COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

OFFICIAL REPORT
(Hansard)

Draft Budget

6 December 2007

Members present for all or part of the proceedings:

Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Rev Dr Robert Coulter
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Ms Sue Ramsey

Witnesses:

Mr Michael McGimpsey Minister of Health, Social Services and Public Safety
Mr Don Hill )
Dr Michael McBride ) Department of Health, Social Services and Public Safety
Mr Andrew McCormick )
Ms Julie Thompson )

The Chairperson:

I welcome the Minister of Health, Social Services and Public Safety to the Committee and thank him for attending, along with the officials who are accompanying him.

The Minister of Health, Social Services and Public Safety (Mr McGimpsey):

Thank you very much.

I believe that we all share the same objective, which is to improve health and social care for patients; people with mental illnesses, physical and learning disabilities; and people who need help and support to look after themselves. I am here to talk about the Budget, and what it means. Our shared objective is to obtain the best possible treatment and support for people who require help and social care. There are no political differences in that; we all must work together for the benefit of the health of our people.

The outcome of the comprehensive spending review (CSR) is critical, because it sets the financial envelope for the next three years. There will be minimal opportunities for change once it sets over the next two years, and that is why I am giving it so much of my attention now. We must get this right. The current draft proposals are for consultation, and this Committee, the Assembly, the general public, and, ultimately, the Executive all have an opportunity to change those proposals. I believe that the draft proposals must be changed, and I hope that you will support me in that.

In Northern Ireland, as in the rest of the UK, about half of the additional resources provided in recent years have been spent on pay and reform. That was not my decision, but I acknowledge that a lot has been achieved with the priority allocations that have been made. Health and social care has regularly received up to 55% of additional resources available to the Northern Ireland block. Good progress has been made on hospital waiting times, and domiciliary care is now the dominant care setting, with more people resettled in the community and supported to live independently at home. Support for children in care has improved; through the new cancer centre, and other measures, support for cancer patients has improved too. Significant investments have been made in workforce training, and, more importantly, we now have arrangements in place to ensure that money goes exactly where it is intended, in order to achieve the target set.

However, we have not kept pace with the rest of the UK. There are many areas where the gap between services here and in the rest of the UK is simply not acceptable. Waiting times for all services in Northern Ireland are much longer. If we had the same adoption rates as England, another 50 to 60 children in care would be adopted each year. If we had the same rate of death from heart disease, 300 fewer people would die each year. Death rates from bowel cancer are 16% higher than the UK average, and children leaving care here are 40% more likely to have no qualifications. The simple reason is that, despite the priority given to health funding by direct rule Ministers, it is not enough to address need.

Many people say that health and social care is inadequate because it is inefficient and wastes money, and I totally agree. There are significant savings to be made — £146 million in cash-releasing savings, and £125 million in non-cash-releasing savings, have been made over the last three years. John Appleby suggested a range of areas that needed to be addressed, and they all have now been, or are being, addressed.

I will meet the CSR efficiency target of £343 million over the next three years, which will mean a total of £500 million in efficiency savings over six years. However, efficiencies are not enough. In drawing up my approach to the CSR, I fully recognised that public expenditure resources would be lower than in recent years, and I therefore submitted a relatively modest series of development bids, rising from £101 million in year one to £302 million in year three.

In line with the Wanless conclusions, I placed the greatest emphasis on prevention and care in the community and rather less emphasis on hospital developments. Mental health and learning disability was my number one priority. My bids were based on what I regard as the priority needs of people in Northern Ireland, rather than on simply keeping pace with England. Health and social care should be the Executive’s number one priority, and resources should be skewed to fund that programme.

The draft Budget gives health and social care a lower priority than in previous years. Contrast that with England, where the increase is 3·7% in real terms compared with 1·1% here. If I was able to match increases in England, I would have £300 million more in year three, which would be enough to meet all of my bids. Instead of continuing to get 55% of additional resources available for allocation, we have received about 50%. My share of the Northern Ireland block has increased, but only by 0·4%, and the annual uplifts are the lowest in recent memory. That reflects a degree of priority, but the figures also reflect a conscious decision to reduce the priority of health and social care.

As a result, I need to use the majority of my efficiency savings of £118 million in year one, £233 million in year two and £343 million in year three to cover inescapable pressures. I have sent the Committee details of those. I am left with only £16 million in year one, £32 million in year two and £97 million in year three for new service developments. Effectively, I have a standstill budget for the first two years.

With that £97 million in 2011, I can make some extremely belated progress on some elements of my bids. I have given the Committee details of what I can and cannot do, but it is a little too late. I stress that I am not disputing the proposal that priority should also be given to the economy. A healthy economy is essential for a healthy workforce, but the reverse also applies. There seems to be a naive view that because health and social care accounts for 47·7% of the Budget, an increase of some 0·4% should be enough. Wanless, Appleby and others have highlighted the need for a real-terms increase of over 4% in health and social care expenditure — we are a long way short of that.

Our need to increase expenditure is even greater because of demographic differences. If this draft Budget is approved, we will be hiding our heads in the sand when it comes to funding of health and social care, and the losers will be the sick and the vulnerable. Much has been said about the comparisons with England, and my officials spoke about the figures at a previous meeting. My arguments are based on what is needed, and is affordable, here, but the comparative figures are simple: if CSR increases here were the same as in England, I would have an additional £300 million to spend, all my bids would have been met and I would be fully supporting the proposals in the draft Budget. The latest assessment of relative needs shows that Northern Ireland needs health expenditure to be 10% higher and social services expenditure to be 36% higher. Our actual expenditure is £300 million short of meeting that need. The CSR settlement means that the gap will grow to £600 million. That has nothing to do with efficiency or waste. The simple question is: do you think that it is acceptable to spend much less in Northern Ireland than in England? No matter how efficient we become, patients and clients here will not get the same standard of care as people in England. Is that what we want to happen?

As far as the outcomes under the infrastructure strategy are concerned, with some additional resources we could do much more to accelerate the programme during the period. However, there are some things that we cannot make a start on. We can make a start on a number of key projects, but Antrim and Craigavon will be deferred. I will be able to press ahead with projects such as Omagh and the south-west hospitals, and to make a start on more primary and community care centres during the CSR period. I have indicative allocations of £2·4 billion for the following six years, which will allow a number of major projects to begin, but existing proposals will have to be re-phased. Before you ask, it will be several months before I can decide how those resources will be used.

In conclusion, I know that additional funding on its own is not the answer. We need to work smarter, and we need to work differently if we are to make the most effective use of resources. Major efficiency savings can and will be found. Over the last few years, it has been shown that health and social care is up to the challenge of reform. By exceeding the Gershon targets we have shown that we are up to the challenge of greater efficiency. However, even with the future efficiency savings of £343 million, the proposed Budget addition is not enough. We must do our part in giving a higher funding priority to health and social care to prevent Northern Ireland from slipping far behind England and the rest of Europe in access to health and social care. By working together, we can make that happen.

The Chairperson:

I am sure that Members share my keen interest in putting questions to you. You mention a 0·4% rise in real terms. In 2000-01 we sat with £2 billion in the Health Service, and now we are looking at £4 billion, which is 48% of the Northern Ireland block from Her Majesty’s Treasury. Can you honestly say that we are seeing double the improvement for the money that is going in?

As you will know from the letters that I forward to you from my constituents, I deal day and daily with people who are dissatisfied with the service. What actions have been taken to increase innovation in the delivery of services? What incentives or sanctions are in place to improve performances? What impact could delaying the review of public administration (RPA) reforms have on increasing productivity? Fourthly, is locally-based commissioning likely to lead to improved productivity?

Mr McGimpsey:

The 0·4% of which you speak is the increase in our share of the block grant. We got 2·7% plus 1·1% in real terms. England got 3·8%, so there is a major disparity between those figures and what we want. Let me put it in different terms: the Wanless Report was commissioned some years ago, and the key question was whether we could afford a Health Service as Aneurin Bevan envisaged it — cradle-to-the-grave healthcare, free for all citizens. Wanless’s conclusion was that that can be done. Three things were cited as necessary in order for it to work: one was sufficient investment to get the service up to a modern standard; the second was that there had to be efficiencies; thirdly, the local population had to engage in its own health. People have to take responsibility through their lifestyles, their actions and how they live in order to address their own health needs. Therefore, prevention, efficiency and funding are the three things that we are examining in order to develop in terms of efficiency, adequate investment and taking responsibility.

Therefore, 1·1% is not adequate. That is the real increase; 2·7% is envisaged as inflation. Given that drugs inflation runs at around 9%, one can see that there is a disparity. That disparity is also obvious when one looks at the demographics and the need for new processes. There are lots of things that we cannot do. Our block grant has increased by 0·4%, and we cannot cope with that as things stand. We have already achieved £144 million of efficiencies under Gershon. Over the next three years, I will hit the target of £343 million of efficiencies. Added to the other efficiencies that I talked about, we have a total of roughly £500 million. That is a huge saving and a huge efficiency, and it will take a tremendous amount of work.

That is the strategy. If any one of those goes wrong, the other two will tip. I will make the efficiency savings; we are concentrating on preventing for health and on the third arm of the Wanless report. The first part — the draft Budget — is causing problems, and John Appleby’s report strongly reinforces that.

With regard to the RPA, the reports of Appleby, Wanless and others looked at our structures and made them more efficient. The number of trusts has been reduced from 19 to five plus the Ambulance Trust, and that is the key efficiency. There are other parts to that efficiency, such as the single health authority — that grand body to take over large functions. I am looking at that as far as the functions are concerned. It was a direct rule model, and one of its key parts was that there would be no local representatives about the place. That is a mistake, particularly with regard to the third arm of the strategy — prevention being better than cure, health promotion and the move towards primary care and work in the community, particularly those suffering health inequalities. There is a strong role there for local representatives and local government.

You also asked about locally-based commissioning. That will be one of the ways — along with performance management and financial management — of managing efficiencies through the trusts. I see a strong role for that, and that will be one of the key planks of the RPA when it comes out. We have had this discussion before, and I will be in a position to share my thinking sooner rather than later.

Dr Andrew McCormick (Department of Health, Social Services and Public Safety):

The large increase in the total budgets over the past couple of years has been a direct consequence of the decision by the Prime Minister and the Chancellor in 2002 to raise UK spending on health to a larger proportion of GDP towards European and world standards. It was a deliberate decision to give a stronger priority to health. It is only natural, therefore, that the number has risen significantly, and it should not be surprising. It is a recognition of a strategic decision at UK level to do that, and it has been sustained. The recent Wanless report states that ongoing real-terms increases of around 4% a year should be sustained, and Appleby also said that about our situation. The rest is mathematics. The increase from £2 billion to £4 billion is what happens if you want to raise health spending as a proportion of GDP.

There has been significant progress in performance through the implementation of an incentive-based system, and we are working on other ideas. Waiting times have improved through a combination of investment and strong managerial and political commitment from Ministers and management. The outpatient waiting list has dropped significantly. It needs to go further, but major progress has been made. In recent weeks, there have not been any 12-hour trolley waits in accident and emergency departments, and there has been a significant improvement on the four-hour standard. We are making progress through incentivising the trust leadership teams, and they are working well with us; there is strong progress on that. There have been significant improvements in performance, driven not solely by investment of money but by better management and better incentives. In looking at the design for our financial system, we want to build on that and make it stronger.

Mr Don Hill (Department of Health, Social Services and Public Safety):

Your first question related to innovation, of which I am sure that there are many small examples. However, perhaps the biggest example of innovation relates to the pharmaceutical budget, which amounts to £0·5 billion. An innovative approach to therapeutic tendering has been the prime factor in securing savings of £55 million to date. It is expected that a saving of a further £40 million will be achieved during the period of the comprehensive spending review. People in England and further afield are considering the techniques that are used by pharmacists in the Department and in the boards. Therefore, the work on the pharmaceutical budget has been the best example of an excellent piece of innovation, and one that has a genuine return.

The Chairperson:

The Committee will not reach agreement today on some of your points, but we will deliberate on them. We saw a massive improvement when Shaun Woodward — an English Minister — decided that he wanted to see an improvement in waiting lists and a reduction in waiting times. Why, in that case, can we not accept again the Agenda for Change system, which was established under direct rule? For some years, it had been agreed that adopting Agenda for Change was the way ahead, thus allowing the savings to go through the one authority and the local commissioning groups. The management of the four boards is top heavy and is staffed by people who would like to leave their employment but are unable to do so because of the Minister’s indecision about whether to have one authority, rather than four boards. That issue will run on for some time, and a great deal of money could be saved in that area.

I could describe many other areas in which I feel that savings could be made; for example, in the cluster of A&E units in the Belfast city area. If Shaun Woodward’s approach to reducing waiting lists was a good idea, what is the reason that the direct rule Agenda for Change and all that it encompassed is not implemented, with the single authority included as a way to gain efficiency savings. We must bear in mind that we have just lost David Sissling, who was brought in to oversee the new dispensation and to be the authority’s chief executive. If the problem could be resolved by including people who had not been included in the previous idea, surely it is simply a matter of identifying those people and putting them in.

Mr McGimpsey:

We are fully utilising Agenda for Change, and we have done our job-matching exercise. Alex Easton has consistently asked about that. All matching for Agenda for Change will be completed by the end of December, and everyone will receive new rates of pay by the beginning of April 2008. We have given that undertaking. However, there have been delays, and I have met with trade unions to discuss those. All the matching was done, but we had yet to complete work on the administrative and clerical grades, which were basically at the end of the tail. However, those are being worked through now. It takes one hour of staff time to match each individual under Agenda for Change. Therefore, the project represents a huge amount of work, especially when one considers that approximately 70,000 people are involved.

It was anticipated that by the time that the boards were amalgamated, we would have saved 20 posts by 2007-08, 50 posts by 2008-09, and that the bulk of the savings would come in the third year. We are ahead of the first and second years as far as those numbers are concerned. We have already made those reductions; therefore, there is no cost as far as the anticipated efficiencies of 2007-08 and 2008-09 are concerned.

Bringing new people in is more complex. For example, the direct rule Minister decided that there would be seven local councils that would be coterminous with seven local commissioning groups. It seems to me, and I am a member of the RPA ministerial subgroup chaired by Arlene Foster, that it would be extravagant to have 26 local commissioning groups for the 26 local councils that presently exist. We are trying to find agreement on the number of councils, and it is highly questionable whether we could agree on seven. Therefore, there are an indeterminate number of councils, and I am looking at other possible numbers. That is one of the indeterminate factors; for example, we could make the local commissioning groups coterminous with the five trusts.

The local commissioning groups are an important tool in ensuring that the efficiencies required through the trusts are delivered, so I want to get the right. Of the 15 members on each commissioning group, four are GPs, but we must ask whether that is enough. I want a mental-health and learning-disability practitioner on each group. The level of financial discipline that those commissioning groups can exert is important as it will be a key way for them to assist in the required efficiency drive. The local commissioning groups are about matching local need and provision; instead of the trusts providing what they think they can, the commissioning groups must plan and determine the healthcare requirements of the area and population for which they are responsible. The commissioning groups are not sitting around doing nothing; they are very busy. I had a meeting with the chairpersons of the commissioning groups last week, and they assured me that they are fully behind me in working through the process. We will tackle that issue sooner rather than later.

Commissioning groups are a key element that must be got right, as are performance management and ascertaining how targets and tariffs are worked out. We are dealing with large organisations; for example, the Belfast Health and Social Care Trust has over £1 billion and a large population to deal with. Therefore, achieving efficiency through the system is imperative, and that is one of the three key aims in the Wanless Report. Although achieving the efficiency target of £343 million is a huge ask, I am determined to do so.

The Chairperson:

Before I ask Alex Easton for his question, I will relay some comments from the BMA, which were not flattering about the treatment of the local commissioning groups. One south Derry chemist said that they are all sitting in sheer frustration knowing:

"that our knowledge is not being utilised in the commissioning of services."

The BMA says that a considerable number of pharmacists are telling the Minister that the delay in the review of public administration could have serious consequences for NHS patients. Those people must be listened to, given that they are at the coalface and are trying to do their job with, it appears, their hands tied.

Mr Easton:

The Minister said that there is a shortfall of roughly £300 million in the draft Budget. Given that, what Departments does the Minister think that that £300 million should be taken from in order that his Department can get the extra money that he claims that it needs? Does the Minister agree that it is possible that his priorities and budget are wrong? The Department bid for £8 million, £12 million and £16 million over the three-year period, yet when Professor Roy McClelland gave evidence to the Committee, he said he could get stuck into the Bamford recommendations with bids of £4 million, £8 million and £12 million.

If Professor McClelland is saying that, and the Minister is quoting a different figure, surely the Minister’s figures might be slightly out. Do you see where I am coming from? Perhaps the Department’s productivity figures are not quite right: they seem to be at odds with those of Professor McClelland.

The Minister referred to inescapables. Are many of those inescapables new functions? If that is the case, is it not true to say that there are an awful lot of new functions, and that it may be misleading the public to say that we are not getting a lot of new functions?

Compared to the rest of the UK, our spend for each member of the population is 10% higher than that in England; the number of health-related jobs is 23% higher; and we have 51% of all additional new resources in the Northern Ireland Departments, which is around £454 million. Does the Minister agree that he has new money that is worth £454 million? Where does he propose to get the extra £300 million? He has 48% of the overall Budget, he will have £4·3 billion by 2010-11, which is up 19% since 2006-07, his efficiency savings will provide another 9%, which is more than double the level of 2000-01, and he will have over £2 billion more than the previous Executive gave to his Department in 2001-02.

However, staff productivity is down 11%. In the past five years, staff costs are up 21%, with hospital activity increasing by only 6·3%, which indicates that the 12·5% productivity drop will see staff costs increase by 40% for the period 2001-06.

The number of Health Service administrators has increased by 36% since 1997 — I hope that I am not going too fast for the Minister — and the average cost of prescription items is 10·3% higher than in the rest of the UK. Where is the Minister going wrong? Why can we not reduce efficiencies and costs in order to improve our Health Service?

Can the Minister tell me whether he is planning to ring-fence any money for carers’ packages for senior citizens who are looking after people who have learning disabilities and mental-health issues? There appears to be a lack of funding for those carers, and there is a great deal of concern about them. Some of those people are elderly and are not getting any respite care, and many are concerned about who will care for their loved ones when they pass on. Will the Minister fill me in on that situation? It is very important to me.

Will the Minister comment on a newspaper report from Dan McGinn — I think that he wrote the article — about his Department’s leaking information about a fire station? Is there an investigation into the reason that his Department is leaking such information to the press? Further to that, does he take such matters seriously?

I think that is enough to be going on with for the moment.

The Chairperson:

I will hand over to the Minister and his officials. Mr Easton asked a number of questions in one fell swoop. However, I suppose each person takes their turn and gets the questions.

Mr Easton:

I was just scared that Kieran was going to ask questions before me.

Mr McGimpsey:

As far as the Budget is concerned, simple mathematics has been used to keep us on a level with the Health Service in England. We need £300 million; the gap is currently £300 million and is not closing. Our gap will be £600 million in three years’ time; that is indisputable. I never hear anybody —

Mr Easton:

Where will we get that extra money?

Mr McGimpsey:

I will try to pick up those points as best I can, and if I have missed a few, I will bring in my officials.

With regard to the service development in mental health, which is my number-one bid, the Department originally asked for £11 million, £15 million and £24 million. It got £2 million, £4 million and £10 million. Therefore, in years one and two the Department is getting roughly one quarter of what is needed. I appointed Roy McClelland as chairperson of the Mental Health and Learning Disability Board, and he is very enthusiastic. I am not saying that the Department can do nothing with £2 million and £4 million for mental-health services, or £2 million and £3 million for learning disability in years one and two.

Roy McClelland is keen to see movement. For example, the allocation will allow me to recruit about 30% more psychotherapists, to resettle in the community about 36 long-stay mental-health patients, and to provide better support for victims of sexual and domestic violence. Over the three years, it will allow me to resettle and support learning-disability clients at a rate of 10 in year one, 20 in year two, and 44 in year three. It will also allow me to provide respite packages and improve autism services.

That is all that I wanted to know.

Mr McGimpsey:

Our expenditure is increasing by £700 million. That leaves a deficit gap of - £250 million. That is the state of the Northern Ireland Health Service’s current account: a deficit of £250 million.

You made a few other points about hospital productivity and staff. It is important that we deal with those points.

Dr McCormick:

The levels of expenditure and staffing are higher for each person in Northern Ireland because need is greater. That is an established and well-known fact. In 2002, the Department of Finance and Personnel-led needs-and-effectiveness evaluation agreed a figure of a 17% differential need. Therefore, a differential expenditure of less than that leaves a gap. That position was agreed formally by the Department of Finance and Personnel in 2002 and confirmed with similar figures — according to our information — following the work of John Appleby.

The differential expenditure can be explained mainly by social deprivation. Where there is greater social deprivation, there is a greater need for healthcare. That is well established, and strong research evidence shows that correlation. Our academic advisers, who have been working with the Appleby steering group following John’s work, confirm that. That is well established.

The Chairperson:

Colleagues, I am aware of the time and —

Mr Easton:

Will the Minister explain why he has just said that there is a gap of £250 million, yet five minutes ago he said that the gap was £300 million?

Mr McGimpsey:

The member is confusing two figures. We are £300 million behind England. That gap will double over three years and become £600 million. The £250 million that I mentioned is the difference between the £450 million of new money and the £700 million cost of inescapable pressures. That leaves -£250 million. If you want to express that as though it were the balance sheet of a private business — and I have been a businessman all my life —it reads as follows: income: £450 million; outgoings: £700 million; result: -£250 million. We will close that gap, but it must be done with efficiencies made in the Departments.

Dr McCormick:

With respect to the member’s point about productivity, the differential established by the Appleby research applies only in the acute hospital sector, which is around 40% of the total budget. Therefore, there is no evidence for a productivity differential in the remainder of the budget.

In the hospital sector, as a result of judgements made by previous Ministers over the years, we have a more dispersed system of hospital provision than England. That is a matter of fact, and the region chose to have such a system, which is, by definition, less productive. Furthermore, features have been added in the past number of years, such as the European working time directive, which limits the hours that staff can work. We are therefore coping with legislative constraints that require reduced productivity.

Therefore, the system, the management and the leadership teams are working to improve productivity, but the context dictates limitations. We are doing all that we can, but there are limits.

The Chairperson:

Alex, if you wish, at some stage, we will return to that point.

Rev Dr Robert Coulter:

I look at the problem from a different angle. The Health Service says that it puts patients first. Dr McBride, please tell the Committee whether you are satisfied with the draft Budget. If not, and if it remains as it is now, tell us how patients will be affected.

Dr Michael McBride (Department of Health, Social Services and Public Safety):

It is my role as Chief Medical Officer to monitor the health of the population in Northern Ireland and to advise the Assembly and Ministers. I have done that, and I was afforded the opportunity of presenting my first annual report to the Committee in June of this year.

In that report I sought to highlight the significant differential need that exists in Northern Ireland compared to other parts of the United Kingdom. We have enjoyed significant improvements, including the increased life expectancy of the population and better health outcomes. For example, there has been a 55% reduction in deaths from heart disease over 10 years, which is due to the priority that has been given to health. However, a persistent and significant health inequality remains regarding the life expectancy between the poorest and the most affluent in our society.

If we compare our 20% most deprived areas to the Northern Ireland average — not the most affluent — we will see that the difference in life expectancy between those areas is four years for men and two years for women: that is a fact. Those are the challenges that we face in Northern Ireland. Indeed, we have already discussed some of those this morning.

The stark reality is that people who live in the most deprived areas are three times more likely to die before the age of 75. The draft Budget, if accepted, will present us with significant problems, particularly in those communities that are hard to reach. Years one and two will be particularly challenging.

As the Minister has indicated, we had ambitious plans to reduce the health inequality gap by investing in preventative measures to improve the health of the people in those areas. Other health problems that are prevalent in those areas include: childhood obesity; high numbers of smokers; alcohol and drug use, including binge drinking and underage drinking; and sexual health and teenage pregnancy.

The community health programmes and the programmes aimed at reducing harm to children in the homes of the 16,500 problem drinkers in Northern Ireland that we proposed will now be delayed until 2010-11. That will have a significant impact, and I have major concerns about that.

I am conscious of time, so I will briefly highlight a couple of other areas that concern me. Over the CSR period, if the draft Budget is accepted, Northern Ireland will be the only part of the United Kingdom that does not offer breast-screening services to women over the age of 64. Approximately 900 instances of breast cancer are diagnosed each year in Northern Ireland, some 300 of which are picked up through routine screening. We know that the screening programme is effective because the five-year survival rate of those women is in the region of 97%. As I have said, all other parts of the UK currently provide that service. We will now not be able to provide it until 2010, which will mean that 40,000 to 45,000 women each year will not benefit from that programme.

We proposed to introduce a vaccination programme for the human papillomavirus to prevent the 80 cervical cancers that are diagnosed each year in Northern Ireland and the 30 deaths. The constraints that the draft Budget — if accepted — will impose will significantly delay the implementation of that programme. For the first time ever, Northern Ireland will be the only part of the United Kingdom that has not rolled out an immunisation programme in concert with the rest of the United Kingdom.

The Joint Committee on Vaccination and Immunisation recommended that the most cost-effective way to run that programme was to provide it for 12- to 13-year-olds through schools, with a catch-up programme for those aged from 13 to 17. As we are unable to provide that catch-up programme until 2010 at the earliest, there is every likelihood that there will be two cohorts of children — fifth formers in 2009-10 and those in lower sixth in 2010-11 — who will not be offered that vaccine in schools.

We may be able to devise other means to offer that vaccine through GPs or elsewhere, but a significant opportunity will be missed for that cohort — 11,500 girls in year 12 to 13, and perhaps fewer in fifth form and lower sixth. Those young women and children to whom the programme cannot be offered will therefore miss a lifetime vaccination opportunity.

Bowel cancer is common in older people. We will be offering bowel cancer screening in a limited way in 2010 to people between the ages of 60 and 69. Wales and Scotland already offer a similar programme for people between the ages of 50 and 74. The Health Service in England is about to introduce proposals to extend its programme to include people between the ages of 50 and 75.

The draft Budget, as it stands, will present us with particular challenges over years one and two, given the level of need, which I highlighted and explained to the Committee in my annual report. I am concerned that those who are most disadvantaged in the community will be further disadvantaged, particularly in the first two years of the proposed Budget.

The Chairperson:

OK. That was a lengthy and detailed explanation. What will be done about the breast screening unit that was chased out of the Markets area? There has been a low uptake among women in that area. What will be done to ensure that they get the appropriate screening, following the intimidation of the two women on the bus?

Dr McBride:

That was a novel pilot scheme being taken forward by the Eastern Health and Social Services Board to try to target people in disadvantaged communities. Look at cervical screening in particular — only seven in 10 women take the opportunity of vaccination. The programme was designed to offer smoking cessation services as well as cervical screening, breast screening, and advice on diet and obesity and other matters. That pilot scheme will continue. It operates on the basis of engagement with local community groups to ensure that women have the opportunity to avail themselves of the service somewhere close to their homes.

The Chairperson:

I hope that the matter will be investigated and that the person who issued the inappropriate threat dealt with, because he is paid by the Health Service.

Mrs O’Neill:

I thank the Minister for meeting the Committee today. I agree that we have to get things right. There are high expectations out there, and we must meet them as best we can. We have seen the document explaining the inescapable pressures facing the health budget. It helps me to understand that they really are inescapable. However, it gives the costs of pandemic flu over the next three years as £4 million, £4 million and £20 million. Maybe there is a simple explanation, but why is there such a big jump from £4 million to £20 million in the third year?

At lunchtime today we met the allied health professionals (AHPs), who raised concerns about insufficient representation in the Department and the various trusts. The Committee will come back to you on that issue, Minister. One of their biggest concerns is that, because they are not properly represented, they will be most adversely affected when the Department comes to make efficiency savings.

One of the Department’s public service agreement targets is that, by 2011, it will provide more enhanced respite care packages. Will the Department be able to meet that target with the Budget resources that it has?

The Committee has today received the consultation document on the stroke strategy. Has money already been set aside for that strategy, or will that also be placed in jeopardy because of the Budget?

Mr McGimpsey:

Allied health professionals play a key role in the process, and I will ensure that they are not disadvantaged. I have met them, and I will ensure that they are represented all the way through the local commissioning groups.

I launched the stroke strategy last week. Approximately 4,000 strokes are reported every year in Northern Ireland. One third of stroke patients make a full recovery; one third die within a month; and the other third survive, but with forms of disability that require support. The key thing about the stroke strategy is to get help quickly in order to best prevent brain damage, and that means increasing the number of people who are scanned quickly so that they can benefit from clot-busting thrombolysis drugs. That is an important area, as is rehabilitation. There is some money there but it is not what we were looking for, and it is not enough. It is one of those areas that will suffer. We suffer some, and, although we are getting money through, it is not always what we want, and this is one of the areas that we see as vital.

Dr McBride:

The pandemic flu figures represent the Northern Ireland contribution to a UK-wide preparation for pandemic flu. As the Minister has said, the assessment is a scientific opinion, and the advice is that it is a question of when, not if. Therefore, our level of preparedness must be high, and we have been involved in a number of significant exercises across Government to ensure that our level of preparedness is as it ought to be.

The money will fund a number of objectives, such as increasing our stockpile of antivirals — we aim to have enough for upwards of 50% of the population, to allow for the anticipated attack rate of flu virus. We also need to put in place sleeping contracts with drug companies, so that as soon as a vaccine becomes available — it will become available, but perhaps not for six months or more — we can vaccinate the population that has not been infected with the flu virus. Clearly, under health and safety legislation we have a need to protect healthcare professionals — doctors, nurses, general practitioners, allied health professions, and all of those who will be working in this area to treat and care for patients.

We estimate that the attack rate will be somewhere in the region of 50%, that the case fatality rate will be approximately 2·5%, and that it will come in several waves. We anticipate that in Northern Ireland, during each wave of six to eight weeks, we will have approximately 10,000 to 15,000 excess deaths per wave. Therefore, the scale of the moneys that are being set aside is significant, and it is significant because we have a significant problem on the horizon. You will be familiar with recent media reports that H5N1, or avian flu virus, is still circulating. There have been 329 cases of H5N1 transfer to humans, and over 200 deaths, so it is a significant problem. The costs in terms of stockpiling drugs, antibiotics and facemasks, as well as the sleeping contracts for pre-vaccine production, are significant, and they escalate as the contract kicks in in the third year.

Mr Hill:

Respite features significantly in disability and learning disability. The figure is something like 200 packages for disability and 100 for mental health, which is significantly less than is required. The care strategy was a significant influence on what we were trying to do when we submitted our bids, and it has been prioritised within the reduced amounts that are available, but is limited in terms of its impact, particularly in the first two years.

The Chairperson:

Are you aware that there are over 6,000 allied health professionals, and that one person sat on the board? That person has been off on sick leave for eight months, and has not been replaced. There is a wide spectrum of allied health professionals, from speech therapists through to all of the other professional services; does that representation not seem inadequate?

Dr McCormick:

That point has been made many times, and I recognise —

The Chairperson:

You have to look at that as a matter of urgency.

Dr McCormick:

We have written to the trusts to strongly encourage them to have AHP representation within their structures. We are trying to move away jobs being defined by particular professional disciplines, and have all professionals — including AHPs — contributing to leadership and management roles in the organisations. That is our strong commitment, and we depend, in many ways, on AHPs in a whole range of services. That is well recognised, and care must be taken to ensure that, when we implement the efficiency gains and so on, the right balance is in place to enable effective delivery of services.

The AHP representative in the Department has now returned to work after her period of illness. In her absence, we tried to maintain some working relationships and representation. More could be done, but I assure the Committee that we remain strongly committed to listening to, and working with, the AHP group.

Mr Gallagher:

Quite apart from my role as a member of the Health Committee, as an Assembly Member I support your bid for additional funding, because my experience of the Health Service has been that there is a great unmet need for services and that there is poor delivery at present.

I blink when I see the list of inescapable pressures and your bids for resources to meet those needs. You say that, if the bid were successful, the main component of the care needs for older people would be met within six weeks. Given the situation that the Health Service is in at the moment, I cannot envisage that happening. You talk about the importance of people being comfortable and safe in their homes, regardless of whether they are young or elderly. Indeed, there are many young people for whom the level of available care is by no means what it should be. As a member of the Health Committee, I certainly support your bid, although I have some reservations about efficiencies and service delivery.

We are three-quarters of the way through the first year of the new trust structures, and, as yet, I see no sign of any greater efficiency in services. The new structures were heralded as cuts in bureaucracy, and it was claimed that the people on the ground would see a difference in service delivery. At this juncture, can you say whether the trusts are delivering more efficiently in any way? Has some of the top-heavy administration has been thinned out of the service, allowing the money to reach the services on the ground, where it is needed?

I would also like some clarity on another point. You said that, under Agenda for Change, back pay is due to workers, and I think that you mentioned April. I just want to be sure about this matter, because it is brought up so often by the people who are affected by Agenda for Change. Can you say in which month workers will receive that long-overdue pay — will it be April or May?

Mr McGimpsey:

As far as Agenda for Change is concerned, all job matching will be completed by the end of December. Folks will be on their new rate of pay from April, and they are entitled to back pay. I am not 100% certain which pay packet that back pay will be in. I can write to the Committee to let you know about that.

The number of trusts has been reduced from 19 to six — five hospital trusts and the Ambulance Trust. That is a major saving — or will be, as the process rolls out. The new trusts have been in operation for only nine months, so it would be premature to say that the new structures are a bad idea. Time will tell. Although the new arrangements for the trusts were based on a direct rule model, I have confirmed that that is the appropriate number of trusts, and that seems the proper way to proceed. That said, I do have concerns about efficiency within the trusts. That is why I am examining in detail areas such as performance management, financial control, commissioning, and so on in order to try to ensure that the trusts deliver in the way that was envisaged.

As far as older people are concerned, an important part of the Department’s strategy is to move patients out of hospital where possible, because they do better at home. Therefore, care packages are needed in order for those people to be looked after at home. It is clear that people who are moved out of hospital and cared for in their own homes live longer and are happier. That is why the Department has made a couple of bids for care packages. I am disappointed that those are not being met, not least because care packages help to free up hospital beds. It is more cost-effective to look after people in their own homes than in a hospital setting. Last week, I spoke to a district nurse in the Royal Group of Hospitals, who told me that her per annum budget is £140,000 to look after several patients, compared to an annual £1 million in terms of the cost per week of hospital beds. Although it may not always be as much as that, there is obviously a strong cost-effective argument for care at home. However, the prime reason is that patients live longer and are happier. Moving patients out of hospitals is, therefore, a key part of the strategy.

Mr Gallagher:

I do not believe that I said that it would be a bad idea to reduce the size of trusts, and I certainly did not intend to imply that. However, if efficiency is to be achieved, the Department must assess that and keep the pressure on, even from year one, in order to ensure that progress is made.

Dr McCormick:

The Department will do so.

Mrs Hanna:

I welcome the Minister and his colleagues. I am sure that, 60 years ago, Aneurin Bevan could not have imagined the almost infinite demands on the Health Service, not to mention the expectations. However, I am a strong believer in the National Health Service, which must be free at the point of need.

It is worrying that screening is having to be limited. Not only does it save lives, but there is, undoubtedly, an economic argument to be made for diagnosing diseases earlier. The mental-health spokespeople have also made a good economic argument for prevention and early intervention. However, I am aware that that does not fit easily into short-term budgets, which is part of the problem. Although I agree that there is a shortfall in the budget, more savings must be made.

Last night, I looked through the inescapable bids. I am not sure that even a well-qualified accountant could make much sense out of them. Pay reform and inflationary uplift are mentioned on the first page. Perhaps it is not entirely appropriate to say this here, but I have mentioned it before — as has Appleby. I know that, at times, we all quote Appleby to suit our own needs: his report is all over the place in the sense that while he demonstrates that there is greater need, he makes it clear that we spend more.

Appleby also questions why Northern Ireland stays in line with GB on pay for consultants and GPs. There is such a wide gap now between their pay and that of nurses and other allied professionals. It is almost like a deprivation gap. Even some GPs were shocked the last time that they got more money. However, under the section on pay inflation and pay reform, it states that there will be a minimum of £1 million more per annum — or it could be a totally different amount — for staff and associate specialist doctors as part of a new national pay contract. I do not know what that is about. It is included in the inescapable bids.

Under pharmaceutical services, you mention a 9% increase for drugs. I appreciate that there are many new drugs for cancer and quality-of-life diseases, but have you set targets to reduce the number of GP prescriptions, to ensure that more generic drugs are prescribed, and to prevent repeat prescriptions that seem to go on ad nauseam in some cases, with people not using their medication, but still phoning the doctor for more? Targets must be set to try to at least start to offset the increase. I am not an accountant, and the figures involved are huge and compare with those involved in running a large business. The Committee has only been given the headline figures — we need more detail.

I appreciate that and, as a former hard-working nurse, I do not begrudge the small percentage increase that many people are getting, but a large gap is emerging.

I appreciate that there are many new drugs for cancer, HIV and so forth, but there is no breakdown of their cost here, just one large lump sum. If we had at least a bit more detail on all the bids, we might better understand exactly where the money is going.

Mr Hill:

We are happy to give a breakdown of the figures.

The intention behind reforming the pay of consultants and GPs was to achieve flexibility, to get clarity on what people are doing, to reward the achievement of GPs, and to establish control over how consultants work. The benefit from that is already coming through, and GPs now do much more than they used to. They are doing work that would otherwise have been provided by secondary care facilities and providing services locally that were never provided before.

Mrs Hanna:

We hope so anyway. Kieran will, no doubt, tell us all about that.

Mr Hill:

It is that quality agenda that the contract seeks to buy. You mentioned the pay deal for staff and associated specialists, and the same principle applies there: that pay deal is unlike pay deals in the past that simply meant an increase in salary. The concept of pay deals nowadays is that pay is increased in exchange for flexible, or different, ways of working. The challenge for the Health Service, and for us, is to realise the benefits of that. If we spend over £200 million on implementing all those pay deals and do not get different and more flexible ways of working in return, the money spent on the pay deals will have been wasted. The challenge is to realise those benefits. There is evidence of such benefits coming through in those areas, but more can be achieved.

You mentioned the revenue consequences of capital. Some 60% of that is simply capital depreciation and cost of capital. The balance relates to the opening of new premises, partly because they provide additional capacity, but also because they provide different standards. Therefore, the cost of opening new facilities in the hospital sector is higher than the cost of current facilities, because they are better. The revenue consequences of capital are a serious aspect of capital planning. It is disappointing that that was not highlighted as an issue for the Government in the investment strategy. When we do our review of what the £2·4 billion will buy, it will not simply be a question of looking at the £2·4 billion in bricks and mortar: it is about looking at the £500 million revenue consequences of building it. The revenue consequences of capital involve accounting for the cost of it. Operating it is also an immensely important part of capital planning.

Mrs Hanna:

Will you set targets for GPs to reduce their prescribing? With regard to consultants and GPs, I would reward them after I saw more change, rather than up front.

Dr McBride:

At the outset, the Minister mentioned investment in health being an investment in the wealth of society. A recent report from England on preventative health interventions demonstrated that a one-year increase in life expectancy, through preventing some of the major causes of ill health, such as obesity and promoting better mental health, would translate into an £800 million benefit to society — £20 million in Northern Ireland. A five-year improvement in life expectancy would translate into an additional 0·3% to 0·5% growth per year in GDP. Therefore, there is a strong economic argument for investing in health. The same report showed that it would result in a £4·75 billion reduction in public expenditure in England and a £2·75 million reduction in employers’ costs. Those are significant economic arguments for preventative intervention in public healthcare.

Mr Hill:

I was making the point earlier that there was a genuine success story because measures were being taken with regard to repeat prescriptions and more use of generic drugs. A 10% increase in the use of generic drugs has already resulted in a saving of £55 million a year. We expect that figure to rise to £100 million a year by the end of the comprehensive spending review period. That is a genuine success story that has required a great deal of co-operation across all elements of the health sector, and it is well worth lauding.

Ms S Ramsey:

I applaud that initiative. It can be seen as efficiency savings. It is useful that we now have a local Minister, so I welcome you here today. I agree that the Health Service has been a mess under direct rule Ministers. It is useful to have better interaction between officials, the Health Committee and the Minister. There is a need for a quality service from the cradle to the grave. I hope that it is a top-class service, even if that means upgrading existing services.

On the issue of efficiency savings, Mr Hill gave a presentation to us some weeks ago in which he said that, due to the implementation of some of the review of public administration, there would be a saving of £53 million. However, when we teased that out, we were told that it would cost £70 million to implement at first. I understand that there is legislation, and we need to look at that. Understandably, some people get fed up when they hear that, on the one hand, the Health Service needs additional money, and, on the other hand, £70 million is being used to pay off senior executives.

Agency staff is another issue that we must address. I wrote to the Minister some months ago asking about the millions of pounds that are being paid to agencies for their staff. Those are only my suggestions.

I want to move on to the issue of parity. Some people are all for parity when it suits. The Minister says that we are underfunded by £300 million. Did that money go into the block grant? I assume that it did not go directly into the Health Service but was allocated and then went into the block grant.

My next question is about the Appleby Report, about which we have heard several times. Will the Minister tell the Committee by how much Appleby says that the Department is underfunded? How much money did the report state could be saved through efficiencies? If the Minister gives the Committee that information, it will have heard both sides of the efficiencies argument. Is the Minister aware of any further information outstanding on the Appleby Report from either the Department of Health, Social Services and Public Safety or the Department of Finance and Personnel? The Committee needs to know all the information.

The Minister is well aware that the Committee is conducting an inquiry into suicide and self-harm. In your view, will the Bamford Review be implemented within the time frame that has been indicated?

There seems to be a great deal of difficulty with the issue of breast screening; indeed, Mary Harney is having trouble with that issue. I do not wish to get involved in a political discussion about it, but can the Minister tell us whether there have been discussions with the Department of Health and Children in the South? It strikes me that the problems in the North are similar to those in the South, and it might be useful for the two Ministers to get together to see how they can ensure that a proper service is delivered for those who need it.

Investing for Health has been mentioned again and again. It would be useful if the Minister could give an update as to progress on, and the current position, of acute services.

Mr McGimpsey:

I will run through those points briefly, Sue, then I will have to call in the officials. Michael will respond to your query on Investing for Health and breast screening.

However, the difficulty with breast screening is the problem of recruiting radiographers and radiologists. It is not just a Northern Ireland problem; rather, it is a UK-wide, British Isles-wide, all-Ireland problem. A problem occurred in Antrim Hospital that created a large waiting list with the result that we were not hitting our targets in that area. Any help that Antrim Hospital borrowed from the Belfast hospitals meant that the waiting lists in those hospitals also slipped. However, the position is rapidly being recovered, and within approximately one year we will be back to where we should be.

Full implementation of the Bamford Review is not possible under the draft Budget. However, we will make a start on it. Roy McClelland is enthusiastic about the work, and I do not want to dampen anyone’s enthusiasm. We are in the first three years of Bamford, and it is a 10- to 15-year programme. However, we cannot fully implement it on the resources that are available.

Figures from updated work on the Appleby Report revealed a 10% differential in health need and a 36% differential in social services. An Appleby group works with the Department of Finance and Personnel and with my Department. It has signed off on the 10% health figure, and it is fit to sign off on the 36% social services figure. Altogether, that represents a 14% to 15% gap.

The same formula is used throughout the UK to work out the block grant. The Executive allocates the Northern Ireland block, and it is on that allocation that my argument is based. I have said that there is enough money to pay for my proposals.

The member spoke about agency staff. As we re-examine primary care and, for example, move people out of hospitals, hospital beds will be freed up and staff will move out of hospitals and into a community setting. That means that there should be a much-reduced demand for agency staff. That is one strategy on agency staff that the Department is considering.

A plan is to make efficiency savings of £53 million a year, but an investment must be made to get that started. Over 10 years that amounts to £500 million, and over 20 years it will be £1 billion, never mind pay increments that will be added to the current base. The investment will therefore be more than £70 million, but it will result in savings each year.

Parity was mentioned, but there are national pay deals for doctors, consultants and nurses. As part of the Kingdom, we are entitled to pay those. Everyone here pays National Insurance and tax. If that parity were broken, incomes for consultants, for example, would be less than they are on the mainland. Therefore, the worry is that a brain drain might be started.

Ms S Ramsey:

That was not what I asked about parity. The Health Service here should get an additional £300 million in order to have parity with England. Was that allocated, did it go into the block grant and where is the parity?

Mr McGimpsey:

That is the point that I keep making. The Department asked for parity with England. There is a parity gap of £300 million, and that will double over the next three years.

Dr McCormick:

That issue raises the question of the Barnett formula. The amount of money that comes across is not enough, in itself, to provide for the same rate of growth. That is a deliberate and clear policy of the Treasury’s; it is trying to secure a gradual, long-term reduction in Northern Ireland’s lead in public expenditure. It means that the Executive have a dilemma as it is impossible to use that money, and it can be secured only by other means such as reprioritisation or other interventions. There is a long-term issue with the Barnett formula.

Dr Deeny:

I will try to be as concise as I can. I thank the Minister and the witnesses for coming.

Two of my questions have been answered. First, I add my voice to those of the members who spoke about the allied health professionals (AHPs). I did not realise until this afternoon that AHPs were so underrepresented. For example, I am told that when the LCGs get off the ground, 0·5 % of their staff will be AHPs. As the Chairperson rightly pointed out, AHPs represent a lot of professions, including occupational health therapists and physiotherapists. They are very much in touch with the community, and they work with GPs. They know what the people need. The ludicrous suggestion that was made today was that AHPs would represent only 0·5% of healthcare professionals. That would mean that there would only be one AHP for every two LCGs, which is nonsensical. I suggest that there should be at least one AHP in each LCG.

Mr McGimpsey:

I agree with that.

Dr Deeny:

Thank you for your commitment on that, Minister.

Secondly, I also commend your commitment on the Agenda for Change to correct the wrongs that have been done. A paper was given to me on that matter by a representative of four individuals. However, it applies not only to clerical workers but to people such as builders. If Julie would pass the paper around the Committee, members will see that, for example, there has been a huge discrepancy between engineers and builders over the past number of years. It would be nice if we could reassure our constituents that that will be put right next year. The paper illustrates how the discrepancy between engineers and builders has widened. It is nice to hear the Minister’s commitment on that, and I thank you for it.

On prescribing, and coming in after Carmel —

Mrs Hanna:

It is nothing personal.

Dr Deeny:

Absolutely not.

Sometimes, I think that all of us around the table have difficult jobs. Health is a difficult area. Many GPs, including those in my own practice, have been making a lot of savings in generic prescribing. Although the figures are based on the UK as a whole, the Department is predicting that savings of around £50 million extra a year will be made. Where do you see that money coming from? Will it be made through demand or through the use of statins and so forth?

I did not get a chance to participate in the debate on Health Service reform on Monday because I was in my sick bed with my wife and my political secretary — not in the same bed, I should add. [Laughter.]

I watched the debate on television. As you probably know, Minister, I have been added to the feasibility study group to ascertain the need for a midwife-led maternity unit in our area.

I have a concern about the shortage of midwives, although that situation may not be resolved through this draft Budget. Many midwives are close to retirement. What is the Department doing to ensure that we have an adequate supply of well-qualified young women and, indeed, men, who can deliver a service that provides choice for women? I recently visited midwifery units in two rural hospitals in Scotland, and I saw how delighted the mothers were and how enthused the midwives were once they got used to the system. We must re-examine midwifery training thoroughly.

I have worked in the Health Service for 27 years, bar one in Australia, and I have worries about the impact that the review of public administration will have. Last week I received some information from the Western Health and Social Care Trust on nursing structures, and I shared that with some members of the Committee. There are now four tiers of management in the organisation. Twenty-five pages of information have been emailed to me today on issues such as family support, healthcare, children’s mental health, and disability. I am not alone among health professionals in believing that the review of public administration was going to deliver a great deal more.

Alex Easton said that we spend around 23% more on healthcare administration here than is spent across the water. Having worked as a GP, I see evidence of that. All sorts of people and titles are cascaded down through all four tiers of management. The sum of inescapable bids amounts roughly to £100 million extra each year, and yet people have all those titles, and I do not even know what half of them mean.

We must examine how the Health Service is administrated. The problem is not your fault, Minister; it has been growing like an infectious disease, getting worse and worse. For example, one management position could exist, but all of a sudden another two are being created. I received a letter today from a medical consultant in the Western trust, who is concerned about the number of managers who are employed in the organisation. If we are going to make efficiency savings we must seriously consider the number of people who are employed in the Health Service and ask what they are doing and whether they are necessary. The documentation that I have that relates to a particular trust will show title after title and name after name. If we are going to put patients first, we must consider administration seriously.

There are some good managers. Although I do not want to single out any individual, one person in the Western trust who is responsible for family practice is a marvellous manager. In general, however, the situation has got out of control. We all agree that efficiency savings could be made in this area. Many health professionals have asked me why a fourth tier of management had been established at a time when there were not enough cardiac nurses, when two cardiac catheter clinics in Altnagelvin had to be cancelled, and when nurses had to be sent up from Omagh to Altnagelvin. The Minister is new to the game and so are we as a Committee, but patients are suffering, and it is our job to find out what is going on.

Some very good people are involved in the management of the Health Service, but there is too much duplication and too many people with titles that I do not understand. I ask the Minister to take those issues on board when considering efficiency savings.

Mr Gallagher:

You might not get a reply for six months, despite all those tiers.

Mr McGimpsey:

The point about the allied health professionals is well made, and I share those concerns. We have been very successful — and anticipate continued success — in making efficiency savings on drugs.

With regard to the proposed midwife-led maternity services for Omagh and Downpatrick, the consultation for Omagh is at a very advanced stage and will report shortly. I am looking forward to receiving that report.

Lots of people say that health and social care is inadequate because it is inefficient and wastes money, and I totally agree. Significant savings can be made, and I have said that although we have made savings, I will hit the target of £343 million in the three-year CSR period. That is a big ask, and it means that the Department will have to save over £0·5 billion in six years — moving from the back line to the front line. I am well aware of the need to be efficient.

There are three arms to the Wanless Report: investing in the service so that it is modern; eliminating inefficiencies; and engaging the population in their own health. If those three steps are followed, we will have a Health Service that we can afford. The population will be looked after from the cradle to the grave, and funding will come from the taxpayer. I totally agree with Dr Deeny.

However, as far as staff structures are concerned, I have not come to grips entirely with that, but as you know, I am taking a step or two before I confirm — or not — the direct rule model. Andrew can probably add more to that point.

Dr McCormick:

In relation to the trust management structures, the Minister confirmed that he was leaving the trusts largely as planned. The word "largely" has certainly led the trusts to recognise that they need to look hard at management structures.

However, to be clear, we now have about one third of the senior executive level staff that we had this time last year. That means that there has been a radical reduction in the number of managers. That process is now unfolding. For example, where there were previously six laundry managers, there will now be one. That means that the extra posts will have to be filled. There are several tiers of management, and there always have been, but as a result of this process, trustland will experience a significant reduction — an average of 25% — in managerial staff. However, the percentage will be higher at more senior levels because the trusts will be reduced from 18 to five, resulting in fewer chief executives and directors. The tier of managers will be reduced by a third. That is how the Department plans to deliver a very substantial proportion of the £53 million savings as a result of RPA. The structure will be streamlined, and the Minister is looking at it again to see what more can be done.

The Chairperson:

I am aware that the Minister’s time is up —

Dr Deeny:

Sorry, Chairperson, I have one question that was not answered. It is essential that the Department makes provision for the qualifications of new midwives. Is that being worked through the colleges, or does the Department have any other plans?

Dr McCormick:

A very important part of the Department’s planning process is to ensure that that happens, and work is ongoing on that matter.

The Chairperson:

I thank the Minister and his officials for coming to the Committee. The Committee must now see whether any additional savings can be made. The impression has been given that the inescapables have meant that there will be no improvements, which is not the case. However, everyone agrees that we are over-bureaucratised. The sooner we have a single authority, the sooner that people will be able to retire and the overlapping of duplication will reduced— which is obviously a problem at the minute — and the sooner savings can be made. The Committee can also look at cuts. Prescribing of drugs and the lack of attendances for appointments was mentioned, as were land banks and the clusters of hospitals in Belfast.

I have not yet had answers about what happened between the previous Executive in 1998 and now. At that time, the plan was that the Mater hospital and Downe Hospital were to close. That was the reason that the Lagan Valley Hospital was made an enhanced hospital, enabling it to carry out elective surgery. We have three clusters of hospitals, which results in oversubscribing in the city limits. Efficiency savings could be made if the Belfast City Hospital site were to provide specialist delivery of cancer treatments; the Royal Victoria Hospital (RVH) could specialise in heart and other disciplines; and A&E units across the entire Province could have a specific dispensation or specialist area to deal with.

Northern Ireland is a small place. Many efficiency savings could be considered wherever services are duplicated in the city limits. Obviously, the Committee must examine all the figures, and it would appreciate learning how the Minister arrived at them. It is important that we get that information.

I will ask another question, which I do not expect you to answer right away, about the loss of the Enler centre project at Ballybeen. Will you please tell the Committee what happened to the £500,000 that was set aside, through the former South and East Belfast Health and Social Services Trust, to be the cornerstone of that particular project? That project was planned over a period of seven years, and, just when building was about to begin, the rug was pulled from under our feet.

Mr McGimpsey:

I am happy to answer all those points.

The Chairperson:

I am aware that your time is limited.

Mr McGimpsey.

It is quite all right. I am looking for an opportunity to conclude my comments.

The Chairperson:

OK. That is fine. I was not actually thinking about that. I was simply concluding my remarks by thanking you.

I also wish to raise another issue. In response to my request for papers and documents, I was given a copy of an email that had been sent to John Appleby, before he was interviewed on television about his report. I know that the person who wrote to him, and who shall remain nameless, was one of your departmental staff. That person wanted to have a word with Professor Appleby in order to assist him with his opinions. His emailed response reads:

"Thanks for this. I have already recorded my interview for the Politics Show. I certainly made the point about the tremendous waiting times reduction achievement, but also said that productivity improvement was an absolutely key issue for NI — and indeed for England.

I can’t respond to all the points you raise in your note. But having been involved in a reviewing capacity with subsequent work by DHSSPS on the initial Review’s work, I cannot think of a single instance where the additional work produced a finding which indicated that the Review had either overestimated needs or underestimated productivity/performance relative to England. This hardly seems credible.

My impression is that a lot of work has gone in to disputing the findings of the original report — in particular, as I note, to boost the need for more funding and to underplay the need for tackling poor productivity. Maybe this was only to be expected, but it is disappointing nonetheless.

There has of course been a need to try and establish true comparisons, but the balance of effort seems to have been misplaced. It is surely hard to believe that the NI health and social care system has or is operating at the very edge of its production possibility frontier — regardless of where England or any other system might be.

Given the CSR settlement and decisions in NI over health and social care’s budget for the next three years, surely the appropriate response now is to focus exclusively on how NI can start to demonstrably and radically improve its productivity — both in cost and quality terms. This is also the case in England, by the way. And surely a good example of how real political and managerial focus and commitment can produce results is the fantastic success NI has had in reducing waiting lists and times. During the time I spent on the original Review I was told by a number of people that the problem with waiting times was either intractable or only solvable with large amounts of extra funding. Neither has turned out to be true, and what appeared to be inevitable long term trends have been dramatically reversed."

I hold Professor Appleby in high regard, and I simply wish to put his comments on record. He views productivity improvements as an essential component of improving our Health Service. Indeed, he will give evidence to the Committee at some stage in the future.

I will allow you to respond briefly to that email, Minister.

Mr McGimpsey:

I know that Andrew will want to speak a little about the Appleby Report, as will John, who conducted an inquiry into acute hospitals and consultant episodes in Northern Ireland. That was a very important piece of work. I am looking for a single agency — or something better than was planned — and I am confident that I can get it.

No money was set aside for the Enler centre; the Department does not actually have pools of money that can be set aside. However, our business case has gone through and is with the Department of Finance and Personnel at the moment. I indicated to Sammy Douglas and Maurice Kinkead that I strongly support that case, and the Department of Social Development is has an element of involvement. There will be running costs of about £100,000 per annum, which we can cope with, but finding the £2 million that is required will be more difficult. The key is what will happen to the Millar’s Lane site when we abandon it and it is sold. Will DFP do the same deal for us that it did for the Department of Agriculture and Rural Development? That would make life easier; I do not have that £2 million because it was not part of this process.

I understand that Des Brown said that the Mater hospital will stay open and will continue to provide acute services for a considerable period into the future. As was said at the meeting that you and I had with Michelle O’Neill, you were to write to me with those points to give me an opportunity to consider them.

You raised the question of Downpatrick, which is a new hospital that is about to open, and going ahead with the Enniskillen project was also mentioned. There was a sound business case for the new Downpatrick hospital, so closing it, or, indeed, closing the Mater hospital, is not on the agenda right now. I will read carefully what you write to me and consider the Enniskillen case again, but I have confirmed the better-services case for the new acute hospital at Enniskillen.

The Army presence was a key determinant in enhancing the Lagan Valley Hospital in Lisburn. I am looking for productivity and for the achievement of the three areas that the Wanless Report says are key in delivering cradle-to-the-grave healthcare that is free for all citizens. That is part of our ethos and heritage, and I passionately believe in it: if you do not have your health, you have nothing. I do not want to go back to the position whereby if the people of this country cannot afford to pay for healthcare they will not get it. That is the benefit of the Health Service. However, the issue revolves around proper investment and efficiency; we are not trying to run an old car, we are trying to run an efficient new car. The key role that the Chief Medical Officer is playing is getting the local population to engage in their own health.

The Appleby Report warrants a response from Andrew. Thank you.

Dr McCormick:

The Committee has a copy of the response that I sent to John Appleby in answer to the email that was read out.

The Chairperson:

Yes. After I asked for the email that Professor Appleby sent, there was suddenly a detailed response — after the date.

Dr McCormick:

The response could not have been given in advance.

The Chairperson:

We want the Health Service to provide excellent service, and we congratulate the doctors, nurses, auxiliaries, doormen, cleaners and everyone else at the front line — they do a great job of keeping the hospital empire working. No doubt, we will speak to you again — either directly or indirectly. However, I appreciate your coming today, and I thank you for your attendance.

Dr McCormick:

It is important that the record reflect the fact that we do not accept Professor Appleby’s implication that evidence was skewed. On the contrary, an immense effort has been put into implementing his recommendations on productivity. We recognise that there is more to be done — we are not saying that we are as productive as we could be, but we accept those recommendations and will fulfil them. As a legitimate part of the process, some work has been put into comparisons. Again, that is an evidence-based process. In a further email, Professor Appleby accepted that he had thought that the process had been completed and that we should have been getting on with delivery. He did not appreciate that we were still discussing draft proposals.

The Chairperson:

I understand that. However, the point is that he has also indicated that it is not always about money; it is about productivity and efficiency.

Mr McGimpsey:

That is exactly right.

The Chairperson:

Thank you very much.

Mr Don Hill (Department of Health, Social Services and Public Safety):

The Chairperson:

Mr McGimpsey:

The Chairperson:

"that our knowledge is not being utilised in the commissioning of services."

Mr Easton:

Mr Easton:

Roy McClelland briefed us on 22 November, and he said that he needed £4 million, £8 million and £12 million. Obviously, your bids were higher, so why are his figures at odds with yours?

Mr McGimpsey:

Is it true to say that there has been an increase in inescapable bids?

Mr Hill:

Yes.

Mr Easton:

Therefore, it is misleading to say that we are not getting increases in many areas? We are getting increases, but they are sneakily caught up in the inescapable expenses, if you see what I mean?

Mr McGimpsey:

I am not sure that we are saying that. We are describing the requirements as inescapable. They reinforce existing services because of an increase in demand that we cannot walk away from.

Mr Easton:

However, it is new.

Mr McGimpsey:

Mr Easton:

Is it safe to say that the £450 million that you have is not enough? Much of that money will be used to deal with inescapables, and it is new money added on top of —

Mr McGimpsey:

Mr Easton:

That is all that I wanted to know.

Mr McGimpsey:

Our expenditure is increasing by £700 million. That leaves a deficit gap of - £250 million. That is the state of the Northern Ireland Health Service’s current account: a deficit of £250 million.

You made a few other points about hospital productivity and staff. It is important that we deal with those points.

Dr McCormick:

The Chairperson:

Colleagues, I am aware of the time and —

Mr Easton:

Will the Minister explain why he has just said that there is a gap of £250 million, yet five minutes ago he said that the gap was £300 million?

Mr McGimpsey:

Mr McGimpsey:

Dr McBride:

Mr Hill:

The Chairperson:

Dr McCormick:

That point has been made many times, and I recognise —

The Chairperson:

You have to look at that as a matter of urgency.

Dr McCormick:

Mr Gallagher:

Mr McGimpsey:

Mr Gallagher:

Dr McCormick:

The Department will do so.

Mrs Hanna:

Will you set targets for GPs to reduce their prescribing? With regard to consultants and GPs, I would reward them after I saw more change, rather than up front.

Dr McBride:

Mr Hill:

Ms S Ramsey:

The Minister is well aware that the Committee is conducting an inquiry into suicide and self-harm. In your view, will the Bamford Review be implemented within the time frame that has been indicated?

Investing for Health has been mentioned again and again. It would be useful if the Minister could give an update as to progress on, and the current position, of acute services.

Mr McGimpsey:

I will run through those points briefly, Sue, then I will have to call in the officials. Michael will respond to your query on Investing for Health and breast screening.

Ms S Ramsey:

Mr Gallagher:

You might not get a reply for six months, despite all those tiers.

Mr McGimpsey:

The point about the allied health professionals is well made, and I share those concerns. We have been very successful — and anticipate continued success — in making efficiency savings on drugs.

Dr McCormick:

The Chairperson:

I am aware that the Minister’s time is up —

Dr Deeny:

Dr McCormick:

A very important part of the Department’s planning process is to ensure that that happens, and work is ongoing on that matter.

The Chairperson:

Mr McGimpsey:

I am happy to answer all those points.

The Chairperson:

I am aware that your time is limited.

Mr McGimpsey.

It is quite all right. I am looking for an opportunity to conclude my comments.

The Chairperson:

Ms S Ramsey:

Mr McGimpsey:

Currently, there are no proposals to close any hospitals.

The Chairperson:

Mr Buchanan:

We cannot get even one hospital.

Mr McGimpsey:

It was actually three things — there was also the closure of Downpatrick Hospital and not building the one in Enniskillen. Those are three big decisions for both the Department and the Assembly.

The Chairperson:

Dr McCormick:

Yes.

The Chairperson:

Dr McCormick:

The Chairperson:

I understand that. However, the point is that he has also indicated that it is not always about money; it is about productivity and efficiency.

Mr McGimpsey:

That is exactly right.

The Chairperson:

Thank you very much.

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

OFFICIAL REPORT (Hansard)

Draft Budget

6 December 2007

Members present for all or part of the proceedings:

Witnesses:

The Chairperson:

The Minister of Health, Social Services and Public Safety (Mr McGimpsey):

The Chairperson:

Mr McGimpsey:

Dr Andrew McCormick (Department of Health, Social Services and Public Safety):

Mr Don Hill (Department of Health, Social Services and Public Safety):

The Chairperson:

Mr McGimpsey:

The Chairperson:

Mr Easton:

The Chairperson:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr Hill:

Mr Easton:

Mr Hill:

Mr Easton:

Mr Hill:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr McGimpsey:

Mr Easton:

Mr McGimpsey:

Dr McCormick:

The Chairperson:

Mr Easton:

Mr McGimpsey:

Dr McCormick:

The Chairperson:

Rev Dr Robert Coulter:

Dr Michael McBride (Department of Health, Social Services and Public Safety):

The Chairperson:

Dr McBride:

The Chairperson:

Mrs O’Neill:

Mr McGimpsey:

Dr McBride:

Mr Hill:

The Chairperson:

Dr McCormick:

The Chairperson:

Dr McCormick:

Mr Gallagher:

Mr McGimpsey:

Mr Gallagher:

Dr McCormick:

Mrs Hanna:

Mr McGimpsey:

Mrs Hanna:

Mr McGimpsey:

Mrs Hanna:

Mr Hill:

Mrs Hanna:

Mr Hill:

Mrs Hanna:

Mr Hill:

Mrs Hanna:

Mr Hill:

Mrs Hanna:

Dr McBride:

Mr Hill:

Ms S Ramsey:

OFFICIAL REPORT
(Hansard)