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Northern Ireland Assembly

Monday 21 January 2002


Assembly: Health, Social Services and Public Safety Committee

Assembly: Environment Committee

Care in the Community

Oral Answers to Questions

Office of the First Minister and Deputy First Minister

Department of Culture, Arts and Leisure

Department of Agriculture and Rural Development 

Assembly Commission

Independent commission of inquiry

Closure of Factories in Lisnaskea

The Assembly met at noon (Mr Speaker in the Chair).

Members observed two minutes’ silence.

Assembly: Health, Social Services and Public Safety Committee


That Mrs Annie Courtney replace Ms Carmel Hanna on the Committee for Health, Social Services and Public Safety.
[Mr Tierney]
— [Dr McDonnell]

Assembly: Environment Committee


That Ms Patricia Lewsley replace Ms Carmel Hanna on the Committee for the Environment.
[Mr Tierney]
— [Dr McDonnell]

(Mr Deputy Speaker [Sir John Gorman] in the Chair)

Care in the Community

Mr Gallagher:

I beg to move

That this Assembly notes the increasing difficulties facing those who have to rely on community care packages and calls on the Minister of Health, Social Services and Public Safety to take action to remedy this situation.

If the mark of a civilised society is the way in which we care for our sick, elderly, disabled people or people with mental health problems, clearly we here have some way to go. A key component of our Health Service is what goes on under the heading community care. I have tabled the motion because there are glaring problems with that provision. When we examine what is happening on the ground, we see that community care is something of a misnomer.

At the moment, practically every trust is reporting that it cannot meet the needs of those who require home help and other forms of domiciliary care. In many instances the community care budgets ran out some time ago. In my area, the Sperrin Lakeland Trust reports that it needs an additional £700,000 to provide for the assessed needs of the sick and the elderly.

In many cases, the only way in which home help services can be found for new patients is by cutting back on the home help hours of existing patients. Every week, cases are reported to my constituency office and, I am sure, to the offices of other Members of the Assembly, which show that the level of community care is inadequate. I know of a 90-year-old man being looked after in his home by his 80-year-old wife. They receive only two hours of home help a week. Money is so scarce in the system that the sick and the old are being asked by some trusts to use their own pensions and benefits to pay for community care packages.

I am not suggesting that the state of community care — and it is in a sorry state — is the fault of the Minister of Health, Social Services and Public Safety. In Britain during the 1990s, expenditure on health and personal social services rose by 57%, while in Northern Ireland it rose by 35%. That shows how our Health Service was short-changed under direct rule. That was the difference in funding during the 1990s, and from reports in the media we know that the Health Service in Britain is breaking down. We need to have that historical underfunding put right and made good, and to do that we require the combined efforts of the Treasury, the Executive and the Minister of Health, Social Services and Public Safety.

At Executive level, finding the resources to meet the pressing demand for additional domiciliary care and day-care packages must be made a priority. However, the crisis in community care is not solely about funding. There are steps that the Minister can and must take. The administration of the Health Service has to be streamlined, and the current unwieldy structures have to be sorted out, because they are contributing to the shambolic community care provision. The Health Service needs less bureaucracy and more efficiency, which is something that the Minister and her Department must tackle now.

The inability to deliver meaningful care packages impacts directly on other budgets and contributes directly to bed blocking and spending inefficiencies in the Health Service. People in hospitals are suffering. People are waiting for heart surgery, joint replacements and for fractures to be dealt with. Youngsters are waiting to have their tonsils removed, while their education and health suffer. The list is growing. We have cases of patients, particularly elderly people, being kept in hospital at a cost of up to £900 a week, and no clinical reason is given. The explanation is that no money is apparently available in the home help service to keep people in the comfort of their homes.

Why does this happen? There is clear mismanagement when £100 or £150 a week cannot be found for the home help service, and £900 is spent instead. That is being caused by our crazy maze of health trusts.

Places in nursing homes for those who are unable to return home cost between £300 and £350 a week, but no money is available to provide them. In one case, a lady was kept in hospital for eight weeks solely because no money was available to fund a place for her in a residential nursing home. If that one bed had been available during an eight-week period, how many more people could have been treated?

Community care provision is also vital for cancer patients. There are 8,500 new cancer patients in Northern Ireland every year, and increasing numbers — up to 90% — are being looked after in the community, in accordance with medical recommendations. In some areas the demand for palliative care packages has increased rapidly. The social work department in one of Northern Ireland’s four cancer units reported recently that it receives an additional 17 referrals every month. The good news is that the number of cancer patients who make a full recovery is on the increase, but there is a serious shortage of skilled staff to deliver palliative care. The level of that care is patchy across the North, and in some areas the voluntary sector is too heavily relied upon. The voluntary agencies do outstanding work, and we are all aware of examples of that, but that sector cannot be expected to do everything.

The Alzheimer’s Disease Society recently issued a report on community care support for people who suffer from dementia. In Northern Ireland, 20,000 people, many of whom are under the age of 65, suffer from dementia. That report advises that, in many cases, although carers felt that they needed more support, they were experiencing cutbacks. Seven out of 10 carers had to contend with regular sleep disturbances, yet help is rarely available during the night; the availability of such provision varies according to where the carer lives. That encapsulates the inconsistent approach by our health authorities to community care.

One of the most damning messages of that report is that many of the carers surveyed said that they found it difficult to obtain information from social services bodies. Many described the procedure as a battle. It is wrong that people who are trying to care at home for a family member with a distressing illness should have to battle to get information. The point was made in the last couple of weeks at a meeting of the Committee for Health, Social Services and Public Safety when members heard the case of a carer who had to look after two members of his family in distressing circumstances. That carer experienced great difficulty in getting any information from the system.

These responses sum up what many feel is wrong about the way in which healthcare is provided — it is no longer the service that it should be. It has become, from the carers’ point of view, a system that they do not understand. Putting aside the fact that money is not forthcoming, there is no excuse for the lack of availability of information for carers. I ask the Minister to take every step necessary to remedy the problem.

12.15 pm

Mental healthcare is another important area which, as many Members know, relies heavily on the voluntary sector. The shortage of skilled staff is a serious problem, and mental healthcare also suffers from the problems that affect other areas of healthcare. Recently, I learnt that seven people who were medically fit for discharge were not released from Holywell Hospital because no care packages were available to assist them or their families.

At the other end of the spectrum, some people are released from hospital with little or no domiciliary care available to help them in their home surroundings, which is an important element of the recovery process. The only contact that they have is with the social worker who comes to assess their needs. The social worker can move only those individuals who have no movement onto waiting lists.

Furthermore, there is the question of parity of expenditure. People in rural communities are entitled to the same level of community care and access to services as people in urban areas. There is a disparity of expenditure between health boards and trusts on care programmes for the elderly. Some urban trusts have a greater per capita expenditure on such programmes. For example, in 1999-2000, in the North and West Belfast Health and Social Services Trust area the per capita expenditure figure was £3,200; in the Foyle Trust area the per capita figure was £3,300; but in the Sperrin Lakeland Trust area the figure was £2,700. I will examine those services to check that they have been, or will be, rural proofed to ensure that people who live in rural areas are not being disadvantaged.

I have mentioned only some of the anomalies, inadequacies and inconsistencies of the current community care provision. There are many other examples: stroke patients facing lengthy delays for physiotherapy; people waiting for assessments by occupational therapists for home adaptations; and people waiting for speech therapy — the list goes on.

The Minister was due to receive the preliminary report on care in the community last year. I would like the Minister to announce the outcome of that review. I would also like to see a clear plan of action and a definite management strategy to sort out the mess that carries the misnomer of care in the community.

The inadequacies of the Health Service are having a detrimental effect, not only on the patients and those who care for them, but on the people who work in the service. I want to acknowledge the work that is done by all health workers. In the face of all the difficulties, they endeavour to provide the best possible care.

It is not a matter of simply throwing money at the problem. Undoubtedly, resources are a key element in tackling the growing mess. However, resources must be part of a clearly developed strategy for the whole of the North, not a sticking plaster for the trust that happens to shout loudest about the crisis. If the Minister does not initiate such a strategy quickly, undoubtedly we will face a worse crisis.

Mr Deputy Speaker:

Ten Members wish to speak in the debate, for which just over two hours have been set aside. Therefore I ask Members to accept a limit of 10 minutes for their speeches. That limit will not apply to the Minister, or to Mr Gallagher, who will wind up the debate.

Mr Berry:

I commend Mr Gallagher for raising the important issue of care in the community. The motion reminds us that health provision is not what it should be. While newspaper headlines tell the public about elderly people blocking beds, they do not reveal the human face of those involved.

Recently I had to deal with two constituents who had been admitted to Daisy Hill Hospital. Both were well enough to leave the hospital after having had successful operations and receiving care, but they remained there for 13 weeks. One needed a care in the community package that was not available at that time due to lack of funding. The other needed residential care, which was also unavailable for the same reason. The cost to the Health Service for those 13 weeks runs into many thousands, the vast bulk of which could have been saved had those patients been able to get out of hospital sooner. If it costs a hospital around £1,300 a patient, a week, those two patients were costing Daisy Hill Hospital and the trust £2,600 a week, which adds up to £33,000 over 13 weeks.

These are not unusual cases. The average overstay in some hospitals across Northern Ireland is five weeks. Hospitals are losing a fortune in that area alone. If each of the 150 delayed discharges in December and January were patients who had spent five extra weeks in hospital, each occupying a bed, the cost to the Health Service would be £975,000. That is probably a conservative figure. I suspect that the real cost is around £1,000,000. Had the Department got its act together and applied a holistic approach, it could have saved thousands of pounds every week for care in the community. Those savings could have been used to increase the money paid to the providers of nursing and residential homes, which are closing at an alarming rate. That point does not seem to have registered with the Department, judging by its answers to written questions on this important subject.

While I welcome extra resources for care in the community, that is only part of the problem in the Health Service. The Department seems unable to see the whole picture. There is a problem recruiting and retaining carers and home helps. That has been made acute in places where there are large retail centres close by. Recently I held discussions with the chief executives of two different trusts. They said that they were having a difficult time recruiting carers and people to look after the elderly. In some areas carers are leaving to take up jobs in large shopping centres and retail units where the pay, hours and conditions are better. There is a rising staffing problem, not only in hospitals but also for care in the community. To provide extra resources is good, but if the personnel are not there, we are back to square one.

What is needed is an overall approach by which patients can be discharged into the community or into residential homes on a temporary basis, with resources and staff available to ensure that patients do not end up in hospital unnecessarily, as they do at present. With a clear vision and will it is realistically possible to reduce bed blocking to an acceptable level without the expenditure of huge resources. Savings in one area will more than cover what is paid out in the other.

Until this problem is tackled across the board, piecemeal actions will not resolve it. The longer it remains unresolved, the bigger it will become, until hospitals are no longer physically able to take in any new patients. That is already happening on an infrequent basis. It does not take a genius to realise that at the current rate, it will become a permanent reality. It is important that this issue has been highlighted today. As Mr Gallagher said, it is not about funding or resources alone, but about having a holistic approach to the important issues of care, and carers, in the community.

I commend and support the motion.

Ms Ramsey:

Go raibh maith agat. I commend Tommy Gallagher for moving the motion. I agree that we are judged by how we treat the most vulnerable in society. Steps must be taken within the administration of the Health Service. However, similar steps must be taken in the review of public administration. At what stage is that review? The Executive initiated it, but the administrative issue within the Health Service, boards and trusts also needs to be addressed.

I welcome the Minister of Health, Social Services and Public Safety’s announcement of a 1,000 extra community care packages, which was mentioned by the last two Members who spoke. I am glad that the Minister is here to explain the detail of the package.

The last debate before the Christmas recess was on the Health Service, during which my Colleague, John Kelly, and I tabled an amendment that called on the Executive to provide additional money to tackle issues in the Health Service. That was six weeks ago. At what stage are we now? Every party agreed that additional money was needed. Areas that must be targeted include the acute sector, community care, young people and the elderly.

Everyone is aware of problems within the occupational therapy (OT) sector, which often have knock-on effects for community care packages. The Minister’s officials and officials from the Housing Executive held discussions to tackle OT waiting lists. Measures to solve those problems may involve simply installing a handrail, but a patient is unable to leave hospital until that handrail is installed. How have the discussions progressed? We talk about collective responsibility. Those issues may not necessarily be the responsibility of the Minister or her Department; they may be another Department’s responsibility. The issues must be targeted.

Tommy Gallagher said that the Personal Social Services (Amendment) Bill is currently at Committee Stage. I welcome that Bill. The Health Committee is going through it clause by clause. Examination of the Bill highlighted some problems that carers and their families face. Those problems are being targeted, and the Bill should be brought before the Assembly shortly.

As I said, we could debate the motion all day.

Mr Deputy Speaker:

I hope not.

Ms Ramsey:

I do not suggest for one minute that I will do so or that one problem in the Health Service is more important than any other. The Health Service needs substantial investment. The money must be provided to target the problems.

In a way, the Committee for Health, Social Services and Public Safety pre-empted this debate. Although the Committee supported the Minister’s bids and welcomed the money that was received, it also supported calls for additional money. The Committee, which closely scrutinises those issues, wrote to both the Office of the First Minister and the Deputy First Minister and to the Minister of Finance and Personnel to request an urgent meeting to discuss not only the money that is needed for this year and future years, but for the years of serious underfunding that the Health Service has endured. It is more than ten weeks since that meeting was requested, and it has yet to be timetabled.

Although I welcome the additional money that was announced in previous months, some of that money — if not a large percentage of it — is a one-off.

It does not ensure forward planning or allow a three- year or five-year plan to be implemented. The additional money is a one-off. That needs to be questioned.

12.30 pm

This matter is a test for the Executive because the Programme for Government informed us that health, along with other matters, was a priority. We need to do more than talk about it; we must ensure that the money is allocated to, and invested in, that priority. Rather than have announcements of one-off amounts, we should ensure that money is in place for the long term.

I welcome the motion and congratulate Tommy Gallagher for moving it. My party supports it. Go raibh maith agat.

Mr McCarthy:

I too thank Tommy Gallagher for raising this vital matter on the Floor of the House. Care in the community is a very worthwhile policy, which has the support of many people. However, sufficient funding is needed to deliver a good, comprehensive community care service. Funding is vital and must be provided. I appreciate the Minister’s presence today to hear our concerns.

Community care should be defined as helping those who cannot manage on their own at home. It means helping such people to live in the community in their homes or, perhaps, in sheltered housing or residential care. Different people need different forms of assistance. A range of services can enable some people to stay in their own homes. That is what they want, and everyone should endeavour to bring that about. For others, a place in sheltered housing or in residential care might be more appropriate.

Care in the community is sometimes thought of as only for people who are being discharged from hospital, but many other people need that extra care at home. It may involve the provision of aids or appliances to assist them at home, meals on wheels, a home help service or perhaps day-care respite. Someone with a learning disability or someone who has suffered a stroke might require care and assistance. The list goes on.

Tribute must be paid to all those who care for our sick or elderly people. It must be said that carers do far more than they are paid to do — and they do it out of love and compassion for the people who are so dependent on outside help.

I appeal to the Minister to ensure that sufficient funding is in place to meet the needs of care in the community throughout Northern Ireland. I support the motion.

Mr C Wilson:

This is an important debate. In considering an issue which affects the most vulnerable in society — the elderly who are physically or mentally infirm — we need to give serious thought to how we deal with the crisis.

A report last year disclosed the alarming figure of 162 delayed discharges in the Eastern Health Board’s area. Bodies often find innovative ways of publishing statistics and information to hide the true plight. A more accurate definition of "delayed discharges" might therefore be that at the end of September 2001 162 people were "imprisoned in hospital". They were unable to go home because proper care was not available. Families were unable to have their loved ones brought home from hospital and provided with care packages or have them discharged to proper care in residential or private nursing homes.

The situation is even more alarming. A report issued by the boards’ independent health watchdog body has revealed that 333 people are at home waiting for care packages. That is a great indictment of the Department, because Member after Member has referred to the cost of providing care for these patients who are now imprisoned in hospital. I ask Mr Gallagher to check his figures; he mentioned a cost of £900 a week for bed blocking, but I understand that the figure is nearer to £1,500 a week. Of course, that does not include the capital costs that are normally there for private healthcare.

It is a disgrace: those patients who are blocking beds, against their wishes and those of their families, are denying care to hundreds of patients who require it daily and weekly. Various Members have asked for additional funding to be thrown at this, but we are acutely aware that it is unlikely that that would solve the immediate problem because the amount of funding that would be required is not readily available.

Therefore, I challenge the Department to do what it should have done — grasp the nettle and look at how care can be provided within existing funds and budgets. It should use the money to purchase the care required in a way that will provide the maximum amount of care for the greatest number of people. We would all like additional funding, and it is essential that additional funding be found, but the Department has been lacking.

Dr Birnie:

I thank the Member for giving way. If I am wrong, I am willing to be corrected. However, I understand that the Member may have a personal interest in this particular industry. Perhaps he should declare it.

Mr C Wilson:

I will declare it again. I have made it clear on numerous occasions that I have a personal interest in private nursing care. I represent a body that has spent many long hours with the Department, the trusts and the boards in an attempt to resolve the anomaly. I have often pointed out that a crisis was looming in that industry.

The crisis in the private nursing sector was front-page news in the ‘Belfast Telegraph’ and received other media coverage. The Sandown Group, one of the largest providers of care, was recently placed in the hands of the receiver. That must be of concern to the Assembly and the Department. It would be worse if, regardless of the Assembly’s efforts to find money to provide the care that is essential for these elderly, vulnerable people, it was then the case that there was nowhere to place them following their discharge from hospital.

That is a real problem that the Assembly and the Department must consider. Across the United Kingdom, the private sector is suffering as a result of the statistics that I quoted. Patients who have been assigned beds in a private home, and people whose families have selected a home for them, find that the funding is not available for the care. Something is wrong, and that must be obvious even to people without any experience in the fields of healthcare or care in the community. There must be something wrong with how the money in the system is being allocated.

I am sure that many Members are aware of the ridiculous cases of home care packages that are provided at costs of up to £2,000 a week. They deprive other people of services. The main argument is that the situation depends on the way that funding is allocated — on the Department’s budgeting and system of allocating money.

Anyone who looked at the situation in a sane or rational fashion would see that it makes sense to move someone out of a hospital bed, costing up to £1,500 a week, into the private sector or to provide a home care package that costs substantially less.

I appeal to the Department to do a fundamental root-and-branch reappraisal of the way in which care is purchased and provided in the community. Some patients are bed blocking, while others are sitting at home. The Department should examine ways in which it can alleviate this problem.

As elected representatives, we are all aware of the plight of elderly people who have to provide care for their husbands, wives and others who receive no assistance. At a time when we are moving to provide free care at the point of delivery, we start to hear stories of elderly people having to fund their care from their pensions or whatever small savings they have. This is a matter of urgency, and if the Assembly is wise, it will highlight the plight of those who require our help.

Mr Deputy Speaker:

All Members have been limited to 10 minutes.

Ms McWilliams:

I thank Mr Tommy Gallagher for tabling the motion. It could not have come at a more important time. The serious situation that we face in the Health Service is caused by a combination of the problems in hospitals and community, primary-care services. If we get this right, we can probably find our way through the crisis.

We have seen enormous changes over the years in the way in which illnesses are dealt with. At one time people with tuberculosis were sent to separate facilities. There were cottage hospitals with convalescence and rehabilitation facilities. These have all been closed. People who need rehabilitation treatment or time to convalesce must now stay in hospital. People are moved from hospitals into nursing homes if community care is not available.

If we approached the problem in a different way, we could save a great deal of funding and provide better services, particularly for the elderly and the disabled. We must change the way that we think about health services — we must change their delivery and the culture that surrounds them. To do this, we must take account of a huge rise in the elderly population. Between 1995 and 2025, the number of people over the age of 80 will increase by 50%, and the number of people over the age of 90 will also double. We cannot expect hospitals to deal with an elderly person every time he or she gets a chest infection. When an elderly person becomes ill, the GP is called. If the GP cannot deal with that person, he or she is admitted to hospital.

Having visited several trusts, I am aware that many have recently introduced some innovative schemes, such as intensive home care beds. These enable staff to provide intravenous medicine, carry out blood transfusions and other processes that require complex nursing. The trusts have started some wonderful programmes. The Down Lisburn Health and Social Services Trust, for example, has introduced the Hospital at Home programme and a rehabilitation service for stroke patients called Step Down Care as well as many other interesting services. However, these require 24-hour, seven-days-a-week health and social care services to be in place. The culture of the trusts must change. They must provide nurses in the community.

12.45 pm

I was heartened when the South and East Belfast Trust told me that nurses want to work in the community and that it has 60 applications for every community nursing post, while hospitals have problems recruiting nurses. If we were to reorient nursing services to deal with patients and the elderly in the community, we could avoid bed blocking, delayed discharges and trolley waits. Frequent readmissions to hospitals, risks of pressure sores, exposure to infections, institutionalisation, dependence, depression and confusion present major challenges to a system that requires major service redesign. We must change the way in which we deliver services soon. I am heartened that a community care strategy is being reviewed, and I hope that it will be put in place shortly.

We will need a well-balanced supporting infrastructure between the primary healthcare services and the GPs, and that is why, after April, we must get primary care right. We also need a menu of services so that patients can be maintained and rehabilitated and can receive acute care in their homes. We must stop equating acute care with hospitals — acute care can be delivered to patients in their homes in a complex way by integrated teams of physiotherapists, occupational therapists, nurses and doctors working together.

A thriving independent sector is also needed. I am aware that there are problems with the nursing homes. The Sandown Group has recently gone into receivership. There is a problem with the elderly not being able to find places because of fees. However, that is a debate for another day.

I have just read a recent report from the Northern Ireland Ombudsman called ‘Facing the Future’. In it, the Ombudsman says that it is interesting that the nature of the complaints that he has received recently has changed and that the majority of complaints that he now receives concern community healthcare. He says that that is because of the non-provision of community services and the lack of resources. He believes that, although it may not be a matter of maladministration, it clearly is an issue when people who have a statutory right to services, and who have been assessed for those services, are not given them.

Last week, the Committee for Health, Social Services and Public Safety dealt with the Committee Stage of a piece of legislation that, again, introduces a statutory right to care assessments. I told the Committee that there is no point in that legislation being introduced if the services are not then put in place. Otherwise, people will have their needs assessed and be made aware of the services to which they are entitled, but they will then be told that they cannot avail themselves of those services because they do not exist. Tom Frawley tells us that his mailbag is full of complaints about this. Perhaps we would prefer the Northern Ireland Ombudsman — who is also the Assembly Ombudsman — to be dealing with other kinds of complaints, rather than have his mailbag full of complaints about the lack of community care services.

Clearly, a fundamental review is required. We must think about the services that we provide. My vision for the future of the Health Service is that hospitals will deal only with surgery — be it elective or emergency — and that the majority of people, including those suffering from mental illness or disabilities and the frail elderly, will be treated in their homes or by the independent sector in the residential and nursing sector, with respite services also in place.

We cannot go on simply saying that if we close convalescent and rehabilitation services, those services should be provided in hospitals. Hospitals do not have the resources to provide them. However, there are many dedicated professionals who have the necessary skills but are unable to use them, for example, in the mental illness field. A wonderful initiative has been introduced — the Thorn nurse training initiative — but patients who leave psychiatric units to return to the community quickly find themselves back in psychiatric hospitals, because the nurses have not been able to apply their wonderful skills and give the services that psychiatric patients need in the community.

They are intensive and will require significant extra resources. However, in the end, those resources will be more cost efficient.

Mr McFarland:

The debate on care in the community is ongoing — in fact, I think that our last debate on it was in October 2001. I welcome Mr Gallagher’s motion today, which will, I hope, continue to highlight the issue.

Many would argue that solving the community care problems is the key to solving the difficulties in the acute hospitals, and Members have referred to that already. New patients referred by primary care cannot get into hospital in the first place because recuperating patients cannot get out. It is interesting that some 43% of community care packages are home care packages. Indeed, 86% of community care packages are for the elderly. Those are all important, particularly the packages for the elderly.

Although the Minister has given money towards home care, residential care is equally important. I understand that statutory homes, in many cases, have closed and are continuing to close. However, the most frightening aspect involves the private sector homes, which, in theory, should take over from the statutory sector to deal with the problem. Private sector homes are now closing because the amount per head that is allocated for looking after patients is not enough. What is the Minister doing about it? This has the potential to be a disaster. Even if money were put in, we would have a mammoth problem if there was nowhere for those patients to go to be looked after physically in the community. The Minister should give some thought to that.

I want to raise the unfairness in the present system of charges for personal and nursing care. In Scotland, free personal and nursing care is to be introduced from April. England and Wales have free nursing care. Is it right that people who spend their lives saving end up in their old age having to pay for their care? People who have paid their taxes, assuming that the NHS would look after them, suddenly now find that that is not the case. Indeed, their homes are at risk. The implications of that are that you should all live life to the full, forget about saving and squander your money, because that way the system will look after you. I am afraid that you just lose it all at the end if you are prudent about your affairs throughout your life. That is a frightening thought for all those who have been prudent. Elderly patients’ houses are at risk, and I understand that there is a deferred payment scheme in England, Scotland and Wales to allow the burden of losing your house to be eased. Does the Minister have any plans to introduce such a system here?

Care in the community is not just about money; it is also about organisation. The Minister should look at the whole issue again with renewed vigour. I support the motion.

Mrs Courtney:

I support the motion by my Colleague Mr Gallagher, and I thank him for bringing it to the House today.

In many instances care in the community is assumed to refer to the elderly, but that is only part of the story. Trusts responsible for community care have to ensure that resources are sufficient to meet increasing demands, not only in elderly care but also across a wide range of other services. Chapter 9 of the Hayes Report dealing with primary care states

"our analysis strongly suggested that patients are being treated in hospitals in Northern Ireland who would be treated in the community elsewhere."

We should, therefore, reduce pressure on the acute hospital sector by treating more patients in the community, provided that levels of resources, organisation and motivation in primary care are sufficient.

The Department of Health and Social Service’s consultation paper, ‘Fit for the Future’, presented health and personal social services as a single, integrated service, centred on primary care. ‘Putting it Right’ encouraged general practitioners to work more closely with hospital- based medical teams to extend their skills, thus enabling more services to be developed in the community. For example, minor surgery is now performed at health centres.

‘Building the Way Forward in Primary Care’ points out that close links between primary care and hospital services are essential if people are to receive treatment in the right setting at the right time and if they are to be able to move easily through the health and social care system. General practitioners are effectively the gatekeepers of the wider systems of care, and they have a key role to play in deciding what kind of care, treatment or support is necessary to meet people’s needs.

Equally important is the fact that primary care is often a bridge to back-to-normal health for those who have received more specialist care. Effectiveness in guiding patients in and out of the hospital system is essential if the Health Service is to provide the service for which it was created — appropriate treatment at the appropriate time and free at the point of delivery. When that service fails to deliver, as it currently appears to be doing, there are problems, and we must ask ourselves why.

Health and personal social services are underfunded and have been for decades. However — and this is critical — some figures suggest that the situation has worsened under devolution, despite extra resources. For example, between March 1996 and March 2001 waiting lists jumped by 700%. Trust deficits have more than doubled in the periods 1998-99 and 1999-2000, despite a 7·2% increase in the Budget announced in October 2000 and allocations of £17 million in November 2000, £14·5 million in January 2001 and £18 million in February 2001. The total budget available for 2002-03 will be 37% larger — an increase of £687 million — than when the Minister took office. There is evidence that the Executive and the Assembly are committed to the Health Service, but, I contend, there are arguments about management as well as money.

Resources are only one element, but we have a responsibility to ensure good management and accountability for the way in which they are used. We can all quote instances of patients lying in acute beds waiting for beds in the community, and we must ask why. Usually the reason given is that trust responsible does not have the resources to buy more beds. Nursing homes are closing, and it has already been pointed out that the Sandown Group has gone into receivership. That is sad, because many people depend on nursing homes.

Nursing homes can no longer cope and give adequate care to those who need it. Their allocation is less than £400 a week a patient, yet it costs approximately £1,500 a week to keep a patient in the acute sector. At the end of 2001 the Ulster Hospital had up to 42 beds with delayed discharges, and it is a similar story in all acute hospitals. The Hayes Report stated that 10% to 15% of acute beds were not available because patients were waiting to be transferred to the community.

The last thing that is needed is another review, given that most reviews to date have not been acted on. That point was highlighted in a written answer on 18 January 2001 from the Minister to a question that had been put by my Colleague, Mr Bradley. He had asked her

"to detail (a) the number of reviews that have been initiated by her Department or its agencies since devolution; and (b) the number that were ongoing when she took office".

The Minister replied:

"Since the establishment of the Executive in December 1999 I have initiated six major reviews. My Department has also initiated a further 15 professional reviews/studies. Some 23 reviews/studies have been initiated by HSS boards, trusts and agencies. Fourteen reviews, of which 12 were departmental, were ongoing at December 1999."

There have been many reviews.

1.00 pm

There is still a lack of resources, but we must ask how the current money is being spent. For example, how much of the additional £687 million was spent on consultancy fees, public relations and reviews? The audit trail is so poor that there is no way that we can find out. Instead of constantly referring back to underfunding under direct rule, the Minister must accept responsibility for answering those concerns if confidence in the Health Service is not to dissipate completely.

Mr Shannon:

I am encouraged that the motion is being debated today, but it must be stated that it is ridiculous that we are once again pleading on behalf of our needy constituents to the Minister of Health, Social Services and Public Safety to make the Health Service work here.

A week ago, I watched her agree with a television news reporter that the situation was grave. However, she refused to reveal what she and her Department were going to do to improve it. I also noted that she did not take up Dr Maguire's challenge to experience life on a ward that has not been prepared for her arrival and which is overrun with patients sitting on trolleys because there are no beds available. The Minister does not know what a real ward is like, because she does not make unannounced visits. If she did so, she would see that chief executives do not want to advertise the conditions under which doctors and nurses are suffering day and night. The Minister has certainly not ventured into the Strangford constituency to talk to people who are currently receiving, or waiting for, community care. The Minister for such a failing Department should at least make the effort to look interested.

The lack of adequate funding has overstretched the resources of the whole of the National Health Service. Some elderly and disabled patients are not being allowed home until adequate care facilities become available, and then no community care places are available anyway. Other patients are let out of hospital too early, only to return with complications or to avail of extensive care packages. If there were enough money for the correct and adequate community care packages to address that need, a huge burden would be lifted from the Health Service. Perhaps Sinn Féin can lend a hand now that it is gaining four new office allowances from Westminster.

Recently, the Minister gave the go-ahead for pay rises for chief executives. Has she given any thought to the people in the country? People in my constituency wait for years for hip replacements, and due to the delay they must have community care to help them wash, dress, prepare food and keep their houses clean - the very basics. They were angry to hear that the Government in England have enabled those who have waited more than six months for operations to travel abroad for treatment; some of those patients went to France last week. Is the Minister going to make provision for such facilities here? That would considerably ease the burden on the community care departments, not only in my constituency of Strangford but in the Province as a whole.

The Ulster Community and Hospitals Health and Social Services Trust needs £20 million to sort out the deficiencies in its community care department. The entire Province got £13 million. Is it just me, or is there something lacking in the Department of Health, Social Services and Public Safety? The Department and its Minister do not recognise the daily problems faced by the trusts in the Province and the fact that it is real people whom they are dealing with and not just numbers. We see real people and their problems every day. The amount of money required to help such people is phenomenal, but there is no way around the fact that it is needed. Although the Minister may try to ignore the situation, she cannot.

People in her constituency must also be waiting for community care; their home helps' time is also being cut back and rearranged to cover the increasing number of people needing care. I would love to know exactly what she says to those people, because I, for one, am fed up listening to the same old platitudes and trying to reassure my constituents that the issue will be addressed in the Assembly. It is being addressed today, but what will the answers be? The situation worsens day by day for many of them.

Each year, the Ulster Community and Hospitals Health and Social Services Trust sets out its targets and goals. With disgust, its representatives told me that they could not achieve those aims because they receive no financial back-up or support. They want to provide the service, but they cannot do so because the money is not forthcoming. They say that they must provide £10,000 for each person who needs care management. Using this figure as a barometer, only 1,300 people across the Province were helped by the release of £13 million to the National Health Service.

If all the money went into the community care department, a minimum number of people would be helped. This means that a great many people are being left in pain and without help or the facilities to help themselves. My constituency is laughingly called "better off", but many of the elderly and disabled are living on the poverty line and need this help to survive each day. It is not a service - it is a necessity. It gives many people the independence and standard of living that should be the bare minimum for anyone in our society. I urge the Minister to look at her Department and realise the hardships that many people face. It reminds me of the workhouses in Dickens's novels, and people in this country deserve better. They have paid their National Insurance to have this service, and it is failing them miserably day-by-day. I support the motion.

Mr J Kelly:

Go raibh maith agat, a LeasCheann Comhairle. I too support the motion. I pay tribute to the carers who are working under very difficult circumstances to maintain a service to the elderly. I congratulate the Minister for bringing forward 1,000 extra care packages this year. Sometimes we overlook - for whatever reason, political or otherwise - some of the positive aspects of what is happening in the Health Service.

Jim Shannon's reference to being disappointed that the Minister did not visit his constituency is a revelation. I wish that he would carry that forward and encourage his Ministers to participate in the Executive to help in this very critical area to deliver a better Health Service to our community.

On the question of the Minister not going to the Downe Hospital, the Committee for Health, Social Services and Public Safety met with doctors and junior doctors before Christmas and agreed that it would visit the Downe Hospital, which it did last week. These sensationalisms do not help the Health Service and are detrimental to its conduct. Indeed, they do not have the agreement of many of the medical practitioners in the Health Service.

People are living longer, and I congratulate and concur with the review of the capitation formula that looks at this issue and attempts to provide funding for our increasingly ageing population. It is easy to make political capital out of the Health Service, and there is too much of that going on. I do not say that because I am a member of the same party as the Minister. I have an example of that. Before Christmas - I see Billy Hutchinson has left the Chamber - I had a case where an 80-year-old woman released from hospital could not get access to a wheelchair to be wheeled down a country lane to get some fresh air. When I rang the local trust, I was told that they did not have wheelchairs. When I probed further, it emerged that there were wheelchairs but that they were not being given out in case the trust ran out of wheelchairs and did not have the funding to provide more.

We have this layer in the Health Service. Certain boards are holding back what they have because they are afraid that for some reason they will not get the funding to provide items such as incontinence pads for old people. In this case it was a wheelchair that the trust had to hand but was not giving out because it was afraid that it would not get funding for other wheelchairs. Then the trusts say that they would welcome complaints to the Department and the Minister. Trusts seem to be determined to direct as many complaints as possible to the Department without making reference to the resources that they already have available for those in the community who need them.

As my Colleague Sue Ramsey said, we could go on and on. In response to Tommy Gallagher's point about a health strategy, we cannot have one unless the necessary funding is provided. Finance Ministers Gordon Brown and Charlie McCreevy, when they provided the funds for a health service strategy, looked not only to the immediate health crisis, but five years ahead, in an attempt to prevent health service crises from recurring.

Any extra funding that the Minister may receive will still be inadequate to cater for the strategic view that the Health Service needs. That strategy should include the development of provision for the elderly, including pensioners such as you, Mr Deputy Speaker, Rev Robert Coulter and myself.

Mr Deputy Speaker:

I have just been advised that I should declare an interest in this matter.

Mr J Kelly:

Perhaps I should have declared an interest before I started, unlike Cedric Wilson. A collaborative approach among all the political parties and by all medical practitioners is the only way to solve the immediate crisis in the Health Service and to provide a strategy.

Rev Robert Coulter:

I apologise to the House for being late. I was hosting the Dalriada Doctor-on-Call group in the Long Gallery. I recommend that Members go along for five minutes to hear what representatives of that group have to say.

I thank Mr Gallagher for moving the motion. It is fitting that we should discuss the matter today. The problems that affect the community care sector have already been covered in the speeches that I have heard today. We all know what kind of Health Service we would like. However, we need to discuss not only what we should do to achieve that objective but what we can do in the short term to alleviate at least some of the problems that people face.

At present, I am dealing with the case of an elderly woman in her 80s, who lives alone, and who spent five weeks in hospital recently. When she was discharged, she needed access to oxygen at all times, and she depended on a neighbour for assistance. The hospital did not inform the woman's GP that she was being sent home. When the patient informed her GP, he contacted the local trust, but it was 48 hours before a community worker visited her. There is something seriously wrong with the management of a system that allows such treatment to occur - that incident happened in the past two weeks.


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