Official Report (Hansard)

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Health and Social Care (Reform) Bill

02 October 2008

Members present for all or part of the proceedings: 
Mrs Michelle O’Neill (Deputy Chairperson) 
Mr Thomas Buchanan 
Dr Kieran Deeny 
Mr Alex Easton 
Mr Tommy Gallagher 
Mr Sam Gardiner 
Mrs Carmel Hanna 
Mr John McCallister 
Mrs Claire McGill 
Ms Sue Ramsey

Witnesses:

Ms Mary Hinds ) Royal College of Nursing Northern Ireland 
Mrs Ann Marie O’Neill )

The Deputy Chairperson (Mrs M O’Neill):

I welcome Mary Hinds and Ann Marie O’Neill from the Royal College of Nursing Northern Ireland. I invite you to make a presentation, after which Committee members will ask questions. Thirty minutes have been allocated for the evidence session.

Mrs Ann Marie O’Neill (Royal College of Nursing Northern Ireland):

I am the chairperson of the Royal College of Nursing Northern Ireland’s board and a member of the UK-wide governing council of the Royal College of Nursing. In my other life as a practising nurse, I work as a night sister in Antrim Area Hospital. Members will, of course, be familiar with my colleague Mary Hinds.

We welcome the opportunity to make an oral submission on the Health and Social Care (Reform) Bill. We hope that the comments and written information that you received from us in August will help the Committee in making your decisions. I will now ask Mary to highlight key issues and how they relate to the Bill.

Ms Mary Hinds (Royal College of Nursing Northern Ireland):

I thank the Committee for inviting us to give evidence. In the interests of brevity, our evidence will deal only with the areas of the Bill with which we have issue or concern, and not the entire Bill.

The Royal College of Nursing Northern Ireland supports the Minister’s stated intention to put the public-health agenda at the heart of the health and social-care system, as well as his intention to ensure the involvement of local communities and professionals in commissioning decisions.

How the local commissioning groups, the regional health and social care board and the regional agency for public health and social well-being work together is central to the delivery of those objectives. We have concerns about four key areas: the relationships between those bodies; the strength of local voices; the membership of those bodies; and the timescales that challenge us all.

I shall start with the relationships between local commissioning groups, the regional board and the regional agency. The RCN considers the relationship among those organisations to be one of partnership, not conflict. The legislation as introduced indicates that the regional board must consult the agency and have due regard for any advice or information that it provides. That is repeated for local commissioning groups, which are asked to consult the agency and have due regard for any advice or information they receive. Our view is that the relationship between those organisations must be described in stronger terms if a truly public health-led service, which is informed by local communities and expert professionals, is to be delivered. Advice is not sufficient. Throughout many years, nurses in Northern Ireland have learnt, when holding advisory positions, that advice can be taken, but, unfortunately, can also be ignored.

The RCN also considers the language of direction to be no more appropriate to the relationship between those organisations. We prefer the language of partnership. The RCN suggest that the Bill’s language should be strengthened and, at least, that all plans should be signed off jointly by the local commissioning groups, the board and the agency. In that way, no one body has primacy over the others. We believe that that will provide checks and balances that will help to ensure that good local decisions are made.

As stated in previous responses to consultation, the RCN is extremely supportive of the Minister’s direction on inclusion of local voices in the commissioning of services. Our concern relates to the weight that is given to those local representatives and professionals, particularly at local-commissioning level.

The legislation describes the local commissioning groups as committees of the board. The RCN is concerned about the involvement and level of authority that local professionals and communities, or their representatives, will hold in commissions’ decision-making. If commissioning is to be truly local, an agreed level of authority must sit with local commissioning groups; otherwise, groups will be relegated to no more than debating chambers.

To strengthen partnership between those bodies, as mentioned earlier, is a start. To ensure that optimum levels of commissioning are carried out at local level is another. We also accept that local commissioning groups will have different priorities. Therefore, one solution will not necessarily fit all.

However, the principle of decisions about local commissioning being close to patients and communities, informed by those communities’ representatives and professionals, is one that could be more explicitly described.

I will now move to the issue of membership of the various bodies. The Bill does not provide detail about the composition of the regional board, the regional agency or the local commissioning groups. Although that had caused us some concern, we have since received a consultation paper on the membership of the regional board and the regional agency, and we will respond to that appropriately.

As a general principle, the Royal College of Nursing Northern Ireland believes that clinical-and social-care professionals and community representatives should be central to the membership of all those groups. Indeed, nurses have, to date, successfully contributed to commissioning at regional board and local health and social care group level. However, we believe that it would be helpful to clarify, and if required, make explicit in the legislation, the role of district councillors as members of the regional board.

The Royal College of Nursing Northern Ireland particularly welcomes the inclusion of local representatives in the structures. Health and social care is a public service, and the public should be a part of its governance. We know that that will not necessarily be easy, as it involves all of us balancing competing priorities and interests. However, we believe that problems must be owned, shared, understood and acted on. We can only do that if we do it together.

We also recognise that building trust, confidence and governance capacity will take time. As nurses, we are committed to playing our part by working with colleagues, including our local councillors, to develop the capacity and understanding of the entire team. We look forward to learning from colleagues in return.

The primary legislation does not provide information about the composition of the local commissioning groups. That may be entirely appropriate, given the level of detail. We wish it to be noted, however, that the proposal as it currently stands has the RCN’s support, with the following proviso: having discussed at length the membership of the LCGs, the RCN has chosen not to enter into a debate about who holds however many seats around the table. As we see it, the local commissioning groups must work as a collective team, and not as an adversarial committee in which one group outvotes the other. That said, we expect the nurse on the local commissioning group to be enabled to develop a network of nursing colleagues who will help inform decisions. We recommend that, in the knowledge that no one nurse can represent, on her or his own, the broad church of nursing.

We are delighted that progress has been made, but having waited some time to get to this point, we urge all parties to this reform to work together in order to ensure that the legislative timetable is adhered to. To ask the service, our patients and our staff to endure any more delays in the reform process, which has already stretched over two years, is unacceptable. The staff, particularly of the regional board and the regional agency, who have been affected by this final set of reforms, have lived with uncertainty for too long.

Thank you for listening to our submissions. I am happy to answer any questions.

The Deputy Chairperson:

Thank you very much. We will take on board the concerns that you have outlined today. The concerns about the strength of the local commissioning groups have been a common theme in our deliberations, as have concerns about local voices making local decisions and not being overruled at another level.

Mrs Hanna:

You are very welcome, Mary and Ann Marie. I have raised concerns, as have other members of the Committee, about who will be involved in decision-making. There is no point in being a member of a regional agency or a regional board unless those bodies have decision-making powers. No one that we have talked to, including the members of the regional board when we met them at Muckamore Abbey Hospital, knows what is happening. That is part of the problem; the situation has gone on for so long, and there is still a great deal of uncertainty about the detail. The devil is in the detail, and everyone at the table will agree with me that we must have sight of the composition of the various bodies before decisions are made.

The need for partnership is essential, from the bottom-up as well as the top-down, or the new bodies will not work.

We have a great opportunity, particularly with the establishment of the regional agency, and it is absolutely essential that everybody is involved. Especially with regard to the local commissioning groups, it is essential that you and other health professionals are involved in those, and work with local councillors to ensure that there is a capacity to make a difference, particularly considering the new powers that local councils will have to deal with health and well-being.

Dr Deeny:

Thank you again, Mary and Ann Marie. My contribution will be short, because the proposed changes seem to be on a consistent course, and I am delighted to hear it. I will repeat some of what Carmel has said; what the Committee heard last week from the chief executives of the health and social services boards; and what the patient watchdogs; health and social services councils; and now your organisation have told the Committee: what is needed is a bottom-up approach. I know that there are members of my own profession here today, representing the British Medical Association.

The LCGs that preceded the new proposals did not work, because they were not seen to be taking a bottom-up approach. That message has been expressed by everybody, that there must be a bottom-up approach, and as a Committee we must see that that is the case. We have to stamp our authority on this, and make clear that all of the groups that have given evidence to the Committee have agreed that there must be a bottom-up approach.

Not every decision made locally will be an easy one, or popular with the communities. We know that, but it has to be that way. It would be wrong to establish bodies that are merely advisory, and that can be overruled by a central authority in Belfast. If that were the case, I believe that, not just GPs, but other health professionals, would walk away. The established bodies must have authority, otherwise the proposed reform will fall flat on its face, and we will be back to the situation that has been the case until now. Currently, were one to ask the man or woman on the street, in Omagh or any other town, who is on the local health board, and who has responsibility for commissioning health care in the area, they would not know. There is no knowledge of who makes the decisions on commissioning health care, and there is no accountability. That has been the case for far too long.

My question concerns the number of lay members on the LCGs. I have forgotten what the proposed makeup of those groups is, as the number of groups has changed from five to seven, and other changes have been made. I know that there will be four councillors, four GPs, a nurse, as you say, and different allied health professionals on the LCGs. You say that you do not want to become involved in this debate, but the Committee raised it last week with the representative of the health and social services council. From what I understand, with the establishment of the patient and client council, the patient will have a more of a say, and more authority, not just to complain, but to contribute. How many lay members will there, or should there, be in the new commissioning groups?

Ms Hinds:

I think the proposal at the minute is that there should be two. It must be remembered that, although it is appropriate that such lay members have a say, and they may represent particular specialist interest groups, we should not underestimate the closeness of local councillors to the public, and the public are those who become clients and patients. There are few of us who have not visited a GP over the past twelve months, for instance. The proposal makes provision for a lovely mix of both expert professionals and local representatives, whether local councillors or lay members.

Mrs A M O’Neill:

If the general public are included in the LCGs it would generate great public confidence in the system, and the support of the councillors.

The Deputy Chairperson:

The proposals as outlined by the Minister make provision for the inclusion of two voluntary sector representatives from the health and social care sector in the LCGs. Would those be the lay members?

Ms Hinds:

Yes, we think that that refers to lay members. As Carmel said, the devil is in the detail of such proposals.

The Deputy Chairperson:

No other members have indicated that they wish to speak. You have explained it so well that we do not need to ask any more questions. Thank you very much for coming along to this meeting, and we will take on board the issues that you have raised.

Mrs A M O’Neill:

I thank the Committee for allowing us to present the information that we have given. As you know, nurses deliver the majority of patient care, and it is essential that nurses have a voice on the commissioning groups, because performance and commissioning are key to what happens to our patients, and we want the best for patients, and for all of the people in Northern Ireland. Thank you.