Transforming Your Care:  Implementation Concerns

Private Members' Business – in the Northern Ireland Assembly at 11:15 am on 3rd June 2014.

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Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin 11:15 am, 3rd June 2014

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.

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

I beg to move

That this Assembly recognises the considerable public concern at the pressures on emergency departments and GP waiting times, which have arisen during the period of the Transforming Your Care change agenda; notes with concern that the implementation of Transforming Your Care has not been fully assessed; and calls on the Minister of Health, Social Services and Public Safety to review and measure the implementation of Transforming Your Care to assess its effect on patient outcomes.

I welcome the opportunity to introduce this important debate today.  The health service here looks after just shy of two million people in a service that costs up to £4 billion a year.  In that sense, every pound that is spent has to be valued against its productivity.  Every pound is important and has to be measured. 

I note the amendment, and the SDLP is happy to support it.  In our view, it neither adds substantially nor takes away from the original motion, but it does give its proposer extra time, which I hope he will use to express the genuine concerns of many of the extra 2,000 health service staff who have been employed since 2011, and the many others who share the concerns reflected here today.  Indeed, I ask this question:  did Transforming Your Care (TYC) envisage employing those 2,000 people when it was announced?  We simply do not know.  The ambition of the amendment is vague, but that actually serves to underscore the purpose of the original motion, which is about measurement, accountability and efficiency in the health service. 

The health service here employs nearly 55,000 staff who are dedicated and professional and work to the highest standards in often difficult situations.  Their commitment, energy and compassion must receive the highest praise, and I think that we should all acknowledge that today. 

Let us remember why we are here today.  It is because of severely stressed circumstances that have been rehearsed over and over in the public mind, among health professionals and, indeed, in the Assembly Chamber many times.  I do not propose to dwell much further on them, but only to say that, in our view, those A&E difficulties with, at the worst end, patient deaths potentially caused by system stress and the frail and elderly often humiliated and neglected — all those stories — are, in fact, the symptom, not the cause.

The SDLP has been consistent on that point and it is why we have proposed the motion today.

The biggest single change agenda in the health service here is Transforming Your Care.  Authors considered future demand and present stresses, and they consulted and came up with a plan.  In simple terms, TYC aims to shift the provision of healthcare from centralised institutions and into the community to facilitate people better closer to their homes.  For the moment, let us leave aside the financial arguments and people's views about hidden agendas such as privatisation.  If TYC is about anything, it is about the strategic future of health provision here.  This morning and this afternoon, we will hear lots of individual stories about treatments, cost, time taken and stress, but I would like the debate to stay focused on the strategic future.

The plan itself is a high-level strategic document that initially had 99 proposals, and, because we could find no evidence of it, we recently asked for a measurement of the TYC journey.  We got this tabulated document.  We can see little or no measurement in it either.  A bit like the DUP amendment, there is plenty of woolly narrative and not a lot of substance.  The response we got included a wonderful mechanism whereby the original 99 targets:

" subsumed within the business commissioning and transformation processes highlighted...and reporting will be undertaken on this basis."

Basically, they will be swallowed up by wider health policy.

Let us look at some of the updates given on the 99 targets in the April 2014 report.  Proposal 5 is about incentivising integrated care partnerships to support evidence-based health promotion.  The update is:

"Work on this proposal has been deferred awaiting implementation and subsequent evaluation of the...Integrated Care Partnership model."

Proposal 10 is about a reduction in residential accommodation over the next five years.  The current position is so circular that it is difficult to see how much progress has been made, and the Health Committee's current work on older people and accommodation only solidifies that argument.  In fact, in pursuit of proposal 10, the Northern Trust closed its care homes independently, that led to a public outcry and the Minister reversed the decision.

Proposal 13 centres on more community-based respite care.  Where does that lie?

"Local commissioning groups are currently developing plans for unscheduled care pathways".

There is no concrete measurement.

Proposal 18 is on personalised care.  It points in the direction of direct payments, but there is little uptake and most initiatives are still at the pilot stage, and that is two and a half years later.

Proposal 21 aims to create better partnership working with patients with long-term conditions to enable greater self-care and prevention.  The current position is:

"Pathways are currently being finalised."

Once again, that is two and a half years later.

Proposal 46 is a new head start programme for children aged nought-to-five.  Where is it?

"Services, including parenting skills, are under development".

Proposal 59 is a typical TYC proposal.  It aims for a shift in the balance of spend for mental health between hospital and the community.  This proposal captures the very essence of TYC.  What is the current position?

"This is an ongoing requirement over the course of the TYC implementation period.  Work is progressing on developing a systematic monitoring process and monitoring will take place during 2014/15."

Note that work is not progressing on the issue itself.  We have not even developed how we will monitor the shift of moneys to the community.

Finally, proposal 98 is about the overall reallocation of funds.  It aims for a 4% shift into the community.  Once again, we are told that this is an ongoing process but, importantly, we are told nothing about the process itself.  What are they developing?  A monitoring process.  Plenty of process, little product and certainly not a plan. 

It is for the above reasons and more that the SDLP wants Transforming Your Care properly measured and why we proposed the motion today.

My concerns are shared by the unions, professionals and the public.  Let us look at what the three leading health unions say.  NIPSA said:

"“Transforming Your Care”, despite its visionary rhetoric, is ... creating the space within which universal provision is undermined and the toxic presence of the private sector ... is encouraged."

Representatives from the highly respected Royal College of Nursing (RCN) presented to the Health Committee recently.  They asked what it was because, despite studying the document, they still could not outline what it was or what it was doing.  Once again, that is two and a half years into the process, and they are at the front line. 

UNISON stated:

"TYC fails to control critical risks, and is cost rather than clinically driven.  Therefore the TYC model as presented requires fundamental reconsideration."

That is the considered opinion of three leading health unions, two and a half years into the process.  It all reinforces the fact that the public must be shown how TYC is working, if it is working at all. 

Last week, the Health Committee was faced with the prospect of health service bids in the June monitoring round.  I have to say that, as a public representative, I have serious concerns about a Department that puts its hands out for more money when we are not sufficiently measuring what it is doing with the funding already.  We are simply not being told how much the change agenda is costing or saving.  All we are being told is, "If we do not get more, the system is under threat".  Last week, it was even down to the basic visit to a doctor. 

Officials were asked about how the lack of funding is affecting TYC, and they were not able to tell us.  We are left in the position, as public representatives, of facing a demand for money and a threat that, if we do not pay up, the service will collapse.  That is another reason why we need good, solid, prudent measurement of this massive change agenda.  That is the pressure that we all feel as public representatives, and it is what spurred the SDLP to ask those prudent, rational questions over how this vast amount of money is being spent on a change agenda.  How is the money being measured, and, importantly, how is the product being measured? 

Everybody has an answer, but it is their answer from their perspective, largely from their bit of the wheel.  That is why there is a greater onus on the system to provide a measured and balanced view on the outcomes.  The public cannot see Transforming Your Care change, but they feel it.  It is the public who sit in line in a stressed A&E service.  It is the public who cannot get an appointment.  It is the public who pay for the system that is not delivering what they are asking for.  It is all the more reason why we must have it explained in detail how the change is being measured. 

There is no doubt that the issue of welfare reform will appear in today's debate from the opposite Benches, but that issue exists outside of today's debate.

The TYC plan was established in 2011.  It is a failing when a health service puts out its hand for more and we do not know what it is for and whether it is consistent or not with a plan that is real or not. 

This morning, we heard about a human rights assessment of what is going on.  That may not be the only future inquiry into these plans.  We need a health service that delivers cost effectively and for patients, and we need to see full transparency and accountability in the plan that underpins that.

Photo of Jim Wells Jim Wells DUP 11:30 am, 3rd June 2014

I beg to move the following amendment

At end insert

";welcomes the progress made on patient waiting times, including the significant reduction in those waiting longer than 12 hours in emergency departments to be assessed, treated and admitted or discharged; pays tribute to the dedication of hard-working health and social care staff, including the 2,000 additional staff employed since 2011; and further calls on the Minister of Health, Social Services and Public Safety to reinforce across the health and social care system the necessity for transformational change to respond to the challenges of an ageing population, and to encourage and maximise involvement and leadership from health care professionals on the ground in delivering change from the bottom up at an accelerated pace."

I need to remind Mr McKinney and Members from his party of why we are here and how we have got to this position.  Normally, I would say that it would be unreasonable to expect the honourable Member for South Belfast to know about this because he was not a Member of the House when this was all being discussed but, of course, he was a leading journalist working for a major television company, and he was very much across what was going on in health during his time in that elevated position.  Therefore, he should have known that this document, 'Transforming Your Care', has to be one of the most consulted upon pieces of paper in the history of health service provision in Northern Ireland.  There were public meetings, private meetings, briefings to the Committee and several statements by the Minister to the House.  Everyone had a full opportunity to know exactly what was going on and what it was going to lead to. 

I have to say, Mr McKinney, that members of your party on the Health Committee sat through that entire process and agreed with what was being suggested and supported it, and only now are coming forward with concerns.  I do not want to embarrass the honourable Members by naming them, but one is a very prominent lady from Upper Bann, and one is a very prominent Member from Londonderry.  Those folk sat throughout those meetings perfectly happy with what was being proposed.  What they realised is that we could not go on the way that we were going in health. 

There is a phrase often used in health service provision called the ladder of healthcare.  The problem is, in Northern Ireland, that there are far too many people too far up that ladder commensurate with the needs of their health.

Every time you step up another rung of that ladder, the cost more or less doubles.  If we had continued the way we were going, the health service system in Northern Ireland would have collapsed under its own weight by 2025.  We could not continue.  Indeed, Mr McGimpsey, the previous Health Minister, recognised that as well, because he was proposing a similar review.

Photo of Jim Wells Jim Wells DUP

He did not get a chance to implement it — I accept that — because, obviously, the election came, and Mr Poots was appointed.  The point is that he recognised that there were severe structural problems in health.

Photo of Jim Wells Jim Wells DUP

I certainly will.

Photo of John McCallister John McCallister UUP

Thanks, Principal Deputy Speaker.  I agree that Mr McGimpsey recognised that and legislated to create a Public Health Agency (PHA).  Why are the Member and his party so against the Public Health Agency?

Photo of Jim Wells Jim Wells DUP

We certainly are not against the Public Health Agency.  The Public Health Agency is an important and integral part of healthcare provision in Northern Ireland.  We all accept that unless we get very early intervention, and stop people adopting lifestyle choices that lead to poor health, more problems will be created in the future.  I have always been a very enthusiastic supporter of the PHA.  We certainly did not oppose the establishment of that body.  I am one who would like to see a further enhancement of its powers, so you will not get me on that one, Mr McCallister, I can assure you.

The fact is that we all accepted that we could not go on the way we were going; we all accepted that it required radical reform; and we all accepted that the basic premise of what John Compton was saying in the original 'Transforming Your Care' document was the best way forward.  Not only did we accept that, but so too did the unions, tacitly, and the royal colleges, enthusiastically, and many of the NGOs and the charitable sector were extremely keen on Transforming Your Care.  Behind the scenes, everyone is still telling me at all the various —

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

I thank the Member for giving way.  Does the Member accept that his point that we all agreed that something had to be done is entirely reasonable?  We all agreed with the original proposals, of course, but that is not what is under debate today.  What is under debate today is how we have gone about it and whether it is being measured.  How do we measure it?  Is it succeeding?  Is it failing?  Can we address those points, and not have a smokescreen about what we all agreed?  We all agreed that we would build the car, but what have we got and where is it going?

Photo of Jim Wells Jim Wells DUP

Finally, for one last point, yes.

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

Has the Member read this document?  Does the Member recognise any measurements in it of a substantial nature?

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin

Can I intervene?  You should not be debating across the Chamber, putting questions to each other.  For the benefit of the House, address your commentary through the Speaker.

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

Apologies, Mr Principal Deputy Speaker, but this is the document, and I am merely asking the Member whether he has read it.  If he has read it, can he point out the substantial measures within it that can convince us that this is the right way to travel?

Photo of Jim Wells Jim Wells DUP

If the honourable Member wishes the Minister to come before the Committee to explain the document in detail, I am sure that he will, once again, make himself available.  But it is inevitable that there is going to be a period of transition between the old system that we have and the full implementation of TYC.  There will be pain, confusion and difficulties.  There is no way that you could carry out such a major transformation of a health service anywhere in the UK without that confusion, difficulty and pain, but there is complete transparency amongst the Department about how it will be implemented.

Some of what Mr McKinney is alleging has been caused by TYC has not.  It is simply that the demand for health service provision in Northern Ireland continues to grow, and we would have had many of the problems that he has outlined regardless of whether there was TYC.  The problem was that there was not going to be a long-term solution to dealing with them.  We have to face the reality:  we have a 1·9% real term growth in finance for health.  Depending on how you read it, demand is growing at between 5% and 6%.  That is the inevitability of the problems that have been stoked up in Northern Ireland's healthcare system over the past 20 or 30 years.  Therefore, there are pressures. 

The Member mentioned last week's hearing on the monitoring round.  I accept that the Department has put in a very large bid, but that reflects the increase in demand.  The fundamental difference between the present Minister and the previous Minister, Mr McGimpsey, is that the present Minister has been able to find £600 million of savings within the Health Department's budget to balance the books in the first three years.

The fundamental difficulty is that the amount of low-hanging fruit now left from which to make savings is, unfortunately, a very low figure.  As demand continues to increase, a bid has, quite rightly, been made for, I think, £160 million in the monitoring round, as the Minister is perfectly entitled to do.  While all of this has been going on, we tend to have a lot of gloom and doom from members of the party opposite, the public and the Stephen Nolans of this world about health.  Let us look at some of the figures.  The 12-hour waiting list, which, when the Minister came to power, stood at 4,489, has been cut by 80% in three years.  MRSA and clostridium difficile infections are down by 43% and 14% respectively since the Minister came to power.  Standardised death rates from heart attacks have been reduced from 79 per 1,000 of the population to 61 over the past four years.

Photo of Roy Beggs Roy Beggs UUP

The Member is reading out a lot of statistics.  Why are you not telling us about the waiting time for a first appointment or treatment?  It is easy to pick out one or two individual statistics from areas in which things are going well.  What is the global picture?  Does he accept that there are major difficulties?

Photo of Jim Wells Jim Wells DUP

If I had the time, it would not be one or two, because a litany of successes has occurred over the past three years.

The Member is simply indicating that demand, as we all accept, is rising dramatically.  However, in answer to his question, I say that, although demand is rising, on many of the outcomes by which you measure the success of a health service in any Western democracy, Northern Ireland is doing very well.  We have the highest survival rate for breast cancer, at 81%.  There are 25,330 clients who receive domiciliary care, a figure that is up by 1,800 since 2011.  In December 2013, 12,400 individuals were receiving residential care.  That is up significantly from 2011.

I could go on and on.  In a situation in which the budget is constrained, the number of consultants that we have is up by 160 since the Minister came to power.  That is a 12% increase.  The number of middle-grade doctors is up by 69.  That is an increase of 20%.  The number of nurses and midwives is up by 531.  That is a 4% rise.  Those are excellent statistics, given the —

Photo of Jim Wells Jim Wells DUP

— difficult financial situation we are in.  The Minister has been able to take a greatly restricted budget and make it go much further.  I am not saying that there are not complaints.

Photo of Jim Wells Jim Wells DUP

Yes.  One last chance.

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

On a fundamental point,  the Member talks about the employment of doctors.  If there was not stress in A&E, there would not be the need to employ those doctors, and there would not be that stress around the demand for them.  We still do not know what has caused the problem.  Those are symptoms, not the cause.  We need to rehearse further —

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin

The Member's time is up.

Photo of Maeve McLaughlin Maeve McLaughlin Sinn Féin

Go raibh maith agat, a Phríomh-LeasCheann Comhairle.  I speak in favour of the motion.  I acknowledge that the amendment does not detract in any way from the motion.  It is our collective responsibility to pay tribute to the dedication of the front line staff.  That goes without saying.

It is worth noting that we are debating the motion at the same time as the Human Rights Commission has announced an inquiry into emergency care.  It is very serious when a human rights commission feels that it must investigate the people seeking emergency care in our hospitals.  We need to stop and think about what that means.  It means that patients, many of whom are in desperate need of medical intervention, are being so mistreated in A&E that what happens to them there may be a breach of their human rights.  Such a scenario would be totally unacceptable in any state institution, but in hospitals, which should be dedicated centres of care, it is an utter disgrace.  However, it is nothing new.  As some Members said, the College of Emergency Medicine, trade unions, the College of Nursing, the College of GPs, front line staff, patients, families, politicians and the local media have been flagging the issue for over two years.  I suggest that what we see in our emergency departments is only the front window of a system that is failing. 

Let us look at the facts across the system, which the Minister will point out, and let us look at the public opinion of Transforming Your Care.  The system has simply staggered from one crisis to another.  We have seen a crisis with children in care and child sexual exploitation; a ban on blood donations from the gay community; court cases on adoption and on banning trade unions from appointments; a crisis in residential care; 15-minute care packages; crises in our emergency departments; concern about children's heart services; concerns about a magnetic resonance imaging (MRI) scanner; and serious adverse incidents resulting in deaths in the Royal hospital.  We now have the mess that is the payroll system for our front line staff. 

Whilst the shift left of the £83 million for Transforming Your Care is laudable — let us be very clear about that — it is clearly lacking any measurable outcome framework.  There needs to be a particular focus on health inequalities.  In short, what will be the impact of this shift left on, for example, residential care, domiciliary care, our emergency departments, access to GPs, access to connected health and health services staff?  It is unacceptable that that work was not developed alongside the proposals to move towards Transforming Your Care so that wider communities could have confidence in this system.  In its absence, as I stated, we have simply staggered from one crisis to the next. 

I want to make particular reference to the Put Patients First campaign.  The recent Patient and Client Council report on access to GPs found that 26·5% of people were dissatisfied with the access that they had.  The Royal College of General Practitioners has clearly warned that that situation is not going to get better and that it will, in fact, get worse.  On average, and I say this in the context of the wider TYC situation, GPs in the North of Ireland carries out around 12·4 million consultations a year.  According to the Health and Social Care Board, there has been a 7% rise in that activity over the past 12 months.

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin

Will the Member draw her remarks to a close?

Photo of Maeve McLaughlin Maeve McLaughlin Sinn Féin

Again, the College of GPs said that the situation will get worse.  My request to the Minister today is simple:  act now, because patient suffering and neglect are simply not an option.

Photo of Roy Beggs Roy Beggs UUP

I thank Mr McKinney for tabling the motion, and I indicate the Ulster Unionist Party's support for it.  As regards the amendment, I think that it is right that we should pay tribute to our hard-working staff in the health service.  However, regrettably, not enough is being done. 

Whilst there is some progress with 12-hour waiting times, I do not know why there should be any such waiting times.  They rarely exist anywhere else in the UK, and we should not find them acceptable here.  There are other measures on which we are significantly behind what the public would expect.

Photo of Jim Wells Jim Wells DUP

Will the Member give way?

Photo of Roy Beggs Roy Beggs UUP

I am just starting, if I may. 

The vision of Transforming Your Care was wonderful.  There was to be more preventative care; earlier intervention; patients would get the right care at the right time; treatment would happen sooner; and conditions would be less costly to treat, because they would be addressed earlier, but that is not what patients are seeing. 

We have seen a series of crises — I will use the word "crises" — in our emergency care, where emergency procedures have had to be enacted to bring in additional staff to deal with the excessive waiting times.  As we know, when there are excessive waiting times in our A&Es, there are huge risks.  There are huge pressures on staff, and there is a danger that a change in a patient's condition might not be spotted.  So it is essential that we have appropriate waiting times. 

Look at the type 1 waiting times provided by emergency care departments.  I notice that, in recent months — January, February and March of this year — in Altnagelvin, Antrim, the Royal, the Mater, and the Ulster hospitals, the proportion of patients treated within four hours did not move out of the 60% bracket, yet the target is 95%.  In fact, all of our hospitals are a long way from that target.  As I said earlier, excessive delays mean risks to patients.

A&E departments do not exist in isolation.  They operate within the rest of the hospital system.  It is also interesting to look at what is happening with other waiting times.  The waiting times for first appointment are also growing.  In March 2014, over 127,000 people were waiting for their first appointment.  That is a significant increase of 27% on the figure for March 2013.  For patients waiting more than 15 weeks, there is also a trend that gives rise to concern.  As of March 2014, some 19,000 patients had been waiting more than 15 weeks.  That is a 5·6% increase on the figure for March 2013 and another worrying sign.

Waiting times for inpatient treatment/admissions are also increasing.  There is a growing trend of patients waiting more than13 weeks, and that must be of concern to each of us who relies on the National Health Service.  Look at the patients waiting more than 26 weeks:  at the end of March 2014, there were 4,312 patients who had been waiting more than 26 weeks.  That is a 30% increase on the previous year.  All these trends are going in the wrong direction.  Where is Transforming Your Care?  Where is the transformation?

In the last financial year, over £100 million was given to the Department of Health in in-year monitoring — rightly, as far as I am concerned — to try to address some of the difficulties that it had been experiencing.  Recently, the Health Committee learned that the Department has bid for £160 million in the June monitoring, when the total given out last year was £80 million.  That also shows that there is a huge pressure on our health service.

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin

Will the Member please bring his remarks to a close?

Photo of Roy Beggs Roy Beggs UUP

It is important that we provide additional funds earlier and support GPs appropriately.  I notice that, on occasions, there have been reductions in funding to GPs in Northern Ireland.  Elsewhere, funding has been increasing, and patients have been treated at an earlier point of their condition and at a more appropriate time.

Photo of Kieran McCarthy Kieran McCarthy Alliance

On behalf of the Alliance Party, I support the motion.  On a stand-alone basis, the sentiments of the amendment would be worthy, particularly its tribute to the dedicated and hard-working staff.  It is a pity that the staff cannot all be paid the proper salary for which they have worked excellently for the health service.  However, the effect of the amendment, relative to the motion, is to deflect from serious concerns about the implementation of Transforming Your Care.  That said, Alliance continues to recognise that the status quo in certain sectors of the health service is not sustainable.  As such, we continue to support the broad thrust of Transforming Your Care while sharing the growing concerns about to how it is being delivered.

Transforming Your Care offers the potential for a much more strategic and integrated approach to the changing health needs of our population.  People are living longer, which is good, and the balance of types of conditions that will dominate is changing.  New diagnostics, better technologies, drugs and better procedures are becoming available.  As such, we need to be prepared to rationalise some existing services in order to create new opportunities to do things more efficiently, effectively and timely.

It is right that we try to make greater investment in public health to address health inequalities; focus more on prevention and early intervention; and try to shift towards supporting people in the community, as our community wishes.  We also need to shift more resources into mental health.  One in four people will experience a mental health condition at some stage in their life.  Despite that, Northern Ireland continues to make smaller investments per head in this area than other parts of the UK do.  Bamford must also be kept at the top of our mental health and learning disability agenda.

We all acknowledge and appreciate that there are huge financial pressures on the health service.  There is more demand for new drugs, new medicines etc and patients are absolutely entitled to avail themselves of those if and when required.  It often seems that these pressures are getting worse.  So, in many respects, change cannot come quickly enough if we are to make the most of what is essentially a fixed budget.

Concerns regarding the implementation of Transforming Your Care tend to focus on a number of particular angles.  One is scepticism over the extent to which resources will follow the shift in emphasis towards the provision of services in the community — I think of the reduction in community time and the community meals offered to our population.  Unless that happens and is transparent, the perception will be of cuts to existing acute services.

The implementation of proposals around the future of residential homes has already been subject to huge public anger, rage and debate, so much so that a rethink has been forced on the Minister.  Let us hope that the right decisions will now follow. 

Another concern is the extent to which staff have been engaged in and have bought into the reforms.  One group of health professionals with whom more work needs to be done is our GPs.  There are concerns over the capacity of our GPs to absorb further work on what is already a limited budget and a lower share of the overall health budget than in other parts of the UK.  GPs are expected to become the hub of the new integrated care partnerships.  However, that is not realistic without increased investment in GPs themselves and alternative channels to address existing and future caseloads. 

GP practices are reporting significant increases in demand, as are out-of-hours GP services.  In turn, increased concern is being expressed about the ability to access GP services and secure appointments.  Nevertheless, a properly funded GP service can be the lynchpin of a transformed health system; that is recognised by GP themselves.

The capacity to deliver a transformed system is hampered by ongoing —

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin 12:00 pm, 3rd June 2014

Will the Member begin to wind up his remarks?

Photo of Kieran McCarthy Kieran McCarthy Alliance

— struggles in A&E and wider problems.  We need much more regular and detailed stocktakes of the reform process.  If what has been planned in any aspect of Transforming Your Care is not working, let the Department pause and re-examine better ways before blindly following a wrong course.

Photo of Pam Cameron Pam Cameron DUP

I speak on the motion as a member of the Health Committee.  I believe that Transforming Your Care is still the best means of achieving what we want from our health service, namely a service that provides optimum care for those most in need within realistic timescales and budgets. 

It is perhaps because Transforming Your Care is such a radical overhaul of an ageing service that it is an open target when some aspects of it are perceived not to be working well or changing as quickly as they could or should.  That said, I am pleased that the Health Committee is seriously engaged in scrutinising every step of this plan to ensure that it is given every chance to bring real improvements to what is, after all, one of the most challenging and critical areas of public service and public safety.

Specifically on today's motion, I readily agree that more must be done to ensure that we have fewer such scenes that have arisen in A&E departments recently.  I am aware that, generally, waiting times came down over the winter compared to previous years.  However, that is of little or no comfort to the 1,000 or so people who endured 12-hour waits in what must have seemed to be completely inhumane conditions.    That figure for monthly 12-hour waits seems to have increased in the last few months of April and March, which is a worrying statistic.  I would be grateful if the Minister would indicate why he thinks that increase in happening.

On waiting times for GPs, I am grateful to the Royal College of General Practitioners (RCGP) for the information provided to me, in which it states that it believes that more funding is necessary to ensure that GPs are sought out as a first option and without delay, which, we all recognise, would take pressure off the A&Es.  I ask the Minister to look at the points raised by the RCGP to ensure that it is given the support it requires to deliver the services that are needed. 

The subject of waiting times will always have the potential to undermine confidence in the whole implementation of Transforming Your Care, but only when the full range of measures has been implemented will we be able to judge the scale of the improvement.  That is why I believe that now is not the right time to call for a review, but that is not the same as saying that the policy cannot be scrutinised.  That is why I welcome today's debate and the interest of the Health Committee.

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

Thank you.  Is the Member aware of the views of the new NHS English hospitals' Simon Stevens, who believes that community hospitals should now take the burden in the health service?  Does she have any view on how that impacts on TYC?

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin

The Member has an extra minute.

Photo of Pam Cameron Pam Cameron DUP

I thank the Member for his comments.

There are aspects of the policy that are already displaying positive results, moving forward in areas such as reablement, which is allowing older people to remain at home with proper support and equipment in place to not only ease some of the pressures on the hospital wards or homes but to improve their quality of life.  I recently met Friends of Muckamore, who met the Minister to discuss their concerns about a resettlement process for their friends and family members.  Although they acknowledged that it was the right thing to do, they had some concerns about the haste with which the change was being implemented.  To me that highlights the fact that, in many cases, it is not the end product or the overall aim of TYC that is in doubt; it is the scale of the change required and the challenges of delivering it from the ground.  People generally do not like change until they see and feel the benefits for themselves. 

I support the motion and the amendment.

Photo of Mickey Brady Mickey Brady Sinn Féin

I too rise to support the motion and the amendment.  First of all, like other Members, I commend health service staff for the tremendous work they do in very difficult circumstances.  I also commend carers, because the contribution that carers make to our health service is often forgotten.  They save the health service approximately £4 billion per year, and without them I think the health service would have collapsed a long time ago.

Transforming Your Care was first mooted and came out in December 2011.  I suppose there are two ways of looking at the 99 proposals.  One is that they were a way of reforming and improving the health service.  The other way of looking at it was as the privatisation of the health service.  The more cynical amongst us — which, of course, does not include me — might consider that privatisation was very much on the agenda. 

TYC's key commitments state that it presented us with:

"an unprecedented opportunity to transform our health and social care service. With transformation of such scale there will be difficult times ahead and challenging decisions to be made — it is important to remind ourselves this transformation is about people and services, rather than buildings."

I think people would have agreed with the shift left and the transfer of approximately £80 million from acute care to domiciliary care.  Mr Wells, who is no longer in his place, stated that the Minister had been before the Health Committee more than any other Minister has been before other Committees.  With respect, I think that is because he has had to.  So many issues have arisen that the Minister has had to come before the Committee and try to explain the situation.  Ultimately, the health service needs to be protected at all costs.  We need to continue a free service at the point of need.  That has to be protected above all.

Transforming Your Care, in terms of the residentials, fell at the first hurdle.  The trusts were queuing up to see who could close a residential first.  When I contacted the Southern Trust at the time to ask why it had issued a statement, I was told that it was in response to a request from 'The Nolan Show'.

It seems that 'The Nolan Show' now has an influence on health service policy, which seems to be a strange way, not to mention a bizarre one, of conducting that policy.

On 19 May, the Minister stated in the 'Belfast Telegraph':

"Since 2011, there are 130 more doctors, 640 more nurses and 320 more allied health professionals."

If that is the case, are they being used in the right way?  Obviously, waiting items are a problem, and accessing GPs is becoming an increasing problem.  With all the extra staff, we have to consider whether they are being used in the way that they should be.

Ultimately, the health service affects everybody from the young to the very old, and our ageing society — I think it is accepted that our elderly population will have doubled by 2020 — surely highlights the need for services to be improved and continued.

The Human Rights Commission's view of emergency care has been mentioned.  The latest crisis is with the payroll system, and staff are not being paid properly. This has been going on for months and does not seem to have been addressed.  I really do not understand that.  We are being told that it is to do with national insurance contributions, but those are dictated by mainframe computers in Britain.

The Minister really needs to look at the whole issue of Transforming Your Care.  He must either bring it back to the drawing board or look at ways of ensuring that it is carried out.  Representatives from the Royal College of Nursing were before the Committee very recently and what they said about Transforming Your Care sums it up.  They spoke of "a vision without action".  There are no measurable outcomes, and that needs to be addressed.  As I said, I will leave it to the Minister to answer those questions.

Photo of Gordon Dunne Gordon Dunne DUP

I too welcome the debate on Transforming Your Care.  It has set out proposals for change across the health and social care system in Northern Ireland and a road map to reshape services to ensure that systems deliver in a more sustainable way in the future.

We need to reinforce across the health and social care system the necessity for transformational change to respond to challenges for our increasing ageing population  and encourage and maximise involvement and leadership from healthcare professionals on the ground, so that they can deliver change from the bottom up at an accelerated pace.  The Health Committee has had extensive involvement with the whole process of Transforming Your Care and has worked extensively with John Compton, who, along with his team, came on a number of occasions and spent time with the Committee.

We have always been reminded that full implementation of the report will take from three to five years, depending, of course, on the financial resources being available.  It is important to keep it in mind that delivering change in health does not happen overnight.  It is also important that funding for the resources to manage change is put in place to implement such change and bring about what is needed.

Delivery of Transforming Your Care involves setting up integrated care partnerships, which includes our local GPs, our health and social care providers, hospital specialists and representatives of the voluntary and community sector.  Progress has been made in setting up the ICPs, and they are starting to deliver services more effectively and efficiently in local areas. 

There is a need for real change, especially to the role of the GPs.  On a recent visit to a GP surgery in Bangor with our Minister Edwin Poots, we saw the pressure that GPs are under and listened with interest to their real concerns.  They are working in outdated facilities, and I urge the Minister to look at providing a new health and well-being centre in Bangor.  It is long overdue.  Our GPs work in cramped conditions, and our patients wait in small areas for long times because of the lack of facilities.  We need better buildings, and we need better resources to deliver.  This is all part of Transforming Your Care.  If we are going to deliver in the community, we need to make sure that the proper buildings are in place.

The expectations of patients today are so high, and meeting these expectations is a real challenge.  To do that, you need the necessary resources, the necessary people and the necessary buildings.  It is difficult to manage large surgeries, with GP funding equating to 7·9% of the budget in 2012-13 while the rest of the UK receives 8·39% of the health service spending.  However, people in our constituencies all regularly talk of the problems of getting an appointment with their local GP.  These are real issues that need to be addressed and addressed effectively and efficiently through TYC.

Our emergency departments have been mentioned already, and we need to keep the focus on that.  They continue to be overloaded with patients, with 96,879 new patients going through the Royal Victoria last year and 88,500 going through the Ulster Hospital, which serves my constituency of North Down and is now almost as busy as the Royal.  This equates to 264 patients a day coming through the doors of the Royal Victoria.  That is a tremendous demand on resources.  This highlights dramatically the real challenges and pressures that exist in the health service.  It must be said clearly that the vast majority of these people get good care in the health service.  The vast majority get a good service and go home content.  The vast majority recognise that.

Photo of Gordon Dunne Gordon Dunne DUP

I believe that, when all is said and done, there are issues to be addressed, but it is important that the balance is put in place and that we recognise that the health service provides a good service to the vast majority of patients.

Photo of Sandra Overend Sandra Overend UUP

I welcome the opportunity to participate in today's health debate.  Indeed, the people of mid-Ulster have been very vocal in their concerns regarding health service provision, not least the Cookstown 040 group, which presented a petition here in this place against the closure of Westlands care home. 

The Ulster Unionist Party recognises that our health system is in need of reform.  Our population is ageing, demand on the health service is increasing and finances are diminishing.  It is clear that the current service delivery model is most likely unsustainable.  Indeed, the original Compton report said something similar.  However, it is light on specific details, and, in the absence of an implementation plan, even though it was created at the very heart of the health service, it is difficult to fully assess the evidence on which this overall review has been based and what it has set itself as achievable targets. 

The proposer of the motion raised this issue, and I certainly agree: without targets or an implementation plan, how will the success or failure of Transforming Your Care really be measured?  Nevertheless, what should have started as the opening of a root-and-branch review of the health service has now been mired in controversy and has resulted in the plummeting of morale across health staff and, hugely worryingly, has started to impact on the confidence that ordinary members of the public have in the National Health Service

There are a issues that now need to be addressed before Transforming Your Care can progress.  First is the money.  Again, the original Compton report suggested that service improvements through reorganisation of the delivery of services could have been delivered within the constraints of the current level of funding, supplemented by only £70 million of extra transitional funding.  The concept was diverting money from acute care to primary, community and social care services to treat patients sooner so that they would not need to go into hospital, but that has not happened.  In fact, it seems that the finances are up the left altogether, with the Minister bidding consistently at monitoring rounds.

Transforming Your Care was dealt another fatal blow when it was revealed that health trusts were seeking to close all their statutory residential care homes, rather than half, as was initially indicated in the original plan.  It was very unfortunate that the outworking of Transforming Your Care saw the untimely and badly managed announcement to each resident in Westlands care home that they would have to look for alternative accommodation in the short space of a few months.  That caused terrible anxiety to those residents, and the general health of many suffered as a result.  The play on the phrase "at least" was a manipulation by the trusts.  We expressed concerns at the original Transforming Your Care proposals to close half the statutory residential homes, and we continued to be concerned at the lack of alternatives that exist or are being developed for the growing elderly population, were the homes to close. 

Another contradictory target is the fact that the Health and Social Care Board believes that it can reduce the number of newly referred older people who need long-term domiciliary care by up to 45%.  Where is the care in the community?  The 'Transforming Your Care' document also specifically mentioned domiciliary care as a potential area for income generation.  Therefore, not only was the Health and Social Care Board eager to shut homes but it was keen to reduce the number of domiciliary packages being offered.  However, there is also a high chance that recipients will now begin to be charged for those services.  I would like to hear from the Minister on that issue and to hear a commitment that domiciliary packages will remain free.

The current failures in the health service affect not only the elderly in care homes, those attending A&E, those on waiting lists and all our constituents but the morale of the staff and their mental health and well-being.  In this period of Transforming Your Care, I urge the Minister to take more care with his health transformations.

Photo of John McCallister John McCallister UUP

There seems to be general agreement from most sections in the House that it was necessary to debate this and necessary for the Assembly to be seen to be getting some form of accountability from the Minister.  I would be surprised if we did not need to visit this subject again and again.

Listening to some of the debate, particularly the Minister's DUP colleagues, you would think that all was well in our health service and that, with a few tweaks needed at the edges, all was going according to plan.  I remind some of them that the original time frame that was talked about in TYC was about three years.  We are now two and a half years in to that, and it is being stretched up to five years.  While that is going on, all that anyone has been told and all that the people on the ground — Mrs Overend talked about all our constituents and all the users of the health service — feel is that the health service is at breaking point.  The staff who work there feel that there is a health service that is in crisis and a health service that is stretched to the limit.  That is what is going on on the ground, and that is the perception out there. 

Other Members mentioned a crisis in various parts of the health service, from our children's care system right through to our A&Es.  That is all against the backdrop of trying to change its make-up.  We have experienced that in my constituency and, indeed, in the Minister's constituency, with changes to the Downe Hospital and the Lagan Valley Hospital.  All that is set against the backdrop of rising demand.  When Mr McGimpsey was Minister of Health, we were warned about the difficulties in funding and the relentless rise in demand for our health service needs.  What was the DUP's reply?  It said, "There is no crisis.  There is enough money in the budget, and you just need to manage it better".  The coalition's decision at Westminster about ring-fencing at least health spending and the Barnett consequentials of that have helped the Minister and prevented complete meltdown in our health service. 

Mr Dunne talked about the road map that Transforming Your Care set out.  I have to say that the Minister seems to have pretty well got lost on wherever that road happens to be going, because people are not finding that things are improving.  They talk about needing more time and money.  They have had two and a half years of implementing it.  The Minister has been in office for three years, and his party colleague holds the purse strings.  According to the First Minister, if they needed more money, it was to be made available.  Why has that not come through?  Why are we looking at those crises in various parts of the system, even before full implementation?  This is moving — I have consistently warned about this — £83 million from acute to domiciliary care.  Most people agree with the idea, but I have consistently warned about the sheer management difficulties of moving that size of budget when the one that you are taking it from is in crisis — a deepening crisis. 

For the Minister even to go through with TYC, he is still looking at whether to close Daisy Hill Hospital or the Causeway Hospital.  Where is he making the changes at A&E units, where there is already a crisis?  I have asked the Minister this before:  does this not mean that his flagship policy of Transforming Your Care is in crisis itself?  Is it not unlikely that he can deliver any of the outcomes with the current policy framework?

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin

Will the Member bring his remarks to a close?

Photo of John McCallister John McCallister UUP

Thank you, Mr Principal Deputy Speaker.

Photo of Jim Allister Jim Allister Traditional Unionist Voice

The shine has certainly come off the glossy rhetoric of Transforming Your Care.  The public disillusionment and disappointment are accentuated by the fact that those now in charge were those who, when not in charge, made it sound so easy.  In the years that were spent vilifying Michael McGimpsey as Health Minister, the constant refrain was that there was not a money problem in the health service, just a management problem, and that, if he had been a better Minister and had had the skills that they thought they had, there would have been no problem whatsoever in the health service.  Of course, how different it has turned out to be.  There has not been even a by-the-way apology to Mr McGimpsey for their vilification of him over the years; rather, there has been an arrogant pretence: "Well, everything has changed.  It was totally unforeseeable".  They have, of course, just discovered that running the health service is not as easy a project as they seemed to think it was for so long. 

Transforming Your Care has been a great disappointment to many.  I am not totally surprised, because it seemed to me from the outset that it was over-optimistic in its view that you could simply devolve to the community so much that was being done in the health service and that you could have care packages that would remove the need for doctors, hospitals, emergency units, visits and everything else.

At the same time, we know that the care packages in the community are essentially meagre.  We all hear stories of the carers who have seven minutes in which to do an hour's work.  No wonder, then, that, when you build Transforming Your Care on such sand, it begins to sink in the manner in which it has.

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

I thank the Member for giving way.  Does he accept that the SDLP position on this has been to get transparency and accountability?  Does he therefore share my concern at learning that the board has been putting pressure on media organisations to ignore the negative stories that he is talking about and instead focus on positive stories in TYC and the health service?

Photo of Jim Allister Jim Allister Traditional Unionist Voice

I am not surprised to hear that, and I share that concern. 

Another issue in Transforming Your Care is that we were going to solve the problems in A&E departments without having any regard to the fact that we had guaranteed logjams in those departments by, over the past five years, reducing the number of beds in our hospitals by 16% — in some boards by 20%.  It does not take a lot of brain to work out that, if you reduce the number of beds in hospitals on that scale, you will inevitably produce a logjam at the access point of A&Es, and so it has turned out.

It is supposed to be some sort of creditable, laudable thing that fewer people now have to wait 12 hours: it is scandalous that anyone has to  wait 12 hours in an A&E department.  Yet, that is turned into some sort of virtue. There is nothing virtuous about the fact that our A&E departments regularly see waits of that length, with the serious adverse incidents that have been connected to it.

Then we take the situation relating to statutory residential homes.  The Minister has ducked and dived on this issue so many times, but the fundamental remains that it is his policy to destroy statutory residential homes.  He goes through the motions of consultation but refuses to take the elementary step of making the homes have a viable future by removing the moratorium on new admissions.  You cannot viably test the future of a home while denying access.  It is a means of bleeding the homes to death, and that is the Minister's policy.

The Minister was content to see 100% closure in the Northern Health and Social Care Trust until there was a public outcry.  He had advance knowledge that that was the plan.  I have it in Assembly answers: he had advance knowledge of the plan of the Northern Trust to shut 100% of its homes, and he had nothing to say until a 90-year-old lady, Mrs Faulkner, blew the whistle and set off a public outcry.  Then, he sought to pretend that that was not his policy and it was those unmanageable mandarins doing things that really were against his will.  Where does the buck stop in the health service?  It never seems to stop with the Minister.  Has there been a single issue in his tenure of office for which the Minister has taken responsibility?

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin 12:30 pm, 3rd June 2014

Could the Member bring his remarks to a close, please?

Photo of Jim Allister Jim Allister Traditional Unionist Voice

It seems not once.  It is always someone else's fault.  It was the Minister's fault when it was Michael McGimpsey, but it is never the Minister's fault now.  Strange that, isn't it?

The debate stood suspended.

The sitting was suspended at 12.32 pm.

On resuming (Mr Deputy Speaker [Mr Dallat] in the Chair) —