COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Tyrone County Hospital and Efficiency Savings
29 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 Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Ms Claire McGill
Ms Sue Ramsey
Witnesses:
Mr Alan Corry Finn )
Mr John Doherty )
Mr John McGarvey ) Western Health and Social Care Trust
Mr Trevor Millar )
Mrs Elaine Way )
The Deputy Chairperson (Mrs O’Neill):
We will move on to the session on efficiency savings. I welcome witnesses from the Western Health and Social Care Trust. You can make a short presentation, after which members will ask questions.
Mrs Elaine Way (Western Health and Social Care Trust):
As chief executive of the trust, I want to place on record my apologies to the Committee and, in particular, the MLAs from West Tyrone, for our communication failures on the issue that was discussed at the previous Committee session. We did not want such a situation to arise, and we will learn for future communications.
I am accompanied by Trevor Millar from adult mental-health and disability services, John Doherty, director of women and children’s services, Alan Finn, acting director of acute services, and John McGarvey who is an assistant director of primary care and older-people’s services. Unfortunately, the director of that service is unable to attend because of a personal appointment. Our presentation will be brief. The Committee has received our papers containing all the details, and we do not intend to discuss all 48 proposals. We will highlight and concentrate on the main areas of concern for people in the west.
We have received some good news. When this process began, we thought that we would have to save £37 million. However, because of adjustments through the Department, that figure is now £36 million, and it seems that we are receiving the same amount. We are losing £36 million in efficiencies but receiving £36·2 million. However, that £36·2 million of investment is earmarked for areas such as older-people’s services and, appropriately, mental health, learning disability, drugs, acute services and children’s services.
After the Minister’s presentation to the Committee, we — like all the trusts — had a board meeting and, on 20 October 2008, began a formal eight-week consultation period on our comprehensive spending review proposals. The screening consultation closed on 12 December, and we received responses from 11 organisations and 305 individuals. Furthermore, we received a petition containing 4,225 signatures about the proposed closure of Drumhaw residential home.
All 48 proposals have now been screened. Two proposals require a full equality impact assessment (EQIA), and the various directors will discuss that matter in due course. We have not yet managed to identify all the savings that are necessary in order to achieve the £36 million savings. However, we accept that additional proposals will, where necessary, be subject to EQIAs. The director of acute services, Alan Corry Finn, will outline the significant acute-services proposals.
Mr Alan Corry Finn (Western Health and Social Care Trust):
The trust’s target is to secure £8·7 million in savings over the next three years in acute services. We have developed 13 proposals, all of which have now been screened, and no proposals require additional consultation or EQIA.
Our presentation outlines two areas that will be of interest to the Committee, the first of which is the redesign of surgical services. We will implement a surgical assessment model for emergency surgical admissions and enhance booking arrangement and processes for surgical elective patients. That redesign aims to modernise our services, reduce lengths of stay, improve surgical and pre-operative assessment, and create 23-hour-stay beds. We want to ensure that patients who require surgery are assessed at an early stage. That measure will eliminate possible delay on the grounds of physical health reasons on the day of the surgery. Moreover, we want to ensure that, where appropriate, people are admitted on the day of their surgery rather than in advance, that we assess patients swiftly and that they are informed of their expected discharge date at an early stage. Therefore, all things being equal, they can expect to know the length of their stay in hospital.
The trust engaged an external agency to review its emergency-care and medicine systems in all hospitals in the trust, and we intend to implement the recommendations of the tribal review. We want to increase levels of senior clinical staff — such as Mr McKinney — who involved in the triage and assessment of patients when they arrive at hospitals. Furthermore, we want to ensure that the senior clinician sees those patients, determines the category and seriousness of their conditions, assesses their needs and allows accident and emergency staff to admit them to the medical and surgical wards directly, rather than requesting someone from a special team to complete a further assessment. That will reduce the patient’s journey.
There are several additional plans: to establish an observation unit in Altnagelvin Hospital; to establish a combined assessment unit in the Erne Hospital, as we mentioned in the preceding session; to develop an operationalized ambulatory protocol, which deals with arrangements for many outpatients; and to implement a new model of care in the acute medical unit at Altnagelvin Hospital. The aim is to ensure that admissions to hospital are appropriate.
The trust’s community responses include the rapid response nursing that John McGarvey currently manages, whereby, in conjunction with general practice, we can assess patients’ needs at an early stage and sometimes employ interventions that can prevent hospital admission. Rapid response nursing also determines whether a patient needs to go to hospital and ensures that we avoid, where possible, any delays to discharge. Therefore, we can swiftly discharge patients into the community, perhaps with domiciliary support, which results in a higher greater throughput of patients.
The suggestion is that we further streamline our services; that patients come into hospital only when absolutely necessary, stay for as short a period as necessary and be swiftly discharged into the community. Those are the two areas that I want to draw to the Committee’s attention.
Mr Trevor Millar (Western Health and Social Care Trust):
I must find £3·1 million of savings in the adult mental health and disability directorate. I have put forward seven proposals, all of which have been screened and none requires formal consultation or equality impact assessment (EQIA).
My seven proposals are very much in line with the regional Bamford Review recommendations, and the Committee heard about those earlier today. We are considering downsizing our institutional care and upsizing our community care, and all proposals take those objectives into account. We will consider the integration of mental-health inpatient and intensive care units in the two newbuild hospitals on the Gransha and Omagh sites. That will give us the opportunity to review the community structures there too.
Similarly, for learning disability services, we have just built a brand new hospital on the Gransha site in Derry, and we are considering how best to use that. We proposed the closure of one ward, but it is a matter of examining opportunities to provide new services, such as additional respite, or possibly adolescent services, in that facility. Again, the aim is to bring about reform and modernisation. Re physical and sensory disability, we are examining how to redesign and remodel according to the regional brain-injury proposal. We are reviewing that proposal, which is currently out for consultation. We envisage little change to the proposal, and we have a brand new facility there in which we want to enhance our services. All of our proposals are in line with local and regional strategies.
Mrs Way:
We are happy to respond to questions from members who have read all 48 proposals and wish to pick up on any one in particular. We have determined that there will be two full consultative processes on primary care and older people’s services, the areas for which John McGarvey is responsible.
Mr John McGarvey (Western Health and Social Care Trust):
Over the three-year period of the CSR, I must find a total of £6·9 million in savings in the primary care and older people’s directorate. We have developed 12 proposals, all of which are in line with regional and local policy. As the chief executive said, two proposals will have a full EQIA and go out to public consultation.
I will outline to the Committee the general themes in primary care and older people’s services. The first theme is workforce modernisation and redesign; some regional targets have been set for the mix of qualified and unqualified staff that we must address as part of that redesign.
Secondly, we must redesign and remodel inpatient provision for older people in order to move away from continuing care provision and provide rehabilitative and intermediate services.
The third element relates to the reform of community-care services. I will concentrate on the two proposals that are currently out to consultation, the first of which is the review of day care provision. In response to the new regulation of day care services, the trust proposes to implement a new model across the Western Trust. Since last year, day care services have been regulated by the Regulation and Quality Improvement Authority (RQIA) and must meet certain standards of delivery and provision.
Much of the reform will provide a level-1 model, which will meet regulatory requirements, and a level-2 model, which will focus on social support for older people in community settings, such as luncheon clubs.
The second is the proposed review of statutory residential-care provision in the home. That review proposes that, over the remaining two-year CSR period, four residential-care homes should cease to provide residential provision. That proposal is in line with the reduction in demand for residential care and is in response to a review of care and accommodation that the Western Health and Social Services Board conducted in 2006. That review took into account the views of older people who said that they preferred to remain at home and be supported in the community for as long as possible. That is similar to the regional policy and direction of travel in all trusts across Northern Ireland.
Mr John Doherty (Western Health and Social Care Trust):
As Committee members can see in the Committee papers, women and children’s services are required to yield £4·4 million in efficiency savings. We developed 16 proposals, all of which were screened, and it was determined that none of them required additional consultation.
The first area that I will address is the review of children’s homes. The trust has embarked on a strategy that places more emphasis on family support and early intervention, which is reducing our reliance on institutional care. We have demonstrated our ability to manage at reduced capacity through the monitoring of bed-occupancy levels in children’s homes. Therefore, we propose to further redesign our residential provision by replacing two units with a outreach family support service that will operate 24 hours a day seven days a week. The proposal is to replace one unit in 2009-10, and the second unit in 2010-11.
The second and third areas that I will address are the reconfiguration of maternity beds at the Erne Hospital and the reduction in paediatric beds. Both of those proposals are strictly in line with the model that is contained in developing better services. A comprehensive needs assessment was carried out when the model was developed, and it was recently validated. It has been determined that that level of provision is appropriate for a modern maternity and paediatric service.
The final area that I want to address is the replacement of the children’s day-treatment unit with a consultant-led children’s centre. The children’s day-treatment unit at Tyrone County Hospital used to be operated by locum junior doctors. A review in the former Sperrin Lakeland Health and Social Care Trust made a specific recommendation that that be changed. Consequently, we have moved to have a consultant-led service. The remainder of the proposals on women and children’s services centre on a review of skills in the directorate to ensure that we deliver on services in the most efficient manner, and on a review of the contracts that we inherited.
Mrs Way :
Deputy Chairperson, we wrote to you this week to confirm in writing the implications of those measures for staff. The Western Trust has said that it will do all that it can to avoid redundancies in the CSR, because, although money is going out, it is also coming in. Our best estimate is that 589 posts will be lost in the CSR period, and 482 will be created by the investment.
For completeness, I draw the Committee’s attention to the impact of the review of public administration (RPA), which is being implemented over the same three-year period and requires us to reduce our managerial, and admin and clerical workforce by 170.
The Deputy Chairperson:
Thank you for that information and for keeping it concise but informative. Do you expect voluntary redundancies to be responsible for some of the 589 posts that will be lost? From your letter, it is obvious that you have been in discussion with the unions, but the Committee has heard evidence from unions that felt left out of the process by all the trusts. In their reponses, the trusts state that the unions are involved in all of the negotiations, which leaves us wondering what is happening.
Mrs Way :
I have been involved in discussions with the unions and, not so long ago, met with Patricia McKeown from UNISON, which represents a large number of our staff. We have established that the trusts believe that they are working closely and positively with the staff-side organisations, but that the regional unions feel that they need to understand the whole picture, not just the detail of what happens in a trust
Patricia McKeown and I have agreed to examine how the trust can work more positively with the regional trade unions.
Mr Easton:
Thank you for your presentation. I have no problem with efficiency savings as long as it does not involve cuts to front-line services. We need to discern whether that is happening, but it can be difficult to acquire the necessary information. Is the £36 million efficiency savings all revenue, or is part of it capital?
Mrs Way :
It is all revenue.
Mr Easton:
Is it hoped that natural wastage will account for the 134 nursing posts that may disappear?
Mrs Way :
We have estimated that 350 posts will go; over the same period, 217 nursing posts will come in.
Mr Easton:
I presume that, in making your efficiency savings, you assessed the employment of agency staff. The total cost of employing agency staff in Northern Ireland is around £40 million. Therefore, I estimate that employing agency staff costs your trust about £5 million or £6 million, although that could be wide of the mark. Would it not be more practical to keep the 134 nursing posts and reduce the agency-staff bill? Qualified nurses being kept on could result in more outpatient clinics, more operations and higher productivity. Agency staff cost a lot more to employ, so I would be keen to reduce that cost rather than lose full-time nursing positions.
How many residents of residential homes will be affected by your proposals? In my area, there are no private residential homes, just nursing homes. Where are you going to place all those people, and has that process started?
Mrs Way :
I absolutely share your view; the less money that is spent on agency staff, the better it is for health and social care. It is important that we agree to provide supplementary clarification on the costs. In the Western Trust, the vast majority of the money that we spend on agency staff is spent on locum doctors. Indeed, Alan McKinney spoke about the cost of locum doctors earlier. When I was chief executive at Altnagelvin, we did not use agency staff. Instead, we had a bank of our own staff, some of whom were people who wanted to do a bit of work to cover, for example, maternity leave. You are absolutely right that every penny is well-spent on front-line care rather than on enhanced agency rates.
It is important to place on record that I have met with the Minister on a one-to-one basis on a number of occasions to discuss the comprehensive spending review proposals. He has pushed all chief executives on the issue of whether it is cuts or efficiencies. The Minister has made it clear that unless suitable proposals are identified that are equal to or better than the care that is being provided, he will not support any recommendation that a trust might make about the closure of residential nursing homes. Even quite recently, he stressed that this is a consultation process and that he wants to hear people’s views. John McGarvey can provide detail on the figures of our proposals.
Mr McGarvey:
If the proposal was implemented today, 78 permanent residents, across the four homes, would be affected.
We currently have eight residential homes in the Western Trust area. We have examined our current level of provision and the occupancy levels, and see that as one of the factors to take into consideration in whether the proposal is deliverable.
We are seeing a downward trend in the utilisation of residential care across the trust, and I think that that is similar across all of the trusts in Northern Ireland. Coming back to the chief executive’s point about the Minister’s discussion, we have to demonstrate that we have viable alternatives for people in the community. For older people, one of the good things to come out of the comprehensive spending review is that £5·9 million is coming back in to the system. That is earmarked for demographics, much of which will go directly to older people’s services.
There is also considerable investment in long-term condition management, and if we add up all of the pots of money coming in, we are looking at more than £10 million of additional investment for older people’s services. We are going to use that to enhance and develop further the range of services that we have in the community that help keep people at home and support them. Those services include domiciliary care, community rehabilitation services, working in partnership with the Housing Executive, and supporting people to develop housing and care support services.
That is the range of services that we will be developing in the future, which will mean that the need for residential provision will reduce. There will still be a requirement, but that requirement will probably be for people with conditions such as dementia who require that type of provision.
Mrs McGill:
You are all welcome; thank you for your briefing. Regarding the residential care situation, I welcome the Minister’s comments, if we are hearing correctly, that he is going to listen to the responses that come back. I think that that is critical.
I have some difficulty with the documentation stating that the result of the surveys carried out into whether people want to be in a home — for want of a better word — or in their own home, is that people want to remain in their own home. My understanding of that, from the people who speak to me, is that of course people want to be in their own home. They want to remain in their own home for as long as it is possible. Not enough account is taken of that.
What will the trust do to ensure that people who want to remain in their own homes can do so? This is a grey area. I have been present at meetings in Greenfield Residential Home in Strabane where people have told me that that was not their response. They tell me that Greenfield is their home at this stage. If the Minister has given that commitment, then from here on in, I want to see evidence that the people in my constituency have said that they do not want to be in Greenfield, that they want to be in their own homes. A number of those people do not have what we would call homes to be in. That is an issue.
In coming to some conclusions on this issue, I expect — and I hope I will not have to eat my words — that those charged with handling the consultation would consult further on this issue. It is vitally important.
At this stage in Strabane, there is nothing in place, and there is a great deal of anxiety around that. It is ironic that a health organisation — albeit inadvertently — would create an anxiety among elderly patients and their families, that people are going to be thrown out of their own homes. That is very crass language; however, that is how I see it.
My second point relates to young adults. Previously, I have met with Trevor, John and Elaine to discuss issues of concern around young adults attending resource centres in Strabane. Young adults seeking to transfer from Knockavoe School and Resource Centre are left wondering where they can go next, as there seem to be no places available at Glenside Adult Training Centre. People in the area are worried, despite what help may be put in place for families, that there will be no provision for those young adults. I know that Trevor has, on a number of occasions, articulated that numbers at Glenside should not be restricted; however, I wonder how that will be managed?
Home help is a huge issue in my area. Even as we speak, there are families trying to handle very difficult and painful situations within their own homes. If that situation increases in the community, how will that be managed within the efficiency savings? In Plumbridge, a young woman, who I knew well, provided home help to a number of people for a considerable length of time. Tragically, she died, and it saddens me to say that that invaluable service has been lost. Home help — as in residential homes — provides elderly people with an important opportunity for social engagement, and that is being overlooked. Again I ask; how will that be managed within the efficiency savings? It takes 15 minutes for a home help to go into a patient’s home and talk to them; but it has to be financially worth their while. I know that other MLAs have the same issues in their constituencies.
I do not want to take up any more of your time; those are my three areas of concern, especially the transition plan for young people at 18 years of age. Trevor, if you are not able to give me a detailed response now, I would welcome engagement at a later stage. Residential care and home help are big issues and I am happy to continue this.
Mrs Way :
I was not in either of the community trusts when the Western Board, in conjunction with those two trusts, led this consultative exercise to engage with older people on what they want. I think that some people make a life choice not to go into residential care. However, those people receiving very fine care, in homes such as Greenfield, feel extremely differently about residential care. John was talking about how the strategic document, which engaged as many people as possible in the west about the strategic future, differs from the reality of our proposals, which directly impact on 78 people.
In relation to the consultation, I will ask John to say something about what we are proposing to do in those four homes, and perhaps to talk about home help as well. We started off thinking that we would have a consultation on residential homes; however, we realised that the situation is much more localised, and that a consultation has to be carried out in each locality.
Mr McGarvey:
There are four strands to the consultation timetable that we have outlined. The first and most important of those represents an opportunity for residents — and their relatives — to meet on a one-to-one basis with our staff in order to express their views and opinions about the proposals for the homes in which they reside. Dates are now being shared with residents and relatives over the next two days, and we are asking the officers in charge in each of the four homes to work with residents and relatives to arrange convenient times, within a two-day window, in order to accommodate as much engagement as possible. The views and opinions that are expressed in those sessions will be documented and will make their way into the final consultee report.
Secondly, engagement with our staff is also important. We will conduct sessions in which staff will be given an opportunity to express their views and opinions about the proposals, and there will be discussions with our colleagues in human resources about the “what if?” scenarios, because our staff will want to know what the options might be when change happens and if proposals are implemented. The consultation will be partly about hearing their views on the proposals and partly about giving them an outline of what the options might be if the proposals are implemented.
The third element consists of public consultation meetings, which will take place on 11, 18 and 25 February and 5 March. We have to confirm the venues, but the meetings will be held in Lisnaskea, Omagh, Strabane and on the city side in Londonderry. The meetings will be advertised in the local press. They will be held in facilitated environments that will allow participants to break into smaller groups, each of which will have a facilitator, so that everyone will have an opportunity to express views and opinions. The final aspect is the opportunity for individuals to submit responses to the consultation through our website. Those four strands will be managed by a timetable.
I am familiar with the tragic circumstances surrounding the case of the home-help worker in Plumbridge and the invaluable service that that member of staff delivered to people in isolated rural areas on behalf of the trust. That was a great loss to those people and to our organisation. We are working with our own in-house service and the independent sector to try to put a more robust service in place across the Western Trust area. In the past, we have had home helps who went the extra mile, who worked seven days a week, and who went to work when they were not supposed to be there. In this day and age, however, people deserve an appropriate work/life balance, and we must consider that when we examine our ability to recruit and retain carers.
In order to comply with the new standards for the provision of care we must develop teams of carers. That will not mean that clients will have a dozen different carers coming into their homes. Instead, a smaller number of carers will be deployed consistently, and that will allow the carers to undertake training and to take their holidays, which, in the past, many members of staff did not do. Those people eventually wore themselves out and ended up taking sick leave, which left the trust in a crisis situation with no one to provide care.
In embarking on a programme of reform and modernisation we must look for consistency, and we must ensure that we provide a high-quality home-care service in the community.
Mr Millar:
I will pick up on the issue of transition, about which we have had many conversations. It is a recent issue for the trust, and it goes back to the history of investment — or lack of investment — in services for individuals with learning disabilities or physical disabilities, which has not been in keeping with the increasingly complex needs of those individuals.
You will be aware that we have recently invested in a new day centre and a satellite unit for 15 clients in the Strabane area. I would like to see that developed further so that we can offer the Glenside Adult Training Centre to those individuals with the most complex needs and take the others out into the community and into environments that can meet their needs as well. I would welcome the opportunity to sit down and discuss that further and hear other views.
Mrs McGill:
Taking Glenside Adult Training Centre into account, how many places are available in the Strabane area?
Mr Millar:
The trust has about 84 places in Glenside Adult Training Centre. We took 15 places out of the centre to try to reduce the numbers as much as we could. However, about seven people are waiting to come into the service. Again, there are complex issues. We have a lot of young adults coming through the system who require intensive support in that type of environment. It is up to us to try to deliver on that need.
The Committee will be aware that the Bamford Review is taking the matter forward on a regional basis. A day-opportunities review was carried out by the Western Board in collaboration with the trust. We are looking at new opportunities for individuals. There must also be collaboration with the Department for Employment and Learning. It is not a matter only for us. We must look at new opportunities and new ways of doing things and be able to offer those individuals a meaningful day opportunity, rather than put them in a day centre where 90 or 100 people are gathered together in small rooms. That is not offering a quality service.
Mrs McGill:
It is important that those young people’s parents and carers should not have to go through the stress and trauma of struggling to get suitable provision. The trust must provide it, and it must not come at the end of a long and protracted path. I am not being critical. However, we must get that provision, and parents and carers must know that it will be there. They should not have to bang their heads against a brick wall.
The Deputy Chairperson:
I share Clare’s views on that matter. We have had several debates in the Chamber about transition. It is an important issue that must be tackled. Young people should not be left stranded at home because there is nowhere for them to go.
Mr Buchanan:
I want to focus on Gortmore House. I am concerned about adult mental health, primary care and older people’s services in the Western Trust area and the proposals to close homes — and Mrs McGill has raised that issue already. I attended a meeting recently in Gortmore House. We have been talking about the consultation and the way in which older people have been consulted. The result of that consultation showed that people want to remain longer in their own homes. However, the people in Gortmore House referred to it as their own home. Therefore, when they were asked if they wanted to remain longer in their own home, they said yes: they saw Gortmore House as their own home. There is a misconception about people wanting to remain in their own homes.
I support people remaining in their own homes. However, they must have the complete backup service to enable them to do that. Home helps were mentioned. Currently, help for people in their own homes is unavailable. People are living longer, and the list will keep getting longer. We do not have sufficient resources. During the past month, I had a meeting with regard to two or three constituents, and I had serious difficulty in seeking help for them to remain in their own homes. Considering the difficulties that exist at present, there will be huge difficulties if the changes come about.
The people in Gortmore House feel that they are being sold to the private sector. Obviously, those in the private sector are running a business, and the residents are concerned. I am glad that a four-point strategy is under consideration and that staff, relatives and patients will be spoken to individually. That will help to alleviate concerns.
As far as Gortmore House is concerned, Hillview Lodge is being considered as a site for a new residential home. In 2002 and 2003 consultants were engaged to draw up a plan for Gortmore House. What input did patients and staff have in that exercise? How much did it cost?
I suspect that occupational therapists were told not to refer any more patients to Gortmore House, or any other homes, as long-term patients. Did that happen and, if so, when? I found out that the last referral to Gortmore House was made, if I recollect correctly, in February 2008. Referral must be made by occupational therapy (OT) services. Will you clarify that? All other issues about adult mental health and primary care have been raised and answered. We have been through all this before, but I am deeply concerned about Gortmore House.
Mr McGarvey:
The review of care and accommodation was commissioned and sponsored by the Western Health and Social Services Board and delivered by the legacy bodies, Sperrin Lakeland Health and Social Services Trust and Foyle Health and Social Services Trust. Staff seconded from the two legacy trusts developed and produced the document, in conjunction with support from the Housing Executive.
The objective of that document was to take a strategic look at the future. We were conscious of the projected increase in the proportion of older people in society — over the next 10 years, there will be, approximately, a 40% increase in the numbers of over-65s. The review intended to examine our existing model of provision with a view to determining what type of services we would need in the future. We engaged with age-sector organisations, such as the Senior Citizens Consortium, Allied Foyle Network, and the University of the Third Age, and we consulted professional staff within the trusts. In the community sector, we engaged with some of the rural community organisations to support the consultation and its delivery.
Older people expressed the opinion that they wished to remain at home for as long as possible with the support to do so. Many of those who currently live in our residential homes were not resident at that time. There is a through-put, or transition, of people in residential care. The document was part of a strategic plan for the future, so we had to engage with people who may require our services in the future. That was the focus of the review, and its recommendations focussed on what people told us.
I remember responding to a question from Mr Buchanan about referrals to Gortmore House. In the last calendar year, there were only four permanent admissions to Gortmore. That is not the result of trust policy. The professionals who predominantly assess people’s needs are social workers. They will make a social care assessment of people’s needs and work in conjunction with the client and his or her family to draw up a care plan. The care plan includes a range of services that will support the client and address risks to maintaining his or her independence or health.
People have chosen to stay at home and in the community, and that has resulted in a reduction in the number of people being admitted to residential homes. We have not said that we will not admit them.
Mr Gallagher:
I agree entirely with what has been said about the home-help situation; it is very bad in West Tyrone and west Fermanagh. The idea that somebody should be given only 15 minutes of home help is unacceptable. It is a waste of money and has no benefit. The home help comes into the house, perhaps boils the kettle, turns around and leaves again. That must be examined.
Another issue is that someone might be allocated 20 hours of home help, which is cut to 10 hours then to six hours. I do not understand why a sufferer of Alzheimer’s disease, which is a progressive condition requiring increased home help, should have his or her home-help hours decreased. That does not fit the picture of what home help should provide.
I welcome the chief executive’s report of the Minister’s comments about residential homes — that unless there is equal or better accommodation, he will not support it. I understand that consultation has been carried out; however, it appears that everyone is being consulted except the homes’ residents. You are aware of the extent of the outcry about that. I believe that Mr McGarvey mentioned “viable alternatives”. I am interested in his thoughts about that; for example, is some kind of sheltered housing a viable alternative?
Mr McGarvey:
I cannot generalise because it is our responsibility to assess everyone’s unique individual needs. Sheltered accommodation with a care package may support one person, but not necessarily another. Therefore, if the proposal were to be implemented, we would determine how we would meet individual needs case by case. However, in response to views and opinions that are expressed in consultation, we will need to outline the types of provision. We will consider sheltered accommodation with a care package as one type of alternative provision, if it is available in the locality.
Mr Gallagher:
It seems to have a good deal of merit. I would like to see that type of provision being progressed from where it is at present, which is merely a suggestion on paper.
The respite-care facility for young people in the Omagh and Fermanagh area is not on the ground; it is somewhere in the plans. That is my understanding. Can you tell us when that will be up and running?
Mr J Doherty:
As you know, there were complications with the change to planning restrictions. We have revised the business case, which is currently with the Department. We await permission to proceed, and we are optimistic that we will get it.
Dr Deeny:
Enough has been said about nursing and residential homes. I am delighted to hear that there will be four types of consultation on the matter. It seems that many residents in facilities, such as Gortmore House, feel much more at home there than they would in a new facility close by.
I welcome you to the Committee. I want to focus on community services, because that is the area in which I work. I want to discuss table 4 on page 24 of the ‘Western Health and Social Care Trust’s Strategic Response to the Comprehensive Spending Review 2008/2011: Equality Impact Assessment (Screening) Report’. Perhaps, you can explain to the Committee the new phrase “skills mix”, which appears in PCC 6:
“Redesign of community nursing services with the introduction of appropriate skills mix.”
Can you confirm that that is not simply a way to provide nurses who are paid less to do the same job? Furthermore, item HC 10, in table 5 on page 28, refers to a:
“Review of skill mix of community dentistry support services”.
I do not know whether is appropriate to ask the Western Health and Social Care Trust this question. It may be a question that I should put to the Minister, but, as Tommy would verify were he still here, there remains a major problem with dental services in the West. In the past fortnight, two GPs have told me that, for example, many doctors have been treating dental abscesses for patients and that people will end up in hospital, receiving antibiotics intravenously, because they cannot get an NHS dentist. That is their major problem. Could that review contribute to the situation?
Will you explain the review of the independent sector’s provision of child and adolescent mental-health services that is also listed in table 5? What is meant by:
“Redesign of Psychology Services within Child Adolescent Mental Health Services”
in the Western Trust? The provision for GPs to have young people seen and assessed by child psychiatry or psychology services is pretty abysmal. I know that it is improving.
Finally, Claire McGill made the very good point that it is preferable, when possible, to treat patients in their own homes. For example, OT has been woeful in assessing people’s home needs. If an assessment is not carried out, it becomes impossible to encourage patients to stay at home, because they do not want to put relatives under pressure. Patients require OT-provided equipment in their home, and, without it, they will opt for residential accommodation.
Mrs Way :
I agree that providing NHS dentists is a real challenge in the West. The Western Board is the organisation that approves community general dental practitioners — the people to whom you and I would go for dental care. The board has tried hard to recruit dentists, but without success. Therefore, last year, the board gave the Western Health and Social Care Trust the money to try to recruit, and directly employ, six dentists to treat adults.
I am not sure whether the reason for the recruitment difficulty is a scarcity of dentists. It may be a consequence of something that is common across the UK, such as the dental contract, but the trust has not been able to fill those positions. However, Dr Deeny has described accurately people’s ability to access care.
In relation to the service in the proposal to which Dr Deeny referred, for many years the old community trust provided community dental services for children. John Doherty is responsible for that, and he will elaborate on it and on child and adolescent mental health services (CAMHS).
Mr J Doherty:
The Western Health and Social Services Board has invited the trust to consider NHS dental services, because, for the past few years, the legacy Sperrin Lakeland Trust and the legacy Foyle Trust have reported the highest-costing dentistry services. We plan to establish whether the service can be run more efficiently. That explains the reference to dentistry in table 5. However, the director of dentistry with the Western Health and Social Services Board is taking the lead in an active recruitment campaign that is aimed, through a new process, at attracting dentists to the west. We await the results of that, but the issue is, and has been for some time, a real challenge.
In relation to CAMHS and the reference to psychology, the merger of the two trusts left two CAMHS teams in place. A single CAMHS is being developed. We are trying to ascertain whether management of the two CAMHS can be merged to enhance the delivery of psychology services on the ground. Hopefully, that will enhance and improve management of the service.
Dr Deeny also referred to contracts with various groups. The Western Health and Social Care Trust has inherited a broad set of arrangements from the legacy trusts, which we will review in order to reduce any duplication.
Mrs Way :
If I may, I will invite the trust’s chief nurse, Alan Corry Finn, to say something about the skill-mix issue for community nursing.
Mr Corry Finn:
The skill mix is an issue across all trusts. In the Western Trust, at present, the skill mix is somewhere around 75% registered staff and 25% unregistered. Unregistered does not mean unqualified; many of the trust’s staff have NVQs.
The five directors of nursing, in conjunction with the chief nurse in Northern Ireland, debated the issue approximately two years ago. The skills of nurses in Northern Ireland were compared with the norm in England, and the English skill mix was significantly lower than ours. I speak for the directors of nursing when I say that just because the skill mix was significantly lower in England does not mean that that is good and that we should match the levels there. However, we acknowledged that there was room for some improvement in the Province. Therefore, our proposal is to move to 72% of registered, and 28% of unregistered, staff, and I am content with that.
Those percentages would vary across the trust: in an intensive care unit, 99% of staff might be registered; in a less technical area, support workers with NVQ qualifications would be more appropriate. Therefore, the percentage of registered staff could range from 60% to almost 100%.
Community nursing is one area in which some improvement can be made in the skill mix. That is not necessarily a matter of reducing expenditure, but about putting more people on the ground and putting those with the right skills in the right place.
Dr Deeny:
How long is the current waiting list for occupational therapy assessment? Also, John, how soon are those needs met? The sooner that happens, the more likely patients are to want to stay at home.
Mr McGarvey:
The service delivery unit monitors our performance on the assessment of patients. The target is that, from the end of 2009, the period from the point of referral to assessment will be 13 weeks. We currently meet that target in more or less all circumstances, and we are confident that we will fully meet it by the end of this year. That target will be further reduced to nine weeks in 2010, and we are putting in place plans to ensure that we meet that.
You raised the issue of how soon equipment, aids, adaptations and appliances are delivered once the assessment is complete. Our problem is funding the provision of equipment to the community. We are working with the commissioner to try to secure either non-recurring funding, or an increase in recurrent funding, to ensure that we can address those issues more quickly.
Across the trust, community rehabilitation services are available for people who are in crisis because they require social support. Occupational therapists and physiotherapists are part of that team. Therefore, if someone requires a short-term programme of rehabilitation, that team will provide intensive rehabilitation support at home for six weeks. It is hoped that such support will return an individual to his or her previous level of independence. The same pressures apply to any long-term issues relating to adaptations or equipment.
Mr McCallister:
There are issues relating to residential homes in all trust areas. Elaine, you mentioned that you have not yet identified where all the savings can be made. What would be the impact of not meeting your targets? Are you confident that you can deliver the best standard of health and social care for everyone living in the Western Trust area? Given that you cover a large geographical area, are you confident that people will not be disadvantaged and that you can deliver a standard of care that is on a par with that found anywhere else in Northern Ireland?
Mrs Way :
I have been encouraged by some of the questions that Committee members raised today. You are saying that more resources are required in certain areas, and none of the trusts’ chief executives would say that they have sufficient resources to meet all needs. We are well aware of the gaps that exist. However, we must also live within the resources that we have, and, as John McGarvey said, there are issues about how we work with our commissioners to lobby for investment in, for example, equipment, because that will help to support people in their homes.
Regrettably, the way in which the system works is that the meeting of targets is not negotiable; the money is taken out of the budgets at the start of the year. For example, at the start of last April, £9·6 million was taken out of our budget, and, therefore, if we do not make the required efficiency savings within the year, we will overspend, and we are not allowed to do that. Our legal responsibility is to balance our books.
I am confident that we will meet that target of £9·6 million in efficiency savings this year. I had a meeting with the director of finance the other day, and we have been able to identify £8 million of recurrent savings and, therefore, that amount has already been saved through efficiencies. We have had a gap of £1·6 million, and we have been able to sort it out in-year simply by tightening our belts. However, as we go into the next financial year, we must ensure that we address that shortfall.
Thirty-six million pounds will be taken out of our budget over the three years, and we will have to balance our books. I welcome the opportunity for us to make the case for more investment, and I apologise to those who are not from the west, but it is particularly important there that we lobby on behalf of our patients and clients. I certainly would not say that we have enough funding in the west, but, truthfully, we, as the management team, and all of our staff, are committed to making the best use of the money that we have.
The Deputy Chairperson:
Thank you very much. You will be happy to hear that that ends the questions. Your coming here has been most helpful and informative, and you outlined the situation clearly.