Official Report (Hansard)
Date: Wednesday, 29 May 2013
Committee for Health, Social Services and Public Safety
June Monitoring Round and 2012-13 Provisional Out-turn Report/PEDU Report: DHSSPS Briefing
The Chairperson: Catherine, Julie and Bernie, thanks for the information and the papers that you sent us. Who is taking the lead on this?
Ms Julie Thompson (Department of Health, Social Services and Public Safety): I will do the opening remarks.
The Chairperson: OK. I will hand over to you, Julie, and you can do your presentation, and then we will open the meeting for questions or comments. Thank you very much for coming to see us.
Ms Thompson: I thank you for the opportunity to provide evidence to the Committee on the Department's forecast out-turn for 2012-13 and its participation in the June monitoring round, and to give an update on the performance and efficiency delivery unit (PEDU) report.
First, in the forecast outcome for 2012-13, the Department's current expenditure underspend is £15·9 million, or 0·3% of its total budget, and £2·7 million in its capital budget. There are obviously a range of potential adjustments that will be at play in our final accounts. We will be updating the position as we go through the next few weeks. They are exceptionally low percentages, which continue the strong performance of recent years in this area. Notwithstanding that, the delivery of financial break-even has not been easy and has required a wide-ranging working of plans and savings proposals across all elements of the Department's budget. Budgetary constraint has meant that waiting times can remain too long in some specialties and that there continues to be a divergence from the quality of provision elsewhere in the UK. Looking forward, the level of challenge faced in 2013-14 is no less significant, and, in that context, we need to make the maximum use of our available resources through early planning with the board and our trust colleagues.
For June monitoring, it will be helpful to recap some of the key aspects of the process. First, as outlined in the briefing paper, the Department has been granted certain flexibilities in the management of its current expenditure budget that are not available to other Departments. Those include the automatic retention of reduced requirements and full flexibility to reallocate reduced requirements to other areas within the Department. That means that when it comes to monitoring rounds, our participation is different from that of other Departments. We are not permitted to table bids for current expenditure, except in the event of major and unforeseen circumstances, and we are not expected to declare reduced requirements. Any allocations made through monitoring rounds are typically non-recurrent in nature and should be used within the current financial year.
In determining our approach to June monitoring for current expenditure, we have considered a range of factors. The Department, the board and the trusts have been working closely to identify opportunities for delivering cash-releasing productivity improvements to address financial pressures in 2013-14, and we still have a funding gap that we are working hard to address. In that context, we are proposing to submit current expenditure bids totalling £55·2 million for the following initiatives: £28 million for transitional funding for Transforming Your Care (TYC); £26 million for elective care services; and £1·2 million for additional costs associated with the G8 summit. Our assessment is that it is not possible to fund those pressures from within existing budget allocations without an impact on the quality and standards of services, locations and clients.
In transitional funding, the TYC report estimated that £70 million would be needed over three years to pump-prime a number of key transformational changes to the way in which services are delivered in Northern Ireland. Members will recall that we received some £19 million from the Executive in 2012-13 to fund TYC transitional costs and other Health and Social Care (HSC) savings initiatives. The £28 million bid for the transitional cost requirements for 2013-14 is to support, on a transitional basis, service changes, including integrated care partnerships, changes in relation to stroke and re-ablement services, funding for voluntary redundancy and early retirements, and implementation support.
Additional investment of £26 million is needed for elective care in order to improve performance across a range of regional specialties, including orthopaedics, general surgery, gynaecology and cardiology.
We estimate that £1·2 million of additional costs will be incurred by the Ambulance Service, the Fire and Rescue Service and other HSC organisations on the various work streams established to provide an appropriate response during the G8 summit. It includes the provision of healthcare patient flows, integrated primary and community care, fire and rescue provision and contingency arrangements for existing patients and clients.
Our assessment is that all those bids can be considered as major and unforeseen in the context of the June monitoring round, and, as a consequence, we will be putting those bids forward.
I turn now to capital. As outlined in your briefing paper, the Department proposes to submit capital bids of some £57 million in June monitoring. That will enable a number of key projects to commence in 2013-14, including the development of cardiac catheter laboratories at the Royal Victoria Hospital site and investment in a range of medical devices, equipment and ICT schemes. We also plan to continue investment in maintaining existing services directed towards life-threatening and high-level infrastructural risks in order to address and protect patient safety and service provision.
In conclusion, our assessment is that it is not possible to fund those additional pressures from within existing allocations, and we strongly recommend that the bids are considered favourably by the Committee and the Executive.
The Committee had also requested an update on the PEDU report. Given the First Minister and deputy First Minister's role in approving the terms of reference for the review, we have written to seek the Office of the First Minister and deputy First Minister's (OFMDFM) formal clearance to release the report to the Committee. By way of update to the Committee, the PEDU report was based on the assessment that it carried out in 2011. It concluded that although significant work had been undertaken to make savings and contain costs, this work needed to be built on throughout the Budget period to 2014-15. The Department has been working with the Health and Social Care Board (HSCB) and the trusts to ensure that that happens and that the PEDU report is built on as we look forward and develop our financial plans for the future.
We are happy to take questions from members on any issues as they arise.
The Chairperson: OK. Thank you, Julie. When did you write to OFMDFM about PEDU?
Ms Thompson: We wrote to OFMDFM last year. We are certainly keen to —
The Chairperson: You wrote to them last year asking them to provide the Committee with a copy of the paper?
Ms Thompson: Yes. We have yet to receive that permission.
The Chairperson: What date last year?
Ms Thompson: June 2012.
The Chairperson: We have asked for a copy of the PEDU report. You are saying that you wrote to OFMDFM in June 2012 asking for the paper to be released to this Committee, but that you have had no response.
Ms Thompson: We have not, but we have been liaising with OFMDFM and we are keen to release a copy to this Committee. We will happily take that back to OFMDFM and, hopefully, secure that release in the foreseeable future.
The Chairperson: It has been nearly a year.
Ms Thompson: I appreciate that, Chair. I can tell you that the PEDU report looked at our savings plans for the 2011-12 financial year. As I said, it concluded that a significant amount of work had been done but that we needed to do more, and that we needed to draw around the work that we had done previously on Appleby.
The Chairperson: I appreciate all the work that is being done around PEDU. Are you telling me now that you specifically wrote to OFMDFM last June to ask them to release the PEDU report to this Committee and that, to date, there has been no formal response, but there is an indication that there might not be a problem?
Ms Thompson: We will certainly take that back to OFMDFM and seek to secure that. Our Minister would be keen to see it released.
The Chairperson: But you are only taking that back today, when we have asked for the PEDU report recently as well.
Ms Thompson: We are certainly keen to take that back and —
The Chairperson: I am going to suggest that we write to OFMDFM as well. It is important that we get a copy of the report. Do members agree with that suggestion?
Members indicated assent.
The Chairperson: I am in good form; I am not getting wound up here, but it is an absolute disgrace that this Committee is here to scrutinise the Department, and PEDU was sent in to look at how efficiencies could be achieved in the health service, but we still do not have a copy of its report.
Ms Thompson: I can talk to the Committee more about what is in the report, but if you want to see a copy of the report, we will work with OFMDFM to —
The Chairperson: We will see about getting the report, but we will tease out some of the stuff that is in it.
I appreciate the stuff that you sent to us, but I want to talk about the transitional funding for TYC and the integrated care partnerships. In the tabled papers, Julie, you state:
"The funding will be applied to scale up AHP, Nursing and Social Work capacity".
What does that actually mean? Are you suggesting that new posts will be created?
Ms Thompson: Is that in the service change element?
The Chairperson: No, integrated care partnerships.
Ms Thompson: I will ask Catherine to go through the details of that.
Ms Catherine Daly (Department of Health, Social Services and Public Safety): You are aware of the background to the integrated care partnerships (ICPs) and what they are intended to do under Transforming Your Care. Significant work has been ongoing since the Transforming Your Care report was completed to develop the integrated care partnerships. Support structures need to be put in place to ensure that those who are involved in the integrated care partnerships can be freed up to do the work that is necessary to take forward specific areas at the outset. In terms of —
The Chairperson: I am sorry, Catherine; I need to get this right in my head. We are talking about Transforming Your Care taking a lot of services, where possible, from the acute sector into primary care in the community. Are you telling us that when you are talking about scaling up allied health professionals and social workers — I do not need to explain it to you — it does not necessarily mean that new posts will be created? What do you mean by a support structure?
Ms Daly: There are different support structures. Perhaps I have gone slightly off on your specific question. New posts will be created under the ICPs; that is inevitable. We are going through a transition process. While the work is developing, we need to put in place posts to shore up that work.
The Chairperson: In the community?
Ms Daly: In the community. That is where we will see, as the ICPs roll out, that there will be additional posts in the community that will support primary and secondary care in the delivery of those services.
The Chairperson: That is fair enough, and it is useful to hear. Maybe we can get into more detail on that at a later date. Your paper then says:
"It will also support the implementation of system procedures at a GP practice level".
What does that mean?
Ms Daly: Sorry. Again, this is about the areas of work that the ICPs will look at to begin with: the frail elderly, and elements of long-term conditions such as diabetes, stroke and respiratory conditions. And in terms of —
The Chairperson: So, is this being proactive within a GP practice?
Ms Daly: Very much so. You will appreciate that this is a developing area of work.
The Chairperson: The Committee brought forward a motion a number of months ago, which was agreed in the Assembly, that called for GPs to do annual health checks. So is this going to be a targeted, proactive approach to those who have their condition reviewed?
Ms Daly: We see that as an element of the ICP work.
The Chairperson: So there is a possibility that GPs will need additional support and services for that?
Ms Daly: That is part of the work that the ICPs will look at.
The Chairperson: How much is that bid in total?
Ms Daly: For the ICP element? It is £4·5 million for ICPs.
The Chairperson: So is that all going to be focused on staffing?
Ms Daly: A significant element of it will be. Now —
The Chairperson: Roughly how much, Catherine?
Ms Daly: I do not have it broken down into staff costs. What I can tell you is that the costs to be covered are business and clinical support team, and that will be to support the clinicians and the management of the inter-care projects, from initiation to implementation. So this is very much about the practical implementation of the work that they will be doing. There will also be staff involved in data analysis. That does not account for a big element of this, but it is an important element of the work. Structures need to be put in place to support the integrated care partnerships. There will be a partnership committee for each ICP, and that will account for some of that money as well.
The Chairperson: So, out of that £4·5 million, part of it will be for business, part for staffing. Is that for every GP practice, or are we looking at the possibility of pilots — maybe one GP practice per constituency?
Ms Daly: That is the standard structure of an ICP across Northern Ireland, across all 17 ICPs.
The Chairperson: So all of them will be doing this?
Ms Daly: There will be elements of this funding spread across all the ICPs, and each ICP will have a partnership committee.
The Chairperson: I do not want to put you on the spot, but if you are putting the bid in to the Department of Finance and Personnel (DFP), you should have all that detail. So if we can have that sooner rather than later — you might not have it to hand, but we need that broken down. Just on the transitional funding for TYC around service changes, the paper says:
"Teams of nurses, physiotherapists, speech and language therapists and occupational therapists will be deployed into the community to facilitate early discharge of patients".
Again, are they new posts?
Ms Daly: They will be new posts. The difference here is that —
The Chairperson: Sorry. Are they new posts, or are they posts that were formed in the hospital and are going into the community?
Ms Daly: Given that this is the transition, these are new posts for taking forward the service changes, but as those service changes become embedded, the posts become effectively mainstream and part of the system. The costs that will be released from other parts of the system are what we see when we talk about "shift left".
The Chairperson: I like that, "shift left", being a socialist. I like the sound of that. Keep it in there.
Ms Daly: That is where funding will be released from other parts of the service.
The Chairperson: I am trying to get this in my head. You are saying that, where an occupational therapist or a speech and language therapist is based in a hospital, this money will be used to base that post in a community setting. That post will remain in the hospital until we do that. It is not that they are not there; they are getting there.
Ms Daly: A key element of the transformation process is to ensure that alternatives are in place before a service stops or changes.
The Chairperson: So it is new?
Ms Daly: It is facilitating the transition from how we currently deliver services to the new system. In that sense, it is new. It will not continue year on year, because that is where we will see the shift. Hypothetically, we see £5 million in the community delivering on these services eventually moving out from the secondary sector. That is putting it very simplistically.
The Chairperson: That is further down the line when you change that concept of more services into primary care.
Ms Thompson: That is why it is needed on a transitional basis, effectively, to manage that change process across the years so that you do eventually take the money out from where it was originally provided and reapply it on the community side.
The Chairperson: I know that this is going to hurt you. The paper also says that funding will be used to provide alternatives to statutory residential homes. You did not get that right around TYC. How much are you expected to spend extra on domiciliary care, and how much are you bidding in total for this?
Ms Thompson: In total, the bid is £8·5 million on service changes. I would need to come back to you for a breakdown of how much of that is on the social care side.
The Chairperson: We like to get a lot of this detail when we get the original presentation, so, for future reference, it might be useful that you have this available. The total is £8·5 million, but I want to know how much of that is expected to be spent on domiciliary care.
Ms Daly: I do not have the specific figures for domiciliary care out of the £8·5 million. There are a number of elements to this, and a key element is funding that will be required for stroke facilities in primary and community settings. We will get the breakdown of that.
The Chairperson: Unfortunately, Catherine, we have a duty and a responsibility, and we have a bit of work to do, considering what has just come out of TYC around residential care. You as officials have it, and we as elected reps have to convince people again that TYC is the way forward. Therefore, it is important that we know exactly. If the additional posts that are going in around speech and language and occupational therapy are not being lifted straight out of the acute sector and being put into the community, there will be that transition period. All that information is important to know, because, if we are the conduit between the people who will be affected by TYC and the Department, unless we have the information, people will find it hard to buy into.
Ms Daly: I appreciate that.
The Chairperson: I will come back to some of that stuff, but I will open it to other members.
Mr Gardiner: Has PEDU any views on how to stop mission creep by bureaucrats in the health trusts who go beyond the policy agreed by the Health Minister, the Committee and the Assembly, especially over elderly care home closures?
Ms Thompson: PEDU looked at what was effectively a range of savings initiatives. It was focused on the 2011-12 financial year. It worked through from the findings that were previously put together by McKinsey and Appleby, who did reviews in the health service just prior to that. It worked through a range of different types of initiatives and looked at the extent of savings, going right from the importance of prevention-type work to the management of long-term conditions. It looked at average length of stay in hospital and right through into improving patient flows and better procurement. So, a whole range of work was looked at by PEDU to identify what savings could be achieved.
It found that we were doing a lot of work in 2011-12, but it commented that that needed to be made more strategic. That was carried through into the 2012-13 and 2013-14 years to ensure that we were learning from previous benchmarking reports and that trusts were building on the advice of the different reviews that were done on the health service. It is very complex, obviously. The work that was done by McKinsey, for example, was done at a very high level. It then needs to be worked down in practical terms within individual trusts as to how you would actually secure that saving and what it would actually mean. You can look at benchmarks, but it comes down to actual services on the ground and effecting the change. It did not look specifically at residential care homes; it looked at a range of initiatives across the health service and concluded that, although work was ongoing, more could be done.
Mr Gardiner: You mentioned care homes very briefly; you did not specifically look at them. Are you going to look at them? Those are our senior citizens that have done so much for our community in the past. They need care and attention at a first-class rate. I am disappointed in your attitude there.
Ms Thompson: The Committee has had numerous discussions about the care homes issue. They are still very much part of the TYC agenda and the Minister is very committed to that. A new regional approach is being put in place around care homes, so that will be managed on a regional basis. You asked whether PEDU did much around that; what I am saying is that it did not focus on that particular area. There was certainly an element of looking at social care, but it was not the purpose of the PEDU report.
Mr Gardiner: With all due respect, I think it is time that you did look at it.
Ms Thompson: That is the purpose of TYC and the outworkings that are going through. It just was not the focus of the PEDU report per se.
The Chairperson: I think the Minister has accepted that and has apologised for the way that was handled. In fairness, it is probably no reflection on the people giving the presentation now; it was others and it was the trusts that went further than they proposed. The Minister and the Department have accepted that it was wrong. It has stopped, and what we now need is the information that we are asking for so that we can ensure that TYC is delivered right and the vision of TYC is there. The ethos of the health service is fundamental to all this stuff.
Mr McDevitt: It might be useful to declare an interest as a member of the Policing Board, because I am going to ask you about G8 summit costs. I am familiar with the way policing is being paid for; I know for a fact it is being paid for by the Foreign and Commonwealth Office (FCO) and that no policing costs will hit our bottom line, so it is surprising to see the provision against our bottom line for something that is not our bill. To map it out, if I read your bid correctly, you are saying that there are a whole load of costs that will be incurred by the Fire and Rescue Service that will be picked up by the Foreign and Commonwealth Office. My first question is, how much are they and what are they for? Secondly, how are we liable for any costs for something that is not our gig and is not meant to have any impact on our bottom line at a regional level?
Ms Thompson: The direct cost of provision for the G8 summit on the Lough Erne site is very much part of a Foreign and Commonwealth Office and Northern Ireland Office issue. Our impact is much broader than that because we have to ensure the existing provision. We have to ensure that health services and social services can still be provided to the local residents, visitors, and anybody that is connected from the G8 side, so the actual direct costs within the Lough Erne site are covered, but this is a lot broader than that. I know some elements of the Fire and Rescue Service costs, and I apologise because I do not have information on the element that is to be funded by the Foreign and Commonwealth Office as it is not part of the £1·2 million bid. What remains for the Fire and Rescue Service at this stage is around £300,000 to provide additional support, which at the moment is not being picked up by the Foreign and Commonwealth Office; £200,000 for the Ambulance Service; and £400,000 for the Western Trust. There is also another element in other trusts and some primary care resource.
At the moment, we propose to bid that into the Executive system as part of the June monitoring. Whether the Executive then takes the view that more of that funding should be provided by the Foreign and Commonwealth Office can still be worked through. We have logged the amount of money that we, as a Department, will incur as additional costs across the system. If the Executive take a view that they should not be funding this and that they should get it from elsewhere, that can still happen as part of the process. We have worked out what it means in our system and are putting that through to the Executive. Whether, ultimately, the cost will be picked up by others is yet to be seen.
Mr McDevitt: So, you cannot tell us how much you are going to bill the FCO for as regards the work done by the Fire Service on the site.
Ms Thompson: No; I cannot. I am sorry.
Mr McDevitt: But there will be a sum of money involved?
Ms Thompson: There will be money for that and for ambulance provision and some medical support on the site.
Mr McDevitt: Chair, with your permission, I want to ask the Committee to agree that it will find out how much the Fire and Rescue Service and the Ambulance Service will bill the FCO for as regards that work.
I am curious about the need to bid for the £1·2 million. The example of policing springs to mind. There is just no extra exposure to the PSNI, whether in policing the site in Fermanagh or the potential demonstrations in Belfast. The PSNI has budgeted and made reasonable provision for the overall policing costs associated with the event, and that is being picked up by the FCO. Therefore, I wonder why the Department, through the Fire and Rescue Service, the Ambulance Service and the obvious impact that there will be on A&Es and all that sort of stuff, has not been able to make a very clear and concise bid to the FCO and to say, "Here you go guys, you are going to have to pick up this tab, because this all relates directly to your bringing this event here."
Ms Thompson: My understanding is that that has not happened.
You are quite right. We are talking about additional service provision in A&Es and out-of-hours services; freeing up some capacity in local hospitals, which means bringing some work forward and putting in additional clinics and rotas. Some of this is about us treating our clients and patients and, thereby, freeing up capacity in case it is needed over the period of the G8. I am unsure as to whether that creates a different view in the FCO about funding it. That may be part of the issue.
Obviously, there is also emergency and contingency planning for all sorts of reasons, and a lot of work is being focused on maintaining business as usual as much as possible. That is equally the case on the emergency planning side, as opposed to the direct medical provision to the delegates on the Lough Erne site. There is a distinction between the two.
Mr McDevitt: I want to ask a couple of quick specific questions. You referred to mutual aid arrangements having been activated with the Fire and Rescue Service, and I presume, possibly with the Ambulance Service. How many pieces of equipment and what types of equipment have been brought in from elsewhere? How many fire officers, if any, are being brought in from elsewhere?
Ms Thompson: As I understand it, it has been agreed that one specialist fire officer team will be brought in.
Mr McDevitt: Where are they coming from?
Ms Thompson: I am not entirely sure where they are coming from. I am not sure whether a similar arrangement is needed on the ambulance side, but we certainly need an additional specialist fire service team to get up to the right levels.
Mr McDevitt: Briefly, looking at the A&Es or hospital services, will extra doctors have to be drafted in?
Ms Thompson: Yes. We are looking at additional rotas to boost out-of-hours services to keep people out of hospitals. We are also looking at extra provision in community pharmacies, boosting A&Es and freeing up capacity in local hospitals so that beds will be available should they be needed. So, there is a range of issues.
Mr McDevitt: Can you tell us what sort of numbers are going to have to be drafted in?
Ms Thompson: No, but I can tell you the cost of that. It is around £400,000 for the Western Trust.
Mr McDevitt: What about the Royal? You identified that as an area of work.
Ms Thompson: I do not have the exact breakdown for the Royal, but it will be £200,000 for the rest of Northern Ireland.
Mr McDevitt: OK. Thanks, Chair.
The Chairperson: My personal opinion is that it seems to be more hassle than it is worth.
On the G8, what do you mean by:
"Ensuring that all delegates and visitors to the Summit site have a comprehensive healthcare package available".
What does that mean?
Ms Thompson: The people on the Lough Erne site is the bit that the FCO will be picking up so that provision is available there.
The Chairperson: What do you mean by "a comprehensive healthcare package available"?
Ms Thompson: It is whatever the FCO has stipulated as a specification required for the people attending. The element at Lough Erne is being picked up by the FCO. A lot of our costs are about —
The Chairperson: Your paper states:
"The Western Trust will incur additional costs, in relation to:
Ensuring that all delegates and visitors to the Summit site have a comprehensive healthcare package available."
Are you putting up a field hospital?
Ms Thompson: No.
The Chairperson: The Deputy Chair and I visited one when we were in Cuba, so we could put you in touch with people.
Ms Thompson: As I understand it, the requirement at the Lough Erne site has been agreed with the FCO, and it will pick up the tab for that bit. The element that is then on the —
The Chairperson: So, it is not additional costs to you?
Ms Thompson: Not to us. Where we have —
The Chairperson: But it says —
Ms Thompson: Yes, they will incur additional costs, but, as I understand it, the bit on the Lough Erne site is being funded by the FCO. Away from the Lough Erne site, you are talking about the need to create capacity, the out-of-hours service and pharmacy service, which is part of the £1·2 million bid that we have submitted. That will go into the Executive system and then there can, presumably, be conversations about how it may be funded.
The Chairperson: I suggest that you need to change your paper, because it states that the Western Trust will incur additional costs.
Ms Thompson: It will incur additional costs, but the bit to do with the Lough Erne site will be funded by the FCO. Off-site provision is the element of the bid that we are making.
The Chairperson: Conall touched on the issue of additional provision for the emergency departments at the Royal Victoria Hospital, the Royal Belfast Hospital for Sick Children and the Mater Hospital. Do you have a breakdown of what that means?
Ms Thompson: It is about additional rotas, which could be partly about freeing up capacity. You could be putting in an additional rota prior to the summit to create new beds.
The Chairperson: Will that involve new staff or staff already on the site?
Ms Thompson: Extra staff will be brought in for extra clinics and to clear —
The Chairperson: So, it is not staff outside the Belfast Health and Social Care Trust?
Ms Thompson: As to who they are, physically, I think it will be staff having additional rotas for a temporary period.
The Chairperson: So, will the staff employed by the Belfast Health and Social Care Trust in the emergency department at the Royal have additional rotas rather than additional staff being brought in to deal with that?
Ms Thompson: That will be up to the trust. I do not have an exact breakdown of that.
The Chairperson: Can you get us that breakdown?
Ms Thompson: I am not sure because that goes right down into trust figure work.
The Chairperson: Will you let us know whether it will be locums or staff? There is probably an issue around national security.
Ms Thompson: It will, as you say, be a combination of —
The Chairperson: I am asking that, Julie, because the G8 will come and go. We are dealing with issues about A&Es and our hospitals under pressure. I am just interested to know how if we can provide additional services or provision at some emergency departments to facilitate the G8, why can we not do that to facilitate the problems and pressures that A&Es are under? I would be interested to see that information.
Ms Thompson: Part of the answer will be that the additional cost of funding all that goes back to the previous conversation of who will pick up the tab.
The Chairperson: How will they staff those additional rotas? Will it be by locums? If that is classified information, tell me that.
Mr McCarthy: Your bid for TYC transitional funding states that £70 million will be required for this budget period. Is that for one year?
Ms Daly: That is across the three years.
Mr McCarthy: OK, £70 million for three years. The next paragraph states that £28 million will be required for the integrated care partnership service changes, voluntary redundancies and implementation. That does not add up. If it is £70 million for three years —
Ms Daly: It is not a uniform profile across the three years. In the first year, it was £19 million for transitional costs and that is ramping up as the transformation programme is taken forward. It is not a uniform profile. It is a changing profile, so it will be £19 million in the first year, £28 in the second year and the balance in the third year.
Mr McCarthy: Let us go on then to the £28 million. You already said that £4·5 million is for the integrated care partnerships and £8·5 million is for service changes. That leaves £15 million for the other two. Have you a breakdown of those, or is it just "redundancies" and "implementation"?
Ms Daly: We have a breakdown for redundancies but not for implementation. Our expectation is that the cost of early retirements and voluntary redundancies will be about £10 million.
Mr McCarthy: So, that would give you £5 million for implementation, which brings it up to £28 million.
Point seven on page eight mentions:
"procedures at a GP practice level that will ensure that targeted patient populations are brought in for a regular review of their condition".
Could you explain that a wee bit for us? The Chair mentioned that earlier.
Ms Daly: What does that mean in practice?
Mr McCarthy: Exactly.
Ms Daly: The Chair mentioned annual health checks. The work that the integrated care partnerships will be looking at in this initial phase will be related to those who are frail or elderly and those elements of long-term conditions that we mentioned before. In developing that work, part of that new process will involve those target populations being brought in for regular reviews of their condition. We do not know exactly at this stage how that will happen in practice, but it is envisaged that that will be part of the work on the targeted population — those elements of the population that the integrated care partnerships will be dealing with initially. So, it is not full coverage, but it focuses on the particular areas that we mentioned: the frail, the elderly, and diabetes, stroke and respiratory conditions.
Mr McCarthy: Finally, going back to the funding, I was very disappointed to hear you say, Catherine, that you had not allocated funding for domiciliary care. That surprises me, because this Committee, nearly on a weekly basis, talks about domiciliary care and care for the elderly.
Ms Daly: I did not say that.
The Chairperson: She did not say that: she said that she did not have the figures.
Ms Daly: I do not have the breakdown, so I cannot tell how much is allocated to domiciliary care.
Mr McCarthy: That is strange. You are taking people, elderly people in particular, out of all sorts of places. We have always been told by the officials that there will be sufficient funding for domiciliary care, yet you cannot tell us how much that will be.
Ms Daly: I do not have the breakdown, but it will be available.
The Chairperson: We have asked for that information. In fairness, Catherine did not say that she would not provide it. We have asked for a breakdown of the allocations to be provided sooner rather than later.
Mr McCarthy: That does not give me any further confidence. When the debacle around the closure of the residential homes began two or three weeks ago, I said that that was almost the first breakdown in TYC. Yet, here we are again in a position where we cannot tell how much funding will be going to domiciliary care, which is paramount to our elderly population. That is the second breakdown.
Ms Thompson: This is the TYC transitional support funding, and significant amounts of money are going into a range of pressures, one of which is for older people. In 2013-14, £25 million is expected to go into supporting the changes in demographics, whereby the proportion of the population getting older is increasing. So, significant money is being invested on an ongoing basis. This element concerns transitional support funding under TYC , which is a particular element. So, there is a significant amount of money routinely being invested across the system.
Ms Daly: There will be elements of this —
The Chairperson: We need a breakdown of the allocation to domiciliary care for everybody, not just the elderly and people who get care packages.
Mr McCarthy: Why is that not available now?
The Chairperson: It should be available because the bids went in to DFP, so the information is there. We need the information.
Mr McCarthy: Thanks, Chair.
Ms Maeve McLaughlin: First, the process is very flawed. We are being asked to approve £55 million worth of bids, and three sections have been identified: TYC, elective care and the G8. When we start to ask questions about those sections, there is no information. I find it highly irregular that we are being asked to do that at this stage. We had a similar discussion during the previous monitoring round. How can we give informed opinion on the impact of the proposals on these hugely important issues?
Ms Daly: I will pick up on that. You are absolutely right about the scale of the bids and the areas.
We have not discussed the elective care bid yet, but I can certainly provide details on what that is intended to do and the areas that it is proposed to cover.
The Committee is absolutely right: we need to have a breakdown for TYC. The Department is going through that work. Given the nature of TYC — it is a transformation, a change in how services are delivered — a lot of this will be an estimate of what will be required, and it will not be exact. However, we do appreciate the need for further detail.
There are elements of detail in the G8 bid that do not directly impact on the DHSSPS budget. Our focus has been very much on what directly impacts that budget.
On the elective care bid, if the Committee would like, I can —
The Chairperson: Let Maeve finish.
Ms Maeve McLaughlin: With respect, I can understand that there has to be a degree of flexibility, particularly in relation to TYC. However, a calculation had been done somewhere on these areas, sectors and outcomes, and yet, we have not been presented with that; we have not been given that information.
Ms Thompson: Catherine talked about the elements within that £4·5 million for ICPs. However, we do need to give you more detail on the £8·5 million for service changes, which the Committee is very keen to understand. We can give you a greater sense of what voluntary redundancy and early retirement will be within that as well. We certainly have a lot of information on the elective care bids. So, we can help the Committee today with some bits.
The Chairperson: Just to extend the point that Maeve and others made; it is a matter of the Committee getting a revised paper for next week. As I said, you put detailed bids into DFP, so the information is available, although you might not have that to hand. As you heard from members today, there seem to be more questions coming out of what you have provided to us. Can we get a detailed paper on the information and bids submitted to DFP for next week? For future reference, we should get a copy of that. We need to be able to do our job, Julie, and we cannot scrutinise if we do not get that. Nobody is trying to block you at every opportunity, but we need to ensure that what is happening is happening in the right way.
Ms Thompson: What I would say, Chair, is that the bids have not been submitted to DFP yet. Those are due to go in next Wednesday. We are more than —
The Chairperson: But they are in draft form?
Ms Thompson: Yes. We are more than happy to share that then, because, in respect of the timing, it will be with DFP, and we will then be able to work it up in more detail. I am very happy to share it with the Committee. Hopefully, it will help to deal with the issues that you raised. We can certainly look at coming back to you on that in future.
Ms Maeve McLaughlin: I want to move on, but I will make the point that that information should have been presented today. There was a similar discussion the last time round.
I picked up on your point about flexibility around TYC. How realistic is the figure of £70 million over three years?
Ms Daly: It is the most realistic assessment that we can make at this stage, bearing in mind the service changes that are intended and planned to take place.
A strategic business case was prepared for TYC, which was submitted to and approved by DFP. It indicated that the cost would be £70 million. Subsequently, different elements of business cases need to go forward to DFP to support the validation of those costs. Work on those business cases is going on in the Department. We cannot wait until that work is complete before we submit the bid to DFP. We need to comply with the DFP planning process and the monitoring timelines. We are still going through that assessment, and that is one of the reasons why we do not have the detailed breakdown that the Committee asked for today. We will be able to provide it for next week, with the caveat that the figures will be estimates. From our point of view, and this is something that we work on with the Health and Social Care Board, the business case that is put before us is challenged to ensure that it is realistic, provides value for money and will do what it is intended to do under the transformation programme.
Ms Maeve McLaughlin: Realistically, it could change.
Ms Daly: Realistically, such a plan could always change.
Ms Maeve McLaughlin: Finally, has the £19 million that was to be spent as part of the first year of TYC been spent? What has it been spent on?
Ms Daly: Yes, the £19 million has been spent. We do not have the absolute expenditure figures on all elements of that, owing to the stage in the accounting process that we are at.
Ms Thompson: I can give you approximates: £2 million was spent on integrated care partnerships; £3·6 million was spent on service changes; £10 million was spent on voluntary redundancies and voluntary early retirements; and £3·2 million was spent on implementation support.
Ms Maeve McLaughlin: Again, can we have that information? It is critical that we see that. You quote £3·6 million on service charges. What does that mean? Given the fact that TYC is only coming out of consultation in December, what does that figure mean? I think that it would be useful to get more detail.
The Chairperson: It is déjà vu. We are always looking for the information.
Mr Beggs: I will take the G8 summit first. I still have not got it into my head how you can convince us that you need more money for G8, yet you cannot convince the Foreign Office.
Ms Thompson: As I understand it, the issue with the Foreign and Commonwealth Office is that it has viewed the additional costs very tightly around the Lough Erne site, and those are very easy to identify separately. My understanding is that, at this point, it has not said that it will fund additional costs that are wider than the Lough Erne site.
Mr Beggs: In that case, will you put in a bid in the next monitoring round, when you know what the costs are, and pass the bill to the Foreign Office?
Ms Thompson: We are clear that the costings have been worked up in detail by the trusts and the board. You were asking me questions about additional staffing and rotas, and whatever. The trusts know what they need to put in place, as do the Fire and Rescue Service and the Ambulance Service. It is not a question about not knowing what is required. To go back to the earlier conversation, the question is this: who will pick up the tab and where will the funding come from? We have quantified it, and that has been worked out robustly. The key question, from our point of view, is this: if the health service should not fund it, should it be funded by the Foreign and Commonwealth Office or the Executive? We will put it into the Executive's system, because that is where we are currently at in the process, and if the Executive take the view that the Foreign and Commonwealth Office should fund it and they have the analysis to support it, it will be a question of who will fund it. I suspect that that is going on in a number of Departments as we speak.
Mr Beggs: I give a general welcome to your monitoring bid. I think that everyone recognises the huge stresses that are on the health system at present for those bids. Like others, I would like more information. We should be complimenting you on the end-of-year totals that you ended up with. You stayed just under your targets, which you cannot go over, but you made the best use of the money that was available by committing as much as could be reasonably committed. You deserve compliments for that.
I am looking at the capital spending bids that you put in. Not only have you bid for £55 million of resource expenditure but there is another significant bid for capital expenditure, which is for £57 million. The table in one of your papers shows an overcommitment of £19·3 million. Is that taken care of in your total additional bid? What happens to it?
Dr Bernie Stuart (Department of Health, Social Services and Public Safety): It is, to a certain extent. At this time of year, we always have a level of overcommitment in the way in which we profile the capital. That allows us to take account of changing profiles in projects, such as delays, bad weather, or whatever. Therefore, we change the profiles monthly. As the year moves on, that level of overcommitment reduces to zero. If we did not overprofile, we would underspend by the end of the year. At this time of the year, a level of around £15 million to £20 million is the cushion that we are working towards. We think that that will be managed within our existing profile. That extra money is designed for what is in the table, but we will keep it all under review as the year goes on.
Mr Beggs: In another table, you have an additional £3·5 million for health and care centres. Is that for a new health and care centre or does it reflect an overrun?
Dr Stuart: That is for small refurbishments to complement the Transforming Your Care changes. They may be minor changes, so it is not for one project. That money may be applied to a range of community facilities — perhaps £200,000 here or there. It is a bit like what the general capital is normally used for. It will be bits and pieces to upgrade a range of community facilities.
Mr Beggs: Finally, there is £10 million for maintaining existing services and addressing areas of highest risk to staff and patient safety. Are those essential health and safety issues that must be addressed?
Dr Stuart: To a certain extent. They are not essential health and safety issues in that they are legal breaches or anything like that, but a lot of our facilities are very outdated, and we reckon that our maintenance backlog is approximately £1 billion. The maintaining existing services budget looks at the highest risks to life, including things such as legionella. We largely focus on places where people sleep overnight, as opposed to those that people just visit, and on electrical safety and fire safety. Each year, we have a budget to address the highest risks in the area, and that process is under way. This is an opportunity to get some more money and to go further down that list. Again, it is a range of small projects generally, although there will be some larger ones above the trust-delegated limit. It is about working our way down through the most serious risks to life in the building.
Mr Dunne: Thanks very much for coming in this afternoon again. I understand that around £19 million has been spent to date on Transforming Your Care. Is that correct? We were told last time that there was no funding in the current budget for that and that it has been found from existing funds. Is that correct?
Ms Thompson: The £19 million from last year was financed by the Executive through their invest-to-save scheme. You are quite right: we started the year in the same position as we start this year without it being in the budget. Additional funding was provided for it by the Executive in September last year through the invest-to-save scheme.
Mr Dunne: Is that unlikely to happen this year?
Ms Thompson: We do not know. An invest-to-save scheme has not been announced yet, and it will be up to the Executive to decide whether funding gets provided through a monitoring round, an invest-to-save scheme or not at all. A range of things still needs to be worked out at Executive level.
Mr Dunne: Paragraph 7 under "DHSSPS approach to June monitoring" in your paper states:
"our assessment is that it is not possible to fund these additional pressures from within existing budget allocations."
Are you convinced that you are unable to fund it this year?
Ms Thompson: Yes. As we have advised before and as has been reported, we do not have the funding in our budget to finance it at this stage. That is why the bids fit the category of major and unforeseen. They are certainly significant, and the financing does not exist in the budget at this point.
Mr Dunne: The issue of A&Es comes up regularly, especially at this Committee. It comes up in the media more than regularly, and we are faced with the fallout. What will be done to try to address that in this coming year? Paragraph 5 under "Transforming Your Care transitional funding" states that the integrated care partnerships:
"should lead to decreased hospital usage, including emergency and nursing home admissions".
Will that have an effect on A&Es and lead to less pressure on them?
Ms Daly: Ultimately, yes. It is all part of a single system, and, through the transformation, the intention is to ensure that people can be treated as near as possible to home. An element of that programme will be about facilitating early discharges and ensuring that care is provided in the right place. If all of that is in place and working effectively, that should reduce the pressure on hospitals, which in turn would reduce the pressure on accident and emergency (A&E) departments in hospitals. That is the intention at a strategic level. As we move forward with Transforming Your Care, the board and the trust will continue building up work that was taken forward under the improvement action group to ensure that best practice is applied across the trusts and that lessons are learned and implemented. It is an area of significant focus between the board and the trust in their overall performance management. We are not bidding specifically in this monitoring round for anything directly relating to A&E, but indirectly our bid should assist in supporting the whole system.
Mr Dunne: The ICPs should have a significant impact on the work of A&Es.
Ms Daly: Ultimately, they should do. As we said, they are focused on a limited range of areas at the early stage. They will be looking at developing new care pathways. That is where we envisage that that should free up and provide for a more flexible operation of our integrated health and care system, and that should assist the hospitals.
Mr Dunne: GPs will want funding and support. Is there additional funding in there for them?
Ms Daly: Part of the funding will be to provide resources to free up GPs to work with the ICPs in the development of the work. That is what we mean when we talk about transition costs. That work is developing, and elements of it will facilitate backfilling to allow specialists — not just GPs but others — to be freed up to take forward the work with the ICPs.
Mr Dunne: OK. Through voluntary retirement and voluntary early release, there will be some significant changes in staffing. How will that be managed and what sort of impact will it have? What are we going to see here?
Ms Daly: We envisage that there will be different skills requirements as the systems change. We expect that people will be working in different settings, so requirements will include different skills and training needs. As for the voluntary early release/voluntary retirement (VER/VR) programme, we do not envisage that that can be accommodated in normal turnover on the basis of all the estimates. We expect that it will require voluntary redundancies and early retirements. Our estimate is that the cost of that in the current year will be around £10 million. Roughly speaking, that would equate to around 200 people.
Mr Dunne: So you are expecting to do more with fewer people.
Ms Daly: With different people. The skills requirements and the jobs may be different. Different staff will be required in different settings, and we have set up a regional workforce planning group, which will work with all the Health and Social Care (HSC) bodies to look at their workforce planning in line with the changes to the systems to identify the particular types of staff needed and the changes in numbers in the different parts of the sector.
Mr Dunne: Will it ultimately mean fewer staff?
Ms Daly: Our expectation at the outset is that this will probably result in a reduction in staff of around 1%. That is not exact, but we expect that it should result in a reduction in staff. We expect that that can be accommodated through the VER/VR programme, however.
Mr Dunne: As local representatives, we are continually aware of pressures on staff in the health service. We all feel for them, because we know the pressures that they are under. We want to see something done here that is going to make a difference. Can you give us an assurance that that will happen through Transforming Your Care and that we will see better systems in place and better procedures, with people working more efficiently and more effectively?
Ms Daly: I can give you an assurance that that is absolutely the intention, and the whole staff element is key to that. We have a significant workforce in the health and social care sector. It is critical that we ensure that not just the systems are changed but that the staff are facilitated to be developed and skilled properly to deliver the services that they need and to do that in a way that meets their requirements and those of patients.
Mr Dunne: OK. Thanks very much.
The Chairperson: What figure did you give for the bid for transitional funding for TYC?
Ms Daly: It was £70 million over the three years and £28 million in the current year.
Ms Thompson: Therefore, we will be bidding for £28 million in the June monitoring round.
The Chairperson: It will be £28 million this time around.
You became well aware of the Committee's views on external consultants when we dealt with the issue a number of months ago. Why do we need to employ external consultants again?
Ms Daly: Part of it is about freeing up existing staff in the health and social care sector who actually have the experience and expertise to deal with the significant change. Therefore, part of it will be about backfilling those posts. As well as that, there is a need for experts in a number of areas to ensure that the system is being properly managed as it is changing.
The Chairperson: Catherine, what do you mean by "experts in a number of areas"?
Ms Daly: For the overall strategic change management and all the implications of strategic change, they provide validation to the service that the change is being properly taken forward, planned and executed.
The Chairperson: Do we not have that expertise in the health service in general? How many employees are there? Is it 70,000?
Ms Daly: That is correct.
The Chairperson: Did we not move from 17 trusts to five?
Ms Daly: We do have expertise in Health and Social Care. Where that expertise can be used, it will be used. However, for the plans, it is clear that there is a need for additional support. Some of it will provide assistance to bodies from which staff are being freed up to carry out the change. Some of it will be that expert opinion.
The Chairperson: How much of that £28 million this time around do you propose to spend on external consultants?
Ms Daly: We cannot tell you that, Chair. That is the figure that we are looking at. Even if we had the figure for the external consultancy element, there is an issue of commercial confidence because it could have an adverse impact on tendering for those services.
The Chairperson: I could be wrong about this, but we were told a figure the previous time around. I will check that out. Perhaps you can send it to me privately.
I would like more of a breakdown of what is being spent on that and why. The last time around, external consultants were employed to provide population plans. The majority of members around the table were in shock that the trusts that deliver services did not have those population plans. Can we get a breakdown or even a proposal, suggestion or estimate of how much of the money will be spent on consultants and for what reason, and what the outcome of the external consultancy will be or what it will actually produce? OK?
Ms Daly: We will provide that to you.
The Chairperson: You are actually leaving with more work than you had before you came in. OK, that was quite a useful session.
Mr McDevitt: It was a very good session, Chair.
The Chairperson: You are well aware of the information that we need from now on before you get to this point. We do not want to be fighting with you all the time.
Ms Thompson: No, absolutely. What I will say, Chair, is that there is a timing issue with getting the information to you. We are now putting all the information together for the DFP bid. We happen to be in front of the Committee and giving you the information two weeks beforehand. I hear what you are saying. However, there is a couple of weeks' lag when it is all being put together, if you like. By next week, we should be able to give you the full analysis.
The Chairperson: Yes. However, you just do not think of it overnight.
Ms Thompson: No. I appreciate that.
The Chairperson: Therefore, there are suggestions, proposals or drafts. Give us the ideas. Let us know them. You have some information to provide us with. Thank you very much.