Official Report (Hansard)
Date: 23 November 2007
HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Ministerial Briefing: Miscellaneous
23 November 2007
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Rev Dr Robert Coulter
Dr Kieran Deeny
Mr Alex Easton
Mrs Carmel Hanna
Mr John McCallister
Mr Michael McGimpsey ) Minister of Health, Social Services and Public Safety
Dr Miriam McCarthy )
Dr Andrew McCormick ) Department of Health, Social Services and Public Safety
Dr Ian McMaster )
The Chairperson (Mrs I Robinson):
I welcome the Minister and his officials, Dr Andrew McCormick, Dr Miriam McCarthy and Dr Ian McMaster. The Minister agreed to attend because the Committee did not have time to cover all the issues at its meeting on 4 October 2007. I thank him for coming, and I hope that members can get through the items that we did not have time to discuss at our last meeting with him. The Minister will be here until 3.30 pm.
There are several items that I want members to raise, and I want to give everyone the opportunity to address their specific issues. I appeal to members to make their questions short and to the point. The Committee has provided background papers on the topics that were not discussed previously.
You are very welcome, Minister.
You have spoken to personnel at Cuan Mhuire in Newry, which is a great service for the homeless and those addicted to alcohol. I appreciate the fact that the facility is up and running again, although in a limited fashion. Perhaps you could give the Committee an update on that. I know that the Department for Social Development has also had an input.
The Minister of Health, Social Services and Public Safety (Mr McGimpsey):
You are aware of the difficulties that faced Cuan Mhuire during the summer; that resulted from the standard set down and policed by Regulation and Quality Improvement Authority (RQIA) when there was a concern about patient safety. I was concerned that Cuan Mhuire would be forced to close, because it provides a very valuable resource. It is funded by the Department for Social Development and not the Department of Health, Social Services and Public Safety, although my Department has a particular interest in the services that it provides for people with addictions.
I set up a group, with the chief executive of the Southern Health and Social Services Board, Sean McKeever, as the chairperson. He held a series of meetings to plot a way for Cuan Mhuire to reopen within the required regulations and ensuring that there were no bureaucratic obstacles or strict interpretations. I am happy to say that, as a result of that exercise, Cuan Mhuire reopened on 12 November 2007, although it is now operating a limited service. It did have many places, but, under health and safety requirements for patients, it was not possible to carry out all the necessary work to meet those requirements and open a full facility within a reasonable financial budget. However, it is open, and I am confident that it will continue to provide a very valuable service. I spent an afternoon there, and it reinforced my view that we need to maintain that facility.
The next stage is the new Cuan Mhuire. The Department is helping the board to develop plans for a new facility, and ground has been purchased for the new building. That is where we are at the moment.
There is a dire need for a detox facility, and it is hoped that there will be one at Cuan Mhuire, because there are so few facilities in Northern Ireland.
I was talking to an inter-faith group today called HOPE, and if you have not heard of them already, you probably soon will. Members of that group are coming to talk to the Committee about what they are hoping to do. There is a dire need for detox facilities, especially for young people, but in Newry, Cuan Mhuire is taking care of all ages, especially homeless people.
Thank you for that update.
I met the group to which Carmel referred. I want to reinforce that that is a worthwhile project, and I am sure that the Committee will support it.
That was an easy question. We can relax now.
The next items for discussion are Investing for Health and Agenda for Change. Those issues were originally raised by Carál and Alex, but unfortunately, Carál is not here. Alex, would you like to put your questions to the Minister?
Thank you, Minister, for coming today.
Can you outline what savings — if any — have been made under Agenda for Change? Can you tell me why it is taking so long to implement? It seems to have been dragging on for several years, and although I am not blaming you, you have been a Minister for six months, and I want a reassurance today that you will get on top of Agenda for Change.
Can you also tell the Committee about the position under Agenda for Change of the medical records staff in the Ulster Hospital? They were told that they would be considered as a block rather than as individuals. Can you also comment on hospital pharmacists at junior grades, who feel that they have been poorly graded?
I inherited the Agenda for Change programme, which is a national agreement that was made with the main Health Service trade unions. It applies to over 63,000 members of staff in Northern Ireland. For the first time, it ensures that Health Service staff are paid on the basis of the job that they do and the skills and knowledge that they apply to it. It is consistent with the concept of equal pay for work of equal value.
Currently, a process is under way of matching staff to jobs and the rate of pay that goes with them. Over 97% of the total workforce has been matched. Some 70% of the workforce is now in receipt of Agenda for Change rates of pay, and all matching will be completed by 31 December 2007. All staff will be in receipt of the new rates of pay by 31 March 2008. There will also be some back pay to deal with the time lag since matching. A sequence of how matching should progress was agreed at the beginning of the process, and clerical workers are the final group to be matched.
With respect to staff in the Ulster Hospital, I can remember answering the member’s question for oral answer on that matter, but I cannot remember exactly what response I gave. Perhaps Dr McCormick could help me.
Dr Andrew McCormick (Department of Health, Social Services and Public Safety):
Medical records staff were among the last to be matched in this extensive exercise. It has been an enormous challenge to work through the process, job by job and case by case, matching duties to job descriptions. It has been done systematically and objectively, in partnership with staff representatives and trade unions throughout the process. A sequence was agreed and followed, and clerical and administrative staff are among the last groups to be matched. As the Minister has said, it is imperative that we press ahead and finish that process as a matter of urgency. We are committed to a resolution.
I am also aware of the case of pharmacy staff. Here again, we need to refer to an evidence-based analysis. Within the process, there are mechanisms for appeal to ensure that it is fair and objective.
The Minister mentioned equal pay as a strong driver. Before this exercise, the equal pay issues that lay under the surface across the UK were enormous. This sensible reform will secure proper and fair treatment in pay and a more flexible system for the future. The management benefits that will flow from that are important and recognised by all concerned. This is a better way to manage the pay system; the Department will ensure that the matching is completed and implemented.
I am pleased to hear that that will be sorted out by March 2008 at the latest. Dr McCormick did not touch on the pharmacy issue. Will that be investigated further?
It will be investigated further. That issue is unresolved, but it will be taken through the process.
I have a related question. One of Agenda for Change’s key messages is:
"Greater scope to create new kinds of jobs, bringing more patient-centred care and more varied and stimulating roles for NHS staff."
I know that that fits in with new patterns of working and patient-centred care. However, I hear from nurses and others that they are not incentivised to undertake specialist training because they are not assured that they will get any increase in increments. There are unresolved issues here. If we want nurses in specialisms — such as mental health, theatres or wherever we are short of nurses — we need to ensure that they are incentivised to train and that increments will be added for training. They should be encouraged to do their jobs and given specific time off for training.
Now that Kieran is here, I do not feel uncomfortable about mentioning the fact that doctors have received another pay rise. There is talk of a deprivation gap — a growing gap between junior staff and doctors and senior staff. Many people wonder why that is happening. What was the most recent rise in doctors’ pay about? People do not understand.
I know that those decisions are taken across the water, but there is no real explanation for them. The gap between doctors’ salaries and those of nurses, physiotherapists, occupational therapists, and so on, is widening all the time. They are stuck in that pay structure, yet doctors’ wages — consultants and GPs — seem to increase all the time. Sorry, Kieran.
You are quite right — it is a national pay agreement. As part of the United Kingdom, Northern Ireland follows that pay structure. That is automatic and normal.
I regularly meet representatives of the Royal College of Nursing. I accept the point about incentives for nurses and specialisms. The Committee will be aware that nurses are now banded, and there are shortages in at least one of those bands. I am considering those issues, along with many others.
The advice on pay structures for nurses, doctors and all other health professionals comes from independent review bodies. For the first time, Northern Ireland has been formally included in the terms of reference of those review bodies. Therefore, a recommendation, specifically to the Northern Ireland Assembly and Executive, can be expected in the next cycle. That is a new development.
The evidence exists, and we have outlined the issues on recruitment and retention. The existing system has criteria on which recruitment and retention premia can be considered and negotiated. We have to consider the difficulties, produce the objective evidence and work within the pay policy that is set collectively by the Executive and the Department of Finance and Personnel.
It is hard to incentivise. Even some GPs were surprised at the last pay rise. There did not seem to be any explanation for it.
I do not think that many of them handed it back.
No, they did not.
Ninety-seven per cent of staff have been matched to their new grades as a result of Agenda for Change. Like Alex, I welcome the progress that has been made. You have had meetings with various groups and representatives, and you have visited a number of hospitals. How has staff morale been throughout the process and leading up to the final outcome?
My sense is that morale is very good. However, there is clearly impatience among staff who are waiting to be matched to their new grade. I recognise that, and I am determined that they will be matched by the end of December 2007. I also want everyone to be in receipt of their new rates of pay by 31 March 2008, which will be backdated to 2004.
Therefore, it is understandable that there is impatience and a desire to bring this issue to its conclusion. It takes roughly one hour to match each member of staff to his or her new grade, and there are 63,000 members of staff. That is a huge workload for the Department. Therefore, the Department shares that desire. There will be a collective sigh of relief when this is over.
I thank the Minister for attending today. You have actually answered my question. I was going to ask how long it will take for all employees to be in receipt of their new rates of pay. You have said that it will happen by 31 March 2008. It is important to ensure that that does happen.
I believe that morale is affected by this issue, especially in light of chief executives’ big pay-offs and other big pay-offs in the Health Service. Front-line staff are affected by that. The sooner that the issue is dealt with, the better. I am glad that you have given the commitment that all staff will be in receipt of their new rates of pay by 31 March 2008.
Wrong and mixed signals are being given to the general public, especially when chief executives have stood down from fairly well-paid posts and, within days or weeks, turned up in another part of the Health Service doing another job with less responsibility — and earning more money — than when they were chief executives. I am not naming names, but there have been a few of them. As the Committee has endeavoured to visit all of the board areas and meet officials at each of the acute hospitals, we have come across a few of them on our travels. In fairness, discipline must be shown within our own ranks. There should be some clause or agreement so that, when people step down from prominent positions, they cannot immediately take another position in which they accrue a lot more money than in their previous post.
Reducing the number of trusts from 18 to five meant that a lot of chief executives and directors were surplus. I inherited that situation, and I am not saying anything another than that.
I have several points to make on that. First, I assure you that no-one who has been given a voluntary early-retirement package has been re-employed. That is not allowed, and the Department is very clear on that. Secondly, when the trust mergers happened, the new jobs were generally at a higher level because there was a smaller number of much larger organisations with greater responsibilities. The jobs are evaluated under a UK-wide process in which the Hay Group advises on the weight and value of all the jobs across the trusts. That is a well-established methodology. Anyone who wanted to apply had the right to do so.
The issue was what to do with the chief executives who had not succeeded in getting one of the new chief executive jobs. To have given them all voluntary retirement would have been very expensive. The obligation is on the employer to find suitable alternative employment. We took the line that director jobs in the new organisations were suitable alternative jobs for former chief executives. Keeping them working in the system was better than paying them off at great expense. In a number of cases that I am aware of, they took jobs at a lower pay band than their previous jobs.
We have watched the situation carefully. The trade unions and many political representatives requested that we avoid compulsory redundancies. To do that, we needed to find a way to downsize on a voluntary basis. Around 88 people have left the service on a voluntary basis. We have managed the competition process carefully, but no-one has received anything other than their contractual entitlement. For those leaving, the sums appear large, but a proportion of the payments go into the pension fund to cover the added years of someone who is being allowed to go early; that results in a large amount. Although it looks like a large amount, it is not a one-off payment in someone’s hand. It is payment for added years for their pension entitlement, which is a contractual obligation. No special negotiations have been done; we have only honoured the contractual obligations.
Similarly, if someone moves from a higher-paid job to a lower-paid job, they have the right to pay protection. All of that has been negotiated with the trade unions. The principles that apply at the senior level also apply right through the organisation. We followed the right steps, looking at the matching of available people to new jobs and making sure that redundancies were minimised. There are no plans for compulsory redundancies; we must continue that if possible. Although a voluntary process is expensive, we are sure that the up-front cost will be recouped in around two-and-a-half to three years. In that time, the salary savings will have paid for the up-front costs of redundancy. It has been a delicate process, and we have been in touch with the trade unions throughout to ensure that we are safeguarding the public purse and not spending a penny more than we need to.
I do not want to labour the point, but it must be noted that there have been instances in which former chief executives have obtained new positions in which they had less responsibility but higher pay than when they were in charge of trusts. We must show that we are being careful with public money.
Several chief executive posts were on pay band 4 in the old system, and there are director jobs in the new arrangements that are on higher pay bands. Those pay bands are determined by an objective, evidence-based job evaluation system.
Thank you, Dr McCormick.
The Committee took evidence from the Alzheimer’s Society and the Dementia Services Development Centre on 27 September, and both organisations argued strongly that the Minister should continue to make Alzheimer’s drugs available in Northern Ireland. Minister, will you allow the National Institute for Health and Clinical Excellence (NICE) guidelines to apply in Northern Ireland or not?
You have summed up NICE’s position on the matter; its advice is that the drug should be used for patients with medium Alzheimer’s, but not for those with mild or severe cases of the disease. The Department does not question NICE’s clinical judgement, but we have our own evaluation process to determine whether the guidelines should apply in Northern Ireland. That process is ongoing, but I have not been given any answers as yet. I have still to make that decision, so doctors are still at liberty to prescribe as they see fit. I will have to make that decision in due course, and I will do so on the basis of the advice that I receive from within the system. That has not been done yet. I want to talk to more people who have expertise and who have experience of the disease.
The main thrust of the argument was that we should not introduce the NICE guidelines into Northern Ireland. After all, the drug costs £2·50 a day. A number of members want to explore that issue; others may want to come in on the expense of drugs for conditions such as cancer. Members may want to combine those questions.
The Committee heard evidence from the Royal College of Psychiatrists and the Northern Ireland Dementia Forum, who made the point that those drugs are not appropriate for everyone. However, even NICE has accepted that they are appropriate and effective in the early stages of the disease. So many people are being cared for at home, and their relatives cannot understand why they do not have access to certain drugs, especially if it can make a difference to the patient’s quality of life. It is so important.
I want to talk to more people and consider the matter, because maintaining cognitive function for as long as possible allows a quality of life that is not otherwise available. It is a major decision — one that I am not in a position to make yet. I will bear in mind exactly those points.
It is a real dilemma: as the illness progresses, people do not know if they would have been better if they had obtained the drug earlier.
I know that drugs are very expensive. What is the position on the drug for asbestosis? There is only one drug that can help that condition, and the disease is highly prevalent in Northern Ireland because of the number of people who worked in the shipyard. Can that drug be introduced into Northern Ireland as soon as possible? The figures that I have been given suggest that it would cost around £400,000 to £500,000 to implement, which is a relatively small amount. As we get rid of asbestos from more buildings in the future, those costs will come down.
What is the Department doing about doctors who prescribe tablets unnecessarily — if you know where I am coming from? Are you looking to cut that practice back? Is the Department considering the use of cheaper drugs that do the same job as those that are currently available? Can any savings be made in that regard?
The drugs budget is a major part of our expenditure. From memory, £400 million is spent on GP prescriptions and another £100 million through hospitals. There is clear potential there, and very considerable savings have already been made in that area. I think that those numbers are right, but I might need to confirm them. We have set efficiency targets of some £343 million over the comprehensive spending review period, and we anticipate that a considerable part of that will come from the drugs budget.
As far as the drug Alimta for the treatment of asbestosis is concerned, we are aware that there are approximately 50 deaths a year in Northern Ireland as a result of that disease. I have a background in the construction industry; I worked on building sites as a youngster. We all handled asbestos in the 1960s and into the 1970s, and nobody told us that it was potentially dangerous. In those days, in fact, we preferred working with asbestos, because it was easier to cut with a saw than timber, for example. Large numbers of people were exposed to it, especially those who worked with blue asbestos in the shipyard, so we have that problem to deal with.
NICE has recommended the use of Alimta for patients in the advanced stages of the disease who are not suitable for surgery. That decision has been appealed. We will issue our direction on the use of the drug after NICE issues its findings. As I said, we do not question NICE’s clinical judgement, but we will evaluate the drug’s applicability and use in Northern Ireland. It is a very expensive drug; we are talking about small numbers of patients and about a disease that is, frankly, hard to contemplate.
Dr Miriam McCarthy (Department of Health, Social Services and Public Safety):
The appeal is being heard today. The Committee might hear something about it in the media later, and we hope that we will hear NICE’s final outcome fairly soon. In the meantime, in the period between the introduction of the drug and NICE making a determination, we look to the commissioning bodies to consider the evidence, if they have a request for the drug for a particular patient. They look very seriously at that.
The drug is already in use in Scotland, so, if it is possible to prescribe it here, I urge you to introduce it as soon as you can.
How much are you hoping to save out of the £500 million drugs bill? Is there a figure that you are aiming for?
There is a figure of £55 million worth of savings to be made from a range of initiatives, including the follow-up to the recommendations about generic prescribing in John Appleby’s report. The Department’s chief pharmaceutical officer, Dr Norman Morrow, has an extensive programme of interventions and initiatives to deliver significant savings. Generic prescribing is considered to be good practice across the UK, and our target is to save £55 million.
We need an educational programme to show people that they do not need a pill for every ill. Enormous amounts of drugs are wasted and left in people’s medical cabinets — it is an utter disgrace. I have looked in cupboards in many homes and found an extensive range of out-of-date tablets that had barely been unsealed. We have much to do to enlighten people that they do not need a pill for every ill.
I thank the Minister and his team, and apologise for being late. I was going to ask about mesothelioma and asbestosis. However, those matters have been dealt with.
As far as I am aware, generic prescribing by GPs is going well — it certainly is in my area. Many savings are being made. However, the problem, which is NHS-wide, is that, in my practice and many others throughout Northern Ireland, 90% of people get free prescriptions. The Labour Government must deal with that problem, although I have my doubts as to whether they will.
My question is a practical one. The Committee heard a good presentation on Alzheimer’s disease from a team that included a psychiatrist. I have been in general practice for almost 25 years. Because the population are living longer, I have seen an inevitable increase in the rate of dementia in families. It is a family disease. GPs have seen evidence that drugs for Alzheimer’s disease work. Those drugs cost £2·50 a day. I can prescribe treatment for shingles that costs £150 a week, yet in order to prescribe the treatment for Alzheimer’s, I must go through a consultant.
I do not wish to disrespect consultants, whom I admire. However, first, they are not independent contractors as GPs are. They are directed by trusts and boards, and I would think that when it comes to spending on drugs, pressure might be put on them to be restrictive in their prescribing. Secondly, although they may see patients at the initial diagnosis, the GP and the primary healthcare team know the patients and their families better and know the effect that the disease is having on them much better than the consultants.
Of course, consultants should make the initial diagnosis if we are not sure. However, why not allow the prescribing to be done by the GP? That would be common sense. You see a family where the father has died from cancer and the mother is completely demented. Only one of the family — a daughter — is able to look after the rest of the family and has to take time off from her job in Belfast in order to do so. The disease can cause devastation to a family. GPs see that in primary care. Consultants should diagnose and GPs should prescribe treatment.
I agree that it is vital that that treatment be prescribed in the early stages of the disease, because not only does it delay onset, it also improves quality of life. Will the Minister consider that possibility?
As far as Alzheimer’s disease is concerned, I have yet to make that decision. I still have to think about that and consult on the matter more widely.
I am sure that all of us, including the Minster, have been contacted by the family of someone who has been diagnosed with cancer, who, despite having been advised by the consultant that there is a drug available, cannot access it on the NHS. Is it responsible for consultants to do that and to give people false hope? Those people have already suffered the trauma of being diagnosed with cancer, and then they are told that, although there is a drug that can help them, it is beyond their reach if they cannot afford it. Is it responsible for a consultant to put that on the table as an option if the drug cannot be provided?
Dr M McCarthy:
That is a difficult issue. Obviously, when consultants share a diagnosis and the possible treatment, they tend to talk through the range of options that are available. The first line of treatment will then be initiated. If that does not work, they will have what is often an even more difficult conversation with the patient and his or her family about any secondary options that may be available.
If there are any drugs that are either in the process of being introduced or have not entered the system properly, what often happens — although I cannot comment on individual circumstances — is that the consultant will put in a request to commissioners for that particular drug. It takes commissioners a little bit of time to consider that. Obviously, I cannot comment on what individual consultants share with their patients. However, I know that they aim to do their best to share as much information as possible on the risks and benefits of various treatments. They seek to find the best treatment for every patient, which is, ultimately, the service’s goal.
Do you take my point that it is frustrating for a family to be in that situation?
Dr M McCarthy:
I do accept that.
Last month, Minister, you announced that it was unlikely that there would be any more structural changes in health before April 2009. Bearing in mind that it will take 18 months to two years to consult and bring the necessary primary legislation through the Assembly to implement any new proposals that may be appropriate, when do you intend to make that decision and when do you estimate that the changes will come into effect?
We have heard about the resignation of David Sissling, the chief executive designate of the proposed regional health authority. Will you comment on that, and on how the public should read that, given that his job was basically not there because he was not going to be able to oversee the transformation of four boards into one authority?
David Sissling has gone to a much bigger and better-remunerated job. As I understand it, he was, in effect, headhunted. He has left us in a manner similar to that in which he came; we headhunted him. I had been working closely with him on looking at the single health authority, and I am sorry to lose him.
As you are aware, when I came to this job six months ago, believing in devolution and local accountability and control, I was faced with what was, frankly, one of the biggest, if not the biggest quango that Northern Ireland has ever seen. There was a large health authority, and no clear way to determine how it would be managed. Basically, it comprised approximately 1,600 staff and an annual budget of approximately £140 million per annum, which I wanted to examine.
The bulk of the review of public administration — the reorganisation of the trusts — has already been implemented. I talked about approximately 63,000 staff having been job-matched; over 50,000 of them are employed in the trusts. That has been worked through, and 18 trusts have been reduced to five. I have said that, apart from looking at efficiencies and performance, that number is fixed, as far as I am concerned. Of course, the Ambulance Trust is there as well.
I looked at the single health authority and what it was asked to do. It should be remembered that the single health authority was a direct rule model — a Peter Hain model. Mr Hain had certain views. He was looking at three functions: performance management, financial management, and commissioning. It seems to me that those functions were deficient. Other things have to be looked at, one of those being local representation, or democratisation. The fact was that the direct rule Minsters had a stipulation that no elected representatives were allowed on boards or groups. They were excluded. I wanted to see how we could get a local voice in. That is what I am looking at, and it will affect local government. There was a proposal to reduce the four health and social services boards to one, and the local voice would have been decimated. I am considering that, because it has a valuable role to play.
In commissioning, we are primary-care-led, with doctors having a bigger role and a financial responsibility for commissioning services in their areas. The difficulty is that there were to be seven commissioning groups, based on the seven local councils, according to the Hain model. There is a question mark over whether there will be seven councils. Everyone accepts that seven is unlikely to be the final number, but we are not sure how many there will be. To pluck figures from the air, if there is a move to 11 or 15 councils, how will the Department accommodate the new structures? It can be done, but it is a question of how. Do we brigade councils together and perhaps have a separate one for Belfast, or should there simply be a commissioning group for each trust? I am looking at that.
There are also omissions in the membership: for example, I want each commissioning group to include a mental health and learning disability practitioner. I am making progress and am not far from reaching a conclusion. David Sissling is one of the people who are working with me on that.
Another omission relates to which elements of delivery and implementation can move from the Department to local government. I have been sitting on Belfast City Council for 15 years and know from experience, as do you, Chairman, that councils have traditionally been concerned with emptying bins, cutting grass, leisure centres, and so forth. Councils and councillors can play an important role — if it is properly defined.
I am examining health inequality and the disadvantaged communities that are most affected by premature mortality, increased morbidity, smoking, lifestyle, and so forth, and considering how to address that. There has been a series of initiatives, such as the healthy cities programme, health action zones, community planning, and so forth.
Local government can work well with the Health Department and the health constituency in delivering in those important areas. That is very important. Members are as familiar as I am with the figures that consistently show that those living in disadvantaged areas do not live as long and are more likely to die from chronic diseases. The figures for cardiac disease are equally bad.
I am not taking my time per se, but I want to get this right. Thirty years ago, after the Health Service was reorganised, it was soon recognised that the reorganisation was flawed. Even after repeated tinkering, it was never right. As far as possible, I want to get this reorganisation right, which involves talking to trusts, boards, the British Medical Association, the Royal College of Nursing, the unions, the political constituency, and so forth. I want to end up with the best possible model, but one that can evolve so that if it is not working properly, it does not have to be broken and the process restarted. I have said April 2009, because that is the legislative timetable. However, I will know long before then what direction I want to take, and I will share my decision with all interested parties: the Committee, the Assembly, the Executive, patients, practitioners, unions and so forth.
It is a massive task. The bulk of the money and the employees are in the trusts. The functions of the health authority were guidance, management, control and performance management. A relatively small number of people are involved, and I accept that some of those performing those functions have expressed disquiet, but those functions are crucial if the rearrangement of trusts is to work and a better Health Service is to be delivered.
I accept the point that, because we are not sure of the outcome of the review of public administration, we do not know the number of super-councils and what health provision will be given to them. Even if you make a decision on structures — whether you go for the single authority — by 2009, it will take up to another two years for that to go through its various stages. I think that that is an appropriate estimate of the timescale — I stand to be corrected if I am wrong.
There is a natural wastage because many staff want to leave; is it cost effective to wait for that to go through in primary legislation and keep paying people? We have 26% higher staffing in comparison with GB. There must be savings that can be made immediately through the ready wastage of people who are ready— and want— to go. There is a lot of disquiet in the hospital services.
I accept that there is disquiet in the boards, although the trusts understand that they are in business and are working for the future — that is where five sixths of staff work. Twenty-six per cent higher staffing levels was mentioned; the boards currently have 25% vacancies, which is a comparator, albeit a poor one. The upfront saving that the Department mentioned was 1,700 jobs and £53 million per annum as a result of the investment. That is secure and will not be affected.
Under direct rule, the Department was set a target of delivering £30 million in savings, which was announced by Shaun Woodward. When we moved into the cycle of the CSR, Peter Hain announced a target of £53 million per annum by the end of the CSR period. Therefore, the objective is to achieve that target by the financial year 2010-11, so there is time to work towards it. Given that phasing was built in so that larger amounts of savings come out in later years, there is no direct financial issue at present, and the process of managing the financial budgets is on track. The Department has also been able to secure the upfront costs of dealing with the voluntary retirement scheme; a large proportion of that cost is already covered. Therefore, in financial terms, we are in a healthy and manageable position.
The tricky part is managing that organisational process. A large proportion of the savings is in the trusts, which are designing and establishing their new structures. The Department is working very closely with the trusts to secure their element of the savings. As the Minister said, the boards have substantial levels of vacancies; there has been a tight vacancy control in the health and social care system since early 2006, so that posts are filled permanently only where there is real justification. That has maintained flexibility and allowed the cost to be controlled throughout the process. The Department is working with the boards to ensure that they fulfil their statutory functions until the law changes. That is on course and is being managed as a process.
The Department is operating proper processes, in close consultation with the trade unions on all the delicate and sensitive human resource issues. The Department is doing that because it must maintain the morale across the service, whether that be in the professional or managerial groupings, which make a vital contribution to securing performance improvement, service delivery and care for patients.
I could reply, but I am aware that we have less than 25 minutes left and that other members want to contribute. I will agree to disagree on that issue for now.
Trusts were merged as part of the RPA. I am thinking of Down Lisburn Trust and the Ulster Community and Hospitals Trust, in particular. I received correspondence from the Minister on managerial positions. Each of those trusts, for instance, had a medical records manger, a manager of the X-ray department and an A&E departmental manager, and those managers had to reapply for their jobs.
The Minister’s letter states that there were four voluntary redundancies and that four people took early retirement — at a cost of around £400,000. Nevertheless, there seems to be a high retention of 125 managers. Surely if those two trusts were merged — and, therefore, there were double the number of posts that should be required — half of those posts would be redundant and half the number of managers would be required. Can the Minister explain why there appears to be the same number of managers, even after those trusts have merged? Have half of those managers’ jobs been created to stop redundancies? Can you explain why that has happened?
The sum of £400,000 — to fund the four redundancies and the four retirements — amounts to an average of £50,000 for each person. When one bears in mind that any of those management jobs could attract a salary of £60,000 to £100,000, would it not be simpler to cut costs by reducing the number of managers? I am extremely concerned about the large number of managers. From where have those jobs suddenly appeared? However, I stand to be corrected on that.
What is being done to cut the cost of bureaucracy for doctors and nurses? What is being done to cut the amount of money that is being ploughed into the reduction of waiting lists for outpatients and day-procedure patients by bringing in consultants, at a higher cost, from across the water? I have worked in medical records, and I witnessed many clinics being cancelled by consultants who were engaged in training or who seemed to have an excessive amount of leave. I am going to make myself unpopular by saying that. Can anything be done to stop those clinics being cancelled, because that is adding to our waiting lists?
What are you doing, in conjunction with other Departments, about cross-cutting measures that might lead to extra funding from, for example, the Department of Education for mental-health awareness and the issue of suicide?
May I remind members — and I am as guilty as the rest of you — that when the Minister attends a Committee meeting, we want to ensure that we make best use of his presence. Can I ask the Minister to provide written responses to Mr Easton’s questions? I am keen to move on to another couple of questions, which I also consider important.
Rev Dr Robert Coulter:
I thank the Minister and his team for attending the Committee meeting. I am in the dark about the number of elements that seem to be on the management side of the Health Service and its structure. How will you make all those elements coterminous? How will you manage the division of finance through them?
Perhaps the Minister could reply to those questions in writing. I do not want to curtail the member; I merely want to get through the agenda while the Minister is present.
I welcome much of what the Minister has said about the strategic health "quango", which is the term that he used. I welcome the fact that mental health and learning disability commissioners will be part of the commissioning groups. Carmel and the Bob hosted an excellent event this morning. I would like to have the Minister’s views, in writing, on the RPA. You are being hampered a wee bit by decisions taken by other Departments, particularly the Department of the Environment. I would like to hear some of your views on what we can do with local councils and on delivering some of the agenda about which you spoke, and particularly about building capacity in the community and voluntary sector as delivery agents for some of those matters. What you mentioned is hugely important to all of us in our efforts to tackle inequalities across the board. If we do not address those over time, we will all be seen to be failing. Minister, that is not an extreme left-wing view. I am happy to get a response in writing.
John, thank you very much for being understanding.
I will try to be as quick as I can, and I am happy to receive responses in writing. As I am now a member of a local commissioning groups (LCG), I was concerned about what was happening, so I am glad that the Minister clarified that matter.
Minister, you say that the health and social services authority will cost £140 million a year, but my understanding is that the authority will replace the four health and social services boards. What would it cost to continue with the four boards as they are? Many of us were of the opinion that the RPA was a good idea because its approach was bottom-up as opposed to top-down. After all, our Health Service is paid for by the public for the public. They do not know who is on the boards and the trusts, and I hope that that will change. If the LCGs are not accountable to the health and social services authority, to whom will they be accountable?
I agree; the RPA was, and is, a good idea, and we are working our way through that process. I am not entirely clear that the model for collapsing the four health and social services boards into a single health and social services authority is exactly right, which is why I am considering the matter. I have no doubt that the four boards will merge into one body. I would not call it a board, but that is the direction in which we are headed. It is not the body or what it is called that is the issue; it is its functions that are important.
Those key functions are: commissioning; performance management; financial control; local representation; local delivery and implementation through, for example, local government and that type of model; and dealing with health inequalities. Those include three of the current bodies’ functions, and I have added a couple more. We are crunching our way through this matter, and it will make more sense in time. I have no doubt that we can settle on an arrangement that involves fewer people and less money. I have no doubt that we will establish a body that will perform the functions of, and meet the requirements set down for, the health and social services authority. However, it will also have those added functions.
I have two other quick points, and I am happy to receive a written response.
There was specific talk about 1,700 jobs, and I would like the Department to give a breakdown of those jobs. Two nurses told me of their concerns, possibly within the Royal College of Nursing, of 600 job losses in the nursing profession. That would concern me.
Finally, can the Minister examine the issue of coterminosity with trusts and LCGs? There has been talk about that issue, and some overlap may be good. As LCGs are involved in commissioning, they could perhaps see whether one provider or one trust is doing a better job than another, and they may be able to use that knowledge. It may be a good idea to have some overlap.
Overlap may be a good idea, but there are currently four LCGs overlapping with the Northern Health and Social Care Trust. That seems a wee bit complicated.
Let us quickly move on to healthcare in prisons, as it is quite a burning issue. We can then return to the issue of pharmaceuticals, if we get the time. If not, we will ask the Minister to respond in writing to any issues that we do not get the chance to cover today.
Minister, you are aware that negotiations are ongoing about the transfer of responsibility for healthcare in prisons to the Department. As you know, the Committee met members of the Northern Ireland Affairs Committee in October. That Committee is carrying out an inquiry into prisons in Northern Ireland, and we were told that, although the transfer of responsibility has not been concluded, a transfer of funding took place in April 2007.
We have no idea of the amount of money that was transferred, and we have nothing to compare with because the Northern Ireland Office believed that it was not providing a proper service for prisoners who, perhaps, were suffering from mental-health problems because of alcohol and drug abuse. If the money from the Northern Ireland Office budget was not sufficient to look after those prisoners, will you tell us what additional moneys the Department will get to ensure that funding for prisoners’ health provision will not seep out of its budget? We must know about that important matter and about how much money is in the coffers, pending the completion of the decision process.
I am not complaining, but I inherited that process, which is part of the proposed transfer of responsibilities for policing, the courts, prisons, and so on.
The prison health service, which is similar to a mini-health service that looks after prisoners, is an anomaly. The standard of healthcare in prisons is not as good as it would be were the prisoners living outside. Few would doubt — and I take the view — that if people are in prison and have lost their freedom, for whatever crime they have committed, that does not mean that they should surrender their rights to a proper healthcare system. It is proposed that we take over prison health, and, in principle, I have no problem with that and am working to progress the matter. The transfer of responsibilities to my Department will result in a better prisoner healthcare system.
The question is: what budget will flow with it? A ring-fenced sum of £5 million was added to the Department’s baseline, and that is still sitting there. I also asked whether £5 million would be enough. I have had negotiations and have been to Maghaberry Prison to look at its hospital, and there is a clear need for some capital investment in addition to improvements to healthcare. That will be a matter for the South Eastern Health and Social Care Trust, and I have had discussions with the chief executive, John Compton, who will be responsible for Maghaberry Prison. It makes sense to keep those matters together.
Dr Ian McMaster has worked in prison health for several years, and he advises me on related matters; Dr Andrew McCormick has negotiated the financial settlement. They will answer questions on the two key areas of the financial settlement and the nature of what the Department is inheriting and what must be improved.
We had long discussions with the Prison Service, in which we identified a need for additional investment in mental-health services. That was the key issue. Until now, because mental-health provision has been organised across the Health Service generally, there is room to reorganise and make it more efficient and fit for purpose. There is a specific mental-health need that we have quantified at around £450,000 a year. When Paul Goggins was the Minister with responsibility for health, he set some money aside. Therefore, it is possible to use some of that. The NIO also agreed an additional transfer of £225,000 a year over and above the £5 million that Mr McGimpsey mentioned, which was allocated under direct rule. That has allowed us to recommend that, subject to the other checks that Dr McMaster will touch on in a moment, the Minister can accept that funding as the correct basis from which to proceed. That level of funding is financially acceptable and will not be at the expense of the general Health Service.
Dr Ian McMaster (Department of Health, Social Services and Public Safety):
As the Minister said, the initial transfer was just over £5 million. It was considered as an initial transfer because, before the conclusion of negotiations, it was difficult to judge exactly how much money would be required.
In-year negotiations have increased the revenue by £277,000, identifying shortfalls in areas such as cognitive behavioural therapy and increasing pharmacy costs in some areas. An additional £450,000 was required to develop general mental-health services rather than forensic services. A figure of £225,000 was negotiated from the Prison Service, and the rest was matched by the Department.
If £5 million-plus is sitting in the Department’s account, what was the Northern Ireland Office’s original spend for mental-health provision in the Prison Service? The £5 million-plus has been transferred, but how much was there before? Is that an improvement? Is that how much had been spent on what proved to be a poor service? The Department has additional funds, but they are not significant.
Prisoners require help, especially if they are in prison because they have stolen to fund drug habits. However, my main concern is that it does not eat into moneys for mental-health provision for Joe Public, who has mental-health problems but is not in prison. If we have limited resources in our budget for mental-health services, we need an assurance that those will not be eked out and spread thinner if we have not done a good deal with the Northern Ireland Office.
The £5·46 million that was in the original transfer covered many areas, of which mental health was only one. The additional £450,000 represents just under 10% of the total transfer. Therefore, it is a significant investment to improving mental-health services in prisons. The trust has judged it to be sufficient to provide a service equivalent to that in the community.
A small proportion of the population is in prison. Prisoners are needy, and that has been recognised, with the high incidence of substance misuse, personality disorders and the fact that serious mental illness increases the likelihood of violence. Those people constantly go in and out of prison. The static population in prisons is between 1,400 and 1,500 on any given day. However, in a year, the turnover is 6,000 prisoners. Often, many of the problems are caused by people who leave prison, go back into the community and then reoffend and end up back in prison. It is hoped that better communication and arrangements for early identification of people when they are in prison, transferring them out when necessary and providing continuity of care when they are finally discharged will provide efficiency savings in the longer term.
Finally, will those moneys be ring-fenced specifically for the prison regime? How will that work?
We must ensure that we secure and sustain that service, monitor it carefully and work with the trusts and the Prison Service. It is a transfer of lead responsibility. One cannot separate matters entirely in a prison context, so the trust will have to work carefully with the governors and the prison officers to ensure that we have a better system overall. We can provide the assurance that you are looking for.
That has been noted, Andrew. Thank you. I have hugged this issue, because I was keen to get clarification on it.
Hospital-acquired infections are an emotive issue in many ways, and they cause great concern to many people.
Hospital-acquired infections, such as MRSA and clostridium difficile, have not gone away. We all accept that it is not right to go into hospital with one illness and come out with another potentially fatal one.
My question concerns the recording of incidents, and it seems to be difficult to get agreement on that. We have talked about all sorts of systems — bringing back matrons, monitoring, and so on — but unless we actually record as well as monitor, we will not know whether there has been any improvement. Is that happening?
Yes, I assume that it is.
I know that it did not happen previously.
It did not happen in the past. However, several issues have been progressed as part of Changing the Culture — an action plan for the prevention and control of healthcare-associated infections in Northern Ireland. We also have targets. It does not make sense to have targets if the incidents are not known. Recording and information play a key part. Our targets are for a 20% reduction in clostridium difficile and a 10% reduction in MRSA and MSSA by the end of March 2009. There are other issues about guidance on the use of antibiotics. We are doing the second audit of environmental cleanliness and that, I hope, will lead on to the proposal for running a pilot scheme in a hospital.
Recording and monitoring play a key part. Hospitals cannot work out how well their countermeasures are working if they are not able to record the total and, therefore, the total reductions or non-reductions, which is one of the determining factors in whether a particular policy or strategy is working.
There are different arguments, including the high turnover of beds. On a local level, someone may walk into a ward and run their finger through dust. That person may come back some months later, but unless the level of cleanliness was exactly recorded, he or she will not know whether the ward is any better. I am talking about each ward and each area being recorded, so that when someone returns in six months or the following year, it will not be a matter of doing another spring clean; the cleanliness of the area and the overall level of hygiene will have improved.
I have an issue that I must bring to the Minister’s attention. The Committee went to Craigavon Area Hospital in September and heard about the pioneering work done by Dr Nizam Damani, a consultant microbiologist working on infection control. What are we doing to pick up that good practice? There were media reports about the number of MRSA-related deaths in Craigavon, but that has since been resolved and a proper statement issued on that allegation.
I am meeting later with two or three families; I will not mention the hospital involved. The meeting concerns an elderly gentleman who suffers from dementia. He was wearing clean pyjamas, but it was noticed that his nails were filthy. It turned out that when staff started to wash him, he had a lot of motions stuck to his body. Clean pyjamas were put on the gentleman to cover a lot of dirt. He then urinated on the floor after the family had washed him, but they had to leave. When they came back, the urine was still on the floor. I will have more detail on that matter later.
If we have a system that is working, why is it not being rolled out across the whole of the Health Service? Are we recording the number of deaths properly? Due to the complication of MRSA being picked up — particularly in our most vulnerable community, the elderly — are records being kept to show that a death was associated with contracting MRSA? Perhaps those people would have died anyway, but their deaths may have been speeded up by contracting MRSA.
Rev Dr Robert Coulter:
Four MLAs and two local councillors from the Ulster Unionist Party visited Craigavon Area Hospital last Friday on this very point. One of the issues raised was the introduction of regulations to limit the number of visitors, so as to restrict the possibility of transferring MRSA from visitors to patients. Is that being considered?
Yes. As far as the principle is concerned, of course patients have a right to expect not to be infected while they are in hospital. Patient safety is important. With respect to Craigavon Area Hospital, the experience and practice of the Southern Health and Social Care Trust has been shared across the health trusts.
I am also considering a pilot scheme to look at the feasibility of screening for MRSA: they are currently considering that in Scotland, and we will learn from that. I am looking at the possibility of directly employing cleaners to work to ward sisters. I had agreement yesterday from the Executive as far as excluding cleaning from soft facilities management in the new hospitals in the south-west — Omagh and Enniskillen — in the hope that the pilot will indicate that that is the way to go forward; limiting visitors to visiting times; and creating regimes that do not have large numbers of superfluous people wandering about hospitals who have no business being there. They are liable to bring in infections. Nursing staff should not have to spend time acting as crowd control, but do the job that they are there to do.
There are a number of issues involved: hand hygiene is another. We must ensure that people follow a proper hygiene practice to keep infection, as far as possible, out of the ward and to ensure that unnecessary visitors do not bring it in. This sort of event will always happen in hospitals, almost by definition, but we should limit it as far as possible. Furthermore, guidance should be issued on the use of antibiotics, as far as clostridium difficile is concerned.
Dr M McCarthy:
Recording the cause of death can be complicated. A number of factors are involved. There is the immediate cause and the underlying disease, which is usually the main cause, and then there are contributory factors — things that the patient may have had wrong with them, which co-existed but did not cause death directly. For some patients, it will be difficult to be categorical and accurate about every one of those. However, every doctor who signs a death certificate looks at the detail and the background and records, as accurately as possible, the cause of death.
The statistics are collected. It is impossible to be sure that they are 100% accurate — a degree of judgement is involved, which is as it should be. Some deaths are referred to a coroner, who subjects them to a much more detailed discussion. They are, however, a minority; that is only done for very specific reasons. The vast majority of death certificates are completed by clinical staff in hospitals or in general practice. An enormous amount of clinical judgement is necessary. Recording the facts is a role that all doctors take seriously; they are acutely aware that they are contributing to a database of information that is useful historically and is of great value to us all.
What I wanted to do was to flag up the perceptions of the public that sometimes MRSA is overlooked, because a death associated with MRSA will look bad for the hospital. I am not saying that that is so; I am just flagging up that point. We also have to consider issue of staff wearing their uniforms outside the hospital complex — for example, going shopping — and then returning to the wards. Doctors, nurses and all other hospital staff have a part to play in reducing the carrying in of infections that could end up affecting the patients.
There is one more question to be asked, and it concerns pharmaceuticals. Minister, do you have five minutes, or would you prefer to address it —
We will try to finish up, because that completes the agenda.
The Pharmaceutical Society of Northern Ireland, in evidence to the Committee, expressed concern about proposals on the future regulation of the profession. Minister, you wrote in September that you were strongly minded to embrace the formation of a general pharmaceutical council to cover the whole of the United Kingdom. The society, which carries out that function at present, has made representations to us. Do you intend to make provision in a health and social care Bill for the powers that would be necessary should you decide to follow the Westminster approach?
I am not clear about the mechanism or Bill to be used, but there is a nationwide requirement for a regulatory function. The Pharmaceutical Society of Northern Ireland currently has both regulatory and professional leadership functions; separating those functions would be seen as best practice. The Westminster Health and Social Care Bill includes enabling provisions for a UK-wide general pharmaceutical council. It is important that we are part of that, but that does not preclude the Pharmaceutical Society of Northern Ireland from providing a valuable professional leadership function. I have still to have a final discussion with the society before the final step is taken. However, I have told the society that I concur with the national view that the regulatory and professional leadership functions should be separated.
I have an interest in this matter, because my whole life has revolved around pharmacy. My father was a pharmacist, God rest him, and I have worked with pharmacy all my life. I take it that the requirement for a UK regulatory body is a legal requirement.
I am not sure that it is; it is a proposal.
The Committee spoke to the Pharmaceutical Society of Northern Ireland, and it has concerns about this matter. Pharmacists play a major, increasing role in primary care to meet the rising needs and demands of the population. You referred in your letter to our unique Northern Ireland identity — the personal touch that you do not get in the large pharmacies across the water. I would love to see that uniqueness preserved for the patients’ sake. How will you maintain that unique identity? You said that you had met the Pharmaceutical Society of Northern Ireland. Do they agree with your proposals in terms of maintaining that Northern Ireland identity?
I have met the society, and I will meet them again. All health professions are regulated on a UK-wide basis, except pharmacy. As I am sure you are aware, there are two pharmaceutical bodies: the Royal Pharmaceutical Society and the Pharmaceutical Society of Northern Ireland. The Royal Pharmaceutical Society has 47,000 members and the Pharmaceutical Society of Northern Ireland has 2,000 members. The proposal is for restructuring; it is not about the abolition of any organisation. There are benefits, including: harmonisation across the professions; streamlining of pharmaceutical arrangements; consistent regulatory standards, irrespective of location; and greater cost-effectiveness.
This is a Westminster Bill, but the Northern Ireland identity and voice will be provided for. I have to talk to the Pharmaceutical Society of Northern Ireland about that specific issue. I do not see that society disappearing; it has been here a long time and has a valuable role to play, not least in providing leadership. I have met the society once before and assured it that, before any further step was taken, I would talk to it again. The Bill is moving ahead at Westminster, and we will decide whether we include ourselves or exclude ourselves. I think that it would be a good idea to include ourselves in the national arrangement, but there needs to be a strong local voice and identity.
With respect to that strong local voice, are you minded to keep not just a Northern Ireland identity, but some Northern Ireland control over this field? You might write to me on a second point, which is how we can extend the role of pharmacy and maximise its use in treating conditions such as diabetes and asthma. Perhaps, however, you can address the first point now.
I am happy to write to the member on those issues.
My first point, about keeping actual control in Northern Ireland —
I see the provision of a local voice and a local identity as important functions. The Pharmaceutical Society of Northern Ireland has an important role to play. It has been in business for 82 years, and I would not have it disappear. However, the Bill offers a UK-wide regulatory system and there are economic benefits to be had from a UK-wide approach to harmonisation. The Bill separates regulatory and leadership functions: the regulatory function would be controlled on a country-wide basis, but leadership would stay with the Pharmaceutical Society of Northern Ireland.
Minister, on the Committee’s behalf, I thank you for extending your time for giving evidence. Had I been here at the right time, you would have been able to leave at 3.30 pm. I thank you, your officials and those in the Gallery.