COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health and Social Care (Reform) Bill
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 Craig Allen )
Dr Michael McBride ) Department of Health, Social Services and Public Safety
Mr Ivan McMaster )
Mr Bernard Mitchell )
The Chairperson (Mrs I Robinson):
We shall now continue with the clause-by-clause consideration of the Health and Social Care (Reform) Bill. I welcome back the Chief Medical Officer — one might say that he is a glutton for punishment, appearing before the Committee twice in a row. I will not call you Pinocchio. I also welcome Ivan McMaster, Bernard Mitchell and Craig Allen from the Department of Health, Social Services and Public Safety. The officials are here to explain the meaning of each clause and to provide clarification or answer questions as required.
At last week’s meeting, members considered the first six clauses of the Bill but deferred reaching any formal decision on them. The officials agreed to take away some suggested amendments for further consideration. Rather than going back over those clauses again today, I propose that, at this stage, we resume consideration where we left off and work through the remaining clauses, from clause 7 onwards. We will formally consider each clause at a later meeting.
Before I ask the officials to explain the meaning of clause 7, which deals with the establishment of the proposed regional health and social care board, we should have a more general discussion on the overall structures. I understand that, at last week’s meeting, the need for a separate regional agency for public health and social well-being was raised. It is important that we begin by asking the officials to talk us through the rationale for creating a regional board and a separate regional agency for public health. Although there is strong support for a separate agency for public health, members will note that some of those who made submissions to the Committee had concerns about the lack of clarity about the relationship between the board and the agency and how responsibilities would be split between the two. I invite the officials to address that issue, and members can ask questions afterwards.
Mr Bernard Mitchell (Department of Health, Social Services and Public Safety):
I will start with the broad picture — the perceived role of the agency and the reason for the establishment of an agency as well as a regional board. In today’s earlier evidence session, the Chief Medical Officer outlined the many existing inequalities in morbidity and mortality rates in Northern Ireland. The need to address those inequalities was one of the driving factors underpinning all the reforms and structural models that we have put in place. We must consider the impact on the individuals concerned and whether effective resource utilisation is being achieved; there is an issue about whether the best use is being made of taxpayers’ money if treatment regimes have to be put in place because we have failed to address, at an earlier stage, prevention and health and well-being issues.
One of our ongoing concerns has been to ensure that the profile of public health and social well-being is sufficiently focused and high on the agenda. If responsibility for public health and social well-being is to lie with a regional board that will inevitably be driven by the significant operational concerns and priorities that must be addressed, the prioritisation of funds specifically targeted at public health and social well-being cannecessarily take second place. One of the reasons for proposing the creation of an agency was to ensure that that agenda and the important objective underpinning the reforms would be dealt with in a focused manner.
Another important issue was the need to develop improved partnership, not only with local government but with the full range of public-sector stakeholders and others who have a strong influence and a role to play in improving public health and social well-being. Therefore, the new agency has been specifically charged with that responsibility, and it will be given a very high profile in its management structures and core remit. Indeed, that is a key reason for the establishment of an agency.
Although the consultation responses showed that there is, and has always been, a great deal of support for the development of an agency for public health and social well-being, equally, there is a recognition of the need to ensure that the agency and the board work together in a fully integrated manner. Therefore, we have carefully considered — and will continue to consider carefully — the matter, and, at the end of the day, that approach will be embodied in the framework document to which we referred last week.
I will make a couple of points by way of illustration. First, integrated working between the staff from the agency and the board is a prerequisite of the new structure. The local commissioning groups (LCGs) will operate efficiently only if the support that they receive from staff on the ground is professionally led but with all the other requisite management skills in place. That approach will heavily involve staff from both the agency and the board.
It is our intention, as part of our planning process, to ensure that those units will be fully integrated and co-located, so that staff are working in the same place, many of them in their local communities. We feel that that is where they should be based.
We are also considering how that integration will operate at a regional level. Having talked about the local arrangements, we are thinking carefully about the regional level and how a commissioning plan is developed in an integrated way and is genuinely a joint commissioning plan, with the ownership of the regional agency and the regional board. That will ensure that the regional agency not only has influence over the moneys directly allocated to it but has influence over the £4 billion or £4·5 billion expenditure that the regional board will spend every year on health and social care in Northern Ireland.
There has been a driving imperative from the start and a real belief that the separation of the regional agency was fundamental to the objectives that we were all required to deliver. We were conscious of the resulting organisational issues that were raised, and we believe that we are addressing those issues sensibly, one-by-one.
Dr Michael McBride (Department of Health, Social Services and Public Safety):
May I add to that? Bernard has summarised the issues nicely. It is about achieving a balance, raising the profile of health improvement and health protection and working in partnership with local government and other important bodies in, for example, education and policing. It is about meeting the needs of local communities and working at local commissioning group level, as Tom Buchanan mentioned earlier, with staff outposted from the regional agency and co-located with other staff in support of the LCGs in order to establish services that meet the needs of local communities.
I am sorry that Tom Buchanan has left the meeting, because he raised an important concern about duplication and about the pitch being too crowded. It is about integration, as Bernard said, without duplication. There must be absolute clarity about the respective roles and the shared roles and responsibilities. The operating framework document will provide that clarity. As Bernard also said, we have also considered joint commissioning arrangements and the suggestions about joint sign-off that were made by members of the Committee in a previous meeting. We are actively considering those alternatives in order to ensure that there is complete clarity about who does what in the new system.
The challenges that we face in dealing with preventable ill-health and premature death, particularly in deprived areas, are very real and very stark. We must raise the profile of public-health challenges and increase our attention on them. I am concerned that if we opted for a unitary model, the pressures of which we are all too aware, and which are covered by the media day in, day out, week after week, will determine and drive that agenda.
Regrettably — and tragically — we do not yet see headlines in the media about the fact that there is a difference in life expectancy of two years, four years or seven years, depending on whether one lives in a deprived area or an affluent one. We should be motivated and driven by that. I support the Minister’s view that public health and social well-being must be at the heart of all Government policy. There are clear benefits in added value to the economy. The Wanless and Appleby reports made it clear that investment in health and well-being makes sound economic sense in Northern Ireland. It gives people better life opportunities, better employability and, ultimately, it is a good thing to do. I strongly support the Minister’s outline proposals for the establishment of a separate regional agency for public health and social well-being.
The Chairperson:
I want to quote from a letter to the Committee from Paul McBrearty of the Mental Health Commission:
“One of the major strengths of the HPSS within Northern Ireland is its integrated structure which has been the case at senior levels within the Boards for more than 35 years and is now reflected within the Trust management and operational delivery structures. The proposal to now create two separate bodies (i.e. a Regional Public Health Agency and a Regional Commissioning Board) has significant potential to disrupt this integration. We can see no good reason why this proposal for separation is being made. If separate divisions are necessary to ensure that different interests are served, then so be it but this can surely be achieved while maintaining staff within a single corporate entity, single senior management leadership, and single point accountability.”
The Royal College of Nursing also has major concerns:
“The RAPHSW creates the potential for duplication of effort and waste of resources, and is illustrative of the overly complex and potentially problematic nature of the proposed governance and management relationships between the new bodies.”
Those two significant groups are making strong comments that are worth flagging up.
Mr Easton:
I have no problem with the establishment of the regional board; that is a good thing. However, I am concerned at the establishment of a separate regional agency for public health. I thought that the purpose of the reform was to create savings, create effective structures, reduce bureaucracy and make life easier. The establishment of a separate regional agency adds another layer to the health programme, and I am not convinced that such a separate structure is needed. It should be within the remit of the regional board, and it could work just as effectively as part of that board. It could do a more effective job and would certainly create efficiency savings, thereby saving a lot of money. I do not believe that there is a need for the establishment of a regional agency. It should be part of that whole structure. I am not content to support the Bill as it stands, with the regional agency separate from the regional board. That is my position.
Mr Mitchell:
The commitment to savings will be met within the new structures; it has been hard-wired into all the proposals. The figure of £53 million in savings, and the reduction of posts, is part and parcel of all the proposals, and the savings to which commitment has been given in the review of public administration (RPA) will be made. There are currently: four health and social services boards; the Central Services Agency; the Health Promotion Agency; the Mental Health Commission; and the Northern Ireland Regional Medical Physics Agency. Irrespective of the RPA, there would have been a shared services organisation, because there was commitment to a programme of shared services. Under the new arrangements, there will be a regional board, a regional agency and a regional support services organisation. Three new bodies will replace the agencies that I have mentioned, so there is a clear reduction in the number of bodies.
One of the big questions raised by Paul McBrearty — with whose view I fundamentally disagree — is whether the same focus can be achieved within the regional board. That is the essence of many of the concerns. Would a board that faces the kind of financial pressures that a regional board will face — such as the Committee has been discussing — be able to prioritise the funding required for public health and social well-being in the way in which it should be prioritised? Would that aspect of healthcare receive the kind of additional investment that we think it needs? My argument is that it would not. That will happen only if there is a separate body, with its own focus and its own board. It is worth saying that, in developing the management structures for the two bodies, great care has been taken not to duplicate and to jigsaw the two organisations so that the senior posts and the professional input of each complement each other. We are not in the business of replicating all the functions of a board in an agency, or vice versa. We are in the business of making the two organisations work together as an integrated whole, because no one wants duplication or for us to waste resources in that way.
Dr McBride:
Although I am not familiar with the quotes that the Chairperson has just read out, I assure the Committee that there will be no duplication of effort; the operating framework will provide that clarity.
The RPA savings are a given. Irrespective of what model we select — whether there is a board or an agency, for example — the £53 million savings will be realised. There will be no additional bureaucracy, because that will also be clarified in the operating framework.
Returning to the economic argument, economist Derek Wanless has said that we must do more about the new public-health agenda. We must invest more upstream if we are to continue to have a publicly funded Health Service that is free at the point of delivery. Therefore, there is a solid economic argument supporting that. In the earlier evidence session, the Minister referred to the economic case for that renewed focus.
Compared with how much of our budget we spend on acute services, the amount that is spent on public health pales into insignificance. The establishment of the agency is an opportunity to provide some counterbalances in the system. We will always need to provide, and invest in, acute services, community services and services to ensure that people who are unwell recover and are supported in their homes. However, we must, simultaneously, invest in the upstream side of the wider public-health agenda.
I support Bernard in saying that the ethos and culture of those organisations will be different. Given the pressures that will be put on a single organisation, I am afraid that I know, from past experience, who the poor relative would be. It would be the public-health agenda and the challenges that we face in dealing with the health inequalities and the disproportionate impact that that has on the most deprived areas. Not everyone in Northern Ireland is equally well or has an equal life chance.
Mr Easton:
I do not see how it is not more cost-effective for the service to be provided within a board rather than its having a separate identity. I do not see how the services being managed together rather than separately will disadvantage certain areas. I appreciate what you said, but the agency would be an extra layer of bureaucracy and would be cumbersome, so I maintain that it is better if all services are provided through a single board. However, the matter should not be considered during the scrutiny of clause 7.
The Chairperson:
We will discuss clause 12 later and if a vote is required, so be it.
Dr Deeny:
Gentlemen, I want you to convince me of the need for the agency, as I believe that that is why you are here. I have heard it asked, not only in this Building or this Room, why the agency cannot be incorporated within the board. I am aware that Alex has also asked that question and that you had been explaining the reasons for that, Michael.
I take your point, Bernard, that the amount of unnecessary bureaucracy is being decreased, but that must be done efficiently. How many people do you envisage working in the regional board, the regional agency and in the Department of Health, Social Services and Public Safety? The public ought to be told that.
Michael, you said that you knew who the poor relative would be if there were a single organisation, but surely that day is gone. We now have a devolved Assembly, there is a Committee for Health, Social Services and Public Safety, and there is accountability. I know the chief executive of the Health Promotion Agency well and, as a GP, public education and public health are important to me. Therefore, I agree that those elements must play a major part in the future of healthcare in Northern Ireland. Nonetheless, even if public health were the poor relative, surely it would be up to the relevant organisations to come to the Committee, which would see to it that that was not the case.
Mr Mitchell:
We are in the final throes of a detailed staff-mapping exercise. It requires us to meet all the current employing organisations, and their staff, to resolve their current roles and responsibilities and, depending on what they do, allocate them to different bodies. It is a complicated exercise, which we are carrying out in partnership with the trade unions. It is nearing completion, but I cannot give you the final figures. However, I can give you the figures that are in the public domain.
The Minister has given a commitment that the staffing of the board will be below 400. Earlier, the Minister said that the figure for the regional agency would be between 250 and 350 staff, although I suspect that it will be towards the former rather than the latter. The figure for the Department would be in the region of 700 staff. I emphasise that all those figures are subject to the completion of the staff-mapping exercise and to us working out definitive figures that we can bring back and share with the Committee.
Dr McBride:
I respect the views that have been expressed, and the Committee has listened attentively to my points. However, in relation to the “why”, I have not yet heard a reason that challenges the concept of having a separate regional agency. We are facing huge and stark challenges. As Bernard has said, the tendency will be to focus on the short to medium term, and that has always been the focus of the Health Service. We all agree that we need to address health inequalities, to invest upsteam and prevent ill health and premature death. However, when it comes down to the pressure decisions of where the money will go, we will put it where we always put it — into services.
We need some balance and challenge in the system. The Health Committee has an important role in providing that challenge. Equally, we need that challenge to happen at the front line where the commissioning plans are being agreed: we need to work to support LCGs, local government and local authorities to decide and determine those interventions that will improve the outlook for people in communities. That is the challenge.
I do not believe that we will have the same opportunity to achieve what we all want to deliver within a single body that will be fundamentally focused and directed to the significant challenges of developing, maintaining and sustaining service delivery. This is a unique opportunity.
However, there are real tensions. If a single body is examining waiting times, access targets and the challenge of healthcare-associated infections, and it knows that there is an interrelationship between many of the factors that contribute to one and factors that address another, there must be a tension and an appropriate challenge in that system. I am concerned that the appropriate challenge will not happen in a single organisation. There must be a dynamic tension between the health-improvement and health-protection agenda and commissioning and delivering services, and that is why it is needed.
The Chairperson:
The Committee will raise that issue.
Mrs Hanna:
I will try to be brief. I have listened to your arguments, and I welcome the strong focus on public health. In all my time in the Health Service, I have never heard it being talked up so much. There have been arguments and pros and cons with the previous trustsabout whether they should have responsibility for primary and secondary care. We have mostly considered those services in the acute hospitals. In some ways, I welcome the Belfast Health and Social Care Trust, although I wonder how it will balance its resources. It makes sense for the trust to put money into primary care and keep people out of hospital, although I do not know whether that will happen.
However, if there is to be a separate agency — and I would be happy about that because we need to focus on public health — we must ensure that that body will be able to make decisions. If the agency cannot make decisions about expenditure on public health, there is no point in having it. It needs to communicate well, and public-health professionals and experts need to be represented on the agency if it is to make a difference and work with people in the communities.
I take on board everything Michael and Bernard have said. The challenge is huge. I hope it works, but it will not unless genuine decision-making powers are given the agency.
Dr McBride:
I think that the Minister has been very clear on that.
Mrs Hanna:
Will the regional agency take responsibility for public health in trusts? Will it be responsible for the public-health function?
Mr Mitchell:
The Minister has said repeatedly that the regional agency for public health and social well-being should be at the heart of the full commissioning process. As I pointed out at the outset, one of the givens is the fiscal co-location of the agency and board staff working together to support the local commissioning groups, because that is where the bulk of the money will be committed and the bulk of the decisions will be made. If the agency, nurses, allied health professionals, various managers and other staff all work together, and if they are co-located and supportive of the local commissioning groups and doing what they are meant to be doing, the kind of integration and influence that Mrs Hanna wants is — by definition — built into the process.
The other part of the task has been to try to ensure that that is mirrored on a regional level. Therefore, we have given careful consideration as to how to put in place the kind of joint ownership of the commissioning plan that Mrs Hanna has described. The challenge that we face is to ensure that the agency has influence, which it can bring to bear on the board’s total expenditure. If the agency falls into the trap of solely managing public-health streams, it will find itself in a rut. It needs to look at the full breadth of the health- and social-care system. We want to give the agency input into expenditure across the full range that the board is committing, through service and budget agreements, with the trusts. That will not just be reflected in the public-health aspect of the agreements but in every programme of care within them, whether they are for maternal and child healthcare, care of elderly people or anything else.
Dr McBride:
The difficulty is that the model is so new, and the thinking that underpins it is challenging. Sam Gardiner mentioned at the earlier evidence session that change is difficult for everyone, and everyone involved in healthcare is coping with significant changes. Michelle’s comments on trade unions and her stress on the need to keep staff informed and on board are important.
I return to Tommy Gallagher’s point about local commissioning groups. Bernard is absolutely right: that is where it all locks together. That level is the interface with local government, other local authorities and communities. The teams work in an integrated and collective way to move forward the entire agenda. Alex Easton and Tom Buchanan have raised concerns about that; their questions are legitimate. However, I reiterate that this is about achieving more balance in the system in deciding health- and social-care priorities. By all means, we must continue to support and improve the services that we provide. We must provide better quality and safer services; however, at the same time, we must embrace, and take ownership of, the agenda for improving the health of the population.
Investing for Health was a product of the previous Executive, and it had cross-party support. At the time, the Chief Medical Officer for England said that it was the best public-health document written in the English language; and whereas we have had significant improvements in the health of the population in Northern Ireland, we have not fully realised them. We have not fully delivered so that people in Northern Ireland communities are uniformly and equally well.
To my mind, this process provides an additional opportunity to ensure that the appropriate challenge function is there when we are committing resources and determining commissioning plans so that, as Bernard has indicated, the agency has influence over the totality of the spend. That dynamic tension needs to be in the system if we are to realise the Wanless “fully-engaged” scenario that is recommended for the population of Northern Ireland in the Appleby Report, contain costs, improve the outlook for the population of Northern Ireland and, at the same time, reap the economic benefits. We are beginning to see that investment in health is investment in the wealth of the population and in the Northern Ireland economy.
Mrs Hanna:
At this stage, we must realise that all the issues have been identified. We must also realise that decisions must be made about where resources should be invested. That is why I asked that question. The agency must have some decision-making powers, otherwise it will be able only to identify the issues that we have already spelt out rather than actually make a difference. It must be able to make decisions about where resources are focused — such as prevention and early intervention — rather than to employ well-meaning, experienced, professional people who will tell us what we already know.
Dr McBride:
Perhaps that is at the root of some of the concerns that have been raised, such as whether the agency be sidelined or whether it will be a toothless body that sits on the sideline seeking to negotiate and influence, but yet, as Carmel said, has no real power, control, influence or decision-making powers. The Minister has made it clear that that will not be the case. Do you want to elaborate on that, Bernard?
Mr Mitchell:
We are building that into the entire infrastructure. Specifically, on 1 July, the Minister announced that he was committed to examining the issue of joint sign-off. We are examining the practicalities of that. That is a potential means through which the kind of influence that Mrs Hanna spoke about could be delivered.
Mrs O’Neill:
From an Investing for Health perspective, I support the principle of the regional agency. We must welcome the focus on prevention and promotion. That is essential. There are concerns about how that will filter down on the ground and whether commissioning plans will reflect the agency’s priorities. Among other groups, the Royal College of Nursing has proposed some amendments to strengthen that relationship. As a Committee we can examine those.
The Chairperson:
Michael, are you leaving now?
Dr McBride:
I am happy to stay, Chairperson, if there is anything else that members wish to ask.
The Chairperson:
I know that you came to talk about the specific issue of efficiency savings, but you are welcome to stay, if you wish.
I invite officials to outline the meaning of clause 7 and schedule 1. Afterwards, I will invite questions from members. I remind members that in considering each clause, they may wish to take account of views expressed in written and oral submissions to the Committee.
Mr Ivan McMaster (Department of Health, Social Services and Public Safety):
Clause 7 establishes the regional health and social care board that will replace the four current health and social services boards. Clause 7(1) states:
“There shall be a body corporate”.
That means that the board has rights and responsibilities through interpretation of the Bill including: the right to regulate its own business and to employ its own staff; the power to enter into any contracts and to sue and be sued; and the right to decide its corporate name.
Clause 7(2) states:
“Schedule 1 applies in relation to the Regional Board.”
Paragraph 1(1) of schedule 1 sets out the status of the regional board.
Paragraph 2(1) of schedule 1 sets out the regional board’s general powers:
“the Regional Board may do anything which appears to it to be necessary or expedient for the purpose of, or in connection with, the exercise of its functions.”
The main restriction is that the regional board is subject to any directions that the Department may give. Obviously, the Department will monitor the work of the regional board.
Paragraph 2(2) of schedule 1 states:
“But the Regional Board may not borrow money.”
Paragraph 3(1) of schedule 1 sets out the membership of the regional board:
“The Regional Board shall consist of —
(a) a Chair appointed by the Department;
(b) a prescribed number of persons appointed by the Department;
(c) the chief officer of the Regional Board;
( d) such other officers of the Regional Board as may be prescribed”.
The Department is currently working on the subordinate legislation that prescribes the details of those positions. Decisions have yet to be made on whether those positions should be designated to certain people on the board and what types of skills those employees would require or what types of posts they would have needed to have undertaken previously.
Schedule 1 also deals with other issues such as remuneration allowances and terms of office — that is, when a person may resign or be removed from office. I can deal with any issues that members would like to raise on clause 7.
The Chairperson:
Members will have the opportunity to read through the schedule and raise any issues. I do not see the need to go through each of the headings.
The Committee will revisit clause 7 at a later stage to agree it formally. Is there broad agreement among members with clause 7 as drafted?
Members indicated assent.
The Chairperson:
Schedule 1 is fairly straightforward, but, again, the Committee will revisit it at a later date to agree it formally. Is there broad agreement with schedule 1 as drafted?
Members indicated assent.
The Chairperson:
We now turn to clause 8, which deals with the functions of the regional board.
Mr McMaster:
Clause 8 sets out the statutory functions of the regional board. Those functions are dealt with in more detail in clause 24. Broadly speaking, clause 8 transfers all the statutory functions currently exercised by the health and social services boards to the new regional health and social care board or to the proposed regional agency for public health and social well-being. The functions dealing with health improvement and health protection will transfer to the regional agency, and everything else will transfer to the regional health and social care board.
That provision does not seek to replace existing legislation. Therefore, all existing functions — contained in statutes such as the Mental Health ( Northern Ireland) Order 1986 or the Children ( Northern Ireland) Order 1995 — will remain extantand will transfer en bloc to the regional health and social care board.
Clause 8(2) requires that the regional health and social care board, in carrying out its functions, examine specific areas. It requires that the regional board does so with the aim of:
“improving the performance of HSC trusts … establishing and maintaining effective systems ... managing the performance of HSC trusts … commissioning health and social care”.
Those are the broad duties that the regional board will undertake.
Clause 8(3) requires the regional board to carry out a “commissioning plan” each financial year, and there is a statutory requirement that that plan be published. It also provides a permissive power for the Department to specify what that plan should contain. However, it is expected that that would be used only as a fall-back option.
As currently worded, clause 8(3) requires that the regional board consult with the regional agency and, having consulted with it, to:
“have due regard to any advice or information provided by it.”
The Minister is considering strengthening that power in relation to joint sign-off.
Clause 8(4) explains that the functions given to the regional board in clause 8(1) are deemed to be functions that the Department has directed the board to carry out. It is retrospective in approach, and it covers any future statutes that may also confer directions.
Clause 8(5) relates to the Department’s general powers, which are laid out in clause 3. Clause 8(5) allows the regional board to exercise its wide-ranging power to the same extent. In other words, as the board takes its functions from the Department, the overarching duties of the Department should also be the duties of the regional board. It is a wide-ranging power and limited only to the extent that the action must facilitate, or be conducive to, the discharge of the board’s duty.
The Chairperson:
The Committee will formally agree the clause later. Is there broad agreement with clause 8 as drafted?
Members indicated assent.
The Chairperson:
The Committee will now consider clause 9, which deals with local commissioning groups.
Mr McMaster:
Clause 9 requires the regional health and social care board to establish a prescribed number of local commissioning groups. The regional board will have the power through schedule 1 to set up whatever committees and subcommittees it chooses. However, clause 9 is specific in requiring the creation of local commissioning groups as committees of the board.
Clause 9(1) simply gives them the title “local commissioning groups” and allows for regulations prescribing their number. The current thinking is that there will be five, in line with the number of trusts. However, the Minister has indicated that he may reconsider that, in light of what emerges from the local government review. In any case, the introduction of those measures through subordinate legislation allows more flexibility.
Clause 9(2) permits the Department to specify the geographical area for which the local commissioning groups will be responsible.
Clause 9(3) provides the local commissioning groups with certain statutory functions. Clause 9 (3)(a) states:
“such functions with respect to the commissioning of health and social care as may be prescribed”.
That is a fairly broad term. The subordinate legislation will go a stage or two further than that in breaking down that role.
Clause 9(3)(b) provides for local commissioning groups to perform:
“such other functions as the Regional Board may, with the agreement of the Department, determine.”
The LCGs were established principally to commission health and social care services, which is why the power granted to the regional board to provide the commissioning groups with other functions is restricted and is to be exercised only with the Department’s approval.
Clause 9(4)(a) requires each local commissioning group to:
“exercise its function in accordance with any scheme for the time being having effect under article 18 of the Order of 1972”.
Under the Health and Personal Social Services ( Northern Ireland) Order 1972, health and social services boards were required to submit a scheme to the Department as to how they would carry out their functions. The technical terminology used in clause 9(4)(a) means that, as committees of the regional board, the commissioning groups must provide services for any scheme that the board submits on its own performance and function to the Department.
Clause 9(4)(b) places an absolute requirement on a local commissioning group to consult with the regional agency. That is in addition to consultation on the commissioning plan. In the course of its general duties, a commissioning group must consult with the regional agency. The Department assumes the power to direct any other consultations that it requires the local commissioning groups to undertake. Again, the use of that directing power would be regarded as a last resort.
Clause 9(5) sets out the specific aims that local commissioning groups must strive to meet. They include:
“improving the health and social well-being of people in the area … planning and commissioning health and social care to meet the needs of people in that area”
and:
“securing the delivery to people in that area”.
I will not go through all the aims. They are listed in the Bill.
Clause 9(6) provides the regulation-making power under which the Department makes provision for membership of the commissioning groups and is allowed to make any other provisions to the groups that are considered appropriate.
Clause 9(7) makes it clear that:
“Before making regulations under subsection (6), the Department must consult the Regional Board.”
Mr Gallagher:
It may not be a matter for today, but my question relates to the prescribed number of local commissioning groups. There appears to be an assumption that there will be five groups to reflect the five trusts. I am not sure that that would deliver the best results, particularly in the west, in reflecting and responding to the needs of local communities.
Dr Deeny:
I declare an interest as a member of an LCG. The Committee has had worthwhile presentations over the past few weeks from the BMA, the Royal College of Nursing, the allied health professionals, the chief executives of the health and social services boards, the Regulation and Quality Improvement Authority and representatives of the health and social services councils — the patients’ advocates. We asked them for their views, and they all gave us consistent replies.
Clause 9 deals with local commissioning groups. Clause 9(3) states:
“ Each Local Commissioning Group shall exercise —
(a) such functions with respect to the commissioning of health and social care as may be prescribed; and
(b) such functions as the Regional Board may, with the agreement of the Department, determine.”
Who prescribes the functions? General practitioners and elected representatives share the views of the six groups that I have mentioned. The local health and social care groups that were their predecessors did not work because the GPs saw them as taking a top-down approach as opposed to a bottom-up approach. No one who is interested in becoming involved in local commissioning groups wants them to act simply as advisory bodies or talking shops, in which every decision has to go back to the regional board to be approved.
I liked what Bernard said earlier about supporting LCGs. We must have that commitment from the Department. I spoke to an optometrist who was upset that his profession will no longer be represented on local commissioning groups. That is a backward step. This is national eye care week. Optometrists served on local health and social care groups up to now. We can deal with that matter later. I want to get that commitment from the Department.
I do not want this idea to collapse because it is a wonderful opportunity to commission services according to the needs of our local communities. At the earlier evidence session, the Minister said that different areas will have varying needs. Local people know who is accountable and who will take decisions, some of which might be unpopular, but at least they are known to the local community.
Last week, the editor of a major GP magazines said that what is happening in Northern Ireland is unique and that other countries would watch with interest to see if it works. I hope that the local commissioning groups will have the clout to make decisions. Those decisions will have to be approved by the regional board, which will be backed up by the necessary finance.
Mr McMaster:
The word “prescribed” as used anywhere in the Bill means prescribed by regulations made by the Department. That is defined in clause 31(1).
Mr Easton:
Clause 9(2) states:
“Each Local Commissioning Group shall exercise its functions as regards such area of Northern Ireland as may be prescribed.”
That is a wee bit airy-fairy and does not include the new council arrangements, although you touched on that issue earlier. I would like that to be toughened up by stating that each local commissioning group shall exercise its functions within one of the Northern Ireland local government districts. That would take in the councils and ensure that the LCGs will not be spread all over the place but will take in a solid council area. I propose that wording, because it is tougher and more straightforward.
Mr Mitchell:
Coterminosity with local government is regarded as a fundamental part of the reforms. There is a proposal to have five local commissioning groups to match the existing five trusts; however, we are waiting for the outcome of local government reform and the redrawing of local government boundaries. We previously gave a commitment that the issue would be revisited when those decisions were made. It was always felt that it would embody coterminosity. However, it would not be on a one-to-one basis, but rather it would be between one or two councils and the local commissioning group. That is the intent that underpinned the wording.
Mr Easton:
That is not a definite commitment.
Mr Mitchell:
It is a commitment to review the boundaries after the outcome of local government reform.
The Chairperson:
The regulations will come to the Committee.
Mrs O’Neill:
I want to return to the issue of the work of the agency and the linking up with local commissioning groups. The Royal College of Nursing has made a suggestion that would help to allay any fears. It wishes to strengthen clause 9(4)(b) from:
“in connection with the exercise of its functions —
(i) consult RAPHSW and have due regard to any advice or information provided by it;”
to the following:
“to work in partnership with RAPHSW and be able to demonstrate that the exercise of its functions reflects the priorities determined by RAPHSW”.
We talked about that issue earlier. The priorities for health promotion must be reflected in the commissioning plan.
Mr Mitchell:
I am a newcomer to some of the legislative processes; therefore, some of it comes down to my understanding of what a draftsman advises us. We were advised that “have due regard to” was the strongest legislative wording that could be used. In a sense, that is a belt-and-braces approach, because, for me, the real answer to the RCN query relates to the co-location of integrated commissioning support units and joint membership of the local commissioning groups. The local commissioning group will develop an annual commissioning plan, and public-health consultants, senior nursing staff and allied health professionals will be part and parcel of the development of the plan and its subsequent monitoring. That ensures that we achieve the kind of integration that we all want. We share that view with the RCN. The draftsmen advised us that the wording that we used was the strongest possible wording that could be used for the obligation that we were laying on the local commissioning group.
Mrs O’Neill:
I accept what you are saying, but members have expressed concerns about the role of the agency, and the RCN and other organisations have also expressed concerns about it. Therefore, the amended wording would go some way to allaying those concerns. Perhaps you could take away that wording and discuss it.
Mr Mitchell:
Will you give us the wording again?
Mrs O’Neill:
The wording needs to be strengthened and amended to read:
“to work in partnership with RAPHSW and be able to demonstrate that the exercise of its functions reflects the priorities determined by RAPHSW”.
Mr Mitchell:
We will check that out.
The Chairperson:
The Committee requests that the Department re-examines clause 9 and considers implementing the suggestion made by Michelle O’Neill. Are members in broad agreement with clause 9 as drafted?
Members indicated assent.
The Chairperson:
We will now move on to clause 10, which deals with the power of the regional board to give directions and guidance to health and social care trusts.
Mr McMaster:
One of the duties being given to the regional board is the management and improvement of health and social care trusts’ performance. Clauses 10 and 11 give the regional board stronger powers to fulfil that duty. Clause 10 will give the board legislative power to guide trusts and to direct them to take certain courses of actions. The regional board must consult the trust concerned and obtain the Department’s approval before issuing that legislatively based direction.
As we discussed at last week’s meeting, clause 10(4) deems that it would be inappropriate and impracticable for the regional board to consult in urgent matters of patient safety, for example. Clause 10(5) outlines that the regional board is not allowed to give direction that is inconsistent with that already given by the Department. Under the legislation that established the trusts, the Department has the power to direct trusts in how they carry out their functions. Clause 10(5) ensures that any direction issued by the regional board is consistent with what is already on the statute book.
Clause 10(6) obliges a trust to comply with the duties given to it and to have regard to any guidance given to it by clauses 10(1) and 10(2). Clause 10(7) grants the Department the power to prescribe that the provisions of clause 10 can apply to any other organisation that may carry out functions on behalf of the regional board in the future. However, there is no thinking that clause 10(7) will have to be used in the near future.
Mr Gallagher:
Does clause 10 reflect only the current situation?
Mr McMaster:
At present, health and social services boards advise trusts and manage their performance, but they do not have a formal direction-making power to tell trusts how to carry out their duties.
Mr Gallagher:
Therefore, clause 10 will give boards a stronger power.
Mr McMaster:
Yes; clause 10 will give boards a stronger power and improve performance management in the trusts.
The Chairperson:
Are members in broad agreement with clause 10 as drafted?
Members indicated assent.
The Chairperson:
We will move on to clause 11, which deals with the provision of information, etc, to the regional board by health and social care trusts.
Mr McMaster:
Clause 11 is linked to the performance management role that the regional board will have. The Health and Personal Social Services ( Northern Ireland) Order 1991 — which established the trusts — requires trusts to record and pass on certain information, mostly to the Department. Clause 11 will place a duty on trusts to record information under the direction of the regional board; trusts will have to provide the board with information and furnish its reports. Therefore, clause 11 further strengthens the role that the new regional board will have in managing the performance of the five trusts.
The Chairperson:
Are members in broad agreement with clause 11 as drafted?
Members indicated assent.