The way ahead for health and social care in Northern Ireland will be marked out over the next two months as a comprehensive review of the system approaches its deadline. The review was announced by Health Minister Edwin Poots in June and is due to report back to him by 30 November.

Poots selected John Compton, the Health and Social Care Board’s Chief Executive, as its chair due to his extensive experience but he is assisted by five independent advisors (see box).

The BMA questions the short timescale but Poots says “it is important that clarity is provided urgently”.

Media attention will focus on the future number of hospitals but several services can be provided in primary care centres instead. At present, Northern Ireland has 11 acute hospitals (three in Belfast) and five local hospitals.

Remit

The review should take account of the Minister’s own vision and strategy for health and social care (see issue 48, pages 8-11), existing policy and strategy statements, the system’s structure, staff terms and conditions, and the resources allocated by the Assembly in the 2011- 2015 Budget.

In a frank brief to the review, Poots states: “It will be necessary to stop doing what does not work, become more assertive in challenging out of date practices, and acknowledge that some of today’s services and their current design are no longer fit for purpose.”

Best practice on providing safe and effective services will be considered, including guidance from the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence.

Studies for analysis include the McKinsey report (2010) and the two Appleby reports (2005 and 2011). The latter Appleby report found that the health and social care system required an extra £1.1-1.5 billion to catch up with England.

The review must provide a “strategic independent assessment” across all aspects of services and produce a specific implementation plan containing proposals for specialities and major hospital sites.

Two major factors are outside the review’s scope: organisational structures and funding.

OFMDFM is reviewing all arm’s length bodies accountable to the Executive, including the health structures. The DUP has manifesto commitments to merge the Public Health Agency into the Health and Social Care Board, and review the Business Services Organisation and Patient Client Council.

Since April 2007, the system has saved £49 million and shed 2,259 administrative, clerical and support jobs.

The DFP’s Performance and Efficiency Delivery Unit (PEDU) is investigating the scope for further savings. For perspective, the DHSSPS was allocated £4.31 billion to run health and social care services this year: 42 per cent of the whole Executive’s total current expenditure. Elected representatives are best placed to make spending decisions.

Pressures

The case for reform is clear from three statistical indicators. In 2010-2011, 674,400 new cases went through A&E and hospital admissions stood at 583,599. New cancer diagnoses stood at 56,286 in 2009-2010, the most recent statistical year.

This means that, over a four-year timespan, new A&E attendances were up by 35,900, hospitals took on 27,602 more admissions, and 4,250 new cancer cases were confirmed.

Initial A&E cuts at Lagan Valley and Belfast City hospitals would increase pressure on the Royal Victoria, Ulster and Mater units. To help reduce the resulting pressure, Poots wants an end to “time wasters” turning up at A&E departments. If all patients with minor ailments went to their GPs, casualty staff could focus on treating strokes, heart attacks and major traumas.

Over the next five years, the Belfast trust wants to establish the RVH as the ‘major trauma site’ whilst retaining smaller A&E units at the City and Mater.

Collectively, the public sector unions have agreed to organise “a co-ordinated campaign of industrial action”. They expect “a prolonged period of industrial strife … where specific services and jobs are under immediate threat.”

Poots’ announcements are expected in early 2012 and will be among the most significant ministerial decisions in the 63- year history of the Health Service.

Northern Ireland’s Health Service will run out of money in four years unless fundamental reforms take place. That is the main message from the McKinsey report, commissioned by the Health and Social Care Board.

Four trends, it found, are adding to the pressure on the system:

1. A growing and ageing population (50,000 more people by 2014, 17 per cent aged over 65);

2. Social and behavioural problems (less care within families, increasing drug and alcohol abuse, more patients with chronic conditions);

3. Changes in technology and practice (new treatments and improved diagnosis mean more activity within the system); and

4. Individuals having higher expectations.

The McKinsey report takes an objective, strategic overview. It presents “possible plans” for delivering “high quality, cost effective health and social care services for Northern Ireland”.

A high quality service is defined as effective, safe, serving all of society, and patient- or user-centred. A productive service, it adds, “makes efficient use of all resources, including facilities, staff and supplies.”

Without change, the running costs will rise from £4.3 billion to £5.4 billion by 2014-2015. However, the report claims that £600 million can be saved from this sum: £100 million from optimising the quantity and type of care and £500 million from reducing the unit cost of care.

A reformed system would involve:

• primary care centres acting as “hubs” for health and social care in the community with integrated staff teams (open for 12-16 hours per day, seven days a week); and

• fewer acute hospitals, supported by local hospitals providing local access to urgent care services.

McKinsey puts the one-off transition cost at £280 million (including £45 million capital investment to upgrade primary care centres).

The Health Service is already underfunded, spending 7-16 per cent less per capita than its English equivalent. Depending on the estimate, the province needs £226-606 million to catch up. That gap opened up in 2009-2010 as funding increased at a faster rate in Great Britain.

Past improvements are praised. Northern Ireland’s life expectancy is increasing. Healthcare-acquired infections, such as MRSA, have declined.

The province still has a shorter life expectancy and more deprivation than England and our mental health and learning disability services receive less than half of the English per capita spend. Coronary heart disease, smoking and obesity are more prevalent.

North East England was selected to provide a more accurate comparison as it has similar levels of deprivation. In 2008-2009, Northern Ireland spent proportionally more on hospital services and community prescribing.

“Doing nothing is clearly not an option” but the report also rejects the popular notion that cutting back on management will solve the problem. Administration only makes up 7 per cent of the health budget and the Review of Public Administration has already made most of the possible savings (£48 million).

Recommended improvements include:

• Allowing for a few weeks’ intensive rehabilitation before assessing someone for social care;

• Ending “clinically ineffective or non- essential treatments” (e.g. aesthetic ENT surgery);

• Making better use of minor injuries units instead of A&E; and

• Increasing the use of generic drugs.

Under this model, there would be 358 fewer hospital beds, a 30 per cent reduction in hospital outpatient appointments and 21 per cent more GP consultations, over a timescale from 2008-2009 to 2014-2015. Staff numbers would reduce by 1,000 and would otherwise increase by 10,000 or more.

Strong leadership is required from ministers, MLAs, managers, senior professionals and the unions.

Changes must be communicated clearly before implementation. The wide audience includes patients, clients and their communities, the media and all staff.

If savings are not realised, more radical options “may need to be considered” to close the funding gap.

The most controversial proposal is “co-payment” by the service user. Initially, this could mean bringing Northern Ireland into line with England e.g. ending free prescriptions and charging for community care. Extra steps could involve charges for attending A&E, GP appointments or inpatient stays.

Co-payment could generate £140-302 million but must be carefully designed as people who need care may be discouraged from coming forward. The Republic has exemptions for medical card holders and patients with infectious diseases.

If further reductions were necessary, the Minister would have to consider serious restrictions on services e.g. means- testing and hip replacements only for the over 80s. This draconian last resort could be legally challenged but is described to highlight the risks of doing nothing.

Edwin Poots gave his initial assessment to the Assembly’s Health Committee on 8 June. The report provided “firm evidence of scope for greater productivity while delivering cash-releasing efficiencies”. He added: “That is not to say that I would adopt all of the policies or proposals in the McKinsey report. I will not, because some of them are off the wall. However, as others are practical and sensible, we will treat [its] proposals as an à-la-carte menu.”

“I want to see a Health Service that is responsive to the needs of the people that are using it,” Edwin Poots states. “I want to see a Health Service that is local and therefore I want to see an enhancement of primary care and the availability of more services at that primary care level. And I want to see a Health Service that leads in specialisms and is not lagging behind the rest of the world in terms of the care that’s provided for our people.”

His third term as Minister will involve overseeing a Health Service for all 1.8 million residents of Northern Ireland, costing £4.31 billion this year. The responsibility is heavy but Poots takes a calm tone as he reviews his portfolio. It is currently planned that he will hold the brief until Jim Wells succeeds him in mid- 2013.

The financial constraints cannot be ignored but his priority is better outcomes for those who use the service. Those improvements are achievable but a “fairly significant change” is needed to make them happen, especially a major shift from acute to primary care.

Poots values localism but sees its limits. Keeping acute services in local hospitals can put some patients at greater risk.

His practical example is thrombolysis, breaking down blood clots by using drugs, after a person has suffered a stroke, which can allow 15 per cent of stroke patients to make a significant recovery. Relatively few hospitals can offer that service.

“You ask the question and someone says: ‘I strongly support having a local A&E in this area.’ And that’s fine but you’re not going to have the facilities, the consultants on hand, the scanning facilities to offer that sort of treatment,” he states. “So the Ambulance Service is going to take you directly to a hospital that does have that facility.”

He sees a clear contrast between going to a local hospital that is 10 minutes away, but leaving in a wheelchair after a month, or treatment in a hospital 30 miles away with the prospect of making a full recovery.

“I think that for the individual, that’s a very easy decision to make,” the Minister affirms. “And for people who are making an argument about localism all the time, I support localism but it shouldn’t be to the detriment of the best outcome for the patient and we can’t offer that service at every local hospital.”

Primary benefits

While medical professionals understand that argument, it is put to him that the public is still wedded to a local hospital. Poots responds by explaining what enhanced primary care centres would deliver.

Normally, a patient with a chest infection is referred by a GP to a hospital, where they wait in A&E and are often admitted. If x-rays were available onsite, the doctor could carry out a diagnosis and decide what action to take.

A seriously ill patient could be referred directly to a ward, bypassing A&E entirely. Patients with less serious conditions would not need an admission at all, and therefore avoid contracting other illnesses inside hospital. Older people, in particular, would benefit.

“It’s also considerably better for our economy because we’re not treating someone for something they shouldn’t have had in the first instance,” Poots comments. “You’re treating them for the initial illness in a more effective way.”

Pre-med preparations and diabetes clinics could also be carried out locally, rather than involving hospital visits.

Meanwhile, in acute services, there are “significant opportunities to provide better healthcare” if the best use is made of new technology. Catheter labs, which install stents quickly after a heart attack, can drastically reduce coronary-related deaths.

“And that’s why I have a commitment to ensuring that people go to the right place for the right treatment,” he continues, “and ultimately you have a far better chance of getting the right result in those circumstances and I will not be deflected from doing that by people who make very simplistic arguments that an ambulance needs to get to the nearest hospital straight away.”

On that point, he expects a continual improvement in ambulance services and points out that the paramedic’s care is “key to saving a person’s life” at the scene of a major trauma before taking them to the right facility for further treatment.

Maximising efficiency

“We do need to shift the focus where we have a number of hospitals carrying out the same types of service and we need to probably bring them on to a lesser number of sites,” he notes, alluding to the Belfast hospitals. The Minister sees “little point in having two hospitals within a mile of each other carrying out exactly the same service”.

Inefficiency can also be driven out by more segregation of emergency services and elective procedures. He explains that “if every hospital has an emergency service in association with the elective procedures, that will inevitably lead to patients’ care being delayed and operations cancelled as the emergencies come in.” Instead, some hospitals should carry out elective procedures only while others concentrate on A&E.

In 2009-2010, the average hospital stay in Northern Ireland lasted 5.8 days, slightly behind Scotland (5.3) and England (5.6), similar to the Republic (6.0 in 2009) and ahead of Wales (7.5).

Poots has questioned why the length of stay is longer and suggests that a registrar should be allowed to discharge a patient rather than a consultant, as is currently the case. The decision is ultimately a clinical one and the registrar often does most of the work with the patient.

Culture change

Speaking to the Chief Nursing Officer’s conference in June, Poots promised “greater involvement of frontline professionals in decision-making and service development” as they know “better than anyone else” what was working well or where improvements can be made.

He has been “fascinated” by responses by front-line staff, he continues. Nurses in Daisy Hill Hospital, in Newry, have identified a better way to flush out cisterns in the nephrology unit, which resulted in fewer infections among people using that service. Another nurse in Belfast City Hospital has reduced the number of consultations for live kidney donors from three to one. Transplant numbers rose from single figures to 40 in a year, taking patients off dialysis and letting them resume a normal lifestyle.

In both cases, there was a “double-edged sword” i.e. a better outcome for the patient and a cost saving.

Staff consultation already takes place at a local management level but invest-to- save decisions “have to come further up the line.” He wants a “very good access” between people on the ground and those senior managers.

“There’s no point in having a fantastic idea but we talk amongst ourselves as to how it can make it better but it doesn’t actually get to the decision-maker,” he states. “I want to ensure that people who see solutions on the ground are able to get those potential solutions to the decision-makers and allow the decision- makers to move this on and move it on quickly, because ultimately that will have far better outcomes.”

Private and voluntary

The private and voluntary sectors have a key role to play in the changes that lie ahead. Offers from the voluntary sector “which would have saved us money” were previously rejected. He encourages voluntary organisations to come forward with ideas and sees mental health and learning disability as a particular opportunity.

Domiciliary care also presents “great opportunities” for social economy projects. One existing example in Colin, in West Belfast, was set up with an initial £25,000 investment and now makes over £360,000 in profits, which are ploughed back into community projects. It has employed over 60 people and has trained many more: “There was an area of deprivation which was able to get a hand- up and I would like to see more of that happening.”

Poots adds: “Some people recoil whenever you mention the private sector, as if it is something bad.” Instead, he praises the private sector’s influence on social care, contrasting hospital geriatric units 30-40 years ago with the comfortable residential, care homes and nursing homes provided today. More one-to-one care is provided at a lower cost. All three sectors can help people stay at home for as long as possible.

Joining up

The historic under-funding of mental health and learning disability makes driving out inefficiency “all the more important for me” so that area can get new investment. He wants to take the “huge challenge” on and raise public awareness of suicide and the risk factors.

A silo mentality, Poots claims, has held back action on mental health with departments being reluctant to take on extra responsibilities, in case that involves more cost. Four have a role to play:

• his Department of Health, Social Services and Public Safety;

• the Department of Education;

• the Department for Social Development; and

• the Department of Culture, Arts and Leisure.

“If there is a better outcome and there is an additional cost, we need to identify which department or departments should be picking up the tab for that and where the major benefit lies,” he states. “I suspect it will be across a number of departments that will end up picking up the cost for it but we can dramatically improve outcomes and, if we do improve outcomes, that will ultimately lead to a better economy for all of Northern Ireland because we spend an awful lot of money on mental health. We lose an awful lot of money as a consequence of mental health and people not being available for our labour force and so forth.”

The Civil Service has not been strong enough on working together but he will “push that very hard” with his staff and expects other ministers to do the same.

Decisions

Asked to choose one area where he wants to see movement by the end of his term, he says he thinks differently: “It’s not where I’m coming from on the Health Service. It’s my intention to be holistic and it is my intention to be a Minister that leads change and challenges for change.”

Primary care must be “moved centre stage” to offer the right service to people at a local level. This will also involve upskilling in that service, with a range of allied health professionals supporting that service.

One of his key messages is that everyone can help to improve society’s health. The goal of public health is that fewer people need to use the Health Service because they are looking after themselves: “We will be getting those messages out to people as to how they can make a contribution and how they can change their lifestyle for their own betterment but also for the benefit of others.”

There are also “tremendous opportunities” for improving cancer results and the outcomes of heart attacks and strokes. That said, hard choices must be faced to improve health.

“Ultimately, having ministerial office isn’t about taking easy decisions all the time,” he contends. “Very often, it’s about taking difficult decisions. The scale of the problem within the Health Service is one that’s going to require a series of difficult decisions.”

He expects people will accept those changes if they are explained clearly and debated. People should also see benefits as the change works through the system.

“This isn’t a debate about money,” Poots stresses. “It’s a debate about providing a better Health Service and money is very much a secondary issue. We have a budget of £4.3 billion, which is a very large budget, and that’s been growing for quite a number of years.”

He notes, though, that “there has been quite a bit of waste traditionally within the Health Service and we need to drive that waste out to ensure that every penny of it spent is well spent.” While not sure whether this goal will be achieved, he adds that “it’s one that I’ll aspire to and I’ll drive towards that.”

Profile: Edwin Poots

A DUP MLA for Lagan Valley since 1998, Edwin Poots was previously Culture, Arts and Leisure Minister (2007-2008) and Environment Minister (2009-2011). He entered elected politics as a Northern Ireland Forum member for Lagan Valley (1996-1998). Poots also contested the constituency at the 1997 and 2001 general elections. He represented Downshire, on Lisburn Borough (later City) Council from 1997 to June 2010, succeeding his father Charles.

Married with two sons and two daughters, he has a farming background and was educated at Greenmount Agricultural College.

“Alcohol is still the big problem in Northern Ireland, drugs sometimes get more attention but alcohol is the main problem,” states Addiction NI’s director Claire Armstrong.

A DHSSPS census of drug and alcohol treatment services showed that on 1 March 2010, 5,846 people were in treatment for addiction, a 15 per cent increase from March 2005.

Some 57 per cent of these people were being treated for an addiction to alcohol while 22 per cent were treated for drug misuse and 21 per cent for both drug and alcohol misuse.

Addiction NI is just one charity working to tackle the problem. It offers treatment programmes, counselling, quick appointments without a GP referral, and support for family members, spouses and friends affected by alcohol or drug use.

Armstrong explains that there has been a significant rise in the number of people contacting the organisation: “We’ve seen a 40 per cent increase in terms of numbers of people we have treated in our agency over the last five years, which is a big increase.”

Many factors lead to an addiction, she says, but some of the most common are family problems, trauma, employment or housing problems.

In her experience, drug use is a growing concern with a “very big increase” in the use of cocaine due to a change in social trends, increased availability and lower prices.

However, with alcohol prices cheaper than they were 20 years ago, she says it is the biggest problem: “There does seem to be a link between the price of alcohol and the amount of alcohol consumed but of course it isn’t the only

factor.” A minimum price on alcohol, in her view, might help to reduce the problem.

In many cases, though, if someone has an addiction to alcohol they may also be using drugs. In Northern Ireland, the New Strategic Direction for Alcohol and Drugs strategy outlines the Executive’s approach to the problem over a five-year period (2006-2011).

It recognises the work of “dedicated individuals and organisations” in the statutory and voluntary sector and its main aim is to “reduce the level of alcohol and drug-related harm”. Drugs and alcohol are addressed by separate strategies in England and Wales. Armstrong says that a combined strategy is “useful and helpful” as it is designed to suit people with both problems.

In November, Michael McGimpsey announced that treating addiction in 2009-2010 cost £7.5 million. However, he stated that “without intervention and prevention the Health Service will struggle to cope with alcohol and drug misuse – and related issues such as domestic violence, child protection, mental health and suicide – in the years ahead.”

Armstrong points to a DHSSPS report, The Social Costs of Alcohol Misuse in Northern Ireland, which suggests that the actual cost on society as a whole, could be closer to £700 million. “That includes things like welfare costs, criminal justice costs, the cost to the Health Service of people who are not having treatment for an alcohol problem, i.e. the person that is drunk on a Saturday night,” she states.

More resources should be put into community-based intervention and prevention services, she says, to avoid so many people being admitted to hospital with addiction problems, as this is the most expensive form of treatment.

From her research, Armstrong says that for every £1 spent on alcohol misuse treatment programmes in community settings, £5 is actually saved in the long term.

“In terms of putting money in, we would argue that the voluntary and community sector plays an absolutely vital role. The prevention side of it is very important and doesn’t just have to be leaflets. There’s a whole range of different things that are involved in prevention work, including work with families, one-to-one work and couples work,” comments Armstrong.

With imminent budget cuts, Armstrong says there are major concerns about funding in the voluntary sector: “It’s such an important service that to go down that road would really be very counter- productive in terms of the overall aims to reduce alcohol and drug-related harm.

“If you cut the services there, you will end up with much more expensive problems down the line. You will end up with people in hospital beds that didn’t need to be there if those services had been available earlier.”

In the current climate of belt-tightening and competing claims on the Northern Ireland budget, we are all striving to ensure that we deliver the services we need and obtain value for money.

My committee plays an important part in ensuring that the Health Minister and his department provide the services required and introduce efficiencies by holding him to account and vigorously reviewing his policies and priorities.

The Department of Health accounts for approximately 40 per cent of the total Northern Ireland budget; the Belfast Trust alone employs some 22,000 people, spending £930 million in this year alone.

And while it is welcome news that the health component of the overall budget is likely to be protected, it is clear that the Health Service will be under severe strain over the coming years. Capital spending will be hit hard: the monies available to Northern Ireland as a whole will be cut by 40 per cent by 2014-2015 compared to the level available for 2010-2011.

A number of issues are, therefore, at the top of my committee’s agenda.

First and foremost we believe that the department’s focus must be on protecting front-line services for patients. This is, of course, a complex issue; preserving front- line services requires more than protecting healthcare professionals. We have written to the Minister and a range of stakeholders to delve more deeply into the issue of which posts are essential to providing these important services.

We are also very concerned with the issue of controlling management costs within the health trusts and Health and Social Care (HSC) Board. This whole sector has undergone a radical restructuring under the Review of Public Administration and we are particularly keen to ensure that the monies available are being spent on essential services and not on unnecessary management and administrative costs.

We are particularly concerned that a large proportion of people employed by the trusts to carry out management or administrative tasks are paid between £40,000 and £70,000 and those in senior management teams are employed on very significant salaries, often over £100,000 per annum. To ensure that these salaries and posts are justified, the committee will be initiating evidence sessions with the department and representatives from both the trusts and the HSC Board.

The committee has also been involved, over the past months, in examining a number of important matters.

Currently we are going through the committee stage of the Safeguarding Board Bill. The Safeguarding Board for Northern Ireland (SBNI) will be a new multi-agency body designed to improve child protection and deal with the issues around the safeguarding of children. We believe that the SBNI will have a significant role to play and represents a major step forward. Safeguarding children must be high up on everyone’s agenda and this new board will ensure that all the relevant agencies work together.

Services for autism have also come to the fore during this session. On 8 November 2010, a private member’s Bill on autism was introduced into the Assembly. Many people believe that legislation comes only from departments and while the majority of legislation does come through this route, MLAs are entitled to introduce bills on issues that they feel are important. My committee has been briefed by the member who has proposed this Bill on his proposals.

Another important matter, and one which the Assembly as a whole has debated, is suicide prevention. In 2008 the committee published its inquiry report into the prevention of suicide and self-harm, and proposed 26 recommendations. We have recently asked the Department of Health for an update on the progress and implementation of these recommendations.

My committee is concerned about the recent number of suicides. We are particularly interested in how successful hospitals have been in ensuring that all those who are seen in emergency departments are given a date for an appointment with a psychiatrist before they leave hospital (the so-called ‘card before you leave’ scheme). The committee will be following this up with by meeting with the Belfast Mental Health Rights Group in December to gain their perspective on it and we would also expect to approach the department.

The challenges facing the health department and health sector for the foreseeable future are immense: the Health Committee and Assembly will be pressing hard to ensure that the services required are delivered and that value for money is achieved.

Northern Ireland’s health system is far too focused on what happens in hospital buildings when community services can meet most needs, according to Garrett Martin. The Royal College of Nursing’s Deputy Director in Northern Ireland was speaking to agendaNi about the need to get the right care for the population as demand increases.

“We do need to get away from the almost obsession that the Health Service is based on the acute hospital,” he commented, objecting to the argument that “because we have had a hospital in a certain facility for so long means that it’s right.”

The number of acute hospitals is not the most important factor, in the RCN’s view: “We don’t believe it’s a matter of how many. It’s a matter of which services are available at the various facilities.” In Martin’s words, the central questions are: “What is being provided? Does that fit the needs of the population?”

All acute hospitals serve a “good purpose in terms of the service they provide” and demand is very busy at each one. Hospital beds can only be reduced if the right services are available in the community. If that were the case, a patient would have a “much shorter” stay if he or she needed to go into hospital.

People, of course, need treatment and care when they are sick but he points out that acute hospitals are also the most expensive form of care.

“I think our obsession, almost, with acute hospitals [has] led us to cases where patients are in hospital where an alternative, if available, would have been better for the patient as well as helping to save some valuable resources,” Martin explained.

“The demand is ever-increasing in recessionary times,” he remarked, pointing to the well-documented link between poverty and ill health. Merely protecting health spending would mean “a cut in real terms as the demand increases.”

A further culture change is needed to reduce that pressure. Preventing illness and promoting good health is everyone’s responsibility and must be seen in that way.

Every citizen has a responsibility to live a healthier lifestyle, which would cut down on obesity, diabetes and cardiac disease as a consequence. These are more difficult when personal budgets are tight but personal responsibility can ultimately affect the demand on services.

“Sometimes I do believe the Health Service has been a victim of its own success,” he said. “Albeit we have a right to health care, we all as individuals have to think about making healthier lifestyle choices.”

Every government department has a role to play, not just the DHSSPS.

“We all share a responsibility in terms of prevention and encouraging and promoting good health and well-being. That then can have a dramatic effect in terms of the medium and long term,” Martin added.

“We are fully conscious of the economic situation. We have to look at the next generation, the medium and long term, and if you don’t invest in things that will help promote good health and well-being, we are just creating and perpetuating a problem in terms of demand.”

How society cares for its most vulnerable members is a sensitive subject but one which has a rising importance. Northern Ireland’s population is ageing so an increasing number of older people will require care in future.

Martin wants to see “a service that is really focused on the needs of patients in the right place at the right time” The vast majority of care must take place outside a hospital. The alternative will see older people who need care facing real hardship.

“If we don’t get this right over the next five to 10 years, we could be in a generation where we just find it incredibly difficult to deal with the care needs of older people,” Martin stated. “We have to get this right as a society.”

From acute to local

The debate over how care is provided ties in with the wider shift from acute to local hospitals.

Northern Ireland has 11 acute hospitals (providing 24-7 emergency care and in- patient services etc.) and five local hospitals, which have fewer services. Seventy per cent of the hospital workload can be delivered in a local hospital, according to the DHSSPS.

This compares to 15 acute hospitals when the ‘Developing Better Services’ plan was announced in February 2003. The ultimate aim is nine acutes and seven locals. Five hospitals have made that transition, of which one (South Tyrone) lost its acute services before the 2003 announcement.

Changing a hospital’s status from acute to local therefore involves removing some services over a period of time, which usually results in local opposition.

It was decided that the Mater would become a local hospital “in due course” but should continue to provide acute services for a “considerable period ahead”, due to limited capacity in Belfast hospitals.

At present, Belfast has three acute hospitals, including the Royal and City in close proximity. A DHSSPS spokesman pointed out the Royal and City also provided regional services to the entire population of Northern Ireland (e.g. cancer treatment, major trauma, cardiac and neurology) as well as providing for their local populations.

Developing Better Services

Acute to stay acute

Altnagelvin (Derry) Antrim Belfast City Causeway (Coleraine) Craigavon

Daisy Hill (Newry) Royal Hospitals (Belfast) South West (Enniskillen) Ulster (Dundonald)

Local

Downe (Downpatrick) Mid Ulster (Magherafelt) South Tyrone (Dungannon) Tyrone County (Omagh) Whiteabbey

Acute to become local

Lagan Valley (Lisburn) Mater (North Belfast)

Health affects everyone in society and has been a major political topic since devolution returned. agendaNi summarises the main parties’ commitments from their Assembly, European and Westminster manifestos. Health is devolved except for some sensitive ethical matters e.g. genetics.

UUP
Minister: Michael McGimpsey MLA
Spokesman: John McCallister MLA

The UUP claims credit for bringing the NHS to Northern Ireland in 1948 and took on the portfolio in May 2007. Its Assembly manifesto pledged a move towards free comprehensive eye examinations, free prescriptions, and an extension of the NHS Direct helpline to the province.

New nurses would be guaranteed one year’s employment. Other priorities included investment in dentistry and targeted prevention programmes for diabetes, strokes and cardiovascular disease. A law to protect health staff from assault and abuse would be brought forward, and the Appleby and Bamford reports implemented.

In 2010, Conservatives and Unionists pledged year-on-year increases in health spending, more single hospital rooms and a new NHS dentistry contract.

DUP
Assembly Spokesman: Jim Wells MLA
Westminster Spokesman: Jim Shannon MP

The Appleby report’s finding that Northern Ireland’s Health Service had suffered from long-term under funding was affirmed by the DUP in 2007. Reduced bureaucracy was a particular priority. The party wanted the Health Service to focus on health promotion, early intervention and preventing illness at a community level. More action was needed to tackle suicide.

Enhanced intermediate and community care would allow much earlier discharges from hospital. National Institute of Clinical Excellence guidelines would be extended to Northern Ireland.

In its European manifesto, the DUP called for a ban on human cloning and opposed embryonic stem cell research.

Free personal care, based on medical need, was supported and further financial savings could be made in generic drug prescriptions.

The party criticised the Public Health Agency in its general election campaign, as “vast numbers of staff” were “doing exactly the same jobs within a re-titled organization”.

The detailed Westminster manifesto pledged support for a prostrate cancer screening programme, minimum pricing for alcohol, outlawing smoking in cars with children, and presumed consent for organ donation.

Computerised cognitive behaviour therapy could save nearly £10 million.

Northern Ireland trusts would also benchmark their performance on cancer with those in Great Britain. Patients should receive psychological therapy in two weeks.

A self-referral pilot for physiotherapy was also proposed.

Sinn Féin
Assembly Spokeswoman: Michelle O’Neill MLA
Oireachtas Spokesman: Caoimhghín Ó Caoláin TD

Full implementation of the Investing for Health strategy was pledged in Sinn Féin’s Assembly manifesto The Bamford report and suicide prevention strategy would also be fully implemented.

Primary care would be brought to the centre of the system. Free prescriptions and a minimum purchase

price of 18 for tobacco were supported. Sinn Féin also proposed a rural health task force and backed cross-border health services. Waiting lists were to be dramatically reduced or even eliminated.

Health services should remain under national control, its European manifesto said, although it is unclear whether there were any plans to undo that.

The party’s overall vision is a “seamless all-Ireland health service”, it said in 2010. The Public Health Agency should also “tackle social inequalities earlier and more effectively.” Sinn Féin held the health brief from 1999 to 2002.

Alliance
Spokesman: Kieran McCarthy MLA

Health funding must be brought up to the EU levels within five years, Alliance stated in 2007. The party also called for regional specialist centres e.g. for cancer treatment, and emphasised the benefits of cross-border co-operation.

A lengthy priority list was drawn up, including free personal care for residential and nursing home residents, increasing the tobacco purchase age from 16 to 18, reducing the drink drive level from 80mg to 50mg. The party warned of an “over- reliance on costly agency staff” and sought adequate numbers of occupational therapists and physiotherapists. Eye and dental check-up charges would be abolished.

In 2009, candidate Ian Parsley suggested Northern Ireland could be a European centre for cardiac research and micro-surgery. In 2010, Alliance re-emphasised the gaps in mental health services and social care for senior citizens.

Green Northern
Spokesman: Brian Wilson MLA
Oireachtas Spokesman: Senator Niall Ó Brolcháin

A ‘green’ health service would focus on community care, the party’s Assembly plans stated. Greens called for a health ombudsman office to investigate disputes over healthcare provision and environmental health risks. The pharmaceutical industry also needed more accountability.

Flouridation of water would be stopped. The party also saw a need for new disability legislation, based on needs and rights, the expansion of domiciliary services and the extension of the hospice movement. In 2010, it called for an end to the “business-centric culture” in hospitals.

SDLP
Assembly Spokesman: Tommy Gallagher MLA
Westminster Spokesman: Dr Alasdair McDonnell MP MLA

The SDLP’s detailed Assembly manifesto contained a long list of health priorities. Specific commitments included bringing back outsourced hygiene and cleaning services under hospital management, widening access to NHS dentistry, full funding for the Bamford report and suicide prevention strategy.

Strategies would be drawn up on autism, Alzheimer’s disease, arthritis, multiple schlerosis and protecting health workers from attack. An all- Ireland forum on mental health was also proposed. Carers were encouraged to look after their own health as well; suitable respite care would be provided.

The 2009 manifesto linked public health with environmental policy and called for ‘health impact assessments’ for all policies. Its 2010 successor prioritised all-island services rather than flying patients to England, an eating disorder unit, obesity prevention strategy and a new preventative health fund.

PUP

The continued development of private medicine was “detrimental” to providing adequate secondary care for all, the PUP said in 2007. Public- private partnerships were opposed. The party was keen on community- based health work and supported primary care development. It currently has no MLAs.

“High need” young people from Northern Ireland who have been in residential care most of their lives often lack basic skills such as boiling a kettle.

Despite the fact that from the moment a child enters a residential care home, the focus is on preparing them for independent living, many who have experienced traumatic upbringings still resort to crime and drug abuse. Consequently, staff are on 24-hour call to deal with incidents such as self-harm and mental breakdowns.

“Less than five” children died in care in the last three years up until March 2009. This figure does not include the widely publicised death on 7 June of Darlene Bell who had been living in a residential care home in Newtownards. The Department of Health, Social Services and Public Safety said it could not release the exact figure to protect the identities of the children who died.

Latest figures show that 2,463 children were in care in Northern Ireland as of 31 March 2009. These children range from age one to 18 (or 21 if they are still in education or are disabled) and are in short-term, long-term or foster care. The largest portion of these children are in the 12 to 15 age group. Seventy-two are under one.

A 10-year social work strategy for Northern Ireland is currently being drafted. A departmental spokesman told agendaNi that the initial impetus for the strategy was the RPA but there is now a pressing “need to communicate the role and contribution of social work in improving the health and social well-being of individuals, families and communities in Northern Ireland.”

In addition, some strategic issues have to be faced by frontline social workers and their managers. These include:

• the increasing rise in referrals and the need for integrated health and social care;

• the retention of social workers in child protection practice;

• a poor public image and unrealistic expectations of what social work can deliver, particularly in high risk situations; and

• the need to design social work services around the needs of people who use them.

There are 53 children’s homes in the province. Of these, five are intensive support units which are children’s homes with additional support such as mental health services. There is one secure unit, Lakewood in Bangor. Children who have a history of absconding, or are considered to be a risk to themselves or others, are sent there under a court order.

According to Stephen Knox of Barnardo’s, children in long-term residential care are “one of the vulnerable and disadvantaged groups in society” and are statistically more likely to have poor educational outcomes, be unemployed, become young parents, get into trouble with the law, experience mental health difficulties and be at risk of poverty and homelessness.

Knox told agendaNi: “Residential care over the years has had its difficulties in terms of the issues attached to young people’s behaviour. For example, the dynamics of group living experienced by young people who are coming [into care] with lots of problems because of their backgrounds.”

Similarly a report by researchers at Voypic (Voice of Young People in Care) found that young people in the region have identified “difficulties and frustrations” in care, including “the absence of private space, conflict with peers, problematic relationships between children and staff, and concerns about the use of discipline and restraint.”

Staff in residential care are very keen to improve educational and employment outcomes, Knox says. He points to the ongoing strategy formation and the fact that the health department is currently researching different models of future provision with the Social Care Institute for Excellence.

In addition, he acknowledges that Health Minister Michael McGimpsey allocated £20 million from 2008-2011 to implement the ‘Care matters – Building a bridge to a better future’ strategy.

In November 2009 McGimpsey said: “This investment is already making a difference in the lives of many children and families.”

Knox works on Barnardo’s ‘Leaving Care’ project where young people are given practical and emotional support and temporary accommodation when they are leaving care. He remarks that “sometimes you’re talking about very basic skills; skills of being able to feed yourself and clean your flat, as well as develop personal relationships.”

Because young people are still often moved from one care home to another, this can be disruptive to their development.

“In order to ensure that children have a stable and secure childhood, they need greater continuity of care and we need to ensure that they stay in school so their educational achievement is increased significantly,” Knox concludes.

Northern Ireland faces extremely challenging times in meeting its commitments to maintain standards of service in health and social care. As the Assembly budget process moves forward, it is worth considering the English and Scottish predicaments.

In Scotland the SNP Government is committed to ring-fencing health spending. The block grant to Scotland will fall by £1.8 billion next year, which means local government spending will need to fall by 18 per cent by 2014 if the NHS is ‘spared’. This is a high risk, make or break issue for the Scottish Government.

In England the Coalition Government is also pledged to ring-fence the NHS from cuts. The October spending review left the NHS in England with a 0.1 per cent a year real rise in spending to 2014, which corresponds to a cut in real terms should the inflation rate remain above the 2.0 per cent target. Even more worryingly, King’s Fund health services analysts have calculated that the English NHS needs productivity gains of 6 per cent per annum if it is to keep the service on track to meet what the Wanless Report on the future of the NHS termed ‘solid progress’. Anything less and current standards of quality, safety and access fall.

Hard times ahead

Will finances be quite as badly over- stretched here? The Barnett formula applies a proportionate share of any increase (or decrease) in comparable English departmental spending programmes to the Northern Ireland block grant.

Health and education, which are very significant elements in the formula, have been less harshly treated in England than some non-included programmes such as defence or welfare benefits; hence Northern Ireland is partially protected.

But don’t think this means that hard times are not ahead. Standing still means finding productivity gains on much the same level as those required in England. A year-on-year productivity gain which provides 6 per cent more service from a static budget seems beyond the NHS. According to the Office for National Statistics (ONS), the NHS actually suffered an annual average decline of 0.3 per cent in productivity between 1995 and 2008. They measured productivity on the basis of performance in hospital in- patient, day case and out-patient episodes, GP and practice nurse consultations and prescriptions, dental treatment, sight tests and ambulance journeys.

The ONS generalised for the NHS as a whole but there is no reason to think there is any less of a problem here in Northern Ireland. Realistically a gap of over 6 per cent cannot be ring-fenced away unless dramatic cuts are made elsewhere in the Northern Ireland spending programme. Given that health and social care consumes almost half of total Assembly controlled expenditure, the pain elsewhere would be excessive.

Forget also the popular notion that the NHS and social services can balance the books by focusing on ‘back office’ administrative waste. Administrators are frequently the front-line of the NHS as far as patients are concerned and often much more integral to the clinical care process than is acknowledged. Many administrators come from nursing backgrounds.

Austerity

If we accept that health and social care austerity has arrived, then there are three basic options for coping. Firstly there is the ‘operational gains’ approach. This is in many ways the default mode for management in the NHS and social care and implies that cuts will be made on a ‘salami-slicing’ basis, whereby activities are starved of funds and although made less effective, do continue to exist. The second option involves ‘surgical removal’, that is certain areas of expenditure are cut out in their entirety. The third and most radical approach is ‘transformational’ and signifies an intention to deliver services in new more effective ways.

The operational gains approach will create a boom in micro-management. Managers will feel busy. The nurse at Altnagelvin needs to be told why she can’t have a new pencil and the porter at the City will have to wait until 2012 for a replacement brush. The NHS in Northern Ireland employs around 70,000 people who each provide an opportunity to make lots of small cuts, but to get anywhere near the cuts target means clinical services will suffer.

Conveniently, salami-slicing does not need evidence-based assessments of where the best targets lie; it will be much more random, with unpredictable results for the quality of services provided to patients. The plus side is that managers are pursuing lots of small-scale cuts and, critically, while doctors will be impaired in their ability to provide services, they need not be co-opted into strategic choices.

The second ‘surgical’ option might involve closing hospitals in Northern Ireland or at least ending particular services in selected locations. The key is to avoid ‘peri-operative’ service collapses, the co- operation of doctors is crucial in the process. There is recent experience in Northern Ireland in making such interventions but not on the scale and timescale required to meet the productivity challenge. While performance evidence is available to assist choices, political considerations will inevitably make it hard to close down hospitals and services associated with particular localities.

The third transformational option is to encourage productivity campaigns at the level of the ‘clinical micro-system’, the small teams of clinicians who deliver health care to patients. Supporters of this approach trust doctors, nurses and other clinical professionals to work out ways of combining their expertise to deliver

services of better quality at lower cost.

Vested interests

There are, as always, vested interests in the NHS and social care sectors to resist transformational change. Call them realists or even pessimists if you like, but long-term observers of the NHS and how it responds to financial constraint will almost certainly anticipate a bias in the response to austerity that emphasises salami-slicing rather than clinician-led service re-design or evidence-based closure of ineffective services.

Could Northern Ireland be different? Northern Ireland could be helped significantly by an absence of any further distraction for clinicians in the form of structural change. The English NHS is about to be expensively re-structured yet again, of course. In addition, unlike in England, health and social services are already integrated in organisational terms.

The Assembly could push through changes to allow revenue to be used for capital investment, if that is required to support the development of new more efficient clinical practices. Small but significant changes could be made to financial regimes at hospital level, such as allowing clinical teams to retain end of year surpluses for invest to save purposes. Strong political leadership is needed at this point.

Health is bad for you. Spending time exploring the complex realities of health service delivery is enough to give anyone a headache. We all depend to a greater or lesser degree on the Health Service and require it to deliver a service which meets our endlessly increasing requirements in a time diminishing resources. But even in this situation the last thing the Northern Ireland Executive should do is ring-fence the health budget and here is why.

For over a decade our Health Service has been undergoing a major reorganisation. The new structure, designed to take the politics out of much the Health Service has given birth to an army of managers and a new ‘ism’ nearly as scary as a tropical disease – managerialism. The whole point of this exercise was to bring greater efficiency

and better value for money into the health service.

In July 2005 the Professor John Appleby authored a report in which he identified significant inefficiencies in the Northern Ireland Health Service and made 25 recommendations for change. His report went down like a lead balloon. Two years later a new local Minister reorganised the NHS locally along the following lines:

• a streamlined regional Health and Social Care Board focused on commissioning, performance management and improvement and financial management which both encourages and ensured access to quality services responsive to need;

• dynamic local commissioning groups with the active involvement of GPs, professionals within social work, public health, nursing and allied health professionals; other primary care practitioners; and community representatives;

• a smaller department more sharply focused on its responsibilities for serving the devolved administration, bringing forward legislation, and determining and periodically reviewing policy, standards, priorities, and targets;

• the establishment of a ‘common services organisation’ to provide a broad range of support functions for the health and social care service;

• a new regional Public Health Agency to create better inter-sectoral working to tackle health promotion and inequalities and help realise the shared goal of a better and healthier future for all our people, which would incorporate the functions of the existing Health Promotion Agency;

• action to reinforce the independence of the health and social services councils and strengthen the regional aspects of patient, client and carer representation while maintaining a strong focus;

increased democratization through local government representation on key bodies and improved partnership and local government and other stakeholders in the commissioning and delivery of health and social care.

The first couple of years of managerialism were plum. Lots of cash to outsource the reduction of waiting lists led to some big results. But since the financial squeeze has hit, things have turned bad again. Key performance targets are being missed and the bad headlines just keep coming.

In organisational terms, the number of health trusts has been cut from 18 to five. The rationalisation targeted 1,700 executive, managerial and clerical level posts across both professional and administrative services, freeing up some £50 million to be invested each year in service improvements.

Then several new health bodies were established, including the new Health and Social Care Board, the Business Services Organisation, the Public Health Agency and the Patient and Client Council.

While more than £5 million worth of savings were made initially, in the past year the total trusts’ management costs have risen again to £120 million.

In November, the Department of Health admitted it employs 920 staff in agencies or arm’s length bodies on wages of over £100,000. In October, the department’s Permanent Secretary admitted patients in Northern Ireland receive an inferior service compared to the rest of the UK. Real concerns continue to be raised about key areas such as mental health services and the management of long-term chronic conditions. The cost of free prescriptions is twice as high as the Minister thought it would be. Popular politics maybe, but it is a decision which will cost us all in the long run. And all this even before the impending cuts.

The last thing we need to do is reward this culture by ring-fencing the health budget. Protect front-line services by all means but ring-fencing will send all the wrong signals to a system in need of radical cultural change.