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The Business Committee has agreed to allow up to one hour and 30 minutes for the debate. The proposer of the motion will have 10 minutes in which to propose and 10 minutes in which to make a winding-up speech. One amendment has been selected and published on the Marshalled List. The proposer of the amendment will have 10 minutes in which to propose and five minutes in which to make a winding-up speech. All other Members who are called to speak will have five minutes.
I beg to move
That this Assembly calls on the Minister of Health, Social Services and Public Safety to outline the details of the efficiency savings proposals agreed with each health and social care trust; and to ensure that the efficiency savings proposals and contingency proposals for deficits in the current budget of each trust will not impact on front line services.
Go raibh maith agat, a LeasCheann Comhairle. The Committee for Health, Social Services and Public Safety brought the motion to the Assembly after it became clear through media reports that the health and social care trusts were having difficulties with their budgets. There were also concerns that the trusts were not meeting their efficiency targets. The motion, therefore, deals with efficiencies and deficiencies.
Another reason for the debate is the Committee’s difficulty in obtaining information on the extent of the deficit from the Department of Health, Social Services and Public Safety. In a way, the Committee’s motion is an attempt to hold the Minister to account.
The Committee was dismayed, to say the least, that it heard about the deficits through the media. The Department made no effort to inform the Committee. Instead, the Committee began to hear about bed closures, about new mothers being asked to leave hospital nine hours after giving birth and about other drastic cuts via newspaper reports and the trade unions. The Committee was left in the dark, and it called on the Minister to make a statement to the Assembly to explain what was going on. Unfortunately, the Minister was not available to make such a statement, and the Committee was left with no choice other than to ask the Business Committee to schedule today’s debate.
Over the past four weeks, in an attempt to get to the bottom of the situation by obtaining information that the Department will not, or cannot, provide, the Committee invited each of the six trusts to give evidence. We learned that each trust submitted a new plan to the Department to deal with the deficit in its budget. The drastic cuts that were highlighted in media reports over the past few weeks had nothing to do with efficiency savings; they dealt with how trusts will stay within budget in this financial year. The trusts have a break-even duty, which means that they cannot overspend. They must break even or operate with a small surplus. Under the previous system, the trusts were allowed to operate within plus or minus 0·5% of their total budget, but that flexibility has been removed.
Each and every trust faces a difficult financial situation. The need to make efficiency savings, the break-even duty and debts incurred from the former legacy trusts create financial pressures, which are intensified by the increasing demand for services. Each trust told the Committee that the demand for its services has greatly increased. I do not have time to give examples from all the trusts, but I will cite one example from the Northern Health and Social Care Trust to illustrate what is happening. The Northern Trust services around 440,000 people, and, in the past two years, has experienced a 19% increase in hospital outpatient appointments and a resultant increase in demand for other services such as diagnostic procedures and drug provision.
However, the increased demand must also be measured against the fact that each trust also recycles money and receives additional moneys for new services that are designed to improve the Health Service. In many ways, making efficiencies is a matter of delivering increased levels of service with the same amount of resources. In other words, it is about being more efficient with what is available.
The Committee asked each trust about the duty to break even given that the trusts’ plans straddle financial years. In evidence to the Committee, every trust was clear that it would be better to be able to run at a small deficit in one year in the knowledge that it could generate savings in the following year.
The trusts indicated to the Committee that they would prefer to have a 0·5% leeway, because the targets and financial challenges are spread over a number of years. Given that targets stretch over two or three years, the rigidity of the duty to break even every year is causing difficulties for the trusts.
The Northern Health and Social Care Trust pointed out that the trusts occasionally run at a small surplus that must be spent by the end of the year. The trusts need to spend that surplus quickly, and that means that that money is not always spent wisely. The Committee realised that running a deficit from one year to the next can be dangerous and may lead to an increase in overspend that cannot be tackled. Therefore, on behalf of the Committee I ask that the Minister revisits that issue.
Will the Minister indicate whether other systems in other jurisdictions have a break-even duty? Will he also indicate how he will ensure that the trusts do not end up in the same position next year? Unless someone deals with the issue, can we expect the same media circus this time next year? Can we expect the trade unions to be, rightly, up in arms and threatening strikes? Will the Belfast Health and Social Care Trust again make sounds about reducing beds and sending new mothers home after nine hours?
On behalf of the Committee, I express my disappointment at the press statement regarding the contingency deficit plans that the Minister released on 27 October, given that he did not see fit to inform the Committee of how he intends to deal with deficits in the trusts. Instead, we were left to hear about that through a press statement. The fact that that statement was released during recess only exacerbated the situation. The Committee understands that the Minister was unable to be clear about the extent of the deficits when he gave evidence to the Committee on 15 October because of the financial situation regarding swine flu. However, once the swine flu budget had been issued and settled, the Committee would have appreciated hearing directly from the Minister about the proposals to tackle the deficits. Instead, the Committee was given a one-page press statement that lacked the required detail.
Returning to the pressures that the trusts face, the Committee has some sympathy for the trusts, and members realise just how difficult it is for them at the moment. However, after speaking to all the trusts, the most striking fact was that some were able to live within budget, deliver on all or most of their efficiency plans and incur only a modest deficit. For example, the Southern Health and Social Care Trust opened its books this year with a deficit of £4 million that it inherited from the legacy trusts. However, it is now on target to make efficiency savings of £36 million over three years, even though, according to media reports, its deficiency proposals were for under £4 million. That is a remarkable performance.
The Committee was impressed with the frankness of the Southern Trust, which said that the process had not been easy. It said that it was painful but doable and achievable. Indeed, not only has the Southern Trust basically achieved its targets, it has done so while experiencing an increased demand for its services and while improving its standards.
However, the fact that targets in some of the trusts are not being met is not always the fault of the trusts. Consider the programme for the regional procurement of drugs. In essence, that is an excellent idea that will generate savings through increased buying power. Yet, the trusts told us that there has been a shortfall this year, and that is backed up by information from the Department that the shortfall for 2009-2010 is £4 million. The trusts were relying on that £4 million, which now has to be found elsewhere.
The Northern Trust pointed out that the efficiencies gained by the regional procurement of drugs are sometimes wiped out by large increases in cost by the drug companies or by increased demand for existing and new drugs from a growing number of patients. Will the Minister outline how the issues around regional procurement of drugs will be addressed?
Some of the trusts’ plans for efficiency savings are dependent on finances from other Departments or other programmes or on access to capital funding, and there appears to be a problem with that. The problem lies with the resettlement programmes that are dependent on revenue funding from the Department for Social Development’s (DSD) Supporting People programme. All the trusts rely on making efficiency savings through resettlement programmes. By resettlement programmes, I mean programmes that involve resettling back into the community patients who have been in long-term institutional care or in statutory homes.
The DSD has indicated that it is reviewing the moneys for Supporting People. We understand that there is a difficulty with the revenue element; however, the trusts had hoped to know how much was available so that they could progress their own schemes. The revenue contribution is important because it enables the trusts to provide care in the community, and if that is constrained it will have an impact on what the trusts are able to do.
The trusts’ efficiency plans also rely heavily on moving care and treatment away from acute care to primary and community care. The Committee is clear that if trusts move to that type of model, there needs to be investment in primary care across the North; it needs to be seen and be evident. The Committee heard that there have been delays in that investment. New primary care centres that were promised two years ago are being delayed, and communities are worried that those have been postponed indefinitely.
I now return to the issue of cuts in administration and management, which I think will be of great interest to people.
In giving evidence to the Committee, the Belfast Trust noted that it could remove all of its administrative and bureaucratic costs and still only achieve less than half of the total savings that it has to find. The Committee accepts that the level of efficiencies that are to be delivered require the trust to look at business areas and not just at management and administration.
Trusts must be innovative in how they find savings, and, quite often, that has meant finding new and better ways of doing the same thing and increasing productivity. That is important to the Committee: staff are an asset not only to the Health Service but to everyone across the North who uses it. However, it is clear that productivity levels here are lower than those in Scotland, England and Wales. Nevertheless, the Committee and the general public expect to see that efficiencies and deficit funding proposals are taken from management and administration as far as possible and not from front line services.
No, I am nearly out of time.
In their presentations to the Health Committee, the trusts went to great lengths to make it clear that they have greatly reduced their administrative staff, mainly through the review of public administration (RPA) process. For example, the South Eastern Trust now has four assistant directors of finance. Prior to the RPA, each trust had one financial director supported by perhaps two assistants. The Western Trust has set a target of achieving £9·4 million in RPA efficiencies. The Northern Trust has provided the Committee with evidence that administrative and clerical posts have been reduced to 271 from a total of 506.
When taking evidence over the past few weeks, the Committee asked each trust to quantify how much of its turnover is being spent on administration. It appears that most trusts are keeping administration costs at around 4% of turnover, and, on the face of it, that seems reasonable. However, there are some variations: the Western Trust runs at a figure of 4·6% and the South Eastern Trust has the lowest figure of 3·4%. In addition, we have yet to compare the figures with those in other jurisdictions.
I want the Minister to answer the questions raised by the motion. Given that the new trusts have had to deal with the legacy overdrafts of the previous trusts, find millions of pounds in efficiency savings, and do all of that with a zero tolerance approach to budget overspends, will the Minister assure the Assembly and the people of the North that front line services will not be impacted upon?
I beg to move to the following amendment: At end insert
“; and further requests that the Executive exempts health and social care services from further budget reductions or requirements to deliver any further efficiency savings.”
I thank the members of the Health Committee for tabling the motion, which we will support if amended. With the kind support of Dawn Purvis, the Ulster Unionist Party has proposed an amendment that seeks to add to the motion. Although we all believe in transparency, the Ulster Unionist Party believes that the best way to ensure that front line services are not affected is to make health and social care services exempt from further budget reductions, including any additional efficiency savings.
The additional sentence proposed in the amendment brings us to the crux of the issue. Despite what some Members may believe, we cannot have our cake and eat it. Since the beginning of this budgetary period, certain Members and parties have held contradictory positions. On the one hand, when it came to negotiating the draft Budget, the DUP chose to back the Finance Minister instead of the Minister of Health. That was done despite the DUP stating in its 2005 manifesto that Northern Ireland has suffered from relative underfunding for decades, and that more than 20% extra spending per capita on healthcare is required to achieve the same levels of service as in England. Such pronouncements did not stop the DUP, and others, from supporting a reduced budget for the Health Minister or from voting, on two occasions, for efficiency savings. It is those efficiency savings that are now the source of the DUP’s concerns.
The former Chairperson of the Health Committee even went so far as to accuse the Health Minister of being left wing, and, in more recent times, of being in cahoots with the trade unions simply because the unions happened to agree with the Minister. Yet again, we hear the DUP attacking the Minister and the trust for implementing policies that the DUP supported. Does Mrs Robinson not realise that by attacking the trade unions she is attacking the people that work at the very heart of the Health Service?
The contradictory nature of the DUP’s position was epitomised by the number of Members who demanded efficiency savings two years ago. However, in recent months, we have seen the hypocritical nature of the DUP. The very same Members, including Mrs Robinson and her sidekick, Mr Easton, have opposed all the efficiency saving proposals that have been put on the table. Their pathetic behaviour smacks of hypocrisy and opportunism.
The cheerleader, as my colleague refers to him, accused my two colleagues of opposing every proposed efficiency saving. I concur with their opposition to the efficiencies proposed by the health trusts. Does the Member believe that the closure of beds in Belfast hospitals is an efficiency measure or simply the cut that it is?
I am grateful to the Member for his intervention.
The Member and his colleagues opposed every measure that the Minister proposed to comply with the efficiencies that their party imposed on the Health Service. That is the contradictory nature of their argument: they are cheerleaders for efficiencies, yet they oppose them when tough decisions have to be made. They opposed the Minister on the formation of the Regional Agency for Public Health and Social Well-being, which has put us in good stead and is at the cornerstone of what we need to do. Where is the DUP when the going gets tough? Its opposition epitomises the hypocrisy to which I referred.
The contradiction of the DUP’s position was highlighted on 20 April 2009 when, along with others, it refused to back an Ulster Unionist and PUP proposal to exempt the Health Service from efficiency savings. For more than a year, the Ulster Unionist Party has been warning that we face significant fiscal problems in the current comprehensive spending review (CSR) period, never mind the next one. However, successive DUP Finance Ministers have chosen to deny that there is a problem, and then they do too little too late.
It should not be forgotten that it was a DUP Finance Minister who proposed efficiency savings to the Executive and in the House. In addition, DUP Members, along with others, trooped through the Lobbies to vote for efficiency savings. After hearing what some DUP Members think constitutes efficiency in the public purse — having purchased pens, TVs and handbags — health workers will take no lectures from the DUP on efficiency savings.
The Department of Health, Social Services and Public Safety (DHSSPS) has had to find £32 million in its budget to get a deal on funding to address the swine flu problem. The Finance Minister shamefully joked about the issue when the Health Minister initially appealed for funding in June.
The Minister of Health, Social Services and Public Safety’s record, compared with that of other Ministers, speaks for itself. Would he have been let off the hook for wasting £170 million as DUP Ministers did in the Workplace 2010 debacle? Would he have received a clear ball if he had miscalculated the value of the Crossnacreevy site to the tune of £200 million?
No; the Member had his turn.
If Members are serious about protecting front line services, they will vote for the amendment. Members need to realise that the Health Service is already in a difficult position; demand on it has increased by 9% in the past 12 months. If we add to that by imposing further reductions in the Health budget to fill financial holes, lives will be put in danger. The economy may be the number one priority in the glossy document, but ask anyone in the street about their number one priority, and the answer is health.
It is time that we all showed the required level of maturity. I hope that Members across the House will back the amendment.
We all accept that healthcare is the number one priority in Northern Ireland. I listened to my colleague on the Committee for Health, Social Services and Public Safety Mr McCallister rewrite history. I thank the Deputy Chairperson for proposing the motion. I will address some related and relevant issues that contribute to the larger picture of how the Department is managing issues.
I am aware that the Minister is fairly mean with the truth over how the Department is operating. Many of my colleagues on councils across Northern Ireland have written to him about certain aspects of the current cuts. When he writes back, he claims — surprise, surprise — that the problems are the bad, old DUP’s fault rather than his. Members will recall the Minister’s gloating when he was able to draw down additional moneys after the draft Budget, which was always going to allow the Minister to make a case for more money, was signed off. On 22 January 2008, he said:
“The final budget allocation is a good news story for the health service.”
“in light of the financial circumstances facing the Executive, I believe it is the best outcome possible.”
On 2 February 2009, our Minister came to the House and said:
“No cuts will be made to front-line services.” — [Official Report, Vol 37, No 3, p154, col 1].
Dear, dear. Moreover, on 2 May 2008, he said:
“To start to make cuts is not what people voted us in to do.”
The Minister did receive additional moneys. As I said, he promised that there would be no cuts to front line staff. However, instead of rolling up his sleeves and targeting the over-bureaucratic system that is today’s National Health Service, it was easier to get a chief executive, the unions, some of his advisers and a compliant media deliberately to do his bidding by selecting for cuts beds, nursing staff and other important provisions, such as bowel screening. The resultant public outcry was music to the Minister’s ears.
I understand the public’s anxieties, but it is a disgrace that the Minister used public concerns to cover his inept ability to use his budget wisely. If we were to support the amendment and let the Department off when it came to its making efficiencies, all other Departments would be required to find 6% efficiency savings, even though the Department of Health, Social Services and Public Safety has already been given special treatment. The Minister is allowed to keep any efficiency savings that he makes and plough them back into the Department.
As I was saying, Mr Deputy Speaker, my colleague on the Committee for Health, Social Services and Public Safety was quick to throw out spurious comments about expenses. For the record, that Member’s party is associated with the Tories, who were the worst culprits for defrauding expenses in the Westminster Parliament. I say to the Member and his colleagues that they are happy to link up with the Tories — [Interruption.]
Wise expenditure of taxpayers’ money is always essential, but never more so than in the present economic downturn. It is always a challenge to prioritise and make tough decisions, especially for the Department of Health, Social Services and Public Safety and the Minister. However, we must have zero-based budgeting on all programmes, all of which must be on the table and justified as absolutely essential.
The Minister made some snide remarks about the SDLP over the past few months because it did not support his Department’s exemption from the 3% efficiency savings. I want to set the record straight on that. The SDLP was the only party in the Assembly to vote against the Executive’s Budget. That was because there was no protection for front line services, no flexibility for monitoring expenditure, no provision for unexpected emergencies such as swine flu and no new measures to address the widening poverty gap. The SDLP called for ring-fencing of front line services, and it stands by its reasons for doing so. The party took a lot of criticism for that decision at the time, but it believes that it was the right decision then and that it is still the right decision.
In a meeting of the Committee for Health, Social Services and Public Safety in October, one of the trade union representatives, who are so apparently at one with the Minister, acknowledged that, in retrospect, the SDLP was right to oppose the Budget. The SDLP cannot support one area of public spending being exempted from efficiency savings, even if it is health and social services, which I believe is the most important area of expenditure.
Over the past decade, public spending on health has increased greatly above the rate of inflation. There is considerable evidence that much of that increase has failed to considerably improve services. It has been absorbed in higher salaries and administration, and some of it arose because of the target-setting culture. The Minister assured us that there would be no cuts to front line services; he also told us that he belatedly received additional resources. He may say that he did not know about swine flu at the time, but other Departments have had to give up some of their budgets to deal with the swine flu emergency.
I hope that the Minister, the Department and the new public health body are focusing much more on prevention and early intervention. The bowel cancer screening programme is very much about prevention and early intervention, but it has been postponed because its budget has been taken to deal with swine flu. Perhaps even the swine flu budget should be monitored constantly; we need regular updates on that budget.
I worked for decades in the Health Service, and I champion it constantly as the greatest socialist initiative ever taken by a democratic government. I was a trade union official for most of my working life, but given the financial crisis that we are in, no Department can be exempted from cuts. However, no cuts should ever be made to front line services.
Although the trusts are finding it challenging, the evidence that has been presented to the Committee for Health, Social Services and Public Safety shows that, by and large, they are working hard to meet efficiency savings targets. The many scare stories in the media about front line services have damaged the confidence of the Health Service, so we should all be serious and honourable about how we can address a downturn in the economy and ensure that we get healthcare free at the point of need to those who most need it.
I hope that the debate does not descend into party bickering. Ultimately, this matter concerns the health of the population of Northern Ireland; and I speak as someone who has also worked in the health service for decades. The debate is very important. The issue is about using money efficiently to ensure that our population is looked after to the standard that is expected in a developed country in the modern world.
As other Members have said, survey after survey shows that health is the most important issue to the people of Northern Ireland. A healthy population is also a happy, fit and active population, and that has major positive spin-offs for productivity and for the economy of Northern Ireland. Therefore, the Minister and the Department must strive at all times to provide the best possible modern health services for people.
Health can be divided in two parts; physical and mental. It can also be divided into primary care, which is community care, and secondary care, which comprises our hospitals. I, too, want to defend front line services, by which I mean nurses, doctors and hospital beds. That is very important, and the public must be made aware that Members are doing that. Last week, I had a problem with a patient who could not get a hospital bed and who was kept in an accident and emergency department overnight. That is not acceptable. Other front line services include ambulance services and carers in the community.
If one were to ask a member of the public whether he or she wants fewer nurses and hospital beds or fewer directors and administrators, one knows what the answers would be. I have been concerned about management for some time. I know that the trusts and the Department of Health, Social Services and Public Safety are making efforts to scale down what I have previously called the administrative monster in our Health Service. I know that that is happening; but is the Health Service still over-administrated when it comes to dealing with a population of just over 1·7 million people?
I have said to the Health Committee that the public need to be informed about the Health Service management structure. They do not know the many people who manage health services. In a recent newspaper article, the British Medical Association asked — and since then, I have also been asked — whether there are more than 40 directors in the Belfast Trust. The public want to know who is who and who does what in each of the trusts.
Recently, we discovered that management costs have increased by 13% since RPA. The number of managers has been reduced, but will the Member explain why there has been such a huge increase in management costs, accounting for £13 million? We are meant to be doing away with waste. Could that money not be better used for front line services?
I accept the Member’s point; perhaps the Minister will answer it. We are being told that management is being scaled down to acceptable levels. Hopefully, that is the case.
I suggest that the people in the trusts and the Department who provide healthcare should introduce themselves and tell the public what they do. They should remember that they, like public representatives, are public servants and are paid from the public purse. The public are entitled to know who those people are.
As has been mentioned, community care is very important. For the most part, we in healthcare and health management have often put the focus of health services on the secondary care sector. That has to stop, because there has been a major move towards care in the community, and rightly so. It is often thought that community care is the cheaper option, but that is often not the case. We must be prepared, and the Health Minister and his Department must show that they are prepared, for this major shift in healthcare provision from the secondary sector into the community.
As the Deputy Chairperson mentioned, financial resources must be made available for essential community and primary care services. There must be no delay in equipping those important services with the required resources and personnel.
The proposals concern the health of the people of Northern Ireland. I have worked in the Health Service for many years, and I believe that the public are completely in the dark about how our Health Service is managed. The public have a right to know the details of efficiency savings and the contingency proposals to deal with deficits. They have a right to know whether the savings will impact on front line services. I urge the Minister and his Department to make the public aware of such facts.
As much as I care about health, I hate debating health issues in the Chamber. Regardless of the subject, the Ulster Unionist Party and the Health Minister are always more interested in blaming everyone but themselves for the state of the Health Service than debating the relevant issues.
Let us look at the facts. By 2010-11, the health budget will be about £4 billion. When devolution returned in 2007, it was about £3·5 billion. Therefore, in the space of four years, the health budget will have increased by one eighth and will represent 48% of the entire Northern Ireland Budget.
In its amendment, the Ulster Unionist Party requests that the health budget be exempted from efficiency savings. However, in a way, the Department of Health is already exempt from efficiency savings because, unlike any other Department, it gets to keep its entire efficiency savings. To cap that, the Department of Health gets first call on the £20 million generated from the underspend of other Departments. No other Department gets such preferential treatment but, apparently, it is not enough. Given that our productivity is lagging behind that of the rest of the UK, should we not look at how to improve that situation?
Minister, we in the DUP would like to work with you. However, when you come to a Committee meeting, you attack the DUP.
When the Health Minister comes to the Committee, we are attacked. When the Health Minister is on TV, we are attacked. When we make helpful suggestions to the Health Minister, we are attacked. The Health Minister is obsessed with attacking the DUP, and it is to the detriment of our Health Service.
When the Ambulance Service Trust came to the Committee to discuss efficiency savings and a shortfall in its budget, we found out that it had presented a second set of proposals to the Minister, which he had agreed to and signed off. However, the Committee was told nothing about that, and we knew nothing about it until reports appeared on TV and in the press. Is keeping information from us any way to work or to build a relationship with the Committee?
In a presentation on efficiencies by the unions, one union member stated that trusts are playing political games with their efficiency targets. If that is the case, what will the Health Minister do to correct it? Does it suit his agenda? I send a clear message to the unions: you are being conned by a Minister who is willing to play games with the Health Service and with the people of Northern Ireland.
We offer to meet the unions to demonstrate where £78 million of savings can be found; savings that will not affect front line services but which the Minister is ignoring. Those savings would ensure that no nursing posts would have to go; there would be no need to remove services from hospitals such as Mid-Ulster Hospital and Whiteabbey Hospital; and there would be proper ambulance cover across Northern Ireland. As my colleague has done, I remind the Minister that he promised the Assembly that there would be no cuts to front line services.
The Minister can find money when he wants to. Indeed, he has found £20 million in a so-called “controlled fund” to bail out the Northern Health and Social Care Trust. We knew nothing about that money; perhaps the Minister will tell us how much is in that wee account. As my colleague also mentioned, the Minister has been quoted as saying that he was content with his budget. Therefore, is the Minister saying that he has got his budget wrong? It is strange that the Minister has never raised this as an issue at the Executive. Surely any half-sensible Minister who was having trouble with their budget would have done so.
I offer the Minister the chance to start again. The DUP is willing to work with him, meet him and share his burden if he would only show a willingness to put his bitterness behind him. The offer is unconditional, and it has been made before. The decision to cut front line services rests with the Minister and nobody else.
Go raibh maith agat, a LeasCheann Comhairle. I commend the Health Committee for tabling this motion. As the Deputy Chairperson said in her opening remarks, the Committee tabled the motion because we felt that we were not getting the relevant information that we needed to scrutinise the Department and the Minister. When we do get the information, we get it either through the media or late. That does not help. The fact is that we are there to scrutinise. We are in a new dispensation and the Committee is there to hold people accountable for their actions, but we are not getting the information that allows us to do that.
In saying that, I place on record my view that the Health Service has been underfunded for years. I do not think that anybody could disagree. Some people say that it is underfunded by £100 million, others say that the figure is £600 million. Before I go into the details, I also take the opportunity to commend the staff of the Health Service, at whatever level, for their hard work and dedication over the years. They have faced crisis after crisis, and they have stood up and taken on board that challenge. They are still there and are willing to put in the hours and the work to try to deliver front line services that are second to none.
We need to talk about the block grant. I will shy away from getting into arguments with other parties, but the reality is that the block grant is inadequate. We need to look at the issue of fiscal powers for this Assembly. If we are saying that the Health Service is underfunded, we need to look at ways of getting more money in.
I take on board the last comments that were made by the Member who spoke previously. Like all Ministers, the Health Minister has challenges ahead. We must ensure that there is further investment if it is needed and that the issue of wastage in the Health Service is exposed. I have a good working relationship with the Minister and his Department, and, fair dues, that is how to get things done. However, I have not heard the Minister once mention the wastage in the Health Service. I have not heard the Minister say that efficiencies mean that we are turning the health sector into a streamlining machine so that we can deal with all the issues that exist. We all hear stories about taxis still being used to deliver patient records: is that a fair way to use public money? We still hear about money that is spent on hospitality. I submitted a question — lo and behold, I do not have the answer today — about whether former chief executives are being held to account for deficits in previous trusts. If the Health Service were a private company, would it be held to account? We also need to look at the issue of travel.
If we took the time and opportunity to talk to the staff, they could probably tell us instantly how money could be saved in front line services and hospitals. I meet them on a regular basis and they are able to tell me about all the money that is being wasted. The reality is that the gravy train needs to stop. I know that the Department of Health is underfunded, but there are inefficiencies in the Health Service. If that money were redirected to front line care, who knows where we would be next week? We could end up saving money.
The political argument about taking money from other Departments cannot go anywhere. We are talking about investing for health, and John McCallister asked where we would get the money for that. If we are serious about it, do we take money from education? Do we take it from housing? Do we leave the rural community abandoned? Do we not give people better roads? It is the collective responsibility of the Executive and the individual responsibility of other Ministers to ensure that we are investing for health.
No; I do not have much time. It is Ministers’ responsibility to ensure that we are proactive in dealing with health, inequalities and social deprivation, rather than always reacting.
I am conscious of my time, so I will end with a point about the Northern Health and Social Care Trust. Fair play to the Minister for bringing in Colm Donaghy on that contract. It was a good move; perhaps he will move to other trusts afterwards.
The Northern Trust stated:
“The Trust is required to make savings of £44 million to be achieved over a three-year period. These savings will be reinvested into front line services”.
The trust continues:
“A large part of these savings…are to be achieved through reduced management and administrative costs and general efficiency (such as negotiating better prices for drugs or using computer technology instead of printing all x-ray images).”
To me, that represents efficiency savings.
We all come to the Chamber from time to time to support our party’s ministerial colleagues. We do that out of some sense of loyalty and because, as party members, we share the same policy. However, the amendment tabled in the names of Mr McCallister, Mr Gardiner and Dawn “One Job” Purvis, who, unfortunately, does not seem to be here today, goes well above and beyond the call of duty in showing loyalty to one’s ministerial colleague.
I want to dwell on the amendment. To call for the Health Service to be exempted from efficiency savings that are the harsh reality that everybody in every Department faces is ridiculous. To say that the money for a Health Service that has been force-fed resources for nigh-on a decade has and is being efficiently spent is, in my opinion, wrong. As Mrs Hanna pointed out, the increase in expenditure in the Health Service is now at record levels. Billions upon billions upon billions of pounds are being pumped into the Health Service every year. To say that there is no scope for efficiency in that system is the height of nonsense.
A raft of indicators shows that there is scope for savings, even on administration, never mind productivity and on how things are done in the Health Service. One looks at —
No. In a decade, the number of Health Service administrators has risen by 35%, the number of managers is up 91%, and the number of senior managers is up by 82%. Mr Easton pointed out that there has been a 13% increase in management costs post-RPA, which was supposed to drive efficiency in Health Service administration.
As have others, I have asked Assembly questions of the Minister as part of my work to establish where efficiencies might be achieved. I have asked about equality units, press and communications and a host of back office, non-front line areas of administration. Time and time again I have received the same response, which is none, other than that the details are not held centrally.
For example, because I wanted to know about the subject in general, I asked every Department about the cost of advertising in local newspapers. Every Department was able to answer that question, except the Minister’s. I got no answer at all. Every Department except the Department of Health answered the question.
I, like the Member, am not getting answers. Does he agree that not getting replies to questions for written answer is a deliberate attempt to prevent us from knowing what is going on in the Health Service?
I began to worry whether it was just me, Mr Deputy Speaker, but then I started to do some research, and I found that not only Mr Easton, Mrs Iris Robinson — I thought that perhaps it was just my party — but Members of every party have failed to receive answers from the Minister.
Only two conclusions are possible: either the Minister knows and is not telling us, which is worrying for the integrity of the House, or he genuinely does not know, which is even more worrying. If the latter is the case, the Health Minister is telling us that he cannot explain where the money granted to him in the Budget is being spent. That is deeply, deeply, deeply worrying.
If the Minister or those working for him cannot get their heads around efficiencies, others are capable of helping him to do it.
However, if the Minister has no idea of where his money is being spent, that means that he has no control over where it is being spent, yet he wants to be exempt from efficiency savings. If anything, not being in control of his budget is an argument for greater scrutiny. It does not matter whether that is carried out by his officials or by bodies outside his Department, such as PEDU; there is a case for greater, not less, scrutiny.
Earlier, Mrs Robinson asked about the implications other budgets of exempting the Department of Health, Social Services and Public Safety. The implication is that the efficiency savings that would have to be made in other front line services, such as education and housing, would increase. Therefore, when Members look for ring-fencing and separation and for no further efficiency savings in health, they are asking for increased efficiencies — ergo, cuts — in other areas. I am sick, sore and tried, as I think many Members are, of that emotional game being played with us and, more importantly, with the public and those who work in the Health Service. Nobody in their right mind in this country believes that the Health Service is as efficient or as productive as it could be. Therefore, driving greater efficiency into the service is not only desirable but absolutely essential.
Mr McGimpsey can sit and cry about the efficiency savings that he faces, and his colleagues can back him up, but the fact is that he agreed to those efficiencies when he voted for them in the Budget, and the cheerleaders who sit behind him also agreed to them when they trooped through the Lobby. They supported a Budget that was predicated on his achieving the efficiencies that he now faces. I know that the Minister faces a difficult job in dealing with the Health Service.
The pressure of achieving efficiency savings is nowhere more apparent than in the Department of Health, Social Services and Public Safety. The Minister stated that £700 million of efficiency savings are demanded, when years of underinvestment mean that our services are not as good as those in the rest of the UK. He is quite right that objective measures show that productivity in the Health Service in Northern Ireland is well below that in the most efficient parts of Britain, and that presents a major challenge to his Department. It also puts a question mark over the reference to underinvestment in the past; I will come to that point later.
Health is an ever-demanding funding area. New technologies and drugs come on stream all the time, and medical conditions that the public previously thought had to be accepted now demand a remedy. The Minister tells us that the demand for services is rising by 9% each year. That is a remarkable figure, so I hope that he will give us more details about it. In an arena in which funding is flat and 3% year-on-year efficiencies are required, a 9% annual rise in demand puts an almost unsustainable burden on the system.
I return to the issue of underinvestment in the past. I wonder whether the key lesson is not that opportunities to address the problems in a more deep-seated way have been ignored but that we have tried to nurse the system along when more surgery was required. Surely that needs to change, particularly given that we will soon face real and substantial cuts in the overall Budget.
Some discussions about efficiency savings make a rigid distinction between front line services and administration. The argument is that efficiency savings should come from the administration side and that front line services should be protected. That argument is overly simplistic, and I am disappointed to discover that Dr Deeny seems to live in that world. Front line services and administration are intimately bound up, and the idea that there is some easy way to achieve efficiencies in administration without impacting on front line services is false.
Recently, the pressure on the health and social care trusts to provide efficiency savings has become evident. Efficiency savings do not take money away from the trusts, but they are required to fund new areas of work from money that has been moved around internally. Quite simply, that cannot be done, and I have much sympathy for the Minister when he says that all this is happening too fast. I wonder whether trusts will be forced into so-called efficiencies that, in the long run, will not contribute usefully to real efficiencies and may get in the way of better long-term solutions.
In recent weeks, it has become clear that, in several cases, trusts are not able to deliver the efficiency savings that their targets require and also balance their budgets. Trusts’ total projected overspend is reported as being approximately £70 million. Therefore, to break even, they were going to have to make savage cuts to front line services. The situation has been addressed through the Department’s providing extra funding to the trusts, but that comes at a cost.
It means that key initiatives will, at the very least, be postponed, and, in the present climate, who knows when they will be resumed? That brings me to the Northern Health Trust, which includes my constituency. Its projected overspend for this year was £28·5 million; its chief executive said so at the Health Committee last week. That has now been addressed by the trust’s doubling its own efficiency savings to £7 million and the Department providing the balance, with a contribution to the pension scheme. I note that the Minister has now largely approved the initial efficiency savings plan of the trust, which includes moving acute inpatient surgery from the Whiteabbey and Mid-Ulster hospitals to the Antrim and Causeway hospitals. I note also that there will be more day surgery at Whiteabbey and Mid-Ulster.
I thank the Member for giving way. He will agree that front line services are very important: he has outlined that already. Will he also agree that each year some £30 million may be saved in travel expenses and that that could be used to ensure that front line services are retained while making efficiency savings?
I leave the Member’s comment as he has expressed it.
Two residential homes in the Northern Health Trust will be replaced, including Rathmoyle Home in Ballycastle. I am most enthusiastic and optimistic about this scheme, as it could provide a better standard of care for elderly people and others who need support, whether in the community or in residential accommodation. I welcome the work already undertaken by trust staff in the analysis of local needs.
Taken as a whole, the changes proposed by the trust will enhance services in the trust area. I note that the proposals that have been adopted are almost the same as those proposed by the trust under its former chief executive, who recently retired. I hope that the Minister will acknowledge that and agree with me that the primary cause of overspend relates to deep-seated structural features that have not been addressed historically. That is the key to the future, when there will be a much tighter funding environment. To call for the Health Service to be insulated from those pressures merely dodges the issue.
I have scribbled down some of the points that Members made, and I will try to respond to them. Some merit response, not least Simon Hamilton’s allegation that the number of managers has risen. That is not true; the number of managers has declined. He said that the cost of managers has risen; that is not true either. He said that the size of management has risen; that is not true. In fact, the size of the administration and management has been reduced: from 19 trusts to six and from four boards to one. I have reduced the number of senior executives from 180 to about 60. That pattern is repeated all the way down the line.
I have to say to Members —
Mr Deputy Speaker, it is difficult for me to respond if Mr Hamilton keeps talking at me from a sedentary position; he should have the manners to listen. I had the manners to listen to him and to all his colleagues. [Interruption.]
With respect to Simon Hamilton’s remark that the Health Service has been “force-fed money”, I ask you whether he is the sort of colleague with whom you can go into the Lobbies. He spoke of
“billions upon billions upon billions of pounds” being force-fed into the Health Service.
If I may be allowed to answer: the Member who receives most answers is Alex Easton, who received more than 500 answers. Do Members know how much it costs to answer each of his questions? Three hundred pounds. I have spent about £150,000 answering Alex Easton’s questions. Answering other Members’ questions has cost similar sums. I have answered hundreds and hundreds of questions. Simon Hamilton has asked me questions about flowers; that is the sort of question that I am often asked. As well as intelligent questions, I am often asked trivial ones. One of Alex Easton’s latest questions — since he complains about questions — is whether there will be a Christmas party in Ravarra House. This is purely party political, and we have only to listen to Mrs Robinson talking from a sedentary position to understand that.
I am being asked to respond to a debate on efficiency savings and their impact on health services. Let me begin by reminding Members of the debate in April on the loss of nursing posts. The House debated an amendment that asked for the Health Department to be exempt from efficiency savings. Only the UUP and the PUP supported that amendment. Everyone else in the Assembly voted against the amendment and for these efficiencies. Yet Members criticise me when they see the efficiencies being put on the table. That debate was, in fact, scheduled after every single trust, including the Ambulance Service Trust, had put their efficiency plans on the table.
Everyone in this House who voted against that amendment knew exactly what they were voting for, because the efficiency plans had been published and consulted upon. There had been discussions with the Health Committee and debates. Therefore, everyone knew exactly what they were voting for, and they voted against exemption for Health. They can do it in Scotland, but they cannot do it here, so you tell me what is going on.
Today, Members have an opportunity to look at that matter again. There is no question that health and social care trusts should be efficient, and there is no doubt that we are achieving exactly that. However, let me again remind Members about some of the difficulties that we face: there is the matter of a massive £600 million funding gap between Northern Ireland and England. For us to have the same Health Service here as they have in England, we need another £600 million.
Our local health and social care services are simply not as good as those in the rest of the UK, and it does not matter how efficient we make ourselves — we keep becoming more and more efficient — because we will always be £600 million behind. That gap cannot be closed by efficiencies alone. That means that our services will never be as good as those in England. In fact, the DUP, once upon a time, in its 2005 manifesto, said that a 20% increase in healthcare funding was required. That is another broken manifesto promise.
The motion asks for details of trusts’ efficiency savings and contingency plans. The details of all those were widely publicised. The proposals were subject to full public consultation. Members might also remember that there was major disquiet about proposals to find the efficiencies, in stark contrast to the eerie silence that met proposals by other Departments. Why was that? Is it because health and social care is so important? Of course it is. No other Department or Minister is in the same situation, but then all other Departments are more generously funded vis-à-vis their budgets.
Unfortunately, the concerns of individual Assembly Members and of the general public have not been reflected in the funds voted by the Assembly to health and social care. I said, at the time of the Budget, that it was not enough, but that it was as good as it gets. I said that the increase that I got over the draft Budget was good news, but I was looking for a lot more than I got. Therefore, let me start by —
Let me start by explaining the challenges that we face. First, demand for health services is increasing at an unprecedented rate of 9%. Mr O’Loan wanted details: there are about 48,000 more first outpatient appointments; approximately 13,000 more inpatient procedures; and some 14,000 extra A&E attendances. That gives some idea of the extras. Demand for hospital services is, therefore, rising by around 9%.
In contrast, the DUP, or some Members, talked about the record rise in Health spending. Our growth this year is one half of a percentage point: 0·5% above inflation. John Appleby, who was much quoted and who conducted a review of health and social care provision in Northern Ireland, said that Health in Northern Ireland should get 4·3% above inflation. This year we are getting half of one per cent and dealing with a 9% increase in demand. You do not have to be a mathematician to work all that out.
Funding growth in England and Wales runs at 3·7%; we are well behind that. Does the Assembly want a return to unacceptably long waiting times?
Members talk about productivity. Michelle O’Neill and Simon Hamilton attacked the productivity of the Health Service in Northern Ireland, and I was surprised to hear Sue Ramsey echoing those attacks. The productivity of the Health Service in Northern Ireland is rising, and that is a measure of how good its staff are. It is hard to be absolutely efficient and totally productive in some of the facilities where the staff are working, with some of the equipment that they are working with and in view of the years of historic underfunding. However, Members have seen massive improvements in such areas as waiting times and the availability to MS and arthritis sufferers of life-changing drugs. Those are the sorts of things on which we will be looking to compromise if we continue along the road that we are on.
There is also a need for investment in older people’s services, for example. The number of people over 75 is rising by almost 3% a year. Mr O’Loan wanted to know where that increase is coming from. Within that group, the number of over-85s in our community is increasing by almost 4% each year, and that will bring serious financial pressures. If living longer is to be achieved with dignity, we must provide for the additional services that people need. The cost of healthcare for people who are over 75 more than quadruples, and the cost for people aged over 85 increases by more than 10 times. Does the Assembly want to care for older people? I know how the people of Northern Ireland and I will answer that question. Our priority is to care for every man, woman and child, irrespective of their age.
Further evidence of the difficulty that we face in trying to meet the rising demand was highlighted in the trusts’ contingency plans. There seems to be a misunderstanding about that as well. The trusts attend Committee meetings and explain their efficiency plans. In April, the efficiency plans are consulted on, debated and voted on; they are there for all to see.
The trusts explained their efficiency plans, so everyone knew what they were voting for. With regard to contingency plans, I had within my budget settlement an agreement that I would bid for pandemic flu in those terms — and I say that for the benefit of Mr Hamilton, who clearly has not read my budget agreement. I bid for pandemic flu, and, in June, I could not persuade the Executive to discuss it with me. Therefore, I had to set aside funding as the Department’s contingency to provide for the possibility of not getting money for pandemic flu. Alternatively, I could simply have cancelled the vaccines, antivirals and extra paediatric critical care cots that I had on order, but I did not do that; I went ahead with those provisions. There are accountancy rules, and, by the way, Mrs O’Neill, you cannot have a 0·5% leeway.
It was only at the end of September, when I finally got agreement from the Executive to fund swine flu to the tune of 50%, that I was able to release half of that money from the contingency. That allowed me to take some of the sting out of the contingency plans. It did not allow me to take out all of the sting; there is still an issue there, and I am still grappling with it.
I have said that we will make the efficiencies, and we are making them. I have also said that I will maintain the front line services, and we have done that. In fact, the front line is 7% more productive, which I know will interest Members who have attacked our Health Service staff for not being as productive as those in other parts of the UK. We have done extra business, and we have coped. We cannot cope with an extra if that means making more cuts and paying half the swine flu bill and then being expected to start the process again. We must bear in mind that the Department receives £600 million less in funding than its counterpart in England and that it must also find £700 million of efficiency savings and £32 million for swine flu. We must also bear in mind that, of the first £20 million that the Department was to receive each year from the Budget, it must fund £10 million itself to get a financial settlement. That is why the constant — [Interruption.]
Thank you, Mr Deputy Speaker. I have said almost all that I need to say. Members are well aware of the situation.
All the arguments and the political point scoring in the world will not alter the fact that the Health Service is not funded properly by the Assembly and that it receives 43% of the block grant, not 50%, as some Members claimed. That money is available, and I must make that argument on behalf of the Health Service and the staff who man it. They do a tremendous job for the population in Northern Ireland. I will continue to make that argument, and I will not apologise for doing so.
As a result of the efficiency cuts that the Department must make, we will reach a point where required front line services cannot be maintained. The cuts that are being proposed and those that I have absorbed already add up to the fact that we could be facing reductions, the possibility of closures and the need to reduce costs further. There is no other way to deal with the situation, and, effectively, we will be going from having a cradle-to-grave Health Service that is free at the point of delivery to being in a situation in which there are attempts to ration healthcare provision. Such rationing has occurred in the past; when money ran out, waiting lists rose and new drugs, treatments and technologies were not provided. When the Health Service runs out of money, investment must be prioritised. None of us wants to get to that position, and I know that this is more important —
In making my winding-up speech on the amendment, I want to reflect on some of the remarks that other Members made.
Mrs O’Neill opened the debate by reflecting on some of the management and administration costs of the Health Service. However, when the trusts gave their evidence to the Committee for Health, Social Services and Public Safety, there was surprise among Committee members that the administration and management costs of all the trusts were actually only 3% to 4% of their total budget. That is an incredible position to be in.
I will also highlight some of Mrs Robinson’s comments so that the House can decide for itself what has changed her mind over the years. She spent most of her contribution talking about the good Budget outcome. However, despite her opposition to any more resources being granted to the health budget, she supported and campaigned hard for the initial draft Budget and objected to the additional funding that the Minister secured. The Minister answered her point on several occasions when he said that that was the best outcome in the circumstances.
Unfortunately, the debate has once again descended into a discussion between two parties about personalities.
In my remarks, I accepted that the Health Service is underfunded, and I do not think that anyone in the Chamber would deny that. I specifically asked the Minister to speak about wastage in the Health Service. If the Member does not believe that there have been efficiency savings or that money has not been wasted, why has the Northern Trust said that it will save £19 million by reducing administration?
All the trusts and the Department are saving money on administration. I went through some of the steps that we have taken and will continue to take. We aim to be as efficient as possible, but all the efficiency measures that we take will not change the fact that our health budget is £600 million behind that of England. That will not change, and we are getting further behind. If we want a Health Service that is comparable to that of England, that requires investment. To say that we are not making enough efficiency savings does not alter the fact that we do not have enough headline money.
Mrs Hanna spoke about ring-fencing front line services, and she said that we need to improve services. I support her call for prevention, early detection and early intervention, which would be a huge benefit in many areas. That is the direction in which we are travelling.
Mr Hamilton spoke rather harshly about the Health Service being force-fed money. I remind him that the DUP, in its 2005 manifesto, called for 20% extra funding for health. That was the platform on which Mrs Robinson was elected. What has changed her mind? It did not take her long to break that promise. [Interruption.] At that time, she also spoke about 9% extra funding being insufficient. She now supports and champions a 0·5% growth in funding. Is that an admission that she was wrong in 2005 and that she is right now? What is she actually talking about? Does she even know? [Interruption.]
As the Minister said, demands on the Health Service are rising more rapidly than the requirement for services in any other Department. Health Service inflation is higher, and yet, as the Minister outlined, the growth in real terms is 0·5 %, and we are falling further and further behind our fellow countrymen in England. Some Members seem oblivious to the idea that that will have a knock-on effect.
Members cannot keep bringing motions to the Assembly demanding that the Department commits more resources or takes more action in this area and then wonder why it cannot be achieved. They cannot have their cake and eat it. [Interruption.] If Mrs Robinson wants to make an intervention, why does she not just ask for one?