Official Report (Hansard)
Date: Wednesday, 07 March 2012
Committee for Health, Social Services and Public Safety
Community Meals: Departmental Briefing
The Deputy Chairperson: Before we hear from the departmental officials, I will raise a few issues that have become apparent. There is concern that the Department seems to have a general lack of control or understanding of what the trusts are doing in this field. We were told that the Belfast Trust charges £2 for a meal, and yet the trust has told us that it is £1·50 a meal. There is no information about how the Department is going to tackle the fact that trusts seem to be disobeying the rules imposed that a meal must only be charged at £1·50. If trusts are blatantly disregarding that circular, what confidence have we that they are obeying other circulars on other issues? What checks does the Department have in place and what has it done to audit compliance with that and other circulars?
The Chair is very keen that the officials talk to the Department of Education at some stage about using school meals kitchens for provision, which seems an obvious use of a facility that is there already and which could reduce costs. We are flagging up those issues. However, Christine and her team have been listening to the previous very long session, and I think that they have got a flavour of where we are going.
I introduce Christine Jendoubi, who has been here dozens of times and is a season-ticket member of the Committee. This is about the fifth meeting out of six at which Christine has given evidence. She is director of the Department with responsibility for mental health, disability and older people. You are very welcome.
I also welcome Michael Swann, who is a principal in the Department with responsibility for the elderly and community care; Brian Taggart, who is a deputy principal in the Department with responsibility for the elderly and community care; and Kevin Keenan, who is assistant director for older people in the Health and Social Care Board.
You are all veterans of the Committee and know what you are doing. I invite you to make a presentation to the Committee, perhaps, at some stage, picking up on the points that I mentioned. If you do not, they will be picked up with a question anyhow. I will then throw the meeting open to members. Kieran and Mark would like to come in early with their questions.
Ms Christine Jendoubi (Department of Health, Social Services and Public Safety): Thank you very much, Deputy Chair, for the opportunity to present again. Much of our briefing paper this time centres round the provision of statistics that we discussed the last time we were here, so I will not labour the point again. I am going to keep this quite brief. You have heard from the trusts, and you have had an opportunity to ask them about their arrangements. We are happy to answer any further questions that you might have on a regional policy level.
At the last meeting, you asked us to pursue a couple of points, and I would like to pick up on those. The first relates to the contact with the Department of Education, which you have just alluded to. We wrote to the Department of Education immediately after the previous session asking whether school meals kitchens could be a viable means of providing community meals. The preliminary response from DE is that there is no legal reason why school meals kitchens could not supply to trusts. Education and library boards may legally undertake commercial activities, but that is a matter to be organised at local level between the trusts and the education and library boards. Education and library boards cannot undertake any commercial activity detrimental to their duties under the education orders, any activities that require them to increase manpower, require an increase in public funds, or involve a loss of such funds. In other words, they would need to be able to do it in their own time, and they would need to be able to break even. If they make a profit, it goes back to the education and library board for investment in education provision.
Our information from the Department of Education is that the Western Education and Library Board has had yearly contacts with the local health trusts for more than 25 years. Alan Corry Finn discussed that at some length this morning — sorry, this afternoon.
The Deputy Chairperson: It seems like this morning. [Laughter.]
Ms Jendoubi: It was a long time ago. The Western Education and Library Board charges the full economic cost plus VAT, and, even then, the Western Trust finds that that comes in considerably cheaper than some of the other commercial outlets that are providing meals. The downside is that school meals kitchens are only open during term time and, therefore, operate 38 weeks a year, so alternative suppliers have to be found for the remaining weeks. However, it is worth pursuing that with the education and library boards and the trusts to see whether a 38-week/14-week model would work in some areas.
You asked also about the linkages between the access criteria for domiciliary care and the eligibility criteria to support and maintain service users' independence in meals preparation. I was going to say a few words about that, but the trust representatives have gone into that in a large amount of detail, so I will be reasonably succinct if I can. It is our understanding that the two are neither mutually exclusive nor mutually dependent. The access criteria for domiciliary care focus in the main on personal care but also embrace risks around the inability to carry out what they call vital domestic routines, such as food preparation and eating. The eligibility criteria for supporting independence in meals preparation focus down on a much narrower range of activities. In other words, a person can be assessed as needing domiciliary care for a much wider range of needs than meals preparation. However, if a person is assessed as eligible for help with meals preparation, they are also very likely to fit the criteria for domiciliary care at some level.
You asked what we have done about the trusts' non-compliance. The Department was not aware that the trusts were not complying with the terms of the circular until the Committee raised that issue with us, at which point we started making enquiries. After the last session, we wrote to all the trusts and asked them to confirm whether or not they were in compliance with the circular. If they were not in compliance, we asked how long it would take and at what cost to be in compliance? We have not had a reply from all five yet, but our intention is to ensure that they all come into compliance as soon as possible.
There is a wider issue about our monitoring of adherence to departmental circulars. It has not, in our experience, been an issue before that health trusts or, indeed, education and library boards, do not comply with circulars issued by Government Departments. Certainly, my experience over the years with the judicial review system is that a judge tends to take a departmental circular as, if not the law, then certainly something that an arm's-length body is expected to adhere to, and those bodies will have to account for why they disregard it. This particular circular could not have been clearer, and, as Charlotte McArdle indicated, this is the first year that it has been so specific. In think that in itself has created a problem.
Mr Gardiner: Excuse me, Chair, could I just ask this: could you name the trusts that have not co-operated with you?
Ms Jendoubi: We do not have a full house of replies yet, but you heard from the trusts this morning. The Northern Trust gives a range of charges. The Southern Trust is compliant, and we received a response from it. The first information from the Belfast Trust was that it charged £2 per meal to the client, but it has since corrected that figure to £1·50, so that trust claims that it is now compliant. My understanding is that the South Eastern trust charges £2, and that there are a range of charges in the Western trust, depending on the provider.
The Deputy Chairperson: Thank you for that, Christine. I just want to clarify what you said about the £1·50 charge in the Belfast Trust. Did they suddenly discover that it was wrong and immediately changed their rules, or were they right all along?
Ms Jendoubi: The person who gave us the original information was wrong. That was someone who works in the kitchens, who found it difficult to disaggregate what Domestic Care services are charging them from their overheads and their management costs that are all part of the cost of the meals. They can apportion to the other trusts, but they find it difficult to apportion to their own costs. I am sorry if that does not make much sense.
The Deputy Chairperson: It does raise a slightly different issue. Trusts are audited and the Department checks the books at the end of each year. Obviously, the trusts are the big spending engines in the Department, not the Department itself. This disparity seems to have been drifting along for quite a long time, and no one picked it up. To me, that hints that perhaps there are other things going on that have not been picked up and may be even more serious. Would there not have been a mechanism in the annual audit that would recognise that something was not correct? In other words, why did it take the Committee to discover it rather than the Department's auditors?
Ms Jendoubi: I am not sure how I can answer that, not having looked at the board's books at that level of detail ourselves. That would be for the finance directorate to answer, I am afraid. Indeed, it is the finance directorate that issues the charges circular; it is not a policy circular.
The Deputy Chairperson: It is interesting what little nuggets you can turn up. Are you content that, within a short period, all the trusts will comply with the circular?
Ms Jendoubi: We will certainly tell them that that is what we expect of them.
The Deputy Chairperson: Do they have any option? Can they blatantly disregard the circular? Is it even a choice?
Ms Jendoubi: The Department could not preside over a situation in which trusts blatantly ignore the terms of a very clear circular such as that.
The Deputy Chairperson: Unfortunately, I was at a court case in Newry this morning, so I came in only at the latter end of the hearing. However, I know enough about what is going on generally to ask whether, on the evidence that you have heard today and previously, you are concerned that, after all the new criteria are implemented, there will be a postcode lottery? In other words, that someone who lives on one side of the river will be more likely to have a meal delivered to them than someone on the other. From what we have seen, it looks as if there is a great disparity in how the trusts interpret the new criteria for meals provision.
Ms Jendoubi: That is not what we would want to see, nor is it a situation with which the Minister would be comfortable. What we will have is a situation in which every client is charged £1·50; and in which all the trusts are operating the eligibility criteria. That means that if a client needs help preparing or eating a meal, he or she will get it, but not necessarily in the form of a delivered meal.
All trusts will operate, as they do now, the access criteria for domiciliary care. All trusts will operate the re-ablement approach to helping people to regain their mobility and independence. When all those pieces are in place, when all the trusts are operating to the same rules, the postcode lottery should not exist.
The Deputy Chairperson: You are spending £19·2 million a year on nutritional supplements, mostly for elderly people who have dietary problems. Is there a concern that that might exacerbate that figure; in other words, that, as you gradually withdraw — clearly you are saying that that will lead to a significant drop in the number of people who are entitled to community meals — you will simply lose on the roundabouts in the form of increased prescriptions for nutritional supplements?
Ms Jendoubi: That, again, is outside our remit. It is more of an issue for primary care and what is being prescribed. It is certainly something that we want to look at, but, as Charlotte mentioned earlier, there could be a variety of reasons why people are being prescribed nutritional supplements.
We would certainly not like to see people's need for nutrition not being met through proper food because individuals cannot make their own food or because they cannot afford their own food, which is a benefits issue. As a result, the health system would have to make that up by prescribing nutritional supplements. That is not a quality of life issue at all.
The Deputy Chairperson: Yes, but it is important. Given the very significant budget — I was quite shocked when I saw just how much we are spending on that — I would have thought that, before there was any change in the eligibility criteria, you would have looked at what the knock-on impact would have been at the other end. I accept that it is a different section; you are in to the prescribing budget while, of course, you are in the social care end of things. However, in the joined-up Department that we have of health and social services, you would think that, if we are going to save £1 million by reducing community meals but we are going to add another £2 million in nutritional supplements, it is coming out of the same pot and maybe we had better look at that. I get the impression that there has been no assessment of the eventual outcomes in respect of prescriptions.
Ms Jendoubi: There has not been any examination of that so far. Clearly, however, it is something that we will want to look at. We are going to have to keep an eye out to make sure that we are not losing on the roundabouts and gaining on the swings, as you say.
The Deputy Chairperson: But we are halfway through the process. The Southern Trust is well down the route, and the Belfast Trust is about to embark on it. You are going to look at it only when it is all finished and it is maybe too late to turn back the clock. Would it not have been better to have done that before there was any change in the eligibility criteria?
Ms Jendoubi: I imagine that there is information about spend on nutritional supplements for the past five years. I do not know whether that is the case, but I imagine that it is.
The Deputy Chairperson: But it really did not arise until the Committee raised it with you.
Ms Jendoubi: That is right.
The Deputy Chairperson: It is interesting that mere laymen like us can provoke as vast an empire as the Department to change track or at least consider something different.
Mr McCarthy: Christine, thanks very much for acknowledging the Committee's role in bringing us to where we are at. We are not there yet, but at least you have acknowledged, as the Deputy Chairperson said, that we are doing some good.
You were here all afternoon, so you heard most of the thing. Do you have concerns about the vast drop in the numbers of community meals being delivered, but yet, at the same time, some 38% of older people who are admitted to hospital suffer from malnutrition? Surely, if the stricter eligibility criteria continue to be used, the end result will be further malnutrition, which will mean a greater cost to older people and our health service.
Secondly, would you like to comment on how your policy for provision of community meals will be influenced by the Compton review: for example, the use of social care as a preventative tool, and your recently published nutrition strategy?
Ms Jendoubi: I have to confess that I heard the figure of 38% only today. The most recent information that we had from hospital information branch was that, in 2010-11, there were 56 admissions across Northern Ireland, comprising 51 individuals, where malnutrition was identified as a primary or secondary diagnosis. The 38% of admissions is new to me, and I cannot comment on it.
Mr McCarthy: The trust people said the same, but that is the information that we have been provided with.
The Deputy Chairperson: I understand that that was the secondary diagnosis. They were in for something, and, as a result of a further diagnosis, they were discovered to be malnourished. They were not in the hospital in the first place because they were malnourished. That might explain the discrepancy in the figures.
Ms Jendoubi: The numbers that I gave also included a secondary diagnosis. There were 56 admissions, comprising 51 individuals, where malnutrition was identified as a primary or secondary diagnosis.
Mr McCarthy: Apart from that, are you concerned that the stricter eligibility that I think will be used will further exacerbate what we are talking about — that more people, either through secondary or primary, will go into hospital because of malnutrition? That is the last thing we would want.
Ms Jendoubi: I am afraid that all I can do is repeat what the trusts said earlier, which is that this is not about people not being helped to get food. There is a world of difference between the eligibility criteria saying that people are able to help themselves and have the mobility, dexterity and acuity to be able to prepare their own food and who thereby do not need a community meal delivered; and saying that we are going to do all these assessments and may stop their meals on wheels but will ensure that they get help from somewhere. The purpose of the Northern Ireland single assessment tool (NISAT) nutritional assessment and the purpose of the assessments that the community nursing staff do is to try to ensure that where people are deemed to have a need to have somebody help them prepare and eat their food, they get that, but it is not necessarily in the form of a delivered meal.
Mr McCarthy: Let us hope that that comes to pass. I really worry, as I said earlier, that there are so many lonely and isolated people out there that they will simply miss it and they will end up in hospital for all sorts of reasons. That is my main concern.
Anyway, can you comment on the Compton review? How will it affect the Compton review, which talks about the nutritional strategy?
Ms Jendoubi: Yes; the emphasis on social care, the shift left and supporting people to remain in their own homes. It is all part of the same continuum. It requires a shift left in resources as well as a cultural shift left in where people are treated. That requires an investment in community care of all kinds that we have not yet seen. That will be one of our major challenges over the next few years. Transforming Your Care outlined a major decrease in the use of residential care over the next five years, and the clear implication of that is that we are going to be supporting more people to live at home, and delivered meals is one stratagem in a range —
Mr McCarthy: Are you concerned that the funding resources will not follow that policy? Is that fair to say?
Ms Jendoubi: My concern is that we get to see the shift of resources out of secondary care and into community care that that will require.
Mr McCarthy: That is important. That is vital.
Mr Brady: Thank you for your presentation. We have heard a lot about re-ablement today, and you have mentioned it, too. Some of the trusts appear to be relatively far advanced in its implementation. The Belfast Trust says that it is just starting, but it seems to have had a miraculous effect in the Southern Trust area. It is almost the Lourdes effect —
The Deputy Chairperson: Not all of us would subscribe to that, Mickey. [Laughter.]
Mr Brady: I might not subscribe to the miraculous effect re-ablement has had on the reduction in meals required. Does the Department have any input into that policy of re-ablement? I presume it would be seen as a cost-effective way of making people more independent, and so on, which ties in again with what Compton said about people remaining in their own homes and being relatively independent. Does the Department have any input into influencing the trusts in the use of re-ablement and that kind of policy of making people more independent? It seems to work. Paula said that it works for some but it does not work for others. It is a relatively new concept to me, but I was wondering what input you might have.
Ms Jendoubi: Re-ablement is not a departmental policy issue —
Mr Brady: Maybe that is the question that I was asking. It is more for individual trusts.
Ms Jendoubi: Yes; it is a service delivery issue, or an operational strategy, if you like. It is quite simply based on the belief that it is better for people to have all the functionality that they can have, and, to achieve that, they are now providing an intensive period in which people are worked with to achieve that level of mobility and independence again in such a way that, perhaps they did not have that input before, or maybe the input was less per week but for greater numbers of weeks, and people never quite retained the level of mobility and independence that they had.
Mr Brady: The lack of uniformity across many areas in the trusts has been highlighted today, and re-ablement seems to be one of those areas. Some started much earlier. Is that because people in that trust have a firm belief that it is something that is worthwhile? Has it been tried and tested, and other trusts have then decided to use it? If I go back to the figures for the Southern Trust over three years, there was a 77·5% reduction and no referrals in that period, which seems totally disproportionate.
Mr Kevin Keenan (Health and Social Care Board): With regard to the wider picture on re-ablement, it was first promoted very strongly in other jurisdictions in the UK. The Department of Health across the water pushed it very strongly. It was only latterly that we embraced it here in Northern Ireland. We have to take credit for the fact that it was the board that embraced it, set up the project board and pushed it very strongly. I absolutely agree that it is not a magic bullet. To some extent, it may be a repackaging of themes that have been in the system for a considerable time. However, the financial context in which we are operating has given it a new focus. To a very large extent, re-ablement is about trying to divert people from the system who do not need to be in there or who continue to survive well outside it.
Mr Brady: Can I clarify something? You said that the board pushed the idea. Does that not influence what the trusts are doing? Is it not, in a sense, a policy issue? You are saying that the Department pushed it towards the trusts. It goes back to what we are talking about, which is joined-up thinking in all of this. The trusts are in integral part of the Department, so why is there that disparity?
Mr Keenan: I will look in two directions. It is not inconsistent at all with a whole lot of the policy themes that the Department has been pushing. You heard this afternoon about NISAT. No one has pushed that stronger than Christine and her colleagues. A lot of the good things that are articulated or crystallised in re-ablement have been promoted through the Department. I want to make it very clear that there is no dissociation between the concept that we are pushing in the board and departmental policy.
Mr Brady: Maybe the difficulty is the difference between promoting and convincing.
Mr Keenan: Looking in the other direction, the trust that has adopted it or embraced it most enthusiastically, and you have already recognised it, is the Southern Trust and, latterly, the Northern Trust. You have to win hearts and minds. Over the years, we have learned that just imposing something on five large corporate entities does not work particularly well. If this is about a cultural change or an attitudinal change with regard to a large workforce, we have to sell the concept. We have a project board up and running, which we established in September/October last year, and part of the initial process has been trying to do a stocktake of where people are at. The Southern Trust has progressed things well and so has the Northern Trust. Some of the other players are coming late to the table. However, the important thing that the board is saying: you all have to do it.
Mr Brady: As it has been so successful, apparently, in the Southern Trust and is saving so much, you would think that the other trusts would be rushing to emulate it, but that does not necessarily seem to be the case.
Mr Keenan: Re-ablement is a hugely important strand of what we want to do. We just have to be very careful about thinking of it as a magic bullet. I want to promote it, but I do not want to oversell it. I do not want people leaving the room this afternoon thinking that every single problem in the community or social care can be solved by the R-word.
Mr Brady: I do not think that we will be doing that.
Mr Michael Swann (Department of Health, Social Services and Public Safety): The pilot was run in the Southern Health and Social Care Trust. It was a case of waiting for that pilot to run its course and then getting the information on the outcomes. That took some time to evaluate. It was not a straight run through all the trusts.
The Deputy Chairperson: At the previous meeting, Christine, we asked why there had been no referrals in the past two years in the Southern Trust, and you said that there had been. That must have come as a surprise to the main provider because it did not have a single referral in the past two years in that area. It then transpired that what was going on could relate to the fact that there is more than one provider in the Southern Trust; there is one large provider and several smaller ones. The referrals were being made only to the smaller providers, which looked after specific areas. That still begged the question of why there was a large area of territory covered by the big provider in which there had not been a single referral. There has to have been somebody in that area in the past two years who met the eligibility criteria. It cannot be possible that nobody on the left-hand side of the dual carriageway met the criteria while people on the right-hand side were still being referred. That is roughly the split. What is going on there? The Southern Trust has been evangelical in its application of the new criteria, but you cannot have huge swathes of the Southern Trust where nobody has qualified over the past two years. That has to be wrong.
Ms Jendoubi: You had your opportunity to put that to the Southern Trust —
The Deputy Chairperson: I did not, unfortunately. You provided us with that information the last time. The information that we had was that there were no referrals at all in the Southern Trust.
Ms Jendoubi: My understanding was that there have been very few, but there have been a small number.
The Deputy Chairperson: But only in specific small areas. There has been none in the area covered by Domestic Care. That strikes me as odd. I apologise: I could have asked it of the Southern Trust, but, as I came late to the hearing, I did not feel that I could.
Are we going to get to a stage at which there will be so few people being provided with community meals by these companies that, in fact, the whole viability will crash? If there are only little ones and twos here and there, it will not be viable to drive — to take my area — from Banbridge to Tandragee, Dungannon and Lurgan, or whatever. In other words, the numbers will hit a level at which it will just not be economical for anybody to provide the service and the whole scheme will die. If you extrapolate the southern numbers, that is where we could be going.
Ms Jendoubi: The trusts have given assurances that, where people need assistance with preparing or eating food, they will get it. That need not necessarily be in the form of having a delivered meal. If it reaches the point at which it is not viable for an organisation to deliver meals, that can only be because patients, clients and service users are getting their meals in another way. The Southern Trust has been very clear that it is providing large numbers of service users with assistance in meals preparation through its domiciliary care schemes. To be absolutely blunt: it is not the role of health and social care to keep people in business. If the service is there and is needed, it will be commissioned and paid for, but if it is not needed, it will not be commissioned.
The Deputy Chairperson: No matter how you apply the eligibility criteria, there will still be elderly people in Northern Ireland who will need a delivered meal. However, if there are little pockets of them in very small numbers, it will not be viable for anyone to do it. The entire scheme will collapse because the numbers will be so small that you just cannot spread the costs over such a small number of participants.
Ms Jendoubi: It may not be viable for an organisation the size of Domestic Care Services to operate, but the Western Trust has 28 providers, some of which provide to very small numbers of people. A plurality of providers is not an unsustainable model.
The Deputy Chairperson: Are those not folk who are coming to luncheon clubs or to community centres?
Ms Jendoubi: No.
The Deputy Chairperson: Are there still people who find it viable to transport meals around a large rural area where there are very small numbers?
Ms Jendoubi: I thought, for example, that the Western Education and Library Board school meals were solely provided to day centres, and I asked Alan Corry Finn this afternoon whether his trust delivers to people's homes as well. It does. You got a list of the 28 providers, and all the meals that they provide are to homes. They are delivered meals. So, as a model, it is feasible.
The Deputy Chairperson: Even in a rural area?
Mr Durkan: Especially.
Ms Jendoubi: The Western Trust is pretty rural.
Mr McCarthy: I admire your optimism on that. The Deputy Chair talks about isolated areas. I come from the Ards peninsula, which is pretty isolated, and I fear for the people who live away up the lane, because the contractor may not see that it is profitable to go there. I worry about that. I am depending on you to make sure that those people can survive.
Ms Jendoubi: Charlotte McArdle gave the Committee an assurance this afternoon that, if an individual away up a lane needs help with their food or with feeding, they will get that, but not necessarily in the form of a delivered meal.
Mr McCarthy: Let us hope that that works out.
Ms Lewis: We were given a briefing note by the Assembly Research and Information Service on malnutrition in the community. The British Association for Parenteral and Enteral Nutrition has a series of surveys on malnutrition that is due to be produced in November 2012. However, it says here that, unfortunately, Northern Ireland did not take part in the 2011 survey. Whose responsibility is that? Who makes the decision to take part or not take part in that kind of survey?
Ms Jendoubi: Sorry, Chair, that is not within my remit. I imagine that the nursing side of the Department gets that kind of request.
The Deputy Chairperson: Could you maybe find out and come back to us? I am intrigued to know; it is an interesting point. I know that it is not in your bailiwick, but whoever is in charge of that is, no doubt, listening as we speak and will come back to us. Civil servants all over the Department watch this on the internet. I know that because I have heard from them. They will no doubt be scurrying away looking for the answer to that now.
There are no further questions. Thank you very much. The Committee will probably follow this up in writing. It has been very useful.