COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Health (Miscellaneous Provisions) Bill

Thursday 28 June 2007

Members present for all or part of the proceedings:

Mrs Iris Robinson (Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister

Witnesses:

Mr Raymond Anderson }
Mr Raymond Blaney }Pharmaceutical Society of Northern Ireland
Dr Kate McClelland }

Ms Stella Cunningham }Southern Health and Social Services Council

Ms Maggie Reilly }Western Health and Social Services Council

Mr John Farrell }Department of Health, Social Services and Public Safety
Mr Robert Kirkwood }

The Chairperson (Mrs I Robinson):

The departmental officials attending today’s Committee meeting are Mr John Farrell, an assistant director of the primary and community care directorate, and Mr Robert Kirkwood, from the departmental Bill team. They are on hand to offer advice.

I welcome the representatives of the Pharmaceutical Society of Northern Ireland, who are here to give evidence. Mr Raymond Anderson is president of the society, and Mr Raymond Blaney is its director. Dr Kate McClelland is a member of the Council for Healthcare Regulatory Excellence (CHRE) and is a representative of the Pharmaceutical Group of the European Union (PGEU). I would not like to try to say that mouthful if I had a drink on me.

I ask you to deal specifically with the Health (Miscellaneous Provisions) Bill, and the clauses in the Bill that you would like to see amended, if any. You have 10 minutes to make your presentation, and then we will have approximately 30 minutes for a question and answer session.

Mr Raymond Blaney (Pharmaceutical Society of Northern Ireland):

Thank you for saving me from making the introductions, especially for the Pharmaceutical Group of the European Union. The Pharmaceutical Society of Northern Ireland is grateful for the opportunity to make a presentation and give evidence to the Committee today.

The society is the regulatory and professional body for pharmacists and pharmacies in Northern Ireland. We currently host a register of 1,898 pharmacists and 529 pharmacies.

Although pharmacists are not numerous in Northern Ireland, the discipline is not small in reputation. Queen’s University is regarded worldwide as one of the top universities for pharmacy education. Its degree course has been provided since 1929, which makes it one of the oldest courses in the United Kingdom.

Almac Group Ltd, which was established in 2001 and is based in Craigavon, bought over Galen Holdings plc in 2004. It is now a $600 million company, employing almost 2,000 people across the US and Europe. Almac offers an unparalleled range of pharmaceutical services on a global scale.

Northern Pharmacies Ltd was established in response to the need to provide pharmacy services in areas that did not generate natural business opportunities. Established in 1968 to serve Craigavon, it now has three further pharmacies in Greyabbey, Poyntzpass and Cullyhanna, and its turnover in 2006 was about £2·6 million. Profits are either reinvested into the organisation or it divests itself of them through its charitable organisation, which helps to promote pharmacy practice and education, supporting the advancement of the profession.

The Pharmaceutical Society of Northern Ireland has existed since 1925, and, over that period, it has established itself firmly as the lead regulatory body for the profession. Public safety is never compromised when considering the regulation of the profession. It demonstrates its commitment to the public by operating an independent statutory committee structure and an independent inspectorate. It is the only nation-specific healthcare regulator and the only regulatory body to have an independent inspectorate regime.

The society, like the profession, is undergoing a period of change. The legislation under which it was established, The Pharmacy ( Northern Ireland) Order 1976, is no longer appropriate for the profession and the practices that we regulate today. The recent publication of the Government White Paper, ‘Trust, Assurance and Safety — The Regulation of Health Professionals in the 21st Century’, is the culmination of the work of Foster and Donaldson in response to the Shipman, Kennedy, Kerr/Haslam, Ayling and Neale Inquiries. All recognised the need for regulatory bodies to have the necessary and appropriate structures in place to adapt to modern healthcare practices to ensure the confident delivery of patient safety.

Although the recommendation is, ultimately, that the regulatory and professional representation rules must be split, the Pharmaceutical Society of Northern Ireland acknowledges that this is an ideological position rather than one evidenced in fact. The Harold Shipman case occurred despite the separated functions, and Dame Janet Smith’s report praised the independent inspectorate system while acknowledging that the system was only sustainable in a region of the size of Northern Ireland.

The current legislation restricts the society’s role in defining the structure and make-up of the society’s council; namely, by excluding lay representation. It defines the register of pharmacists as only practising pharmacists, not allowing for those who are non-practising or retired. The range of sanctions that is available to the council is also restricted, because it can only recommend striking off or retaining pharmacists on the register. Remaining outwith our legislated remit are the rehabilitation of professionals and support; the interim measures of supervision and support; continuing professional development; and registration of technicians.

The Pharmacists and Pharmacy Technicians Order 2007 has enabled the Royal Pharmaceutical Society of Great Britain (RPSGB) to advance its powers. It has provided a legislated arrangement that, arguably, provides greater patient protection in Great Britain than we enjoy in Northern Ireland. For example, if the Pharmaceutical Society of Northern Ireland made a direction to remove a pharmacist from the register, that person would still be entitled to practise for up to a further three months, allowing them the right to appeal the statutory committee’s decision. However, in Great Britain, if appropriate, the individual may be instructed that he or she may not practise during that period. The 2007 Order does not remove their right of appeal.

The regulatory environment is changing, and the society is ready for the challenge. It has begun the process of reforming its organisation, has participated fully in Lord Carter’s working group and continues to work with the Department of Health, Social Services and Public Safety (DHSSPS) and the Department of Health in Great Britain to establish the most effective regulatory solution for Northern Ireland.

The society has set up its own working groups to focus on the areas of governance, legislation, functions, registration and education in Northern Ireland. A one-size-fits-all solution to UK-wide healthcare regulation would not necessarily be the most appropriate route to go down. It is important to take into consideration the differences between Great Britain and Northern Ireland in order to ensure that a Londoncentric position is not foisted on Northern Ireland’s patients. It is essential that those differences are recognised and, where appropriate, protected.

Northern Ireland is the only UK nation with an EU land border. The relationship with the Republic is important from a regulatory and employment perspective. Without a clear and agreed regime in place for cross-border treatment and drug control, the Province could be more exposed than any other UK nation. Northern Ireland’s pharmacies have a footfall of 123,000 patients daily. Nearly 29 million prescriptions were dispensed in 2006. Through initiatives such as the minor ailment scheme, the management of prescribed medicines and chronic conditions, and the support offered to guide patients towards healthier lifestyle choices — smoking-cessation clinics, and so on — community pharmacy is becoming increasingly focal.

Northern Ireland has a ratio of 61:39 independent to multiple pharmacies compared with the GB ratio of 52:48. The nature of the pharmacy as part of the community is an essential factor that makes Northern Ireland’s pharmacies so successful across all sectors: specialist; hospital; academia; industry; and community. Pharmacists tend to offer the last opportunity in the dispensing chain to correct an error or to hear about patients’ concerns. Often, it is during a one-to-one conversation between a patient and his or her pharmacist that a side effect is discussed or a worry is shared that can significantly impact on the patient’s treatment. That is not to say that errors do not occur; however, in considering risk management, the society has expressed its concerns about the proposal to allow remote pharmacy supervision.

In the society’s opinion, the question is about the need to balance the desire to provide greater clinical care in the community with the need to manage the risk of increased exposure to dispensing errors. Those issues can be mitigated to a degree by improving and raising standards and processes in pharmacies. In order to implement that, the society is working closely with the Department, to which it has submitted a business plan for the introduction of standards measurement across community pharmacy, the concept of which the society intends to roll out to hospitals.

A further step would be to ensure that all pharmacies have two pharmacists in the practice, that a co-operative arrangement be introduced among local pharmacies or simply that a locum be employed to cover the time when clinical practice means that a pharmacist will be off the premises.

The profession welcomes the fact that the Government have requested an increasing breadth of services from it in order to ease the pressure on the Health Service. However, that must be done in a considered and supportive way that will not compromise patients’ safety. The society believes fundamentally that the introduction of the “absent pharmacist” could be abused in such a manner that it would not achieve the intended aims; rather, patients could suffer as a result.

The Department undertook a survey in 2006 on public attitudes to health and social services in Northern Ireland. The results for pharmacies spoke volumes: 99% of patients were satisfied with pharmacy services; 96% were satisfied with the general attitude of pharmacists; and 18% of service users called for better access to services. The ambition must be to continue to achieve that level of satisfaction and to consider how the needs of the 18% of patients who require greater access can be better satisfied. Would that be achieved by the introduction of remote supervision? It may appeal to the larger corporate organisations that wish to centralise their superintendent- or responsible-pharmacist role across the UK. However, would that satisfy corporate efficiency goals or effective patient-treatment objectives?

As for increasing a health and social services boards’ remit for sanctions, we understand the premise for that, but we do not consider it necessary for a board to go beyond the remit of its employer disciplinary systems.

The Pharmaceutical Society of Northern Ireland holds a central register of pharmacists, and a statutory committee process is in place. It is important for patients and professionals that the Government support the regulatory bodies that statutorily provide a service rather than look elsewhere to bolster regulatory practice.

We urge the Committee to consider the legislative powers that are granted to the society as a primary objective, and to support the tasking of the boards to work with the society to reflect its standards in their disciplinary procedures. That approach would ensure clarity for patients and professionals alike rather than duplicate what is already established or potentially create a situation in which two professional disciplinary systems that are neither compatible nor consistent are in place.

A health and social services board could, for example, instruct that a person be suspended or removed from its list. The statutory committee could determine that an issue does not warrant removal from the register but may agree that a person should be suspended. However, our powers do not allow for that. Therefore a pharmacist who is considered unemployable by a board could be retained on the society’s register. As a result, that person would have extremely restricted employment opportunities. That dilemma is not far-fetched, and has been experienced by other healthcare regulators. That is not helpful to the profession, the patients or the public purse.

In order to address regulatory processes, we must deal with the issues that the professional regulatory body has been raising. Another layer of regulation must not be introduced. When the regulatory issue arose in Great Britain, the Better Regulation Task Force advised that another layer of regulation should not be adopted. We ask the Committee to consider what is best for patient care: a strong regulatory body with appropriate legislative powers, or an additional layer of regulation that could add confusion.

The society, which has been in existence for more than 80 years, recognises the demand for reform and broadly welcomes the changes that are recommended in the White Paper. We have a difference of opinion about the implementation of a solution across the UK, and ask for the Committee’s support to ensure that everything possible has been done to provide the best solution for patient safety and care in Northern Ireland.

Devolution provides us with the opportunity to make our own determinations, and to focus on and address local issues. As the specific regulator for pharmacy in Northern Ireland, the society requests that the Committee recommend that legislative limitations and inadequacies be addressed as a priority in order to provide the optimal regulatory provision in Northern Ireland.

Representatives of the Department — Mr David Bingham, Dr Norman Morrow and Ms Joyce Cairns — are assisting with that process. We urge the Committee to request that addressing legislative limitations and inadequacies be made a priority so that we can be confident that the best solution is in place for patients and the profession.

The Chairperson:

Thank you, Mr Blaney. How many pharmacists have lost their livelihoods since the society was established?

Mr Blaney:

On average, there are two or three statutory committee hearings in Northern Ireland per annum. I estimate that an average of 75% of pharmacists who are called before the committee remain on the register. I do not have accurate figures with me.

The Chairperson:

How do you respond to the accusation — I am playing devil’s advocate — that the society is looking after its own fiefdom, and does not want others involved in overseeing the workings of pharmacists?

Mr Blaney:

There are two responses to that. First, I am the director of the Pharmaceutical Society of Northern Ireland, but I am not a pharmacist. The society is demonstrating that it wants to change.

In dealing with current legal limitations, we try to think outside the box to encourage the involvement of lay members.

Secondly, a regulator cannot operate effectively without there being a connection with the professional body that it is attempting regulate. If there is no such connection, regulation from afar will not necessarily be effective or relevant.

Our primary objective is not to protect the profession but to ensure patient safety. That is done by representing the profession, promoting better standards, and ensuring that the requisite support exists to allow the optimal delivery of services that members want for patients. Pharmacists do not enter the profession without adhering to those core principles. If they did not hold to those principles, they would probably end up before the statutory committee.

Dr Deeny:

Thank you, Raymonds and Kate. We had three Brians before us last week, and now we have two Raymonds.

As a health professional, I have an interest in this matter. Moreover, my father was an old-time pharmacist who worked closely with the community in Downpatrick for years.

Earlier this week, I read in a GPs’ magazine that health professionals seem to spend more time in seminars, learning how to administer the Health Service, than working with patients, so I take your point that new measures may simply be another layer of bureaucracy to ensure safety. With that in mind, but conscious that patient safety is paramount and that balanced decisions are required because one is dealing with someone’s livelihood and reputation, you mentioned that you could strike members off or retain them. That seems to be a case of one extreme or the other. What options can you suggest to achieve a balance?

Furthermore, having worked as a GP in primary care for well over 20 years, and with pharmacy in my blood, I ask what the future holds for pharmacists. The Chairperson mentioned that new hospital wards resemble those in the US. Whether our hospitals wards are copying the US model, I do not know. I have been to the US a few times, and I like the way that pharmacists take responsibility for advice that can be dealt with at their level, rather than having to organise appointments with GPs or trips to hospitals. Do you see such practices as part of the future? If the concept of administration of risk is imposed on Northern Ireland as part of a UK-wide extra layer of bureaucracy, will the community care that I witnessed while growing up be lost, and will community pharmacies continue to play a proactive role alongside GPs and primary healthcare professionals?

Mr Raymond Anderson (Pharmaceutical Society of Northern Ireland):

To the comments that Raymond Blaney and the Chairperson have made, I would add that the independent inspectorate separates —

The Chairperson:

We are having difficulty hearing you, Mr Anderson. Will you speak up a wee bit?

Mr Anderson:

There is an independent inspectorate that does not sit within the purview of the Pharmaceutical Society of Northern Ireland. If pharmacists engage in malpractice, the inspectorate, which is based in the DHSSPS, will carry out an inspection. The profession is separate from that process, and it is the inspectorate that would bring any cases before our statutory committee. Inspections and the regulatory function of the society are separate, and the existence of the independent inspectorate should dispel any sense that we protect ourselves. During the Shipman Inquiry, the inspectorate was acclaimed by Dame Janet Smith as a good system for regulating professionals.

In response to Dr Deeny’s question, my answer is that the society is aware that the sanctions available to it are limited. The organisation is in discussion with the Department about that. The Royal Pharmaceutical Society of Great Britain has introduced the section 60 Order — The Pharmacists and Pharmacy Technicians Order 2007 — which is known as such because it was made in exercise of the powers conferred by section 60 of the Health Act 1999, and has increased its range of sanctions. Those sanctions can include suspension, but they may also involve retraining, supervised training, revalidation or time off the register in which pharmacists must prove their fitness to be placed back on it. Those sanctions are not available to us yet, but we want to see them introduced.

However, when considering whether we should adopt the UK-wide regulation process, it must be remembered that we have a land border with another EU country. That may lead to the movement of drugs, pharmacists and prescriptions across the border daily. Pharmacists here are not allowed to dispense any prescriptions that have not been prescribed by a general practitioner who is on the General Medical Council (GMC) list. The EU has taken a case to the Cabinet Office and to the UK Government. That case is being challenged in the European Court of Justice (ECJ). If the policy were to be changed, it would open up the movement of prescriptions across the border between North and South. Pharmacists could be faced with regulating and managing that daily, as could patients who move from the South to the North. Ways must be found to regulate that so that patients are not inconvenienced. That daily movement of prescriptions is not as important a consideration for England, Scotland and Wales who do not have a land border with another EU country.

Mr Blaney:

Our society is not regarded as a supportive professional regulatory body, because the sanctions available to it only allow the polar-opposite positions of either removing pharmacists from the register or allowing them to remain on it. Pharmacists will not turn to the regulator to ask for help if the only options open to them are to be struck off or reprimanded. The society’s role must change from one of negative regulation to one of positive regulation. It is important to consider how the range of sanctions is constructed, but we must also introduce a supporting framework to advance the profession.

Mr Gallagher:

Raymond Anderson made the point about the problems that pharmacists who work close to the border face. I come from a border area, so I understand that regulations are needed that better reflect the fact that pharmacists work in areas close to the border and that their customers can come from either side of that border. Will you tell us again about your particular concerns about that?

Mr Anderson:

An out-of-hours centre has been established in Castleblaney. That centre covers part of south Armagh. Prescriptions written in that area cannot be dispensed in the North of Ireland, because a general practitioner who is registered in the United Kingdom has not written them. The Cabinet Office is considering changes to the legislation, but if that legislative change goes through, prescriptions could be taken across the border and dispensed in pharmacies in the other jurisdiction. A pharmacist would then have to determine whether it was a legitimate prescription and, if the prescription was for schedule 2, 3 and 4 controlled drugs under the Misuse of Drugs Act 1971 and associated regulations, it would increase the chances of a pharmacist’s deciding not to dispense the prescription because he or she was not sure whether the prescription was legal. Handwriting on prescriptions can easily be forged, and computers can also be used to forge prescriptions.

It can be hard to verify whether a prescription has been written by a GP or whether it is fraudulent. If we allow prescriptions to move across the border and be dispensed in both jurisdictions, pharmacists will have to be very vigilant about whether they are legitimate. That is one concern, although the movement of controlled drugs and the potential for controlled drug prescriptions to be dispensed across the border could pose a problem too.

Mr Gallagher:

I hope that there will be a development of the out-of-hours GP services in border areas, although, as you are probably aware, a pilot scheme has been set up. Are you satisfied that those concerns will arise from the pilot studies that are under way?

Dr McClelland:

The UK delegation is trying to get the Pharmaceutical Group of the European Union (PGEU) to change its name to the pharmacy group of the European Union, which would be so much easier; unfortunately, however, the German and French translations just do not go there. I am a member of the UK delegation, which, more often than not, forgets that the UK has a land border with another European country. The pilot schemes will show the way, one hopes, but let us start with pilot schemes. Let us take it slowly across the border.

The Pharmaceutical Society of Ireland and the Royal Pharmaceutical Society of Great Britain work closely together in Europe. The Pharmaceutical Society of Ireland has gone through huge regulatory changes, and it is now allowed all the derogations. All the problems with opening pharmacies and ownership have been swept away by the Southern Government, and the Pharmaceutical Society of Northern Ireland is waiting to see what happens there. Article 63 of the Health and Personal Social Services ( Northern Ireland) Order 1972 and proposed new article 63AA of the Health (Miscellaneous Provisions) Bill refer to an application being “necessary and desirable”. Europe could sweep that away. The UK delegation would like to keep it in, but our Southern Irish friends have let it go.

However, because we are a group of small islands off Europe, we must learn to work across the border to provide for patients; healthcare in Malta, Luxemburg and other small countries crosses borders, and they have full patient mobility where their Governments fund it. Does that help?

Mr Gallagher:

Yes. Thank you.

Mrs Hanna:

You mentioned community pharmacies and told us that the breadth of services is a plus. Does the proposed legislation puts that at risk? You also said that you do not like the pharmacy supervision proposals. Why is that? You said that one size does not fit all, which I accept. I am not saying that the proposals are good or otherwise, but could they be balanced in a way that would be acceptable? Should pharmaceutical professionals be included? Is the present system sufficiently independent?

Mr Anderson:

I will address the first part of the question, which related to the risk to pharmacies and remote supervision. Regarding the latter, we are aware that some larger organisations are undertaking trials in which a pharmacist sits in a remote office and looks at a bank of screens. Therefore when patients go into a pharmacy, the pharmacist may not be there; instead, patients would use touch screens to take part in videoconferences with a pharmacist.

Mrs Hanna:

Is that remote supervision?

Mr Anderson:

Yes. Such a system could jeopardise the sustainability of pharmacies. It could downscale a pharmacy or remove the skills of the pharmacist from the pharmacy. If patients did not like remote supervision, they could go to a pharmacy where that service is not provided. However, patients might find that there is no longer a facility for them to go to a pharmacy with a minor ailment, or to discuss issues with the pharmacist relating to medicines or their side effects, or with matters that affect the family. Remote supervision risks losing personal contact.

Mr Blaney:

If a patient has been taking the same medication for several months or has been given a repeat prescription, a pharmacist may intervene and ask why a treatment has not been successful; with remote supervision, that personal intervention may be lost.

Our fundamental questions about pharmacy supervision are whether the miscellaneous provisions realise the corporate goal of reducing costs for organisations, whether they upset existing one-to-one care, and whether they will improve patient care. That is a good example of our society not looking at professional ambition but at patient safety and treatment.

We are eager to ensure that a proper support network is in place and that expectations do not become so great that they dilute the community aspect of pharmacists’ services.

Pharmacists welcome the clinical aspects of pharmacy — getting out into the community and working in GPs’ surgeries. They welcome the minor ailment scheme, independent prescribing and opportunities to utilise the professional skills that they have been trained to provide.

We do not want to see a replication of the situation as regards GPs and nurses where, having been starved of an opportunity for so long, any opportunity would be grasped without ensuring that changes will not undermine quality of service. Consideration must be given to how the introduction of additional services and requirements can be supported.

As regards the White Paper, we have been fortunate. The Foster report recommended that the Pharmaceutical Society of Northern Ireland merge with the Royal Pharmaceutical Society of Great Britain (RPSGB). However, at that time, we were assured by Minister Burnham and Minister Goggins that no London-centric decision would be made and that Northern Ireland would have the opportunity to consider the future of its pharmacy regulation.

We set up working parties, but we have not taken a position on the matter yet because we wish to look at the opportunities that a UK-wide college for pharmacy could provide. However, we are concerned about the dilution of the regulatory function in Northern Ireland. At present, we have sovereignty and legislative responsibility and, considering the matter from the perspective of the Northern Ireland patient, we must think long and hard before we cede that responsibility.

The society could be made more open, transparent and inclusive to patients, perhaps through lay representation. However, the legislation does not provide for that. The legislation has been in operation for more than 30 years, so we would push for a re-examination of the fundamental legislative framework that the regulatory body, which is empowered to provide sanctions and to regulate the profession, works to. If that could be changed, the Bill would enable the boards to reflect the requirements of the professional regulatory body.

Dr McClelland:

The Council for Health Care Regulatory Excellence in London oversees all the regulators. However, at its inception in 2004–05, it saw no place for the Pharmaceutical Society of Northern Ireland.

That attitude softened following Dame Janet Smith’s report. The view then was that, because of Northern Ireland’s small population, its land border with another country and because it worked in a different way from the rest of the UK, pharmacy in Northern Ireland was one of the best regulated of the healthcare professions. However, the system was thought too resource-intensive to be duplicated. The chairperson of the Council for Health Care Regulatory Excellence asked me whether I thought that our local system for pharmacy regulation and inspection could be applied across the United Kingdom. I had to answer in the negative, because I thought it too resource-intensive.

If the present system is considered too resource-intensive, we must ask ourselves whether the Bill, with its provisions to set up another register and inspection regime in the health boards and the duplication that that would involve, would not be even more resource-intensive.

Mr Anderson:

We have a high-quality system in which the inspectorate is separate from the organisation, and that is why it received acclaim from Dame Janet Smith. Dame Janet also considered the possibility of rolling out that system across the UK but felt that it was too resource-intensive. We must ask ourselves whether that is a good reason to throw away our system and change to one that might not be as effective or efficient.

The Chairperson:

Thank you for your fine presentation; you have given the Committee food for thought. You will receive a copy of the report of our proceedings. The Committee would appreciate copies of any speaking notes that were used.

I welcome Ms Maggie Reilly, the Chief Officer of the Western Health and Social Services Council and Ms Stella Cunningham, the Chief Officer of the Southern Health and Social Services Council. Please address specific provisions in the Bill and tell the Committee which clauses, if any, you would like to see amended.

Your presentation should last 10 minutes, and then it will be open to Committee members to ask questions. You are most welcome, and I look forward to hearing your presentation.

Ms Maggie Reilly (Western Health and Social Services Council):

Thank you very much. Good afternoon, everyone. Many of you will be aware of the existence of the four health councils — one in each health board area — which were established in 1991. They are often called watchdog bodies for patients as they serve as a voice for them. Therefore the four health councils welcome the opportunity that the Committee for Health, Social Services and Public Safety has given us to present our views on the provisions of the Health (Miscellaneous Provisions) Bill.

Our presentation is based on the views of council members across Northern Ireland and on our analysis of the concerns of the public and service users about the Bill. In particular, we will mention some of the issues that were raised directly with us as we supported people who were making complaints in the Health Service.

The Committee’s invitation gives recognition to the health councils’ role and we thank you for that. We intend to provide a much fuller response to all the Bill’s provisions and amendments later. Ms Stella Cunningham will provide you with our views on general dental services, and I will follow that with our comments on the provisions regarding disqualification by the tribunal, after which you will want to ask questions.

Ms Stella Cunningham (Southern Health and Social Services Council):

The four health councils are pleased to offer comments on the clauses in the Bill that deal with dental services. Dental services are a core part of National Health Service provision and are fundamental to the general health of our population. This is a matter that the health councils have inquired into regularly since our establishment in 1991. You have been provided with recent research by the southern council into patient experiences of general dental services, and you have also been supplied with a joint statement from the four councils highlighting what we believe to be the crucial issues from the patient’s perspective.

I want to make three points this afternoon. Patients’ aspirations are changing and dental work is increasingly seen as a fashion accessory; however, Northern Ireland still has the worst dental health record in the UK, and we live with the political decision not to fluoridate the water supply.

First, we support the provisions of clause 2 for proposed new article 60A: access to NHS dentistry is at a critical point in Northern Ireland. If the new dental contract is not speedily resolved, the NHS will continue to leak dentists until the only option will be private treatment, and that could disadvantage vulnerable groups. In the southern area we conducted a survey of 68 dental practices in October 2006. At that time, 43% of practices in the southern area were registering NHS patients. When we updated the survey in May 2007, only 12 practices, or 21%, were still registering NHS patients. This means that it is virtually impossible to register with a dentist as an NHS patient in Newry and South Down, while in an area such as Dungannon there is extremely limited choice. That situation is replicated throughout Northern Ireland.

In the northern area only 27 practices, or 32%, now accept new NHS patients. There are no practices open in Carrickfergus, Cookstown or Magherafelt. Alongside the situation in Dungannon, we see that there is practically no capacity in the whole of the mid-Ulster area. In the western area there is no statutory out-of-hours dental provision; it has been left to dentists to provide that service. There is now no access to NHS dentists in Fermanagh or Omagh.

The health councils believe that there is a moral issue at stake: the public purse contributes to the training of dentists but does not gain full advantage from that contribution. Access to services also depends on where a patient lives.

Secondly, the health and social services councils welcome proposed new article 61, which the Bill will insert into the Health and Personal Social Services (Northern Ireland) Order 1972, as it will allow health and social services boards to make such arrangements as they see fit to provide dental services, whether by employing salaried dentists or by making local arrangements with primary dental care practitioners. Such arrangements should be based on local need and should aim at ensuring maximum choice for service users in a way that does not lead to NHS provision being perceived as a second-class service.

There will not be a one-size-fits-all solution. The Northern Health and Social Services Board has sought to employ salaried dentists; the Southern Health and Social Services Board’s preferred option is to enter into contracts with high-street dentists for specific NHS slots. Whatever local arrangements may be made, they must be sustainable in the long term and provide boards with the ability to influence the location of practices to ensure equity of provision.

Finally, on proposed new article 61A and proposed new schedule 15A that clause 2(2) and clause 4(3) respectively will insert into the 1972 Order, the health and social services councils believe that the new contract should review dental charges. The present system is cumbersome for dentists, confusing for patients and does not reward health promotion activity. A simpler tariff of charges limited to basic dental care, including health promotion, could separate services that are required for good general dental health from cosmetic treatments. A charging system that allowed patients to retain their NHS entitlement, while paying for enhanced treatments that are not available on the NHS, would retain the principle behind an NHS dental service and meet the expectations of today’s service users. We also suggest that a further group — people aged 65 and over — be added to the list at paragraph 1(1) of proposed new schedule 15A.

We welcome the fact that the Bill allows a new dental contract to be negotiated. We urge that the opportunity to secure quality accessible dental services for all sections of our community should not be lost.

Ms Reilly:

On the issue of disqualification by tribunal, the four health and social services councils welcome and strongly endorse schedule 1(5)

“After paragraph 1 (7), insert—

‘(7A) The third condition for disqualification is that the person concerned is unsuitable (by virtue of professional or personal conduct) to be included, or to continue to be included in the list.’.”

That ground is well recognised by the professional regulatory bodies and is in keeping with the principles of good clinical and social-care governance and of public accountability. We fully concur with the extension of the category of professions to include all practitioners who are on, or have applied to be included on, the board’s list so that all such practitioners will be subject to the tribunal’s jurisdiction.

It is self-evident that if a disqualification judgement is made against a practitioner, the sanction should be upheld in all board areas of Northern Ireland. Arrangements should be put in place to ensure that any sanctions that a tribunal in Northern Ireland, England, Scotland or Wales makes are appropriately communicated across the system to ensure that a disqualified practitioner may not practise in any of those regions. Therefore there is merit in having a UK-wide list that is open to all boards and Health Service commissioners. With the move towards greater co-operation and shared care for patients using the health service in the Republic of Ireland, and given some of the border-area arrangements, we hope that further arrangements will be put in place to ensure that such sanctions are communicated, recognised and enacted in both jurisdictions.

There should be a formal interface and integration between the function of the tribunal and that of the professional regulatory bodies on matters of alleged serious misconduct. That seems to have been missed in the Bill. We fully support the provision to allow boards to suspend temporarily a practitioner on referral to a tribunal, as that will create greater safety for patients.

In our experience, when a matter of conduct is referred to a body such as the General Medical Council and the case is judged to warrant a full investigation, boards do not have the power to suspend the practitioner temporarily. We want reassurance that the Bill will reflect the need for boards to be able to use temporary suspension for matters of serious misconduct, whether such cases are referred to the professional regulatory body or to the tribunal. The Bill makes no reference to referrals to the professional regulatory body. In cases of potentially serious misconduct, it seems logical to offer the same level of safety when a practitioner is referred to the regulatory body as when the matter is referred to the tribunal.

However, we caution against prolonged precautionary suspension as the practitioner has a right to have his case heard in a timely manner.

There may also be issues about a board’s ability to fund and find temporary replacements for suspended practitioners, and that may affect patients. However, neither of those considerations should influence a decision to make a precautionary suspension.

Finally, we want to ensure that provisions to extend the powers and functions of the tribunal are open and transparent so that the public and patients can have full confidence in its workings and decisions.

The Chairperson:

Thank you for your submission. Will the arrangements under the Bill be sustainable in the longer term?

Ms Reilly:

Do you mean sustainable in general or in specific areas?

The Chairperson:

In general terms.

Ms Reilly:

Ensuring that all the provisions of the Bill are enacted will involve a cost. The Bill has been prepared with the present model of four health and social services boards in mind. However, a single health and social services authority, under the RPA, will presumably replace those boards. Therefore to ensure sustainability, account must be taken of imminent changes.

As regards patient safety, it depends what is meant by sustainability. Patient safety is most important, and the Bill reinforces it. The other issue for us is access to services. Therefore sustainability will ultimately depend on how much is invested.

Ms Cunningham:

Since we do not have a sustainable dental service, we need the Bill to drive forward and build one.

Mrs Hanna:

As regards driving forward dental services and improving access to them, we accept the points that you make. Will the Bill achieve those aims?

Ms Cunningham:

It will enable the development of a new general dental services contract. The other important point is the role of the boards, which, as Ms Reilly said, will be replaced at some stage. The boards control the development of doctors’ practices and pharmacies; however, dental surgeries are outside that control. Dental provision is a cornerstone of healthcare, and it should be treated in the same way as the provision of GP services. It is essential that boards have some control over the development of dental practices.

Mrs Hanna:

Therefore a broad spread of services should be covered.

Ms Cunningham:

Yes.

Mrs Hanna:

Will dental provision be covered or is an act of faith involved?

Ms Cunningham:

It is increasingly the case that more dental practitioners operate in the private sector than in the NHS sector, so there will always be some tension. However, giving boards a clearer role in deciding on the location of practices can only strengthen their hand.

Ms Reilly:

To reinforce that point, it is important to note that this is the start of a process that will enable a contract to be hammered out between dentists and a board that will have some responsibility for commissioning dental services.

Mrs Hanna:

Therefore it is the detail that is needed.

Ms Reilly:

Yes, but the Bill is necessary to start the ball rolling and to give it some impetus.

Mr Buchanan:

Why are dental practices closing or no longer taking on NHS patients? Dentists say that the NHS does not pay enough to cover a patient’s treatment and so they cannot carry out the necessary work to the required standards. That is why they are opting out of the NHS.

Ms Cunningham:

We agree with that absolutely. There can only be sustainable NHS dental services if dentists feel valued and are recompensed as part of that. The current funding system is complex and is administratively heavy on dentists. They are not being rewarded for their health-promotion work, which most dentists do as a matter of course, even though they cannot charge for it. Anomalies in the charging system must be sorted out.

Another factor is the change in the way in which dentistry is viewed — affluent sections of society increasingly use the service as a kind of cosmetic-enhancement process. As people who speak from the patient’s point of view in the context of the NHS, we believe that what is required is a dental service that can meet all sections of our community’s health needs. We must ensure, through the Health (Miscellaneous Provisions) Bill, that dentists are rewarded for operating in the less affluent and more peripheral areas. Everyone needs access to good, general-health dentistry.

Dr Deeny:

I agree. Maggie, you said that different areas have limited access to health services and dental services. As a GP, I am aware that there have been access problems in the south-west of Northern Ireland at weekends.

We have just learnt that Mr Shaun Woodward is to be the new Secretary of State for Northern Ireland. He said previously that the review of public administration (RPA) could result in the four health and social services councils being amalgamated into one body, which is to be called the patient client council (PCC). I do not like the word “client”; I prefer “patient”.

As this is the first time that the health and social services councils have given evidence to the Committee for Health, Social Services and Public Safety, for my benefit and that of the Committee, will you clarify the role that they play? How much clout do the councils have? I know that they are supposed to be the patients’ representative or spokesperson. There are many issues and problems across Northern Ireland; I hear about them every day. Do the public know enough about the councils, or about the proposed PCC?

Yesterday, in Omagh, a mother gave birth to twins in a hospital that has no maternity backup whatsoever. That is totally unacceptable, yet that sort of problem occurs all the time. What can be done if patients approach the councils with concerns about services that are completely inadequate and unacceptable? Could the public be made more aware of the councils’ role?

It is good that the councils can lobby a Committee such as this, but will they, in future, be able to address patients’ serious concerns about healthcare and health provision across Northern Ireland? Will a new single body have more power and clout?

Ms Reilly:

The health and social services councils were established in 1990. When they started, they were only ever meant to be a committee of local people nominated to a council to debate and discuss healthcare issues, to raise them through their committee, to write letters to the appropriate bodies, and to lobby in that form.

As they developed, they did not have the appropriate funding to match that development. Furthermore, as the public became more aware that there was an independent body, speaking on their behalf, they began to go to the health and social services councils to ask them to intervene on their behalf, whether that was to support them in making complaints, to lobby on their behalf, or to advocate on behalf of individuals. Therefore part of our remit is to monitor the quality of the services that are provided and the general public’s access to those services.

Our role is not to be a proxy patient, because we think that it is incumbent on the Health Service to speak directly to patients about services or changes to services. However, we will speak in the public interest, in the more general interest of patients or clients, or on behalf of any service users.

One of the most important functions that we perform is to support the public when they want to make complaints. Every health body has a complaints system, but sometimes it is inaccessible to members of the public. We support and help the public to understand their rights, and what they should reasonably expect from the system. The councils are available to ensure that the public have full access and receive full answers, and to monitor their progress right through to independent review.

We agree that it was a problem that we have never had the resources to make the public aware of the complaints system. It is a catch-22: when we make the public aware of the system, we do not have the capacity to deal with the resulting influx of enquiries.

Therefore we welcome Shaun Woodward’s vision of a new PCC, which he outlined when he was Minister with responsibility for health. He said that a new council would have better resources and be much more powerful. However, the power will probably lie in the new council’s level of influence — to whom it has the right to speak directly; whom it can pressure to make changes; its right to be listened to; and how its recommendations are acted on — as opposed to having statutory powers to act there and then. Such power rightly belongs to the regulatory bodies, such as the Regulation and Quality Improvement Authority (RQIA).

The Chairperson:

I see that there are no further questions. That was a short session. I thank you, Maggie and Stella, for your interesting presentation.