General Health Report and Social Care Sector 2012-13 and 2013-14
Session: Session currently unavailable
Date: 25 November 2015
Reference: NIA 282/11-16
Mandate Number: Mandate 2011/16
1. With demand for health and social care services now far outstripping supply and showing no sign of abating, the financial strength of HSC Trusts has continued to decline despite the fact that they receive additional resources year-on-year to shore up their financial position. While only the Western Trust failed to break-even in 2014-15 (a deficit of £6.6 million) this masks an underlying funding gap of Trust pressures from 2014-15 which is reckoned to be over £131 million carried-forward to 2015-16.
2. Putting the HSC Trusts on a sustainable financial footing, therefore, is a significant challenge for all those involved in the health and social care sector unless there is a significant change in funding or transformation of services. The fact that HSC Trusts have no authority to move money from one year to the next impedes their ability to undertake longer-term financial planning. Ongoing service redesign on a major scale will be needed if the HSC Trusts are not only to provide efficient health and social care, but that they can do so by living within their means.
3. Exceptionally high levels of spend on locum doctors has been a key driver in expenditure growth, particularly within the Western HSC Trust, where difficulties in recruiting and retaining permanent consultants continues to put pressure on budgets.
4. The decline in the financial stability of HSC Trusts is mirrored in widespread breaches of key waiting times targets for elective, emergency and outpatient care. In particular, hospitals have been breaching key waiting times for cancer that are meant to ensure speedier diagnosis and treatment in order to maximise patients’ chances of survival
5. Going forward, it is hard to see how the current service model can be sustained as financial savings start to dry up. Transforming Your Care is heralded as the great transformational saviour for health and social care, but the pace of change has been at best mediocre. As result, Trusts are likely to struggle to stem the deterioration in performance.
6. Aside from financial and activity issues, our report also covers a range of other issues, for instance:
- Whistleblowers still face real problems in speaking out in the health and social care services despite the push to create a more open culture. While steps have been taken to improve things over recent years, a "culture of fear" still exists in many parts of the HSC sector. Creating the conditions within which high quality, compassionate care can Report on General Report on the Health and Social Care Sector 2012-13 and 2013-14 flourish needs to ensure that where individuals have concerns about service provision they can have their concerns heard and acted upon in an open and honest manner.
- In exceptional circumstances, health and social care bodies can use direct award contracts where they consider competitive procurement to be inappropriate. In the two years to March 2014, however, Trusts let over 2,600 such contracts incurring expenditure of just under £130 million. While this has since reduced considerably to £48 million in 2014-15, the Committee considers that the level of expenditure is not fully consistent with a supposedly narrow range of scenarios in which competition can be bypassed. The tendering process should be as transparent and competitive as possible to ensure that purchases by health and social care bodies achieve the maximum benefits and corruption and favouritism is minimised.
- The consultants' contract of employment enshrines their right to treat patients privately. While the Committee acknowledges the commitment and dedication of hospital consultants, it considers that the mechanisms for managing how their private work interfaces with their work for the health service may require tightening to ensure that health service patients always receive the most flexible and responsive treatment they can get.
Summary of Recommendations
High quality care and the efficient and effective use of health and social care funding go hand in hand. Action is needed, therefore, to place the finances of health and social care organisations on a more sustainable footing. The Committee considers a more flexible system is required (like that which exists in Scotland) which would involve a move from annual to medium term financial planning to avoid the annual budgetary constraints and monitoring round bail-out arrangements which currently afflict Trusts. The Committee recommends that the Department approach DFP to explore the options available for introducing three-year budgets for the HSC Trusts.
The Department needs to explain in detail how it will tackle the issue of consultant shortages. In particular, the Committee recommends that it examines the extent to which the consultant contract allows Trusts to award incentives to attract consultants to geographical areas and specialities where there are shortages, without financially disadvantaging the organisations concerned.
The Department must work cooperatively with the HSC Board and Trusts to seek innovative and cost effective ways of enhancing staff flexibility. For example, consideration should be given to the possibility of recruitment on a Northern Ireland regional basis for certain specialties as a way of matching skills to need. Moreover, we recommend that the Department should explore the extent to which it may be possible to insist that, for a limited period after qualification, newly qualified consultants would be expected to fill a vacancy where their specialism met the need.
The HSC Board should ensure that it can pinpoint why cancer waiting time targets are not being met and should set out the action needed to meet the targets, and the date by which it expects Trusts will achieve those targets again.
The HSC Board, working with Trusts, should begin a process of identifying best practice in those hospitals/specialties where performance against waiting time targets is bucking the trend, both locally, and across the wider NHS, so that the lessons learnt from successful innovation can be disseminated across the Trusts.
In the interests of transparency and value for money the Department should take steps to get together with its counterpart Departments in the UK in order to agree the specific indicators that would provide the most insight into health and social care performance, establish the data needed to make valid comparisons and identify how to collect that data cost-effectively.
The Committee recommends that the Department clarify the expected time period over which it expects the benefits of TYC to be realised.
Particularly in light of the Trusts’ poor financial performance, it is essential that goods and services are procured competitively in order to ensure value for money. The Department must lead efforts to make sure that the Committee’s previous recommendations on the management of Direct Award Contracts have been effectively embedded and applied across all Trusts.
While recognising the positive action which has been taken to date, the Committee calls on the Department to continue to do all it can to foster and grow a culture of openness and honesty across all health and social care bodies. It is essential that employees in the health and social care sector have trust in the system for handling whistleblowers and that they have confidence they will be taken seriously, protected and supported by their organisations if they blow the whistle.
The Committee recommends that the Department undertakes a review of existing guidance and controls around private practice arrangements to assess whether, as far as is practical, all necessary steps are being taken to ensure that health service patients are not being disadvantaged as a result of the close intertwining of public and private health care. The Department should report its findings back to the Committee by 31 March 2016.
Recent revelations and reports from elsewhere in the UK have ensured that the priority and status of patient safety has risen to the top of the agenda among health and social care bodies. The Committee is concerned, however, that, as the other major issues dealt with in this report become ever more prominent, such as reducing waiting times and achieving financial balance, the focus on patient safety may diminish. It is vital that the momentum built up in recent years in terms of learning and improving patient care is not lost.
To help inform the development of a culture of openness and transparency across the Trusts, the Committee recommends that the Department should monitor the safety culture in Trusts by arranging to have them use one of the established tools available to undertake a cultural audit.
It is important that Trusts lift their game in paying invoices promptly. The Committee recommends that the Trusts develop individual action plans to help them implement measures which will bring about the needed improvement in their performance.