I am grateful for the opportunity to have this debate, albeit in the dying moments of this Parliament. I again raise the issue of health, having done so at the Northern Ireland Grand Committee during the draft Budget debate. However, as the Minister who then responded was not the Health Minister, I hope for better answers today, and I am delighted to see the Minister in her place.
Health service provision is a major concern for people in Northern Ireland, because it has the worst waiting lists in the United Kingdom. As I said in the Grand Committee, the Audit Office report into the Province's hospital waiting lists, which was published last year, confirmed that Northern Ireland has the worst waiting lists in the United Kingdom. The Ulster public face longer waits to access services than patients in England, Scotland or Wales.
The latest quarterly waiting list statistics for the Province indicate slight improvements in relation to in-patient lists, which have been deemed a departmental priority. However the number requiring an initial hospital out-patient appointment continues to rise, and has almost doubled since 1998 to 164,672. In England, 1.8 per cent. of the population are on waiting lists for treatment, but in Northern Ireland the comparative figure is 3 per cent.
In seeking to improve the in-patient list, the out-patient lists are suffering. We even have waiting lists to get on to waiting lists. Greater investment in the training and recruitment of health professionals is essential and I also want to see the prompt restructuring of our dozens of health bodies to streamline decision making and enhance accountability.
Although a proposed increase of 9 per cent., up to £3.3 billion, in the current expenditure of the Department of Health, Social Services and Public Safety may, on the surface, appear generous, health service inflation continues to grow at a much steeper rate. By 2007–08, the percentage rise that direct rule Ministers have committed themselves to will be less than 6 per cent. The positive public messages from Ministers do not equate with the demands and restrictions that they are placing on senior managers away from the media spotlight.
Differential access to private health care, as well as rurality, and factors related to ability to pay, reduce the differential spend per head on health and social services. Statistics indicate that, after assessing relative needs, to provide services at a comparative level would cost 17 per cent. more per person in Northern Ireland than in England. Different levels of private health care elevate that to 21 per cent. more to achieve the same level of service. However, the Barnett formula makes no allowance for differential need.
I want to make a particular point about the quality of Northern Ireland's hospital stock, which is very poor. There is also a greater backlog of maintenance compared with that in England. Many of our hospitals are of a substantial age and require redevelopment or replacement. Imaging and laboratory equipment that is more than 10 years old needs to be replaced to improve quality, effectiveness and staff productivity, and to reduce patient delays.
Although the cost of treating the victims of 35 years of terrorism soaked up hundreds of millions of pounds from the local health budget in past years, some imagine that, because violence has significantly reduced, those extra costs are no longer being incurred. Sadly, however, apart from the many new victims requiring attention, which do not make the headlines to the same extent, the health service still has to care for the victims of the past. For instance, bomb victims still require prosthetic limbs, and many still live with the psychological consequences of terrorism. And, of course, the trauma has not stopped. I unsuccessfully sought an estimate of the costs associated with caring for recent victims of the ongoing paramilitary beatings and shootings.
I am sure that the Minister has been briefed on the fact that the local press in Northern Ireland were this morning reporting the tragedy that is waiting to happen as ambulance cover falls to dangerous levels across the Province. Union officials report that large swathes of the Province were left without sufficient cover over Easter. On Easter Saturday, the entire city of Londonderry had no ambulance crew. Staff in other divisions had to scramble around to provide personnel.
On the same night, there was no vehicle to cover the night shift in Strabane, County Tyrone, so the crew were forced to drive a minibus the fifteen miles to Altnagelvin hospital to find an ambulance. Staff from Enniskillen were sent to Londonderry to cover an area with which they were unfamiliar. A patient was transferred in a day-care vehicle in order to free an emergency ambulance. Last Saturday night in East Antrim there was only one crew covering Whiteabbey, Rathcoole and Carrick, but there should have been at least two. The depot in Downpatrick regularly takes ambulances off the road because staff are unavailable.
A major overhaul of ambulance staffing is required to ensure that each depot has the appropriate number of personnel. I trust that the Minister will address that most critical matter. I fear to contemplate what might happen were a major incident to occur while we are reliant on an unsatisfactory skeleton service.
I hope that the Minister will deal also with the question of chemotherapy drugs, which illustrates the problem of rising costs in Northern Ireland. A new regional cancer centre will open its doors at Belfast City hospital early in 2006. However, hospitals, including Belfast City, recently had to produce emergency contingency plans because of multi-million pound shortfalls. One area identified for savings was that of cancer drugs. Thankfully, an injection of cash averted the withdrawal of those vital medications, but it highlights the difficulties that we face.
Diagnosing cancer earlier, and keeping more people alive, means treating cancer as a chronic disease, with third and fourth-line drugs often being required. Experience in other countries indicates that the rapid growth in the use of chemotherapy and haematology drug-based therapies will continue. Cancer drugs are also being used more frequently for symptom control.
Chemotherapy drug costs at Belfast City hospital rose by about £3 million last year, and £1.4 million had to be found just to maintain the services currently being provided. More cancer patients are being diagnosed and treated in the Province every year. Day case and out-patient attendances at the City hospital were up by a staggering 30 per cent. in one year. We are building a new cancer centre of excellence and attempting to attract world leaders in the field to come and work in the Province, and funding is proving problematic. Cancer sufferers should be entitled to the very best treatments. It is dreadful to think that life-saving treatments may not be available to those in the greatest need because the local health service cannot afford them.
Haematology patients also have concerns. A constituent of mine, Anne Aitchison, a lovely lady, has been campaigning for many years for improved local health services. In particular, she has been promoting the provision of coagulometers. Not only would those devices benefit patients, but they would save the local health service money and time. Patients currently face a trek to the hospital warfarin clinic, and they often have to wait several hours for the results of an invasive blood test before seeing a doctor.
Regular hospital attendance can swallow up a significant part of the lives of patients whose blood needs to be checked every week; it can result in the loss of a whole day from work or education. Massive resources are used in warfarin clinics. Doctors and nurses are needed to conduct expensive blood tests, and ambulances are sometimes required to collect patients, whereas the new coagulometers can be used by patients in their own homes, and involve only a small pinprick, much like blood glucose monitoring. It is much easier to use them, especially where elderly and confused patients are concerned, than to take intravenous blood samples.
In Germany, hand-held coagulometers have been provided for approximately 100,000 patients, but in Northern Ireland, where some 1.5 per cent. of the population requires oral anticoagulation therapy, they can be acquired only by private means or through fundraising. The use of coagulometers empowers patients to take greater responsibility for their care, something that the Government have been keen to encourage. They should be made more widely available through the national health service, and I hope that the Minister will consider favourably the ongoing pleas of warfarin patients.
My party has been considering general improvements that could be made to the health service in Northern Ireland, and we aim to publish proposals in a policy document shortly. There is little direct responsibility or accountability in any tier of health care management in the Province. We need transparency in spending and detailed audit trails. In recent years, a huge amount of money has been thrown at problems, and it has disappeared without trace. There must be targeted strategies with clear responsibility and accountability. Under the 1998 Belfast agreement, the Sinn Fein Health Minister acted as she pleased, regardless of the views of the Health Committee, the Assembly or her Executive colleagues. If ever a new Executive is created, there must be more opportunities for scrutiny, and Ministers must be prevented from acting unilaterally.
The Minister will know that our health care staff perform complicated procedures in pressurised environments. However, they often feel unappreciated, and are suffering a morale problem. That must change if the national health service is to retain the cream of the health professionals, who are frustrated that they cannot deliver the optimum service. Maximum use should be made of highly trained staff. It is inappropriate for specialists to perform tasks that could be done by others who are less qualified.
Despite the new general medical services contract, general practitioners struggling to find beds for their patients feel undervalued, overburdened and unsupported. They do not have enough time to spend with patients, and that sometimes results in inappropriate referrals to already crowded emergency departments. Approximately 90 per cent. of national health service patients are dealt with in primary care. That speciality must not be allowed to suffer on account of acute care pressures.
The DUP wants to decrease administrative bureaucracy, not just to save money but also to streamline decision making and create a more efficient system. We advocate that, as a result of the ongoing review of public administration, the number of boards and trusts should be slashed to leave no more than half a dozen authorities. A single body should oversee regional services, and money must be channelled to front-line services rather than being frittered away in administrative costs. However, it is essential that the expertise developed over many years should not be lost as a result of such rationalisation. A co-ordinated health care network must develop, and replication of services must cease.
Significant investment is required in order to improve efficiency in the service. We advocate increased funding, in excess of the Barnett formula, to ensure that those in the Province receive a standard of care that not only matches the best found elsewhere in the United Kingdom, but relates to need. We are talking not just about providing extra beds but about finding more staff, which will lead to an improvement in hospital services. We urge the provision of more radiographers and extra physiotherapists, occupational therapists and speech therapists, and we would like more doctors and nursing staff to be trained locally.
We should invest in areas in which improvements are most likely to result in reduced spending in future. We must think holistically about the impact of ill health on our society; that includes the costs of long-term care, benefits and absence from work. There are insufficient residential, domiciliary and nursing home places and, of those that exist, a large proportion are nursing home places, which are the most expensive. At any one time in the Province, there are 400 individuals blocking beds in Northern Ireland hospitals because the resources do not exist in the community to support them. That contributes to access difficulties at the opposite end of the hospital admission cycle. A concerted effort must be made to remove that persistent brake on the system.
We have to plan for our ageing population. People are living longer now, which means a growing demand for health care among the elderly. More patients require treatment for conditions such as fractured hips, dementia and strokes. Our health service has been consistently overstretched for a number of years. That cannot continue indefinitely without repercussions. Rapid patient turnover contributes to rising levels of health care-acquired infections such as MRSA. Patients, including the infirm or disabled, and particularly their relatives, are fearful of their even going into hospital in case they come out in a worse condition than when they went in. That is totally unacceptable in today's age.
Aside from the threat to life, those acquired infections have massive resource implications for the health service. The Government must clearly address that issue rapidly. The capacity levels at which our hospitals consistently operate also raise questions about how we could cope if there was a major outbreak of influenza or an unpredicted pandemic. We must ensure that we have and maintain a sufficient stockpile of antiviral drugs for such an eventuality. I would be interested to hear from the Minister what level of preparedness exists in Northern Ireland.
I have previously expressed concerns regarding the contracting out of cleaning services at local hospitals. There must be appropriate regulation centrally of standards of cleanliness in each trust.
Individuals should be encouraged to adopt greater personal responsibility for healthy living, particularly in relation to diet and exercise. There still needs to be greater awareness of the danger and effects of binge drinking, smoking and illicit drug use. I strongly support a comprehensive ban on smoking in public places, which should be introduced with immediate effect. Another issue that concerns the general public is the difficulty patients and their relatives have in accessing details about their condition or treatment. Those on waiting lists should be provided with the best possible indication of when they are likely to be called for treatment. Uncertainly only exacerbates their ill health. Greater health service transparency would be welcomed.
Conditions such as diabetes are rapidly becoming more common. Many such illnesses do not attract media headlines, but lead to lifelong suffering for those affected. The long-term costs are very high when people with those conditions deteriorate. I contend that early and best treatment is not only best for the patient but for our economy. Equally, new anti-TNF medications have the potential to transform the lives of the most severe sufferers of rheumatoid arthritis. Such patients could return to or remain in work if more of those drugs were funded. Let us ensure that that medication is distributed where needed, rather than on a postcode basis.
Mental health and learning disabilities have traditionally been underfunded. The child and adolescent psychiatry service in the Province requires major improvement, particularly given the large number of suicides among young people in Northern Ireland.
This Government maintain that, alongside education, health is one of their greatest priorities. The public in Northern Ireland have not seen the improvements over the past four years that they would like to have seen. It is to be hoped that whoever has responsibility for the Province's health after the election will do everything that they can to ensure that the people of Armagh, Antrim and Ards are treated exactly the same as those anywhere else in England, Scotland or Wales.
I am grateful to Mrs. Robinson for raising the issue of health service funds in Northern Ireland. I apologise for not being available to answer her questions in the Committee. I am sure that she understands that I always make a great effort to answer the many questions that she asks, and am happy to do so. I hope that my colleagues were able to deal with her queries.
The hon. Lady is right to say that, like other health services, health and personal social services in Northern Ireland has had to cope with the combined effect of increasing demands, increased public expectations and the high cost of new technologies. Given the pressures, the service has responded well to those demands, and I praise the staff. On each visit I have made to every hospital, care home and other institution in the health service, I have had nothing but praise and admiration for the work the staff do, sometimes under pressures that we are doing our best to alleviate but which are not acceptable. I hold the staff in the highest regard for the work that they do.
Demand for health and personal social services varies across the UK, but we have to recognise that there are high levels of need in Northern Ireland. To start with, it concerns me that general health is worse across Northern Ireland than it is in England. The morbidity and mortality rates for major disease risks are among the worst in Europe. There is a high level of severe disabilities and I have no doubt that 30 years of conflict—euphemistically called the troubles—has had an impact on people's mental health. That is sometimes not recognised until it manifests itself in some physical way, but it is a pressure that must be recognised.
I am also concerned that injuries from road traffic collisions in Northern Ireland are higher than anywhere else in the whole of the UK, which creates additional pressure on hospital admissions. The way to tackle that is by reducing the number of collisions that take place, reducing the number of people who are killed or seriously injured. The hon. Lady will be aware of the efforts made by the Department of the Environment, and as the Minister responsible for road safety I have made a particular commitment to reduce those numbers. There have been some successes but not enough notice has been taken of the messages we have put forward.
In all those areas demands will continue to increase. There have been technological developments and medical advances but Northern Ireland will also be affected by the growth in the elderly population. There is a projected growth of 52 per cent. over the next 20 years compared with 41 per cent. in the UK as a whole.
Having outlined where there are difficulties, which the hon. Lady has done as well, it is right to outline some of the achievements. We should look particularly at the areas of improving health and reducing waiting times. I am always loth to talk just about reducing waiting lists; I do not think that people care much how many other people are on the list. It is a question of how long it takes someone to get the treatment they need.
I want to look at what is being achieved. I am sorry that the hon. Lady said that money has been wasted and that people have seen no response. I dispute that. Although there are enormous pressures, a lot has been achieved and staff work particularly hard to see the results of the investment put in. I can tell her that since 1997–98 the volume of hospital in-patient and day case activity has increased by 17.5 per cent. More people are being treated.
Community care packages are particularly relevant when we refer to bed blocking. That is not a phrase I like to use; I think delayed discharge is more appropriate. The person in that bed would probably welcome the opportunity to be moved from hospital and have a proper care package. The phrase "bed blocking" can be detrimental to them. The number of community care packages increased by 36 per cent. between March 1998 and March 2004. The average length of stay in hospital has reduced by 10 per cent., allowing better use of hospital beds, and the throughput per bed in the acute hospital sector has increased by 17 per cent. Again, more people are being treated.
Comparing 1997–98, when we first came into government, with 2003–04, the day case rate has increased from 25.5 per cent. to 31.3 per cent. That means we have got people through hospital more quickly to allow others to have operations. In relation to general health issues, between 1998 and 2002, life expectancy has increased in Northern Ireland by 1.3 years for males and 0.9 years for females.
The hon. Lady did not mention oral health in her comments, but she has put questions to me on that before, and I know that she has interests in that area. Oral health is still very bad, but it has improved significantly for both adults and children. From 1979 to 1998, the proportion of adults without any natural teeth fell from 33 per cent. to 12 per cent. and over the past 20 years, the average number of decayed teeth per 12-year-old child has dropped from 4.8 to 2.7. Looking at the health cost weighted activity index, we see an increase in health output. People are getting generally healthier; we are moving in the right direction.
Among the key reasons have been the financial priority given to the needs of health and personal social services in recent years, as well as the financial stability of boards and trusts, and the ways in which they have operated. The hon. Lady said that she wanted the treatment of Northern Ireland to approach closer to equality with England. As to outcomes, I agree; but I do not think that the hon. Lady would agree about that in relation to financing, because current Treasury figures show that expenditure per head of population is 12 per cent. higher in Northern Ireland than in England.
Health needs remain Northern Ireland's top priority when resources are allocated across Departments. That is reflected in the increase in spending of nearly 25 per cent. in the past three years, and the planned growth of more than 23 per cent. for the next three years. That planned increase over the next three years can be compared with other Northern Ireland Departments. In health and personal social services, the increase will be 9.5 per cent., 6.8 per cent. and 5.3 per cent., and across other Departments the figures will be 6.6 per cent., 4.9 per cent. and 4.3 per cent. The financial uplifts will be £290 million, £230 million and £188 million.
Much of the increased funding will be required to meet the cost of reforming the pay and conditions of practically all staff, under "Agenda for Change", the general medical services contract and the consultants' contract. Those pay deals are significantly higher than the cost of inflation, because they are intended not only to make the health service more competitive in the job market and properly to reward the staff, who make a tremendous contribution, but to facilitate increased flexibility in working patterns and the redesign of existing jobs. The result is improvements in quantity and quality of work. Our biggest asset, in health and personal social services, is the staff we employ. I make no apologies for the fact that the increases are going to the staff, who are the people who make the difference.
The increases in funding also bring several new developments into play, including the cancer centre that was mentioned, the acquired brain injury unit, the medium secure unit, redevelopments at the Ulster hospital and the Mater advanced wards. There will be additional capacity at Antrim hospital and—I am pleased that the hon. Lady mentioned this point—the regional centre for adolescent psychiatric inpatients. The hon. Lady will know what heavy pressure there has been on that service, and I have, with officials, been considering ways to meet the very heavy demands, and to adopt perhaps broader and more holistic ways of thinking about the pressures on young people, which in some cases lead them to feel that the only way forward is to make an attempt on their life. We want to improve services and think more holistically about the range of services available to young people.
Specific resources will also be ring-fenced for a range of specific service developments, including the improvement of foster care, the introduction of improved child protection arrangements, renal, cancer and cardiology services, support for carers, further enhancement for ambulance services, which, we recognise, is needed, and additional medical students; the last point is relevant to the issue of staff that has already been raised.
The hon. Lady specified the need for capital investment. I do not know if she is aware of the moneys that are being made available through the Budget statement; however, resources totalling nearly £600 million were made available for capital developments in health, social services and public safety, for the incoming budget period 2005 to 2008. That will continue the major hospital modernisation programme set out in "Developing Better Services", alongside a range of continuing regional and local developments, including primary and community care, learning disability and residential child care. Further phases of development programmes at the Royal Victoria, Ulster and Altnagelvin sites will continue, and planning and enabling work for new hospital modernisation schemes will be taken forward; that will include the new south-west hospital, redevelopment at Craigavon hospital complex and expansion at Antrim.
On examining the figures and the spending increase I do not find it acceptable that spending that is 12 per cent. higher than spending in England does not give good or better quality outcomes for patients. I do not think that it is enough to say that Northern Ireland experiences greater pressures and that the only answer is to spend more; we are spending more. Clearly something must be done about how we spend the money more wisely. I want every penny to count, in the interest of patients. We need to undertake a critical review of the matter.
The hon. Lady will be aware of the Appleby report. We have asked Professor Appleby of the King's Fund to conduct a review of health and social care provision across Northern Ireland. Similar reviews have been carried out in England and in Wales.
The review will consider how the money is spent. It may have other terms of reference, but I am confident that it will highlight the ways in which we can use the money that we have more effectively and, if additional spending is needed, how we can use that most effectively. We need to consider current demand in relation to the funding available and decide whether we are doing the best for patients with the money available.
The hon. Lady also mentioned the structures of the health and social services, which sometimes strike me as overly bureaucratic. A point was made about transparency. The staff do the best that they can but the structures hamper them in many ways.
The review of public administration is open for consultation and addresses many of the points that have been made by ensuring that we have a structure that is commensurate with the work that is to be done and that does not overburden staff, officials and others who are trying to provide a better health service.
I hope that those two points will address the hon. Lady's questions and will show that they are being taken very seriously. We have every intention of ensuring as quickly as possible that we have the best possible structures to secure the best possible outcome.
As far as modernisation, reform and efficiency are concerned, we want the same targets for health and social services as we do for other parts of the public sector. The challenge is not simply to spend more but to spend more wisely. What is most important is the outcome for patients. Unless we achieve the necessary outcomes, we are not doing them the service that they need with the money that we have available.
The hon. Lady asked about pandemic preparations. I assure her that the Department has done a considerable amount of planning for some time and continues to do so. A supply of antiviral drugs has been obtained and currently amounts to more than 4 million, which is equivalent to the number of antiviral drugs available in the other parts of the UK.
The hon. Lady also mentioned a smoking ban, which is close to my heart. The consultation on that closed on
I do, however, urge a word of caution. There is a view in some quarters that a smoking ban solves all health problems caused by smoking. It does not. Even if we had a smoking ban, we would still need to pursue our current strategy: the tobacco action plan. Such a ban is all very well for people who smoke in public places, but many people smoke in their own homes and with children around. Smoking must therefore still be addressed, regardless of any smoking ban.
I can tell the hon. Lady that £400,000 of additional funding is being provided in the 2004–05 Budget for the ambulance service. The same amount will be provided in the following Budget.
Staffing issues are serious and have been a problem for some time. The amount of additional support that is being given through the "Agenda for Change" to provide better support, salaries and training for staff does make a difference. I am optimistic that that addresses the problem, although I do not underestimate the size of the problem. Work has been done through the "Agenda for Change" to address the sorts of problems to which hon. Members referred.
More places are also being provided for medical students. Some 81 places have been created at Queen's medical school this autumn, which is a 50 per cent. increase in the number of medical students in only two years. The hon. Lady also mentioned specialist drugs, and I assure her that additional funding is being found to try to address the increasing needs.
I hope that our discussion of a range of issues has shown that much planning has been done to ensure that we meet the demands of the health service in the 21st century, and that we are doing our very best within the Budget to meet the increasing demands that have been placed on us. We must decide whether we are spending our money wisely enough, whether we can do more and whether we can do some things better. All those questions are constantly under review to give us the best possible health service.