COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health and Social Care (Reform) Bill
25 September 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Ms Claire McGill
Witnesses:
Mr Dominic Burke ) Western Health and Social Services Board
Dr Paula Kilbane ) Eastern Health and Social Services Board
Mrs Fionnuala McAndrew ) Southern Health and Social Services Board
Mr Stuart MacDonnell ) Northern Health and Social Services Board
The Chairperson (Mrs I Robinson):
I welcome Dominic Burke, acting chief executive of the Western Health and Social Services Board; Paula Kilbane, chief executive of the Eastern Health and Social Services Board; Stuart MacDonnell, chief executive of the Northern Health and Social Services Board; and Fionnuala McAndrew, director of social services in the Southern Health and Social Services Board. You are all very welcome. I invite you to make a brief presentation, and I will then invite questions from members. I will allow around 40 minutes for the evidence session.
Dr Paula Kilbane (Eastern Health and Social Services Board):
Thank you, Chairperson. I am the current chairperson of the chief executives’ group, so I will briefly outline some points in our submission, because the main purpose of our visit is to answer questions.
We welcome the underlying themes of the review of public administration (RPA), including the reduction of bureaucracy through simplifying systems and avoiding duplication. We particularly welcome public health and well-being’s significantly enhanced profile in the Health and Social Care (Reform) Bill, because, although we all recognise that it is very important to cure, and care for, those who are unwell, it would be better if we could prevent them from becoming unwell in the first instance.
It will be very challenging to deliver the reforms in the Bill. We are attempting to reap the benefits of reduced bureaucracy in the context of new organisational arrangements. There is a particular challenge in bringing together those different interfaces, particularly that between the regional health and social care board and the regional agency for public health and social well-being. The functions that the health and social services boards currently carry out will be transferred to one or other of those two bodies. Indeed, some will be transferred to a third body, the regional support services organisation (RSSO). The core functions of the regional health and social care board itself are: commissioning; performance management and improvement; and financial management. The regional board must have primacy in commissioning, taking account of, and paying due emphasis and regard to, input from the regional agency.
The range of commissioning activities and functions to be carried out should equate to what the health and social services boards are currently doing — those activities and functions should be both regional and local. The commissioning arrangements should deliver improved health and well-being, and reduce inequalities. That will depend on how efficiently the regional board interfaces with the regional agency. Importantly, the board will be a regional body with an intense local focus. The Bill contains a major and welcome emphasis on the views of service users, communities and the public, and, in particular, it provides for local representation from locally elected councillors.
The regional board will be multi-professional; that is absolutely essential when dealing with the complex range of services that will be commissioned. However, there will also be adequate provision in the commissioning arrangements for specialist and vulnerable services. The local commissioning groups (LCGs) will be fully involved in performance management and improvement, and, importantly, the Bill recognises that the regional board should be accountable for the management of family practitioner services. I remind Committee members that 20% of all resources are spent on family practitioner services. The strategy and policy is to move increasingly from providing services in hospitals to providing them in the primary-care arena and in communities themselves. It is very important that that be seriously represented in the structure of the regional board.
The local commissioning groups should play a lead role in engaging communities and in identifying local priorities for improving health and well-being. The majority of services should be commissioned locally. Only very specialist or vulnerable services, or services that cater for small numbers of people, should be commissioned regionally.
In order to do that, people must be located locally. One cannot be in touch with the needs of one’s local community, and with its activists and representatives, unless one is co-located and close to the ground. We firmly believe that staff from the board, the agency and the regional support services organisation, whose jobs directly relate to local issues, should be co-located in order to ensure that they work together properly — that should be done locally. Over-centralisation of those structures would not be a good idea.
As far as the regional agency for public health and social well-being is concerned, the three domains of public health should also be integrated and co-located in order to facilitate local working. The first of those functions is health improvement — including initiatives such as Investing for Health — and health promotion.
The second function is health protection — including vaccination — against outbreaks of communicable diseases. Health protection also covers environmental hazards, which is an issue of increasing importance and of public interest and concern, and emergency planning — ensuring effective responses to pandemic outbreaks of flu, major outbreaks of communicable diseases or a major emergency event such as the disastrous aftermath of a dirty bomb. Responsibility for the aforementioned should lie with the regional agency.
The third function is to provide input into the commissioning process, which will assist integration of the regional agency with the LCGs.
There is a need for the LCGs to be properly informed, so important links must be made with the regional agency, the Department of Health, Social Services and Public Safety, and bodies such as Ireland and Northern Ireland’s Population Health Observatory (INIsPHO), the Northern Ireland Cancer Registry and relevant departments at Queen’s University. Yesterday’s announcements about the increase in melanoma rates will not have been lost on Committee members. It is important for a public-health agency to have that kind of intelligence and information, enabling it to monitor progress against targets.
I will now move from structures to people. People are a vital resource in making the changes work. There will be fewer of them, and we must ensure that we have the right people in the right places. We welcome the fact that, at this stage of the proceedings, the chairpersons’ positions have been advertised and the appointment panels will sit in early October. As well as that, the advertisements for the posts of chief executive have been published. That is all about trying to meet an exacting timetable and moving to a position in which people can tell their staff that, all things being equal, and assuming that the Health and Social Care (Reform) Bill passes, they will be able to transfer on 1 April 2009. In bringing people along, it is important to be able to tell them where they are likely to be situated and what they will be doing.
That takes me to the next point, which is all about location, location, location. We support the need to implement the reforms as quickly as possible. We recognise, however, that if we have regional bodies with local outworkings, it is important to ensure the equitable distribution of local employment opportunities to match. We understand that there are some policy issues outstanding, and Sir George Bain and his team are currently reviewing those in another place.
We expect that, although the new bodies’ headquarters will comprise more senior staff, they will have to be supported by people in lower grades, who may be much less mobile. We must be careful that nobody feels that they are being asked to work in places that are unsuitable for them for practical, and other, reasons. Many women in the lower ranks have other responsibilities that tie them near to where they live. There are issues of equity and fairness, but those issues differ from issues that arose at the time of the trust mergers. In that instance, staff largely stayed where they were, particularly those who were working at the coalface.
The Minister is fully committed to avoiding compulsory redundancies, but no guarantees have been given. ICT and modern ways of working, in a remote sense, can enable those changes to happen.
Accountability is about having clear lines of distinction among the roles of the new organisations, and among the Department, the Minister and the trusts. The Department of Health, Social Services and Public Safety will retain financial accountability for the trusts, while the board and the agency will have responsibility for the commissioning of performance management. The operating framework, which underpins the legislation, must be clear about who does what and when, in order to prevent a situation in which the commissioners pursue the implementation of targets and priorities, while performance and financial accountability is pursued on different lines. It is vital that there be crossover.
Although we welcome that fact that local councillors will be represented on the regional agency and the local commissioning groups, the issue of dual mandates should be considered against the number of councillors required under the latest proposal to establish 11 new councils. The roles and responsibilities of members of the LCGs, the regional agency, and the patient and client council should not be duplicated. There may also be issues around how local councillors are identified and selected to serve on those bodies. However, that is not for us to comment on.
In conclusion, we recognise the huge scale of change. The process is more complicated than the trust mergers. We are creating four new organisations, whereas the trusts were merged to form bigger organisations that performed the same functions. As leaders of our boards, we are committed to managing that transition. We try to maintain the morale and knowledge base of our staff. We want them, albeit in fewer numbers, and their expertise to transfer to those new functions.
The Department has set up a number of work streams aimed at planning the fine detail of the operating framework. There is a number of projects groups. For the Committee’s information, I appended a communications document, issued by the Department, which lists the names of who runs what and who belongs to which work stream. A further 19 pages may be downloaded from the Internet, if members want to know exactly who does what.
In the background, people are working hard to produce the essential operating details, which will underpin the structure and help it to work. Clearly, communication is vital in order to keep everyone on board and to deliver the reforms to the timescales.
My colleagues, who have also contributed to the process, will wish to discuss a variety of issues.
The Chairperson:
How is staff morale? Are staff being kept informed of developments?
Dr Kilbane:
Every attempt is made to keep staff informed. However, we await movement on some issues. Staff enquire about what kinds of jobs they will have to apply for and where those will be located. Some of those questions cannot be answered. Structures are being worked on at a departmental level. The working groups are building up a head of steam, and we expect staffing issues to become clearer soon.
Our staff see the end point approaching, and that is helpful for them. Our vacancy rates being what they are, I do not pretend for a minute that staff do not struggle daily to get everything done — they do struggle. However, my general sense is that, as we approach the end point, people who were in a dark place a while ago are now beginning to see the light at the end of the tunnel. My colleagues may not agree with that comment.
Mr Dominic Burke (Western Health and Social Services Board):
No, that is the situation. Staff fall into two, if not three, categories. One category is those people who are charged and ready for the new world; they want to be involved, and are clearly up for it and ready to go. Many of them will continue to do the jobs that they currently do to the same standard as before.
Some staff are coming to the end of their career and are getting ready to leave. The people whose morale is most significantly hit are those who are uncertain at present. People who are leaving see the end in sight and are up for delivering in this transitional period to ensure that the 2008-09 activity is carried out to a high standard. Those who will be in the new world will join the new teams and get on with planning for 2009-10 and beyond. As is to be expected, it is those who are uncertain about what is happening who have a degree of anxiety.
The Chairperson:
Has there been a mass exodus of professional staff in any significant healthcare areas to the private sector or elsewhere?
Mr Stuart MacDonnell (Northern Health and Social Services Board):
There has been a significant exodus, but I would not say that it has occurred at any particular grade. Like my colleagues, I try to meet staff informally once they have handed in their resignation to find out their reasons for leaving. A mixture of reasons is usually involved, with the need for certainty featuring most often. Some people are moving horizontally to a place of certainty. Small numbers are moving across the water, with others moving to the private sector.
A significant number are moving into the trusts — they are further down the road in the restructuring process. They may have reached a point in their restructuring whereby they have been unable to fill some posts in what they call the legacy trusts — the previous trust in that geographical area. In those cases, the trusts open the posts to the wider RPA group, and people apply for them simply because they are the first jobs to become available. We have suffered as a result of that trend. I hope, however, that it is coming to an end. In November, three years will have passed since the first changes under the RPA were announced — that is a long time. We assume that, once the senior staff take up their posts in the new agencies over the next couple of months, matters will begin to speed up.
The Chairperson:
Let us hope so.
Mrs M O’Neill:
You said, Paula, that the effectiveness of the local commissioning groups will hinge on local input. Should there be a statutory requirement for them to carry out proper consultation? I know that they will have a public consultation role, but should a statutory requirement be placed on them to consult publicly on their decisions?
I also want to know about the role that the Department will have in drawing up frameworks and in establishing aims and objectives for the different health and social care organisations. Will that give the Department a mechanism through which it can exercise control over the new bodies?
Mr S MacDonnell:
It was a politician who said that all politics is local — I think that it was the late United States senator Tip O’Neill. The Minister is clear that a significant number of elected local representatives will sit on the boards of the local commissioning groups — perhaps four. An issue may arise with the establishment of the groups when the outcome of the new Local Government Boundaries Commissioner’s review is known. However, let us assume that that has all happened. The local commissioning groups will technically be committees of the regional health and social care board, which will be accountable to the Department. The regional board will be bound to implement the wishes and policy of the Minister of the day, and, in turn, it will ask the local commissioning groups to ensure, through service frameworks and the like, that they are working to that policy.
However, that said, there should be a large range of issues within the local ambit of a local commissioning group. There should be scope for difference rather than adopting a uniform approach.
Key to how the new system will work is how much autonomy those LCGs are afforded, after they have dealt with the pressures of the Minister of the day and the financial situation, which is not of the LCGs’ making. I believe that there is a requirement in the Bill for the regional board to consult widely on any plans. I am sure that it, in turn, could by management instruction bind the LCGs to do the same. However, whether enshrined in legislation or not, I am convinced that the LCGs will do that anyway.
Mrs Fionnuala McAndrew (Southern Health and Social Services Board):
Having a statutory duty to consult does not necessarily mean that that consultation is more effective. Sometimes consultation can be tokenistic, even when required by statute.
Stuart is saying that if there is a duty on local commissioning boards to consult, and if the framework document or plans for how the LCGs should conduct their business are clear, that will encourage creative consulting methods. That consultation would then be conducted with a range of people with an interest in health and social services, and could be more productive than through statutory duty, where some people just tick the box.
Mrs M O’Neill:
What about the creation of framework document? Clause 5 of the Bill states that the Department must work with each new health and social care body to draw up a framework document that establishes that new body’s functions. Will that be advantageous and defeat any further problems down the line?
Dr Kilbane:
That will ensure that all the boundaries join up, which is very important. We must know who is accountable for what, what the rules of engagement are and what it is that people must do when working with one other. Furthermore, if certain functions are not delivered, we must know who takes action and what the sanctions, or, alternatively, the rewards, may be. It is essential to have a framework document, and that document must be thoroughly developed and tested. That will ensure that the people who work in the different arenas are quality-assured.
Dr Deeny:
First, I declare an interest in LCGs. My question relates to what Stuart was talking about.
The regional health and social care board can overrule the LCGs. Therefore, LCGs are really local advisory groups, dealing with public-administration systems. They are not commissioning organisations in the sense that primary-care trusts in England are. Given that, do you not feel the term LCG to be misleading?
You have both referred to the fact that decisions are best made locally. My concern is that people on the LCGs will believe that they can be overruled by the regional board at any time. What do you think about that? Do you think that that should be the case, or do you believe that the LCGs should have the same clout as primary-care trusts in England? There, the primary-care trusts commission only in exceptional cases, and only very exceptionally are they overruled by a central body.
Mr S MacDonnell:
Dr Deeny has hit on a pivotal issue. There need to be checks and balances in any system. Wearing his MLA hat, Dr Deeny expects the Committee to hold the Minister to account for what happens in health and social services, and, in turn, for him to have control over the various agencies that act on his behalf. As MLAs, you would not accept it were the Minister to say that a matter has been delegated to people for whom he has no responsibility. However, if everything is controlled from the centre — the point that Dr Deeny makes — what scope exists to have creative and energetic people working locally to resolve local problems?
It is more to do with the style used to operate the arrangements than it is to do with the statutory basis on which the different agencies are established. If the centre is very controlling — I am sure that all members are aware of organisations that operate like that — parts of the organisation, on the peripheries, may feel marginalised. Equally, I am sure that it would not be acceptable, certainly not to the Northern Ireland Audit Office or to the Assembly, if the centre were relaxed and did not know what was happening on the peripheries. There are, therefore, checks and balances.
The framework document, which is intended to wrestle with those checks and balances, is what we are all interested in seeing. None of us has yet seen it, Dr Deeny. Therefore, when the document emerges, I want to bench-test it to see how it deals with the issue of autonomy versus the mandatory requirement to implement the Minister of the day’s wishes.
Dr Deeny:
I know some GPs who sit on local commissioning groups, and not only on the group on which I sit in the west, who would like to think that they are accountable to a regional body yet have the power to commission locally, and with the necessary financial backup. That is a concern at LCG meetings that I have attended, and in other LCGs. If commissioning groups do not have the clout and financial resources to back their decision-making, I do want to see GPs or other primary-care representatives walk away from local commissioning groups.
Mr S MacDonnell:
What you have said is what, in principle, the policy direction is trying to achieve. My colleagues and I are beaten down by the pragmatism of our experiences. Sometimes the pressure of the issues of the day is such that, by the time that one has dealt with them, it is the end of the day. One then goes home, only to come in the next day to encounter more issues.
The framework document will, therefore, have to address the freedom to manoeuvre that you seek in the system, and I urge you to make your suggestions, whether as an MLA or through the British Medical Association (BMA), or both, in order to ensure that those freedoms are there. As I said, however, much will be in the style of operation as opposed to what the framework document says.
Dr Kilbane:
I am more optimistic, because the intention — although we will have to wait and see what emerges — is that there will be devolved local budgets. The emphasis is that only those functions that can be commissioned regionally should be commissioned regionally — the power should lie locally. That is the intention, and I believe that people are genuine in that intention.
Furthermore, locally elected representatives on the LCGs will undertake a great deal of scrutiny; therefore, decisions will not be taken in darkened rooms. There will exist real power for LCGs to commission within the scope of the policy framework. They cannot send rockets to the moon if that is not the purpose of the enterprise, but they will have enough power to make decisions about local issues.
There is another side to that coin, which is that some of the decisions that LCGs make may not be popular locally. Therefore, be careful what you wish for, because living in the straitened circumstances of a confined budget means that it will be possible to do some things and not others, and some things will have to change — all of which is difficult to achieve.
The object of the exercise is that if everyone is on board and given the freedom to make decisions, that represents an important step change, and one that is genuinely expressed in anything that I have seen so far.
Mrs Hanna:
The rationale behind the framework document is, I suppose, to reduce bureaucracy and bring services closer to people and patients. The bodies must, however, have members with the necessary expertise and knowledge, particularly on public-health matters. I am thinking particularly of health inequality, which is a big concern for everyone, because the gap it is getting wider all the time. Therefore, people must be in place who can make the necessary decisions, and we do not yet know that that will be the case. I will have a concern until more is known about what is happening.
The Chief Medical Officer is talking up prevention, rather than talking of picking up the pieces, so it is important that the expertise is in place, and that expertise must be joined-up. Bottom-up and top-down approaches must be taken, in order that the groups on the ground, such as those concerned with healthy living, are properly involved. Everyone is concerned about how that will all come together to make a difference.
Mr Burke:
You are absolutely right. The important point concerns working together, and Dr Kilbane made that remark in her opening statement. The regional agency for public health and social well-being must work with the regional health and social care board. People who are currently involved with Investing for Health and health action zones will work as part of the regional agency. Local commissioning groups will include local representatives and will have the voice of the people.
Those people will come together to ensure that effective local health-improvement initiatives are running. The test will be whether joint planning emerges at the top level that is informed by local commissioning and by local groups. People will recognise that working together at ground level results in the implementation of the most effective plans.
Mrs Hanna:
Therefore, it is not only about consultation. The people who are closest to the problems must inform the legislation.
Dr Kilbane:
We understand the concept of a joined-up approach in the local areas to mean that the relevant folk from the regional agency — representatives from organisations such as Investing for Health and Wellnet — will work alongside the regional board at a local level to ensure that informed and sensible decisions are made. Otherwise, they would not be able to write a local commissioning plan, part of which requires them to outline what they are in doing, for instance, to invest in community groups and narrow inequalities.
At the regional level, the chief executive of the regional agency will have to ensure that that adds up to something that will deliver on inequalities across Northern Ireland. On that regional level, work must take place on an inter-agency basis. We acknowledge that that is not simply the Department of Health, Social Services and Public Safety’s baby; the work is also concerned with housing and education. Whoever gets the interesting job of chief executive of the regional agency for public health and social well-being will have to fulfil that role regionally, and that will be on the basis of joined-up local arrangements.
Mr Burke:
Community planning, on which local councils will lead, will have a key part to play. That will bring more people to work together by statute in order to deliver that agenda.
Mr Gallagher:
How do you see the reforms progressing? You talked about the importance of a balance that allows for grass-roots involvement in the regional board. Local influence on service delivery is important. How do you envisage that happening? The purpose of the exercise is to trim down our Health Service and to try to ensure that money is spent on front-line services rather than on bureaucracy. If the two elements are to be the regional board’s central function and local influence, can that be done, and can savings be achieved at the same time?
Dr Kilbane:
The aim, and the challenge, is to cut 25% of the current cost of the health and social services boards and the other legacy bodies in Northern Ireland over three years. Therefore, the new designs will be based on a target of having 25% fewer staff by the end of that period, or whatever equates to a 25% reduction in costs, which is between £12 million and £13 million. That is achievable. It is happening already, because a vacancy-control programme has been in place in recent years — that is, since the changes were mooted — with the result that organisations are already operating with significantly fewer people in permanent positions. Therefore, even before the point of change, we have started managing the numbers downwards.
Earlier, we referred to the fact that some staff will decide not to stay with the health and social services boards. As present, our assessment of the numbers shows that we are well on target to achieving those savings, which, paradoxically, could result in a scenario in which we lose more of the necessary expertise than we should. We have lost a number of key people to organisations that seem to have a more certain future, so we must be sensible and make appropriate decisions about enabling people who need to work locally to do so. We will not be in control of the process after 1 April 2009, but, from where we are standing, we are definitely on target to achieve the reforms.
Mr S MacDonnell:
To set that in context, the comprehensive spending review’s three-year target for the entirety of health and social services in Northern Ireland is £343 million, which is a huge sum of money. The target for the organisations that we represent, as well for the Central Services Agency and the Health Promotion Agency, is £13 million, which is approximately 4% of that target.
The RPA saving from reform of the first-phase organisations — the trusts — is £39 million. Therefore, the overall RPA target for Northern Ireland’s health and social care sector is £52 million. I agree with Paula that the £13 million target is achievable. We are halfway through the first of the three years and, as I said to you earlier, Chairperson, because so many people have left ahead of the change, we are almost ahead of the wave of change.
However, that target only equates to 4% of a very large figure, and, as the Committee is well aware, freeing up that amount of resources is a task that the trusts are wrestling with. It is a huge challenge for them. Our £13 million saving is welcome because it is a significant sum of money, but it remains a small part of a very big challenge for the entirety of health and social services in Northern Ireland.
Mr Easton:
Are there any functions that the trusts are concerned about losing to the regional board, the regional support services organisation or any other agency?
Mr S MacDonnell:
In time, some functions will migrate. From memory, those will include financial systems management, HR, recruitment, processing, some aspects of estate management, and so on. Those are outside my remit, but I am aware that seven or eight trust functions have been highlighted as moving to the RSSO. In turn, those may be grouped together in different sectors in Northern Ireland rather than their all moving to some kind of central administrative factory.
When it is appointed, the RSSO management team will have to liaise and negotiate with the trusts. A document setting that out has already been published and consulted on. I am sure that, in due course, the Committee will want to hear from the people who are driving that. That is not something that we are driving; however, one of the work streams that Dr Kilbane mentioned is dealing with that issue. A small number of board staff will migrate to the RSSO
The entire Central Services Agency will migrate also. However, the greater number will come from trusts, and I expect that to happen over the next three to five years.
Dr Kilbane:
We do not believe that any functions will be lost as a result of the reforms. As custodians of the boards’ functions, we must perform due diligence to ensure that the new structure — although it will have fewer staff — carries out the essential functions. We have no reason to believe that that will not be the case.