of the Bann' at the Mid Ulster Hospital in Magherafelt. The case for locating this unit at Mid Ulster Hospital is strong. The hospital currently supports the population of Magherafelt and Cookstown Council areas, totalling 70,670, compared to 48,235 in Dungannon, 47825 in Omagh, and 57,472 in Fermanagh. 7. Specialist elective centres The Trust supports the principle of developing local hospitals as elective centres. The growth in emergency medical admissions means that elective work will otherwise be constantly at risk in acute hospitals due to insufficient bed capacity. The range of procedures will require careful selection, and there must be proper protocols for transfer to acute centres, supported by adequate ambulance provision. The mode of operation of these centres in not clear, but the logistics of professional cover will have to be carefully considered. The Trust does not consider that only two centres for the Province will provide equitable access to all parts of the population, and consideration should be given to provision of elective capacity within each Trust. Nonetheless, the Trust has considered the model with relevant clinical staff, and intends to express interest in developing the second elective centre 'west of the Bann' at the Mid Ulster Hospital in Magherafelt. The case for this geographical location has been outlined above. 8. Co-operation with the Republic of Ireland The Trust has no common boundaries with the Republic, therefore it will not be making any specific comments in this area. 9. General Comments Human Resources Strategy The Trust is disappointed that, despite its previous calls for a comprehensive human resource strategy to address the human resources implications of the proposed changes, which are among the most significant ever seen in the HPSS, the document does not attempt to provide any reassurances to the large numbers of staff who will be affected on how the change process will be managed. The implementation plan should be accompanied by a human resources framework which sets out broad personnel principles in terms of equity, consistency, transparency, protection arrangements etc. Furthermore, while there is reference to the need for investment in other staff to support the clinical and professional staff, no effort is made to quantify this. While clinical staff are at the heart of the service, they could not do their jobs without the support of a wide range of other administrative and ancillary staff. Timing The Trust has emphasised at every opportunity the difficulties caused by delays in determining the future profile of acute services in Northern Ireland. It has made determined efforts to maintain services at its two smaller hospitals, Mid Ulster and Whiteabbey, pending the implementation of any changes arising from the current review. This has been through significant investment in enhanced staffing and support arrangements in which the Trust has been supported by its main commissioner, the Northern Board. However, these services remain vulnerable to even quite small changes, which could lead to unanticipated and unavoidable service failure. The Trust therefore considers it vital that the current consultation process should produce not only a prompt and clear determination of the shape of hospitals services, but also a detailed implementation plan which addresses all facilities and services and sets timescales for completion. Since implementation is likely to take a number of years (the document refers to a 10 year development plan, which will be subject to allocation of resources by the Assembly), consideration should be given to earlier phased transfer of some particularly vulnerable services where to do so is professionally appropriate and the necessary infrastructure is in place. In any event, Antrim Area Hospital should be accorded priority for development in acknowledgement of the demonstrated existing pressure on capacity, and the inability to develop a strategic plan for the site pending final decisions on acute hospital provision. Funding The Trust would argue against the use of private finance as a source of funding for the key elements of the proposed change. While this Trust has experience of a successful PFI project, we believe that, in delivering a new service configuration for acute hospital services in Northern Ireland, it is necessary to have a Regional scheme which is centrally funded and is not subject to any uncertainty. This is especially important due to the need to ensure public and staff confidence that the necessary facilities will be in place before changes are implemented. I hope these comments will be of use to the Committee, and I would be happy to provide further detail on any aspect if required. The Trust would also be pleased to provide its views on the proposed organisational structures when the Committee is considering this aspect of the paper. MR J B MITCHELL WRITTEN SUBMISSION BY: 27 August 2002 I refer to your letter of 24 July 2002. I note your Committee's wish to receive comments on the benefits to be achieved or problems arising from the re-shaping of hospital services arising from the proposals in the above document. The Western Health and Social Services Council will be taking an active role in testing out the opinions of the communities in the area of the Western Board. However the bulk of the public consultation events will not take place before your closing date of 9 September 2002. I would be very keen to provide comments from the West but the Council has not met during July and August. The next meeting will be held on Thursday 5 September 2002. In addition you will be aware of the extension to the Minister's consultation period up to 31 October 2002. May I enquire as to whether you may extend your closing date in order to receive a better overview of the anticipated outcomes? STANLEY E MILLAR 1 Available at www.dhsspsni.gov.uk
2To avoid any confusion, the white areas at the fringe of the map in Counties Fermanagh, Tyrone and Antrim are areas without roads to which the software cannot allocate a distance band.
3Black D (2000) Working together for equity. Health Economics 9:567-8
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5DHSSPS (2002) Investing for Health. Department of Health, Social Services and Public Safety.
6Effective Health Care (1996) Hospital Volume and health outcomes, costs and patient access. NHS Centre for Reviews and Dissemination, University of York.
7The Royal College of Physicians (1996) Future Patterns of Care by General and Specialist Physicians. London. RCP September.
8Joint Consultants Committee (1999) Organisation of Acute General Hospital Services. JCC July
9Sainsbury R, Haward B, Rider L, Johnston C, Round C. (1995) Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet 345: 1265-1270
10Dolan B, Dale J, Morley V (1997) Nurse Practitioner: the role on A&E and Primary Care. Nursing Standard 11, 33-38
11Raftery J, Stevens A. (1998) Day case surgery trends in England: the influences of target setting and of GP fundholding. J Health Serv Res Policy 3:149-152
12DOH (2000) A Conscious Decision. A Review of the use of general anaesthesia and conscious sedation in primary dental care. (Available on)
13 DOH (2000) Comprehensive Critical Care. A Review of adult critical care services. (Available
14Department of Health Social services and Public Safety (2002) Review of Community Care - First Report. HMSO. (Available on )
15 Healthy Cities Belfast (1998) Towards a city health plan. A statistical profile. Healthy Cities Belfast.
16North Belfast Community Action Project (2002) North Belfast .a Patchwork of Communities. Report of the Project Team.
17Towards Safer Childbirth (1999)Towards Safer Child Birth, Minimum standards for the Organisation of Labour Wards. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives.
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19Acute Hospital Review Group (2001) Acute Hospital Review Group Report. Page 51.
20The Scottish Office (1998) Acute Services - Review Report the Scottish Office
21Smith R (2001) How best to organise acute hospital services? British Medical Journal 323:245-246
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