The Forum for Political Dialogue met between 1996 and 1998 in Belfast as part of the negotiations that led to the Good Friday Agreement.
To examine the health needs of the community in Northern Ireland, with particular reference to health care administration, acute hospital services, community care services and access by the rural community and report to the Forum by 31 December 1996. [Note that the Committee is alleged to meet every Thursday but we do not have records of their meetings. To avoid speculation on meeting dates we have only modelled sessions which we know took place.]
To see the full record of a committee, click on the corresponding committee on the map below.
Report of the operation of the health service in Northern Ireland [Evidence for this committee session is found in the Forum minutes 26/09/97]
Northern Ireland Forum
for
Political Dialogue
~~~~~~~~~
AN EXAMINATION
OF THE OPERATION OF THE
HEALTH SERVICE IN NORTHERN IRELAND
BY STANDING COMMITTEE C
(Health Issues)
~~~~~~~~~
Presented to the Northern Ireland Forum for Political Dialogue
on September 1997
Note
DRAFT REPORTS
This report has been prepared by Standing Committee C for
the consideration of the Northern Ireland Forum for
Political Dialogue. Until adopted by the Forum in
accordance with its Rules, this report may not be reproduced
in whole or in part or used for broadcast purposes.
ACKNOWLEDGEMENT
The Committee is indebted to those organisations and individuals who
willingly gave of their time and expertise to assist it in its efforts to come to
grips with this most complex area.
This report is theirs as much as anyone's and we are grateful for their
participation.
CONTENTS
INTRODUCTION
Section Page
1. Background 1
2. Committee Remit and the Report 1
3. Why This Exercise? 3
4. Structure of Report 4
5. New Administration 5
6. What We Did 5
7. SDLP Involvement 6
8. Structure of Health Service 7
9. Finance 12
THE THEMES
10. Regional Strategy 15
11. Research and Evidence-Based Medicine 17
12. Men's Health 19
13. Deprivation and Ill-Health 20
14. Modelling and Measurement 21
15. Priorities 22
16. Boards and Trusts 25
17. Targets 27
18. Home Help Service 29
19. Fundamental Review of Health Service Spending 30
Section Page
20. Acute Services 31
21. Late Purchasing 32
22. How much should we spend on the NHS? 34
23. Prescription Charges 36
24. Private Finance Initiative 37
25. Children Order 38
26. Market Testing 39
27. Waiting Lists 40
28. Administrative Overheads 41
29. The Workers in the Health Service 42
30. Elective Treatment 44
31. Primary Care 45
32. Targeting Social Needs 46
33. Capital Spending 47
SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS 49
APPENDICES
Appendix A: Committee Membership
Appendix B: Committee Visit to Belvoir Park Hospital
Appendix C: Committee Visit to Royal Victoria Hospital
Appendix D: Committee Visit to Altnagelvin Hospital
Appendix E: Committee Visit to Whiteabbey Hospital
Appendix F: Committee Visit to Belfast City Hospital
Appendix G: Committee Visit to Mid-Ulster Hospital
Appendix H: Committee Visit to Sperrin Lakeland Trust
Appendix I: Committee Visit to Down Lisburn Trust
Appendix J: Copy of Letter to SDLP
Appendix K: Compendium of Oral Evidence
INTRODUCTION
1. Background
The first meeting of the Northern Ireland Forum for Political Dialogue
was held on 14 June 1996. One of its earliest actions was to set up a
number of Standing Committees with remits to look into key issues
affecting the people of Northern Ireland. Standing Committee C (Health
Issues) was among the first of the Committees to be established (26 July
1996). Its remit at inception was a wide one, and largely because of the
Forum's early foresight it has not been necessary for it to undergo any
change or modification.
1.1 The Committee has already carried out two substantial pieces of work of
a very specific nature. This third major item, as will become apparent, is
a much more wide-ranging examination.
2. Committee Remit and the Report
2.1 The remit of the Committee is:
To examine the health needs of the community in Northern Ireland
with particular reference to health care administration, acute hospital
services, community care services and access by the rural
community and report to the Forum.
1
2.2 In many ways this Report, to a degree, touches on all of the aspects of
this remit. Because of this it is a 'landscape' rather than a detailed study.
This probably makes it quite unique in type and its value is that:
(a) some of its aspects will serve to provide a foundation for future
in-depth independent studies - something we feel to be vitally
important;
(b) it tackles a number of issues just as a new administration has taken
up the reins of office. It will allow the new Minister to take on
board the content of this Report as he approaches the difficulties
of developing policy in a complex and fraught area;
and, because of its breadth,
(c) it affects a wide spectrum of people - both within the Health and
Personal Social Services and within the population at large, for
whose benefit the National Health Service exists.
2.3 The Committee has looked at the question of the Health Service in
Northern Ireland but it is readily understood that the National Health
Service is just that: it is a National system. Because of this some of our
recommendations and observations are bound to impinge on operations
at National level. Where this is the case we would ask the Minister to
ensure that the report is copied to Cabinet and Ministerial colleagues as
appropriate.
2
3. Why This Exercise?
3.1 The Committee deliberated long and earnestly before it embarked on this
study. Different members had voiced concerns in Committee: some
related to the operation of specific services on the ground; others were
to do with finance - its shortage and its application - but there was a
central thread which ran through everyone's concerns and this, in a
word, related to efficiency.
3.2 Much has been written in the sphere of management science on
efficiency but here it is understood in a generic sense that encompasses
what are commonly referred to in the public sector generally as the three
Es; that is Economy, Efficiency (in the practical sense of 'doing things
right') and Effectiveness. There is also a fourth E; that of Equity. For if
treatment is not delivered equitably then, by definition, it cannot be said
to be efficiently delivered.
3.3 Efficiency then in the context of Health and Social Services is to be
measured in the extent to which the resources available in this area are
used to maximise the desired outcomes. Poor efficiency means that
people's lives are cut shorter or are less satisfactory than should be the
case in light of what is achievable.
3.4 The Committee at no time under-estimated what it was taking on in
looking at the service through so wide a lens but the consensus was that
this would be a foundation exercise; an investment, that would only be
fully realised through future more finely focused work. It was also the
3
feeling that this was possibly the best way of achieving the greatest
impact through recommendations that benefit people in the shortest
possible time. The Committee's commitment to those it serves has never
been far from its collective mind.
3.5 The exercise enabled the Committee to meet people at all levels
throughout the Health Service, from the present permanent head of the
Department of Health and Social Services to staff and patients working
in the Acute and District Hospital sectors.
4. Structure of Report
The first part of the report, of which this is constituent, is introductory
and its content is fairly self-explanatory.
4.1 The body of the Report is thematic in nature. Each section deals with a
major topic which was brought out in evidence. All of the topics, in one
way or another, relate to the efficient operation of the Health Service in
Northern Ireland. The lifeblood of the Service is obviously its financing
and there are a number of sections concerned with this. The themes we
believe represent some of the major issues facing the Health Service
today.
4.2 The sections are discursive - they comprise a mixture of factual
reporting, reasoning and recommendation. The latter is shown in bold
and there is a summary of conclusions and recommendations at the end
of the report, prior to the appendices.
4
5
5. New Administration
5.1 One of the difficulties faced by the Committee has been the fact that the
exercise was punctuated by the General Election, and that whilst it was
possible in the earlier phase of the study to evolve and develop a critique
of what was done and planned by the previous administration this is now
much less practical since we are in a state of flux.
5.2 Having so said the Committee welcomes the openness of approach of the
new Minister and notes his expressed willingness to consult and to take
on board the views of the people. We believe that this Report, prepared
by a cross-party body of democratically elected politicians, will
eminently help in meeting the Minister's aim and represent the beginnings
of a process of consultation.
6. What we did
6.1 Having acquainted itself with the broad structure of the H&PSS in
Northern Ireland the Committee decided to take evidence from
representatives of the various strata within this pyramid structure - it
would have been beyond our scope to speak to managers in all the
Trusts (these account for the vast majority of Health Service resources
including staffing), etc, but the Committee attempted to balance this up
to some extent by organising a programme of hospital visits in parallel
with conventional oral evidence-taking sessions at the Forum.
6
6.2 Evidence was also taken from Unison, the main Health Services trade
union, and from a commentator on the Health Service, Mr John
Simpson. Mr Simpson was subsequently retained to provide a final
"quality assurance" for this Report and the Committee is indebted to him
for his valued help.
6.3 In addition reference was made to published literature and to
documentary evidence provided by those who participated in the
exercise. Where appropriate this is cited.
6.4 Because of the nature of the investigation, and because of the limitations
of time and resources, evidence was taken on what was thought to be a
representative basis. There has been no 'scientific sampling' or anything
of that sort - for the purposes of such a broad report this would not have
been feasible or appropriate.
7. SDLP Involvement
7.1 During the course of this exercise the Committee was anxious to ensure
that there was as much cross-community participation as possible. In an
effort to secure this a letter was sent to the SDLP inviting them to join
with the Committee, by whatever means they would choose, in its
cross-community effort.
7.2 A copy of the letter is appended but at the time of writing no response
had been received.
7
8. Structure of the Health Service
8.1 The National health Service was first established in the UK in 1948 under
the provisions of the National Health Insurance Act (1946). It provided
the most comprehensive medical care scheme of its time and the
development and building process has continued ever since.
8.2 The Health and Personal Social Services (HPSS) in Northern Ireland is
by far the largest employer in the province. It is structured hierarchically
as shown in Figure 1 (page 10) and is designed to operate what has been
described as the "internal market".
8.3 Atop the structure is the Department of Health and Social Services
(DHSS) which operates through the agency of its Health and Social
Services Executive (HSSE). This body funds the main spending for the
"purchasing" elements of the Service - the Health and Social Services
Boards and the Central Services Agency. Funds are sourced 85% from
the National Exchequer, 11% from the National Insurance Fund and 4%
from other sources (mostly charges, including charges for private
treatment). The total cost is around £1.7 billion.
8.4 The Boards provide an integrated service that is unique in the UK. They
are Health and Social Services Boards. Their task is to improve
standards of health and social well-being and provide a range of core
services. They do this within policy guidelines laid down by
Government. The typical purchasing cycle in operation by the Boards is
shown in Figure 2 (page 11).
8
Funding, in theory, also passes through this system to fund-holding
General Practitioners within each of the H&SS Board areas although in
practice the Boards act on behalf of fund-holders. Fund-holders taken as
a whole throughout the Province represent a major force to be reckoned
with in terms of their aggregated buying power.
8.5 The GPs themselves, whether fund-holding or non-fund-holding, are also
direct providers of a primary health care service to the community.
Within this service GPs prescribe drugs for their patients. These are
provided by retail pharmacies and their cost is met by a combination of
public and private money.
8.6 The main "providers of services" within the market are the Trusts of
which there are two main types. Firstly there is the hospital Trust (eg,
the Royal Group) and then there is the Community Trust (eg,
Homefirst). Northern Ireland is unique in that it also has a small number
of hybrid trusts which cover both categories (eg, Sperrin Lakeland).
The market, supposedly, engenders competition; trusts compete to
provide services and in this way the purchaser gets better value for
money for the individual patient to a stated quality standard through this
supply and demand dynamic.
8.7 The original concept of the internal market was to allow funds to follow
patients so that the most efficient providers (hospitals and community
trusts) would attract more patients. The introduction of GPs into the
system was to create a greater focus on primary care and to keep more
9
people out of hospitals. The Northern Ireland market is largely confined
to the Province but not exclusively: purchasers can and do look further
10
DHSS
HSSE
BUDGETS
Family Health
Service
FHS
Hospital, Community Health
and Personal Social Services
Other smaller budgets paid directly to
Trusts or managed directly by HSSE
(eg Teaching, Research and Admin)
.
Central
Services
Agency
(CSA)
HSS
Boards
for GPs, Dentists
and Pharmacists
Mainly
HSS Trusts in NI
Fees and Charges ø
ø Note: This is paid out
on behalf of the boards
who carry the budget in
their accounts. CSA acts
largely as a cash payments
agency.
GP Fundholders*
* Note: Payment to Trusts is in practice undertaken
by the Boards which carry fundholding budgets.
In this case the Boards' act for the fundholder who
retains the power to spend up to the level of his
budget.
afield once they have met locally agreed quotas. Purchases beyond
quota are at marginal cost and can be made locally or otherwise.
Providers can sell any surplus capacity to customers in the wider UK
market and indeed to customers outside this. They may also
sub-contract.
11
Appraisal of Service
Delivery Options
Agreement
of
Health Boards
H&SS
BOARDS
Specification
of
Services
Monitoring
and Review
Negotiation
and Letting
of Contracts
8.9 We must not forget the Voluntary sector here which attracts some public
finance but operates largely outside the market. There is also a number
of publicly funded agencies such as the Health Promotion Agency and
Blood Transfusion Agency that attract direct funding.
8.10 This in broad outline is the structure of the Health Service in Northern
Ireland. It is not, at this time, useful to consider its other aspects.
12
Fig 1
Funding within the Internal Market
13
Fig 2
The Purchasing Cycle
14
9. Finance
9.1 Public funds flow into Northern Ireland from the UK Exchequer. The
annual process of determining funding is known as the Public
Expenditure Survey. It is a difficult process with many more requests
for money being made than can be accommodated. The early work is
carried out by officials dealing between departments. The determination
of the amount of funding is subject to negotiation at Cabinet level and is
heavily dependent on prevailing economic policies. Once funding for the
year is settled it becomes part of the NI Block controlled by the
Secretary of State. She determines her priorities within the block,
adjusts these as she sees fit at any time, and spends accordingly. The
total block size is now approximately £8bn.
9.2 Obviously the system which is managed by the Department of Finance
and Personnel (DFP) (equivalent, at the provincial level, in many respects
to HM Treasury), is in reality much more complex than this.
9.3 The current Northern Ireland Public Expenditure priorities were
published in December 1996 by the previous government and are:
1. To maintain Law and Order.
2. To promote self-sustaining economic growth.
3. To target social need.
15
4. To resource key public services and associated infrastructure
(Health and Education are specifically cited here).
5. To promote improved community relations.
9.4 It will be seen that items 3 and 4 bear, to a high degree, on Health. All
Government departments are currently engaged in a Comprehensive
Spending Review (both here and in the UK) and it is possible that this
will affect the list of priorities.
9.5 Funds pass between DFP and DHSS on the basis of a formula. The
formula is negotiated between the Departments and from here most
money goes through the agency of HSSE to the H&SS Boards.
9.6 The breakdown of planned spending for 1997/98 is as follows:
£1.1bn H&SS Boards
£47m Capital Works
£380m Family Health Services
£59m Centrally Financed Services
£44m Special Initiatives
9.7 The breakdown to the Boards varies according to need. Assessment of
need is once again formula-based and at the time the evidence was taken
this was under a process of review. This is a complex area and age
profile now plays a large part. As a broad rule of thumb for every £1.00
spent on looking after someone under 65 it costs £2.00 to look after
16
someone in the 65-75 age bracket and £4.00 to look after someone over
75. Projections indicate that by the year 2000 there will be a 35%
increase in the over-90s and 20% increase in the over-75s.
9.8 Currently money is allocated to Boards as follows:
Eastern £463m 41%
Northern £260m 24%
Southern £199m 18%
Western £184m 17%
9.9 It is for Boards to decide upon and account for their spending, but the
Eastern Board, for example, divides its spending into what it describes as
Programmes of Care, covering Acute Services, Mental Health, Family
and Child Health and Care, Learning Disability, Health Promotion and
Primary Care, Elderly, and Physical Disability. Indices are used to
measure local needs and funds earmarked accordingly.
9.10 Northern Ireland has been very successful in achieving real increases in
the health budget over recent years and present allocations are up to 10%
more than the UK average. This is recognition, to some extent, of a
higher level of need in the province. Having so said we were told that
health and social services funding in Northern Ireland is now lagging
behind Scotland, although pressure is being applied to budgets there also.
17
9.11 Spending on Health and Social Services is truly enormous and is second
only to spending on Social Security. For this reason it is vital that such a
resource is well directed and that waste is minimised.
18
THE THEMES
10. Regional Strategy
10.1 The Department of Health and Social Services has published its fourth
Regional Strategy Document. This covers the years 1997 to 2002.
Almost certainly, with the advent of a new administration, this document
will have to undergo some change.
10.2 The Committee awaits with interest any revision of this document and is
likely to comment upon it at an appropriate time following its publication.
10.3 The current document states in relation to Target Setting, Monitoring and
Evaluation, that annual progress reports will be published and that "The
performance of the health and personal social services in implementing
the strategy will also be monitored through the annual accountability
processes of the Department" (Page 9).
10.4 The Committee however notes that departmental accountability
processes have been in place since the establishment of Northern Ireland.
These do not specifically address efficiency nor were they designed for
such a purpose; they are rather part of an accounting mechanism
designed to report on public expenditure to the United Kingdom
parliament (and in earlier days to a similar Northern Ireland constitutional
body).
19
10.5 It is noted that public policy on health and personal social services is
co-ordinated within government by two groups, namely, the
Interdepartmental Group on Health, and the Social Steering Group. We
are not satisfied that steering groups of officials are a sufficient
mechanism for reflecting the expressed World Health Organisation
view that "a well informed, well motivated and actively
participating community" is a necessity if its goal (that of the
WHO) of health for all by the year 2000 is to be realised.
20
11. Research and Evidence-based Medicine
11.1 Epidemiologists have drawn attention to the lack of good evidence for
the clinical efficiency of common and sometimes very costly
procedures.
11.2 In light of the vast and growing resources spent on health care -
accounting for something like one-fifth of public expenditure and
growing at a rate greater than that of the economy as a whole - it is vital
that there are efficient treatments based on sound diagnoses.
11.3 The Audit Commission which audits the NHS in England and Wales has
done some good work on the examination of the effectiveness of
treatments including the prescribing of drugs. The principles which
apply in England and Wales are readily applicable here and should be
read-across by policy-makers to Northern Ireland. However whilst
occasional studies provide useful indicative evidence there must be a
more established systematic means of research and reporting on the
effectiveness of treatments and care if value for money is to be achieved.
11.4 A Northern Ireland dimension is needed to provide for the adaptation of
research elsewhere, where this is necessary, to the local situation, for
co-ordination of work and to provide a central focus. We note that
DHSS is committed to implementing the recommendations of the Culyer
Report within Northern Ireland. It is crucial that future decisions have a
sound basis in knowledge and that research is adequately resourced and
co-ordinated.
21
11.5 We recognise efforts already made in the areas of Research linked
Evidence Based Medical Studies but we would urge the Minister to
see this as a priority. It is not enough for sentiments to be
expressed in general terms in strategy documents. The concept
must be translated into a practical reality on the ground and the
implementation of the ideal must be clearly visible with the
Minister recognising that this is something for which he should be
accountable.
11.6 In addition to this, Clinical Audit - the technique allowing 'peer
review' in the practice of medicine - needs to become a regular
routine activity in hospitals and there needs to be some sort of
central guidance on, and co-ordination of, this.
11.7 In terms of targeting it may make more economic sense to spend more
on research (and treatment) of illnesses that affect people of working age
for when treatment adds to the quality of life over a longer period, eg
back problems and multiple sclerosis (and also on health promotion and
prevention of illnesses and disability).
22
12. Men's Health
12.1 Evidence was given that very little work, in terms of research, has been
done on the health of men and on what they think in respect of their
health. We were told that as a group they did not often attend their GP.
This was particularly the case among the younger groups. It is not until
men become middle-aged and 'fetch up' with pains in their chest that
notice is taken.
12.2 The EHSSB has commissioned a specific survey on men's health in an
area of Belfast to assess how they feel about their health and how the
Board could influence healthy behaviour and provide more appropriate
services.
12.3 The Committee was impressed with the initiative taken by the
EHSSB to research men's health and would call for replication of
this effort in a co-ordinated way perhaps under the aegis of the
agency envisaged in Culyer.
23
13. Deprivation and Ill-Health
13.1 Health and well-being depend on a range of biological factors but there is
also a well-established link between social deprivation and ill-health and it
has also been suggested that societies that are less equal may have poorer
overall health (on average) than those that are more equal.
13.2 It is also probable that the better educated people within the community
are more likely to be more attuned to their health needs and to interact
better with health care structures and operatives.
13.3 Taken as a whole the Northern Ireland population is more disadvantaged
than other parts of the United Kingdom - the proportion of long-term
unemployment has been consistently higher and household incomes are
lower (despite a larger average household size).
13.4 The standard of health within Northern Ireland, by whatever
measure is used, tends to be among the lowest in the UK.
Morbidity and mortality rates, and levels of disability are all
markedly higher than in the better regions of the UK.
24
14. Modelling and Measurement
14.1 There have been various attempts to provide frameworks for assessing
the determinants of health but the primary task of the NHS is to meet
the health needs and look after the well-being of the population.
14.2 There has to be a means of modelling which shows the effect of the
elements of the health care system as they stand, as they are
adjusted, and as they are added to. For example, in what
circumstances is prevention better than cure?
14.3 Some work has been done in this area in Canada using Quality Adjusted
Life Years as a measurement of output or outcome. It is appreciated that
the Department is committed to establishing an information base for
professionals (page 21 of its Strategic Plan) but there needs to be more
thought on the strategic use of this information where key spending
decisions are made. We do not ask for a simple prescription - there is
none to be had - we do ask however for some consideration and
analysis of how this could be done.
25
15. Priorities
Acute Hospitals
15.1 It has been clear for some time that there is an imbalance between the
cost of maintaining the present establishment of acute beds and the
proportion of overall health service activity that is actually hospital-based.
Given changing and growing pressures on resources this area needs to
be kept in mind.
15.2 The Health Service has to be flexible and able to respond to changing
needs, perhaps including some rationalisations - but these must be in the
right places and they have to take local communities fully into account.
Suspicion is inevitable when there are arguments advanced for a few
centres of excellence to the detriment of provision for local communities.
A balance must be struck that is demonstrably for the greater good, and
that crucially, has fully involved those affected, within the
decision-making process either directly or through those whom they
elect.
15.3 Community hospitals are being developed within the province. We
welcome this as a logical extension of the present primary care
arrangements - one that will provide a smoother continuum of
treatment than exists at present. GPs are highly trained and have
expertise that they want to use in the continuing care and
disease-management of their patients' chronic illnesses (such as diabetes,
26
asthma and hypertension), rather than sending them to see a Senior
House Officer at a main hospital every six months.
27
15.4 Technological advance allows for instant communication of data on
patients between consultants at a remote location and doctors in the
community hospital. Nurses also are nowadays highly trained with some
nurse practitioners specialising in post-coronary care and the treatment
of diabetes.
15.5 Recent research findings on volumes, outcomes, costs and access
published by the Nuffield Institute for Health, University of Leeds, in
collaboration with the NHS Centre for Reviews and Dissemination at the
University of York show the following:
" There are some pressures for acute services to be concentrated in
hospitals with larger volume.
Much research examining the relationship between hospitals or
clinician volume and health outcomes is of poor quality and does not
make adequate adjustment for differences in patient case-mix.
The best research suggests that there is no general relationship
between volume and quality. However, in some specialities there
appear to be quality gains associated with increased hospital or
clinician volume.
There is no evidence that cost savings can be secured merely by
increasing scale in acute hospitals beyond 200 beds and it is likely that
large hospitals (above 600 beds) display diseconomies of scale,
though these inefficiencies may be offset in other ways.
28
There is evidence that utilisation of some health services is lower for
patients living further away. When services are concentrated, some
of the costs are shifted from the health service to patients and their
carers."
15.6 We also put the point, bearing in mind the needs and views of local
communities, that some district general hospitals should continue
to have a long-term role although the number of these hospitals
needs to be carefully considered.
15.7 We have more to say on the Acute Services under item 20.
Community Care
15.8 It has already been stated that the system is a globally integrated one
right down to the Board level and in a few cases down to Trust level.
This very integration may blur the distinction between the two services
and cause the "poorer relation" of community care to suffer. Equally the
joint approach may yield economies of scale and the fact that the two
systems exist alongside one another provides a golden opportunity for
comparison to be made on their financial operations. The difference
could be drawn out on whether a community served by two Trusts
(one health and one social services) and those with one are in any
way advantaged or disadvantaged by the differences in structures.
The question needs to be looked at and answered.
29
30
16. Boards and Trusts
16.1 H&PSS are provided within a model of Hospitals, Community and mixed
Trusts. We recognise that this system is the result of social factors -
including geography, history and political and budgetary considerations.
Evidence given points to there being too many Boards and Trusts and we
believe that change is necessary. This should be carried out with proper
consultation with elected representatives, and the rationale for proposed
alternatives should be made clear and explicit.
16.2 At this point in time there is no clarity as to future models of organisation
within the overall HPSS system. It is to be hoped that this will change
soon. A new and improved regional strategy document is now
needed. The apparent pause in policy formulation is to be
regretted. It would be less worrying if it had been displaced with
some form of public debate but this has not been the case.
16.3 For the present however the Committee is of the view that existing
structures as they stand are not in the longer term tenable. There
are clearly too many Trusts and too many tiers and this needs to be
looked at systematically and in detail and a discussion document
produced. One argument advanced in favour of the number of Boards
was that a reduction would result in a deficit of local advocacy and that
sub-structures would have to be put in their place. Whilst the need for
local advocacy is recognised we feel that there are other ways of
providing this - particularly through developing democratic structures.
31
Interestingly, the local advocacy argument is one that is also used by GP
fundholders in support of the case for fundholding.
16.4 Indeed Northern Ireland, with a population of 1½ million, should not
need a Government department (DHSS does not look after Health
exclusively but its Health element is bigger than some other Government
departments), a Government Agency, four Boards and twenty Trusts.
16.5 There can be little doubt of the need for change in the interests of greater
organisational efficiency. Of particular concern is the large and
apparently increasing proportion of health service spending on
administration. Necessary change needs to be carefully identified
through a clearly disinterested and competent review and the change
arising from this needs to be sensitively managed.
16.6 This particular issue is one that will not go away and the Committee may
wish to return to it at a later date.
32
17. Targets
Regional Strategy
17.1 DHSS has set a number of targets, at province level, in its 3rd strategic
plan covering the period 1992-97. It is clear from published figures that
good progress is being made towards some of these targets. We are also
persuaded that there is great value in having something to aim for so that
focus can be provided.
17.2 However there is some concern that, whilst there is a need for the long
view to be taken, it can be unrealistic to take too long a view and to set
targets, in one case for the year 2010, without developing a series of
interim targets for the shorter and medium terms. It is, for instance,
relatively easy to show that there is 'progress' to the 2010 target through
year-on-year improvement, but if realistic shorter term targets do not
exist in published form then the challenge is lessened or removed and the
effort and commitment relaxed.
17.3 The second point in relation to targets is the issue of how they are set in
the first place. As has already been pointed out the levels of ill-health are
greater in Northern Ireland than elsewhere; perhaps we should be aiming
higher in the long term but in a step-by-step way.
17.4 Rather than the long-term aim seeming to determine what is achieved in
the interim perhaps the long-term target should be informed by what is
achievable in stages. A target of the year 2010 devised during the earlier
33
part of a document covering the years 1992-1997 is unlikely to be based
on strong data to put it mildly, and if it transpires that it is unrealistic to
look that far forward then we should refrain from doing so.
17.5 Management Plan
DHSS publishes a Management Plan annually. This contains shorter
term targets. These targets have broadly been arrived at by reference to
what is happening in Great Britain and are not always easily related to the
rather nebulous targets of the Regional Strategy Document. Boards act
on the basis of targets within the Management Plans and they produce
their own related Action Plans - these may contain their own specific
additional actions not published in the Management Plan.
17.6 Viewpoint
It is our view that there should be an examination of the
management of information to ensure better co-ordination of
indicators of performance. Strategy Documents should be reviewed
annually in the light of better information. In other words there
should be an annual update that demonstrates that strategy is an
ongoing consideration and not just a series of five-year plans.
34
18. Home Help Service
18.1 The Committee was concerned to hear evidence of restrictions placed on
the vital Home Help Service and, more recently, of DHSS proposals to
Means Test this service.
18.2 It was also clear to the Committee that there are inequities in this service,
not only across the province but within Board Areas where, at least, one
might have expected outcomes to be more uniform.
18.3 This leads to two main issues. The first relates to availability of the
service, that is a service based on need. We are concerned that funding
in this area is apparently deficient. The formal evidence given in this also
appears to be supported by strong anecdotal evidence.
18.4 The second issue is to do with the fourth E mentioned earlier, namely
Equity of Treatment. In sum what we have said earlier is that where
there is inequity there is inefficiency.
18.5 We call on the Minister to review the needs of the elderly with
particular reference to the services of Home Helps. His objective
should be to provide a more uniform and fairer service where a
defined need is demonstrated.
35
19. Fundamental Review of Health Service Spending
19.1 We are aware that Government departments are currently in the throes
of Comprehensive Spending Reviews (CSRs). Some witnesses were of
the view that there should be a Fundamental Review of Health Service
spending. We agree with this view and recommend that it should be
conducted, either as part of, or alongside the CSRs. Ideally such a
review should have a strong independent element, have a declared
objective centred around the needs of the community rather than of
existing structures or organisations, and, involve as full public (and
public representative) participation as is feasible.
19.2 Efficiency of spending in the Health Service is not a subject that is well
understood. The service has developed incrementally and has, or so it
appears, become convoluted. We believe that it is widely held by
many in the service that a fundamental review of health service
delivery and spending is long overdue. We therefore call upon the
Minister to initiate this now.
36
20. Acute Services
20.1 The Government has been committed to a policy of investing in
community services and reducing the financial burden in the acute
sector. Published documents point to what the press described as a
'Golden Six' acute hospitals but this appears to have been modified with
the building of the new Causeway Hospital. These establishments
provide 'centres of excellence': trauma and maternity care, cancer
services etc, and patients can expect expert care and attention.
20.2 The trend of rationalisation in the acute sector is likely to continue
but it needs careful management. The situation in Health care is
changing rapidly and constantly. Treatment is becoming more
sophisticated and more expensive and whilst there is a case for change
there needs to be balance in how this is paced and flexibility to
allow for any necessary reassessment following new developments.
20.3 The acute sector also faces the additional costs associated with the
employment of more junior doctors - junior doctors nowadays, quite
properly, work fewer hours.
37
21. Late Purchasing
21.1 The Committee is strongly of the view that within the Health Service the
main determinant of access to treatment should be clinical need but in a
'market' situation the ability (and willingness) of the purchaser to pay
may determine who is treated and when.
21.2 Evidence was given to the Committee that suggests that there was some
financial incentive for purchasers, be they boards or GP Fundholders, to
buy acute services later in the financial year because of the sale of
surplus capacity at marginal cost by some Trusts. We do not know the
extent to which this occurs but we find the very fact that it even has the
potential to occur most worrying. It is appreciated that there is an
ongoing review of policy on the future structure of the market and
would urge that this flaw in the present system be removed.
21.3 The present system of public finance encourages the holding of
funds in reserve at every level, and, in a sense penalises in the
next financial year those who hand funds back unspent. This does
not make for a rational and planned spending system in any area
but it is particularly the case in the Health Service with its
many-layered structure. The HPSS would perhaps be better moving
to a business plan that covers a number of years. This would further
better financial management. We believe that an example of such a
system exists in Holland. This impinges on the work of Central
Government Finance and that of the Chancellor himself. It is well
38
understood that the Secretary of State is limited in what she can do
in this area but the Committee calls upon her and the Minister to
raise this matter with the Chancellor and the Treasury.
21.4 We recognise that a new Resource Accounting system is in the
process of introduction within Government. But this will not be
effective for some time and the Committee is unclear as to
whether the system, as presently designed, will address the
problems of deficit funding.
39
22. How much should we spend on the NHS?
22.1 At the launch of the NHS it was thought that health costs would
decrease as the health of the nation improved. There was no realisation
then that the success of the Health Service would lead to the present
increase in the elderly population or of the enormous costs of modern
hi-tech medicine.
22.2 Demand for Health Service treatment has never been greater. Patient
expectations are greater and there is now a Patient's Charter. There are
also increases in day surgery and laparoscopic surgery (a technique used
to examine the contents of the abdomen, the taking of biopsies and the
carrying out of minor surgery).
22.3 The NHS in total across the UK consumes of the order of 7% of Gross
Domestic Product (GDP) - in essence 7% of the national income. This
is about half of the proportion of GDP spent in the United States and is
generally much lower than many Western European countries.
22.4 The issue of how much we should spend on the Health Service is, of
course, a national one. We operate, to a large extent, on the principle of
parity with Great Britain but these international comparisons have not
escaped our notice and we would urge the Minister and indeed the
Secretary of State to be aware of the priorities that others place on
Health when contemplating 'cuts' or 'savings'. These are justifiable only
on grounds of greater efficiency but certainly not where they cut across
community need.
40
22.5 Annual percentage cuts to budgets in the name of 'cost
improvements' should not be directed at patient provision.
Savings, where found in administration, should be ploughed back
into patient care. The Government requires Trusts to audit their
management costs annually. Such costs vary from Trust to Trust and
there may be good reasons for the differences, but we believe that at
least some element of the difference in the management costs of
the various Trusts can be related to differences in efficiency and
that Trusts could learn from each other. An underlying market
assumption is that competition will take care of efficiency but in some
aspects of health care there is no competition. A good example would be
in the area of cardiac surgery which is a regional speciality carried out at
the Royal.
41
23. Prescription Charges
23.1 There are some interesting statistics associated with Prescription
Charges. The most recent figures indicate that some £220m is expended
in prescriptions per annum in Northern Ireland. Of this only 2.8% or
£6¼m is paid for by those for whom drugs are prescribed. Put another
way, some 20 million items are prescribed annually and over 92% are
free. Those entitled to free prescriptions amount to around 52% of the
population and the extent of prescribing for this section of the population
can possibly be accounted for in a number of ways, eg deprivation, little
generic prescribing, high morbidity levels etc.
23.2 The interesting question on Prescription Charges is that if the
gross yield to the taxpayer from Prescription Charges is only 2.8%
is it worth the effort of collection when the administrative costs of
this are taken into account? We pose this simply as a question for
Government.
23.3 It is appreciated that policy on prescriptions is a national one and that
statistics for the country as a whole tell a somewhat different tale, but,
as we have already suggested, the Northern Ireland figures are indicative
of generally higher levels of deprivation here.
23.4 Evidence points to the fact that an examination of the Drugs
budget will confirm differences between the spending of
42
fundholders and that of non-fundholders. An analysis and
explanation of the differences by the HSSE, we feel, is called for.
43
24. Private Finance Initiative (PFI)
24.1 The PFI has now been renamed the Private Public Partnership. There is
a perception that the process, by whatever name, is secretive and that
details can be kept from public scrutiny on the grounds of 'commercial
confidentiality'. There are also concerns over the inability of the public
sector to compete for and provide a service and that the process was, in
effect, a closed shop for the Private Sector.
24.2 The PFI is, once again, a national initiative that is applied in the province.
Our primary concern is that the PFI is likely to affect large
numbers of people within the province and yet there has been no
meaningful local consultative process. The merits or de-merits of the
initiative take second place to this and have not, at this time, been studied
by the Committee in depth.
44
25. Children Order
25.1 The Children Order is a wide-ranging piece of legislation introduced
to provide protection for the young. We took evidence which indicated
that the implementation of the provisions of this legislation have been
grossly underfunded and under-resourced. We feel we must ask why
the perception of underfunding for it is so widely held and we call
on the Department to explain:
(a) what is expected under the Order? and
(b) what resources are earmarked for its continued
implementation and when they will be/have been allocated?
45
26. Market Testing
26.1 This is a very broad-ranging report and we therefore do not wish to
enter the very contentious area of market testing within the Health
Service in any great depth. Suffice to say that the Committee is aware
of the report by the Equal Opportunities Commission on Market Testing.
This report has some 35 recommendations which highlight some of the
inefficiencies and inequities of market testing.
26.2 We feel that it would be unfair to express a view on Market Testing
until there has been a substantive Government response to the
EOC report on it. We would at this time merely call for an early
response.
46
27. Waiting Lists
27.1 The Committee received evidence on Waiting Lists. We believe that
long and inequitable waiting lists are suggestive of a market that is
not working. Inequities are particularly stark between fundholders and
non-fundholders (GPs). The Government, we know, accept that this is
wrong. We would call for action now to correct these inequities.
One possible solution is the introduction of locality-based purchasing for
viable populations along the lines already operated by some of the
Community Trusts.
47
28. Administrative Overheads
28.1 The Committee heard some disquieting evidence on the administrative
costs of the HPSS including the costs of running an internal market.
These costs occur at every level within the system including the GP
fundholding level. Overall staff numbers in the Health Service have
shown a decline over the last five years. This decline is particularly
noticeable among student nurses and home helps, but surprisingly,
there has been a big increase in the number of administrators.
Given the present state of information technology, we are bound to
ask how this can be justified? It is a question for others to answer but
on the face of it the balance seems to us to be wrong.
48
29. The Workers in the Health Service
29.1 It should be remembered that the Health Service is Northern Ireland's
largest employer and its employees are entitled to some consideration, in
the interests of everyone concerned and of the efficient running of the
Service. It seems to us that reductions are affecting key workers -
nurses in the hospital sector and home helps in the community sector -
and yet in many ways these are the 'on the ground' doers. Nursing staff
particularly carry out an enormous range of functions and their training
and background offers great potential for developing this valuable
resource and deploying it in new areas. The nurse practitioner is an
example of such a promising development.
29.2 There are also many support and ancillary workers within the Health
Service who work in the background and often tend to be forgotten.
29.3 It should be remembered that in the drive for efficiency, people have
been the main casualties and no profession has been immune; this
includes medicine itself. But is this entirely necessary?
29.4 We are of the view that health service managers should be allowed
to manage and they should, within certain limits, be permitted to
do so with flexibility and sensitivity. They should also be informed by
the longer view and by the need to recognise their people as a useful
resource, very often capable of development to the betterment of not
only themselves but of the Health Service generally. Resources should
not simply be valued in terms of cash. Finance and Personnel need to
49
come together at some point and employees need to have some sense of
inclusiveness, whether it be through their trade unions or through any
other consultative/participative process.
29.5 The Committee was particularly alarmed at the selective use of
Performance Related Pay within the Health Sector. We believe
that the use of this mechanism creates precisely the wrong
incentives for top managers in a service that should be concerned
primarily with effective delivery to those in need.
50
30. Elective (Planned) Treatment
30.1 We were given evidence on a particular weakness and unfairness of the
existing system. It is that whilst GP fundholders can negotiate directly
with Trusts negotiation is done on behalf of non-fundholders by the
Boards.
30.2 One difficulty here is that the system does not allow for differentiation
between elective and emergency surgery. This potentially, and in fact,
results in a reduction in capacity for elective surgery on the non-funding
side since the Boards have to manage on a fixed budgetary system that
ordinarily takes no account of in-year change.
30.3 We recognise that changes are planned to the present system of
patient funding and would urge that these take account of the need
to maintain and improve levels of Elective Treatment and do so
equitably.
51
31. Primary Care
31.1 Access to health care systems varies across the world. There are, for
example, the polar extremes of, on the one hand, the American health
care system whereby entry is restricted, and the Israeli system which is
characterised by ease of entry, with fairly immediate access to specialist
services.
31.2 The current primary care system in the UK is a type of halfway
house but if the GP and the nurse practitioner working in the
primary sector are to be allowed to develop to their full potential,
and the Community Hospital concept is transformed from its pilot
stage to a province-wide commitment, we believe this will lead, if
properly managed, to greater efficiency as resources are more
appropriately deployed.
52
32. Targeting Social Need
32.1 It will have been noted earlier that the targeting of social need was one of
the key aims of Government in Northern Ireland. Within the Health
Service the term changes to Targeting Health and Social Need (THSN).
32.2 A DHSS-led working group oversees this initiative and the Department
accepts that:
"The major task for 1997-98 will be to develop the specific actions
needed to convert the THSN concept into practice, including the
guidance, support and monitoring required."
32.3 The Committee warmly welcomes the THSN initiative within the
Health Service and looks forward to seeing tangible results on the
ground.
53
33. Capital Spending
33.1 We were given evidence that raises our concerns over the present capital
spending structure of the service. It has vast under-utilised or redundant
assets. Decisions need to be taken on the disposal of these. On the
other hand there seems to be a lack of adequate and planned capital
investment in the service. This results in the running down of the value
and utility of assets. Indeed we have doubts as to the wisdom of some
of the development that has taken place recently. Could it, for instance,
have been efficient to proceed with a £60m development at the Royal
Trust without a firm prior agreement with the City Trust on the
provision of services?
33.2 We understand that investment in capital of £144m which includes the
proceeds from the sale of surplus land and property is planned for the
next three years with priority to be given to investment in the
rationalisation and concentration of acute services etc.
33.3 It is our feeling that the level of capital investment is insufficient
for the needs of the Health Service in Northern Ireland - we would
like to see investment in buildings, new equipment and technology
and in the renewal or replacement of existing equipment of at least
double the £144m three-year figure, and, while it is necessary to plan
well ahead for such investment we would like to see the issues in this
report fully considered before more money is committed.
54
34. Health Promotion and Education
34.1 It is clearly much more efficient to prevent illness than it is to treat
preventable disease. The work of the Health Promotion Agency (HPA)
and of the boards in educating the public is to be greatly encouraged.
The Committee feels strongly that there is a need to adequately
target the young in the promotion of health, particularly at
secondary school level. Such targeting should not be confined to
health education but should be extended to training in the skills of
first aid. This should be recognised as an important life skill for the
future and ways should be found to incorporate it into the curriculum.
The Departments of Health and Social Services and Education
should see this as a valuable goal for the community and work
together (perhaps through agencies such as the HPA) to bring it
about.
34.2 Statutory organisations, and also voluntary bodies like the St John's
ambulance Brigade and the British Red Cross offer first aid training. The
voluntary bodies do so at low cost.
34.3 Health and education are recognised as two key elements of public
concern and together they account for a large chunk of public spending.
It seems to us to follow that the promotion of good health should be
firmly embedded within the medium of education and we call for the
necessary action to facilitate this as part of a strengthened preventative
effort.
55
SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS
We are not satisfied that steering groups of officials are a
sufficient mechanism for reflecting the expressed World Health
Organisation view that "a well informed, well motivated and
actively participating community" is a necessity if its goal (that of
the WHO) of health for all by the year 2000 is to be realised. (Para
10.5)
We recognise efforts already made in the areas of Research linked
to Evidence Based Medical studies but we would urge the Minister
to see this as a priority. It is not enough for sentiments to be
expressed in general terms in strategy documents. The concept
must be translated into a practical reality on the ground and the
implementation of the ideal must be clearly visible with the
Minister recognising that this is something for which he should be
accountable. (Para 11.5)
In addition to this, Clinical Audit - the technique allowing 'peer
review' in the practice of medicine - needs to become a regular
routine activity in hospitals and there needs to be some sort of
central guidance on, and co-ordination of, this. (Para 11.6)
The Committee was impressed with the initiative taken by the
EHSSB to research men's health and would call for replication of
this effort in a co-ordinated way, perhaps under the aegis of the
59
agency envisaged in Culyer. (Para 12.3)
The standard of health within Northern Ireland, by whatever
measure is used, tends to be among the lowest in the UK.
Morbidity and mortality rates, and levels of disability are all
markedly higher than in the better regions of the UK. (Para 13.4)
The primary task of the NHS is to meet the health needs and look
after the well-being of the population. There has to be a means of
modelling which shows the effect of the elements of the health care
system as they stand, as they are adjusted, and as they are added
to. We ask for some consideration and analysis of how this could
be done. (Paras 14.1-3)
Community hospitals are being developed within the province. We
welcome this as a logical extension of the present primary care
arrangements. (Paras 15.3 and 31.2)
Bearing in mind the needs and views of local communities, some
district general hospitals should continue to have a long-term role
although the number of these hospitals needs to be carefully
considered. (Para 15.6)
The difference could be drawn out on whether a community served
by two Trusts (one health and one social services) and those with
one unified Trust are in any way advantaged or disadvantaged by
60
the differences in structures. The question needs to be looked at
and answered. (Paras 15.8 and 16.1)
A new and improved regional strategy document is now needed.
The apparent pause in policy formulation on Health issues is to be
regretted. It would be less worrying if it had been displaced with
some form of public debate, but this has not been the case.
(Para 16.2)
The Committee is of the view that existing structures as they stand
are not in the longer term tenable. There are clearly too many
Trusts and too many tiers and this needs to be looked at
systematically and in detail and a discussion document produced.
(Para 16.3)
Of particular concern is the large and apparently increasing
proportion of health service spending on administration. (Para
16.5)
It is our view that there should be an examination of the
management of information to ensure better co-ordination of
indicators of performance. Strategy Documents should be reviewed
annually in the light of better information. In other words there
should be an annual update that demonstrates that strategy is an
ongoing consideration and not just a series of five year plans. (Para
17.6)
61
We call on the Minister to review the needs of the elderly with
particular reference to the services of Home Helps. His objective
should be to provide a more uniform and fairer service where a
defined need is demonstrated. (Para 18.5)
We believe that it is widely held by many in the service that a
fundamental review of health service delivery and spending is long
overdue. We therefore call upon the Minister to initiate this now.
(Para 19.2)
The trend of rationalisation in the acute sector is likely to
continue. Whilst there is a case for change there needs to be
balance in how this is paced and flexibility to allow for any
necessary reassessment following new developments. (Para 20.2)
The present system of public finance encourages the holding of
funds in reserve at every level, and, in a sense penalises in the
next financial year those who hand funds back unspent. This does
not make for a rational and planned spending system in any area
but it is particularly the case in the Health Service with its
many-layered structure. This impinges on the work of Central
Government Finance and that of the Chancellor himself. It is well
understood that the Secretary of State is limited in what she can do
in this area but the Committee calls upon her and the Minister to
raise this matter with the Chancellor and the Treasury. (Para 21.3)
62
We recognise that a new Resource Accounting system is in the
process of introduction within Government. But this will not be
effective for some time and the Committee is unclear as to
whether the system, as presently designed, will address the
problems of deficit funding. (Para 21.4)
Annual percentage cuts to budgets in the name of 'cost
improvements' should not be directed at patient provision.
Savings, where found in administration, should be ploughed back
into patient care. We believe that at least some element of the
difference in the management costs of the various Trusts can be
related to differences in efficiency and that Trusts could learn from
each other. (Para 22.5)
63
The interesting question on Prescription Charges is that if the
gross yield to the taxpayer from Prescription Charges is only 2.8%
is it worth the effort of collection when the administrative costs of
this are taken into account? We pose this simply as a question for
Government. (Para 23.2)
Evidence points to the fact that an examination of the Drugs
budget will confirm differences between the spending of
fundholders and that of non-fundholders. An analysis and
explanation of the differences by the HSSE, we feel, is called for.
(Para 23.4)
Our primary concern is that the PFI is likely to affect large
numbers of people within the province and yet there has been no
meaningful local consultative process. (Para 24.2)
The Children Order is a wide-ranging piece of legislation. We feel
we must ask why the perception of underfunding for it is so widely
held and we call on the Department to explain:
(a) what is expected under the Order? and
(b) what resources are earmarked for its continued
implementation and when they will be/have been allocated?
(Para 25.1)
64
We feel that it would be unfair to express a view on Market Testing
until there has been a substantive Government response to the
EOC report on it. We would at this time merely call for an early
response. (Para 26.2)
We believe that long and inequitable waiting lists are suggestive of
a market that is not working. We would call for action now to
correct these inequities. (Para 27.1)
Overall staff numbers in the Health Service have showed a decline
over the last five years. This decline is particularly noticeable
among student nurses and home helps, but surprisingly, there has
been a big increase in the number of administrators. Given the
present state of information technology, we are bound to ask how
can this be justified? (Para 28.1)
We are of the view that health service managers should be allowed
to manage and they should, within certain limits, be permitted to
do so with flexibility and sensitivity. (Para 29.4)
The Committee was particularly alarmed at the selective use of
Performance Related Pay within the Health Sector. We believe
that the use of this mechanism creates precisely the wrong
incentives for top managers in a service that should be concerned
primarily with effective delivery to those in need. (Para 29.5)
65
We recognise that changes are planned to the present system of
patient funding and would urge that these take account of the need
to maintain and improve levels of Elective Treatment and do so
equitably. (Para 30.3)
66
The current primary care system in the UK is a type of halfway
house but if the GP and the nurse practitioner working in the
primary sector are to be allowed to develop to their full potential,
and the Community Hospital concept is transformed from its pilot
stage to a province-wide commitment, we believe this will lead, if
properly managed, to greater efficiency as resources are more
appropriately deployed. (Paras 31.2 and 15.3)
The Committee warmly welcomes the THSN initiative within the
Health Service and looks forward to seeing tangible results on the
ground. (Para 32.3)
It is our feeling that the level of capital investment is insufficient
for the needs of the Health Service in Northern Ireland - we would
like to see investment in buildings, new equipment and technology
and in the renewal or replacement of existing equipment of at least
double the £144m three-year figure. (Para 33.3)
The Committee feels strongly that there is a need to adequately
target the young in the promotion of health, particularly at
secondary school level. Such targeting should be extended to
training in the skills of first aid. The Departments of Health and
Social Services and Education should see this as a valuable goal for
the community and work together (perhaps through agencies such as the HPA) to bring it about (para 34/1) 67