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 Martin Dillon )
Mr Colm Donaghy ) Southern Health and Social Care Trust
Mrs Mairead McAlinden )
Dr Gillian Rankin )
The Chairperson (Mrs I Robinson):
I welcome Colm Donaghy, chief executive of the Southern Health and Social Care Trust, Mairead McAlinden, director of performance and reform, Martin Dillon, director of finance, and, last but not least, Gillian Rankin, director of older people and primary care.
Mr Colm Donaghy (Southern Health and Social Care Trust):
Thank you very much. We are delighted to be here to make a presentation.
The Southern Trust has, quite deliberately, set its requirement for efficiencies in the context of its strategic direction. It is a journey of improvement. As we improve services for patients and clients, we are also very conscious of the need to provide efficiencies. There is an alignment between the requirement to deliver efficiencies and the duty to improve care to patients and clients. Hopefully, we will demonstrate that this afternoon.
The approach of the trust is to have a strategic alignment, with clarity for the local population and for people who have a stakeholder interest in the trust’s services, to ensure that the direction in which the trust is moving is clear to them. The trust has a three-year development investment plan, and has gone to public consultation with its five-year strategic development plan. I know that that document has been shared with members of the Committee. It outlines the impact of the changes in trends in service provision, and also, therefore, the areas that require formal consultation — that consultation is currently taking place.
Resulting from the strategic direction, there are a number of changes that need to take place — and change is never easy. In the environment of health and social care, change is not an option but a necessity. That is apparent from the way in which drugs and technologies are changing, as are trends in the provision of care. Change will be with us in the future. We want to ensure that that change is positive for the people of the Southern Trust area.
By way of context, the Southern Trust employs 12,000 staff, has a turnover of £420 million, and delivers care to a population of 343,000. It also delivers care to a wider population in mid-Ulster and the west, particularly maternity services, for example. The population of the Southern Trust area is growing exponentially. In the last 10 years, for example, the census information shows Banbridge to have been the fastest-growing town in the UK, if not Europe. That is a reflection of the population of the Southern Trust area generally.
I will set some context in relation to those demographics. At times there is a lot of talk about the capitation formula as people perceive it. We consider it as fair shares. At the moment, the Southern Trust area does not receive its fair share of the resources required for the population. The Department has given an undertaking to move closer to allocating that fair share of the resources that we require to deliver care for our population, and that is happening over the next two to three years.
The number of births in the Southern Trust area has increased exponentially, and we have a rapidly growing older population.
The Chairperson:
Can you give me a ballpark figure for the differential?
Mr Donaghy:
Certainly; there has been an increase in births in the Southern Trust area of between 17% and 20% over the last four to five years. For example, Craigavon Area Hospital, which four or five years ago delivered 2,800 babies, is now delivering 3,900. There has been a big increase in the number of births.
In having a relatively young population, we have the biggest potential to have a rapidly growing ageing population. A lot of the population between the ages of 60 and 75 are now moving into the higher age brackets. What is well established in research is that the two parts of the human life cycle that require most investment are very early, as children, and as older people. We believe that that is a reflection of the capitation formula in our fair share of resources.
It may be of interest to Committee members to examine the Department’s published reference costs, which measure the efficiency of acute hospitals in each of the areas in Northern Ireland. Those reference costs currently show that, in the Southern Trust area, we have the most efficient acute hospital system of any of the five trust areas in Northern Ireland. That is in the context of our striving to deliver a 3% cash-releasing efficiency. There is an argument that there is a need for a differential in efficiencies, but we will still strive to deliver a 3% efficiency, or 9% over the three years.
The review of public administration, as members are aware, has entailed the amalgamation of the four trusts in the Southern Trust area into one. We have to find £6·1 million of reduced management and administration costs over the three-year comprehensive spending review period. We are well on our way to doing that. The £6·1 million is a reduction around bureaucracy, management and administration costs in the new organisation. We have shared the reform, productivity and efficiency plan with Committee members. That identifies £15·3 million in efficiency savings, and there are 33 specific projects within that plan, some of which I am sure you will want to discuss.
We have initiated a best-care, best-value approach in our organisation. What we mean by that is that we have a belief in our organisation that the two groups of people who can tell us the most about what we can do differently or better are the people who receive our services and the people on the front line. They can tell us how to improve those services in order to make them even better. We have decided, through the best-care, best-value campaign, to engage more closely with those two stakeholders to ensure that they inform us much more about what we can do differently. That process is under way, and is bearing fruit for the organisation.
Finally, we have an underlying deficit, which is made up of the cumulative deficits for the four legacy trusts that existed prior to our establishment. We estimate that deficit to be around £7 million. In total, over the next three years, we reckon that our requirement is £43 million in cash-releasing efficiency. That will be extremely challenging for us. We believe that it is a challenge that we, as an organisation, are up to. It is one that we believe that we can put in place in the context of the right thing to do and the proper strategic direction for our organisation.
In the vision that we, as an organisation, aspire to, the first priority for service change is providing safe, high-quality care to the right person in the right place at the right time. Own-front-door solutions and independent living is another issue that runs across programmes of care for us; from children to older people to people with learning disabilities or mental-health problems. People tell us that, as much as possible, they would prefer to have their own front door as a solution — with the provision of proper support — rather than be in an institution.
There is also the issue of earlier intervention and prevention, and a healthier population. We have organised ourselves on a programme-of-care basis. As an example, the director of our children and young people’s directorate is a social worker. He manages paediatrics in the hospital, child-health services and child care and protection. He manages across all of those disciplines, and we believe that that gives us a much more external-facing purpose. In other words, we can work more closely with sectors such as education in areas such as obesity. People’s well-being is also extremely important to the trust.
The next issue is expert patients — people empowered to manage their condition. With the investment that will be made in chronic disease management and the use of remote technologies over the next few years, we believe that we can put in place many solutions that people can use to manage their conditions. Those solutions will enable patients to be much more comfortable with how their condition is managed, because, potentially, they will not require hospital admission over time.
Two aspirations that we will strive toward in order to deliver care are to listen to the voice of the users, who drive what we do, and to develop partnerships in care. We have put in place a number of processes to ensure that that happens.
Dr Gillian Rankin (Southern Health and Social Care Trust):
About 12 months ago, the trust set out to engage with older people to find out what they seek from our services. Their comments became clear drivers for change. Using best-practice methodology from the NHS in England, we set up focus groups comprising small numbers of older people from across the geographical area of the trust, and facilitated discussion around a whole range of issues — where people see themselves in the future, housing options and care options.
Unsurprisingly, the focus groups consistently said that they want to live independently and to maintain control of their environment and their living. They said that they want to live with, or close to, their family and among their communities. They also said that they want the right support at the right time, and they want to maintain their capital asset.
The second series of drivers for change which come into play at this stage are the significant investments that the Southern Trust has made in community services over recent years, and those which it will continue to make under the new health and well-being plan into next year.
We have developed intermediate care services — specific services to support people and their rehabilitation at home on discharge from hospital. We have increased home care and respite and carer support for people who remain at home. We have examined increased housing options, such as the supported housing care scheme in Banbridge. We have also examined a range of specific service developments, such as chronic disease management for people who have chronic obstructive pulmonary disease or heart failure; palliative care to support people dying at home; community dementia services using technology to remotely monitor people at home; and a range of service developments that are happening, and which will continue to happen with further investments.
As a result of that, we undertook a review of the need for residential care and found that there was a reducing need in both the statutory and independent sector. There were clear indications that the number of people seeking to go into residential care has fallen over the years. Places are available, and nothing has changed in the system, but people are choosing to stay at home longer, particularly when they have 24/7 home care support. People want own-front-door choices. They want to move into sheltered accommodation, or supported housing schemes. The Committee will be familiar with the Northern Ireland Housing Executive’s ‘Older People Housing Policy Review Action Plan 2008-10’, which was published in June 2008. The action plan recognises the need for more housing-with-care options and the need to examine the concept of retirement villages in Northern Ireland.
Our proposals for change are predicated on the fact that a reduced number of people use our statutory residential homes. That number has fallen from 132 people to an average of 108 people. Today, there are only 102 people in our five homes, and we project a much lower rate of admissions to our residential homes this year. Some 63% of the people in our residential homes have the same level of dependency as people whom we support at home through domiciliary care, and 25% have equal dependency to those who are in nursing homes.
We also are mindful that the Department of Health commissioned the ‘Audit of Statutory Residential Homes for Older People’, which raised the issue of value for money as regards the comparison of costs between the statutory and independent sectors. The report clearly recognised that supported housing and domiciliary care are robust alternatives to residential care.
At present, therefore, the trust proposes to close two out of its five homes. That will leave one home in each of the three localities for the trust. If the proposal to close goes ahead, it will impact on 30 residents; 18 residents in one home and 12 in another. Both of those homes are significantly underoccupied.
The second proposal for change is in relation to non-acute hospital care. There are three locations for non-acute hospital care in the Southern Trust area: Mullinure in Armagh, Lurgan Hospital and South Tyrone Hospital. With the development of intermediate care, which provides rehabilitation at home following hospital discharge, we have seen a complete change in the process of hospital discharge. Gone are the days of people waiting to get into hospital — trolley waits — because beds are being used by people waiting to be discharged. Those are a thing of the past. With the build-up of services to support people at home, stays in hospital are much shorter in length. Therefore, there is a reduction in the use of non-acute beds and there are shorter lengths of stay. Continuing investment in domiciliary care and chronic disease management teams means that people can be sent home earlier when they are medically fit; they do not need to stay in hospital for quite the same length of time, as support is available on a daily basis at home.
We have witnessed a significant decline in occupancy in non-acute hospitals, particularly at the Mullinure site; in that small hospital, on any day over the past year, only 19 beds out of a total of 36 beds have been occupied. That is due to shorter lengths of stay and the services available to rehabilitate people at home. In its commissioning intent, the Southern Health and Social Services Board quite clearly seeks to continue to invest in community services to ensure that people can be independently rehabilitated at home, and, therefore, the number of non-acute beds will be reduced. There is an expectation of a further reduction in non-acute beds over the next three-year period.
Through the trust process, our proposal is to reduce the Southern Trust’s non-acute beds from three sites to two sites. We have looked at a range of issues; however, given the significant underoccupancy at Mullinure, the option appraisal has brought forward a consultation on the closure of Mullinure as a hospital for the assessment and rehabilitation of older people. The 18 beds at the Mullinure site would be relocated to the South Tyrone Hospital so that all of the non-acute beds for the Armagh/Dungannon locality would be located there.
Of course, we will continue to provide a range of outpatient, day-hospital and rapid-access assessment clinics for older people at the Mullinure site in Armagh, with a view to developing it as a specialist outpatient centre, thus maintaining a focus and providing easy access for ambulance services in the area. We propose to use the inpatient ward accommodation as a replacement for the dementia assessment unit, which is currently in St Luke’s Hospital on the same site in Armagh. Those are the proposals for older people within the Southern Trust area.
Mrs Mairead McAlinden (Southern Health and Social Care Trust):
In the interests of the Committee’s time, I will be brief in outlining the proposals for children and young people, mental health, learning disability and acute services. My colleagues have already outlined many of the strategic themes, and our proposals in the areas I mentioned are entirely in line with the strategic direction of developing preventative services, focusing on early years, further development of family support services and specialist services, and improving child protection. Over the last three years, £6·5 million has been invested in those services, and that investment has and is bearing fruit. Plans have been agreed with our commissioner for a further investment of £2 million over the coming three years in child protection services and services for young people. That is our strategic plan.
That has allowed us to look very critically at how we currently use the residential care sector for children and young people. The investments and service developments that we have made have already resulted in a reduced demand for short-term assessment. There are a range of alternatives available which are working very well. We have seen a reduction in the usage of our two homes; there are 15 available places and the average occupancy is nine. Therefore, the trust has put together a proposal to redesign its statutory residential care provision for children and young people, and the future model is included in our submission to the Committee. We propose to have 18 long-term places, split over three homes, with one home in each of our localities across the trust area. In Lurgan, there is already an area-wide intensive support unit, which is working extremely well, and we propose to locate a short-term assessment unit in Drumglass in Dungannon. That will result in the cessation of residential services at the Edenvilla statutory residential home in Banbridge. With our stakeholders, we are exploring the potential future use of that facility. We have engaged with a range of stakeholders on those proposals, and we have met directly with representatives from Banbridge District Council. It would be fair to say that the proposals are largely supported.
The mental-health and learning-disability proposals are entirely strategic and linked with the Bamford recommendations. Our strategic direction brings forward many of the Bamford recommendations. We have had a significant investment in mental-health services over the past three years — somewhere in the region of £4 million. That has allowed us to develop a wide range of services as alternatives to hospital admission. We have our home treatment and crisis response services, which are working extremely well. Through our strategy, we have brought forward proposals for a new model for mental health. The focus of that new model includes a strand on rehabilitation and recovery.
We plan to extend our home treatment services, extend our day hospital provision with new day hospitals in Dungannon and Craigavon, and invest £1 · 25 million in primary mental-health provision. That historic investment, and the planned investment, is continuing to reduce our hospital admissions. We are on target to meet the ministerial requirement to reduce hospital admissions in mental health by 10%. Our plans are in line with Bamford, and they are also in line with the Southern Health and Social Services Board’s strategy and that of our commissioner, and we intend to reduce the number of beds to 94 by 2011.
Our plans have been enabled by the new development at the Bluestone unit in Craigavon Area Hospital, which has been visited by some Committee members. It is an impressive facility, with an investment of £14 million to provide a higher quality of service. We plan to centralise our mental-health acute psychiatric intensive care, functionally mentally ill, and addiction services on that site. We have made proposals to the Department for an enhanced capital of £6 million to facilitate the centralisation, and we have had a favourable response.
The resettlement proposals for mental health and learning disability set out in the strategy need no further development to Committee members. You said this morning that you had visited facilities where a hugely enhanced quality of life was available through the supported-living schemes. Our mental-health and learning-disability proposals for resettlement have been set out in our strategy, and they will impact on the number of wards in Longstone Hospital and St Luke’s Hospital on the Armagh site. Armagh City and District Council has raised concerns about those proposals. However, we feel that they are the right thing to do, and they are in line with Bamford. Again, through our consultation processes, there has been little negative reaction to them.
Our strategy for acute services is one of consolidation and expansion of our hospital network across Craigavon Area Hospital, Daisy Hill Hospital and South Tyrone Hospital. Our express intention is to provide safe, high-quality care in all of those facilities. We have had an ongoing programme of development of acute services. We have introduced new trauma and orthopaedic services, we have our cancer centre and we have expanded our ophthalmology services. The chief executive has already referred to our expansion of maternity services.
We are providing local services to populations who previously had to travel to Belfast and other areas, and that service has been well received by the local community. However, it has put pressure on our hospital facilities and the fabric of the buildings. We have site development plans in place with the Department for an investment of over £100 million in Craigavon Area Hospital and £54 million in Daisy Hill Hospital.
Since the inception of the new trust, we have had particular issues around access to car parking. Mr Gardiner and others have raised that issue with us directly, and have helped us to lobby the Department to attract new money for investment. We have been fortunate in receiving around £1·5 million to expand car parking, which will address issues of safety and site congestion. The trust has developed a traffic-management strategy which sets out our intentions to provide safe, secure and accessible car parking and, in line with the Minister’s review of car parking, to recover the costs to the trust of providing it. We have a public consultation on an equality impact assessment on our charging policy, and we trust that that will allow us to ensure that we introduce a charging regime that does not place financial hardship on any vulnerable group. For example, 85% of people who visit our hospital sites stay for less than two hours, for which the maximum charge is £1.
Mr Donaghy:
The next steps are out for public consultation, particularly on those areas that require formal consultation. That consultation process ends on 6 March. A trust board meeting will take place on 26 March to take account of the outcome of the consultation, and decisions will be made on the proposals that are in the public domain.
The Chairperson:
Thank you very much for those comprehensive presentations; members will wish to tease out some of their concerns. Given the nature of today’s discussions and our location, what additional provision is to be put in place for adults with autistic spectrum disorder (ASD) and Asperger’s syndrome? We are well aware that the adult population in particular seem to disappear into a black hole when it comes to backup services. What targets have you set in order to ensure that that does not happen?
Mrs McAlinden:
We have had detailed discussions with our commissioner, the Southern Health and Social Services Board. The Southern Board and the Southern Trust were among the first bodies to develop autism services for early intervention, and we wish to build on that provision. We have recognised, as has our commissioner, that to focus on children with autism does not cover the full range of people affected by the condition, so our plans extend into adulthood and cover the transition into adulthood. We are finalising those detailed plans with our commissioner and they are reflected in the commissioner’s plans for the next three years. We are happy to release the details of those plans to the Committee over the next month.
The Chairperson:
That will be most helpful. What contact do you have with Autism NI and autism initiatives? Are you working hand-in-glove with voluntary-sector providers?
Mr Donaghy:
Yes, we are. I have personally been in contact with Autism NI and have met staff on several occasions. This year, £300,000 will be invested in ASD in the Southern Trust area; the plans for that investment will take account of the adult population, of which we are conscious.
We invested in the diagnostic stage of autism services a few years ago, and put in place a much better diagnostic service. We found that it was fine to diagnose, but the difficulty lay in co-operating with, for example, the education and library boards. We now have a closer relationship with those bodies. On the one hand, we identified people with autistic spectrum disorder, but, on the other hand, resources were unavailable in other sectors to deal with the diagnoses that we were making.
The Chairperson:
I said earlier that the situation is more complicated because it straddles the Department of Health, the Department for Employment and Learning and the Department of Education, and it is always much more difficult to get a consensus. However, I appreciate the response — later on, I will ask the people at the back if they are satisfied with that response.
You mentioned services for the elderly. I am concerned that there does not seem to be any provision for people to stay at home and keep the capital investment of their homes and a roof over their heads. I do not want to see that being the underpinning factor in keeping people in their homes. We hear frequently that not enough community care packages are available, and, as you said, the number of people who are moving into the older age bracket is rising. Eventually, no matter how much people want to stay at home, it becomes impossible. My concern is that we will close residential nursing homes too quickly, to the point at which people struggle to find accommodation that is suited to their needs in their old age.
Mr Donaghy:
You are quite right. There will always be a requirement for some form of institutional care, whether that is nursing care or other types of care. Our proposals do not impinge in any way on the volume of nursing care that the trust will continue to provide. However, as a reflection of the increased investment in community care, less residential care is needed. We are not saying that it will not be required at all in future. In fact, there are still well over 300 places for residential care in the trust’s independent sector, and in the statutory sector there will still be three homes to provide that level of care.
I agree that, in future, the better form of care for people will be supported housing, as the Committee experienced this morning, through such things as health villages. The trust has been encouraging the private sector to enter that market. It is very difficult in the current economic environment, but we have had discussions. People who currently have an investment in their home, rather than having to sell that home to go into institutional care, would be able to sell their home and buy another in a retirement village. That would mean that they still had an asset and an investment, but would have further support provided in that retirement village. The concept of retirement villages has taken off in other parts of Europe and the UK, but has not really done so here. We have done some initial work with the private sector.
Supported housing in the statutory sector requires the support of the Department for Social Development’s (DSD) Supporting People funds, in relation both to the revenue and the capital that might be required. We know the position of the public sector in relation to funding — DSD is not currently flush with money. We must think creatively about how to find the funding to deliver the supported housing of the future. There are ways of doing that, such as, for example, bridging funding, which would allow that transition to take place. Then, over a period of time, after the bridging funding had run out, either DSD or the efficiencies that we make could pay for long-term care for older people in future. We are considering a range of options.
I should also mention that the proposals that are in the public domain are most difficult for those people who are currently in residential homes in the Southern Trust area. When we go through a process of change, those most affected are the people in the areas affected by the proposals. If the trust board does make a decision on 26 March, the trust will ensure that, if the proposals take two years to implement, it will take two years. We want to be sensitive to the needs and requirements of our current residents. With the investments that the trust has been making, and the alternative care that it can provide in, for example, the independent sector in those areas, it will be able to cope with that in the future.
Dr Rankin:
There are over 350 places in the independent residential sector in the Southern Trust area, and there is no proposal to diminish that. There are some 1,750 people in nursing-home care in the Southern Trust area, and we are not proposing to have any impact on that at all. The closure of two homes is a relatively small impact in regard to the overall number of places.
It is also important to recognise that for several years now there has been no delay or waiting list for community care. That is partly because of the intermediate care service, through which people are supported at home and the care management process occurs outside of hospital. There is time for that to happen, rather than the process of assessment and the decision on long-term placement being taken in the hospital environment.
It is important to illustrate to the Committee the work that we have been doing in seeking to create alternative housing choices for people. We recognise that as yet in Northern Ireland there are no retirement villages, but there are in England, in the South of Ireland, in Australia and much farther afield. We felt that it would be useful to take a market sounding, so an open day for any interested developers or landowners was held last June, and we received a very interesting response — there were over 40 interested parties. The trust is now actively working with nine organisations. Some of them have a track record in providing housing; some do not, but are interested in learning. We are working with them in order to make sure that they understand the standards of housing and the concept of homes for life.
If someone is seeking to move out of a large house at 65, 70 or 75 years old, they may want to move into their own environment, yet ensure that they do not have to move from that if they become frail and need mobility aids. Therefore, there are certain standards. People might develop cognitive impairment. There is now much knowledge and information on design standards for people with dementia. We are working actively with a range of developers and making them aware of that information. Nothing is yet secure in that environment, but some parties are interested in considering how the marketplace can provide alternative homes for older people to purchase so that they can remain in their own environment. Thereafter, the trust could provide the care or commission another provider to do so. We hope that that route will provide solutions for older people in the Southern Trust area.
The Chairperson:
That seems a logical approach, and many such models have been successful in America.
Mr McCallister:
I live in the Southern Health and Social Care Trust area, and I am worried to hear that we are not receiving our share of resources — a situation that is usually more associated with the Western Trust. We need to examine that, and it is our responsibility to press that matter, given the growing population in the trust area. People are concerned about legacy debt, and earlier this week the Assembly debated the problems in the Western Health and Social Care Trust.
As you have said, the major concern is managing the change. I congratulate you on the fact that hospitals in the Southern Trust are more efficient. We should be proud of that achievement. However, that leads to another difficulty, because the more efficient the trust is, the more difficult it is to achieve the 3% efficiencies.
The Chairperson mentioned residential homes. I am concerned about Skeagh House in Dromore and, particularly, Slieve Roe House in Kilkeel. The geography of the area is of huge concern to residents and families there. There are concerns about the meaningfulness of the consultation, the equality impact assessment (EQIA), some of the rationale that has been used and the practicalities of moving people from that area to locations such as Bessbrook. As the Chairperson said, we must ensure that care packages are available. People have raised concerns with me that the system for remote monitoring of patients has not bedded down particularly well. I want you to comment on those issues, which are of serious concern to people in the Southern Trust area.
Mr Donaghy:
I am satisfied that the Department is taking steps to ensure that, over an incremental period, the Southern Trust and the southern population receives a fair share of funding. The funding for the Southern Trust area will be drawn from finite resources that must come from somewhere else. We must make difficult choices. However, the fifth review of the capitation formula is the most sophisticated formula in Europe for allocating funds. The fair-share issue will always arise, but, at this point, I am content that the Department is addressing the incremental move towards fair allocations.
Mr Gallagher:
Are you happy with how the capitation formula works?
Mr Donaghy:
I am content that the capitation formula allocates funds as fairly as possible. The fifth review has identified the population in the southern area as being well short of its fair share. The Department has come up with incremental proposals to address that, and I am content that those proposals will assist us in beginning to meet our fair share of resources. We have carried out equality impact assessments on all of the proposals, including Slieve Roe House and Skeagh House, and they are in the public domain. We had a pre-consultation on the equality impact assessments prior to going out to formal consultation, which gave people an opportunity to comment.
Moving people from Slieve Roe House to Bessbrook was mentioned. Dr Rankin has maps that she will share with the Committee. The nearest statutory residential home that we own is in Bessbrook. However, there are other residential homes, for example, in the independent sector, which are much closer to Slieve Roe House as an alternative, rather than people having to move to Bessbrook. Other alternatives are available. As Dr Rankin will explain, not all the people in Slieve Roe House are from Kilkeel, and not all of them require residential care. For example, some people require nursing care: therefore, the alternative nursing provision that will be provided is also important.
The Chairperson:
You seem to be relying quite a bit on the private sector.
Mr Donaghy:
The independent sector has availability and vacancies in the Southern Trust area to be able to provide alternative care for residents.
Dr Rankin:
Only the independent sector will provide nursing-home care. There is no statutory nursing-home care.
Mr McCallister:
Can the independent sector provide a cheaper service per head?
Mr Donaghy:
We plan to take our time in implementing the proposals. If they go ahead, there will be a net saving to the trust of £590,000 after we net off the costs of alternative care for our residents.
Dr Rankin:
As Mr Donaghy said, the map illustrates that the nearest statutory residential home that the trust provides is in Bessbrook. However, there are nursing homes with dual registration and residential beds in Kilkeel, Rostrevor and Warrenpoint. There are 12 permanent residents in Slieve Roe House, and we are seeking to reassure those residents. Some of them may find that a nursing-home place may be more appropriate for their needs when, and if, we come to a point of assessing their needs and discussing the choices and options for their alternative placement. However, Bessbrook is not the closest. There are many homes that can cater for significant numbers. As of today, places are available in those homes. There are 12 residents in Slieve Roe House, and we are keeping a close eye on the vacancies in the surrounding homes in both areas and tracking the trends. If we need to have a discussion with individual residents and their families, we will be aware of what places are available as alternative choices.
Mr McCallister:
Residents in Kilkeel may be concerned that if Rostrevor, as the closest alternative, is not available, every other home is almost 20 miles away. Rathfriland and Warrenpoint are almost 20 miles away and Newcastle is approximately the same distance away.
Dr Rankin:
There is a large nursing home in Kilkeel.
Mr McCallister:
The road structure and the distances that loved ones will have to travel are a big concern. One has to take into account the geography of the area with the mountains and the sea, and the three roads in and out of Kilkeel.
Mr Martin Dillon (Southern Health and Social Care Trust):
None of our legacy trusts ever ran up a deficit. Mr Donaghy was referring to the fact that we do not have recurring funding in place for a number of the services that we provide, particularly in domiciliary care and high-cost packages. However, we continue in dialogue each year with commissioners to try to cover that. That is the £7 million that Mr Donaghy referred to. None of the southern area legacy trusts ran up a deficit on the scale of the Sperrin Lakeland Health and Social Services Trust.
The Chairperson:
You have to sell it. [Laughter.]
Mr Easton:
For once, I concur with John McCallister.
The Chairperson:
Are there two suns in the sky? [Laughter.]
Mr Easton:
I lived in Kilkeel for a short period when I was younger. It is quite a distance away, so I urge you to be careful on that one.
I am impressed that the Southern Trust’s hospital services are the most efficient of any trust, and your proposals for efficiency savings are probably not as harsh as those of other trusts. I spoke to you about nurses a few minutes before we started. However, I was confused by something that I read in your briefing paper, and I hope that you can provide clarification. Your trust is getting rid of 488 nursing posts but estimates that it will create 499 posts, which is good news. The paper also mentioned that there will be a reduction of 116 in mental-health posts; are those 116 jobs on top of, or part of, the 488?
Mr Donaghy:
Those 116 jobs are part of the 488 jobs that will be lost.
Mr Easton:
Given that you will ultimately be getting more nurses, would it not be possible to move nurses rather than getting rid of nurses and reappointing them?
Mr Donaghy:
Absolutely; redeployment is one of the tools that we can use in managing the process. However, it is easier in urban areas, because people can be redeployed within a short distance. The Southern Trust covers a largely rural area. It would be unreasonable for us to redeploy someone who works in Kilkeel, for example, to a vacancy in Clogher Valley.
The Southern Trust has a considerable number of staff who are over the age of 55, particularly in mental-health and disability care, which is primarily based in Armagh. Those people will qualify for voluntary early retirement or voluntary redundancy, and some will not want to redeploy. We would like to be able to give them that option, and that is another leg of the stool of the management process.
We will maximise redeployment where possible. However, given the age profile of some of our nursing staff, the process is also about enabling people to take voluntary early retirement.
Mr Easton:
Am I correct that your trust will not be affected by the 722 nursing posts that are to go across the Province?
Mr Donaghy:
No, we are affected by that. For example, we have proposals to resettle some people with learning disabilities and mental-health problems out of long-stay institutions. Therefore, some nursing posts will not be required in future. However, the posts that we are creating are a different type of community post. We hope to re-skill and develop staff who are currently in the long-stay sector so that they can be redeployed in our new community sector.
However, that is difficult in some cases. For example, we recently opened a respite unit for learning disability in Dungannon. We deliberately did not advertise externally for staff for that respite unit because we wanted to redeploy staff from our organisation and give staff in long-stay institutions the opportunity to work in that setting. That was successful in that some staff did redeploy. The long-stay posts are not required and will go, but jobs for those individuals will remain.
We want to ensure that people who want to continue to have a job in our organisation continue to have a job. However, some of the posts that they previously occupied in our organisation will no longer exist. We want to use the tools of voluntary early retirement, voluntary redundancy, redeployment and turnover to manage the process in such a way that we do not have to make any compulsory redundancies for staff who will no longer be required in the posts that they currently occupy.
Mr Easton:
In the Southern Trust, 30 residents are under threat of being moved from their residential homes. Are you confident that you will be able to provide those people with suitable accommodation elsewhere?
Dr Rankin:
Yes, I am confident about the number of places available, which we will project into the one- to two-year period which Mr Donaghy mentioned. We will have sufficient places in the independent residential- and independent nursing-home sector in both those environments.
Mr Easton:
If the Minister does not like your plans, do you have a plan B?
Mr Donaghy:
Yes. I mentioned our plan B earlier. The trust has an ongoing initiative called best-care, best-value, where we engage directly with the staff and the people who use our services to help us to identify other forms of efficiency.
The Chairperson:
If you can identify further efficiencies in a plan B, you are leaving yourself wide open.
Mr Donaghy:
I am. I said that it will be extremely challenging over the three years. If some of the proposals did not go through, then in an area identified in the best-care, best-value initiative as needing to find £14 million, it would increase to £16 million or £18 million in terms of the effort that we would have to put in with staff.
The Chairperson:
I will speak to my colleague about that later.
Mr Gardiner:
You mentioned two homes that you propose to close. What is the timescale for the closure of Skeagh House, which I visited about two weeks ago?
Dr Rankin:
We never proposed to close Skeagh House any earlier than March 2010. If there are issues that require the homes to stay open for a longer period, we will honour that. The issue is not about unsettling current residents. Fewer people are going into those homes, and we want to work with the residents to take their views in terms of options and choices.
Mr Gardiner:
You said that you do not want to unsettle the residents, but I visited Skeagh House two weeks ago, and I can tell you that the residents there are very unsettled. I was very impressed with the residents and with their comments about the home. In fact, I met a lady coming down a corridor who was totally blind, and the manager of the home told me that if that lady lived in a small house, she would be unable to walk around. However, in the home, she can walk around, as there are corridors. Furthermore, the home has the most up-to-date facilities for bathing patients. It is one of the better homes, and it has excellent car parking for visitors. There is space all around the home for walking, which is part of the cure.
I hope that you have second thoughts about the closure of Skeagh House. You will face a lot of opposition to its closure, and you will lose a lot of credibility. The home is only about 30 years old, yet you are talking about closing it. I am opposed to your recommendations there.
What are your future plans for Lurgan Hospital?
Dr Rankin:
Lurgan Hospital has 64 beds. It is an assessment and rehabilitation non-acute site. It contains a stroke unit, and, although there might be minor adjustment to beds in line with the Southern Health and Social Services Board’s commissioning intent, at the moment, we continue to need the non-acute beds in Lurgan Hospital, and we will continue to do so for the short to medium term.
Mr Gardiner:
Do you agree that there is space for additional beds to cater for more patients at Lurgan Hospital?
Dr Rankin:
Given the investment in community services that I have already talked about, and the continuing investment pattern, we are not clear that there is a need for additional beds in the non-acute assessment and rehabilitation function for older people, because so much of that is now happening at discharge from hospital and at home, with the intermediate care service and the development of chronic disease management specialist services. Therefore, there seems to be a reduction in the need for non-acute beds.
Mr Gardiner:
Lurgan Hospital could continue to perform minor surgery and things like that. The day will come when Craigavon Area Hospital will be unable to cope with the number of patients. It is a massive hospital, and it is a good hospital. There was a problem over the Christmas period, but I am glad to learn that there are now 12 new midwives in the maternity unit. I apologise for straying, but is that the quota for midwifery in that area?
Mr Donaghy:
Yes, that is the quota at the moment. However, our birth rate is growing exponentially, so we will have to continue to invest in additional midwives, and we intend to do so. We have made a proposal to the Department to expand the physical environment of the maternity unit. The difficulty is that only so many patients and staff can fit into the current environment. However, we have made a proposal to the Department to expand the physical environment. When that happens, we will also increase the number of staff in Craigavon Area Hospital.
Mr Gardiner:
That is why I am returning to the issue of Lurgan Hospital: there is space there that could deal with some minor operations, and that would open up more space at Craigavon Area Hospital, which is much busier. I do not want Lurgan Hospital to be closed, or Skeagh House either, so go back to the drawing board, please. I will speak to the Minister, no problem. [Laughter.] I have already spoken to the Minister.
Mr Donaghy:
I want to be clear; there are absolutely no plans to close Lurgan Hospital at all.
Mr Gardiner:
Will you add Skeagh House on to that?
The Chairperson:
Do not push it. [Laughter.]
Mr Donaghy:
In relation to the proposals that we have for non-acute care, Lurgan Hospital is one of the non-acute hospitals that we are consolidating care in for the long-term future.
The Chairperson:
One view that Mr Gardiner and I share is that, once a place like Skeagh House is targeted, the inevitable result is that it is like rats from a sinking ship: people will not consider it because of the high risk of it closing at some stage. Even if it is a long-term plan, it inevitably becomes a short-term plan, because there are not enough people going into it.
Mr Gardiner:
It is one of the updated homes that I have been in.
The Chairperson:
I understand. You have made your point very well.
Mr Gardiner:
People from my own constituency have visited Skeagh House, and there is an awful lot of unrest with the staff and the residents.
The Chairperson:
I think that the point has been well made; once a place is targeted, it starts to go into decline.
Mr Gallagher:
I would like to get your views on the development of sheltered accommodation or village-type accommodation rather than residential homes for the elderly. I notice that you have spoken to developers about that. The widening out of this discussion among all interested parties is to be welcomed.
How do you see this progressing? It is currently pretty difficult to get a package together. Could something be developed by a private developer, from which you could then purchase the accommodation and other facilities? You referred to the Department for Social Development; is it that Department’s role to fund the accommodation part of it?
There is an issue about your staff and skills mix. You propose to reduce the numbers of allied health professionals (AHPs) to a ratio of 80 qualified to 20 unqualified. Has that been discussed with your allied health professionals in the trust? Given, for example, occupational therapy and the needs of the elderly, it sometimes appears to those who need it that there is an endless waiting list. Have you checked that, by doing it in this way, you might end up with longer waiting lists than you have now?
Mr Donaghy:
You are quite right about the alternative care options and how those are put in place. There are two elements to developing those schemes. One is capital; the one-off capital that is needed to build the actual fabric of the building. The second element is revenue, and that concerns the care costs required in order to care for the people in those buildings.
The private-sector developments that we have been in discussions about are around the provision of the fabric. In other words, a private developer might take a risk and build a housing-with-care village on the basis that they will be able to sell it on the market. In the current economic climate, it may be more difficult to encourage private developers in. Several that we spoke to were quite encouraged to do so. It would be the builders who would provide capital for the development.
Subsequently, we would provide supported care to people in the health village. That revenue will be a mixture of residents’ and trust contributions, with the trust’s contribution coming from several sources, such as DSD’s Supporting People fund, which can be used to support people in their own homes. We are aware that that revenue source is constrained, and DSD and the Housing Executive have informed us that it has not been uplifted as result of the comprehensive spending review. However, there is potential to source revenue elsewhere, and that is why I mentioned the bridging scheme, whereby we would fund the change process until DSD could provide ongoing funding.
It is about having a source of capital to construct the fabric of the building — our own capital programme is very constrained — whether it is in the voluntary housing sector or the private sector, and a revenue source to support the care.
Dr Rankin:
The Department of Health requires us to achieve a balance in the ratio of qualified to unqualified AHP staff, and we can confirm that we will meet that target. In the past two years, the allied health professions have undertaken an important journey. As members will be aware from the performance management framework, the Department has set access standards for waiting times for all allied health professions. By March 2008, waiting times were to have been no greater than 26 weeks and, by March 2009, they must not be greater than 13 weeks. I am able to inform the Committee that, approximately four weeks ago, the full range of allied health professionals in the Southern Trust met the 13-week target. Therefore, no one waits longer than 13 weeks for a first appointment with any therapist.
That has been achieved through clear reform and modernisation approaches. We carefully considered the assessments and tasks that qualified practitioners undertake and the tasks that could be delegated, under supervision and training, to unqualified but competency-trained staff in the therapy department. A careful balance is required to ensure that we meet the population’s needs and that we reform, modernise and reduce costs in order to meet departmental targets.
Mrs McGill:
My question may have already been answered. I live in the Western Trust area. Mr Donaghy said that the financial deficit was a legacy of the rationalisation of the trusts. Mr Dillon said that there is no deficit; however, the other day in the Chamber, we had a debate about legacy debt. Your submission mentions an underlying deficit of £7 million. If that is not a legacy deficit, to what does it refer?
In light of this morning’s events, when we were informed about autism, I wonder whether you have had any engagement with Dr Clare Mangan. I sit on the Western Education and Library Board, and I am wondering about the depth, breadth and joined-upness of that engagement.
Mr Donaghy:
Dr Mangan is heavily involved, and has had ongoing involvement, with our staff in planning the trust’s investment profile for learning-disability services.
Mr Dillon:
Like all trusts, we do not have recurring funding in place for several services that we provide. Each year we might get non-recurring help from commissioners or from others to help bridge the cost of those services. That is what we mean by the baseline gap of about £7 million. There are services that we currently provide for which no recurring funding is in place. There are issues of contestability between our trust and commissioners about the validity of some of our costs, but that is the measure of what we think is the cost associated with services for which we do not have recurring financial cover.
Mrs McGill:
Did those issues start with the new trust, or were they a carry-over from the previous trusts?
Mr Dillon:
It is a combination of new cost pressures that have arisen since our inception as a new organisation and cost pressures that the legacy organisations had that were never fully funded.
Mrs McGill:
Is that a legacy deficit?
Mr Dillon:
It is not an overspend by any trust in one year; typically, those cost pressures would have been covered by the Department of Health or by commissioners on a one-off basis. There was no breach of financial duty.
Mr Donaghy:
To be as clear and transparent as we can: when the new trust was formed, none of the legacy trusts had a deficit. They balanced income with expenditure, but some of the services that they provided were not funded on a recurring basis. It is a question of the language that is being used; one could refer to that as an underlying deficit, because those services were not recurringly funded. They balanced the year’s income with expenditure when they handed the funding over.
Mrs McGill:
It is not the same situation that existed in the case of the Sperrin Lakeland Health and Social Services Trust’s deficit of £3·3 million.
Mr Donaghy:
No. It is entirely different.
Mrs Hanna:
I want to make a few comments about the proposed closures of residential homes. There is an awful lot of uncertainty about, particularly for very frail elderly people, who find it traumatic to be moved. However, there are many senior people, particularly those who live alone, who are trying to plan their future. I take on board what you said about alternative choices, and I know that that culture is changing, but it is all very uncertain.
There is no money for social housing and no free personal care, and that is causing a lot of concern. There are people who are unable to look after themselves and need more support. I know that you said that you have enough resources for primary care and care management, but are you saying that you do not have any delayed discharges now that you have got to that stage?
Dr Rankin:
Yes.
Mrs Hanna:
Does that include step-down beds as well? Do you have enough of those?
Dr Rankin:
Yes.
Mrs Hanna:
It is good to hear that you are at that stage. However, there is still uncertainty about closures of residential homes. Are the residential homes still accepting people, or are they trying to wind down?
Dr Rankin:
We are still fully accepting new admissions into all five homes.
Mrs Hanna:
Once there is a whiff that a home is closing, nobody wants to move in there or move a relative in, because they do not want the trauma of having to move them again.
Turning to maternity services, I know that there has been a problem in the past few months with sick leave and the increasing number of births, and that you needed all the agency nurses that you could get. I know that for one year there will be an increase in the number of midwives that are being trained, but what will happen after that? You said that you needed more capacity. The birth rate is increasing, and although there will be an increase in the number of midwives, by their very nature they are — I will not say senior people. We need more midwives; I believe that there are 80 midwives being specially trained. Is there not an argument that we need more midwives trained over a number of years in order to get up to capacity?
My final point is about the reduction in the number of nurses. You talked about 100-odd qualified posts and about the nursing workforce. Are all those posts for qualified nurses?
Mr Donaghy:
Yes. Are you referring to the figure of 488?
Mrs Hanna:
You talked about 116 qualified nurses and about 488 posts over three years. They are all qualified nurses too. Are you reassuring us that no one will lose a post if they do not want to go?
Mr Donaghy:
I am saying that that is our aspiration, Carmel. If people want to continue to work in our organisation, we want to enable them to do that. We do not want compulsory redundancies. The turnover in the organisation, and the opportunities for redeployment, voluntary retirement, early retirement or voluntary redundancy, will enable us to make those efficiency savings. That three-legged stool must be in place to ensure that that happens.
Mrs Hanna:
People are concerned that the trust will lose senior staff who have a lot of experience, particularly in dealing with learning disability and mental health. We know that people need to be up-skilled to do certain jobs. Dr Rankin spoke about delegated work and competency training for all the allied health professionals, and for nurses in particular. We must up-skill rather than downgrade. In the past, nursing posts were cut. Thatcher did that and it caused chaos, because that workforce is, by far, the biggest. There is a concern that it is easier to slice the numbers. Only if and when we see those reassurances will we be convinced that that is not the case.
Mr Donaghy:
We are conscious that nursing staff need to be up-skilled in certain areas. We have put in place development programmes for nursing staff in those areas that are earmarked for change.
Mrs Hanna:
I work with a lot of people with long-term chronic conditions — multiple sclerosis, neurological conditions, muscular dystrophy — who live in the community, but who are forgotten, because it is not the sexy end. Those people simply need the support of one or two nurses in the community. If they had such care they would not require an acute bed in a hospital. I am sure that you have heard about that.
I haven spoken to the Minister and his Department on behalf of many groups. I am concerned that we will lose some good nurses who could be up-skilled with a small amount of training. Economically, there is a good argument for doing that. It is also the right thing to do. Sometimes, people who suffer from chronic conditions are neglected, not on purpose, but because they are quiet and because their carers do much of the work. If those people do not get more support, that work will have to be done in the acute sector.
Mr Donaghy:
As you know, chronic disease management is one area in which there will be investment over the next three years. We are working closely with our GP colleagues and nursing colleagues to identify how to make best advantage of that investment for primary and community healthcare. It was not that long ago that we were talking about a primary healthcare-led service. In generating solutions for delivery of care, we are keen to work as integrated teams with our GP colleagues in order to take best advantage of the investment that we want to make.
There are a number of aspects to the investment that we require for the maternity unit at Craigavon Area Hospital. The Minister has been very supportive of our business case for the capital investment and the revenue consequences. I know that the Department is examining the business case and is in favour of it.
We are confident that we will be able to put in place a solution to Craigavon’s maternity services over the next 18 months. We require additional midwives, but we are also examining the provision of neonatal care, special nursing, obstetrics and gynaecology. That is an entire package. As Mrs McAlinden said, the Minister has identified £100 million for investment in Craigavon Area Hospital. We will seek to use that money to improve women and children’s services in Craigavon Area Hospital.
Mr Buchanan:
You said that nursing posts may go, but that nurses may stay for redeployment. Will that have any bearing on the salaries that nurses receive?
As we move toward a more community-based primary healthcare system, one in which more elderly people remain living in the community, will you have the proper care packages in place to deal with that, such as home helps and carers? The Western Trust faces real difficulties at present in getting care packages for people who require them. How is the Southern Trust coping with that increasingly common scenario?
Mr Donaghy:
The trust may ask staff of a certain grade to transfer to posts at a lower grade, but salary-protection arrangements are in place for those staff. Primarily, staff — particularly qualified nurses — will transfer on the same grades, because qualified nursing staff are at a certain grade. The issue is how to manage that process. Part of the difficulty for the Southern Trust is its rural setting. It is not easy to redeploy nurses across wide geographical areas. Therefore, a major mechanism to avoid compulsory redundancies will be the trust’s ability to offer voluntary redundancy or early retirement to people who qualify and who make that choice.
Dr Rankin:
Care packages are important; if they cannot be put in place in time, the whole system blocks up backwards. However, I must say that there is not, and has not been for some time, a waiting list for care packages in the Southern Trust area.
We must continue to be creative about our recruitment of home carers. We recently ran recruitment drives in rural towns and villages in order to ensure that we had enough carers to manage those packages. Ultimately, carers provide services in the areas in which they live. Therefore, the trust has developed creative recruitment processes to maintain the correct number of staff. We work hand-in-glove with the independent sector, which also provides home care, to maintain a comprehensive service.
Mr Buchanan:
Do recruitment drives face any difficulties in attracting nurses and more senior staff, such as consultants?
Dr Rankin:
Each recruitment process is different. For instance, in respect of home carers, we will hold a recruitment fair in a village, which involves people coming to see what is on offer, filling in a form and being interviewed on a one-stop basis. It varies from the normal process in which people apply by post, are shortlisted, and then interviewed. We streamline it as much as possible for applicants, thus easing the process.
The Chairperson:
You will be glad to hear that that concludes the questioning. Thank you for your patience and time.