COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Efficiency Savings

19 February 2009

Members present for all or part of the proceedings:

Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Ms Claire McGill
Ms Sue Ramsey

Witnesses:

Mr John Compton ) South Eastern Health and Social Care Trust
Mr John Simpson )

The Chairperson (Mrs I Robinson):

We now move to our evidence session on efficiency savings with the South Eastern Health and Social Care Trust. I apologise to John and John for having to sit through a previous long meeting, and not be called because of our schedule. You are very welcome, and we look forward to hearing your presentation. You will have 10 or 15 minutes to make your presentation, and then we will open up for discussion with our members.

I congratulate John Compton on his appointment as chief executive designate of the new health and social care board, and I thank you for all the work that you have done in the trust. I know that you will be in situ until the end of the review. I wish you well for the future.

Mr John Compton (South Eastern Health and Social Care Trust):

Thank you very much for the opportunity to appear before the Committee to talk about the efficiency savings as they affect the South Eastern Trust. I propose to briefly explain where we are with the efficiency savings, and to particularly focus on the areas of service change. Those are the areas that have created the most interest and concern from the public.

We will expand on the presentation given to the Committee by the Minister on 9 October 2008, when he related all of the efficiency savings. There will be a commonality to that theme and to the information that the Committee has already received.

We have approached this issue straightforwardly on the basis of efficiencies and ensuring value for money. We are not about cuts; we are about value for money. The service changes that we are considering and have talked about are a matter of public debate, whether we were in the current financial climate or not. They are about looking at the future of services — not reflecting backwards, but looking forward. There needs to be quite an earnest debate because of simple things like demography, public expectation, safety standards and value for money. That is a very important issue to grasp.

Members will be aware that our contribution to the comprehensive spending review (CSR) target over the three-year period of the review is some £37 million. However, we expect, as an organisation, to receive some £43 million back in the same period, hence my comment that this is not about cuts; it is about realignment, re-profiling and re-deciding how the resources that we have are spent.

That £43 million will include money that is profiled to be invested in new services and also in new facilities that arrive in the trust area. In the context of this year, the most notable new facility is the new Downe Hospital, which will receive an additional £3·1 million to assist in its running as a new and modern local hospital.

Broadly speaking, there are seven areas in which we are considering our CSR proposals. Those include the reform of public administration; workforce control; service redesign; and our relationship with the voluntary and independent sectors. There are also some non-pay issues and modest income generation. Our approach to the process was on the basis that it was a comprehensive evaluation of where we spent our money as an organisation, rather than simply studying the areas that may be regarded, in a public arena, as the front end and as service delivery.

We will deliver some £6 million over the period of the review of public administration. That is a consequence of the two organisations coming together. I am sure that the Committee will be completely aware of the targets that we had to meet in that regard. We achieved our target in the context of the year that is just finishing, which was to find £2·9 million of resource.

We are considering our workforce control, which is about the proper and responsible management of the workforce in the organisation. It is also about how and when people join the organisation, issues of agency and locum budgets, and the management of that entire arena. We are also dealing with service redesign and re-profiling, about which I will talk for a moment or two.

Furthermore, we are considering issues of non-pay, which leads to issues such as telephony, and energy and efficiency. We have spent a huge amount of time putting together the proposal that will deliver the £37 million. To date, we have been very successful in reaching targets. We achieved 93% in year one. At the end of February, the organisation will recurrently set the target for the year, and we expect to be at 100% or very close to that as we run into the year end.

It is reasonable for the Committee and others to ask us to talk about the efficiency of the organisation in addition to those achievements. I simply point to the information that is produced by the Department, which very constructively demonstrates that the South Eastern Health and Social Care Trust has paid a lot of attention to efficiencies. The productivity of our hospital workforce has increased by 11% since 2006-07. We have the lowest proportion of administration and clerical staff in the Province, and we have the best ratio of new appointments to reviews at outpatients. We also have the highest achievement of day cases for selected procedures, and we have the second-lowest average length of stay, at 3·4 days.

In addition, we have a rapidly declining sickness-absence rate, which currently sits at just over 5%. That was the largest decrease in the Province during the 2007-08 period. Again, as I indicated, we are robustly studying our requirements for agency staff and locums. That is a complicated matter, into which we may stray. We have approached the process from a balanced and mature point of view. We are assessing the totality of the organisations in regards to efficiency.

Our consultation document was entitled ‘Local Services for Local People — Safe and Sustainable Services for Populations’. In some senses, that encapsulates how we approached the whole activity. We want to maintain services as locally as we can where appropriate, but we recognise that not everything can be local because of technology and other modern issues. When that is the case, we should look to a larger population to enable us to maintain those safe and sustainable services.

We have also set ourselves a number of principles by which we judged the targets that we considered. One was safety — by which I mean that we do not do harm to anyone in any situation, and also that the outcome is good for the individual who receives the care. Sometimes, safety is simply linked to not doing harm, but it should also be about the outcome of the intervention. As I have said, sustainability is very important. Value for money is another issue. In the public arena, we have been unapologetic in talking about the need to have a debate about value for money. Technology is another important issue. In addition, we need to be responsible and pay attention to equality and human-rights issues.

The four specific sets of proposals about which we talked lie in the field of mental-health services. Specifically, the focus is on Downshire Hospital and its future. Without going into the long history of a building that is 150 years old, at one time it had close to 1,000 patients: it now has 55. The time for it to deliver has come to a natural end and we should manage that conclusion. Why look at it? Later this year, we will open new facilities in the new Downe Hospital and on the Ulster Hospital site, both for adults with mental health problems and older people suffering from dementia. The investment that we have made and the services we provide will allow us to plan that transition over a period.

Contentiously, we have also talked about the transfer of consultant-led inpatient obstetric services from Lagan Valley. I can clarify a few points. We are talking about transferring the delivery aspect of that service, not the antenatal and post-natal services. The rationale behind that is straightforward. ‘Developing Better Services’ signalled that the future of Lagan Valley was as a local hospital. We have been involved in developing a business case which reshapes the hospital in that way, along with the elective surgical unit. Rising standards of safety will make it impossible for us to maintain that service in the future. It is an excellent service at present: we are proud of the service and the staff, but we must think forwards and into the future. We know that consultant-led units will require 24-hour paediatric cover; increasingly, 24-hour on-site anaesthetic cover; on-site laboratory services; and separate theatre facilities. Those services are not deliverable on the Lagan Valley site, and we are faced with the choice of either managing the transition, or waiting for the transition to happen in a haphazard manner.

Reform and modernising our elderly persons’ homes has probably attracted the most contention. We have considered what should be done with homes for the elderly. The rationale behind it is as follows — essentially, we provide four levels of service to older people: services in their own home; services to those designated as in need of residential care; services to those designated as in need of nursing care; and services to those designated as needing care for dementia. We anticipate increases in three of those four areas: home care, nursing-home care and care for dementia. We do not anticipate an increase in demand for residential care.

That is a difficult message to communicate to the population, but it is essentially to do with an individual’s level of disability. Traditionally, in a residential home, the expectation is that an individual will be able to provide for themselves a fairly significant level of personal care and look after himself or herself. In nursing-home care, it is the reverse: there is a clear expectation that that individual needs substantial support. We have a number of residential units and we think it appropriate to consider the future and where we are. The investment will go into such things as housing with care and increased community-care packages.

To illustrate the value for money aspect, we have invested in the current year £1 million and will invest something similar next year in additional home care packages. Those are for people with complex needs, not standard, traditional home-help services. In the context of each year, we are able to buy about 50 additional places for those individuals. That contrasts with residential facilities, which provide generally 30 to 35 places and cost more than that. It seems that quality and value for money points in that direction. We will no doubt discuss that.

The reshaping of service provision at the Ards Minor Injuries Unit reflects the activity base. We understand and accept that from Monday to Friday the unit is busy, but on Saturday and Sunday it is not. On that basis, we have included it in the restructuring of services. It is a minor aspect. It is important to separate decision and implementation. Much of what I have talked about involves decisions that are unavoidable, and proper and mature reflection is required. The real issue is about implementation.

We carried out extensive public consultation: we held five public meetings, and we contacted many, many people, including local representatives and local interest groups, families and carers. It was a good consultation exercise. We listened to what people said, and, by and large, their main concern was about the implementation. When we talk about care for older people, they want to know that community care and the alternatives are really there. Specifically, people are concerned about what will happen to the small group of people who are in a given facility that is earmarked for closure.

In all of our proposals, we made it abundantly clear that, as an organisation at the centre of delivering health and social care, our objective is not to do this in a haphazard, disorganised way. If our proposals, which are still out for consultation, were to go through, there would have to be an implementation process to take account of all the dynamics involved in translating the services from one place to another. We have made it clear, for example, that we will not transfer obstetric services in such a way that 1,200 women will be left completely distraught about where to go. We want the decision to be taken in a manner that will enable us properly to plan and implement the translation into that area.

The areas that we have mentioned are those in which we consider that change is required. Changes are inevitable, but we understand that some are quite difficult, and we have spent a huge amount of time trying to explain to individuals that we are not going about this in a casual or callous manner. Rather, we are considering changes because some areas genuinely merit an energetic debate.

The trust has delivered its efficiency savings for year 1, and it will continue to work on that process in years 2 and 3. What has struck us in the consultation process is the need to understand what the primary decision will be, and then to handle the implementation in a mature and balanced way.

The Chairperson:

Northern Ireland has an ageing population and, as I said on the radio this morning, 22,000 people are suffering from dementia-related illnesses. As people continue to live longer and suffer from more health complications, that figure will rise by 30% by 2017. Having said that, some younger people present with the illness; my sister-in-law, for example, was only in her fifties. How many elderly mentally infirm (EMI) beds will be available in your trust area?

Mr Compton:

I cannot give you a specific answer over that period of time, but the number of people aged over 65 in the trust area will have increased by 36% by 2017. On the day that we were last scheduled to meet the Committee, no one was waiting for a residential placement, but approximately 10 people were waiting for placements in dementia facilities.

We want to provide more of those facilities by redirecting resources, and that means that we must examine the existing, as well as the new, resources. We understand that the demand for services is always likely to outstrip the supply of resources available to provide them. Therefore, we must look responsibly at the money that we are spending, which is also part of the aim of the efficiency drive. If our proposals are implemented and have the expected impact on homes for the elderly, we could reinvest that resource, particularly in areas such as dementia, to increase the number of places available. That is the rationale and purpose behind the process, and it reflects the fact that fewer and fewer people are looking for residential care, and more people are looking for nursing-home care because of dementia. That is the issue that has driven us. If you wish, I can provide you with the specific information that you requested.

The Chairperson:

Various surveys have found that our end of the world, around Strangford and Lisburn, has one of the highest proportions of elderly people.

Mr Compton:

Absolutely. The 36% increase is the highest in the Province and, in absolute terms, it means that the numbers of people with dementia will double. It is not just a percentage; it will be a big increase. We must all have a debate on how we want to shape our services for older people. The trust has presented how it thinks the services should be shaped. It has carried out an extensive consultation exercise, which closed on 12 February. However, the trust will not be bringing any final proposals to the trust board until March, and those will then go on to the Minister for his decision.

The Chairperson:

You will appreciate that you are talking about closing residential facilities, and that there is a greater need for the nursing element and EMI. You are closing facilities and, while you are planning to reintroduce other elements, such as EMI and more beds, the reality is that they are not there on the ground at the minute. Many families face having to travel quite a distance because loved ones have to take the few beds that are available.

Mr Compton:

We are aware of that.

The Chairperson:

That, in itself, is quite a burden on the carer.

Mr Compton:

I absolutely agree. We know of situations where people have had to travel and where people have had to go to less than the most appropriate placement because family circumstances were difficult. The ability to purchase more beds will increase the supply of beds and support for such individuals. The state needs to be involved centrally in the planning and development of that. Of course, many people pay for themselves because of the current assessment rules and regulations. However, there are still many people who are heavily supported by the state. The people who want to run and develop those services need security to develop those services into the future, and this would give them that security.

The Chairperson:

How many people are on waiting lists in your trust area for community-care packages?

The other area that I am most concerned about is mental-health provision. What will you do with the psychiatric nursing unit (PNU) at Ards Hospital? I took the Minister there last year, and it is just not on to have screens between a man and a woman in a mental-health facility. I have never seen a poorer establishment, and that is no disrespect to the staff at Ards Hospital, who do an excellent job in very distressing conditions. What are the plans for the PNU at Ards?

Mr Compton:

The PNU is very straightforward, and I hope that it is a good-news story. The PNU will relocate into new and refurbished accommodation on the Ulster Hospital, in what was previously referred to as the care-of-the-elderly building on the right-hand side of the site as one looks at it. The unit will cater both for individuals who suffer from dementia, and for the adult stage — those aged 18 years to 65 years — who need acute admissions. They will be coming into a much better environment.

Those relocations are scheduled to happen in May and June. Like you, when we looked at the facilities in the Ards Hospital, we found that they were not acceptable. No one would pretend that they are acceptable facilities. The trust has spent in excess of £2 million on refurbishing the accommodation at the Ulster Hospital, and that is the first stage in improving the level of mental-health services overall to that population.

Taking that into context, and the fact that the Downe Hospital is opening in June with 45 beds for people with mental-health issues — either dementia or adult mental health — it is an opportunity to finally reshape the Downshire Hospital. The Downshire Hospital has a very proud history and a very proud record of delivering psychiatric care, but it is a nineteenth-century building, its footprint is what it is, and it is extremely difficult to do anything in the context of the footprint of that building. It seems more appropriate that those services transfer to the Ulster Hospital and the Downe Hospital — and a small element of the services will go onto the Knockbracken site. That goes back to what I said about local services and safer services for the population.

Of the 55 people remaining in the Downshire Hospital, 35 have been there for a long time, and their solution will be housing with care in the local environment. The remaining 20 people have behavioural problems associated with their mental illness, and 50% of those have rather chronic behavioural problems and will need specialist care. The other 50% have more transient problems associated with an acute episode.

Therefore, there are a small number of people who need specialist support and expertise. It is highly appropriate that they go to a specialist facility that has that expertise available. The real debate is about the outcomes for those individuals, not so much the location of the care and treatment. There is an opportunity for the facility in Belfast to be a centre of excellence for the entire eastern area.

We will provide the Committee with all information on waiting lists in relation to community care, residential care, dementia care, and so forth.

The Chairperson:

That would be helpful, John. I remind members to switch off their mobile phones. I can hear funny sounds that, for a change, are not coming from my tummy.

Mr John Simpson (South Eastern Health and Social Care Trust):

Currently, over 3,500 people are receiving complex care packages, either in nursing homes or in the community. Half of them receive that care in the community. In 2008-09, we will have put in place over 90 new complex care packages that have a degree of sophistication and intensity of input.

No one is waiting for a complex care package. However, some people are in the process of having their packages worked up. Packages are ramped up and, of course, ramped down again as people recover during rehabilitation. We are achieving targets for getting the main components of care into place for people within the time frames that we are set. Therefore, although there is a process to go through, no one is waiting for a complex care package.

Other elements of care in the community are less complex and might take a little longer. We try to target those services at people who are in most need and to support other services, such as acute hospitals, in discharging patients who have complex needs. I have explained that 50% of those people receive that care in their own homes.

Mr Easton:

I am sure that the two Johns are sick of looking at me.

I have no problem with most of your efficiency savings. However, I have concerns about nursing and residential care, which I have already highlighted to you on several occasions. You probably agree that the public’s perception is that these are really cuts. However, I understand that the money will go back into those services in a different ilk, as it were.

I accept that there will not be any redundancies in nursing, but will the loss of those nursing positions not result in a reduction in productivity, which could lead to waiting lists going up and to all of the good work that you have already done to bring them down being undone?

Later, we will be discussing clostridium difficile. One of the clostridium difficile report’s findings was that lack of nursing staff helps to increase infection rates. Do you not fear that a reduction in nursing staff might result in an increase in infection rates because there will not be enough staff to help to reduce the already-high rates of infection?

I notice that no one is being admitted into Ravara House in Bangor, the residential home that is under proposed closure. Does that mean that a decision on its future has already been made — before it goes to the Minister? My colleague mentioned the increase in the elderly population. Bangor is the third-largest town in Northern Ireland, after Belfast and Londonderry, despite other places being called cities. Do you not consider that Bangor, with such a high population, will be left vulnerable by the closure of Ravara House?

We had presentations from the Northern Health and Social Care Trust and the Southern Health and Social Care Trust last week. They were good enough to admit that they each had a plan B — do you have a plan B, in the event of the Minister rejecting some of your proposals?

Mr Compton:

I will take your questions in the order that I noted them down — that may not quite be the order in which you asked them.

I am pleased to report to the Committee that, as far as our facilities are concerned, we have very good results in relation to clostridium difficile. That is because of the energy and effort that is put in by a whole range of staff, with such measures as antibiotic policy management, proper leadership on the ground, and a commitment by the nursing staff on the ground. I do not think that the changes that we are proposing will affect that. What is important in the clostridium difficile debate is the emphasis that the organisation puts on that as a problem and how it approaches it in a systematic and methodical way. We and our fellow trusts are all doing that with some degree of significance and concern.

The reduction in the number of nursing staff is happening right across the nursing spectrum. Sometimes, people immediately equate nursing with the idea of the staff nurse in the ward. However, efficiency affects us all. We spend roughly 80% of our money either directly on salaries or on organisations that spend that money on salaries. Therefore, becoming more efficient involves working on the payroll to try to derive efficiencies from it. Nursing is the largest workforce; therefore, it is going to be involved in that.

Earlier, I mentioned that we have a very good record on day-case support and day-case treatment. We are looking toward increased seven-day working and shift patterns in order to increase efficiency. That will give us the opportunity to properly and responsibly shrink the workforce if we have to do it. We are not in the business of shrinking the workforce in a casual, off-hand manner; we would do it in a proper and responsible way. Throughout our consultation, we have said that we have done our best to explain to people why we are considering these areas. We have wanted to reassure people that we will not take decisions that are casual and offhand.

With regard to Ravara House, we do not have anyone waiting for a place in residential care. I know that, when I say that, people will sometimes say that they know someone who needs a place; however, what sort of place is needed? A residential care home is a building that is registered to deliver care at a certain level and a certain standard; it is not supposed to deliver nursing-home care. I know that those boundaries become blurred on occasions because, for example, when people go into a facility we do not like to move them through the facility if we can avoid it. Nonetheless, we do not have anyone waiting for residential care. We had — and still have — a small number of people waiting for dementia care, in particular.

I would be surprised if the Minister were to tell us that he does not want us to implement any of the proposals. He might tell us that he does not want us to implement all of them, in which case we will have to look at alternatives. We spent a lot of time deciding the best way to approach this. We believe not only that it is the right direction — even though it is painful in some situations — but that it is the right thing to do because it is unavoidable to have the debate in this area. Therefore, if it is the case that the Minister tells us that he does not want us to do something or that we should think again, we will think again and present alternative plans to him.

Trying to get efficiency savings and a handle on the budget in the way that we are doing is not without controversy or contention. Therefore, it would be impossible for us to make a plan B and not face more controversy and contention in another area.

The Chairperson:

Keep your powder dry, John; do not give away your plan B.

Mr McCallister:

Some of the same issues are going to come up for the different trusts; however, I am probably encouraged, at least. In our constituency offices, the big question that we all probably hear is whether the care is really available. A lot of people on the ground feel that the answer to that is probably no. That is what must be addressed when considering all these issues. Obviously, Grove House Day Centre is an issue, as is St John’s House and the replacement for that in Downpatrick. Where are we on that? Where do you see that fitting into your plans?

There has not been as much talk today as there was last week about use of the independent sector. What are your views on that? Could efficiencies be made by using that sector, or would it be better to stay in-house?

The handling of the Lagan Valley Hospital issue is huge. Approximately 1,200 babies are born at the hospital every year, and one must consider how, if that service were removed, the hospitals to the east of it in Belfast, or to the west of it in Craigavon, would cope. A lot of consideration and work must be put into that issue. It is a huge issue, and it covers a significant area around Lagan Valley.

Mr Compton:

I must re-emphasise that we have said clearly in public that if a decision were taken to transfer those services, we would not transfer them until it was appropriate to do so. That requires us to work in an orderly way with other interested parties.

There has been much debate about whether there will be a midwifery service at Lagan Valley, and the trust’s position has been absolutely clear on that. We have said that we stand ready to run a midwifery service if the investment for such a service is part of the new money that comes to us in terms of the efficiency. We have no difficulty with that, and we are absolutely clear about that. As you know, we are going to open a midwifery unit later this year in the new Downe Hospital in Downpatrick. As an organisation, we have already nailed our colours to the mast about what we think about midwifery units.

One issue that is important for the people of Lisburn is that they have confidence that someone is paying attention to the fact that they need to have a major health facility in the city. We have made that quite clear, and we will shortly be constructing two new theatres on the site, which relate to elective surgery. We are also working alongside the development of a business plan for the rebuilding of the hospital on the existing site and the remodelling of the hospital on the existing site. We are currently in discussions about that. Therefore, we have a very clear, coherent view about what services should be available in the Lisburn area, and I believe that that model of care and treatment in the Lisburn area will be an exemplar for that type of situation.

One of the issues about local hospitals is that you have to tailor a local hospital to the arena in which it is going to sit. Therefore, what works in Downpatrick may not work elsewhere, and what will work in Lisburn may not work elsewhere. The component parts are the same, but about one third of the buildings are different because they have to reflect the local geography, local issues and local connectivity with other hospitals. We are very committed to a progressive and positive future for the Lagan Valley, and I have articulated that on many occasions.

With regard to St John’s, the planning permission is through for the housing-with-care scheme. We expect that to go on site, and we expect it to be completed towards the end of 2010 or the beginning of 2011. That is part of the future. Instead of having a traditional residential care home, we see housing with care, and the increase in housing with care, as adding a huge component to how we want to treat older people. In a way, society is often judged by how it treats older people and also very young people.

If one is being objective about it, I am not sure that people would say that our traditional pattern is the best expression that we can have as a society for our older people. Therefore, we are very committed to the whole housing-with-care spectrum as being an integral part of the replacement of residential care facilities, if not in every case. If one home closes, it will not automatically be replaced by a housing-with-care scheme. However, it is part and parcel of the total package of services.

With regard to the independent sector, many people have a view that the issue is about privatisation; I have heard that sort of argument presented in the past. I am not here to talk about the rights, wrongs or policies of the independent sector. People do not appreciate the scale of the independent sector in the Province. It is huge; in income terms it is the equal of one of the trusts. It is not a small player; it is a central player with regard to the amount of money that is being expended.

As an organisation, we must be clear about the standards and the quality of service that is provided by the independent sector. In many instances — whether it be housing with care or the provision of nursing homes — one might marshal an argument that other people are better at constructing buildings, for instance. We should be concentrating our efforts on ensuring that the assessments and standards are proper and that the professional support to those institutions and organisations is of the highest quality, because that is what makes the project successful.

There is a debate to be had about that, but the trust works in the real world. At present, the independent sector is a real and substantial player. Some people talk about the independent sector as if it is an add-on or something small. It is huge, and lots of money is spent in the sector. Annually, hundreds of millions of pounds are spent on the independent sector. With regard to the delivery of care and treatment that the sector provides, it is not a small player.

Mr McCallister:

When you are redesigning the services, it is important to reassure people about what will be available. I accept that there are good examples. You facilitated my visit to St Paul’s Court in Lisburn, which is a modern example of what we should be providing. It would be good to see such a project replicated throughout the trust.

Mr Compton:

With regard to our current proposals, as you know, we have one in Lisburn, we have one now in Downpatrick and we are planning one in the Ards area. We see those as important stepping stones in building the planks that will make available a constructive range of services that are fit for the future.

There are always difficulties at the point of translation from one level of service to another. Residents in the facilities that are facing closure — as they see it — are, naturally, anxious about the transfer, and they are concerned that the services that are available to them will be reduced. Those concerns have to be dealt with, and we have given strong undertakings about how that will be handled.

The Chairperson:

Did you say that there would be antenatal and post-natal services on the site?

Mr Compton:

Yes.

The Chairperson:

Do you not think that a woman who goes to a particular facility for her antenatal appointments will feel robbed if she is unable to give birth at the same facility? Where will she go? As John McCallister said, Craigavon Area Hospital is bursting at the seams, but there is a cluster of hospitals within half a mile of one another in Belfast — the Mater, Belfast City Hospital and the Royal. However, there are no hospitals between the city of Lisburn and Craigavon.

Mr Compton:

I understand that, but that touches on a conundrum. The debate about whether there can continue to be a consultant-led obstetric unit in Lagan Valley Hospital touches on the debate on the role and function of that hospital. No one disputes that, in the future, running a consultant-led unit will involve access to paediatrics, intensive care and other services. It is clear that the Lagan Valley Hospital will not have that infrastructure. It has not had those services, so it is not as if those services are disappearing; they did not exist on that site. There is that debate about safety and standards.

In an ideal world, we want a decision that will allow us to begin to plan for the implementation. It took us well over a year to do the work for the new hospital in Downpatrick — which was equally contentious. We did it in partnership with other organisations. It involved investment in those other organisations, and we had to get clarity about protocols and about how and when ambulance services were available. It also involved ensuring that arrangements were in place with the Downe Hospital’s A&E department against the event that a pregnant woman came to the hospital in advanced stages. We want to plan that in a sensible way.

There will be a debate about a midwifery unit under those circumstances. The people who advocate a midwifery unit at Lagan Valley could argue that its proximity to the large hospitals in Belfast, which is usually regarded as a negative, makes it a much more viable alternative. As a trust, we are enthusiastic about examining how that would happen, but it needs to happen in the right way.

A decision that allows us to plan for the future needs to be taken. Our anxiety is that events, such as safety standards, might overtake us if we do not have a debate about planning those services for the future. We are concerned that we might have a disordered end point to obstetric or psychiatric services on the Downshire site. That would be in no one’s interest and especially not in the interest of the people who use those services.

The Chairperson:

Thank you, John. We will agree to differ on some aspects of that.

Mrs Hanna:

Good afternoon, you are very welcome. Before I ask a few questions, I want to talk about public health, keeping people healthy and such elements as early intervention, care for babies, parents and older people, podiatry services and adaptations.

From being out and about and from having been a community nurse for a long time, I know that simple things that do not cost that much money are sometimes not done. There can be huge waiting lists for services that could keep people on their feet and out of acute beds. It would be interesting to see a more holistic approach to public health. The new public health body is about to be set up — I am not sure how it will work with the trusts, but I would like all trusts to talk up public health, prevention and early intervention.

How many beds were there at the Downshire Hospital? I appreciate that the culture is moving away from mere provision, but have you estimated supported-housing and staff needs? We are constantly being told about getting people out of hospital beds, but staff and supported social housing have needs for which there are not adequate resources. What are your calculations for the available bed provision?

I also want to say a wee bit about Lagan Valley Hospital. As the Chairperson said, the culture has been for women to expect to deliver at the same place that they went for their antenatal services, and women are often treated by the same midwife from start to finish. There is currently not the same capacity for maternity services anywhere else, and you have said that changes will not be made until that is sorted. The new regional hospital has not yet been built, and Belfast is bursting at the seams, even in respect of complex deliveries. Distance is central to this issue; pregnancy is a healthy function and not an illness, and people expect to deliver closer to where they live.

Lagan Valley has a very successful day-procedure unit. However, that hospital is concerned that, although it has the capacity to carry out more procedures, such as bowel investigations, patients from Lisburn are being told to go to the Ulster Hospital and elsewhere. Those patients could be treated at Lagan Valley Hospital, so that situation does not seem to make much sense and could perhaps be better organised.

I am a little concerned that there is still an unmet need in residential care for the elderly. I appreciate that we are trying to provide more care closer to home, but a lack of free personal care is the real reason why people are not going into residential care. Those people are not ready and they do not necessarily need nursing care, but they need care that may not be appropriate at home.

They cannot afford that kind of care. They do not want to have to sell their house, and so on. That has been ignored to some extent, because although it is promised, the money is not available and it is not happening.

There are people in the community who are getting frailer and who are trying to plan for the future, because people have to plan for the future. They cannot afford to leave it to chance now, and they are looking around to see what they can do. Many of those people were thinking of something between residential care and supported housing, but that is not available.

You have mentioned the fact that a lot more packages are available, and there are. However, there are people who may need some support, but not need an individual package at home. There are more and more of them, because there are more and more older people. There is still a need for residential care. It is being ignored because of the lack of free personal care; it costs money. I do not think that that problem is being tackled.

I also wanted to ask about job losses. There is a concern that, because nurses are the biggest workforce, that would somehow make it easier to slice numbers in that area. However, we are also told that there is so much need: there is unmet need. If we are going to have more people in the community with mental-health needs and more elderly people with needs, I do not understand how we can afford to slice those jobs.

Although we need a better skills mix, we are told that we need to work smarter, and I think that everyone accepts that. There are certain jobs that could be done by someone other than a nurse, but we should be upgrading rather than downscaling people. I cannot understand how we can afford to lose those nurses, because there is so much unmet need.

Mr Compton:

I would not disagree with much of what you have said. I mentioned the workforce earlier, and I think that nursing is a very attractive job for anyone who wants to go into it. It has great career prospects, and, in recent times, there have been tremendous developments in nursing, with the emergence of nurse practitioners and a whole range of positions such as specialist nurses. I am sure that that will continue in the future.

As these jobs become, on one level, more specialist, other parts of the jobs will be done by other people. That is just the ebb and flow of the matter. We are very mindful of the fact that, in handling a very complicated situation in which you are handling a major change in the workforce, that has to be done prudently. We have indicative figures, but frankly, we will be managing those all the way through to ensure that we do not arrive at a situation where we do not have someone.

The debate about need is an interesting one. The trust is given a certain amount of money: we do the best that we can with it. People can argue about whether we do it well, but we do the best we can. We cannot meet all of the need. That is a different issue, and a different debate for a different arena. We will contribute to that debate with you about unmet need.

For me, the debate about older people’s services is really a debate around the range of services that we want to have. I have discussed this issue with colleagues and, apparently, there are some rather fixed points. A patient can get care at home, go into traditional residential care, or maybe go into nursing home care or dementia services.

In looking forward, we can offer a much better spectrum and range of services. We will need residential care. We will have residential care: not as much as we currently have, but we will have some. There may be people for whom social isolation would be the primary reason for their coming into a residential care situation. It is not a matter of our not having residential care; it is the proportion, the emphasis and the direction of travel.

In the midst of that, there is an issue around unmet needs, and we are driven to look at that from the point of view that we know what money is likely to be coming in, but equally we have to look at how we currently spend our money. We have to put those two blocks of money together and see if that can give us a better shape and a better direction of travel.

Regarding Lagan Valley, there is now a lot of movement between hospitals. That is often to do with the clinician involved.

Equally, although some people go from Lisburn to the Ulster Hospital, many people go from the Ulster Hospital to Lisburn, for all sorts of reasons. The Lagan Valley Hospital has enabled a lot of the larger hospitals in greater Belfast to reduce their waiting times for surgery, because staff there are able to carry out the diagnostic work and medium-level interventions, which allows the larger hospitals to concentrate on cancer treatments and so on.

That is the important role for Lagan Valley Hospital in the future, and that seems to me to be a very sensible configuration. There may be one or two people who transfer, but that is probably in relation to a clinical perspective of that individual, as opposed to the trust deciding wholesale to bus lots of people from Lisburn to the Ulster Hospital.

There are now a large number of consultants who come to work in Lagan Valley Hospital but are not based there. They do that because that is the nature of elective surgery. Wherever one looks at any system that has reformed itself and its surgical organisation, it has always done so through the creation of an elective surgical unit, because that ensures efficiency.

In relation to the Downshire Hospital, there are currently about 35 people who will need housing with care. The planning and discussion on how that will happen is at a fairly advanced stage — it will happen in an orderly way, so that, even if a decision is taken tomorrow morning to go ahead with the proposals for the Downshire Hospital, that does not mean that the current residents will have to be out the following day. The proposals and plans are reasonably well advanced.

I could not agree more with you about the public-health agenda. As an organisation, the trust spends a lot of time working with communities, particularly in areas that might be described as significantly disadvantaged. If one wants to make an impact on health, that is how it can be done. There must be a connection with the community. Although there is a lot of discussion about services for older people, and those who are particularly frail, thankfully, many more people are now fitter and healthier as they get older. We want to encourage and promote that in all sorts of ways, and to do the simple things, which are not costly, to enable people to remain at home.

We may all have experience of someone, either personally or in a work situation, who has had to leave home, and it really is a very traumatic time. The ideal solution is to avoid that.

Mrs Hanna:

Are there any plans for the Downshire site? It is a very big, interesting and attractive site.

Mr Compton:

There are a range of plans for the Downshire site. The trust has earmarked areas where there should be housing with care, because we see that as an asset for health and social care. As you are probably aware, the PSNI has acquired a site. There are discussions about the local council acquiring a site, as well as the Housing Executive. From our point of view, it seems sensible that a site that provided a public service should continue to do so, but in a way that looks towards the future, and does not look backwards. Those are our aspirations, and we are working towards achieving them.

Mrs Hanna:

That would perhaps make resources available to the trust.

Mr Compton:

Not so much to the trust. As you know, all of the disposals of assets will now have to be done centrally, but ultimately it may mean that money will return to the trust.

Dr Deeny:

Thank you John and John, I apologise for missing the beginning of your presentation. I came down the M2 today for the first time, as I had promised to visit a patient outside Cookstown. It is even longer than the M1, so it is the last time that I will be using the M2. My question is a practical one: I am interested in the community-care packages.

You may not have been asked this question before, but do you foresee a situation in which it is difficult to get the carers to provide the care, particularly in the present climate — which, we hear, is going to continue for a while? I know of a situation in my own area where there were no carers available; the money was there, and the trusts were up for it, because there were people on benefits. Central Government are currently putting pressure on GPs not to write too many sick lines, for example.

I believe that, in the next year or so, primary care providers will begin to see even more people with mental-health problems — it is happening already. As a GP, I have noticed that trend — we all have — and, rather than a decrease in the number of people claiming benefits, there will be an increase, because people will be depressed as a result of losing their jobs. Consequently, I wonder whether you will be able to attract enough carers to deliver care packages.

We do not want the circumstances to arise that I came across in a particular area, whereby so many people were on benefits that those providing care packages could not attract enough carers to deliver those services. Looking ahead, if the number of people out of work increases — the construction industry, for example, is gone — more people will suffer from depression, and therefore, more people will claim DLA or sickness benefit. Do you foresee such problems?

Mr Compton:

From time to time, all organisations experience difficult circumstances. Nevertheless, I am slightly more optimistic. As an employer, the health and social care system is pretty good. Although there are occasional difficulties, it looks after its workforce well and, in the round, it is a good employer. In difficult times, people want a degree of security, and the health and social care system offers relative security.

Furthermore, my trust has invested, and, even in these difficult times, will continue to invest, a lot of money in learning and development, which provides staff with opportunities to progress in new directions. Therefore, I am not so pessimistic.

Working differently with communities can afford real opportunities. For example, direct payments are an option. Although people become anxious about taking on direct payments, there is nothing to stop them from forming a local community interest group to manage direct payments for its members. Such groups are good for employment and for the community.

There will be difficulties — no one will tell you that everything is perfect — but I genuinely envisage more opportunities than problems in that arena. From time to time, we will encounter difficult situations, usually specific to particular circumstances, but, in the round, we should be OK.

Mr Gallagher:

You mentioned direct payments. Are any such community organisations managing direct payments in order to provide care for individuals?

Mr Compton:

Not as such, but in Sue Ramsey’s area —

Ms S Ramsey:

Just be careful what you say. [Laughter.]

Mr Compton:

In Sue Ramsey’s area, we set up and maintain a close relationship with a not-for-profit organisation, which employs 25 local women to deliver home care. Those women have access to our training, and the exercise, which is run independently, has been hugely successful. Indeed, several of the employees from its first intake have gone on to formal nursing training. As I understand it, those individuals would have found it difficult to undertake such a career, but we created the environment in which they could do so.

There are one or two other good examples of projects in which we have been involved, and, if members wish, I would be happy to share information about them.

Mr Gallagher:

Does that scheme involve direct payments?

Mr Compton:

Yes, it involves dealing with families that are in receipt of direct payments.

The Chairperson:

That is interesting. I would like to know more about that.

Ms S Ramsey:

I welcome the two Johns; it makes a change from the two Ronnies. [Laughter.] I commend John Compton for his years of working in the community to advance the public health strategy.

Having said those nice things, although John has a duty to the people who live in his trust’s area, he will appreciate that we also have a duty to the people who put us where we are.

Are you happy with the order from the Department and the Minister to deliver 3% efficiency savings, or do you see them as cuts? In my view, the people in that area, including the elected representatives and community leaders — and, indeed, some people here — see them as cuts. How do we believe the line, “It is efficiency savings; it is not cuts” when services are being lost? We must tease the matter out. You have been given a direction or an order from a Minister and a Department, but are you happy with it?

It might be useful to get an assurance, even at trust level, that the most vulnerable will not be the most affected. Is there any way that you, as chief executive of the South Eastern Health and Social Care Trust, can assure us that services or funding for the most vulnerable will be ring-fenced? Again, that assurance would give the community a bit of confidence in the process.

In addition, can you give us figures to show how much money your trust has spent on consultations, consultants’ fees, publications, and meetings with staff — including the cost in staff time — as part of the attempt to achieve 3% efficiency savings? Chairperson, I would like all trusts to provide those figures, because that would give us an idea of whether we are constantly throwing good money after bad.

Mr Compton:

I suppose that I am just like everybody else; when I heard the figure of 3%, I took a sharp intake of breath. That is the truth of it. Having said that, when one really looks at the figures and considers our situation whereby £37 million is going out and £43 million it being put back in, I have to say to myself that is it not unreasonable to be thinking about such an approach.

Some of the most complicated issues concern timing. On occasion, people will feel a bit of pressure as regards the timing of certain aspects, but I do not think that what is being asked is unreasonable. In fact, it is probably a responsible approach — I would say that it is a moral imperative to consider how we can spend the money that we have in the most efficient way possible. The task is not unreasonable, nor is it unreasonable to be asked to carry it out. Like others, if I thought that what I was being asked to do was ridiculous and non-deliverable, I would say so very assertively. I do not think that that is the case. I hope that that answers the first question.

We should be targeting our resources at the most vulnerable in society, full stop. Whether we are talking about people with mental-health problems, cancer patients or children who have been taken into care, those are the people in the most need. We should make it a priority to focus our support, efforts and energy on those people. I believe that that is part and parcel of the reform programmes that are under way.

I know that there has been discussion about whether the consultation process will cost an arm and a leg. In our case, we have spent very little money on the process. Any documents that we have prepared have been produced in house. When booking consultation meetings, we have tried to use venues that are anything but expensive. We used facilitators to ensure that the meetings worked well, but they were already on existing contracts; for example, we already have a contract with the Beeches Management Centre. Therefore, we did not need additional money, and the majority of staff who participated in process did so as part of their job. No extra remuneration or payment was made to individuals who attended evening meetings, and so on. We have spent very little on the consultation process, but we will provide the Committee with indicative figures.

I must add that the consultation process has been really good and hugely beneficial. To speak plainly, we have learnt a lot. People spoke to us very honestly, and sometimes quite passionately, about certain situations. As an organisation that delivers care, it has been very informative and helpful to be able to really begin to engage with those who receive care.

Mr J Simpson:

That was the point that I was going to make. It is impossible for us to plan our services or to implement any sort of change without engaging with the public in a consultation process. We should be continuously involved in such consultation in any case as part of personal and public involvement initiatives.

As John Compton said, we have learnt a considerable amount from that process, and it is imperative that we engage with communities in order to develop services and to determine which services they desire. Although there will always be a cost — not necessarily an additional cost — it is part and parcel of the day-to-day management of services and the day-to-day planning of future services.

The Chairperson:

I thank both Johns for attending and for making an interesting presentation. I wish you all the best for the future.