COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

New Directions – A Conversation on Future Delivery of HSC Services in Belfast

15 January 2009

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

Witnesses:
Mr William McKee ) Belfast Health and Social Care Trust
Ms Denise Stockman )

The Deputy Chairperson (Mrs O’Neill):

For today’s evidence session we have been joined by representatives of the Belfast Health and Social Care Trust, who are here to discuss ‘New Directions: A conversation on the future delivery of health and social care services in Belfast’. A copy of the consultation document has been tabled, as has a response from the trust about its efficiency savings, which we mentioned earlier. I welcome the trust’s chief executive, Mr William McKee, and its director of planning and redevelopment, Ms Denise Stockman. I invite them to make a presentation, after which I will open up the session for questions.

Mr William McKee ( Belfast Health and Social Care Trust):

I will say a few words by way of context, and then hand over to Ms Stockman. I am grateful for the opportunity to apprise the Committee of the conversation that we have been having with the citizens of Belfast and Castlereagh about the development of services in Belfast over the next 10 years.

It is important to set that conversation in context. The Belfast Trust is a very large and a very young organisation: it is probably one of the largest public bodies in Europe, and is certainly the largest public body here. The trust spends £3 million a day; it has one eighth of the Assembly Budget. Indeed, the trust’s budget is greater than that of six Northern Ireland Departments.

It is hard to give a flavour of the huge range of services that are delivered for that £3 million a day by the 22,000 staff in the 350 different job grades that we have in such a complex organisation. Today, for example, the trust is responsible for 600 looked-after children in care in Belfast. There will be 18 births today; 45 theatres will be in operation; 600 new outpatients will have attended trust facilities following a referral letter from their GP, 1,500 other outpatients will be attending follow-up appointments; and in the 24 hours up to 9.00 am today, 67 emergency patients have been admitted to the three central Belfast hospitals.

The organisation is very young: it is only 20 months old, and it began from a standing start, because the legislation to establish the trust was enacted only a few months before it came into existence. Only 20 staff had been appointed to the new organisation on the day that it went into operation. The other 22,000 staff were transferred under European legislation. In the first year, we concentrated on delivering the ministerial targets, mostly around access, and we succeeded. We concentrated on trying to deal with an underlying inherited deficit — if I may so, Tommy — and we delivered £20 million of savings in that first year. We concentrated on managing the merger, in which six separate legal entities were brought together to form the Belfast Trust. We appointed all our managerial staff, down to fifth level, by competition. We had a busy first year, making substantial savings, balancing the books, delivering on the ministerial targets and achieving organisational control.

We initiated other projects on top of those that were required of us. First, we applied for — and this May will receive — the coveted Investors in People award. That is not because we want to display a badge at every entrance; it is to demonstrate that we have a learning and development strategy for all 22,000 staff and show that we are using the expertise and commitment of staff to deliver the organisation’s business objectives.

Secondly, we initiated a dialogue with the voluntary and community sector, in particular, about the Involving You document, which set out how user engagement and community development would be at the centre of all that we do. That was a way of making a clear statement that although our business is the delivery of timely, cost effective and safe health and social care, our higher-order purpose is to work with others in partnership in order to deliver health and well-being and tackle widening health inequalities in society.

Thirdly, we worked with staff and other stakeholders to produce a document setting out the values and behaviours that we expect of one another in the organisation. Those were the building blocks in year 1.

In year 2, we entered into a dialogue about a vision document that would set out the strategic direction for the whole organisation. We call it ‘The Belfast Way’. It has been well received and is the starting point for all other documents in the organisation. It is given to all 22,000 staff as a guide to how we expect them to work and behave. It led to the work that we commenced in the summer, which is entitled ‘New Directions: a conversation on the future delivery of health and social care services in Belfast’.

We took it upon ourselves to do that work — we were not asked to do it. Therefore, I will conclude by setting out the three main reasons why we did that.

First, year four to year 10 of the health stream was not fixed in the investment strategy for Northern Ireland, and we wanted to make a bid for Belfast’s need for new capital as part of the process of deciding how to allocate year four to year 10 of the investment strategy. Bids for buildings are usually made when there is a clear idea of what the services will be like in 10 years’ time. Therefore, one has to get a view of what those services will be like so that one can determine the configuration of buildings across Belfast that will be required.

The health stream, which includes public safety, has about £3 billion, but promises and commitments mean that only £500 million will be available to spend in year four to year 10, and most of that will be available towards the end of the 10 years. We have made a bid for £1·4 billion, which sounds like a huge amount of money, but the problem is that if one is spending more money than six Government Departments, then every figure associated with the Belfast Trust is a huge figure.

However, £1·4 billion is less than 5%, or one twentieth, of the total running costs of the trust over those 10 years, even at current prices. If we spend £1 billion every year for the next 10 years, that is £10 billion of revenue, for which we are only going to get £500 million of capital, when we made a bid for nearly three times that amount.

Secondly, we have to make substantial savings against our budget, which is part of the Assembly Budget that was given to us. In our case, that amounts to £123 million. Of that sum, £93 million is a result of the comprehensive spending review, and £30 million is from the underlying deficit we inherited. Therefore, we have an internal process to deliver £123 million in savings this year, next year and the year after that. Although we can make economies and efficiencies, the greater part of our savings will come from thinking about new ways of delivering services to at least the same volume, and, ideally, to a better quality, but in different ways. Therefore, one needs to have a clear view of what one’s services will be like in the future, so that things are not done that will go against the grain but are done in line with one sees services developing over the next 10 years.

I will give one example of that. Fifteen years ago, my now long-dead mother-in-law had her cataracts done, and she spent four days in hospital. More recently, my mother had her cataracts done, and she spent four hours in hospital. She had two pre-operative assessments, which took two hours, and then she had day surgery, which also took two hours, and I know which procedure was considered better. Those are the sort of changes that are happening, and we have to harness those modernisations to allow us to deliver this level of savings.

Thirdly, an 18-month-old organisation is expected to say how it sees things going. It is a very uncertain and difficult time for health and social care, but that is all the more reason for us to say how we see things developing.

Ms Denise Stockman ( Belfast Health and Social Care Trust):

I have circulated a generic presentation to the Committee, which we used when we spoke to the general public about the New Directions document. I hope that it will assist members to understand what I am going to say.

New Directions very much represents an initial direction of travel for how services will be provided. We have described it as the start of a conversation with the citizens of Belfast, which we expect to continue over a long period of time.

The New Directions document sought to guide readers through the complex range of services provided by the trust. It did so through questions involving the key stages in a person’s life when he or she might access trust services. The questions covered everything from where people will go when they are having a baby to where they will go if they need support because they are an older person — and everything in between.

For each of the seven key questions asked, the trust described the principles that will guide how its services are provided; the things that it will keep in mind when it talks about service provision, and how it is going operate in the future. The trust also described its favoured model of care. We then asked a number of key questions of the people who received the consultation document. We asked them whether they agreed with the principles, whether they could think of any additional principles that we had missed out, and whether they agreed with the proposed model of care.

We did not write the document straight away; rather, we undertook a pre-consultation process. In April 2008, we started the conversation with our staff. Then, in May 2008, we spoke to more than 200 people from the community and voluntary sector at the launch of the Involving You strategy, which William mentioned. In August, we met a number of political parties and MLAs and many media representatives. We also took guidance from the trust advisory panel, an internal panel to which we bring major documents and policy decisions. That panel comprises users of services, patients, carers, and representatives from the statutory, and community and voluntary sectors.

Having listened to the views of those people, we distributed more than 2,500 copies of the New Directions document to a wide range of organisations, the community and voluntary sector, the statutory sector, and general practitioners across the board. Between August and November, the chief executive and I made 17 presentations and spoke to approximately 400 people about the document. During each presentation, discussions lasted around two hours, but some lasted even longer. We also received 71 written responses to the document.

Rather than talk about the document itself, I will tell members what people said about the document to provide a flavour of the feedback that we received. The trust listed the guiding principles that it will use for the reform and modernisation of all of its services. Although people were in overall agreement with those principles, there were some further points made, such as that carers form an integral part of the trust’s services and this should be reflected in the document. Also, when the trust talks about its focus on an individual’s needs and choices, it also needs to reflect the fact that it views care holistically through its provision of not only physical care but psychosocial care as well.

There was much support for the trust’s goal of addressing health inequalities, and there was general acknowledgement of the fact that there are wider determinants of people’s health above health and social care. Factors such as employment status, education, family support, and income, for example, can all affect well-being and health. The importance of partnership also came through in the responses that we received. People said that the trust would see a greater realisation of its objectives, improved use of its resources, and better health and well-being for all its communities if it worked in partnership with others. That is something that the trust strives to achieve on a day-to-day basis.

I will refer to the wellbeing and treatment centres, which come under the heading of community health and social-care services. One of the trust’s guiding principles is to localise services where possible and centralise where necessary, and that principle was accepted. However, some people raised concerns about the trust destabilising services in hospitals and expertise. Equally, there was a request that the trust be more ambitious with regard to the services it provides at the wellbeing and treatment centres. That is something that we are going to work on over the next few months.

The first key question that we asked was: Where do I go if I am having a baby? I will give members a flavour of what people said to us. There was general agreement with the principles associated with that question, revolving around choice, continuity, and control from the perspective of the expectant mother. There was no significant opposition to the model of care, which favours a holistic and community-based model delivered in a variety of settings, the creation of a single inpatient obstetric unit for Belfast at the Royal Hospitals Trust, and the creation of a midwifery-led unit. That will be the subject of separate and ongoing discussions in the future. A number of replies also suggested that that model of care could only be realised when there was investment in the new women’s hospital.

The second question that we asked was: Where do I go if I need to access services for children? Again, there was general agreement with the principles we had outlined. We were asked to consider stating implicitly in our principles that the trust has responsibility for child welfare, safeguarding and child protection, and we will do that in the revised document. There was also agreement with the model of care we had put forward. The general point raised was that the trust needs to carefully manage the transition between children’s and adult’s services.

The next question was: Where do I go if I need support or care because of my physical or sensory disability? Again, there was general agreement with the principles that were outlined. We had many comments that we need to, and should, recognise that carers form an integral part of our services. We have acknowledged that in the revised version of the document. There was overall agreement about the model of care, which is that someone with a physical or sensory disability should be supported to live as independently as possible in the community. There was also support for the fact that the trust will continue to provide a range of specialist rehabilitation services at the Musgrave Park hospital site, and support for the transfer of the neurology services from the Forster Green hospital site to Musgrave Park.

The next question asked was: Where do I go if I need support because I have a learning disability? Again, there was general agreement with the principles outlined. We acknowledge the important role that carers play as an integral part of our services to those with a learning disability. We have agreed that services should be planned, implemented and evaluated in partnership with people who have a learning disability and their carers. There was broad-ranging support for the model of care, which supports people with a learning disability to live as full and active lives as possible in their communities through the provision of a range of other services; whether from the voluntary sector, their family, or the statutory sector. There was support for the trust’s commitment to the resettlement of the residents of Muckamore Abbey Hospital within the shortest possible time scale: in fact, there was positive encouragement that we achieve that.

The next question was: Where do I go if I am and adult and need mental health services or I have an acute mental illness? There was agreement to the principles that we outlined regarding mental-health services. There was support for a model of care that provides more community-based services, such as day-treatment services and crisis beds in the community. The trust’s aim is to have a general shift from acute inpatient models of care toward the enhanced provision of services within the community. There was also a recommendation that we move from having three inpatient mental-health units to having one inpatient mental-health facility for those patients whose mental-health problems cannot be managed at home. That will be the subject of an ongoing debate as we go forward.

We then asked the question: “Where do I go if I need acute hospital services?” Again, there was general agreement with the principles that will guide us in that service reform. The biggest issue there was that we could never reflect all of the changes that we had with acute hospital services in an overall strategic document. The trust is committed to engage further on any other proposals for change that would affect particular services.

Finally, we asked: Where do I go if I need support because I am an older person? Again, there was general agreement on the principles that we had outlined and for the model of care, which is that older people should be maintained in their own homes and supported by a network of caring services that enables them to maintain their quality of life.

A number of other themes emerged from the consultation exercise. Many respondents expressed concern about the financial pressures facing the trust. A large number of replies were associated with the very important role that carers play in the services we provide, and we wish to acknowledge and recognise the contribution of carers of all ages. We want to respect the individuality of service users and carers, involve them in service development, and, as a trust, try to target and improve the support that we provide to carers.

Respondents commented that we must ensure that there is good signposting of our services; we have a responsibility to inform users, carers and stakeholders of the care pathways that are available to them. Indeed, many organisations that replied asked us to signpost the services of other organisations within the voluntary and statutory sectors. Needless to say, we are confident that those other organisations are effective providers of a high-standard service.

We received comments about encompassing the totality of the client pathway; people do not want to look only at physical care, rather, they want to concentrate on the holistic aspects of care, including psychosocial support. The importance of respite care was also highlighted, as was the importance of end-of-life care and palliative care provision — an important cross-cutting aspect of all of the services provided by the trust.

Finally, many comments focused on health and social care inequalities, and partnership working. William mentioned that the core purpose of the trust is to improve health and well-being and reduce health inequalities, and that resonated with all respondents. The trust has been encouraged to plan and use its financial resources to tackle health and social inequalities; that is something that we do on a daily basis and highlights the importance of partnership working. The trust is only one dimension that contributes to the health and social care of the general population.

The trust is committed to engaging on all of its key proposals for change. To that end, within the next couple of weeks we will be focusing on adding greater detail to specific proposals associated with adult mental-health services and older people’s services. Those will be subject to consultation from the end of January until March.

The Deputy Chairperson:

Before I open up the meeting for questions, William; do you want to comment on efficiency savings? Following the conversation that the Committee had earlier on front-line services being affected, what assurances can you give?

Mr McKee:

I will say two things. I wish to be quite firm with the Committee: this is a decision that has been taken by the Assembly.

The context for us is that due to the comprehensive spending review, £93 million is being taken off our budget this year, next year, and the year after that, and we have to balance our books. However, we also have an inherited underlying deficit. Therefore, we are aiming to make savings of £123 million. Under RPA, we are making around a 15% reduction in managerial grades, in the support for those managerial grades, and in other professional support positions — they are the savings that one would expect to gain from merging six organisations into one. We have already merged six personnel departments into one, six finance departments into two, and have moved almost 1,000 staff across Belfast: those are things that we can do.

Let me be quite clear; we are not planning to make any cuts, closures or compulsory redundancies — the three Cs. In our view, we earnestly do not have cuts in front-line services. I will give members three examples of the sort of things that we are doing: we still admit a lot of patients for planned surgery the day before their operation date, and, in some cases, two or three days before. If we reorganise how we do things, we could admit patients on the day of surgery and therefore treat the same number of people, arguably to a better quality, using fewer beds and fewer staff to manage them. That is one example of how, internally, we can create more efficiencies within our hospitals.

Secondly, there is a trend to rely less on institutions and more on supporting people as independently as possible in their own homes: after all, who wants to live in an institution? That will provide us with an opportunity to make savings. For example, in some parts of the world, technology is used to monitor — remotely and electronically — and support people with long-term illnesses in their homes. Therefore, a community nurse does not have to visit patients regardless of how ill, or well, they are on a particular day. Resources are targeted at the people who require the care. Daily electronic monitoring enables the health professionals to know which patients require a visit. Rather than spending 10 minutes with 1,000 people, they can spend an hour with 200 people. That is a better quality service, and it can be carried out with fewer staff.

Thirdly, there are four pharmacy departments and three imaging departments in the trust, so we can chunk things better in Belfast. We have a range of other measures. The cuts will mean changes in service. Frankly, we are talking about highly-qualified and highly-committed professional staff who are working at this. They do not believe that they are making cuts in services. Furthermore, any closure will occur only because something better has been put in its place — it will either be a better building or an alternative way of delivering. We have no plans to make compulsory redundancies.

I have difficulties with the concept of front-line staff. Let us think about that idea for a moment. Nurses are usually considered to be front-line staff; but we have nurses who are carrying out valuable and important research: they are not front-line staff. Doctors are also considered to be front-line staff; but we have some doctors who are in managerial posts. There are also front-line social workers who are looking after vulnerable children who are under our protection. However, what about ward clerks, who relieve other front-line staff of administrative duties? That is a better use of people’s time and expertise. What about the engineers who make sure that medical gases are pumped across the hospital to provide emergency services? What about the technicians who work in the operating theatre? What about the laboratory scientists who do the tests? What about community liaison workers who work with the third sector to ensure that we are seamlessly delivering care to vulnerable communities? What about telephonists?

What about the coder? I know that there was an Assembly question recently about the number of coders in Belfast. A coder is someone who allocates a procedure to a technical world classification of a disease or operation. In north America, for instance, a coder is required to have a PhD. It is a valuable job. Therefore, the notion of what constitutes front-line staff is difficult for me. We have 350 different types of front-line staff. Finally, what about the people who ensure that people are paid every month? They may not be classified as front-line staff, but I would not get too far if I did not ensure that the people who work for me were being paid every month.

Ms S Ramsey:

I mentioned that issue earlier. I know that you are not getting at me, William, but I did not mention front-line staff.

Mr McKee:

I am not getting at you, Sue.

Ms S Ramsey:

I mentioned front-line services. You have said that the policy of admitting patients one or two days before their operation was going to be changed: that is efficiency savings; it is not attacking front-line services. It is common sense. I agree that the people who provide support are as important as the nurses and doctors, because they have to be freed up to do their job. I am talking about ensuring that front-line services are protected. We need a holistic approach.

I agree with you that there is no need to admit patients one, two or three days before their operations. That policy is a waste of resources that could be better spent on patient care.

The Deputy Chairperson:

As Sue said, the examples you have given are positive, William. Residential homes in all trusts are being closed, and people are concerned about that. The support that is required to help people is not available in the community, and there is a perception that the trusts will turf people out. There is not enough home-help provision or social housing, and those are among the biggest challenges that will have to be faced.

Mr McKee:

Let me talk about statutory homes for frail elderly people. We are not going to consult on the closure of residential homes. Instead, there is an intermediate step. Looking forward, there is a wider societal trend where older people do not choose to go into residential homes. Residential homes tend to be 30- or 40-year-old buildings — the residential homes in Belfast were all built during the days of the Belfast Corporation welfare committee. They also tend not to have en suite accommodation, and older people are not choosing to live in them.

In contrast, over the past 10 years, there has been an exponential increase in the uptake of intensive packages of care to support older people — including those who are frail — in their own homes. Therefore, we are going to consult about what the future holds should we continue to use residential homes as places to live instead of places for respite care or short stays. People agree with that, because it is different from saying that we are going to close residential homes and turf people out. Other trusts are not saying that they will close residential homes. My trust is saying that, if the use of residential homes is agreed to in the consultation, it is something that will happen in the future — anyone who is already in a residential home will, to use the vernacular of my wife’s family, have their day in it. Those people will only move if they agree to it, which has always been the case, and will continue to be as such.

Nor is it true that residential-home buildings will close. Although they are not suitable as a home due to the communal sitting areas, lack of en suite accommodation and institutional food, they are good enough for other uses. Therefore, if people agree that those 40-year-old buildings should not be used as places where people live permanently, we will deal sensitively and carefully with the consequences of that over the next couple of years.

That can only happen, because we can show that there has been a year-on-year increase in the number of older people who are supported in their own homes and choose not to go into residential homes where there is very little nursing and support care. Residential homes are a throwback way into the last century. People want to live in their own homes. The policy is not about people who are living residential homes — they will have their day or move if they agree to — it is about looking forward to what we should be doing over the next 10 years. When we consult on that, people will say that, if the issue is separated from buildings and the people who are already living in residential homes, they agree that those homes should not be used if other accommodation can be provided.

Mrs O’Neill:

People do not disagree with that — they agree that there should be care in the community. However, in addition to a health approach, a holistic approach is required to ensure that sufficient support exists. That will not happen overnight, and the concern is that people will be turfed out. Although there are no plans in your trust to close residential homes, there are in other trusts, which is a genuine concern and is something that the Committee wants to get to the bottom of.

Mr Easton:

William, thank you for your presentation and thank you for any help that you have given me in the past couple of years — you have always been quick to respond.

What you regard as efficiency savings are viewed differently by me and the wider public. I hope you can accept that. You said that those who are in residential homes will have their day. Are you giving the Assembly a commitment that people who live in residential homes in the Belfast Trust area that are earmarked for closure or a change of usage will be allowed to stay there until they have passed on?

Mr McKee:

On the record, I am saying that no one will move to another support and care in the community without their own and their family or carer’s express agreement, and that will take several years to effect.

Anyway, we are not going out to consult on the closure of homes; that is not the issue. The issue is whether, in the future, we want to retain a mid-twentieth century approach to the support of older people. I do not believe that would be a respectful, dignified or independent way in which to support older people. We must do more to support them in their own homes.

I would not wish my mother to be sitting in a day room, in a high-back plastic chair, looking at other people in the same type of chairs, looking at her. My mother is becoming quite frail, and she wants to stay in her own home as long as possible, as does everyone else. If it were not possible to look after her in her own home, a residential home would not be the right place for my mother. That is because she would leave her own home only if she were too frail to squeeze every ounce of independence and dignity out of her life. That is what we are really discussing.

Any decision taken to change the use of, or close, those buildings, would be only after working our way through the conversation on the future delivery of services. The trust is saying absolutely no one would be turfed out. No one will be moved without their express agreement.

The Deputy Chairperson:

Across the Belfast Health and Social Care Trust, £123 million of savings is a huge burden on all staff. They are trying to deliver health and social care and, at the same time, think of new ways of delivering care that allows us to do that while still saving £123 million, which is a larger amount than the budgets of some Government Departments.

Dr Deeny:

Thank you for your presentations. I have two quick questions — one is a practical question and the other concerns me as a member of primary care for a considerable number of years.

My first question is relevant to patients. Although it does not happen very often, it has occurred occasionally over the years. Extra-contractual referrals occurred when, for example, a patient who lived in the west saw a consultant in Belfast. Does that still occur? I presume that the decision of whether to pay for such appointments would still be taken by the future commissioning groups. I declare an interest as a member of the West local commissioning group. I hope that that is the case because we are — after all — talking about putting patients first. Patient choice is paramount in the Health Service.

My second question is of concern to me and many members of our primary care teams and healthcare workers in the community. I have asked this of my trust, and I will also ask you. We need a commitment from all of the five new trusts to finance an increase in resources, because that is needed in the community. The Utopia that we talk about of everybody being looked after at home will be wonderful if it works, but we need a commitment from trusts to finance the increase in resources in relation to facilities and healthcare personnel. You mentioned the fact that people are in hospital for far shorter lengths of stay, which is an advance. The population is also becoming increasingly elderly. The telemedicine and electronic monitoring is exciting. It is a new development in medicine to which we look forward.

Although I see evidence of it, I do not want to see a battle between primary and secondary care. When I talk about efficiency in the Health Service, everybody seems to talk about money. That is certainly of prime concern, but efficiency of time is equally as important. Last week, a lady came to me. Her consultant — to whom she was referred — assessed her in a hospital outpatients’ department. She was then told to see her GP to have blood tests done. Those blood tests could easily have been done in the hospital department — they take five minutes. That happens a lot, William. You may know that. I wrote to the consultant last week because I was quite angry about what happened. We need to stop that sort of behaviour, because duplication takes up people’s time.

The patient then had to make an appointment to see me, and I had to ask my practice nurse to do the blood tests. She had to get a relative to take time off work to bring her to the health centre, which is a return journey of 18 miles. I thought that it was a grossly inefficient use of time. I suspect that secondary care was trying to prevent money being taken from its budget by passing the work on to GPs, although I hope that that was not the case.

Forget the financial element; my point is that a gross inconvenience was caused to an elderly patient, and there was an inefficient use of time. As we make progress on implementing the impending changes, I would like to see secondary and primary care working together to achieve an efficient delivery of healthcare, rather than competing to save money. Perhaps the Belfast Trust could take a lead on that.

I wrote to the consultant and junior doctor involved in the case of my elderly patient requesting an explanation for their actions, but that is only one example of what happens, and many of my colleagues relate similar experiences. I have read in magazines for GPs that it happens across the water too. Secondary care seems to be engaging in an ongoing battle to save money by pushing much more work on to those of us working in primary care.

I have outlined three reasons that you and the other four trusts must commit to financing increased staff and facilities for those of us working in community healthcare: the increase in the elderly population; the shorter stays in hospital, and the increased workload being moved from secondary to primary care.

Mr McKee:

You raised several important points, Kieran, and I will try to address them one by one. In financing the system, it is important that, where appropriate, referrals can be made across board boundaries until 1 April 2009. After that, referrals should be made across local commissioning group (LCG) boundaries and, in rare situations, even to elsewhere in Great Britain. I hope that that is, and will be, the case, but it is a funding issue that will be a matter for the new regional board and the five LCGs, which will have devolved budgets after 1 April 2009. I agree that it is important to keep that flexibility.

Let me give a couple of concrete examples of the boundary between secondary and primary care. First, in November 2008, we launched a single telephone number that all healthcare practitioners in Belfast, particularly GPs, can ring to get a mental-health referral. When we talk to GPs, they tell us that one of their burdens is managing mental illness. Now, a sister in accident and emergency, or a GP who has a patient who is clearly distressed, anxious and in need of immediate support, or a patient whose increasing level of clinical depression is interfering with daily life, can call that number and a referral will be made.

Secondly, we keep track of the number of readmissions to hospital within 30 days, because that is a good proxy of whether we are discharging people too quickly, and that figure has not been rising. However, I assure you that when my mother, who had cataract operations last year, went home after four hours in hospital, she was much fitter and better able to look after herself than my late mother-in-law, who spent four days in hospital when she was already in her 80s.

Therefore, it cuts both ways: there may be times when those working in primary healthcare face the added burden of having to dress a wound, for example, but we are providing support. On the other hand, however, there is no evidence, certainly in Belfast, of increased readmission rates.

Kieran, your last point was about streamlining, which is the Holy Grail. Everyone in the trust is working very hard, and, in emergency services, staff are working extremely hard to cope with the exceptional level of seasonal flu. However, the trick is to work smarter: to manage the handovers better; to manage better how we work with other parts of the Health Service; and there is huge room for improvement on the boundary between primary and secondary care.

In the Belfast Health and Social Care Trust, we have put all our services for older people — whether it is supporting the in their own homes, day centres, residential homes, nursing homes or intermediate care — into a single key service group.

In the three medical units in Belfast, the three emergency departments are all under one director who reports to me. Her job is to get a much more seamless, streamlined, citizen-centred approach to delivering health and social care. We are banking on achieving a significant chunk of our efficiency savings by getting our front-line staff to work smarter, rather than just harder. There is a huge opportunity there.

Dr Deeny:

Do you not agree that efficiency is important? If blood samples are needed, a single session in an outpatient ward should suffice. Anything else wastes time. I have another example of that. I received a letter last year about a patient who was seen by hospital dietitians. I was asked to refer that same patient to the community dietitians. That merely increases workload and bureaucracy. We need to have people in primary care address that and prevent that sort of thing.

Mr McKee:

I agree entirely with you, Kieran. We provide much of the primary care, except for the important part played by general practitioners. We have standing arrangements to try to liaise more efficiently with them. I agree with your point that getting it right first time makes for better quality and is cheaper. There is a good relationship between high-quality care, efficiency and effectiveness. If one is careless and insufficiently diligent, it will cost more both in the short and long term. There is a close relationship between quality and safety, on the one hand, and cost on the other. In Belfast, we are trying to drive the savings agenda through the quality and modernisation route that will deliver savings for us.

Mrs Hanna:

Good afternoon, Denise and William. You are very welcome and thank you for the presentation.

I understand your guiding principles: the widening equality gap has to be the main priority. Your focus on prevention of illness is addressed to the public, and for that reason I would like to have seen a greater emphasis on the public-health message and greater encouragement for people to take more responsibility for their health. We are moving in that direction, and that is important and I would like to have seen more emphasis on it. I appreciate what you have said about moving away from structures; however, there is a focus on structures in the presentation. Most of patients’ time is spent in the community. As Kieran said, it is important to keep people healthy and out of expensive acute beds. We may need what one might call “step-down beds” as an intermediate stage to get people out of acute wards.

I agree that it is important to localise services where possible. However, there were to be four well-being centres but that has now risen to seven. That begins to invite comparison with provision of leisure centres in Belfast. I dislike it when allocation of the centres is open to accusation of sectarianism, as they are established first on one side and then on the other of the sectarian divide. I make that comment as an aside: I understood that there was to be one in each of the four Belfast constituencies, but now they are allocated willy-nilly. Do we need seven well-being centres when the population of Belfast is declining?

I must ask about physical and sensory needs. You spoke of neurological services: will they transfer from the Forster Green Hospital? Is that still the plan?

I have spoken to many psychiatrists and the professionals who work in mental health, and they maintain that there is a serious shortfall in supported housing. However, that was not mentioned in the presentation. While we want those with mental-health problems to be able live in the community, there are many who are incapable of living on their own. The great need is for halfway houses, and not just to provide temporary accommodation. Some people will need to stay in them for the long term.

I turn to acute care. You spoke of the three accident and emergency units: the Mater, the City and the Royal. Will they be categorised? Will they have different take-in nights? Will the emergencies go to one of the three? Three emergency departments seems to be a lot for a place the size of Belfast. How has that provision been worked out?

Furthermore, are GP referrals being monitored for appropriateness in an attempt to reduce the number of patients arriving at accident and emergency? Could those patients not wait until Monday or be seen by the out-of-hours doctor?

Finally, I want to ask about the role of the heart centre in the RVH, particularly when there are cardiac services in all three hospitals in the trust.

Mr McKee:

If I may, I would like to work backwards through your questions, Carmel. I agree entirely with your opening comments; we could be rather more proud of our health and well-being centres —

Mrs Hanna:

They are very good. I have visited all of them.

Mr McKee:

I will let Denise say something about that.

Yes. On the issue of the three emergency departments in Belfast, those departments are already differentiated. For example, major traumas, such as long-bone fractures, penetrating chest injuries, high-energy impacts and head injuries, all bypass the other hospitals and go to the Royal.

In the future, the trust believes that it should differentiate services to complement each other. However, we have no plans in the immediate future to make proposals that will radically alter emergency services in central Belfast.

Mrs Hanna:

I expected to see in relation to efficiencies things such as the out-of-hours use of theatres or scanners. Indeed, many people have suggested that, because of lengthy waiting lists. Why are those services not being used more frequently? Is it because of staffing issues or is it for some other reason?

Mr McKee:

Mrs McGill:

What exactly did you say? Your letter to the Committee refers to the review of residential services currently provided in four homes, and a proposal to replace two of them. It goes on to state that the proposals are dependent on successful inter-agency working and funding from DSD and the Housing Executive, etc. Am I reading that correctly? The planned efficiencies from residential homes will amount to £2·5 million by year three. Can you reconcile what you said in your responses to Sue Ramsey, the Deputy Chairperson, and Alex Easton about what you intend to do about residential services with what is stated in that letter? I am particularly interested because representatives from the Western Trust are due to appear before the Committee, and there are a number of issues in my own area to be considered.

On another point, will the planned efficiencies on out-of-hours telephony services —amounting to proposed savings of £68,000 over three years — mean that people will be unable to get through on the phone? Finally, earlier you were speaking about the Assembly voting in favour of those efficiencies. Tommy Gallagher made the point about the legacy deficit in the Western Trust, and he was quite right. You referred to the legacy deficit in the Belfast Trust. The Assembly did not vote for that.

Mr McKee:

I do not want to appear too clever or slippery, so I will try to set things out as clearly as I can.

The CSR challenge for the Belfast Trust is £93 million. Of course, if we made savings of £93 million, I would still not be meeting my statutory duty to balance my books, partly because pay awards and new contracts were not fully funded, and partly because one of the boards took a considerable chunk of money away from the trust’s baseline in anticipation of efficiency savings that it thought that the trust should make. However, the trust has made those savings.

My best estimate is that there will be a deficit of £30 million. I could present evidence to suggest that the figure is much higher, and I would be hard pushed to provide a paper stating that it was lower. I am trying to be honest. Mrs McGill asked about CSR; the actions that the trust is taking to make efficiencies include the £30 million over the three years.

As regards old people’s homes: the trust was asked to set out, last autumn, the way in which it could make savings within three months. That is what is in this consultation document, because that is what we gave to the Department and it is what the Minister brought to this Committee. If we start to chop and change, people will become even more confused. This was the trust’s best estimate of what it would do some months ago. We have decided to take a step back and say that before we rush to do that, we will ask a different question: should we be using those statutory homes as people’s long-term residences? The proof of the pudding will be in the formal consultation we begin in the next couple of weeks, which Ms Stockman talked about. The future of those homes will depend on the comments that we receive.

There might be a change of use, rather than a closure, and people who are already in residential homes will be moved only with their express agreement. In many cases, people will have their day in the home. Without being too brutally frank, people will die in residential homes. No one will be moved against his or her wishes. There is an important difference, and I hope that I am getting the message across without being too clever.

Mrs McGill:

I will look at the Hansard report. I am interested because the matter will be raised in the trust in my area.

Mr McKee:

I forgot to say one thing. If, as a result of getting agreement to the policy that the trust should no longer use the homes as people’s long-term residences, and we wish to close a residential home at some stage in the future, then we will consult separately on that. We are not consulting on the closure of homes in the next few months. However, in the next couple of weeks we will be consulting on a service development direction that says that those places are not suitable for people to have their homes in the twenty-first century.

The Deputy Chairperson:

Are you happy with that, Mrs McGill?

Mrs McGill:

Yes, but there was also the issue of telephony.

Mr McKee:

I am not an expert on this, but I understand that there are electronic telephony services that will allow a switchboard to be staffed in a place that is physically removed from where telephones would be answered when calls are put through. We can create the situation in which telephonists are managing emergency bleeps, or fire alarms, and can answer the telephone out of hours for other facilities. They will know that callers want to speak to another facility because of the electronic system. To staff out of hours we must have telephonists in certain locations. However, we can staff out of hours using those telephonists who must be in a certain location providing telephony services to other locations. We can use the new technology to reorganise where, physically, telephonists are based.

Mrs McGill:

Will it be a call centre?

Mr McKee:

No; it will look nothing like a call centre; however, it will use call-centre technology. The trust’s staff will be based at what looks like a switchboard, but they will be able to answer calls for other facilities, know that they are calls for other facilities, and put calls through to other facilities.

Mr McCallister:

Mr McKee said that efficiency savings are just short of being well nigh impossible. If the draft Budget, which some members of the Committee supported, had gone through, savings may have been entirely impossible. I am sure that Mr McKee is relieved that the Minister managed to secure more funding with the support of the majority of members.

My constituency is covered by two boards and, along with other members, I share the concerns about residential-care provision. As other people said, before closing one facility, it is important to ensure that an alternative is in place. All too often, that is not the case, which causes much anxiety and many problems. On my patch, such a circumstance will arise shortly.

The consultation document is a great start, and it is encouraging to see that level of dialogue between the trust, which provides so many of the services, and the people who use, or might use, them. The document is excellent; it is well presented and it sets out a good vision for the future. How will you measure progress in achieving the strategy’s goals in its various categories, such as care for the elderly and services for children leaving care, and how will you maintain the dialogue with citizens and the community and voluntary sector? Indeed, how will elements of the community and voluntary sector actually deliver some services for the trust, and is that a model on which you could work? How do you plan to deliver the vision in reality, so that when you address the Committee again, there will have been action on the ground that will have benefited the majority of citizens.

Ms Stockman:

We have always said that the consultation document is just the start of the conversation, and our commitment to keeping the dialogue going will be demonstrated in bigger documents on matters such as mental-health services and services for older people.

Furthermore, the document is not a static tome; it must change, because health and social care always changes in order to respond to different circumstances, and we will have to amend and adapt our plans. We will probably repeat the process every two or three years, and produce further large documents to outline the strategic plan for services in the Belfast Trust area.

Each group that provides services received a copy of the report and a copy of the consultation replies in which individual operational matters were brought to light, and they will utilise that material when addressing people’s queries.

Many other forums are available for talking to people. For example, the Involving You document included several commitments to the community and voluntary sector on how we will maintain a relationship with them and on certain actions that we must achieve. Indeed, in May 2009, we will measure our progress in achieving those actions. So, there are a number of ways for us to ensure that what we stated in the consultation document will be realised, and we have various mechanisms and forums with which to measure our performance against the targets that we have established.

Mr McKee:

I shall add a word of caution. Many of the things that we would wish to do, and we have touched on some of them, are dependent on access to capital. I made the point that less than 5% of our total turnover is going to be devoted to capital in this investment strategy, which is not enough for something as highly technological as health and social care. There are constraints on us, and one of the main ones is capital.

Mr Buchanan:

I welcome the New Directions concept. Perhaps Mr McKee would share it with colleagues in the Western Health and Social Care Trust. At least in the Belfast Trust there is a vision and something to work from: there is no vision in the Western Trust, and it appears that it is stumbling from pillar to post and from one crisis to another. I ask that you share the document with them.

What buy-in did the doctors, consultants and nurses have to the New Directions concept? What concerns did they have, if any, and how were those addressed? The focus of the debate today seems to be on the elderly and care homes. On a number of occasions, Mr McKee said that no one would be moved from their home against their wishes. If somebody wanted an elderly relative to be placed in one of those homes, would they still be open for new admissions?

The model of care that the trust is talking about reflects much of what we have heard from other trusts. Older people want to remain in their own homes longer and be supported by a network of services, and that seems to be the direction in which the trusts are heading. What is Belfast Trust doing to increase the network of services to support elderly people and enable them to remain in their homes? If the Belfast Trust is anything like the Western Trust, its services are currently not adequate to meet the community’s need for support. Just yesterday, I had a meeting with constituents to try to get help and support to allow an elderly mother to remain in her home. Therefore, the required support is not available. What increase in support will be required by the Belfast Trust to move in that direction and keep more people in their homes for longer, rather than putting them into institutions.

Mr McKee:

I will answer the second part of the question and then hand over to Denise to answer the part about engagement with our professional staff on the New Directions document.

Our residential homes are still open to new admissions, and the earliest that we would close them to new permanent admissions would be in April, after we have completed our consultation on that policy development issue.

Secondly, as part of the further conversation that we want to have with citizens in Belfast about services to older people, we have set out, quite starkly, the huge increase in the number of older people who are being supported in their own homes through intensive care packages that are way ahead of the total number of residential spaces that we have. I must emphasise that this is about residential homes, not care homes or nursing homes. Very little, if any, health and social care is provided in them because they are older people’s homes. Therefore, they are still open to new admissions — permanent new admissions — and the earliest that we would change that service would be in April when the board considers the comments that we receive after we have had that conversation with the people in Belfast.

Ms Stockman:

With regard to the engagement with our staff, the New Directions document does not reflect Denise Stockman sitting in a darkened room somewhere and hatching a plan. We talked to all our service groups, and the senior teams within the service groups, to ask them for their vision for services in the future. We asked them what they see the principles as being, now that we have combined six trusts. For example, the service principles were developed by them, not by us. We had discussions on the model of care associated with that. As I said, even in the pre-consultation phase, before committing the document to paper, we talked to hundreds of staff and received general feedback from them.

When we published the document, we were careful that it went via our service groups and that our staff had access to it via the intranet. Staff had an opportunity to come to various sessions to talk about their views on the document and respond to it. A number of our staff took that opportunity.

We recognise that in order to achieve many of the targets that we have set for the trust in New Directions, we require staff to buy into those, because they have to deliver the services. In proposing the changes, we are committed to ongoing engagement, not only with the patients and the carers but with the staff who provide the services. With each detailed proposal for change, we will go through the process with the staff who are involved in delivering that service.

The Deputy Chairperson:

Thank you for coming. I am sure that we will talk again.