COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Evidence Session with the Minister of Health, Social Services and Public Safety
09 October 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
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
Witnesses:
Mr Michael McGimpsey ) Minister of Health, Social Services and Public Safety
Mr David Bingham )
Mr Martin Bradley ) Department of Health, Social Services and Public Safety
Dr Michael McBride )
Dr Miriam McCarthy )
Ms Julie Thompson )
The Chairperson (Mrs I Robinson):
I welcome the Minister of Health, Social Services and Public Safety, Michael McGimpsey, to the Committee, along with representatives of the Department: David Bingham, director of human resources; Martin Bradley, chief nursing officer; Dr Michael McBride, chief medical officer; Julie Thompson, director of finance; and, last but not least, Dr Miriam McCarthy, director of secondary care. You are all very welcome. I will hand over to the Minister and then open the session for discussion.
The Minister of Health, Social Services and Public Safety (Mr McGimpsey):
Thank you, Chairperson. I am grateful for the opportunity to discuss the efficiency proposals. We — I, as Minister, and you, as the Committee — have a shared objective to ensure that people who require health and social care have the best treatment and support that are possible with the resources that are available. I hope that members will find the paper, which has been provided for the Committee and which outlines those proposals, informative and helpful in appreciating the scale of the challenge and how the targets will be delivered.
The efficiency proposals will have an effect on the health and social care of patients, people with mental-health illnesses and physical and learning disabilities, as well as those who need help and support to look after themselves and children in need. Delivering the best care for patients is at the forefront of all our minds. However, that means that difficult choices will have to be made as the process moves forward. Resources are finite, and we can always do more. I have made it clear that the process is not about front-line cuts — it is about front-line changes. There will only be change if it is change for the better and for the benefit of all our patients and staff.
It is important to put the funding in context to demonstrate what it means for patients. Some people say that health and social care is not good enough and that our Health Service is inefficient and wastes a lot of money. I accept fully that significant savings need to be made. All Departments have to deliver efficiencies. That was agreed by the Executive, and there is no alternative. My Department’s comprehensive spending review (CSR) efficiency target for the next three years is £118 million in year one, £233 million in year two, and £344 million in year three. That is recurrent and adds up to almost £700 million at the end of the three-year period. There is no doubt that those targets will be difficult to meet, particularly in the light of the current dire financial situation, which will bring only added pressure to our already-limited resources. However, the paper that has been provided for the Committee outlines how those targets can be delivered, bringing a total efficiency saving of £0·5 billion between now and 2011.
I am referring to the efficiencies of £146 million recurrent that were made under the Gershon exercise, plus, by the end of year three, £344 million, which are required moneys. More efficient services are a part of the answer, but the simple truth is that health and social care need significant and increased resources each year to meet need and to improve quality.
Although we can argue about the figures, the reality is that health and social-care services here are not as good as those in the rest of the UK. They cannot be, especially if one considers that compared with England, Northern Ireland faces a funding gap that will widen over the next three years to some £600 million by 2011. Members will recall that the original draft Budget would have made that position even worse. I was able to secure a better outcome through the final Budget, and I acknowledge the part that was played by many individuals and organisations in responding to that consultation process. The flexibility that I obtained in the final Budget allows me to honour my public service agreement (PSA) commitments and introduce proposals such as free prescriptions, subject to Executive approval,
No matter how efficient we become, patients and clients here will not get the same standard of care as they would in England; however, we need to ensure that our resources are used as effectively and efficiently as possible. A significant element of the proposals identified in the paper relates to savings being made in pharmaceutical expenditure, procurement initiatives and administration costs through the review of public administration (RPA). Combined with trust proposals to improve productivity — such as increasing the proportion of surgical procedures that are performed as day cases, reducing absenteeism, and agency and locum expenditure — they add up to savings of some £319 million, or 84% of savings achieved.
It is essential that we achieve the maximum possible savings from those initiatives and that good practice is implemented across the region. Staffing levels will also be affected. We will need to retrain, reskill and redeploy some of our staff to ensure that we make the most effective use of our resources. I am confident that any reduction in the number of posts can be achieved without compulsory redundancy.
As our workforce becomes more efficient, we can provide services to the same high levels with a more effective use of resources. Staff will move from front-line hospital care into communities. More importantly, those staff will provide care for people in their local communities and in their own homes, helping people to manage their chronic conditions and supporting elderly people to live more independently at home.
We must all recognise that service change is necessary. We are getting better: our productivity is improving. New systems have been introduced with great success, most notably in that there have been significant reductions in waiting times for surgery, diagnostics and outpatient appointments. My Department has set itself challenging targets to ensure that the Health Service delivers better-quality, modern and responsive services to the public.
However, challenges remain. The rapid advance of information technology, communications systems and medicine has rendered many of our models of care outdated. People may ask whether the proposals are driven by the need to balance the books, but I hope that they also ask whether the proposals are in patients’ best interests. People want easy access to excellent care. Time and time again, patients and users tell me that they want to be cared for in their own homes or local communities.
To help meet that need, I have ensured that, over the next three years, more than £44 million, or some £21 million per annum recurrently, will be directed towards preventative primary community and social-care services to deal with long-term conditions. Regardless of whether people are in Belfast, Ballymena, Lisburn, Armagh or Londonderry, we are creating new, community-based teams that are focused on keeping people out of hospital. Those teams will provide community services for the mentally ill, and they will monitor regularly patients who have chest conditions, diabetes or high blood pressure. In other words, we will ensure that people are treated in the community as far as possible before they need to go to hospital.
Thanks to the additional funding that I secured in the Budget, I can implement a range of new service developments, such as providing almost £40 million extra to improve cancer services, £12 million for cardiovascular services, £14 million for stroke services, £33 million for learning disabilities, £54 million for mental-health services, £22 million for children’s services, and £11 million for acute services. To put that in context, the extra money that I secured will extend breast screening to those aged 65 to 69, it will fund 700 extra cardiac surgery procedures, reduce waiting times for treatment for cancer patients, introduce bowel cancer screening, start vaccinations against cervical cancer for young girls, and fund action to reduce binge drinking and smoking. The extra money will save lives and transform the lives of thousands more.
The trust-efficiency proposals predominantly recognise that strategic change of direction, and they propose reduced levels of acute hospital care, an increase in the resettlement of long-stay patients and an increase in the provision of residential-care facilities through alternative models. Several of those proposals will be subject to formal consultation processes in which the Committee will, undoubtedly, want to play a role. I am also keen that the proposals have been discussed fully with local stakeholders, and I reserve the right to make the final decisions, if necessary, following the formal consultations.
In conclusion, given the scale of the savings that is required, the proposals are wide ranging and complex. They will bring about genuine changes in how services are delivered — difficult choices must be made. I hope that Committee members take the necessary time to understand the proposals fully and provide their support and advice to make the changes possible. If that is not the case, alternative proposals will have to be identified, because the efficiency targets must be delivered. Failure to achieve the efficiencies will mean that either planned service developments or inescapable commitments — or both — will not be met. Working together, we can make a real difference to the health and social care that is delivered to patients and users.
The Chairperson:
Thank you for that presentation. The list of questions is growing by the moment. I welcome the additional moneys that the Department received after the draft Budget. We all welcome your announcement about free prescriptions, because it is a measure that we have all been working to achieve, and it sent a very positive message to the public.
There is a great deal of talk about patients wanting to be treated at home and about the community-drive initiative. I support community-based back-up services. However, we all travel round our constituencies, and there are not enough community-care packages to deliver those services. Although we want to achieve the objective of having sufficient numbers of such packages, I hear the same story at every hospital I visit. Even at Muckamore Abbey, which the Committee visited several weeks ago, we were told that some people stay there because there is not enough community-care provision. How will we address that major problem?
The Minister of Health, Social Services and Public Safety:
I agree that that is a major problem, and it is one reason for the strategic redirection of health services — we do not want to get into the situation in which patients become institutionalised. We have a resettlement programme for patients at Muckamore Abbey, and we are on course to achieve our target to resettle 40 patients over the next year. However, I could be corrected on that number.
Investing in community-care packages is one of our main priorities. For example, after acute services, care for the elderly takes the biggest share of the departmental budget, costing over £600 million. We are also investing further moneys into care for the elderly for those with long-term conditions, as well as investing in domiciliary packages and other required packages. An investment of some £60 million is being put into domiciliary care, and that will buy many such packages.
We are similarly investing in mental-health services for community mental-health teams. We are investing in learning-disability services in order to meet our target to reduce the number of patients whose long-term permanent address is that of a hospital. The target is to provide 44% of people who need care packages with those services at home. I appreciate that that is a challenge; however, we must meet it. The investments will be made, and I am monitoring them carefully.
We can all find issues or problems in our constituencies, and I seek to get over those and to make investments. I hear the constant message, particularly from the elderly — as I am sure do Committee members — that people want to be looked after at home with familiar people and family around them. They do not want to end up in a home or face a long stay in hospital. We support people in that need, not least because it means that they will live longer.
The Chairperson:
Thank you, Minister. I will come back with a few points later, but I will give my colleagues an opportunity to ask questions.
Mr McCallister:
Thank you, Chairperson. I welcome the departmental team and the Minister; it is good to hear that the Health Service is developing and really gearing up to face the challenges of the future. I welcome the extra money that has been secured. Efficiency savings have been made in pharmaceutical services, which take a huge chunk of the budget. It is therefore crucial to focus on those. Will you talk us through how you hope to achieve efficiencies, given that fairly significant sums can be saved in that area?
Long-term conditions must be dealt with, and I welcome the significance that has been given to identifying how we can keep people with such conditions at home in the best possible health, thereby reducing hospital admissions. The Minister knows of my personal interest in the stroke strategy. Will those moneys go a long way towards implementing the strategy that you identified today?
The Minister of Health, Social Services and Public Safety:
I will bring in Michael McBride shortly to talk about the stroke strategy because he is primarily its author. You are quite right in what you said about the drugs budget. It is running at almost £500,000 per annum, with around £100 million of that being spent in hospitals and around £400 million in primary medicine. That figure is growing and demand for expenditure is growing. As far as service developments are concerned, we have invested in specialist drugs. Those drugs are starting to take up an increasing chunk of the budget, with an extra £12 million per annum after year three being spent on specialist drugs alone. Over the past few years, the use of generic medicines has been successful in creating efficiencies. However, we still lag behind the rest of the UK in the percentage of generic medicines that are used versus brand medicines. We are looking to catch up on that, and there is certainly scope to do so.
By enrolling patients in repeat dispensing schemes we can achieve better compliance and reduced wastage. It has been identified that procuring more cost-effective medicines resolves those inefficiencies that arise from inappropriate and unlicensed prescribing. The entry of new medicines will be managed through the development of a Northern Ireland formulary, and drug tariffs will be removed from those products that are normally blacklisted. That is where I hope to go with that.
Several steps are set out in the strategy, and, to date, they have been successful. I want that to be the case, because, frankly, the more success that I achieve on the issue of drugs, the less pain and upset that will be caused elsewhere in the system. I have no choice but to find efficiencies, and the more funds that I can extract from a static cost such as that, the less upset will be caused to the rest of the system.
As far as long-term conditions are concerned, the key goal as outlined in the Programme for Government is to help people with chronic illnesses to live more active lives and to reduce unplanned hospital admissions for such patients by 50%. That is the target, and part of the way in which that will be achieved will be to provide 5,000 patients with remote healthcare monitoring through technology.
That relates somewhat to the Chairperson’s first question about how we are dealing with the challenge of keeping people out of hospital, given the demographics and the challenge that long-term conditions present. I will ask Michael McBride to discuss the stroke strategy.
Dr Michael McBride (Department of Health, Social Services and Public Safety):
Thank you, Minister. Developing a stroke strategy is one of the most important challenges that the Department faces. Having attended an event as part of the consultation on the cardiovascular service framework, members will be familiar with the great passion, drive and commitment displayed by those providing the service and, indeed, by those who have actually suffered a stroke and received the service.
Stroke is a major factor in morbidity and mortality rates, and there are several major risk factors connected to strokes that we are trying to address through our approach in improving the health and well-being of the population and reducing some of the causative factors. Clearly, we want to reduce risk factors in the treatment and care of people who have had a stroke. That is a key message to be communicated to the population, and there are things that individuals — and we as a society — can do to reduce the risk of stroke. When someone has a stroke, it is important that they have access to appropriate and responsive treatment and care, and, most crucially, access to the rehabilitation services — including speech and language therapy and other support — to ensure that they can contribute productively again.
The Minister has set challenging targets for stroke services. One such target is to ensure, as a result of the investment, that by 2013 everyone who suffers a stroke is assessed within 90 minutes for their suitability for thrombolysis therapy — the clot-busting therapy for those who have developed a clot that is blocking the arteries feeding that part of the brain. As a result, it is hoped to reduce the incidence of mortality from stroke by 15%. There is also a challenging public service agreement (PSA) target to reduce mortality, and, indeed, long-term disability — which is another effect of stroke — by 10%.
The approach taken to deliver those targets is about providing staffing infrastructure and about providing 24/7 CT-scan availability that will be placed appropriately in the hospital system to ensure that people are assessed rapidly. It is about ensuring that there are sufficient radiographers, so we will recruit more. It is about ensuring that there are sufficient neuroradiologists to give their expert interpretation of those scans. It is also about recruiting allied-health professionals, physiotherapists, occupational therapists and speech and language therapists to provide the ongoing support and rehabilitation that is needed by individuals who have tragically suffered a stroke. I anticipate, as a result of the moneys and the investment that have been secured, that there will be a fundamental improvement in stroke services for the people in Northern Ireland who have been affected.
Mr Easton:
Thank you for coming today and for providing some documentation. I accept that efficiency savings are vital to improving our health resources, but I am concerned about the number of jobs that will be lost and that people simply will not be replaced — the figure stands at 2,475. My deepest concern is about nurses and midwives, 722 of whom will be lost to the service over the three years. Minister, you gave a commitment that there would be no cuts in front-line services, but, to my mind, nurses and midwives provide front-line services. Can you explain the change in emphasis for those front-line services that will not be affected?
Other issues that could help towards savings have yet to be addressed. I have yet to see any movement on reducing the number of cancelled clinics or reducing waiting lists by making less use of independent providers. Agenda for Change describes discrepancies between different boards and trusts about what people are paid to do the same job. Levels of pay should be uniform across the Province, but that is not the case.
At one stage, the Minister of Finance and Personnel referred to sickness levels. Will you explain what measures are being taken to reduce those? What are you doing to cut down on management roles? I noticed that most of the managers are still hanging on even after the trusts were merged. When I was employed in the Ulster Hospital, initially in the Accident and Emergency department, one manager was responsible for Accident and Emergency, medical records and the X-ray department, but there now seems to be five or six managers.
I welcome all the measures that have been introduced and the actions that have been taken. However, I am deeply concerned about the hundreds of vacancies for nurses, especially when those are added to the vacancies for doctors and auxiliary staff. Productivity of the Health Service would surely increase if all those positions were filled. What are you doing about that?
The Chairperson:
Mr Easton asked several questions, Minister. I am sure that your colleagues will answer some of those, but feel free to answer now.
The Minister of Health, Social Services and Public Safety:
I will run through my responses to those questions. I agree that nurses are front-line staff. Although there is a net reduction of 2,500 in total, it must be remembered that much of that was contributed to by the RPA, which has already taken place and is working its way through the system. The total RPA reduction was approximately 1,700 staff, which provided £53 million, and a large proportion of the RPA numbers are in that figure of 2,500.
Shortly, I will ask David Bingham to talk about the numbers in more detail — he is more familiar with them — but there will be no compulsory layoffs or redundancies. The figure will be achieved through natural wastage and through new services that are being developed, such as nurses working in the community rather than in a particular hospital or institution, which have been referred to as “hospitals without walls”.
We are also considering issues such as locums and agencies, and we are pressing hard on that matter. We are also examining the private sector, which recruits in the Philippines routinely. Due to our discussions with the private sector, a recent job fair in the Philippines was cancelled.
There are big staff shortages and retraining opportunities in mental-health nursing. We do not plan to reduce the number of student nurses coming from college. They are all needed, but not necessarily in acute nursing, for example, which is where many of the student nurses want to go.
As far as independent providers are concerned, each trust looks to do its own business. I am not particularly keen on using independent providers, so I share your concerns.
As you are aware, Agenda for Change was a national deal between trade unions and Government. We are playing our part in it, but it has been very time consuming. We granted an extension period earlier this year — which David Bingham will talk about — and the process is now at the wash-up stage.
I agree that the sickness rates in the Health Service are higher than are in many other areas. Sorting those out is a key efficiency target. One of the Health Service’s key productivity targets is a 3% improvement in hospital productivity from its 2006-07 base, which we are on target to achieve.
I also share your views on managers. The trusts must deliver their share of RPA requirements, and I will keep them under close scrutiny to ensure that they do so throughout the staff grades.
I will ask Mr Bingham to talk about productivity and the jobs that we have been talking about.
Mr David Bingham (Department of Health, Social Services and Public Safety):
The total estimated number of jobs that will go is approximately 2,500. We recognise that that is a significant number, but it has to be seen against the context of significant increases in the number of staff since 2000. We have seen a growth in staffing of 3% to 4%. The reduction that we are proposing will take us back to the figure for 2005-06, and should be viewed in that context.
Members will be aware that Professor John Appleby had negative things to say about labour productivity in the Health Service. One of our core assumptions, based on his work, is that we can provide at least as great a service with the reduction in numbers that we are talking about by improving labour productivity. Each trust has been given a target over the next three years, this being year one, to improve labour productivity by 3%. By meeting those targets we will be able to provide the service with the reduction in staff numbers. We will be returning to 2005-06 staffing levels, and, with improved productivity, we can deliver the service.
It is interesting to note that there are significant variations in sickness absence across trusts. There are good performers that would compare well with health authorities anywhere in these islands. We have set individual targets for trusts, and reductions in sickness absence can be achieved in two ways: one is through investment in occupational health services, which try to get to the root causes of absence; the other way is to apply current regulations and tighten control over individual absences, so that when an individual is absent, we ensure that the issue is followed up by the line manager and dealt with appropriately. Most absenteeism is caused by genuine illness, but where it is not genuine, that will be clamped down on. That is very much a part of what the trusts are going to be doing over the next three years.
Are we seeing a reduction in the number of managers? Through a programme of voluntary severance, nearly 300 managers have already left or are about to leave our service. In addition to that, about 150 managerial posts that were vacant were not filled. Phase 2 of the review of public administration, which will cover the mergers of boards and agencies, and will take place on 1 April 2009, will herald another significant removal of managerial posts from the service. Very significant progress has been made, and the next major step will take place in April 2009 when the abolition of the four boards and the other agencies will occur, as proposed in the legislation that the Committee is currently scrutinising.
Mr Easton:
I declare an interest in the Agenda for Change programme, because mine has not been sorted out yet. I note that the there was to be a reduction in the number of nurses by 550, but that that figure is now 400. Are those reductions part of the general reduction in nursing services?
Mr Bingham:
No. I will explain that in a little more detail. Each year, Queen’s University, the University of Ulster and the Open University produce around 550 nurses who are seeking employment in nursing in Northern Ireland. We employ about 550 a year. Our estimates over the next three years are that the number of recently qualified nurses that we require will drop to about 400. That is a problem. However, we have discussed the matter with the private sector, and in particular the nursing home business, which has had to rely heavily on the recruitment of overseas nurses.
In their case, that has been expensive but necessary over the last few years. By turning down international recruitment, they can make up the gap between the 400 that we are likely to recruit each year and the 550 that are likely to come into the market. Those figures are estimates, and the numbers may vary, but as the Minister has said, we have taken the decision not to downturn the number of nurses in training because, if we reduce that number now, then in four years time when they graduate, hopefully there might be more growth in the system and we would find ourselves with a shortage. It is in trying to get out of this boom-bust cycle of the availability of professional staff that we believe that we are right to stick to those numbers.
The Minister of Health, Social Services and Public Safety:
The Chief Nursing Officer will talk about the opportunities available for nurses, particularly students.
Mr Martin Bradley (Department of Health, Social Services and Public Safety):
Thank you. No one likes the idea of job reductions, but it is very important to see this in the context of the type of services that we will try to deliver in the future. There is a movement away from a focus on services within a hospital environment to having more services in the community. That will impact on the number of nurses and other workers that we may well require, but in addition to that, we also have to bear in mind that it is a large workforce — more than 13,000 whole-time equivalents on the qualified side, and more than 4,500 on the support side. The numbers need to be seen in that context.
We have a turnover of around 450 nurses per year, and as a result of our conversations with the independent sector, we anticipate that they should be able to recruit around another 150 per year. We are working with the universities and the private sector to make the private sector a very attractive place to work. We also want to get nurses to think about pursuing careers in the independent sector, and to be able to move between sectors — not just the independent but the public sector — and be able to move between the hospital and the community sectors. We are also talking to the trusts and universities about re-training programmes for staff who will be moving with their patients as the service begins to change, and as it is redesigned and modernised. That needs to be seen in a positive light as far as possible.
These are difficult times for everybody — there will be an impact on staff but we have tried in our conversations with the trusts over the last couple of months to minimise the impact of that as far as possible, and to try to make sure that they realise that they also have a responsibility to train people for what will be new jobs.
The Chairperson:
OK, Alex, I think that you got a fair bite of the cherry there.
Mrs O’Neill:
Several previous questions have concerned staffing, and I note that under the subject of productivity, one planned saving by trusts is under workforce and vacancy management: it is about trying to suppress, re-grade or partially fill posts with existing staff when they become vacant. I presume that a process such as that would involve the unions and workforce representatives because of concerns about already stressed healthcare workers being pushed into more stressful situations if those situations were not handled properly.
The other issue that I wanted to raise was about the £53 million saving that will come through the RPA. I know that the figure has been in the public arena for a number of years, and some savings have already been made. Has that money been reinvested in frontline services at this stage?
The Chairperson asked a question about Muckamore Abbey Hospital. Correct me if I am wrong Minister, but you said that the Department was on target for resettlement over the next few years. With the best will in the world, I do not see that happening. The Committee was at Muckamore three weeks ago, and members met people who have been in there for a long time. Last week, we met a number of health groups. The Tell It Like It Is group was present, and we met two young men who are desperate for a community placement. Although I accept that that is a cross-departmental issue and not just a health issue; of those two young men, one has been waiting for seven years to be placed and the other has been waiting for two years, and the placements keep falling through. They are young men in their early twenties, so it is disheartening for them. Therefore, with the best will in the world, I do not see how the target will be met.
My final question is about the minor ailments scheme. I met the Pharmaceutical Society, or perhaps it was the contractors — I am not sure which because there are two separate groups. What were the findings from the initial pilot scheme? Were any savings made? The pilot scheme was targeted at deprived areas, and my impression is that, by taking part, the pharmacists saved the Health Service money.
When I last spoke to the Pharmaceutical Society, negotiations had broken down. I am curious about the current situation, because the scheme is an opportunity to produce efficiency savings for the Department through people not taking up doctors’ time with appointments. The Pharmaceutical Society has not calculated the exact cost of the scheme, only an approximate cost. Has any analysis been made of the savings that the pilot scheme made for the Department?
The Minister of Health, Social Services and Public Safety:
I will run through those issues as quickly as I can.
All organisations operate with a level of staff vacancies, and that is standard practice in managing workforces. Staff retire, are promoted, or move on, and, by actively managing the vacancies that arise, trusts can be sufficiently organised to ensure that the right person at the right grade with the right skills is employed, and bearing in mind the impact of several trusts having been collapsed into one, that is important.
There is no double counting of the 1,700 jobs that will save £53 million under the RPA. The Department is working its way towards that target. A substantial number of those jobs to which I referred — almost 1,000 of the total of 2,500 — are still being processed under RPA. As I said to Alex Easton, I will ensure that the trusts deliver on their part of the RPA and that there is no slippage.
The situation at Muckamore is extremely challenging. The Chairperson brought a group from the Society of Parents and Friends of Muckamore Abbey to talk to me. Although the target is for everyone to leave Muckamore, several patients have been there for 20, 30 or 40 years, and their families are beside themselves as they wonder how that will work in practice. There are, therefore, many issues to work through.
That said, Mrs O’Neill mentioned a case involving two young people, and those are exactly the type of patients that we should be able to deal with. From memory, the target is to resettle 70 long-stay patients by 2010-11, and we are on schedule to achieve that. However, bear in mind that many more patients remain in Muckamore. Supported living and sheltered housing are required, which require the support of the Department for Social Development. However, the current economic climate has hit its income because it is not receiving cash from house and land sales, and so forth.
The minor ailments scheme is non-cash releasing. It negates the need for some patients to go to their doctors. When an individual asks a chemist for advice on what to take for a cold or flu, the Department has been paying for that consultation. Subsequently, we tried to extend the concept and ran a highly successful pilot scheme.
At one stage, I could not persuade the organisation to come to talk to me, although representatives have been to see me since. On one hand, I understand their argument about money, but we are offering them much more money to participate in the minor ailments scheme. They also argued that the Department was capping the number of consultations per pharmacist. On average, a pharmacist was performing approximately 300 consultations, and we capped the number at 1,000, but said that the figure would be reviewed within six months.
The group from the Pharmaceutical Society withdrew from the minor ailments scheme and stated that I and the Department had cancelled it. That is not true: the minor ailments scheme exists, and it is available. I am keen on the scheme: it was the Department’s initiative, it saves time in the doctor’s surgery, and it enables people to ask chemists for advice on a range of ailments, although most frequently about colds, flu and other common complaints. The Department pays £8·00 for the first over-the-counter consultation.
I felt quite strongly about the issue, not least because it was an important service. However, pharmacists arbitrarily withdrew it. They just took it away, leaving patients in the lurch. If other elements in the Health Service behaved like that, where would patients be?
We are still discussing the matter. However, it seems to me that there are issues about money. A pharmaceutical licence, for example, changes hands for between £500,000 and £1 million. I understand that the pharmacist at Forestside paid £4 million for that licence. There are very large sums of money involved. As was said earlier, £400 million worth of drugs cross the counter. There are, therefore, major cash flows, and if some pharmacists not making a living then I am prepared to discuss that with them.
The situation was that there was a minor ailments scheme. It was, I understand, agreed. We had a pilot to extend it, which was successful, and then pharmacists withdrew. Withdrawing is not the way forward for the Health Service. Pharmacists have since talked to me, and I will talk to them again. They are seeking substantial investment in IT and resources. As members are aware, resources are not unlimited.
Mrs O’Neill:
Does the minor ailments scheme save money in the long term?
The Minister of Health, Social Services and Public Safety:
It is a non-cash-release scheme. The fact that the scheme has stopped does not mean that an extra penny comes back. The scheme means that GPs may have fewer people in their waiting rooms.
Mrs O’Neill:
Would that not, therefore, save money in the long term, because is it not the case that a GP receives payment for each patient seen?
The Minister of Health, Social Services and Public Safety:
The argument can be made that although the scheme is non-cash-releasing, it makes for more efficiency in the service. I am looking to see if other efficiencies can be made.
Mrs O’Neill:
I hope that those negotiations are continuing, because nobody – whether from the pharmaceutical side or from the Department – can afford to close the door and say that they are no longer talking. That scheme does, I believe, save money in the long term.
The Minister of Health, Social Services and Public Safety:
My door is open. I wrote asking the pharmacists to see me, and they refused. I wrote again, and they came to see me. We had a discussion, and I said that we will continue the conversation. The Department’s offer was fair and reasonable. Consultation does play a role, but there is no substitute for visiting the doctor if one is unwell. However, if people are content with going to a pharmacist for minor ailments then that will ease doctors’ workloads. Although the scheme is non-cash-releasing, it can be argued that the doctor has less to do and, therefore, has more time to spend with patients.
Mrs O’Neill:
The scheme was targeted at areas of social deprivation.
The Minister of Health, Social Services and Public Safety:
Yes.
Mrs O’Neill:
Areas in which there were, perhaps, a lot of health inequalities, and where people are less likely to visit a doctor. In addition to saving money in the long term, the benefit of the scheme is in targeting people who would not, as a rule, access a GP service.
The Minister of Health, Social Services and Public Safety:
I totally agree with you. I am totally behind the scheme, I have not withdrawn it, and I want to see it work.
Dr Deeny:
Wearing my GP hat, I am delighted to hear that you remain committed to the minor ailments scheme. You are quite right to do so. From a doctor’s point of view, professionally speaking, GPs will work much more efficiently as a result of the scheme.
Still wearing my GP’s hat, I, like my colleagues, welcome your recent decision on prescription charges. I have family, and a lot of friends, who are GPs, and there may come a time to examine items on prescription that can be bought in a supermarket, for example, moisturising creams and rubs. There is a fear among GPs that they will be overwhelmed and inundated with everything and anything that is requested on prescriptions, thereby taking up a lot of our time. Some prescription items can be bought for less than £1 in a supermarket and without even having to go to a pharmacy.
My other issue relates to efficiency savings. I know that it is a difficult job, and that you are working hard. I have a win-win proposal for you. You referred to the hospital in Omagh earlier in the week, but I was not in the Chamber. Why not provide a hospital in Omagh along the lines of, and with the same services as, the hospital that he is providing in Downpatrick at a cost of £61 million? We would accept that, and it would solve the health-deficiency problems that have been ongoing in Omagh and County Tyrone for years. You would also save the National Health Service £130 million. Few members of the Committee would disagree with me. Are you prepared to consider that — and do it? If you are not prepared to do that, will you explain why? You have the power to do it. You could put the problem to bed and, at the same time, save £130 million that could be used for other services. Many members will feel that that is a sensible proposition.
I am asking for healthcare equality. In my native town of Downpatrick, you are providing a hospital with acute inpatient medical facilities, coronary-care beds, consultant-led accident and emergency, and a midwife maternity-led unit. You told us at the beginning of the year that an announcement on Omagh was imminent, but we still have not heard anything. We feel that we are being treated like second-class patients.
I am putting forward a win-win proposal. You win by saving £130 million, and you also win by having health professionals and political representatives off your back as the problem will be solved. The £130 million saved could be used elsewhere in the many services and ideas that you have.
Mr McCallister:
Chair; is the Department not here just to —
The Chairperson:
Sorry, I did not call you. The Minister —
Mr McCallister:
I think that he is out of order.
The Chairperson:
Excuse me. You are out of order. First of all, you are not speaking through the Chair.
Mr McCallister:
I was: I said “Chair”. Check the record.
The Chairperson:
No. You did not indicate. [Interruption.] Please; I am speaking. The Minister will answer Dr Deeny’s question.
The Minister of Health, Social Services and Public Safety:
I have to make a distinction. I am here to talk about efficiencies, which is resources.
Dr Deeny:
I am talking about —
The Minister of Health, Social Services and Public Safety:
If you will allow me to speak: you have asked a question, and I will answer it. We are talking about capital, and the money is coming out of the capital budget for Omagh. The figure is not £61 million; it is £190 million.
Dr Deeny:
Sorry, Minister, the £61 million was for the hospital in Downpatrick. I did not say that the hospital in Omagh would cost £61 million: it will cost £190 million. I am asking you to provide a hospital in Omagh at a cost of £61 million — the same as it cost to build the hospital in Downpatrick — thereby saving £130 million. Omagh would be happy to have a hospital exactly the same as the hospital in Downpatrick, and it would save you £130 million.
The Minister of Health, Social Services and Public Safety:
Madam Chairperson, I will try again. I am talking about efficiency savings in relation to resources — the money it costs to run the Health Service — not the capital. Capital is different: it is the investment made available for buildings, equipment, etc. The hospital in Downpatrick cost somewhat more than that. It is a different development in a different time frame. There is a difference in the capital bill. The proposal for Omagh would cost £190 million. If that money does not go to Omagh, it will go somewhere else.
I have had a procurement process on Omagh because I am committed to an enhanced local hospital. I announced the acute hospital in Enniskillen over a year ago, and that procurement is running well. I have also taken forward the Omagh hospital procurement process as quickly as possible. The Department received outline planning permission for the hospital in May 2007. We are governed by European procurement rules, and we have a very short space of time. I am rushing towards a deadline of whether I press the button to go ahead with it or not. The only way forward, that I can see, is to get the support of the local community. The message that I am receiving from the local community is that it is behind it. However, the messages that I am receiving from local political representatives is that they are adamantly opposed to it. Dr Deeny is quoted in the paper today as saying that he would not give 190p for it, never mind £190 million.
Dr Deeny:
Absolutely: as no life-saving services are involved, it is not a hospital.
The Chairperson:
Please address your remarks through the Chairperson.
Dr Deeny:
I am sorry. We ought not to call it a hospital, as it has no life-saving services.
The Minister of Health, Social Services and Public Safety:
Madam Chairperson, I have already discussed these matters with you and the Committee. I have had a series of meetings, public and private. The situation is that we have a plan for an enhanced local hospital in Omagh, costing £190 million. It will meet between 70% and 80% of the hospital needs of Omagh and the surrounding community. I am now working to a deadline and I cannot build it in the face of the local community’s implacable opposition. That could mean that we are rushing to build a hospital that has no support.
I have a capital budget that is 50% of what we need. Let us remind ourselves that, when the Health Service was established 60 years ago, there was a rash of hospital-building. Many hospitals were built in the 1950s and 1960s, which were worn out long ago. By and large, capital funds were not devoted to hospitals during the 25 years of the Troubles, for the money went elsewhere. I face challenges in the Ulster Hospital, the Royal Victoria Hospital and the Belfast City Hospital — which was built in 1973, is now 35 years old and has had little money spent on it since. We have had problems with Craigavon Area Hospital, which was built in the 1960s; Daisy Hill Hospital, which requires investment; and Altnagelvin Area Hospital, which was built in the 1950s and needs redevelopment. I could go on and on. Everywhere I look, I must find investment. I have less than half of what is needed: we have £3∙3 billion gross and we need more than double that. With inflation deducted, the net sum available is about £2∙7 billion. The comprehensive spending review period is back-end loaded: most of the money does not come in the early years.
I have made the announcement and I am committed to Omagh: however, £190 million is the capital budget. You will not save me a ha’penny by telling me not to build it, because I will take the £190 million and spend it somewhere else.
I need that answer: yes or no. The deadline is looming.
The Chairperson:
I appreciate that this difficulty has rumbled on for a long time in the area. I am sure that we have not heard the last of it.
Mr Gardiner:
I thank the Minister for his presentation and the enlightening information he has given the Committee.
Earlier today, some members met with representatives of the Royal College of Speech and Language Therapists. That organisation has some concerns, and there is room for improvement. Having said that, I recognise that you are the Minister of Health, Social Services and Public Safety, and you have raised the bar in those departments. We have not seen a Minister like you before: and I congratulate you.
Earlier, you referred to the trade unions. It is vital that you meet their representatives and carry them along with you. People get set in their ways and they do not like change: one can even see that in this Committee. However, you are making changes for the good in the Ambulance Service, the Fire Authority and doing away with charges for prescriptions. Well done and congratulations, Minister. Keep on the right track.
The Minister of Health, Social Services and Public Safety:
Thank you, Sam. Speech and language therapists form a part of Allied Health Professionals, who play a vital role, which is increasingly important as we move towards care in the community and wrap-around care packages. Michael McBride’s stroke strategy recognises speech and language as a key part of rehabilitation and emphasises that area.
I feel strongly that we should have union representation at every level in the Health Service. My proposals for local commissioning groups will see Allied Health Professionals involved. Local government will be strongly represented in the new bodies, including the board and the common services agency. Unions will be represented on those bodies as well, and they will speak for the staff.
It is important that the unions be kept fully informed. The trusts, the Department and everyone else are all working as part of a team — it is a team game, and the staff are the key element in the team. They are represented by the unions, so union representation must be embedded in the various levels of the organisation so that the staff know what is happening, do not get surprises and are treated fairly and properly by management. I feel strongly about that and I believe that that is one of the key ways of making the Health Service work.
Mrs McGill:
I am another MLA for West Tyrone, but I will not comment at length on the issues that have been raised already by Kieran Deeny, other than to say that I am aware of those issues and that my silence should not be taken as some kind of compliance. I will not comment further than that — I heard what the Minister said the other day.
The Minister of Health, Social Services and Public Safety:
I am ready to go with the new Omagh hospital, but I need some sort of support.
Mrs McGill:
I thank the Minister for retaining the £2 reward system in the Western Health and Social Care Trust for people with learning disabilities. There were great concerns about that system being withdrawn — people from my area had approached me about it because they were distraught for their young people. Obviously the Minister listened to those concerns, because he asked the trust to do something else, and I thank him for that. People in my area are grateful — although perhaps I should not even use that word when we are talking about £2 a week — but we are glad that it has been resolved.
There is a sizeable community of people with learning disabilities in West Tyrone, particularly in Strabane. There are concerns regarding the impact of the so-called efficiency savings on the provision of respite care for carers and for the people in their care. Will the Minister comment on the concerns about that issue in the Strabane District Council area?
The second point that I want to raise also relates to the efficiency savings. There are concerns that out-of-hours provision for the Strabane area is gradually being withdrawn; that is an issue that I have written to the Minister about. We are hoping that, rather than being withdrawn, provision will be increased. I have been told that there is only one mental-health professional working in out-of-hours provision for the wide geographical area that includes Strabane, Derry and Limavady — is that the case? If it is, how is the situation managed when, for example, there is an incident in Strabane but the mental-health professional is in Limavady? That is a cause of great concern.
The last point that I want to raise relates to home helps. I have serious concerns about the efficiency proposals relating to elderly and community care that were suggested by the Western Trust, as outlined in the departmental briefing paper. I am aware that the issue has been discussed in the media lately, and I support the Minister’s recent comments that it must be looked at again. In particular, the proposal relating to domiciliary care suggests that a different model for providing that care must be put in place, but many people who live in my area are concerned that that kind of provision should not be lost. In fact, some people would say that the existing provision should be increased, rather than reduced. That is a major concern, and I hope that the Minister will understand that.
The Minister of Health, Social Services and Public Safety:
We are investing £60 million in domiciliary care over the next three years, which will provide extra packages to many more people. The regional access criteria are used; therefore, people who are at the greatest risk will receive the highest priority. Our aim is that 45% of people with assessed community-care needs will be supported at home by March 2010. I take the point about the need for investment in that area, and we are addressing that. The Western Trust should not withdraw — it should go forward. I understood that that is the way that it was going. There is talk about reducing duplication and underutilisation; that is very much part of the investment strategy, not just in the west but throughout all the trusts.
Respite care is another area of investment. We are providing 200 new and enhanced respite packages a year, which will effectively provide respite care for an extra 800 people. That will provide care in the community. A key part of the package relates to the support that vulnerable people and those in need get from the wider family circle. Family members need to have time off, and that is where respite care comes in. We will continue to expand and invest in that service.
As I said, I intervened in the funding for people with learning disabilities. It was a small sum of money, but it was an indication that those individuals were valued. We are not placing a value on them — we are simply letting them know that they are people with value whom we value and appreciate. Some people contacted me to tell me that members of their family would have been devastated to lose the funding, and I took that very much on board.
Mr Gallagher:
That was well done.
Mrs McGill:
I wrote to the Minister about the matter, and Tommy and other members of the Committee also raised it at the Committee. That support is very welcome, so thank you.
The Chairperson:
The Committee was concerned that the other trusts were going to roll out a similar agenda — it would be an utter disgrace if they did.
The Minister of Health, Social Services and Public Safety:
I agree with you. These are not hard positions — they are merely trust proposals. It is not a done deal. We are now in a process of consultation, and I am keen to hear what the Committee has to say. There will be other points to be made, and there will be consultation through the trusts and responses from trade unions. Therefore, there is a whole process of dialogue and conversation, starting now with the Committee working its way through the issues, before we come to any final decisions. I will have to make the decisions if the positions are not agreed, but I hope that we can agree positions on most of the areas.
Mrs McGill:
I am still waiting for a response on out-of-hours provision in Strabane.
Mr Gallagher:
I also have an interest in that matter.
Dr Miriam McCarthy (Department of Health, Social Services and Public Safety):
I may not have all the necessary details on the matter. As you are aware, each health board commissions out-of-hours services, and they will tailor those services to meet the needs within communities. A number of out-of-hours services operate across Northern Ireland. I am not aware of the details of the arrangements in Strabane. I know that, in some parts of Northern Ireland, consideration is being given to how many doctors and support staff are needed in the very early hours of the morning, when calls are not as frequent as they are at other times.
You asked about particular mental-health issues. I am aware that the activity in that area may be such that not a lot of individuals are required to be on duty. However, I hope that most of the needs are being met, between staff who are on duty to support the mental-health function and those working in primary care and inpatient services, if there is an emergency in Gransha or elsewhere. We can check on some of that detail, if that would be helpful.
Mrs McGill:
Thank you, Dr McCarthy; that would be very welcome. The information that I have received is that one mental-health professional works across that very wide geographical area. From some of the documentation, I see that efforts are being made to address the issue to ensure equality in service provision. There could be an incident in Limavady and another one in Strabane or Derry, so we must consider what would happen in such instances. I would welcome some more information on that.
The Chairperson:
We are waiting on a response from the Minister on that issue.
Mr Gallagher:
First, I want to ask the Minister to keep pushing on with that hospital in Enniskillen. I am not saying that because of any lack of concern on my part for the people in the Omagh area; this matter has been ongoing for years, and it has been a very difficult time for people there, particularly elderly and other vulnerable people. The uncertainty has made the matter even more traumatic for them all. I hope that we will soon get certainty all around.
Clearly, some very difficult decisions will have to be made in relation to efficiencies. Services will be trimmed back, and some may be left almost threadbare. The best way to deal with this matter would be to have local commissioning groups in place. That would certainly help to ease the pressure on secondary care and allow for a quicker and more direct response to the needs of people in local communities. What stage are the plans for local commissioning groups at? We have no certainty that all the groups that we want to have involved will be involved and signed up for this process. It would be helpful to get an update on how the Minister believes that the local commissioning groups will develop
You talked about the difficulties in recruiting staff for certain sectors. A recent difficulty that has cropped up involves the vetting procedure and getting clearance through AccessNI. I want to make it clear that I am not being critical of AccessNI — I do not know enough about the organisation. However, the delays in recruitment are a bit worrying. I understand that many applicants in the system have applied to work in the health sector, so the health sector may have a greater interest in this issue than will other sectors. Can the Minister find out more about the current difficulties with AccessNI and whether the applications can be processed more quickly?
The Minister of Health, Social Services and Public Safety:
Although the NIO is in charge of Access Northern Ireland, I share Tommy’s concern about how long the process takes. In fact, I wrote to Paul Goggins on the matter. The Safeguarding Vulnerable Groups ( Northern Ireland) Order 2007 will bring about a new position in October 2009. From that date, the same system will operate in England, Wales and Northern Ireland. Scotland’s system is separate, but will be fully meshed in. That will create a seamless information stream that will allow us to vet anyone who works with children and vulnerable adults. It has come about because of recent absolute tragedies, not least what happened in Soham. That is where the situation will progress to.
Enhanced disclosure will give the Department access to criminal records, soft police intelligence and employment history — information on why people have left employment, taken employment breaks, and so on. All of that data will be contained in one enhanced disclosure certificate. The 2007 Order provides for a vetting scheme that will be introduced in 2009. It will be carried out by Access Northern Ireland, which currently works under interim arrangements in order to try to deliver the provision before the scheme is introduced. Several delays have occurred. The Department has developed interim arrangements in order to allow organisations to go ahead with recruitment by following a series of criteria that include applications for enhanced disclosure certificates. However, even under the interim, emergency arrangements, applications have fallen behind. I have, therefore, written to Paul Goggins again.
The Department is constantly being contacted by employers who wish to recruit, but are being held up. It is quite worrying because in 2009, the process will become law. Access Northern Ireland must deliver. Effectively, the issue is in the NIO’s hands. I have received assurances that normal service will resume by the end of 2008. I will not say that I am sceptical; however, I am concerned. I will continue to put pressure on the NIO.
As far as local commissioning groups are concerned, they are wrapped up in the RPA arrangements. You are aware of the situation in that regard. In May 2007, I was faced with the prospect of a huge health services authority, which was, effectively, like a black hole. It was supposed to deliver everything. I did not agree with that, and Assembly Members shared my view. I have proposed new arrangements, of which you are aware. The legislative proposals are currently being considered by the Committee. The Executive Committee passed them unanimously before they were presented to the Health Committee. They set out structures for the board, agencies, shared services and the patient and client council.
One feature of the NIO’s plans was that they did not include any elected representatives. That was a major mistake. The NIO wanted to abolish the Health Promotion Agency and to drop its functions — health promotion and public-health work — into the remit of the big health authority. Public health is one of the Department’s key agendas for Health Service efficiency — to press down on matters such as drug and alcohol misuse, unwanted and teenage pregnancies, smoking, early morbidity, cancer, and so forth. Getting all of those key public-health messages across and taking on the drinks industry, examining licensing laws, and so on, are ways to engage the local population. Strong representation is needed, from elected representatives all the way through to other disciplines in the Health Service.
Local commissioning groups will play their part. They will commission services for the health needs of the community that they represent. There will be five groups to each trust. I have not been prescriptive about what sort of arrangements there will be beneath the groups. Arrangements will be necessarily varied. For example, what a commissioning group in Belfast needs to reach its local community will be different from what groups in the west need.
I have changed the numbers on those local commissioning groups. I envisage that they will be led by local GPs and primary-care professionals. Four doctors will sit on each one. It is proposed that there will then be four local elected representatives, who are the best people to speak for the local community and will play an essential part. Other groups, such as nurses, allied health professionals, the voluntary sector, dentists, pharmacists and so on will all be represented.
The make-up is before the Committee, and I am interested to hear members’ views. I want to achieve as broad a representation of providers and community as possible. The best people to drive the structure are the local GPs, who have the clearest view of the community’s needs. My target is for that to begin operating at the beginning of the new financial year, in April 2009.
The Chairperson:
How much contact has the Health Promotion Agency had with publicans about happy hours and related topics? I am concerned that young women are the group that is most involved in binge drinking. The knock-on effects of continued binge drinking for women who become pregnant in later years are serious, for both mother and foetus. Have contacts been made with the industry, and is the agency trying to get it to look seriously at what it promotes?
The Minister of Health, Social Services and Public Finance:
We have developed a new strategic direction for drugs and alcohol. The drugs and alcohol strategy team meets routinely and impacts on the drinks industry. It is a part of the young people’s drinking strategy, for which a plan will be forthcoming. We spoke about that last week in the Assembly.
The Health Promotion Agency has contacts with the drinks industry and works in the area. However, it is too small an organisation and it has too small a budget to have punch. The public health agency will be powerful and will make an impact. It will be a key factor, as the local groups commission health needs and the board looks for what the Health Service delivers. We have to have a powerful public health agency to deliver the necessary punch to get the messages across about the damage that alcohol and binge drinking cause. Some 70% of the population of Northern Ireland drink; more than half of them binge drink. The numbers are horrendous. One can add in the effects in stroke and cardiac problems. I am looking for a means to combat that. The drinks industry spends vast sums on advertising and on enticing people to drink, but we have only a small budget for trying to get across the contrary message.
It affects other areas besides health: it cuts right across departmental responsibilities. The Department of Social Development is currently reviewing licensing. A great deal must be done about access, availability, price and educating people about the harm that they do to themselves. We do not say do not drink: we say drink sensibly. That has to be the message.
Dr McBride:
I cannot add much to what the Minister has said. The key issues are access, availability and pricing. He has pointed out the clear connections between young people’s drinking and risk-taking behaviour, and between that and poor mental health, with an increased risk of suicide. Society faces real challenges, and I sought to highlight them in my annual report this year. We are clearly at risk of creating a blue-bag generation, where young people face all the short-, medium- and long-term harmful effects of alcohol.
We have a new strategic direction, and we have groups working in each of the board areas. They are engaging with local communities as to how they can best address those problems. We work with other key stakeholders in other Government Departments, the PSNI and other groups. Under the new strategy, there is a specific group looking at young people’s drinking; another looks at binge drinking.
As the Minister said, we will shortly be producing an action plan around drinking, particularly young people’s drinking. The Minister and I have met representatives from the on-sales and off-sales community and have seen a positive outcome from that. One particular approach that will be taken was announced last week, and we will continue to engage at a range of levels with the retail and drinks industries. The average age of first alcohol consumption is 11, with the most rapid increase seen in those between the ages of 11 and 13; 43% of men and 33% of women binge drink — it is a huge problem.
The Chairperson:
I just want to place on record my thanks to those churches that go into Belfast over the weekends to offer safe-home care, get people onto buses, help people come round, and often offer tea and coffee. I salute them for taking the initiative; we need to help young people to get back on the straight and narrow.
Mrs Hanna:
Page 3 of the briefing paper warns that if the 3% efficiency savings are not made, the current service delivery will not be met. Think about the last few weeks, the last 48 hours even; the Treasury has put a further £500 billion onto the national debt, around five times the budget for the whole NHS. There are bound to be concerns about future services. That extra pressure comes on top of the fact that an awful lot of the burden falls on the five trusts. The efficiency proposals are very linear across the three years; however, I notice that the total for the Belfast Trust, 37%, is higher than that for the other trusts. I know the Belfast Trust well; there are a large number of older people in Belfast and some very high levels of deprivation; I do not know if there is any particular reason why the percentage is higher there.
A lot of those savings will have to be across productivity, around absence management, which I appreciate has to be brought under control; downsizing; and jobs. Martin Bradley mentioned the big turnover of nurses, and I have a special interest in that. What seems to be lacking is specialist training for nurses. An awful lot of patients would love to have a nurse who specialises in their condition, be it a neurological condition, cancer, osteoporosis or something else; however, there is only one specialist nurse available and when she goes on holiday there is absolutely nobody else. There is a gap in training. A lot of nurses would love to be provided with extra training, but it seems that they are expected to do that in their own time, which makes it very difficult.
We know the situation across the Treasury; there is no money available, and that is a real concern. It would be hard enough to meet those efficiencies without that burden. Is there a contingency plan in case the efficiencies are not met? I presume that the situation will be monitored and that you will be reporting back to us if it does not happen.
The Minister of Health, Social Services and Public Safety:
To put this in context, over the next three years the new money through the budget comes to £885 million. Over those three years, the efficiencies will generate £700 million. That roughly totals £1∙65 billion, a huge sum of money. The total amount for inescapable commitments is £1∙4 billion; if those services are not continued, folks will come to harm. Those inescapable commitments include extra pressures on pay, elderly people needing more care packages, and more people needing renal services.
Of the extra £1·65 billion that we are receiving, £1·4 billion will be spent on inescapable commitments. That leaves slightly more than £300 million, over a three-year period. If efficiencies of £700 million are not made, all the new developments will go. That will include bowel-cancer screening and screening for breast cancer for women over 65, together with new moneys for mental health, learning disabilities, dementia and the implementation of the Bamford recommendations that I have previously detailed. Furthermore, our total will still be roughly £400 million short.
Ms Julie Thompson (Department of Health, Social Services and Public Safety):
The service-developments moneys total around £315 million over the next three years. If the efficiencies are not met, those new developments will not be achieved. We are already monitoring the trusts quarterly to ensure that the efficiencies are achieved. The achievement of those savings is a vital part of balancing the Health Service’s books. That is why we have a monitoring process already in place.
All of the trusts have the same percentage of target savings. The numbers look bigger for Belfast, simply because of the size of the trust. However, all trusts must achieve 2·5% savings in the first year, 5·5% savings in the second year and 9% savings in the third year. Those targets are evenly spread across the organisations and the monitoring process will continue over the three years. The Department must take steps to ensure that the efficiencies are achieved in order to balance the books.
The Minister of Health, Social Services and Public Safety:
Furthermore, we require the efficiency moneys to pay for the new developments and for a portion of the inescapable expenditure. The Health Service will receive a double hit, if efficiency saving does not work.
Mrs Hanna:
I welcome the developments, particularly the cardio-vascular framework. The Committee has been waiting for many of those developments.
However, there is a concern — not only in the Committee, but outside, where a feeling of doom and gloom exists — that a great deal of responsibility is being placed on the trusts. Much of that responsibility is based on productivity, and it will be difficult to achieve the productivity targets.
The Minister of Health, Social Services and Public Safety:
Yes.
The Chairperson:
Everyone will feel the pinch right across the board.
Mr Buchanan:
I thank the Minister for visiting the Committee today and for presenting his Department’s proposed efficiency savings. There is no doubt that it is a difficult time for the Health Department and efficiencies must be made. However, efficiencies must be made across all Departments. In achieving such efficiencies in the Health Department, we must ensure that equality of service is delivered right across the Department’s remit. That is crucial, and it is a particular concern of mine.
Under the review of public administration (RPA), if proper efficiencies are to be delivered in a beneficial manner, a strategic policy is required from which all the trusts can work. That means that all trusts will be singing from the one hymn sheet, rather than moving in their own directions. I want some assurances about that.
Another issue in relation to RPA is the proposed establishment of an agency to stand alongside the board. The Minister knows of my concerns about that matter, as I have voiced them previously on the Floor of the House.
Both the Mental Health Commission for Northern Ireland and the Royal College of Nursing are opposed to the creation of that agency, as it will separate the integrated structure under which the Health Service currently operates. I too have considered the need for the establishment of a new agency, and I have talked to people about it, and I am not convinced that there is an argument for the creation of two separate, costly bureaucracies.
The establishment of a regional health and social care board is a key priority, and setting up a dedicated directorate for public health within it would be a much more appropriate way to proceed. I must air my concerns today about the proposal to set up the additional agency. Perhaps the Minister will elaborate on the necessity for such an agency to stand alongside the regional board to advise it on what it should be doing.
The other issue is that of locums and agency staff. The way in which the Western Health and Social Care Trust has handled that matter has taken a huge chunk out of the health budget. It would be much more cost-effective to provide our own staff. We must consider ways in which we can cut out the use of locums and agency staff, because that takes a huge chunk of the Health Service budget. As Alex Easton pointed out, if 722 nurses are lost, it will leave us short of new nursing staff, and the dependency on locums and agency staff will continue. That will not result in the required efficiencies.
I am concerned about the minor ailments scheme. I am glad that the Minister has left the door open for talks with the Royal Pharmaceutical Society of Great Britain, and I hope that an agreement can be reached on that issue. Before I came here today, one of my constituents came into my office accompanied by a youngster who was suffering from a head cold. Unfortunately, no pharmacy in Omagh could fill the prescription for the necessary medicine, and there is a 48-hour wait to see a GP. No efficiencies are being made in that case. The minor ailments scheme must be put in place so that we can cut the number of visits to GPs. Long-term efficiencies can be made, and I would like to see the minor ailments scheme coming to fruition soon, if at all possible.
There are other issues about efficiencies, although I do not wish to dwell on them. The Minister has got the wrong end of the stick when he talks about the west of the Province. I am talking about the entire south-west quarter of Northern Ireland. We have seen a reduction and a decline in service delivery, and that has come about as a result of the debacle surrounding the capital build schemes in Enniskillen and Omagh.
The political representatives of both towns have raised concerns about the decline in services. If we want to see the services move forward efficiently, we must have a proper networking facility to enable us to utilize fully the services in Enniskillen and Omagh. That is not happening. The Western Health and Social Care Trust promised me that that facility would be in place and that it would work. It is not working, and I am not sure whether it is in place, because there is no evidence of it. Concerns have been raised about the continuing removal of life-saving services from Omagh. Some services are being removed from Enniskillen. That networking facility should be in place, so that it can seek to address the deficiencies in healthcare provision in the west of the Province.
The Minister has said that he will withdraw the capital build scheme. He has the responsibility to provide services for the people of the south-west quarter of Northern Ireland. Whether he takes the money away or not, I remind him that it is still his responsibility to deliver equality of services for the people of Fermanagh, Tyrone and the entire south-west quarter of Northern Ireland. He cannot get away from that responsibility.
County Tyrone is the largest county in Northern Ireland and has a population of more than 166,000 people, and yet it is the only county that does not have acute hospital services. I ask the Committee and the Minister: is that equality of services? Some counties have two acute facilities, but County Tyrone has none. I ask the Committee and the Minister again: is that equality of services, or are the people of Tyrone being treated as second- or third-class citizens?
The Minister of Health, Social Services and Public Safety:
I will do my best to address those issues again. I will also invite Martin Bradley and Michael McBride to speak, because of the references to nurses and to the public health agency.
We had a reasonable discussion about the minor ailments scheme when Michelle O’Neill raised the matter. The Department and I remain committed to that scheme, and I regret very much that the pharmacists have withdrawn from it.
We organise the make-up of trusts according to regions rather than counties. The Western Trust — of which Omagh is a part — has two acute hospitals. One of those is Altnagelvin Area Hospital, which is Northern Ireland’s second major hospital after the Royal Victoria Hospital, and the other is in Enniskillen. We are committing £265 million to build a new acute hospital in Enniskillen. Omagh will be within the “golden hour” of both hospitals in Enniskillen and of Craigavon Area Hospital. The level of resources that are being assigned to the Western Trust contradicts the notion that services are being withdrawn. Indeed, even allowing for efficiency savings, resource allocation to the Western Trust will continue to rise substantially over the next three years.
The member also mentioned the RPA and the public health agency. The authority that I assessed had 2,200 staff — which is a very large number — and the board that I am talking about will have considerably fewer than 400 staff. That reduction is about driving efficiency by having commissioning groups and performance management in the trusts. On the other side is the need for public health, which Madam Chairperson talked about earlier. I have said repeatedly that the Department’s overarching strategy focuses on investment, efficiency and engaging the local population in its health. The public health agenda is arguably the most important element of the strategic way forward, and it requires a visible public health agency rather than one that is hidden away within a giant authority, as was the original plan.
All of the health inequalities in Northern Ireland must be addressed by a public health agenda; issues such as the postcode lottery of morbidity rates — the length of people’s lives being dependent on where they live — smoking, lifestyle, diet, obesity, alcohol consumption, teenage pregnancy, strokes and cardiac illness. If we do not send out the correct public health message and engage with the public, we will not be able to sustain our Health Service in its current form indefinitely.
The public health agency will not consist of hundreds and hundreds of people. It will have a maximum of 250 or 300 people. It will be embedded throughout Northern Ireland and will work closely with local government and councils, because local authorities are best placed to deliver much of our policy. It is absolutely essential to have a public health agency because rises in alcohol abuse, unsafe drinking, binge drinking, teenage pregnancy, antisocial behaviour and so on show that we have not yet been able to turn the corner.
I invite Michael and Martin to speak about the public health agency and nursing respectively. Incidentally, the Royal College of Nursing fully supports the move: it is not opposed to it. The Mental Health Commission for Northern Ireland does not want to merge with the Regulation and Quality Improvement Authority (RQIA). The Commission’s position has nothing to do with the proposed public health agency.
Dr McBride:
There is a saying that if you always do what you always did, you will always get what you always got, and that is very true. We all talk the talk about public health. We talk about, and fundamentally believe, that it is good to invest upstream in order to prevent downstream consequences. We have a once-in-a-lifetime opportunity to add pace, drive and determination to the delivery of that agenda. Such a unique opportunity must be grasped. As Chief Medical Officer, my role is to advise the Minister, this Committee and the Government on steps that can be taken to best improve the health and well-being of the population.
The truth of the matter is that Northern Ireland’s society is not uniformly well. Michelle O’Neill referred to the challenge faced in relation to extremely high areas of deprivation in Northern Ireland. There are 3,500 premature deaths annually in Northern Ireland, and that compares unfavourably with the rest of Europe. Where you live always matters in Northern Ireland; it actually determines how long you live.
In the most 20% of deprived areas, some of which are rural, the life expectancy for a man is four years less, and for a woman two years less, than the Northern Ireland average. The life-expectancy gap between the most deprived and the most affluent areas is seven years for men. That is morally and ethically unacceptable. Efforts to address those challenges must be redoubled.
People who live in the most deprived areas of Northern Ireland are 40% more likely to die before the age of 75 than those who live in the most affluent areas. Deaths among children under the age of one are 30% higher. Those are huge challenges for society to face.
The consultation on the Minister’s RPA proposals revealed unanimous support for a refocus on public health and social well-being. I accept that concerns were raised around duplication. Those concerns will be addressed. There must, and will, be absolute clarity in the operating framework in relation to the respective roles and responsibilities of the agency and the board. They will work together and in partnership with local commissioning groups to ensure that that happens.
The agency will work with a new and exciting agenda with local government. It will also pursue the programme of reform led by the Department of the Environment’s strategic partnership boards. Through community engagement and community planning, those efforts will ensure that real changes are made that affect individuals and communities. That is the prize. This is a once-in-a-lifetime opportunity that must be grasped with both hands.
I urge members to give their unanimous support. If we take the challenges seriously, a fresh and reinvigorated approach is needed in order to deliver to people on the ground.
Mr Martin Bradley:
I will be brief. We agree with Mr Buchanan that dependence on agency and locum staff must be reduced. That is an issue for medicine as well as nursing.
The challenge is that the Health Service is among only a few major public services that try to offer services 24 hours a day, 365 days a year. Attempting to cover every eventuality for every service involved will always be a challenge. Therefore, locum and agency staff will have roles to play. However, reducing the level of dependence on such staff over the current CSR period is a major objective in the proposals from each of the trusts. That can be achieved by a variety of measures, including more imaginative use of staff banks within the trusts in order to allow staff to work extra hours if they wish. It is not as easy as I have made out, but it is something that the trusts will work at.
Carmel Hanna raised the issue of specialist staff, which affects both medical and nursing personnel. Given the size of Northern Ireland’s population and its health economy, there is a limited number of specialist staff and a limit on the number of specialists who can be trained at any one time. If, for any reason, specialists go off stream, they are difficult to replace. The trusts are examining that issue. We are about to engage in a fundamental workforce review to try to deal with some of the issues around specialist nursing, to which Carmel Hanna referred and which peek through in the use of locum and agency staff.
I hope that that answers some of the questions. All of the trusts seem to have acknowledged that they must deal with that issue in the next year.
The Chairperson:
Before you leave, Minister, what are you views on the efficient use of hospital theatres? Are we getting the maximum use out of them? Are consultants working on a rota basis to try to reduce waiting lists and waiting times for people with serious illnesses? Why are there are so many delays? Many people have written to me to complain about their operations being cancelled after they were prepped for theatre. One element that ties in with that issue is the choice of private work versus NHS work for some consultants. Perhaps you will answer those questions briefly. I realise that our time is up.
The Minister of Health, Social Services and Public Safety:
Those are important points. We are making good progress on the reduction of waiting lists, waiting times for accident-and-emergency treatment, and so on. Changes to pre-operation assessment and the booking system also mean that there is much more consultant activity and use of operating theatres. We have set several targets, such as improving the level of hospital activity that was achieved in 2006-07 by 3% for each year of the CSR period. Another target is to ensure that, by March 2009, no more than 2% of operations are cancelled for non-clinical reasons on the day of admission. That is an important target, because theatre slots are lost when operations are cancelled without warning on the day of admission.
Performance management is now firmly embedded, and one of the key ways in which it will be implemented will be through the board. The service-delivery unit monitors performance management and reports routinely to the Department and to me. The unit also meets routinely and regularly with the trusts to ensure that everyone is hitting targets. We are aware that productivity has some way to go. However, we are making important advances and improvements across the sector.
Ms Thompson:
Efficiency savings of £120 million were proposed to be gained through that productivity agenda. We have been working closely with the trusts to ensure that the Northern Ireland Audit Office’s recommendations about operating theatres have been implemented. That will help to improve future productivity. The productivity of hospital theatres is a key element in the flow of hospital patients.
The Chairperson:
I thank the Minister for attending today. The Committee will want to arrange a further meeting to discuss more general issues, rather than a specific agenda. My colleagues and I have several issues that we wish to see addressed. I thank everyone for attending; no doubt we will see you very soon.