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COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Evidence Session on Comprehensive Spending Review Efficiency Savings
with the Western Health and Social Care Trust

22 October 2009

Members present for all or part of the proceedings:

Mr Jim Wells (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill

Witnesses:  

Mr John Doherty )
Mr Alan Corry Finn )
Mr Joe Lusby ) Western Health and Social Care Trust
Mr Trevor Millar )
Mrs Elaine Way )

The Deputy Chairperson (Mrs O’Neill):

Our next evidence session is on comprehensive spending review (CSR) efficiencies with the Western Health and Social Care Trust. I welcome the team: Elaine Way, the chief executive of the trust; Joe Lusby, the deputy chief executive and the director of acute services; Alan Corry Finn, the director of primary care and older people and the executive director of nursing; Trevor Millar, the director of adult mental health and disability services; and John Doherty, the director of women and children’s services. You are all very welcome. You have appeared before the Committee previously, so please begin with your presentation.

Mrs Elaine Way (Western Health and Social Care Trust):

We have a presentation to hand out. I wonder —

The Deputy Chairperson:

I am sorry. I remind you that we are running late. Please keep your presentation short.

Mrs Way:

We will rattle through the presentation, which will allow more time for questions.

I will begin with an overview of the facts. The Western Health and Social Care Trust provides care to a population of almost 300,000 people, it receives a £455 million budget and employs 12,500 staff. The trust is required to deliver £36 million of efficiency savings between 2008 and 2011, and, if those savings are delivered, the trust will receive £36·2 million of investment.

The trust briefed MLAs from the Western Trust area at Stormont in November 2008, and it also briefed the Committee for Health, Social Services and Public Safety in February 2009. Today, I intend to update the Committee on the proposals that were outlined in February, which were approved by the Minister of Health, Social Services and Public Safety in July 2009.

The trust has broken down the achievement of the £36 million efficiency savings over the three years of the CSR. In 2008-09, the target was 2·5% — £9·7 million; in 2009-2010, the target is 3% — £12·1 million; and, in 2010-11, the target will be 3·5% — £14·2 million. The trust has also divided the targeted efficiencies by directorate, whereby the approach is to subtract the corporate and review of public administration (RPA) efficiencies of £9·4 million from the £36 million required. That means that each directorate has to achieve the same proportion of savings. By the use of that method, the savings that each directorate was required to make are: acute services — £8·7 million; adult mental-health and learning disability services — £3·1 million; primary care and older people’s services — £6·9 million; women and children’s services — £4·4 million; and drug and procurement services — £3·5 million.

The trust brought 48 proposals to the Committee in February 2009, and we will provide an update on those proposals today. All 48 proposals were equality screened, and two proposals — those relating to residential homes for elderly people and day care services — were subject to a full equality impact assessment (EQIA).

I particularly draw the Committee’s attention to that fact all the trusts are experiencing significant financial pressures in 2009-2010 because of the way in which the investment has been arranged. That system means that the Western Trust has had to make £12·1million in efficiency savings and has received only £5·4 million in investment, leaving it with a net decrease of £6·7 million.

However, the Western Trust has a good story to tell about the delivery of efficiencies in the first year of the CSR when it delivered 81% — £7·9 million — of the required savings on a recurring basis. All the savings were met in-year, but £1·8 million was non-recurring, and those have been carried forward into 2009-2010.

The Western Trust has developed recurring plans that equate to 63% of the proposed savings for 2009-2011 — £7·6 million. The trust has not yet identified all the proposals to meet the efficiency targets, and there is a shortfall in the plans of £2·3 million for 2009-2010 and 2010-11. However, the trust is working to develop alternative proposals, and it is firmly committed to ensuring that further equality screenings, consultations and EQIAs are undertaken when necessary.

Mr Joe Lusby (Western Health and Social Care Trust):

As Elaine said, the Western Trust shared its proposals with the Committee in February 2009, and those proposals were approved by the Minister in July 2009. Of the 48 proposals, 13 were identified in the acute directorate of the trust to make total savings of £8·7 million. However, there is a current shortfall of £785,000, and the directorate is examining additional proposals to make up that shortfall. One such proposal is a regional replacement of X-ray films with digital technology. That project ties in with similar work being carried out across all the trusts, and, through it, the trust hopes to save an additional £300,000. The directorate is also considering skills mix reviews. All the trusts have a priority for action target in 2009-2010 for those reviews, particularly in the areas of nursing and allied health professional services. The directorate hopes to save an additional £140,000 through such initiatives in the Western Trust area.

In the acute directorate, up to 30 September 2009, the surgery and anaesthetics division has achieved £444,000 of savings against a target of £2·9 million; the emergency care and medicine division has saved £1·5 million against a target of £4·2 million; the diagnostics division has saved £217,000 against a target of £550,000; and pharmacy services has saved £180,000 against a target of £230,000.

There is a typo in the total planned savings that the Committee received in the trust’s submission. That figure should read £7·9 million rather than £4·9 million, and the difference between that figure and the overall £8·7 million of savings that the directorate must achieve is made up of plans that the directorate has still to develop. Therefore, the Committee will realise that the acute directorate of the trust has significant challenges in meeting the planned savings in the later part of the three-year CSR period. It has effectively achieved around £2·5 million and must now save a further £6·2 million.

In the context of increasing demand for all the services for which I am responsible, we have to undertake a significant number of reform and modernisation initiatives. For example, quite sensibly, we are increasing day case surgery throughout the trust, and, if we compare the last completed year with the previous year, provision has increased by 12%. In addition, in those two years, outpatient attendances increased by almost 10%, and overall A&E services increased by 7%. Given the increasing demand, meeting our CSR savings is a difficult challenge, and, in my 35 years in health and social care, I have not experienced challenges as significant as the ones that we are facing now. That is an explanation of the situation on our performance to date and on the outstanding issues.

I shall finish by talking about the acute directorate, because it is important to leave members with some idea of the successes that we have achieved in the past year and a half. Committee members and, indeed, other MLAs will be aware that, for a number of years, there have been complaints about fracture services throughout Northern Ireland. In the Western Trust, 90% of patients who require fracture services are treated within 48 hours. Only a couple of years ago, MLAs regularly complained on behalf of their constituents about people having to wait from two to seven days to access fracture services in outlying facilities and hospitals. We are now in a position in which 90% of fracture patients are treated within 48 hours. The Department also set what it calls a “backstop” of seven days, after which time no one should have to wait. In the past year, no one has had to wait beyond the seven-day backstop. Therefore, 90% of fracture patients are seen within 48 hours, and no one must wait more than seven days. In the Western Trust, fracture services are now provided in Altnagelvin Area Hospital, so fracture patients are not delayed in any other facilities.

As a result of the transfer of acute inpatient medical services, Tyrone County Hospital has one of the best cardiac assessment units in the Province, with 89% of its cardiac patients being investigated, treated and discharged through it. That unit is a good example of a locally accessible, highest-quality service.

The medical and surgical assessment unit in the Erne Hospital is unusual. One comes across medical assessment units and surgical assessment units, but to have a combined medical and surgical assessment unit is unique. The Erne Hospital has 14 beds and two trolleys, and it is consultant-led, which means that senior clinicians make decisions at the front end of services. The standard is for investigation and treatment in two hours, discharge in four hours, and a maximum stay of between 24 and 48 hours. On average, there are 16 admissions a day to the medical and surgical assessment unit, 81% of people stay for less than 24 hours, and 18% of people stay for between 24 and 48 hours. Of those who go through the unit, 49% are discharged to home, and 51% are admitted. Those are three examples of first-class services.

Mrs Way:

We will not have the time to go into much detail on every slide in the presentation. However, while we have been waiting to give our evidence, we have been making notes. I ask my team to keep their presentations short, although members can ask for detail if they wish.

Joe’s point is that, with £36 million in savings and £36∙2 million in investment, we are trying to use the investment to improve services for patients and clients.

Mr Trevor Millar (Western Health and Social Care Trust):

I will speak about the adult mental-health and disability service. The directorate made seven proposals, which were identified at our last meeting. A total saving of £3∙1 million is to be achieved. We have already achieved, or have plans to make, savings of £2∙9 million, leaving a shortfall of £232,000. I have examined a new proposal that will be developed in learning disability services during 2010-11, which is a review of current high-cost packages in the independent sector. It is a contractual review rather than a service review.

We have two proposals for the mental-health service that will produce £1∙8 million in savings. Of that, I have to date achieved £617,000 of savings. In the learning disability service, I have four proposals that will amount to savings of £912,000; of that, we have achieved £507,000. In the physical disability service, we have one proposal to save £104,000, which has now been achieved. In residential nursing homes across the three areas, £52,000 in savings has been identified, and all of it has been achieved. Once again, that saving was made in respect of contracts.

As Joe did, I wish to highlight some of the good work that is done in the area. In learning disability services, we are introducing a new crisis intervention team across the trust. It will cater for families and carers who are unable to cope and have reached a crisis situation in the home. Rather than admit the individual to hospital, we will put the team into the community to support them there. That will account for 10 or 12 new staff in the trust.

A range of psychological therapies, including psychosexual disorders, eating disorders, personality disorders and primary care slots, both in the trust and across the voluntary sector, will account for about 10 staff. In the personality disorder service, which is a regional development, we will put eight new specialists into the community, allowing us to deal with personality disorders in mental health. We welcome that new development. Those are all in line with the regional strategy that was outlined as part of the Bamford review. We are delighted with those service developments.

Mr Alan Corry Finn (Western Health and Social Care Trust):

In primary care and older people’s services, we have identified 12 proposals, which include: encouraging people to become less dependent on long-term institutional care, which is a strategic commissioning direction; modernising the workforce and its facilities; and improving the patient’s journey and efficiency. Total savings of £6∙9 million are required, and there is no shortfall in our plans.

We are working on the following areas: in the reform of continuing care services, we have a plan for a saving of £1 million, of which £900,000 has been achieved; in the reform of residential care, we have a plan for a saving of £1∙6 million, of which £356,000 has been achieved; in the reform of day care and day hospitals, we have a plan for a saving of £425,000, of which £170,000 has been achieved; in the reform of older people’s medicine, we have a plan for a saving of £1∙5 million, of which £230,000 has been achieved; in community care efficiencies, we plan savings of £1∙9 million and have achieved £1∙2 million; and in workforce redesign, we plan to save £426,000, all of which has been achieved. There is still some work to be done in achieving most of those targets.

I now turn to investments and developments. In the development of the new stroke service, we will make an investment of £1∙4 million over the next few years. Most of that is already made. We have invested in thrombolysis services, which ensure that people receive swift access to lifesaving services, and also in community stroke rehabilitation. In our case management model for long-term conditions, we, along with the other trusts, have identified some patients who have long-term conditions such as heart failure, chest disease or diabetes. Those people are regularly admitted to hospital, so we have put specialist staff in charge of those case management reviews and are ensuring that they receive help at an early stage and are monitored to prevent hospital admission. Finally, £140,000 has been invested in additional respite services for people with dementia, which will be spent on direct payments, domiciliary care and a sitting service.

Mr John Doherty (Western Health and Social Care Trust):

Sixteen proposals were identified in women and children’s services, and we were required to yield up £4·4 million. We have a shortfall of £1·3 million, and, as we speak, additional proposals are being developed. The proposals are split across the subdirectorates as follows: family support — £1·1 million achieved; children’s healthcare — £1·6 million achieved; children’s mental health and disability — £65,000 achieved because we started from a low base for those services; and goods and services — £270,000 achieved.

I will identify the developments in children’s services. First, in recent years, there has been a significant increase in domestic violence referrals to the trust. The establishment of a dedicated domestic violence team has had a positive effect on the trust’s work. Secondly, we inherited significant waiting lists for children with autistic spectrum disorder (ASD); some children had to wait for four years. We have received targeted funding and now have a dedicated ASD service in place. By the middle of 2010, we anticipate that no child will have to wait beyond 13 weeks. Thirdly, there had previously been several points of entry to the trust for child protection services. Earlier in the year, we established a child protection gateway team that provides one dedicated point of entry, which is staffed by people who are specially trained and dedicated to that work.

Mrs Way:

Our largest single overall target was for our corporate CSR savings. We were asked to deliver £5·7 million in RPA savings, which we achieved by the end of September 2009. We also achieved corporate efficiencies of £200,000, drugs savings of £900,000 and some procurement savings. We have saved approximately £7·6 million. We have developed plans to make regional savings from shared services next year of £600,000 and corporate efficiency savings of £2·9 million.

I will make some final comments about the RPA savings. I know that the Committee has received reports from other trusts about the effect of the mergers. In the west, three trusts merged into one. We have reduced the number of chief executive and director posts from 22 to nine, and the number of non-executive directors has been reduced from 18 to eight. We have had a reduction of 193 management and administrative posts across the Western Trust.

By the end of September 2009, we delivered £7·9 million in efficiency savings and £7·6 million will be delivered this year — a total of £15·5 million — which represents 43% of the savings target halfway through the three-year period. I want to emphasise that that has not been easy. We have described some shortfalls, and the challenge for us is to deliver on those plans. There is increasing demand on our services, and our primary aim is to provide safe, high-quality services for our patients and clients. We tend to respond to that demand; the money is always a secondary consideration, although we are required to balance our books. Our productivity is up, and we have performed well overall. I will conclude by paying tribute to our staff, who have delivered that performance in difficult and challenging times.

The Deputy Chairperson:

I will ask the members from the Western Trust area to ask questions first. We welcome the positive aspects of your presentation. You have described the challenges that you have been able to meet. I want to ask you about the break-even duty to realise 0·5% year on year. Would that be easier to achieve if it were spread out over three years, or would it make the burden worse?

Mrs Way:

The break-even duty, regrettably, is that we have to reach zero or a small surplus; it is not 0·5% either way. Some years ago, a trust could have either a surplus or a deficit of 0·5%. However, the break-even target has now been clearly defined as zero or a small surplus. It would be easier if we had the 0·5% leeway, because 0·5% on those large budgets is a significant amount. The target will be easier to achieve if financial challenges are spread over a number of years.

The Deputy Chairperson:

We now understand that all trusts must submit contingency plans for deficit funding. Your presentation refers to, for example, a shortfall of £1·3 million in women and children’s services; is that deficit funding?

Mrs Way:

No; our presentation is on the comprehensive spending review. Part of the way through the year, the Western Trust had anticipated a deficit of almost £10 million by the end of the year. We received additional income in-year, which reduced the figure to £8·4 million. Therefore, we developed contingency plans to ensure that we reached the break-even target. The contingency measures are separate from the comprehensive spending review, and the contingency plan proposals that we have been developing relate to areas such as vacancy control measures, delaying the implementation of our service development funding, reducing goods and services expenditure, delaying some backlog maintenance and health promotion initiatives. The contingency plan aims to tighten our belts in-year to ensure that we reach the break-even target.

I understand that the Executive’s decision last week on swine flu funding will ease our position. We anticipate an announcement that we will receive additional funding. If that is the case, it will provide some relief in-year and will reduce the contingency target that we have been planning towards. That is welcome news.

The Deputy Chairperson:

Trusts rely on regional programmes such as generic tendering to meet their targets. How much does a central delay affect you? It has a negative impact on your ability to meet your budgets.

Mrs Way:

Some of our 48 proposals are described as regional initiatives around, for example, procurement. If those savings are not delivered regionally, trusts must meet the shortfall in-year. Therefore, it has an impact on us. We work closely with our regional colleagues to help them to deliver regional savings; that is in both our interests. However, there have been shortfalls, and we have had to fill those gaps.

Dr Deeny:

I will try to be as quick as possible. I agree with Joe; the cardiac assessment unit in Tyrone County Hospital is excellent. I am delighted that it has turned out much better than we had hoped. I assume that it will not be touched and that our X-ray department, which is also an excellent local service, will not be touched.

I have some concerns about the savings. There is concern about the foundation of the new hospital in the south-west. Is there an emerging overspend in that area? We also talk about value for money. I am concerned about the ability of the paediatrics and obstetrics and gynaecology departments in the Erne Hospital to attract staff. For example, two nights ago, the ‘Belfast Telegraph’ had advertisements for three additional paediatric posts — two for specialist doctors and one locum appointment for training. Are those departments achieving value for money, or are we trying to prop up those units? Given the difficulties in attracting junior staff to obstetrics and gynaecology, will those units be sustainable for the future? I am told that two locum consultants are still working in obstetrics and gynaecology at the Erne Hospital. Is that the case?

It has been highlighted that using locums costs much money. I wonder about the value for money if we are relying on them and are facing difficulties. The European working time directive states that junior doctors can work legally for a certain number of hours only, which is a difficulty for those two departments in particular. I question whether we are spending money sensibly in propping up two departments that are finding it difficult to manage and survive.

All the trusts tell us, and I take their comments on board, that administration has been scaled down. I had a look at the trust’s management structure on its website. I am curious about it, because people continue to talk about wanting good managers and administrators but without duplication or triplication. I saw that the trust has a director of finance and three assistant directors of finance. If there is a damn good director, why are three assistant directors necessary? There is also a director of nursing and three assistant directors. I want to know, and the public will want to know, why four directors of finance and four directors of nursing are needed for 300,000 patients, if that is, indeed, the case?

Mrs Way:

Dr Deeny covered many topics; forgive me if I forget something, and please come back and clarify anything with me.

The cost of the new hospital in the south-west is tied down; it is a private finance initiative (PFI) build, and there will be no additional costs. The trust has signed a contract with the contractor to provide the hospital at a certain cost. There is speculation about whether the build will cost more money, but it will not; it will be within the contract.

Dr Deeny asked about paediatrics and obstetrics and gynaecology, and I hope that I can rely on the MLAs from the west to support me in ensuring that we receive our fair share of the resources for doctors in training. Indeed, I have picked up on that issue over the past couple of days as I listened to you speak about it. Patients in the west are entitled to have access to the same quality and numbers of doctors as elsewhere. As Dr Deeny said, the impact of the European working time directive means that there are fewer doctors available working different shift patterns. There are not enough numbers of doctors to fill all the posts that are needed. Recently, Tommy Gallagher asked a question for written answer in the Assembly about junior doctors being placed in obstetrics and gynaecology departments, and it was clear that the Erne Hospital had been most disadvantaged of all. We are making a strong case that we must ensure that “peripheral” hospitals — such as Altnagelvin and Erne — receive their fair share of doctors because we rely on those doctors to deliver services to our patients.

We were supposed to get six junior doctors for the obstetrics and gynaecology department at the Erne Hospital; we got one. All we can do is to bring in locums, who cost more money. The choice is between bringing in locums and carrying that cost or stopping the service. There are many challenges in delivering services, particularly in rural areas, but we are committed to delivering paediatrics and obstetrics and gynaecology in the new south-west hospital. I will work hard with people such as Dr Deeny, who understand the medical workforce issues well, to ensure that we receive our fair share. Similarly, the middle-grade rota in paediatrics at Altnagelvin Area Hospital is significantly challenged, and we rely heavily on locums to provide that service. We must work hard to get doctors to the west.

My background is as an administrator. Many of my colleagues here at the table come from professional backgrounds. I am passionate about the contribution of our administrative staff. I assure the Committee that we do not want to carry a single unnecessary cost for an administrative post because we want as much of our resource as possible to go towards front-line clinical staff. We have scaled administration down, and we are committed to doing more.

However, there are issues; for example, when the trust’s finance director was examining rationalisation, we received strong representations from councils in the west asking us not to move jobs from that area. Therefore, there are concerns about ensuring that people have fair access to employment opportunities, particularly in the west, where unemployment is quite high. Sometimes, we could avoid duplication, but there are wider considerations that we have to take into account.

Dr Deeny mentioned there being a director of finance and three assistant directors. I assure you that we compare ourselves not with the Belfast Trust, which is twice the size of the Western Trust, but with the three other trusts. Two of those trusts have a director of finance and three assistant directors, all of whom concentrate on specific areas. The South Eastern Health and Social Care Trust has four assistant directors of finance. Before the reduction in the number of trusts, each of the former trusts had three directors of finance, perhaps supported by two assistant directors. Therefore, the number of administrators has been reduced. I put on the record that no one is working harder than our director of finance and her team. We could not run the Western Trust without our administrative staff, and many professional staff tell me that they would rather have an administrator who could help them than another professional post. I assure you that that is the case. The professional staff value the administrative staff highly.

Dr Deeny spoke about Tyrone County Hospital and its cardiac assessment unit. It is top drawer, and we are proud of the unit and do not want to touch it or make it vulnerable. We spoke earlier about contingency plans of, initially, £10 million, which have been reduced to £8∙4 million. During that process, we considered issues such as on-call for the X-ray department in Tyrone County Hospital and elsewhere. However, it is important that we do not do anything without working closely with our clinicians. Our starting point will be clinicians telling us why a service is needed.

We will also work closely with our staff. To break even, as the Chairperson described, we have no intention of riding roughshod over the staff who deliver these services on our behalf. I am trying to be completely open with the Committee. The issue was discussed as part of our contingency planning. However, we are in a different position now because of the Executive’s decision on swine flu funding, and I hope that we will not have to introduce such a difficult contingency plan.

The Deputy Chairperson:

I have asked this question of all trusts: what percentage of employees are administrative staff?

Mrs Way:

I do not have that figure with me.

The Deputy Chairperson:

Will you come back to the Committee on that point?

Mrs Way:

Yes, I will.

Mrs McGill:

You are all very welcome. There have been rumours about the radiology, radiography and X-ray departments at Tyrone County Hospital. For the record, when I heard the rumours, I rang Joe, and he came to the phone. I put the points to him, and we followed them up later with further discussions. I welcome that type of engagement. When we met, I was able to bring some matters to the table, and I welcomed the opportunity to do so. I was able to tell the people who had raised issues about radiology, radiography and X-ray what would happen to those services, particularly at night-time. That went some way towards reassuring them. I have heard what you have said today, and that is further reassurance.

Particular concerns were raised about what would happen at the urgent care and treatment centre at Tyrone County Hospital at night-time. Would it mean that that centre would no longer be viable because people could not be X-rayed? We talked about some of those issues and about how, whatever your contingency plans were, you would at least listen to elected Members. I felt that you listened to me, and I look forward to the outcome of that engagement. I thank you for that. For some reason, there were concerns and rumours. I do not know where they came from, but they certainly created some difficulties.

There is a second issue, and I want to be sensitive about how I frame it. I want to be clear that it is not at all in the context of anything to do with swine flu. As it happens, Foyle View School raised the issue of whether its school nurse would be removed or would continue. This does not, in any way, reflect on plans to train up classroom assistants, and so on. However, the issue was raised with me, and it would be remiss of me not to bring it to your attention today. I know that we are strapped for time, and I will accept it if you are not able to respond today. I will take a response at a later time, but I want to put the issue on the record. People have told me that the school nurse at Foyle View School is invaluable. I again repeat that that is not to take away from whatever training may be proposed for classroom assistants and that it is not in the context of anything to do with swine flu.

I welcome the fact that the waiting time for the autistic spectrum disorder service has been reduced to 13 weeks. That is still three months, but it is good that the waiting time is down from four years because, as an elected Member, I receive many queries from parents and carers of autistic children. They really have it quite hard, and they think that an elected Member can do something to help. That is not always the case, but I certainly welcome the reduction in the waiting time.

It is important that engagement takes place because rumours can create difficulties for all of us. Everyone is aware of the issue of learning disability in my council area. I have spoken to Trevor about that, and I raise it because people contact me about the issue, and I hear about it in my constituency office. Will you reassure me that the broad learning disability community, particularly in Strabane, will receive the services to which it is entitled, regardless of contingency plans, efficiency savings and whatever the trust has to do to break even? That community, with some justification, feels that it has been disadvantaged over time. It has not received all the resourcing that it should have. I am open to correction, but we hear that there are not enough places. People wonder whether a young adult who is about to leave Knockavoe School will be offered a place in Glenside Adult Training Centre. I want a reassurance about that.

I have sympathy with all the staff at this difficult time, particularly in the Western Trust.

The Deputy Chairperson:

There was plenty in that contribution.

Mrs Way:

Unfortunately, rumours are flying around. It is desperately important that we communicate as clearly as possible about issues so that rumours cannot fill the space.

The Western Trust is absolutely committed to running the urgent care and treatment centre at Tyrone County Hospital on a 24/7 basis. I take the opportunity to state that before the Committee. I have responded to Assembly questions on that issue, but it may not make as much impact as saying it here in Committee. Other centres that carry out similar work may consider doing so part-time, but Omagh is far away from other centres, and it would not be fair to ask people to travel long distances for the types of service that we offer. We are committed to providing that service on a 24/7 basis.

The school nurse issue at Foyle View School is too extensive an issue to discuss before the Committee. However, I am happy to meet with the member who asked the question, because we have had approaches from other parties on that matter.

Mr J Doherty:

I thank you for your comments.

We welcome the focused investment that we have received in services for children with autism. I regard it as a good start. Traditionally, over the years, we have not had much investment. By having a dedicated service, the emphasis can no longer be solely on assessment, but on assessment and treatment. Part of our strategic aim in women and children’s services is to enhance support services, and that applies especially to families in which there are children with autism. Strategically, we want to build on the assessment arrangements that are in place and to have a comprehensive range of services that allows children to remain with their parents for as long as possible.

Mr Millar:

Claire, you and I have had numerous discussions on the provision of learning disability services in the Strabane District Council area. I do not disagree with you that, over time, that area has not received the appropriate investment. Learning disability and physical disability services across the trust have not received the appropriate resources to allow them to develop. It is not that we have not been developing in Strabane but that we have not developed to any great extent in the way that we want to, based on the needs of individuals across the trust area.

We have highlighted the Strabane area in our discussions, and we are considering a new unit to accommodate people with complex needs at Glenside Adult Training Centre. That will be built shortly, and it will enhance the service at Glenside. We would like a new residential facility to replace the 10-bedded unit there, provided by an independent provider, and making it a 12-bedded unit, which will be brand new. I hope that we can work with the Department for Social Development on funding for that unit. It is another good news story. We also want to enhance our community service. We are considering crisis support, and we hope to provide additional staff for community services such as social workers and community learning disability nurses.

Over time, investment will increase. However, if £1 million is taken out of the service, it has an effect, and all service areas will have to bear the brunt of that. However, I place more emphasis on investment than on the removal of services. I support you on that.

Mrs McGill:

I have just one point to make. For the record, there are other issues that I will not raise now. Let no one think that those are the only issues.

Mr Easton:

I am pleased that you are trying to increase the attendance rate for outpatients. The Western Trust is the first trust to do that, so you get a gold star. It is a big bugbear of mine. Well done on that score.

You presented 48 proposals to the Committee, and you cleared them with the Minister. Were any changes made?

Mrs Way:

No changes were made. We have taken forward those proposals. We are considering a couple of additional items — for example, savings on X-ray film, which will save us £300,000 a year. Trevor also mentioned renegotiating the cost of complex care packages.

Mr Easton:

Will you have to go back to the Minister?

Mrs Way:

We will have to go back to identify the gap.

Mr Easton:

Are there still plans to reduce nursing positions by not filling them, or is that not happening now?

Mrs Way:

We reported to the Committee, and responded to your Assembly questions, about our original plans for nursing posts that were likely to go out or be introduced under the comprehensive spending review plans. I use the word “likely” only because we are examining the situation from the point of view of our service changes. It is inevitable that changes will happen over the years. When we made our presentation to the Committee, we said that we believed that 350 nursing posts would be lost under the comprehensive spending review and that 216 posts would be introduced. The position has changed, but that does not mean that it will not change again. We checked those figures before this meeting, and, to date, in the first 18 months of the comprehensive spending review proposals, there are 66 additional nurses in the workforce.

Mr Easton:

That is slightly more encouraging than it was originally. Have you considered a reduction in the number of agency staff? Are you comparing those with the number of bank staff, or are you going for a mixture?

Mrs Way:

Our first preference is to use our bank staff, because they are always cheaper, and some of those staff already work for the Western Trust. The use of agency staff incurs additional costs. We have had several patients with complex needs, particularly in Altnagelvin Area Hospital, where we do not have enough nurses. We use agency nurses to care for those patients, who have to be looked after 24/7. Under our contingency plan, we proposed to move away from using agency nurses to employing temporary staff, which would reduce our costs. We are constantly examining how we spend, be it on locum medical consultants or junior doctors, agency staff or bank staff. We are working on all three elements.

Mr Easton:

I am glad to know that that is the case.

Mrs Hanna:

There is not enough time to ask you how you made savings, but I want to pick out two aspects that will give me some idea. You made savings of £52,000 in residential nursing homes, and you are making, and propose to make, savings of £1·5 million on the reform of older people’s medicine. How do you plan to do that?

Mrs Way:

Before I answer that, Alan Corry Finn, our director of nursing, has told me that I did not respond to Dr Deeny’s question about the Western Trust having three assistant directors of nursing. When Alan makes his contribution, perhaps he could answer that question.

Mr Millar:

The £52,000 that was mentioned refers to proposals for savings in my residential homes budget. There was a proposal to renegotiate contracts: we were able to re-evaluate the patients in each of those areas and negotiate lower costs for providing care for those individuals. We must continue to re-evaluate because people’s conditions change. It is important to do that, and we made those re-evaluations in some residential homes. We were able to renegotiate with each of our independent providers, and small savings were made in each of the homes, which amounted to the total figure. However, in real terms, everyone received exactly the same service as previously.

Mr Corry Finn:

I will answer Dr Deeny’s question about nursing leadership in the Western Trust. I am the executive director of nursing as well as being the director of primary care and older people’s services. I probably spend 60% of my time on primary care and older people’s services and 40% on nursing. I am charged by the trust’s board to ensure that we meet the statutory standards.

Dr Deeny asked about the three assistant directors of nursing. There are three individuals who are actually two and a half whole-time equivalents: one works part-time at the University of Ulster, and she is our research lead. However, members will be aware of the statistics relating to the areas of work in which we are involved across the trust. We have approximately 12,500 staff, of whom between 50% and 60% are nursing staff. They work across our six hospitals and in thousands of people’s homes in an area of 2,000 sq miles. In those circumstances, governance is challenging, much more so than in an urban development. One assistant director works in governance and practice development, one works in education, training and workforce planning, and the third is the research lead. Our areas of work aim mainly to support the more junior members of staff in the organisation such as ward managers and lead nurses. As the chief executive said, there are 25% fewer of those staff than two years ago.

Like Joe, I have worked in the Health Service for 35 years, 32 of which were spent in the east. Given the number of managers and leaders in the Western Trust, it is the leanest place in which I have ever worked. We aim to ensure that the right people are employed in posts in the first place, that they are educated and developed and that we develop policies and strategies to support front-line staff. Moreover, we aim to develop practice and a culture of enquiry so that sound governance arrangements exist throughout the trust. Our focus is to provide safe, effective, high-quality patient care; the assistant directors and I are committed to that. That is how we spend our time.

The trust reviewed emergency care and medicine. There were suggestions that our use of hospital beds should be more efficient and that we should consider lengths of stay, and so on. As I said earlier, we manage people with chronic diseases. Where possible, we try to intercept people at an early stage when the vital signs begin to go off to ensure that they do not become seriously ill and being admitted to hospital. We respond to such cases with rapid response nursing and with monitoring arrangements in the home. At the other end, we are able to effect a swifter discharge. Lengths of stay have been significantly reduced in the past couple of years. However, more work must be done.

The Deputy Chairperson:

That concludes questions from members. Thank you for attending. I am sorry to have kept you waiting for so long; as you know, the swine flu issue took over. I am sure that we will keep in regular contact.