COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Evidence Session with Trade Union
Representatives on Efficiency Savings

27 November 2008

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Claire McGill

Witnesses:
Ms Mary Hinds ) Royal College of Nursing Northern Ireland
Ms Breedagh Hughes ) Royal College of Midwives Northern Ireland
Mr Kevin McAdam ) UNITE
Mr Kevin McCabe ) Northern Ireland Public Service Alliance
Ms Patricia McKeown ) UNISON Northern Ireland
Mr Tom Sullivan ) Chartered Society of Physiotherapy ( Northern Ireland)

The Deputy Chairperson (Ms O’Neill):

I welcome Patricia McKeown, Kevin McAdam, Mary Hinds, Breedagh Hughes, Kevin McCabe and Tom Sullivan. We will allow up to an hour for this presentation, and members may then ask questions.

Ms Patricia McKeown (UNISON Northern Ireland):

We represent independent organisations acting on behalf of the Health Service workforce. We strive to work collectively, with a high level of success, although each of us will make our own separate submission on the comprehensive spending review (CSR) cuts. I will present the UNISON response on the overview of the five current main areas of crisis in the Health Service. Our clear view is that we cannot consider the comprehensive spending review cuts in separation or isolation from anything else that is happening.

I will address the issues of finance and underfunding. Within the past month, the trade union movement has met the First Minister and deputy First Minister. We made some trade union proposals to address the current economic crisis. Those include the need to pay particular attention to the most vulnerable people in society and the crucial role of healthcare and healthcare investment at a time of economic downturn.

The world community is united in prioritising public spending in order to respond to the crisis. It would logically flow that the Health Service in Northern Ireland should be exempt from the proposals for 3% efficiency savings, which are not efficiencies but real cuts in service provision. As currently being processed, they are a symptom of deep, underlying crises. The Executive’s conversation with the UK Government on legacy financing issues has rightly identified the need to redress matters such as the reform of water charges and equal pay in the Civil Service. However, there is no evidence whatsoever that the key legacy issues in health have been addressed. In November 2007, the Department of Health, Social Services and Public Safety confirmed that acute healthcare in Northern Ireland is underfunded by 17%. At the same budget consultation meeting, the Department acknowledged that primary care — including community and mental-health provision — is underfunded by 35%. The report from the Children’s Commissioner established an underfunding figure of 30% for children’s services, including those in health. That analysis was verified by civil servants in the Department of Finance and Personnel.

We now have the reality of a 3% efficiency drive that has been imposed as a UK policy — irrespective of the figures that I just quoted. Given the pre-Budget report and its impact on the Northern Ireland block grant, we expect pressure for savings in the Health Service over and above 3% in 2010-11 and beyond.

Your Committee and the Minister, with widespread public support and direct support and analysis from UNISON, were able to raise the new service element of our health budget by a significant amount. However, we circulated recent analysis about the impact of new spending and the capitation formula, and it points to a depressing conclusion. New money is primarily going to meet the elective surgery needs of those living in the more prosperous areas of Northern Ireland.A proper baseline for working with healthcare expenditure needs verification and policy change to ensure that precious resources go to the right places. Otherwise, blanket efficiency savings compound the damage.

Last year, the Chief Medical Officer informed the Committee that seven years of effort on health inequality — including the Investing for Health strategy — had not changed any of the key statistics on health inequality in Northern Ireland. That is not to denigrate the outstanding efforts that have been made at local level. It is our considered view that the pressures of the review of public administration (RPA) and the CSR are now leading the Health Service as a whole to lose focus in that area. Cuts that are emerging in areas such as domiciliary care and residential care provision will have a negative impact on health inequality. The trusts, boards and agencies do not have a health inequality assessment process in place to implement the savings that were reported to the Committee.

As the Committee knows, the first stage of the reform was the creation of the five trusts. The second stage is the Health and Social Care (Reform) Bill. The structures that are being created detach commissioning and provision. That leads to high transactional and bureaucratic costs, which are unnecessary and reduce accountability for delivering healthcare. There are real areas for an examination of costs and effectiveness that are unaddressed in the savings drive.

The process of equality screening and assessment that is undertaken by each of the trusts is ineffective. In some cases, it is derailed by a consultancy approach that is used by some of the trusts and is supported by the Department. There is a fundamental failure of joint working between the trusts and the Central Services Agency to realise targeted non-pay savings, and we are in the blame game. The Committee should ask tough questions of all concerned as to how and when targeted non-pay savings will be achieved in this financial year and future ones.

Some proposals that have emanated from the trusts have been unacceptable and unethical — for example, consigning young people in Muckamore Abbey Hospital to remain there as home for life until 2016, or charging people with learning or physical disabilities for transport to their day centres.

In relation to domiciliary care, there is a drive to substitute publicly provided care hours by privately provided care hours without effective standards, monitoring or recognition of the sheer extent of the abuse of work practice that occurs in some areas of the private sector. Such abuse is, of course, damaging to care.

Residential care proposals are cuts-focused rather than outcome-focused. The drive to re-provide residential services in the community through the use of the private and voluntary sectors is taking core skills out of the National Health Service and fails to recognise the serious instability of those sectors in current and future financial conditions. There is now widespread awareness that a number of residential care companies here are operating at the margin of survival or are going through fundamental financial restructuring.

In the cuts proposals, there are also a number of top-down initiatives to raise productivity in order to save money. The fundamental concept of working more smartly to release more time for care is being lost. Industrial approaches, involving performance management techniques such as Lean Technology and Six Sigma, fail to take account of the fact that it is an absolute priority that those who do the work must be involved in improving its outcomes. Our members are full of ideas and frustrations about how the situation could be improved; however, no one is asking us for those ideas.

Instead, we see crude CSR proposals being introduced. Examples of those are the removal of 1·13 nursing staff from each ward through electronic rostering in the Southern Health and Social Care Trust; the use of textile factory methodology for setting ward staffing levels in the Western Health and Social Care Trust; and the unjustified, non-sustainable assumption made by the Belfast Health and Social Care Trust that everyone can work 13% harder.

Bed closures are being introduced without proper analysis of the effects on waiting times or the cancellation of operations. Crude GB benchmarks are being used instead of proper analysis of the throughput of patients. Again, there is no effective consultation with healthcare workers and unions about the consequences of bed closures for patients and effective working in the ward.

At this stage, skill mix proposals in nursing and social services lack the clarity of ratios for what the employers call “qualified” and “unqualified” staff, recognition of latent skills and clear profiles of future duties and responsibilities. There is much more work to do on that issue, and the current CSR pressures are driving trusts towards crude and ineffective solutions.

Critically, we are beginning to see the cuts impacting on training programmes and job-access initiatives in regeneration areas. Such programmes have been highly commended at all levels of Government for having the triple impact of creating access to entry-level healthcare jobs, upskilling the existing support service workforce and improving healthcare in areas of disadvantage. The most significant of those programmes is the greater Shankill/west Belfast area programme that, in another example of short-term, knee-jerk reactions to CSR cuts, will have its funding removed from March 2009.

In conclusion, we need to move out of the current CSR process, use all the Executive’s resources to address the legacy healthcare issues with the UK Government and use the process of Budget allocation for year 2 of the Programme for Government to re-prioritise healthcare. Waste is never acceptable, but we are cutting to the bone and beyond, and our healthcare services are now in a critical condition. There is, however, time to rethink, but that requires the full co-operation of all parties in the Executive, the Committee and the Assembly.

The Deputy Chairperson:

Thank you for that overview, Patricia. About a month ago, the Minister attended the Committee — I am sure that you read the Hansard report — and members attempted to question him about several matters that you highlighted. Nevertheless, as the people working with the staff on the ground, you are able to give us the best information with which to challenge the Department about its proposed savings.

You said that members of staff have loads of ideas, but they are not being asked about them. When planning the way forward, how much input do the trusts take on board from their consultations with the unions?

Ms McKeown:

The direct consultation that should be taking place with staff and unions is not happening as it should. The creation of the five trusts is the first phase of reorganisation, and that has created a new, and distant, human resources framework in which the unions must work. People — including those on the management side — feel dislocated by the unseemly haste with which the restructuring proposals were rushed through. As members will remember, before power was devolved again to the Assembly, under direct rule, the proposals were rushed through staggeringly quickly. Consequently, there is a great deal of dislocation, some of which may be deliberate and some not.

We are losing what has worked effectively in the past. If one wishes to deliver a service better, one should sit down and discuss how to do that with the people involved in the direct delivery of that service. There are many fine examples of partnership working in the Health Service that demonstrate how much better things can be done, particularly if work that is carried out locally is taken seriously as part of the process of running the Health Service. Currently, we are losing such input.

Ms Mary Hinds (Royal College of Nursing Northern Ireland):

Patricia is absolutely right about local consultation. There is a lot of talent, and there are a lot of ideas out there. In addition, there is a lot of rumour, which affects staff morale; when people read newspaper headlines, they are rightly concerned about their jobs. Therefore, as we go through this period of change, we all have a responsibility to keep people calm, and one of the best ways to do that is to engage with staff at a local level.

If there must be change, and if people can see that it will benefit patient care and will not be to their detriment, they will stand up to make that change happen. For many years, all Northern Ireland healthcare staff have innovated and accepted the challenge of change, so they are not afraid of change. They wish to be engaged with change rather than merely being recipients of it. Although some trusts are trying hard, others could do better.

Ms Breedagh Hughes (Royal College of Midwives Northern Ireland):

I agree with Patricia that services in Northern Ireland are being crudely benchmarked with GB standards. In maternity care, we continually hear that we are overstaffed compared with England; however, everyone seems to ignore the fact that, on several occasions, Alan Johnson has publicly recognised that England is short of between 4,000 and 5,000 midwives. Therefore, we are being benchmarked against a figure that is totally inadequate. Although I can only speak from the perspective of maternity services, I am sure that the situation is no different for nursing or for any other area of the Health Service. Unless we lose the benchmark-them-with-GB approach, everybody here will be done a grave disservice.

The Deputy Chairperson:

Patricia mentioned delays in discharging young people from Muckamore Abbey, but, with the best will in the world — and I put this point to the Minister — that situation will not be improved with what is currently on the table.

You also said that training will be affected by cuts. How will people be able to carry out their jobs and progress in their careers if they are not provided with the necessary opportunities for ongoing professional development?

On numerous occasions in recent weeks, cuts in domiciliary, residential and respite care have hit the headlines, so, despite assurances from the Department that front-line services would not be affected, the reality seems to demonstrate that they are being affected.

Ms McKeown:

As far as we are concerned, front-line services are being profoundly affected. Let me be clear: I do not believe that the Minister of Health, Social Services and Public Safety has the power to decide that the CSR 3% efficiency savings stop, or are abandoned, in the Health Service. That decision clearly lies at the door of the Minister of Finance and Personnel and of the Executive, collectively. The whole Executive decided that health, which had been the number one priority in the Programme for Government for many years, ceased to occupy that position; it was replaced by the economy.

The outworking of that was to further reduce a health budget that already had major historical legacy problems. There are things that can be done within existing parameters, one of which may be to have a proper conversation with staff; however, not with a foot on their necks. It really is a question of whether — in the new world in which we live — something different can be done. Why must the 3% cuts be imposed? If there are new conversations to be had with the First Minister and deputy First Ministers about imaginative and innovative responses to the global financial crisis, the credit crunch and the situation in which we find ourselves, the other side must show some imagination. Dialogue is one way of achieving that.

Other than in health, I cannot see a direct impact on something as important as patient care in any other set of CSR cuts that are proposed for public services.

Mr Gallagher:

Thank you for the presentation. A picture is being painted of the consequences of CSR. Patricia raised an interesting point about the Budget, which my party and I voted against, partly because my membership of the Committee meant that I could see what was coming. It did not take a genius to foresee that.

The Budget voted in the CSR in the Assembly, and we are now living with the consequences. We have been landed with that, but there has not yet been an opportunity for a proper review of CSR and how to shift moneys around, because Executive problems meant that there was no discussion at all about a recent monitoring round. Key areas — such as shortfalls in the Health Service — did not surface. The December monitoring round is under way, and it is not clear whether there will be an opportunity for it to be properly debated in the Assembly. It might involve letters asking Committees where they are at and the Minister of Finance and Personnel declaring the situation that obtains and what will be done. Therefore, since the Budget, there has never been a proper opportunity to discuss those issues.

After that moan, will you elaborate on equality screening and that type of assessment to which you referred? With cuts in trusts now in the public domain, there is growing concern that residential homes, for example, will be closed through a screening mechanism rather than proper consultation. I am interested in what you have to say about that.

I also want to know whether the panel has any views in respect of a matter that concerned me at the time of the Budget, when five new trusts were put in place, and the Western Trust was left with a £3·3 million shortfall — the only trust in deficit as a result of rationalisation. On top of CSR, that really hurts people and professionals in the Western Trust area. Perhaps you know something about that, and, if so, it would be worthwhile hearing your views.

Ms McKeown:

The equality issue is not rocket science; it is about trying to make better decisions. That is precisely the aim of section 75 of the Northern Ireland Act 1998. It can be as difficult or as simple as you wish to make it. In order to conduct a screening exercise on a set of cuts proposals, one really ought to have a conversation with others and not just with oneself; that seems to be what has happened with a number of trusts.

In each trust, there are people with expertise in promoting equality of opportunity. It is their job to move this forward, but not in isolation. There is also a good deal of expertise on the union side, so a conversation with the unions would be good in the first place. That conversation did not take place at any stage.

Some of the trusts used external consultancy firms, which took what was essentially a tick-box approach. No database was provided on what the precise outworkings of any CSR proposals might be. Several proposals were declared to have been screened out, and it was decided that there was no need to go any further with equality assessment as those proposals would not have an equality impact. Interestingly, the consultation documents have been arriving in the past two to three weeks; they arrived in Belfast only yesterday. Issues such as the relocation of services and the reorganisation of district nursing have been screened out. Someone sitting behind a desk has declared that relocating services and reorganising district nursing will not have an equality impact. That surprises me, and it surprises anyone who works in the field.

The current exercise is flawed. I also have a problem with the five trusts doing their own thing, because, as members know, many facets of healthcare delivery are regional and located in one trust or another. Obviously, a majority of those services are concentrated in Belfast, but they have an impact beyond the citizens of Belfast, stretching throughout Northern Ireland. There is a need for a much more collective approach. To carry out good equality impact assessments, there must be processes that include unions taking a direct involvement with the public body, having discussions, considering ways of collecting data and potential impacts, and making sound decisions. I will not accept the current process. I am raising major formal complaints about it. The Minister will have to go back to the drawing board.

Ms Hinds:

Tommy also raised the impact that deficits, the comprehensive spending review and the review of public administration will have on staff. I am aware that in the west of the Province there are many concerns among the nursing team — and I am sure that that is the case among the other teams — about what amounts to abuse of senior nurses working across multiple sites, who invariably will spend most of their time driving from one place to another instead of doing the essential job that they should be doing.

We are trying to engage with the trusts. A major source of frustration for everyone is the lack of detailed information. The reform and modernisation programme — when talked up as much as possible — is supposed to remove resources from one area to reinvest in another. It seems like a reasonably simple equation; A is taken away from B and added to C. Unfortunately, it seems to be quite impossible to get the answer to that simple equation. In the absence of that answer, staff have no idea about their futures and the future shape and make-up of services, so the rumour mill starts to work.

In the absence of information that we can challenge if we feel that it is not good for the service and for patients, people will make information up and morale will plummet. I know that that is happening in the west and that nurses and others are concerned about their future. It will be no consolation to you to know that that is happening in other areas. The absence of detailed information from the trusts is concerning.

The consultation is under way, so it is not appropriate to name and shame trusts. However, one trust did send me a response to my request for detail with a simple sum of maths. It simply said that it took the percentage and applied it. It strikes me that enough talent is available to be able to reshape our services. We are all signed up to a public-health-driven service, and we know that that is the way in which services should be delivered in the future. However, the application of simple maths and percentages and a cut across the board is neither an intelligent nor a sustainable way in which to design services for the future.

Perhaps the Committee can help us with that frustration. We are knocking at the door to get that information, and we are trying to engage in the debate in a professional and measured way. We accept that change has to happen in certain areas, but we can enter into that debate only if we are given the appropriate information.

Ms Hughes:

Mary has described how some trusts have adopted a blanket approach with 3% cuts across the board. I will name names because the information is in the public arena. In the South Eastern Health and Social Care Trust, the initial, knee-jerk reaction was to save 3% by shutting the maternity unit at Lagan Valley Hospital. That trust did not consider that that might have an adverse impact on one section of the community — women. It did not consider the impact that that might have on staff. The easy answer was that all the women and all the staff could go to the maternity unit at the Ulster Hospital, which is miles away.

We tackled that suggestion with the trust’s board, and, as Mary said, we are now in a process of discussion while we consider reshaping the service in a way that leaves something that is acceptable to the women of the area. It is not on for the trust to say that it could not see any adverse impact of closing a maternity unit on any one of the groups that are defined in section 75 of the Northern Ireland Act 1998.

The Deputy Chairperson:

When the Minister spoke to the Committee about union representation and union involvement in the process, he said that we are a team. He said that it is important that unions be kept fully informed, that staff are a key element in the team and that they are represented by unions. He said that union representation must be embedded in the various levels of the organisation so that staff know what is happening, that they do not get any surprises and that they are treated fairly and properly by management. That is not the case if the unions are getting surprises on how the process impacts and on how it is rolled out.

Ms McKeown:

Oddly enough, that is the case when we do business with the Minister, but it is not the case when we do business with the employers. We have formally said to the Minister that we want clear signals to be sent to the employers. UNISON will not be incorporated or marginalised in the process, and one of those two things is happening. A tactic of incorporation is being used whereby, in any of the five trusts, local union representatives are expected to sit on up to 70 committees. That is certainly one way to kill an overview or real analysis of what is happening.

A proper dialogue is not taking place, either in partnership or in consultation, on the fundamental and vital role that we play in delivering decent healthcare and protecting the people whom we represent. There is no real conversation about how to engage the workforce better.

The Deputy Chairperson:

From today’s meeting, we could perhaps talk to the Minister to say that his message to the trusts and to the employers must be clear.

Mr Easton:

If it is any consolation, the Committee does not easily get information from the Minister either.

I am alarmed at the cuts that have been announced — especially the 700 nursing jobs. It is hoped that Members will get an opportunity to debate the issue in the Assembly. There are threats to jobs in the domiciliary and residential care sector in Bangor and Donaghadee, which are in my constituency. I have many concerns, especially since the Minister said that there would not be any cuts to front-line services — but it seems that that is not the case. There is something terribly wrong with the process.

It is unfair to say that the Minister has not got new money, because he received £500 million more over the past year. The problem is that the Minister seems to be making an announcement every two or three days about a new service and spending new money. I do not understand where it is all coming from; it amounts to more than the extra money that he received. The amounts involved do not add up.

The Minister provided the Committee with a document on his plans for efficiencies, but none of the plans allows for a common-sense approach. One of the objectives of merging trusts was to reduce excessive management levels, but most managers retained their jobs or were given jobs at a lower level. Therefore, the opportunity to cut back on management levels was wasted.

There does not appear to be a commitment to cut independent sector providers, which are a terrible waste of money. Furthermore, their work should be carried out within the Health Service. Claims for medical negligence cost over £75 million, but the Department does not seem to be doing anything to cut back on that. Costs for the employment of agency staff amounted to £40 million last year, but the Minister wants to cut back on nursing jobs. If he saved on the agency staff, he would not have to get rid of nurses. He has a strange approach to efficiency savings, and the issues that could be addressed with some common sense are not being tackled. What are your views on that?

Ms McKeown:

The responsibility for this lies at the door of the healthcare employers; they make the proposals, but they do not back them up with the equality data that we need to see. We are on a mission to ensure that Health Service jobs are not lost. One cannot go for a crude attack on the level of senior posts. However, I have seen differentiated approaches across the five trusts, when there should have been a common approach about what the restructuring from the review of public administration meant. Too many people have gone off and done their own thing rather than engaging in a collective approach to achieve a good Health Service.

If truth be told, a number of the trusts threw everything but the kitchen sink into these proposals. Under the old system, outrageous measures were suggested as ways of making cuts, but it was widely accepted that those measures would not be accepted. However, such measures have been accepted now, and that is a serious reason for a rethink. Some of those proposals cannot be serious.

We have heard that no nurses will be lost from the system. I am asking the employers to tell me what that means. Will they cancel the work permits of Filipino nurses and nurses from other countries? Will they transfer some of the Health Service jobs into the private sector, where they intend to put some of the services? Do they have access to figures on the skill mix that they are not sharing with us? Will we have some unacceptable ratios of nurses to healthcare assistants, for example?

The people who know the answers to those questions are the healthcare trusts, the trust boards and the CEOs, and it is from them that we must get the information. The information is not held in the coffers or the files of the Department of Health, Social Services and Public Safety. Those people need a kick to remind them that the information should be provided to the unions and to the Committee, and that kick should come from the Minister and the Department of Health, Social Services and Public Safety. That is precisely the point that Mary has already underscored.

Ms Hinds:

Many nurses choose to work for both an agency and the Health Service. That is a stopgap at the moment, but it requires robust management, and that is the disappointing thing. I understand where you are coming from with regard to the review of public administration, which was to sort out excessive management. Sometimes we are in danger of being under-managed but over-administered, and we chase lots of pieces of paper, but we are not actually managing the situation. However, that is the best way to control agency budgets. I have been a director of nursing, so I know that firm and robust management is required. When we get through the consultation period and know what is going to happen and where, I hope that the Minister will state clearly the timescale for reducing the agency budget.

In fairness, trade unions do not want any nurses or members of healthcare staff to face redundancy. That would be totally unacceptable. However, trusts are holding vacancies, which is putting huge pressure on staff, and, with the best will in the world, continuity of care is lost when many agency staff come into the work environment. That is not a criticism of agency staff or part-time staff. Indeed, I speak as a former part-timer, so it is not a criticism — it is simply the reality. It means that we must get through the process as quickly as possible so that clear messages go out from the Minister to the trusts, as Patricia said, to where we require good, firm, robust management. Therefore, let it happen, and let us reduce the bills, because they are exorbitant.

Mr Gardiner:

Miss McKeown, if you care to look at your notes again, you made a comment in your opening remarks that the better-off areas were being catered for or getting more attendance as a result of the Minister’s decisions.

Ms McKeown:

I am not saying that it is specifically the decisions of the Minister; it goes to the capitation formula.

Mr Gardiner:

Will you read that portion for me?

Ms McKeown:

It goes to the capitation formula. We have already shared some responses with the Committee.

Mr Gardiner:

Will you just read that portion for me again?

Ms McKeown:

What portion are you talking about?

Mr Gardiner:

I am talking about the portion where you said that the better-off areas would benefit from some of the Minister’s decisions?

Ms McKeown:

I did not refer to the Minister in the allocation of resources. I said:

“New money is primarily going to meet the elective surgery needs of those living in the more prosperous areas of Northern Ireland.”

Mr Gardiner:

I think that you included the Minister’s name somewhere along the lines there.

Ms McKeown:

No; I have presented to you precisely what is written here. I said:

“Your committee and the Minister, with widespread public support and direct support and analysis from UNISON, were able to raise the new service element of our health budget by a significant amount.”

We took a collective approach on that last year.

Mr Gardiner:

You said something about people living in better areas.

Ms McKeown:

I said:

“New money is primarily going to meet the elective surgery needs of those living in the more prosperous areas of Northern Ireland.”

That is because of the impact of new spending and the capitation formula. We have produced evidence and analysis on that.

Mr Gardiner:

The Minister’s attitude is that everyone is a patient, and everyone will be respected as such. The Minister is a colleague from my party, and I do not have to defend him.

Ms McKeown:

I am not attacking him.

Mr Gardiner:

He is a Minister who is interested in the people and patients of Northern Ireland.

Coming to nursing part —

Ms McKeown:

Before we leave that, I really must say that there is nothing in what I am presenting here that is an attack on the Minister.

We made a formal submission, as have others, on the capitation formula. That is how the resource allocation is taking place. I am not pointing the finger at the Minister saying that he is sending the money elsewhere. I am merely saying that allocation of resources is an area that is currently under review, which was why we were all consulted in the past few months and have responded to the capitation formula. Work that was carried out — and, I think, funded by the Department of Health, Social Services and Public Safety — has demonstrated that there is a problem with the allocation of resources. They are not hitting the TSN areas. They are being used to meet elective surgery needs, which means that they are being directed at more prosperous areas. Therefore, the issue is more detailed than that.

Mr Gardiner:

That matter will be noted and will go back to the Department. The Minister made it clear when he met the Committee that fewer nurses would work in hospitals but that there would be more care, even round-the-clock care, in the community. Where possible, he would discourage long-term stays in hospital. That is the policy that he is trying to present. Certainly, fewer staff will be in hospitals but more will work with patients in the community, particularly elderly people who need round-the-clock nursing care. Nurses are not being sacked for the sake of it; we need them, but the age factor is coming into play. Many are leaving nursing because they have reached retirement age, and so on.

Ms Hinds:

You are right; patients should be in hospital only for as long as they are required to be there. While they are in hospital, they should receive the best care possible, administered by the most appropriate person. We know that there will be change ahead. Our concern is that that transition from hospital to community has yet to be defined clearly, trust by trust. It is a case of misinformation and no information. Nurses and staff in hospitals are beleaguered. They face targets daily. I have no problems with targets when they improve patient care, but if they simply increase bureaucracy, I do have a problem.

In fairness to the Department of Health, Social Services and Public Safety and the Minister, we are working with them to see if we can do something to support ward sisters in making that transition. If we are successful, that will be of some help. I look to the trusts to start to develop transition programmes. If services are to be provided in the community, they cannot be switched off on a Friday and switched back on again on a Monday. We must start to develop the programmes in order to make change happen. Enthusiastic nurses and healthcare practitioners in all fields will want to make that change happen for us. No one in this room will make the change happen — it will be practitioners in the field who will do it. Their single concern is their patients, not their budget. Those practitioners will step up to the mark. They are talented, enthusiastic and optimistic people, and our job is to help them to step up.

Mr Gardiner:

Can you name the trusts that are not co-operating with you?

Ms Hinds:

It is unfair to do so at this stage, because we are in the middle —

Mr Gardiner:

If you want the Committee to push issues, this is the time to be open and transparent.

Ms Hinds:

What you can do for me and for nurses in Northern Ireland and the Royal College of Nursing is to ask them: where are the posts coming from and what grade are they, and where are the posts going to and what grade are they?

Mr Gardiner:

Ask who?

Ms Hinds:

All five trusts. You do that for me.

Ms McKeown:

We cannot get the answers.

Ms Hinds:

An early Christmas present would be great.

Ms McKeown:

They do a lot of talking, but they do not give us the answers.

Ms Hinds:

I do not mean to be flippant, and the information I seek seems to be very basic. However, that information on the planned changes will help us all, every person in this room. That is not a criticism; it is a request for basic information.

Mr Gardiner:

I am sure that, as a Committee, we can use our influence to tease out that information, one way or another. I have no problem with doing that.

Ms Hinds:

Thank you very much.

The Deputy Chairperson:

We intend to invite the trusts to appear before us, and we will ask those questions of them. In the meantime, we have no problem writing a letter to request that information.

Ms McKeown:

I will give you an example of how this matter is playing out. About four weeks ago, trade union officials discovered that a ward in a hospital was to be closed that week. They asked for that not to happen, because they had not yet thought the issue out. If the ward were to be closed, it would have a knock-on effect on operations. However, the ward was closed, and the operations were cancelled. Waiting lists have grown, and the hospital has been thrown into chaos. Those decisions were all part of the drive to make savings of 3%. I can understand the crazy pressures on people who take operational decisions like that on the hoof. They are under pressure, and that pressure must be lifted off them.

Mr Gardiner:

I do not like statements that tar everyone with the same brush. You have made a statement about a trust closing a ward. As a member of the Committee for Health, Social Services and Public Safety, I want to know which trust that hospital is in and which trust is not co-operating or coming up to the standards required. It seems that all five trusts are being —

Ms McKeown:

None of the trusts is coming up to the standard of co-operation that we have grown to expect when the trade union movement was part of the architecture. There are several reasons for that, which I have already explained in relation to the impact of the review of public administration, which has dislocated people and systems, and continues to do so. Some of that may be wilful at certain levels.

However, we are talking about five large employers that have been established for just over a year. Those employers have come into a system that is underfunded, does not have enough money and must make more cuts. They are, I hope, as frustrated as we are about the position that they find themselves in, and mistakes are being made everywhere. When I say —

Mr Gardiner:

I asked you a simple question, and you have given me a speech. I asked you for the name of the trust that was not co-operating. You do not seem to want to name it so —

Ms McKeown:

Do you want me to say the names of five trusts that are not co-operating as they should be?

Mr Gardiner:

I thought that you had referred to only one trust.

Ms McKeown:

No; I gave you an example of someone working in a hospital in a trust which, in the past four weeks, took a decision to close a ward. I also gave you the impact of that decision.

Mr Gardiner:

Where is that hospital?

Ms McKeown:

It is Musgrave Park Hospital in the Belfast Trust.

Mr Gardiner:

That was all that I wanted to know. Thank you.

Ms McKeown:

We provide those examples to illustrate what is happening. It is not about witch-hunting; those people are also under pressure.

The Deputy Chairperson:

I think that it is clear that there are problems in all the trusts in their engagement with the unions. The Committee must address that issue. Furthermore, the Minister has said that he wants increased engagement between the trusts and the unions.

Ms Hughes:

I want to add a caveat to the issue of agency staff. Mary has rightly pointed out that many nurses choose to work both in the Health Service and with an agency. In Northern Ireland, there is no such thing as an unemployed midwife because every trust has a shortage. If it were not for agency midwives from Glasgow and Liverpool, the service could not function. It comes back to the issue of imposing blanket terms on any area of the service. Such an imposition must be done judiciously and — as Mary said — the use of agency staff must be managed accordingly. Throwing the baby out with the bath water is not a good place to go.

Mrs McGill:

I thank the witnesses for their briefing, and I welcome them to the Committee. It is obvious from the contributions that information is not flowing to staff from the employers. The Deputy Chairperson and other members have said that the Committee will address that matter. Given that 3% so-called efficiency savings must be made, I am not sure how we can change that.

Mary, you talked about reshaping the services. Is it possible to improve the situation if the trusts work with the unions, the Committee, the Minister and other people who should be involved? I want to put on record that I am concerned about the loss of front-line staff. What are your views on that? What can we do? Can something be done within the current boundaries? We are all aware of the difficulties of legacy issues, deficits, and so on.

Patricia, you quoted the Chief Medical Officer, who said that there are certain strategies to deal with health inequalities and that there had been no advance about dealing with those strategies, including Investing for Health. What are your views on that, and do you agree with the Chief Medical Officer?

Ms Hinds:

I am happy to comment on whether 3% efficiency savings can make a difference. Patricia described the financial situation eloquently. We all need a reality check: to achieve 3% efficiencies every year for the next three years will be tough. It will not be without pain for some areas of the system. We do not accept that it should happen, but that it will happen. You are right, Claire; the fact is that that is the situation. It is unprecedented in the Health Service. I do not want anyone to be under any illusion that achieving those efficiencies will be slightly painful; it will be extremely hard in some areas.

To a degree, the Committee, the Minister and the trusts are between a rock and a hard place —difficult decisions will have to be made. Members have had the courage to step forward and be elected to the Assembly; therefore, they must make those difficult decisions. That will be tough. It would be mitigated if staff were engaged and if there were a shared vision about the direction in which we want to go. Investing for Health is accepted worldwide as one of the best possible public-health strategies.

As Patricia said eloquently, historically, we have not made the differences in health and well-being that we could or should have. However, if we are not optimistic now, how can we encourage our staff and members to look forward to the future? How dare we not try to be optimistic for their sakes? Although we accept that it will be extremely difficult, we have a responsibility to try to look to the future as positively as we can.

We are keen for that new model of services in which more services are based in the community and are commissioned by local general practitioners, nurses and councillors who work in those areas and know those communities to be introduced. It represents a revolutionary change to the way in which services are run. That one change alone will start to revolutionise services because it will make services feel more local and more responsive. The challenge to trusts is that they must start to respond in a similar manner. I have no illusions that that will happen overnight; it will not. Sometimes, people will respond positively; at other times, they will have to be taken by the teeth. That is the reality. However, that change is possible.

There are a few concerns. Patricia mentioned equality impact assessments. Some of those changes look great in theory. However, they will impact on carers in particular. Please remember that in your deliberations. Care in the home is wonderful. My father died at home. Although it was wonderful that he could be cared for at home, the strain that it put on my mother was, at times, excessive. Therefore, we must be careful. If we move towards that model of care, we must ensure that resources are directed where they are needed so that patients — rightly — receive the services that they deserve.

More importantly, attitudes must change. The entire thrust by the Minister, the Department and the Committee is towards a public-health-driven service, in which investment is made in prevention of illness rather than in treatment of it when all goes wrong. That is led by general practitioners in the community and by schools. It is led by parents who learn to be good parents and bring their children up well. It is led by elderly people, who now live longer and, I hope, have fruitful, high-quality lives and are not consigned simply to sit in a chair. Therefore, I must be positive, because to be anything but positive would be a failure on my part.

Ms McKeown:

I want to add to that point before I deal with the question about the Chief Medical Officer. I believe that we must prove what we say. I have run projects for around eight years, primarily in the area that is now the Belfast Health and Social Care Trust. They are partnership projects between the people who run the Health Service and the workforce. Some of them are sponsored by the Department of Health, Social Services and Public Safety.

Through those projects, we have demonstrated that money can be saved when the workforce is involved and engaged. We have demonstrated that we can upskill people, improve workers’ attendance and, indeed, their health. At present, we demonstrate that working in such a way results in better quality of life and services for people in residential care homes.

Those projects have all been pretty labour-intensive and have required much commitment. However, they show what can be achieved when Health Service managers, workers and their unions all work together. Changes have been tangible and measurable.

The Chief Medical Officer gave evidence to the Committee. We read what he had to say in the Hansard report, and a representative of UNISON was at that meeting. It is depressing that the necessary marked changes are not being experienced, seven years after Investing for Health was launched. There are many reasons for that. A proper reorganisation of the Health Service was needed, but that was fraught with problems under direct rule. Investing for Health was launched seven years ago, and then the Assembly was suspended. Direct rule returned, and a completely different model of healthcare began to be applied. If that had continued, we would be in even worse trouble than we are today.

Fortunately, devolution was restored. The Minister called a halt so that the system could be examined. The next stage of restructuring will now take place, but some damage had already been done. If the targets that are set out in Investing for Health are to be achieved, there must be an holistic approach to health that Mary mentioned. There must be a system that ensures that the acute sector does not gobble everything up, because that is what is happening currently.

It must also be recognised that healthcare is not solely the responsibility of the Department of Health, Social Services and Public Safety. Every Executive Minister has a responsibility to deliver the Investing for Health programme, because it concerns housing, education, jobs, and so on. If many people lose their jobs, health statistics will be even worse. A collective response has not yet been taken seriously. The Department is absolutely committed to delivering Investing for Health, but other Departments must pull their weight. That has been a mantra of UNISON for many years. People in Northern Ireland are not well used to working in collaboration. Perhaps the Committee could push the other Departments and make them aware that Investing for Health is not merely the responsibility of the Department of Health, Social Services and Public Safety.

Mr Tom Sullivan (Chartered Society of Physiotherapy [ Northern Ireland]):

I want to respond to Claire’s point about service redesign. Professionals are often at the core of the delivery of innovations and efficiencies. A simple efficiency could be created by introducing self-referral for physiotherapy. That would give patients here a better choice. Similar programmes in England and Scotland have saved over 400 weeks of GP time in a year. That is a simple, efficient and effective innovation that could be introduced here.

Ms Hughess:

Midwives could be the first point of contact for pregnant women, which would also free up valuable GP time.

The Deputy Chairperson:

More genuine engagement could yield further innovations.

Mrs McGill:

Thank you very much for your detailed response. I also thank Tom for his practical suggestion, because such ideas are key to the process. Patricia mentioned that proposals for residential homes are cuts-focused rather than outcome-focused. The Greenfield Residential Home in Strabane, which is part of the Western Trust, is targeted for closure. Before making any statements that may have alarmed local people, we spoke to staff, residents, carers and helpers at the home. We did not want to create the sort of fear culture to which Mary referred. Immediately after that meeting, we raised the issue of the proposals being cuts-focused rather than outcome-focused, but the trust insisted that the recommendations were outcome-focused and aimed at moving people into the community. Do you have any comments to make about that?

Ms McKeown:

That is where transition becomes important. One simply cannot take people from residential care and tell them that, in their best interests, they will be sent out into the community, unless a thoughtful approach is taken. Recently, I heard it argued that some of the care homes in the Western Trust area have been scheduled for closure because they do not meet the monitoring body’s standards — for example, they do not have en suite facilities.

I am involved in a health partnership between the union and employers in New York, which sometimes faces bigger problems than ours. However, it would solve such problems imaginatively, for example, by renting accommodation that is up to standard and putting transition arrangements in place.

We operate in a fairly rigid system, which makes it difficult for people to come up with innovative ideas. That is not the case at local level, where people can come up with good ideas, but when such ideas are proposed, people’s first thought can be, how would I ever get that decision through the system? We need a system that would allow such decisions to be made.

Transition is important. As unions, we are all signed up to the idea of a world in which people have a much better chance of living, with proper support, in their own homes and environments, instead of in institutional care. However, if people are already in such care, it is grossly unfair to decide to close care homes and decant the residents.

Mrs McGill:

How long is the transition period?

Ms McKeown:

That depends on the resident population and what one is trying to do. There will always be a need for residential care. We cannot assume that we will never need care homes or that we can embark on a programme that aims to close every care home. That will not necessarily be the case; that is a long way into the future.

The Deputy Chairperson:

I suppose that goes back to Mary’s point that one cannot shut down a service on a Friday and start a new one on a Monday.

Ms McKeown:

Exactly — you cannot do that. At the core of the matter, we are dealing with human beings. Therefore, we must have sensitive systems that enable changes to take place.

Mr Kevin McCabe ( Northern Ireland Public Service Alliance):

I wish to make two points. First, consultation and engagement are lofty principles. However, I wish to return to the member’s point about the equality agenda. It is a fact that trusts are proceeding apace with screening in and out policies. I submit that the type of issues that would be appropriate for a full equality impact assessment include changes to service delivery provision and the closure of facilities for older people, especially closures in areas where the level of service is being reduced. We should commit to push for a full equality impact assessment.

My colleague Patricia McKeown referred to the reliance on external consultants, and that is the case. The Committee will have seen KPMG’s report on residential facilities. I think that that report is mainly about facilities for elderly people, but it might have included children’s homes. It concludes — and it is an accountant’s prognosis — that the facilities are in an awful, dilapidated state. Is it a coincidence that closures in certain trust areas are being proposed? Were they predicated on that report or on a proper rationale?

I have heard that, in some of the areas that have been mentioned, closures have been proposed because usage has diminished or because the old argument was used about community care and people not wanting to be cared for in a residential setting. I have no difficulty with moving to a policy of community care, for all the reasons that have been mentioned. Like Mary’s father, my father died at home. However, before he could leave acute care, he had to wait for five to six weeks before assurances were given that a package of home help and care would be available. It is a complicated issue because it comes down to resources and budgets, and so on. In principle, I have no difficulty with improvements to service delivery, but if they are being driven by cutbacks, I would wish to put a marker down.

Secondly, the question of skill mix was touched on in the overview. Patricia said that much work needs to be done on ratios. However, CSR pressures lead trusts to use crude and ineffective solutions. I have an example: in social services, skill mix is a big issue. We recently met each of the five social work directors. One of our concerns is that some trusts are using semi-skilled or unqualified staff to carry out the first-point assessment in family intervention services. We say that that is absolute lunacy: the most experienced staff are needed in such instances. It risks the same systemic failures to identify risk and to allocate resources accordingly, as happened in the Omagh fire situation. Trusts should be held to account for practices that are potentially unsafe. They may be well motivated, but they have to get the skill mix right. A skill mix is fine, but it should have no detrimental effect and should not be purely cost-driven.

Dr Deeny:

I apologise for being late. I thank the witnesses for their presentation.

This evidence session concerns efficiency savings, and I hope that it will not have a negative outcome. This is the time to worry and to think about the future. As recently as two weeks ago, I was told that morale in the Health Service, in the area in which I work, has never been lower among health professionals, nurses and doctors. That is the bottom line, although I am sorry to have to say it.

Even this morning, I had to hold a surgery. Next month, my practice hopes to have an additional doctor. Nurses also tell me that times are bad. I cannot agree more with the witnesses who said that. I have told the trust and the Department to stop all the nonsense about the utopia of community care if they do not intend to back it up with finance and personnel. Those of us who work in the community will be overwhelmed — swamped. It is as simple as that. Plans must be properly considered, outstanding issues teased out and the entire matter properly resourced.

I will cite an example of what is happening. The Western Trust gave a presentation to the Committee; I do not mean to single out that trust for criticism, but it happens to be the trust for which I work. I worry that much has been screened out; that comes across constantly. I agree with Kevin; all the areas that he mentioned must be subjected to equality impact assessments — they cannot be screened out and dismissed. They are important issues.

Our population is ageing, and I am worried about many issues that affect elderly people. I see that every day in hospitals, day-care centres and nursing homes.

The Minister and the Department told the Committee that front-line services would not be affected. However, when 722 nursing posts are terminated — even through natural wastage — we will still have 722 fewer nurses. I work in the community with nurses and midwives, and I was told recently that, in Craigavon, midwives are running from patient to patient because they do not have the time to give the patient the treatment that they previously gave. The bottom line is that we will have 722 fewer nurses in three years’ time.

I am also concerned about the Northern Ireland Ambulance Service, which is being restructured. It will use fewer accident and emergency vehicles and more rapid response vehicles, in which one person rather than two mans the vehicle. That will cause many problems.

Many people who work with me in health politics are or were healthcare workers, not just doctors and nurses. For example, the Western Trust area was told that some 350 nurses were leaving and some 230 were being recruited — I am not sure of the exact figures. I worked out the difference at roughly 120. Nothing was stated about the quality or standards of the nurses being recruited compared with those leaving. Workers in the Western Trust, where I have worked for 22 years, tell me that morale among nurses is poorer than it has ever been. I will sound a positive note after I finish the negative stuff. There are four tiers of management in the Western Trust, and healthcare workers want to know how in God’s name that has happened.

Professor Appleby, who is a very well-known health academic, told the Committee — as did Mary— that trusts were over-administrated rather than over-managed. He could not believe the level and cost of administration in Northern Ireland.

I will comment on Tom’s points: optometrists, who know much more about eye examinations than I do, must refer patients to GPs in what constitutes a completely bureaucratic waste of time. Worse than that, some months ago, I received a letter from a hospital dietetic department requesting me to make a referral to the community dietetic department. That is the unbelievable sort of stuff that goes on in our Health Service. That is bureaucracy gone absolutely crazy. Therefore, Tom’s point about physiotherapy is well made.

I am up to the challenge and hope to be involved in the commissioning of healthcare, provided it does what it says on the tin and proves to be right. It is up to the commissioners, the regional board and the public health agency, which I have closely considered, to focus on disease prevention rather than waiting until people are ill. Health promotion and public education are the new approach. It is up to the local commissioning groups and the board to start picking and choosing the right level of management, reducing administration and getting enough health professionals on the ground in order to look after people in the community. Ultimately, efforts must be made to look after as many patients as possible at home, including the terminally ill. That is exceptionally difficult and involves weekend work, but my practice does not even use a hospice. However, people want to die at home. Unless the new approach is properly managed and commissioned from next year, it will not happen.

Are there four tiers of management in every trust area? I am repeating what I have been told by health professionals, and such a situation is ridiculous when jobs are in jeopardy and nursing grades are being cut. Have the Minister and the Department lost control of the five trusts? The Department must bring them under control and direction.

Ms McKeown:

I do not know whether we can deliver a collective view. The process is very imperfect, and we did not want any trusts. However, they were imposed by a direct rule Administration. Scotland got rid of trusts because they served no real purpose.

UNISON’s position is that a split between commissioners and providers is not needed because it causes all sorts of problems. It is possible to return to a comprehensive system of healthcare planning and delivery that does not have those artificial separations and that creates extra tiers of bureaucracy. However, to some extent, that was what we were stuck with.

A bold step must be taken at some stage in the next phase of reorganisation, because this is the third or fourth reorganisation that has happened in my time as a Health Service union official. Another bold step must be taken; however, we were stuck with some things. Dr Deeny, you are stuck with some things, not least the five trusts and their structures.

There has been no cohesive approach. Five employers have been doing their own thing. A collective approach is needed, because the system is flawed. The picture is not necessarily the same everywhere, and I will not know the reason for that until I get some answers myself. At present, one tier of the structure is missing, and I do not whether the situation will get better or worse after the implementation of the Health and Social Care (Reform) Bill. It is probably very difficult to reorganise something as significant and important as the Health Service. It is difficult to reorganise something after someone else has already tried to do so. That is the position facing the Committee.

Ms Hughes:

I want to pick up on the issue of administration in the Health Service. Undoubtedly, the Health Service in Northern Ireland is heavily — needlessly in some areas — administered. However, a redistribution of administrative staff in order to support front-line staff in some areas is crucial. That has not happened.

Some ward sisters spend half of their working day answering the telephone, and some midwives run backwards and forwards after 5.00 pm to open the locked doors of the wards for visitors. Doors must be locked for security purposes — namely, to protect mothers and babies. Why should midwives do that? Why should ward sisters answer the phone? Why are highly trained staff nurses left to record blood results from the lab? Some front-line clinical areas would really benefit from having extra administrative staff. Somewhere along the line, some thought must be given to that.

Mr Gallagher:

In the maternity unit of one local hospital, midwives spend time setting up beds for expectant mothers that were taken down two days earlier.

Ms Hughes:

Domestic staff also do that. Services cannot be cut to the bone in some areas simply to protect the professionals. Those professionals work as part of a team. Professionals need the support of front-line staff throughout the Health Service infrastructure to help them to work effectively.

The Deputy Chairperson:

Thank you very much for your presentations. The Committee has much work to do to progress the matter. I take on board your comments about legacy issues and the trusts’ flawed consulting exercise.

The Committee must send a clear message to the Minister about his aspiration to involve the unions in decisions, because that is not happening. The Committee has to tackle several issues, including discussions with the trusts. The matter does not end here, so I am sure that the Committee will want to speak to you again.