COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Efficiency Savings

12 February 2009

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill

Witnesses:
Mr Oscar Donnelly )
Ms Norma Evans ) Northern Health and Social Care Trust
Dr Peter Flanagan )
Miss Bronagh Scott )

The Chairperson:

I On behalf of the Committee, I welcome representatives from the Northern Health and Social Care Trust. Norma Evans is the trust’s chief executive; Bronagh Scott is its director of emergency primary care and older people’s services; Peter Flanagan is its medical and governance director; and Oscar Donnelly is its director of mental-health and disability services.

Ms Norma Evans (Northern Health and Social Care Trust):

Thank you very much, Chairperson. We will keep it simple. I apologise at the outset because I have a sore throat and a bit of a chest infection. I will keep drinking water.

We welcome the opportunity to explain the comprehensive spending review efficiency proposals on which we are currently consulting and which we will forward, after the trust board’s approval, to the Minister. The development of proposals for the level of savings that is required of us has been challenging. However, it is fair to say that it has afforded us opportunities to examine in fair detail how we work and how we deliver services. Therefore, we view it as a mixture of challenge and opportunity. There is no doubt that there are always efficiencies to be derived in any organisation, such as ours, that spends £540 million of taxpayers’ money and employs 14,000 staff. Therefore, we have taken the opportunity to bring forward proposals in that spirit.

Our efficiency target under the present costing proposals is £44 million over three years: 12 million in year one; £15 million in year two; and £17 million in year three. Over half of the efficiencies that we have brought forward are straightforward reductions in cost and, therefore, pure efficiency. We have provided members a paper outlining from where those efficiencies are coming. You will be aware that, as a result of the review of public administration (RPA) and the amalgamation of three health and social services trusts — Homefirst Community, United Hospitals Group, and Causeway — we were required to save 25% of management costs and 10% to 12% of administrative and clerical costs. In our case, that amounted to £7·4 million. That has been a major contributor towards achieving the first year’s savings of £12 million.

We have listed the other general efficiencies; for example, the regional efficiency on drugs procurement, which yields £4·9 million for the trust. We estimate that managing locum overtime and staff absence due to ill health, and so on, could yield £5·5 million. There are several other, smaller proposals, such as the introduction of packs for computer imaging. We are aware that if we stop printing so many X-ray films as part of the regional initiative, we could save around £400,000 on goods and services. Community services productivity could probably realise around £4·4 million. Further reviews of structures and ensuring that we achieve the greatest level of efficiency in the use of human resources could yield another £4 million, which takes the total to £23 million. All of that is extremely challenging.

We examined service reform and modernisation proposals. I suggest to the Committee that, in some ways, the Northern Trust is in a unique position. It currently has nine hospitals, which serve a population of 450,000. Four of those hospitals attempt to deliver acute hospital services. The trust has 11 homes for older people, nine of which provide general services and two of which are for people who have dementia. It is fair to say that, as regards many of the changes and proposals that we are bringing forward to reduce the number of smaller rural hospitals, and to reduce and modernise the stock of provision for older people, none of the other trusts in Northern Ireland is further ahead than we are. The Northern Trust is a large trust; no other trust has nine hospitals and 11 homes for older people. Our proposals are mindful of that fact.

I will outline the proposals in each programme area: children’s services, disability services, mental-health services, older people’s services and acute hospital services. My colleagues are here because they can outline the specific details of the issues in each programme area.

In children’s services, we want to provide alternatives to residential care for looked-after children in state care. Given our investment in those alternatives, we probably do not require all six existing children’s homes. We propose to do without the Princes Gardens children’s home in Larne — the oldest of our stock of children’s homes — by using foster carers as an alternative.

The Northern Trust has six residential homes. Under the Children Matter capital provision, when we replace Ballee in Ballymena — for which we are currently making a business case — five of the six homes will have been replaced in the past six or seven years. Three have already been replaced — Dhu Varren in Portrush, Ardrath House in Magherafelt and Barn Court in Carrickfergus. We are currently replacing a home in Newtownabbey. However, we did not achieve planning permission and local agreement to locate the replacement home in Newtownabbey, and, therefore, it will be situated in Antrim. The build will be completed in spring 2009 and the home commissioned by the summer. As I have already said, Ballee, for which we are drafting a business case, will be the only remaining home.

In planning to replace each home, we have sought to bring some focus to the provision. For example, the Ballee proposals are for an intensive support facility for older children who demonstrate challenging behaviour. Barn Court in Carrickfergus is for younger children; best practice suggests that mixing older and younger children is not necessarily in the child’s best interest. Furthermore, the departmental target to reduce the numbers of children in care by 3% in each of the next three years is another driver. We believe that we will be in a position to do without that home.

The proposed changes to Cherry Lodge have been more controversial. Cherry Lodge is a small facility; it comprises two domestic bungalows that were bought by Barnardo’s over 20 years ago using funding that was provided by the Northern Health and Social Services Board. It originally opened as a day support facility and provided that service satisfactorily. It was upgraded to provide residential respite for children and was run by Barnardo’s. The structure of the building creates some inherent difficulties, but families who care for disabled children and young people undoubtedly need respite.

About two or three years ago, the home experienced some difficulties, which led to Barnardo’s withdrawing from the provision of the service, and the home closed for approximately six months. I was familiar with the outworkings of those problems when I was the chief executive of the Homefirst Community Health and Social Services Trust. In order to maintain the service and to provide continuity for the families, the trust assumed the management of the home. We lease the building from Barnardo’s and have spent money to enable it to reach fire code standards, which it has just about managed to do. As the property was built as domestic bungalows, many children — especially when three are there together — find it slightly claustrophobic.

Furthermore, one of the three bedrooms cannot be used by the children because there is an ongoing problem with a pungent smell of oil. That problem existed when we took over the home’s management, but we were unaware of it. We have applied the best of our estate services brains to dealing with that smell. We have dug up floors and drains, we have replaced boilers — we have done a number of things, but we have still been unable to bring that room into use, although we continue to work on that. Therefore, only two of the bedrooms have been available for use since the trust took over the running of Cherry Lodge from Barnardo’s.

We propose to implement the widening choices and opportunities programme for people with a disability by developing alternative day opportunities for Broadway workshop in Newtownabbey. I think that Broadway may now be the only contract-type workshop that exists in Northern Ireland. It is a large, old building attended by 90 people on a daily basis. Some of whom are from north and west Belfast; the rest are from the Northern Trust area. They are people who have a learning disability but are at the more able end of the spectrum: for example, they all travel independently to the facility. They engage in, or have engaged in in the past, contract-type work like — I am so old that I can remember it — packing hairbrushes for hairbrush manufacturers, putting together packs for central sterile supplies or applying labels. That is they type of activity that they were engaging in.

Increasingly, there is a requirement to provide more opportunities and more normal kinds of activities for people with a learning disability. At the moment that applies to around half of the people who attend Broadway. There are other opportunities, such as attending skills training offered by further and higher education colleges. Some of them are in volunteering schemes where they might work in nurseries, hospitals or homes for older people. Some of them are in training positions, where they are trained to take on some simple clerical or administrative work, like photocopying or shredding. Some have progressed to the point where they are in both sheltered and open or part-time employment. We believe that, in line with the Bamford Review, it is appropriate for us to now try to extend that and to try to re-provide for all of the people who attend Broadway. That would leave the Broadway facility empty.

We also want to extend the provision of respite services by extending community- and family-based respite provision, with less dependence on bed-based respite. There are a number of people for whom we provide respite care who use family-based respite for children, young people and adults. Particularly n the north, in what was the Causeway Trust area, there had been a lot of investment in and development of family-based respite for children, young people and adults, because they did not have easy access to any other form of respite.

We also provide respite in some private-sector residential and nursing homes. Generally speaking, the feedback that we get from people who use respite indicates that people find family-based respite more acceptable. It is more flexible, it is more personal for the individual, and it is less disruptive to the people who live in residential homes, because many of them do not like people coming in for respite and the constant interruption of their routine. We propose to try to extend the number that we provide family- or community-based respite for, and reduce our reliance on buying beds on a spot or contract basis with the private and independent sectors.

There is no local inpatient or residential service in Northern Ireland for people with personality disorders. That means that we have to support, at fairly significant cost, a small number of people — low volume, but high cost — in England. We believe that the development of better outpatient and community-based services for people with personality disorders might prevent some people from having to travel to England, or reduce the length of time that they have to spend there, and enable them to be supported more appropriately, close to their families. It is a case of speculating to accumulate — investing in a brand-new service would save by avoiding transferring people to England or by bringing them back more quickly.

Bamford also places a lot of emphasis on the development of home treatment services for people with mental-health problems, in order to avoid their having to go into hospital. A lot of people find going into psychiatric hospitals very traumatic. They like to do as much as they possibly can to avoid it. Many people have to be admitted because our community services do not have the resources to provide dedicated and comprehensive support for people undergoing a psychiatric or mental-health crisis.

We believe that linking home treatment to the existing 24-hour crisis response service that is provided throughout the trust area would reduce the requirement for inpatient beds by the equivalent of at least 19 beds. That would allow the closure of ward 8 in Whiteabbey Hospital, which is an old ward that has undergone some limited refurbishment, but is not the most conducive of environments for the quick recovery of people with mental-health problems. It has shared dormitory spaces, fairly poor sanitary facilities, and little space for daytime activities, for private interviews or for visitors to spend time with patients on their own. Whatever else we do, ward 8 is not a terribly appropriate environment.

The other significant issue about ward 8 is that it already deals with people who have less severe forms of mental illness. People with more serious acute mental illnesses are not admitted to Whiteabbey ward 8; they are taken to Holywell Hospital in Antrim or to the Ross Thompson unit of the Causeway Hospital in Coleraine.

We also propose to provide more community-based rehabilitation, which will reduce the need for the rehabilitation ward at Holywell. Once more, Bamford has outlined the standards that should pertain to rehabilitation. In general, it is recognised that people who rehabilitate in a community setting do so more satisfactorily and quickly, and integrate back into the society from which they came much better. Therefore, we propose to replace the rehabilitation ward at Holywell with community-based rehabilitation.

Holywell has a ward called Inver 4 in which people with dementia are looked after. The patients in Inver 4 have mostly proved extremely difficult to resettle or to provide for in the stock of accommodation that is available in the community at present. We believe that by working with an independent provider, we could create a purpose-built facility in which the raised levels of care, support, skill and expertise that are required to look after those people could be provided. Those patients should not have to live out their days in a hospital; they should be in the community with other older people.

I was here when my chief executive colleague from the Southern Health and Social Care Trust, Colm Donaghy, talked about the issue of statutory residential homes. I have already explained to the Committee that the Northern Trust has 11 statutory homes for older people. The Northern Trust has been less proactive in developing alternatives to residential homes. One of our facilities — Greenisland House — was originally built in the 1900s, since when it has been added to and upgraded. The rest were built in the 1960s and 1970s, and are quite old. I was personally shocked when I discovered that nine of the 39 bed spaces at Rathmoyle Home in Ballycastle are in shared rooms. Someone could end up sharing a room with someone who has no familial relationship at all with them, with just a curtain between the two beds in what is not a very large environmental space.

All of the trust’s facilities for older people need to be replaced, and we should begin to do that. The proposal is to start by replacing up to five of them. There has been a very mixed reaction to the proposal, and we accept that our handling of it has perhaps not been as good as it could have been. However, we have gone out and explained to people what we are proposing to do, which is to replace the homes with a sheltered scheme — housing with care. People have been offered the opportunity to see the Brook care home in Coleraine — a service that was developed by the former Causeway Trust, where a home for 29 people with dementia was replaced with 61 units of housing with care, including six registered beds, which is the equivalent of a residential home. In other words, the trust rents the six bed spaces from the provider, Fold Housing Association. The trust pays the total cost of them and provides the total support. The other part of the facility has the opportunity for people to live independently in bungalows, flats and bed-sitting rooms, where the trust provides the level of support that they require to maintain their independence. It is for people with dementia, not for the general elderly.

That is the model that the trust is seeking to introduce, and I am pleased to say that, after a very bad start, we are beginning to find that some communities, councils and staff groupings are showing an interest in working with us. We began consulting at a very early stage; at the moment there are no plans to show people. We think that that is the wrong way to do it. People should be offered the opportunity to work with the trust to develop a scheme that suits Ballycastle, Antrim, Larne, or wherever it is, and the trust would then work with that community.

Barn Halt Cottages in Carrickfergus would not suit every community, and neither would the Brook in Coleraine. As Mr Donaghy explained, we have gone out to look for partners with capital to bring to the table to work with the trust. Although clearly there is not the amount available to replace all of the trust’s homes — and we now accept that we cannot replace five in the two- to three-year time frame — we believe that we can find partners who will work with the trust to replace some of them. The trust board will make a decision and a recommendation to the Minister, but I anticipate that perhaps less than five of the homes will be replaced.

No home will be affected until the alternative accommodation and services are ready — on the same site, if possible. Some of the sites have quite a bit of space around the home, which would allow room for replacement onsite before moving the residents. That is what was done in the Brook. There will be a minimum timescale of two to three years, which offers the opportunity for the trust to provide domiciliary care and support to the level needed by the individual, rather than their having to be looked after in totality when they go into a residential home.

When the trust brought forward proposals for its older people strategy two years ago, the message from older people and older people’s organisations was that they want to stay at home, or as close to a domestic home as they can, for as long as they can. They do not like giving up their pension book, their attendance allowance and their income support, and perhaps having to sell their family home in order to support themselves in residential care. They want access to social housing. We believe that they are entitled to it, and that they are entitled to expect the trust to provide them with reasonable levels of support to help them to maintain their independence. Many of the people currently in residential homes are there because the trust failed to provide them with the level of support that they required to stay in their own home. We are trying to redress that. It is a hard message to sell in some places, but we are making progress.

As I said, there are nine hospitals in the Northern Trust area, four of which are trying to provide acute medical and surgical services. We find it impossible to maintain services in all of those hospitals. There are not enough doctors, and the governance arrangements and standards that pertain to the delivery of twenty-first-century medicine leave us unable to sustain four sites. The result of our trying to maintain four sites is that none of the sites are adequately staffed. I can go into the detail of that later.

There is a strong need for a local health presence at Whiteabbey Hospital and Mid-Ulster Hospital. A number of important and vital services for the population can continue to be provided locally in those sites safely, but some services should be centralised onto the larger sites in order to ensure that we look after patients to the highest standards of patient safety in the twenty-first century.

We propose to retain day surgery, outpatient and diagnostic facilities at the Mid-Ulster Hospital and Whiteabbey Hospital and to develop high-quality minor-injuries services that are capable of seeing around 70% of the people who attend Whiteabbey Hospital and Mid-Ulster Hospital. We intend to extend some of the services that we provide. We will probably move quite a bit of the day surgery — in other words, surgery that does not require an overnight stay — to those two sites, because it can be done safely, effectively and efficiently there.

There is a business case with the Department for the provision of a mobile computerised tomography (CT) scanner, which would certainly be deployed at times to Whiteabbey Hospital, which does not currently have a CT scanner. If people need a CT scan, they have to go either into Belfast or to Antrim Area Hospital.

Therefore, we propose a mixture of taking out some services that are not safe, replacing them with services that are safe to be delivered locally and, in some respects, enhancing those services. Rehabilitation would continue to be provided through 60 beds in Whiteabbey and 29 beds in the Mid-Ulster Hospital. That would allow people to have their acute episode of care in the larger hospital, where they have access to all the services that they need, and then be discharged closer to their home or their family and convalesce and have rehabilitation.

The changes at both hospitals are dependent on a new ward block being built at Antrim Area Hospital, which currently has just over 400 beds. It was originally intended that that hospital would have over 600 beds. It was to be a phased development, but only phase 1 was ever completed. Phase 2 is the development of more beds, and the trust wants 72 beds. We are developing a business for 48 beds plus another 12 beds in partnership with Macmillan Cancer Support for specialist palliative care.

To support those beds, increased space for services such as diagnostics, anaesthetics and theatres is needed, and those would have to come with the wards. Those beds are needed before the changes that we wish to make at the other two hospitals can be made, and we propose to move on Whiteabbey Hospital first and Mid-Ulster Hospital later.

There are big issues in the mid-Ulster area. The public consultation has revealed major concerns about travel time and the ambulance service that is available in the mid-Ulster area. That will take longer for us to work through. We have included it because it is part of our strategy, but it is not likely that much will be done at the Mid-Ulster Hospital in the current three-year comprehensive spending review period. We are flagging it up because it is part of the plan.

When the Minister went to Larne, he announced that a health-and-care centre would be provided in Ballymena. The business case for it is fairly well advanced, and it is likely to be the first health-and-care centre that will be built in the Northern Trust area. We are a bit behind some of the other trust areas, because we do not currently have any health-and-care centres, and Ballymena would be the first. During the next 10 years, additional health-and-care centres are planned for Larne, Carrickfergus, Newtownabbey and Magherafelt.

Those are the main service proposals. The other general efficiency proposals that I did not include in my comments about the £23 million were a car-parking policy and a traffic-management policy. The trust has a major problem, particularly at the site of Antrim Area Hospital. I know that the Health Committee has a great interest in that issue, and I am happy to talk about the detail of that.

The other thing that we are looking at, and have begun discussions around, is the £80 million of residential and nursing-home care that we procure. In the early days, they tended to be individual, independently-owned nursing homes, where it was extremely difficult for there to be any tariff negotiation. There are now a number of quite big providers in the Province, and we believe that we could negotiate. I am just using that as an example; we believe that we could get some better funding arrangements by using the power that we have over the quantity of purchasing that we make, and try to achieve some better value in that.

We have tried extremely hard to ensure that any proposals we are making are in line with national, regional and trust strategy. Everything that we are proposing around mental health and disability is completely in line with Bamford and with Equal Lives. The proposals around children’s services are in line with the Children Matter strategy. The proposals in older people’s services are in line with regional and trust policy, and the acute services proposals are simply the outworking — the manifestation — of developing better services, which had always envisaged Mid-Ulster and Whiteabbey as local hospitals with a concentration of acute district general hospital-type provision in Antrim and Causeway.

The Chairperson:

I would normally give 10 minutes, but because we are dealing with the comprehensive spending review over a three-year period —

Ms Evans:

I apologise.

The Chairperson:

No, no; it is important to hear all of the headings, so there was considerable leeway given for both presentations. I hope that I have been fair in allowing you to go through those headings.

I would like to clarify two things. First, are you indicating that nursing homes or the care of the elderly are dependent on the private sector per se? Secondly, can you tell me what your in-house provision is for adults with autism and Asperger’s syndrome? It is relevant to where we are today, and I think that it is only right that we flag up the issue when we are in the home of Autism NI.

Ms Evans:

All nursing-home care in Northern Ireland, as a matter of policy, is provided by the independent sector. That does not necessarily mean the private sector — it could be voluntary or charitable. None of it is provided by the trust. We, like other trusts, do not provide nursing-home care.

There are 900 beds for residential care for older people in the trust area: 600 are provided by the private sector and just under 300 by the trust. Some of our beds do not provide permanent residential care; some of them are to provide respite and step-up, step-down care. We provide permanent residential care for about 270 people.

In the proposals that I have outlined in developing supported housing, the capital build part would be done by a third party. Our experience to date in both the Brook and Barn Halt has been with the Fold Housing Association. In learning disability, for example, there has been some private-sector development, which has worked satisfactorily. It depends on where we can get it.

The provision of care is mainly a mixture of trust provision in the Brook: some of it is provided by Fold, which is the Supporting People element, and the rest is provided by the trust. There are different models where there can be different providers, but this is not about privatising the care of older people. It is about trying to find the most efficient way possible to use the resources that we have. For example, the average cost of a residential place in the Northern Trust is £605 per week. If it is provided in the private sector, they get £405; a nursing home gets £510. People ask why our residential places cost more — part of it is because we have to pay the bills for heat, light, rates, capital charges, and maintenance.

Money that could be used for providing front-line health and social care, which is what we are good at, is being used to maintain 11 residential homes for older people. We think that in a modern society in the twenty-first century, it would be better if we did what we are really good at, which is providing health and social care, and allow the people who are good at providing accommodation to do so. People in residential care need good accommodation, rather than specialised environments like a nursing home.

Miss Bronagh Scott (Northern Health and Social Care Trust):

I do not have much to add, other than to say that we want to provide a range of better services for our older people. In the statutory sector we provide 24-hour residential care; as Ms Evans said, not everyone needs that, but we did not have anything else. All our residential homes require upgrading to modern standards.

Our commitment to older people is to give them the very best that we can possibly give them, and to allow them the independence of living that they have told us that they want, as far as we can, through supported living or residential care where it is required. The example that Norma gave, the Brook in Coleraine, provides that range of care. We have invited people in our area to go up and see the Brook in order to get a picture of what we are talking about.

The Chairperson:

What provisions does the trust make for adult autism and Asperger’s syndrome?

Mr Oscar Donnelly (Northern Health and Social Care Trust):

I manage the trust’s mental-health and learning-disability services, and autism cuts across those. Our services have improved in recent years, and there has been an increased recognition of the need to improve services. For example, our transition planning for children moving into adulthood has improved greatly. The degree of specialisation in our adult centres and the use of communication tools such as Makaton and the Treatment and Education of Autistic and related Communication-handicapped Children (TEACCH) system have been spread more widely. We also have a well-established psychology-based behavioural support service, which assesses people’s needs according to their behaviours and provides statutory support for parents who manage people with autism and who have particular problems.

There is still a significant need, particularly in mental-health services; our learning-disability services are much better developed. Last year, the Northern Health and Social Services Board launched ‘Colouring Lives: A Strategy for Autistic Spectrum Disorder’. We worked with the Northern Board and Autism NI on the project team that put that strategy together. As part of that exercise, we received funding this year for an autistic spectrum disorder co-ordinator, who will co-ordinate services across the trust for adult mental-health and learning-disability services and children’s services.

The Northern Board has agreed that we can recruit two further link workers, with the intention of setting up a multi-agency steering group as part of the strategy. It is important to recognise that our services are not just about health and social care; there are a range of services to be maintained and developed in a way that can better support people with autism and their families.

The Chairperson:

It is reassuring to know that you have liaised with Autism NI, which has led the field.

Time is not on our side.

Mr Easton:

I will be quick.

How many residents will be affected by the five closures and the rebuilding programme? How many nurses’ posts will be going? Mr Donaghy was honest enough to say that he had a plan B. Do you have a plan B if the Minister turns down some of your recommendations?

Ms Evans:

I will answer the third part of your question. I will ask Bronagh to respond to the other specific matters.

The Chairperson:

That goes with a health warning, as you will be recorded.

Ms Evans:

Our consultation has been a genuine consultation. You can see the effort that we have made during the past three or four months to have briefings and meetings with staff, residents, the public, political parties and councils. We have listened carefully to what those groups have said. Therefore, it is likely that, as a result of that consultation, the proposals that I have presented may well change before they are put to the Minister.

As regards plan B, the rules within which the comprehensive spending review’s efficiency savings must be achieved are challenging. We must not reduce the quantum of service. We must avoid compulsory redundancies. However, £12 million was taken out of my baseline budget on 1 April 2008 and a further £15 million will be taken out on 1 April 2009, which is a total of £27 million.

We are doing absolutely everything that we can within those constraints. I cannot recall the name of the scheme that Mr Donaghy mentioned; ours is called Mind the Gap, because there is still a gap between what we must achieve and what we anticipate that our proposals will achieve. Work on the scheme is chaired by Briege Donaghy, who is sitting in the public gallery. We work with staff and trade unions and have asked them to suggest how we can be more efficient. Proposals have been forthcoming.

When we are clear about what proposals we will make to the Minister and what efficiency savings those will achieve, we will determine what the gap is and what the Mind the Gap project has produced. We suspect and anticipate that a bit of a gap will still exist. We will continue to work at that during the next two years. Therefore, the answer is yes and no: we have a Mind the Gap project, which, at present, has not indicated efficiency savings that would close the gap that must be closed. However, it is a model — a way of working — that is popular with staff because it is owned by staff and is, therefore, likely to be effective.

Rather than being primarily about major transformation of services, our aim is to look after the pennies so that the pounds will look after themselves. It is about making small-scale efficiencies that keep building towards achieving our desired outcome.

Mr Easton:

During a recent debate, when I suggested that certain small savings should be made, I got hammered by people who said that that was silly. You are saying that some slight changes are possible?

Ms Evans:

On the back of a workshop that we will have with the trust board on 19 March 2009, slight changes could be made to the proposals that we eventually submit to the Minister at the end of March. We will meet him to discuss those proposals and our rationale.

Miss Scott:

You asked about the number of residents that will be affected. Each of the five homes has between 30 and 40 residents. There are around 179 residents overall, not all of whom are permanent — we use some intermediate and step-up, step-down care. Around 167 of those 179 residents are permanent. We do not propose wholesale closure of residential homes. We are looking at different ways of providing care. That could well mean that the number of places is increased in the new provision, as happened at the Brook in Coleraine. It depends on the local area’s needs. We will work with local people and their representatives, as well as staff and residents and their representatives, in order to determine their needs.

Mr Easton:

How many nursing positions will be lost, if any?

Miss Scott:

At present, we estimate — and it is only an estimate — that, after the reinvestment of nursing posts, there will be a net loss of around 41 posts.

Mr McCallister:

I note that, worryingly, nursing posts will be reduced by 41, and that social services posts will be reduced by 221. Can you elaborate on where those reductions will be made? The Committee has heard in the past that social services waiting lists can be quite long. Approximately 1,000 cases are waiting in the social service system across Northern Ireland. Admittedly, those cases are not all within the Northern Trust, but 221 posts is quite a reduction.

Is there a waiting list for care packages in the Northern Trust? How efficient are the hospitals in the Northern Trust compared with those in the other trusts across Northern Ireland?

Ms Evans:

As I said, the trust runs nine hospitals — including Holywell Hospital — several of which are smaller community hospitals. Three of the four hospitals that provide acute services are not particularly efficient. The Causeway Hospital is a new hospital and has been described as being too small to be big and too big to be small. Its reference costs — how we measure efficiency — are quite high. That is simply a measure of scale. A sufficient number of medical staff must be put on a rota to cover a shift, and that automatically puts up costs. In contrast, Antrim Area Hospital is very efficient. As regards reference costs, it is one of the most efficient hospitals in Northern Ireland.

Given that Mid-Ulster Hospital and Whiteabbey Hospital are small and that the throughput of activity — in Whiteabbey, in particular — is relatively modest, they are quite expensive to run. Antrim Area Hospital has an economy of scale; the other hospitals have diseconomies of scale. Every night in Whiteabbey Hospital there must be a rota to cover general medicine and surgery. That means that the consultants have to work on-call one night in three, whether they are busy or not. There are other rotas operating in Antrim Area Hospital, Mid-Ulster Hospital, and the Causeway Hospital.

Every time that a new rota is created, one and a half to two programmed activities must be removed from a consultant’s availability. Perhaps I should let Dr Flanagan speak to this, but that is my understanding. The rotas reduce the amount of time that consultants are available for clinical activity. If we were to deliver acute services out of two sites, the guys and girls who cover Mid-Ulster Hospital and Whiteabbey Hospital would be placed on the larger hospitals’ rotas so that the consultants would be working less frequently, thereby making the consultants available for more clinical activity.

Therefore, the Northern Trust has inbuilt inefficiencies that are unique, because it is delivering acute services out of four sites. We can get the Committee the details of the reference costs.

Mr McCallister:

The reference costs for your two key hospitals — Antrim Area Hospital and Causeway Hospital — are worrying.

Ms Evans:

The reference costs are merely a reflection of scale. I am sure that Mr Donaghy would say that his reference costs for acute services in Daisy Hill Hospital are proportionately higher than those for Craigavon Area Hospital, and I am sure that Elaine Way would say that the reference costs for the Erne Hospital are purely a reflection of the scale. If you want more detail on reference costs, the Northern Trust’s director of finance, Neil Guckian, is here and can provide you with that.

Miss Scott:

You asked about social services staff. One of our proposals is to transfer a significant amount of our in-house domiciliary care to the independent sector. At present, the Northern Trust provides around 82% of the in-house domiciliary care and the independent sector provides the remaining 18%. That is significantly higher in-house provision than any other trust in the Province. Therefore, we propose to transfer to a balance of approximately 60% in-house and 40% out-of-house. As the service transfers, the posts will, through natural wastage and turnover, be lost. As people leave and posts become vacant, we will replace them with temporary staff in order to hand the service over to the independent sector. That approach will save a significant amount of money, because care packages in the independent sector are cheaper than in-house provision.

Mr McCallister:

Are there waiting lists for care packages?

Miss Scott:

Yes. Waiting lists and delayed discharges have significantly improved in the past two years. We do not have the same problem with delayed discharges in our main acute sites. However, domiciliary care is significantly underfunded. We have been working closely with the commissioners and have recently reached agreement that the underfunding amounts to approximately £3·7 million. Therefore, we are devising a plan with our commissioners to determine how to address that matter. We have demonstrated the growth in demand and, although the commissioners have made a fair amount of investment in the past five years, there is still a capitation underfunding for older people’s services in the Northern Trust area. We have now reached agreement on our needs, demand and expected growth, and we are working to address those issues.

Mr McCallister:

Would it not be critical to have that in place before even considering any residential movements? Today’s presentations have suggested that that is a key issue, if only to reassure the public.

Miss Scott:

We are addressing that matter at the minute. We have been working closely with our commissioners to reach agreement on the exact demand. On residential homes, we are looking at a re-provision and a range of services. That will include enhanced domiciliary care for people who want to stay at home, the supported living approach and, where required, residential care. We will work closely with our commissioner on domiciliary packages. Although we have improved significantly on delayed discharges and are meeting the targets, that degree of underfunding makes it difficult. We receive some non-recurrent funding, but it is difficult to plan the use of such money. It is difficult to reach agreement on figures, but we have done so and can now consider our plan for the future.

Ms Evans:

We spend the equivalent of £25,000 a year on each person in a residential home. If we release that money to, for example, support people through domiciliary care and in other ways, it will probably be possible to support more people for the same amount of money. At the minute, everybody receives the same level of care regardless of their needs. A blind person in a nursing home might require a high level of nursing. However, someone else might suffer an orthopaedic fracture, lose their confidence, go into hospital and not want to return home. A residential home might not provide sufficient care, and they could end up in a nursing home. We provide all catering, cleaning and other services in all residential homes, regardless of the individual’s need.

Moving to the model that we are talking about could provide the necessary level of support required by each individual, and it could be geared up or down depending on their changing needs. In the Brook, people moved to a bungalow and, for a while, were independent for quite a while. When they became less independent, they switched to the more supported part of the scheme. Therefore, there is an inbuilt efficiency in freeing resources that are currently tied up in the bricks and mortar of residential homes.

Mr McCallister:

The difficulty is that the community will think that you are removing services and have no alternative in place.

Ms Evans:

That is why we want to work with communities. We are pleased that, after a bad start, community representatives, having been to see the Brook in Coleraine, are beginning to acknowledge that it is pretty impressive and that they want one for Antrim, Larne or wherever. If we can get such agreement in principle, we will sit down with everyone who needs to be round the table and develop schemes that suit particular localities. For example, Ballycastle would not require 61 units, and Larne might require more or fewer. Bespoke schemes must be created to meet the needs of particular localities.

Furthermore, we have 11 residential homes in 11 locations, and many of those are in east Antrim. A gentleman who was being interviewed on the radio said that when he could not look after himself anymore, although he was from Ballyclare, he was persuaded to come to Larne. He went on to say, nevertheless, that having been there for a couple of years he did not want to move. However, if one wished to replace, for example, Lisgarel residential home in Larne, should it be replaced by a facility with 42 units, as it currently has, or should some units be located in Larne and some in Ballyclare? Consequently, that someone who lives in Ballyclare, where his or her doctor, family, church and social networks are located, could remain there. Introducing more localised services would support people in their own environments for longer.

The Chairperson:

What size of population does the Northern Health and Social Care Trust serve?

Ms Evans:

We serve 450,000 people, which is the largest population served by any of the trusts here.

The Chairperson:

The Southern Health and Social Care Trust serves a population of 343,000, and its budget is £420 million. Your trust has a budget of £540 million for 450,000 people. Is there any liaison, or exchange of views, between the chief executives in the five trusts?

Ms Evans:

Yes. We meet regularly to share opinions, and there is a lot of cross-fertilisation within the directorates, not just at director and senior management level, but throughout the organisations. There is no point in reinventing the wheel. For example, when I was chief executive of the Causeway Health and Social Services Trust, and we were developing the Brook in Coleraine, we spent a lot of time at the Seven Oaks Fold in Derry and with colleagues from the South and East Belfast Trust in the Sydenham Court supported housing scheme. Those developments were delivering the kind of services that we were aiming to provide, so that type of liaison does go on. Furthermore, as well as having regular meetings with the permanent secretary, the chief executives meet once a month.

Mrs Hanna:

Your presentation was helpful in providing an overall picture of what you are doing. You certainly face challenges in the acute sector. Efficiency savings there are difficult, but they must be achieved. Do you anticipate being able to make any in the acute sector?

You explained in detail the new models and schemes for older people who presently receive a higher level of care than perhaps they want or need. I appreciate that there is a good argument that you will make efficiency savings in the long run; however, will implementing such arrangements not cost more money initially? I am trying to understand where you will make efficiency savings; much of what you described anticipates new services that will cost more.

The last time you were here, you spoke about the need for a proper car park, because the existing facilities are used not only by hospital staff and visitors but by people leaving their cars all day. Have you managed to introduce a special arrangement for people who attend regularly, perhaps for long-term care? Even if car-parking charges are reduced to £1 or £2, someone who is not well off and who must attend regularly will still have to pay a lot of money.

Ms Evans:

I have one general comment on efficiency. The immediate efficiency savings that we suggested from closing five homes would amount to less than £1 million. The efficiency is really more about recycling that resource into the general pot in order to target it better and to use it more efficiently.

We have had a project group developing proposals for car parking for Antrim Area Hospital and Causeway Hospital. For example, at Antrim, which is a parking nightmare, we propose a car-parking scheme that will introduce 168 additional parking spaces — 100 for staff and 68 in the general car park. The rationale is that, at present, a lot of staff park in the car park at the front of the hospital, because there is inadequate car parking. The number of staff has risen since the hospital opened 15 years ago this April. Therefore, we want to require staff to park in the staff car park, leaving the rest of the car park free for visitors and patients.

We would put in a management system with barriers and tickets. The group recommends tickets as the best way to manage car parking. People with exemptions, as suggested by the Minister — everyone receiving chemotherapy, renal dialysis, and end-of-life care, and their families — and people who face a financial challenge in paying for car parking would not have to pay.

We are used to providing public-transport rates through the cash office for some people who have to come to hospital for certain reasons. The proposal is for 50p for the first hour and another 50p for the second hour, so £1 would pay for parking over the entire visiting period, and should cover most attendances at clinics. We felt that being allowed to introduce that modest charge would enable us to employ people to manage the car park and ensure that it is used appropriately. Since the motorway slip road opened, Antrim has had a particular problem with people parking and car sharing.

Miss Scott:

I will talk a wee bit about the efficiency in residential homes. Our proposals do not show significant efficiency savings, because they are not so much driven by the need for savings as by the need to modernise and to provide better services. Therefore, had it not been for the comprehensive spending review (CSR), we would have had to do this piece of work anyway.

However, by doing it we hope to gain some efficiency through partnerships with the independent sector. Our other fear is that we have a fast-growing older population in most of the trust’s areas. If we consider planning for need, that need is growing, which is something on which we must work closely with the commissioners.

Dr Peter Flanagan (Northern Health and Social Care Trust):

The same points could be made in relation to the hospital side of things. As Ms Evans said, a major reason for the change is all of the issues around the quality, the standards, the increasing specialisation in clinical services, and the need to build specialist teams, which is impossible to achieve when working across four acute sites. Working across two sites with the European working time directive in force will still be a challenge, but it is more doable than four sites.

Mrs Hanna:

Are you putting down markers about the acute sector, which probably has to happen?

Ms Evans:

We are going further than that. We will bring forward recommendations to move on Whiteabbey within the CSR period. For a number of reasons, we will continue our attempt to maintain the Mid-Ulster Hospital for as long as we can. We have listened to the consultation process, and there is no doubt that there is a very strong concern in mid-Ulster. I had a conversation with a Committee member about Tyrone the last time I came.

There is a very strong sense in the population in the middle of the Province that they are a long way from acute hospital services. There is a very strong sense that the road traffic network is not good. People in areas like Gortin and Pomeroy are a considerable distance from an acute hospital, and there is a concern about the ability of the Ambulance Service to respond in a timely manner. There are also issues about the removal of A&E and the skilling-up of ambulance personnel to be able to provide treatment to patients before they attempt to stabilise them and transfer them to a distant location. We are very mindful of that.

Our principal difficulty, however, is that because the second phase of Antrim Area Hospital has not been delivered, there are not enough beds there to move on Whiteabbey Hospital and the Mid-Ulster Hospital without the new ward block. I will be honest with the Committee: maintaining services in the Mid-Ulster Hospital is becoming increasingly difficult. We have just received the resignation, through retirement, of a senior surgeon. At a public meeting in Cookstown on Tuesday evening last, I was advised that another surgeon requires medical treatment and is considering early retirement. That will leave us with one surgeon and a locum.

It is extremely difficult to recruit to those smaller hospitals. I know that people say that we do not put enough effort into it, but maintaining the A&E department in the Mid-Ulster Hospital is extremely difficult. Members will recall when it closed between 5.00 pm and 11.00 pm on three nights last year. There was considerable public disquiet about that, but the reality is that people are queuing at the doors of Antrim Area Hospital and the Causeway Hospital to be treated, while there are five or six attending the Mid-Ulster Hospital. Nevertheless, we have to have it fully staffed because it is open and has to be there for the public. Big decisions will have to be taken, but from a political point of view and a community point of view, it is an extremely challenging proposition.

Mr Buchanan:

You said that 179 residents would be affected by the closure of residential homes. In response to John McCallister, you said that care packages were not in place, and you mentioned developing schemes such as the Brook in Coleraine to cater for that. It is obvious that facilities such as that will not be in place before the end of the comprehensive spending review. If that is the case — and you said that none of the closures would take place until an alternative was available — are you actually saying that although there are proposals to close those homes, they will not fit into the comprehensive spending review period, because the alternative facilities will not be in place? I hope that I have taken that up correctly. Can you give us some clarification?

You gave us some background information on the Cherry Lodge facility, which caters for children. Quite a few people in the area have expressed concerns to me about that facility, and about proposed closures. The equality impact assessment (EQIA) has been completed, but people have said to me that it has been put out in order to equality-proof the proposals that are already on the table to close Cherry Lodge. Consultation has not been effective in this case; the EQIA has been used to equality-proof proposals to close the facility, meaning that the consultation has been a farce. Perhaps you could expand on that.

I am glad that A&E services at the Mid-Ulster Hospital are continuing for a little while longer, because of the situation in West Tyrone. You mentioned the people from Gortin and Pomeroy who use that service. I am glad that you have admitted what we have been saying in West Tyrone for years: that people are so disadvantaged by the removal of acute services from Tyrone County Hospital. I am glad that someone has admitted to the plight that people in that area have found themselves in. I am glad to see that that is being retained, and I hope that it will be retained for a little longer.

You mentioned difficulties with the recruitment of staff. What about the issue of networking? I hear much talk about networking between Altnagelvin Hospital, the new Omagh hospital and the new Enniskillen hospital, but it is only talk, not action. What about actioning networking in your trust area between Causeway Hospital, Antrim Area Hospital and the Mid-Ulster Hospital? That should help to provide the necessary staff that are required to run the A&E ward at Mid-Ulster Hospital.

Dr Flanagan:

Your question is about using networking to help to staff the A&E department. We have tried networking between Causeway Hospital and Mid-Ulster Hospital on the basis that, as you mentioned, a hospital can be part of a bigger team. We have found that difficult. We recruited some staff, but they have now left again. That remains a challenge.

It is also important to remember that, although staffing is a big issue for the A&E department, that is only one part of a hospital. For an A&E department to work effectively in the care of acutely ill people, backup services are needed — specialist teams, specialist X-ray facilities and an intensive care unit.

The quality concern is that, if people are brought to the A&E department of a small hospital that does not have the backup facilities, precious time might be lost that could have been better spent bringing them directly to a bigger hospital that has all of those facilities. That goes with what Ms Evans said about the Ambulance Service. We are all extremely sympathetic to the gap in the middle of Northern Ireland, which you and Ms Evans mentioned. Our trust is working with what has been set out to deliver better services.

Mr Buchanan:

In this case, unfortunately, developing better services has left a black hole in Tyrone.

Ms Evans:

At the public meeting that we attended on Tuesday evening, a gentleman brought a map to show us that all the hospitals were on the periphery of the Province. He proposed that Causeway Hospital and Antrim Area Hospital be closed and that a new 700-bed hospital be built in Cookstown. We had to explain to him that, although we could understand his logic, and we did not disagree when he assured us that Cookstown is the centre of the Province —

The Chairperson:

Did he have an anorak and open-toed sandals?

Ms Evans:

No, he did not. He was making a relatively serious proposal, and we had to point out that we are mere public servants. If someone in a higher position were to make that decision, we would co-operate fully.

Miss Scott:

The figures that I quoted were for the total number of places across the five homes that we are discussing. We realise that it is very ambitious to replace five homes. As Ms Evans said, it is likely that, following consultation and the dismay that some people felt at the proposals that we put forward, we will not move with the five, although those people are now coming on board as they understand what we are talking about.

We are working, developing and building up the domiciliary care packages in the community. We have come a long way with our commissioner in at least recognising the demand and what we need. We will spend the same period of time working with the commissioner to ensure that we get the funding to meet that demand. A couple of programmes are working together, but we have been reassuring people that we have no intention of closing our current homes until replacements and re-provision of services are in place. We will do that in partnership with the people.

Mr Buchanan:

I am informed that Cherry Lodge can take emergency cases if it is required to do so. However, that provision will not be in place should Cherry Lodge close.

Ms Evans:

No. That is not accurate. Cherry Lodge is in a housing estate in Randalstown. It has three beds, two of which are operational. If children are booked into those two beds and someone has an emergency, Cherry Lodge does not have the capacity to accept them.

The amount of money that closing Cherry Lodge would potentially save is actually relatively modest. As a professional who worked in learning-disability services for virtually all my life before I became a chief executive, I genuinely believe that we could give flexibility and opportunity to families if they would work with us to develop trust. It is about trust and about fear — it is about very precious young people who are very dependent, and about families, in many cases, having to go through a pain barrier in trusting a school to look after them or trusting staff in a hospital to look after them, and equally in Cherry Lodge.

At the moment Cherry Lodge can accommodate two people at any one time — hopefully that will soon be three. If 12 salaried foster parents were recruited, 12 young people could be accommodated in those different foster homes on any one night. Furthermore, the way the scheme works in the Causeway Hospital is that the families are linked, so that, for example, one foster carer might offer respite to perhaps three different families. We would agree with them what the requirement for respite was, and then, as they do in Causeway, leave them with a degree of flexibility about how and when they use it. At the moment, if mum takes ill, she is heavily dependent on there being an empty bed in Cherry Lodge. If she had a linked foster carer she could ring that foster carer and tell them that she had a cold, or a chest infection, or vomiting and diarrhoea — whatever — and ask if there was anyway that they could help out. That could be done on an individual host family-to-family basis.

It is certainly not without challenges or issues. There are issues about modifying buildings in some cases if an individual child requires those modifications, perhaps for lifting and handling, toileting or bathing, or even for going to bed. However, it is being done. Some schemes have been developed. We sent some staff to Nottingham, where there is quite a sophisticated and well-developed scheme that is working extremely well. Thought must be given to insurance, vetting, and training.

The proposal is for the trust to recruit the foster parents, who would be salaried employees of the trust. That would be an important difference; the current foster carers are paid an allowance for working on behalf of the trust, but those will be permanent staff of the trust. There should also be a small support team, which would include two or three healthcare assistants. If, for example, there was a child who was perhaps very frail from a medical point of view, and the family felt that they needed 24-hour waking care, that care assistant could provide that overnight while the foster parents take their normal rest, before resuming caring the next day.

It is challenging. We are not saying that it would meet the needs of absolutely every child, but the experience elsewhere is that it meets the needs of the majority of children. The trust will continue to provide residential respite in Whitehaven in Whitehead, where there is an eight-bedded unit, and at Rainbow Lodge in Ballymena, which is run by a voluntary organisation. It will be a case of trying to develop a service and wind down the existing service, because the building is genuinely not suitable for the purpose, but it provides a fantastic quality of care, and we understand that.

The Chairperson:

I knew that my colleague would not fail me by bringing up Omagh at some point in the deliberations, and he has not let me down.

Ms Evans:

I was not expressing an opinion; I was reporting opinions that have been presented to us.

The Chairperson:

That is noted. Thank you very much for your attendance today.