Official Report (Hansard)
Date: 11 September 2008
COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health and Social Care (Reform) Bill
11 September 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey
Mr Craig Allen )
Mr Ivan McMaster ) Department of Health, Social Services and Public Safety
Mr Bernard Mitchell )
The Chairperson (Mrs I Robinson):
The Health and Social Care (Reform) Bill is an important piece of legislation that will greatly affect health provision across the board. Today marks the beginning of the Bill’s Committee Stage, and departmental officials are here to brief the Committee on its provisions. Over the next few weeks, we will hear evidence from interested groups before embarking on a clause-by-clause consideration of the Bill.
We are subject to a very tight timescale, and we must complete our report by 23 October 2008. I refer members to the separate red folder, which contains a copy of the Bill, a briefing paper from Assembly Research and Library Services and a copy of written submissions to the Committee’s consultation on the Bill, which took place over the summer. In total, 29 responses to the consultation were received. I remind members to bring their red folder to each meeting during Committee Stage.
I welcome Mr Bernard Mitchell, Mr Ivan McMaster and Mr Craig Allen from the modernisation directorate in the Department of Health, Social Services and Public Safety (DHSSPS). I invite the witnesses to outline to the Committee the background to the Bill and its general provisions. Members will then be able to ask questions. I will allow up to one hour for the evidence session.
Mr Bernard Mitchell (Department of Health, Social Services and Public Safety):
On behalf of my colleagues, I am grateful for the opportunity to begin this process of engagement with the Committee in considering the Health and Social Care (Reform) Bill. I will start by thanking the Committee for its input to date to the legislation. I acknowledge the helpful comments that were made during the Bill’s Second Stage in the Assembly on 1 July 2008.
The Chairperson has highlighted the tight timescale, for which I am also grateful. We are working hard to try to deliver the proposed changes by the due date of 1 April 2009. It is important to do so from the point of view of all those staff who need certainty about their futures and about the way forward. We have a busy few months ahead of us in going through the detail of the Bill’s proposals. Several proposals are still under consideration and subject to final decision. I will cover those areas if Committee members have questions about them. We will, of course, be available to answer any questions during the Committee’s consideration of the Bill, and we will call on other officials if additional expertise is required.
We intend to give a short explanation of the Bill’s main provisions, based on the broad thrust of its proposals. We will then take questions. I will now hand over to my colleague Mr McMaster.
Mr Ivan McMaster (Department of Health, Social Services and Public Safety):
I will quickly run through the broad provisions of the Health and Social Care (Reform) Bill, and how those provisions are set out. First, it is important to say something about the Bill’s general content, and, perhaps more importantly, what it does not contain. The Bill’s purpose is to provide a legislative framework within which the proposed new healthcare structures can operate. The Bill’s aim is to set out, as transparently as possible, the high-level functions of DHSSPS and the various health and social care bodies that will be created under the legislation.
The Bill seeks, either in the body of the document itself or by securing the powers to make subordinate legislation, to establish parameters within which each of those health and social care bodies will be permitted to operate; what is expected of them; and the necessary governance and accountability arrangements that would support the effective delivery of health and social care in Northern Ireland.
It is probably just as important to note that certain measures are not included in the Bill. It does not rewrite Northern Ireland’s entire body of health legislation. Functions that existing health bodies carry out will still need to be performed. The Bill will legislate that functions once performed by A will instead be performed by B.
Pieces of legislation that bestow a vast number of functions, such as the Children ( Northern Ireland) Order 1995 or the Mental Health ( Northern Ireland) Order 1986, are extant, and the Bill will not seek to replace them. Rather, the Bill puts in place a framework of new structures. It will amend existing legislation only where it is absolutely necessary. For instance, pieces of legislation that were used to establish bodies that the Bill now seeks to dissolve must be repealed. In general, however, the Bill is to be read with, rather than instead of, other legislation.
The Bill does not address a number of issues. No mention is made of organisations such as the Northern Ireland Medical and Dental Training Agency (NIMDTA) or the Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC). Bodies not mentioned in the Bill will continue to exist in their present form.
The Bill has 35 clauses, which come under 10 broad headings. I will cover those as quickly as possible. The fairly explanatory heading, “Restructuring of administration of health and social care” covers clause 1, which defines health and social care bodies. It is at the beginning of the Bill, along with explanations of abbreviations and acronyms that appear throughout, to facilitate the reader.
Clauses 2 to 6 deal with the “Department’s role in promoting and providing health and social care”. The clauses explain the Department’s general duties, powers and priorities. It is important to bear in mind that the Department will maintain all its existing duties. Those provisions broadly replicate the Health and Personal Social Services ( Northern Ireland) Order 1972 by establishing the Department’s overall duty for health and social care in Northern Ireland.
However, the clauses, by providing an explanation of the Department’s duties, go one stage further than the 1972 Order did. The 1972 Order outlines the Department’s overarching duties to improve the health and social well-being of the people in Northern Ireland, whereas the Health and Social Care (Reform) Bill explains, in more depth, related issues, such as introducing policies and holding people to account. Clauses 2 to 6 set out clearly what the Department should and should not do, thereby allowing people to hold the Department to account if a duty is not performed properly.
Clause 5 introduces the new concept of the framework document. It sets out how the new bodies will be accountable in the discharge of their functions; how they must conduct their relationships with the Department; and, as equally important, how they will conduct their relationships with the other organisations to create an effective joined-up approach.
The introduction of the framework document is recognition that total clarity is needed about the roles and functions — local and regional — across all health and social care organisations, and of the Department.
The next broad heading, which covers five clauses from 7 to 11, deals with the establishment of the regional health and social care board, including its functions and objectives, and makes provision for the establishment of local commissioning groups (LCGs).
The existing four boards will be replaced by a single regional health and social care board. The regional board will focus on the main areas of commissioning health and social care; managing and improving the performance of health and social care trusts; and resource management. The legislation will give the regional board the power to offer guidance and direction to health and social care trusts, as well as to place a responsibility on them to abide by the regulations and to provide information as the board requires.
The reform will seek to ensure co-ordinated commissioning at all levels. The clauses will require the regional board to draw up a regional commissioning plan, and to consult with and to have due regard to advice or information that the proposed new regional agency for public health and social well-being (RAPHSW) provides.
Clause 9 deals with the establishment of local commissioning groups. The legislation allows the regional board to establish whatever committees it likes, but it specifically states that it must establish particular committees called local commissioning groups. Those groups will involve local health and social care professionals, local government and lay representatives. They will bring together their innovation and expertise and deal with local communities’ needs in the planning of services.
The number of local commissioning groups and the areas that they will cover will be specified in subordinate legislation. The current thinking is that there will be five groups, which will be coterminous with the five trusts. Those details will be covered by subordinate legislation because the issue may be re-examined when the local government boundaries are finalised. Therefore, it is slightly easier to deal with the matter through subordinate legislation than through primary legislation.
The membership of the LCGs will also be prescribed by subordinate legislation, which allows for more flexibility should any changes need to be made. The current thinking is that each group will comprise four GPs, a pharmacist, a dentist, four elected local representatives, two social-care professionals, one nurse, one public-health-medicine professional, one allied health professional and two health-and-social-care-related voluntary-sector representatives. If my maths is right, that is a total of 17.
The Bill requires the commissioning groups, in exercising their functions, to consult the proposed regional agency and to have due regard to any information that the agency provides. Again, that is an attempt to encourage joined-up thinking.
The next heading deals with clauses 12 and 13, which simply establish the regional agency for public health and social well-being. The creation of the agency stems from a desire to bring a higher profile to public health and social well-being and, equally importantly, to reduce health inequalities. The thinking is that a dedicated body is the best way in which to create a sustained and enhanced focus on the matter and to drive the public-health agenda forward in a manner that is not possible under current arrangements.
The new agency will have three key functions: health improvement; health protection; and the provision of public-health support to commissioning and policy development. It also has a particular responsibility for promoting improved partnership-working with local government and other public-sector organisations. Indeed, the clauses will place an obligation on the new agency to co-operate with other bodies that carry out health-protection or health-improvement functions. Again, we are aiming at some kind of joined-up work.
Clauses 14 and 15 will create a regional support services organisation (RSSO). Believe me, over the next few weeks, members will become familiar with those terms and initialisms. If members are struggling with them, do not worry. We are still struggling with them as well, so bear with me. The organisation will incorporate the majority of services that the Central Services Agency currently provides, but it will offer a broader range of support functions for the entire health and social care service.
Those clauses will impose a specific duty on the organisation to ensure an economic, efficient, effective service to all users. It will be required to operate within clearly defined standards, with measurable performance indicators. Clause 15 places a duty on the RSSO to put in place arrangements to that end, and the Department must approve those arrangements beforehand.
Clauses 16 to 20 deal with a broad range of “Patient representation and public involvement”. The five clauses deal primarily with the establishment of the patient and client council. They also deal with enhancing patient choice; meeting the needs and expectations of patients, clients and carers; and ensuring that their views are heard and listened to at all stages in the planning and delivery of services. The patient and client council will replace the four existing health and social services councils. It will build on the excellent work that those councils have carried out in the past, and it will combine the strong local focus that the councils provided with a powerful regional voice — a voice that has been missing in the current set-up.
Although the patient and client council will have a clear regional focus, subordinate legislation will provide that it must have five committees at local level, and those committees will be coterminous with the five integrated trusts. Those satellite offices will provide the important local presence that the health and social services councils do currently, but they will feed local issues and perspectives into the formulation of wider regional aims through the patient and client council.
Clause 18 places a duty on the Department, the regional board, the regional agency, the trusts and special agencies to co-operate with the patient and client council in the discharge of its functions. That is a statutory duty. There is also a duty to consult with the patient and client council, to give such information to it as it requires and to have regard to advice that it provides. That gives the patient and client council a statutory footing that it may not have had before the legislation was drafted.
Clause 19 also requires those bodies to prepare a consultation scheme, which the Department must approve. In the past, such a requirement has been known as a statutory duty to engage. The consultation scheme places a duty on all health and social care bodies to show that they will make arrangements with patients, clients, the patient and client council, and carers to ensure that they are involved in, and consulted on, the planning and provision of care, the development of proposals for change and decisions that affect the provision of all aspects of health and social care.
Clause 20 states that the bodies are required to have regard to the comments given — they cannot ignore them. The bodies will have to prepare a written statement that summarises the comments, and set out a response to those comments.
The next heading, “HSC trusts”, comprises clause 21, which deals with health and social care trusts. It places a duty on trusts to aim to improve health and social care, despite any competing priorities that they may have. The duty imposed in the clause already applies to the other organisations that we are creating in the Bill. However, for consistency, it was considered important that the provision be applied to trusts also, even though the legislation does not deal with trusts.
The next heading, “Public-private partnerships”, comprises clause 22 and deals with public-private partnerships (PPPs). Current provisions in legislation permit PPPs. The inclusion of that provision in the new structural arrangement clarifies that the Department, the regional board, the trusts, the regional agency, the regional support services organisation and special agencies are permitted to form, or participate in forming, partnerships to provide facilities or services. The inclusion of the clause is not about encouraging the use of PPPs, but it is acknowledged that private finance initiatives (PFIs) are only one of a range of procurement models and should only be used where it can be demonstrated that it represents better value for money as a conventional option over the lifetime of the contract. The clause permits, rather than encourages, their use.
The next heading, which deals with the “Transfer of assets, liabilities and functions”, covers clauses 23 to 28. The Bill becomes technical at this point. Clauses 24 to 26 deal with the dissolution of the health and social services boards, the Mental Health Commission and the Central Services Agency, plus the subsequent transfer of their assets, liabilities and functions. It does not seek to replace existing health legislation but merely states that functions that were previously performed in one place will now be carried out elsewhere. That is what the Bill does — it states that the responsibility for functions that were carried out previously by body A will be done by body B. Therefore, it does not interfere, detract from or add to those functions.
Clause 23 requires the Department to produce schemes for the transfer of assets and the liabilities of dissolved bodies, including staff who can be listed by name or by the type of work that they do. The staff have to get from body A to body B, and the technical provisions contained in clause 23 allow that to be done.
Clauses 29 to 35 become even more technical. They deal with the Department’s power to make supplementary, and other, provisions by amending or repealing legislation where necessary, and several are necessary. Although I said that we were leaving all legislation as it was — for the most part — some elements need to be amended or repealed, and those clauses deal with that.
There are seven schedules to the Bill, the final two of which set out in detail repeals and minor and consequential amendments. The first four schedules deal with the establishment of new bodies: the regional board; the regional agency; the regional support services organisation; and the patient and client council. Schedules 1 to 4 deal with details about the constitution and operation of those bodies; their committees and who shall serve on them; how their boards will be constituted; and how they will be established.
That is a very quick run-through of the Bill. I will leave copies of our submission with the Committee Clerk, as our submission may assist the Committee at a later stage in its scrutiny.
May I ask a simple question? The consultation period ended on 12 May, and you received around 120 responses. Can you indicate what the general thrust of those responses is, percentage-wise?
I may not be able to give a percentage breakdown, Chairperson; however, I can say, and the Minister will have said this in his announcement, that broad support was received for the thrust of the proposals. Having read through each and every page of all the received proposals, I can say that the quality of response was high and that the responses included some really good material. If you are interested, I will be happy to talk in detail at some point about changes to the proposals that have arisen as a direct result of the consultation responses.
A number of broad themes emerged from those responses; there was a great deal of support for the regional agency’s proposed role and for the renewed focus on public health and social well-being. There was a concern that the Bill be comprehensive and that it not be driven by a solely health-orientated agenda but that it take into account social well-being. That explains the name of the new agency in the Bill:
“The Regional Agency for Public Health and Social Well-being”.
It was chosen to try to get across the message that the agency will adopt a comprehensive approach to the public health and social well-being of the entire population.
There was much support for the new agency’s role, and for the establishment of a regional board to replace the four existing boards. The responses included a great deal of advice on how we might ensure a good relationship between the regional agency and the regional board; it was felt important that those two bodies operate seamlessly to a common agenda. It was suggested that the Department put arrangements in place to ensure that that is the case.
We received a limited amount of comment on the regional support services organisation. Responses that we did receive were broadly supportive, with the major theme being a concern that the RSSO be genuinely accountable to its customers to whom it will provide a service, especially those smaller agencies that will rely on it for support. It was felt important that those concerns and wishes be given due regard.
There was overwhelming support for our proposed patient and client council model, which is to have a regional council and five local committees. The notion of creating a strong regional voice with a good local presence that reflected local concerns and struck the correct regional/ local balance was also welcomed. That is an overview of the consultation responses, Chairperson.
Thank you very much indeed, Bernard. I now ask Committee members to put any questions that they may have to our panel.
In your consultation, did any groups highlight major concerns? Is there anything to be worried about?
It was a good consultation so, as you would expect, two or three concerns were raised. As I have already said, the relationship between the regional board and the regional agency was raised. That is what I mean by a “good consultation”; many comments were insightful and came from people who had a good understanding of the importance of roles and relationships in an organisation. Therefore, the Department is paying a great deal of attention to that issue, and it is a key piece of work with which the Department is dealing and will continue to do so over the coming weeks.
Representatives from the voluntary and community sector expressed concern that that sector should play a proper role and be seen to have its place in the new system. The Department has sought to respond to that point in several ways. For example, the increased membership of the local commissioning groups — which now have two representatives from the voluntary and community sector — was a change to the original proposals that came about as a direct result of comments from the consultation. Another decision that was made as a result of the consultation was that the Department will seek to have an individual director with an allocated responsibility for the voluntary and community sector at executive level in the regional agency and the regional board so that there could be direct input into the work of both bodies.
A concern was raised that there should be more than one social care representative on the LCGs, so the Department has proposed that there should be two. That ties in with a related issue because notionally, at this stage, the Department has adult and children’s services in mind. Concern was also expressed that the broader agenda for revisiting arrangements for children’s services planning, and its multi-sectoral nature, should not be lost because of the new arrangements. The Department had several meetings with constituencies representing that side of the house and has agreed arrangements with them on how that part of the agenda will be developed.
I do not believe that any of those concerns would fall under the category of serious, below-the-waterline problems; they simply reflect a thorough response from the consultees.
Some concern was expressed that the regional agency for public health and social well-being might take away from the good work that is already being done on the ground. As a result of that, there was an original proposal that many health-protection and health-promotion personnel from the trusts would transfer to the new agency. Given those concerns, it has been decided that community-development and other health-improvement staff who currently work in trusts will not be affected in the shake-up. Therefore, the Department recognises that much good work is currently being done.
When the proposals were initially announced, at a meeting that I attended with the Minister, members raised that point. A decision to bring a much-reduced number of staff into the regional agency was directly based on that concern and the subsequent consultation responses.
I joined the Committee only recently, and I have a question about the number of groups that have evolved because of the proposed changes. Is there confusion about that issue, or is there likely to be confusion? Given that you have said that the changes relate to the structure of care rather than the actual care that is being delivered, will you comment on the responses from those consultees? The Mental Health Commission responded and had some concerns about the lack of integration that might ensue as a result of the changes.
I should have referred to the issue of the Mental Health Commission in answer to Mr Easton’s question. That concern was expressed, and it was considered carefully; several meetings were held with those concerned.
The view taken was that the functions of the Mental Health Commission could be undertaken more effectively within the broader infrastructure of, and with the greater resources held by, the Regulation and Quality Improvement Authority (RQIA). If the Committee plans to meet representatives from the RQIA, that would be an opportunity to seek some reassurance on that point. That was the rationale for the carefully considered decision to proceed with the transfer of the functions of the Mental Health Commission to the RQIA.
In the second reform phase, the number of bodies was significantly reduced. The first reform phase involved a significant reduction in the number of trusts, which now amounts to five trusts and the Northern Ireland Ambulance Service. The current phase will involve the amalgamation of the four health and social services boards into one regional health and social care board. The number of agencies affected was reduced from the original proposals, because it was felt that some of those agencies, such as the Northern Ireland Medical and Dental Training Agency,were doing good work. There was no reason to change the functions of that agency and other bodies because they were carrying out their functions effectively.
I declare an interest as a member of Strabane District Council. The Mental Health Commission submission states that councillors will be at arm’s length from commissioning decisions. Will that be the case?
The view of the Department is that the functions currently undertaken by the Mental Health Commission will be fully addressed by the RQIA and that greater resources will be available to address those functions than is currently the case.
Is it only the elected councillors who will be at arm’s length from commissioning decisions? Will there still be local accountability?
The proposal is that there will be four councillors on the LCGs.
There is provision for four local government representatives on each local commissioning group. There is also provision for local government representation on the patient and client council and in the regional agency for public health and social well-being. From the Minister’s perspective, the introduction of improved democratic accountability through active engagement with local government representation is an important element of the reforms. The current proposals are significantly strengthened in that regard compared with those that were previously being progressed under direct rule.
Is it unusual for a Bill to contain provisions for the use of PPPs at this stage? I accept your view that that does not mean that such schemes will be used, but it seems strange to have that provision in the Bill, particularly as there is so much concern about PPPs. It seems as if the provision has been inserted so that, even if the use of PPPs is opposed, the option is still available to make use of them.
The Department was conscious of that. The view was that legal clarity was needed in the event that it was decided to make use of a PPP scheme, and, if it were felt that the legal framework were not sufficiently clear, it would then be too late to address concerns from a contractor. The aim was to insert a provision into the Bill that was permissive but that made it explicit that the provision simply made the use of such a scheme possible, if it were required. As my colleague said earlier, it is not the Department’s intention to insert that provision with any motive to encourage PPP schemes. It is simply a permissive provision, and it provides the legal clarity that a PPP scheme can be used if it is required and is judged appropriate in individual cases.
I am concerned that, if people are opposed to a PPP in any given case, it would be difficult to oppose it if the provision is already in the Bill.
The provision simply allows the use of PPP schemes, and it is not prescriptive about whether such schemes should be used; it simply permits their use. Timing is the issue; the provision for the use of PPPs does not sit altogether comfortably in the Bill. However, the Bill is probably the biggest structural change to health services since 1972, and the Department feels that the Bill is as good a place as any to insert a clarification that such a PPP scheme is available.
It flags up the issue of PPPs, which people may not otherwise have thought about.
My other main concern is that powers are still centralised and do not flow down, despite all the discussions about personnel being in place to allow that to happen. The proof of the pudding may have to be in the eating; we will have to wait and see whether the powers are provided so that personnel will be able to make decisions and budgetary controls will be given to people nearer ground level. For many people, that has been a concern throughout the process.
I want to comment on that, because several work streams are ongoing across a range of initiatives.
First, work is being undertaken on the proposed improved partnerships among health, social care, local government and other stakeholders. Those partnerships are at the heart of the proposals, and there are plans to run pilot schemes from April 2009. If that works and the pilot arrangements are put in place, that will be a real step forward in front-line, ground-level partnerships among the respective stakeholders who have an influence and interest in public health and social well-being.
Secondly, if LCGs and GPs feel that they do not have the required devolved authority, they will not participate and, therefore, will not function. Indeed, if Dr Deeny were here today, I feel that he would agree with that point. Effective commissioning is required, a sentiment that was expressed to me at a meeting this morning. I do not believe that the four local government representatives would be content to sit on a body if they felt that it did not have devolved authority.
Therefore, the Department is developing operating frameworks for the local commissioning groups. They begin with the premise that funds will be devolved to the LCGs through the governance arrangements of the regional board. However, that is done on the basis of empowering them to make decisions about local services. Many of the reforms rest on a number of factors, but that is one of the key foundation stones.
The Department is attempting to change the public’s perception of the scale of the LCGs, which is an issue that arose from the consultation process. Although LCGs are local, many people think that they will be large groups. The LCGs must think about how they will engage with local communities.
Those are my thoughts. That is particularly the case with public health, where we want to reach the most vulnerable people. The LCGs must be linked in on the ground.
Some of those people say that they are not represented by national bodies that represent the larger organisations. Therefore, the Department is introducing specific proposals for that type of stakeholder community engagement with the LCGs.
By the same token, there is expertise beyond the Department on the current boards to make the decisions, particularly on public health issues.
I recently met representatives from the Food Standards Agency, and they were enthusiastic about the potential role of that agency in focusing the agenda. That is what the Minister had in mind when he made the proposal.
The Appleby Report identifies notable deficiencies in the Northern Ireland Health Service and also the distinct absence of an explicit performance management system. The report contends that the current performance management system is devoid of clear and effective structures, information and, most importantly, incentives — both rewards and sanctions — at individual, local and Northern Ireland organisational levels to encourage innovation and change.
Will you comment on that view and how it weighs up with the Bill’s proposals?
That is an interesting aspect of the Department’s current work. It is akin to the blood flowing through the arteries rather than the bones of the structure.
Something similar to the current basic skeletal framework mechanism will remain, with the Programme for Government feeding down to a public service agreement, priorities for action, health and well-being plans, and trust development plans, with accountabilities at various levels.
There are real opportunities at present, because changes are being made that allow for a fresh examination of what is being done. The reduction in the number of boards, and the setting up of a regional board, provides an opportunity to consider greater consistency of information and for a more comprehensive and co-ordinated approach to the sort of management performance to which the Appleby Report aspired.
The very presence of the regional agency for public health and social well-being will allow a focus on the development of measures that can effectively gauge whether the progress in public health and social well-being that is expected as a result of the creation of the agency is being made. There are real opportunities. Colleagues with whom I met this morning are working on the detail of that performance regime, taking in all the relevant issues, including the regulatory framework, the role of the RQIA and the revised role of the slimmed-down Department, with an improved focus on how the regional agency and the regional board will work together and how the LCGs will play their part in that function and relate to the trusts.
The Department will provide a definitive framework for performance management. The reforms have given us the opportunity to do that. The Department is working hard on that matter, and proposals will be published in the next four to eight weeks.
The provisions of the Bill include a statutory responsibility for the regional board to performance manage the trusts. The board can now be told that that is no longer something that it should be doing but which it absolutely must be doing.
I am glad that there will be that level of accountability and scrutiny. We are only at the start of the long process of considering the Bill in detail. Members have had to go through a lot of reading material. I thank the departmental officials for attending this afternoon; it has been very helpful. Thank you for your time.