COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Health and Social Care (Reform) Bill

02 October 2008

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey

Witnesses:
Mrs Liz Cavan ) Allied Health Professions Federation UK
Mr Tom Sullivan ) Allied Health Professions Federation NI
Ms Liz McKnight )

The Deputy Chairperson (Mrs M O’Neill):

Our next session is representatives of the Allied Health Professions Federation. I welcome Liz Cavan, Liz McKnight and Tom Sullivan to the meeting. I invite you to make a short presentation and answer Committee members’ questions.

Mr Tom Sullivan (Allied Health Professions Federation NI):

I thank the Deputy Chairperson and members of the Committee for allowing us to present the case of allied health professionals at short notice. We appreciate that the Committee has a busy schedule, so we will try to keep our presentation as brief as possible.

Like our medical and nursing colleagues, we have a number of concerns about the proposals for health and social-care reform. We also have a different perspective from our medical and nursing colleagues on how some of those proposals will be played out. The purpose of our presentation is to demonstrate the unified and collective view of allied health professionals.

The Allied Health Professions Federation represents more than 6,000 health and social-care workers throughout Northern Ireland. We work on all programmes of care and with all age groups. Initially, we welcomed the proposals for health and social-care reform as an opportunity to redress deficiencies at departmental, board, local-commissioning-group (LCG) and trust level and to reposition allied health professions in those various structures. Some of our concerns have been addressed, but the proposals overlook many of the concerns that we have raised.

I appreciate that the evidence session’s focus is not on the departmental structures. However, the departmental structures should also be reviewed to ensure that they are compatible with the other proposed arrangements. The legislation outlines the remit of the Department as a policy-development role for improving the health and social care of the population of Northern Ireland. However, the top-structures review, which was completed in August 2006, highlights the deficiencies of the department’s policy process.

Like our medical and nursing colleagues, we welcome the creation of a single regional health and social care board and the abolition of the four trusts. However, we have reservations about the representation of allied health professionals on that regional board. We welcome the emphasis that the regional agency for public health and social well-being will place on health promotion and protection. Allied health professions have a significant role to play in the public-health agenda. Our skills have been underutilised in the past, but that deficiency can be addressed now.

My colleague Liz Cavan, who is the chairperson of the council of the Chartered Society of Physiotherapy and a member of the Allied Health Professions Federation UK, will present our concerns about the proposed commissioning arrangements.

Mrs Liz Cavan (Allied Health Professions Federation UK):

The Allied Health Professions Federation broadly supports the concept of commissioning to secure the best possible outcomes for health and well-being. We promote an inclusive approach, in which the staff who deliver the services have genuine ownership of the local commissioning groups’ plans.

It is planned that each group will have one allied health professional on it. Like the Royal College of Nursing Northern Ireland (RCNNI), we believe that each allied health professional will have a very broad church to deal with, and will need their colleagues’ support in order to deal with that effectively.

We very much believe that a bottom-up approach should be adopted, with professionals, users and local government having input into the plan. Working together, the front-line services could really take ownership of that commissioning plan and feel that it is theirs and is seen to be inclusive.

I hope that this does not ruin me, but I was involved with the commissioning arrangements for the local health and social care groups (LHSCGs). Although there were definite deficiencies — particularly their not having GPs on board — those groups achieved some good things. They would have been strengthened, unlike our British Medical Association colleagues suggested, by the inclusion of local-government officials. Some members may be aware of some of the initiatives that the LHSCGs started.

Allied health professionals work with local government: speech and language therapists work with SureStart in areas and wards of deprivation; and occupational therapists work with their housing colleagues. New work is taking place in leisure centres, where physiotherapists are training leisure-centre staff so that people with long-term conditions can receive rehabilitation to keep themselves as fit as possible. Working with our colleagues has made that work possible.

That partnership will do nothing but help the health of the population. Physiotherapists and dietitians are working with leisure-centre staff to tackle obesity. Our dietitians are also working with environmental health officers to give consideration to the issue of food-labelling. There are many areas in which we feel that health and well-being will be supported by taking a bottom-up approach.

From that point of view, we differ a little from our medical colleagues. Clarification is required in the commissioning process on the extent of the financial controls. We agree with the RCNNI that there must be clarity on the groups’ authority. Care is also needed to ensure that there is no duplication between the regional board’s role and that of the LCGs. It must be clear who commissions what, in order that duplication is avoided. Regional commissioning must have a local flavour — localities must have an input into what is commissioned regionally. The problem is that we have yet to see some detail.

Ms Liz McKnight ( Allied Health Professions Federation NI):

I shall talk about the proposed patient and client council. We fully support the establishment of one patient and client council, but one in which the five local offices cover the same geographical area as the trusts.

We need to ensure that there is adequate capacity in those local offices to provide a strong voice for our local population to be able to understand the structures in the individual trusts. There is a great deal of variance among trust structures and processes right across Northern Ireland. It is important that local people can get to grips with their local trusts’ processes. When working in a trust, it is sometimes difficult to know what the processes in that trust are, let alone try to figure out what is going on in another trust.

We would also support and acknowledge the role that the voluntary and client-representative groups would have in those local offices. That is important, because it would provide patients with a real voice. Patients who currently feel unable to voice their concerns could do so, and there would exist a representation that could channel and challenge patients’ experience.

We know that patients sometimes find it difficult to access the healthcare services that they require because of barriers, and they want someone to represent their view. Voluntary groups can often be a useful advocate for patients.

We also want to comment on the Regulation and Quality Improvement Authority (RQIA), which is responsible for overseeing the quality of patient services across Northern Ireland. Our medical, nursing and social-services colleagues are all represented at director level in the structures of the RQIA. However, allied health professionals do not have similar representation, despite a recommendation from the Department. Therefore, there is a gap in the monitoring of the delivery of the quality, effectiveness and safety of the services that our patients use.

Allied health professionals want to work in partnership with all the groups that are involved in healthcare delivery, including our colleagues from the different professions, local government, and, particularly, our patients and clients. Having all parties engaged in the process is the right direction for the new structures to take. We thank the Committee for its time.

The Deputy Chairperson:

When we met informally, one of your concerns was the inadequate support structure in the Department for your professions. Has that situation improved any since we last met? I know that all trusts were supposed to appoint someone to liaise with the allied health professions, but has that happened?

Mr Sullivan:

Last Friday, we were informed that there is nobody at a departmental level with responsibility for issues that pertain to the allied health professions. There is an allied health professions adviser in the Department, who has been on long-term sick leave for a while. Some civil servants were seconded to do specific project work and undertook the adviser’s role to provide advice to the Department. Those secondees have since retired. Therefore, as of last Friday, there is no one in the Department with the appropriate expertise and experience to advise it on issues that affect the allied health professions.

When the review of public administration (RPA) proposals were being considered last year, the allied health professions adviser was, again, on long-term sick leave, which meant that there was nobody at departmental level to advise appropriately the various working groups that were examining the proposed changes to the structures. Therefore, there was no effective input from the allied health professions. We raised that issue with the Minister last October, and secondments were made. However, as I said, those people have since left, so we are in a worse position, because there is no one in the Department to offer advice on issues that affect the allied health professions. It would be unimaginable to have no nursing or medical advice at the Department, yet that is the position in which we find ourselves.

The Deputy Chairperson:

That is incredible, especially after the representation that the Committee made on the matter after we first met the allied health professionals. We will have to take that issue up with the Department. You must be concerned that, despite all the restructuring, the views of allied health professionals have been left out of the equation.

Mr Sullivan:

Even if the adviser were to return from sick leave, there remains an issue of capacity — there would be only one person to cover all the work streams in the Department, including workforce development, training, and strategy and policy advice. Therefore, there would still be no capacity or structure for allied health professions at departmental level. The adviser’s status in the Department is not reflected as it is in other areas of the UK. In England, Scotland and Wales, there is a chief health-professions officer at departmental level, who has a direct link to the relevant Minister. Our adviser does not have that status in the Department. Even if the adviser returns, neither the structure nor the support for the role is in place.

The Deputy Chairperson:

The Committee will raise that point with the Department.

Mr Gallagher:

Thank you all for attending the Committee this afternoon. You expressed your concerns about the proposal for only one representative from the allied health professions on each new local commissioning group. I share that concern, because there is a wide range of allied health professionals, from speech therapists to occupational therapists. Indeed, I know from experience that occupational therapists are further split between those who work solely in a hospital unit and those who work in the community. The two, therefore, have different perspectives. I understand that such a split means that increased representation would be better.

What is a fair level of representation? Is it a minimum of two representatives on LCGs, or have you a different preferred figure in mind? Moreover, I am not clear about how you feel about representation of allied health professionals on the regional board. Your submission states that the Committee should, under the reorganisation, note:

“the roles and career prospects of a high number of very experienced and valuable AHP colleagues have been cut in order to make further savings.”

I am sure that other Committee members are aware of the demand for therapeutic support. That remains on the increase. Therefore, such a cut seems strange.

Mrs Cavan:

We have a grave concern that, through the reorganisation, we seem to have lost an entire level of allied health professionals. That presents many difficulties, because those who managed the allied health professions were often, particularly in the smaller professions, allied health professionals who worked in a clinical capacity for part of the time.

In the other, larger professions, some managers had the important duties of ensuring that more junior staff were looked after and properly trained, and of maintaining the governance of the systems for which they were responsible. The removal of that layer of management means that that looking-after, the arranging of leave, and so forth, are now the responsibility of people who are specialists in their area and should be at the coalface with patients.

We are concerned that to remove a complete layer of management will affect patient care and leave less time for those professionals to carry out clinical work, because all those activities must still be carried out somehow. It is a matter of striking a balance: the management structures should not be overbearing, but they must be able to look after staff needs, including their training needs, and ensure the safety and care of patients.

You asked how many representatives we want to have on LCGs. We do not have a specific number in mind, but each new local commissioning group needs an allied health professional. However, underlying structures, from which those professionals can obtain support and advice, are also required.

The allied health professions — from radiography to drama and art therapists — are also part of a broad church. Consequently, so that a person striving for good commissioning is not left alone, he or she must have good support from staff with the time to provide it. We do not say that we require one of everything, or that two people should be present; however, we do require a support system.

Mr Sullivan:

We do not want a situation similar to that which arose in the past, when there were seven commissioning groups, and one AHP representative had to look after two, and in some instances three, groups. Clearly, it was a conflict of interest for that individual to represent more than one commissioning group. Therefore, unlike the previous situation, we want a dedicated AHP representative for each group.

Dr Deeny:

Next year’s changes to local commissioning are important. Last year, someone from one of the GP magazines rang me about an article and said that, although that commissioning system exists in primary care trusts in England, it does not exist anywhere else. Consequently, if next year’s proposals achieve the expected results — if they do what it says on the tin — and entire communities, including GPs, health professionals, nurses, elected representatives and community representatives, get involved, that will be a unique achievement, and I hope that it works.

I could not agree with Liz C more — I shall call Mrs Cavan, Liz C, and Ms McKnight, Liz Mac. [Laughter.] An individual allied health professional or nurse, who might be commissioning for 300,000 people, really does require support.

I am delighted that the Allied Health Professions Federation is here, because there was a time when that appeared unlikely, and, given that its members play a vital role throughout the healthcare system, the federation’s attendance is important.

You said that adequate resources and financial controls should be devolved to local commissioning groups. I am on the current western LCG, so I must declare an interest. However, if LCGs are to work, will AHP state on the record that, without those financial arrangements, people will become disinterested? I have no doubt about that, and that is my worry. Does AHP agree?

Given that the membership of my local commissioning group will have to be renewed next year, I may not be on it. Nevertheless, LCGs might become simple advisory bodies, which could be overruled at a whim by regional boards. They will be required to include representatives from the entire community — professionals of all forms and community representatives — who will all attempt to commission for local requirements. Everything, however, will require a rubber stamp from civil servants in Belfast, and might not be agreed.

I believe that such a system would collapse. Do allied health professionals agree with medical, nursing and, indeed, community people that, to be effective for people at a local level, commissioning clout must be backed by adequate finance? Otherwise, we are not interested.

Mrs Cavan:

The straight answer is yes. We are keen that the local commissioning groups will not just be talking shops; that their role will be clear; that they will know how much they can commission; and that their financial structures will be specified. All of that must be clear in the detail, and, given that, we will support the proposals.

Ms McKnight:

Allied health professionals have bitter experience of those in advisory posts being listened to, but not acted on.

In some of the working-out of healthcare delivery and the development of the structures, we have seen how an advisory capacity limits getting things done. We have seen how advisory posts do not necessarily meet the needs. There should be a financial ability to make decisions and act on them, as opposed to having to go to another level to take that action forward.

Dr Deeny:

The person who phoned me last year will be watching with interest to see how the local commissioning groups work when they are up and running in Northern Ireland. It may be a model that other countries might follow — if it works.

Mr Buchanan:

I notice that you support the setting up of a regional agency for health and social wellbeing, alongside the regional health and social care board. You say that that can act as a conduit for best practice and signposting the regional health and social care board and the LCGs. I am concerned that that would be nothing more than another talking shop. I am not convinced that setting up a regional agency alongside the regional health and social care board is a good move. It is currently integrated, and I cannot see why a section cannot be set aside in the regional health and social care board to continue with that practice, rather than set up another regional body alongside the board. What would that regional body do and what would its role be? The Committee has had various meetings about the issue, and I feel that it would be acting only in an advisory role to the board — and that is what you have stated in your submission.

Why do you support the setting up of another regional body alongside the social care board? What will its role be, and why is it necessary to split the integrated health system already in place?

Mr Sullivan:

I take your point about the board and the regional agency. It echoes the comments that our nursing and medical colleagues have made, in that there is a lack of clarity on the roles defined for the different groups in the legislation. We would also like to see more clarity and meat on the bones as to how the different agencies would operate. However, from my perspective, the regional board has a role in the performance management of the Health Service as well as overseeing the commissioning arrangements, and a financial management responsibility for the other HPSS agencies. The regional public health and social wellbeing agency, however, is focused on health promotion and health protection and, therefore, has a different and broader focus. It can act as a catalyst for bringing the other organisations, departments and agencies together to work in a more multidisciplinary way across different departmental boundaries, such as education and social development. The regional agency, because of its social wellbeing aspect, would be much more focused on those aspects of health promotion and health protection

I can see a role for a regional body, but I agree that the details of how the different organisations interconnect must be clarified.

Mrs Hanna:

I take on board your comments about your skills being underused. Is that connected with your lack of representation at the top? You said that performance management was not happening.

What about the local commission groups? Have you had discussions with the nurses and GPs about how the partnership would work and whom it would comprise? It would be useful if those discussions were to happen locally. The GPs were not involved previously, but discussions should be happening now. Is that the case?

Ms McKnight:

Unless we are at the table, AHP are often an afterthought in discussions regarding planning services. At those discussions, a service is considered and developed, up to a point; subsequently, however, someone will realise that to get a patient well, mobile, rehabbed or out of acute care, he or she will require the services of a physiotherapist, occupational therapist and, perhaps, a dietitian. At that stage, someone will tell the AHP that it is required; however, not having been factored in at the start of the process makes it more complicated and difficult.

That goes through the whole of the structures. The AHP should be part of the discussion at every level: from planning and delivering services to acute and primary care, and through the different structures for the commissioning and developing of services for patients.

Mrs Cavan:

Although the GPs were not at the previous commissioning arrangements, the professionals and the members of the community — our users — who were present, worked well together and came up with lots of imaginative ideas. It was wonderful to hear people say that they needed more of a particular service, sharing the small amount of money that there was and benefiting each other.

If you are not at the table, people do not remember. In their submissions, the Royal College of Nursing and the British Medical Association said that they wanted to be at the table with their colleagues from social services and nursing or social services and medicine. No malice was intended, but they tend to forget our special role. AHPs can get people out of beds more quickly and prevent people from going into hospital. That is our role, but it is sometimes overlooked. It can be an important factor in the Health Service’s finances, because bed days are expensive, and it is a role that AHP plays well.

Nurses or doctors at the table sometimes forget the role of the other professionals who may have those skills ready and willing to help the needs of patients. If we are present, we can remind them and make care better.

Mrs Hanna:

Have discussions on partnerships with the local commission been facilitated by the Department?

Mr Sullivan:

It is difficult for that to happen, because the Department does not have the capacity to bring that together. Currently, there is no AHP adviser.

Mrs Hanna:

It would make sense if that were to happen.

Mr Sullivan:

We would welcome discussions. Discussions are ongoing between various chief officers in the Department, but we are not at that level; we are not included in those discussions.

Ms Cavan:

We tend to be forgotten.

Mr Sullivan:

That is part of the difficulty.

The Deputy Chairperson:

Thank you for your presentation, and we will talk to the Department and ensure that you are not forgotten. We will see what we can do.