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

[Addition of material on West of Northern Ireland, rural areas, and the correction of Mid-Ulster hospital from Community to district general hospital]