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Health and Social Care Review Statement

ORAL STATEMENT TO THE ASSEMBLY BY HEALTH MINISTER EDWIN POOTS – TUESDAY 13 DECEMBER 2011 – HEALTH AND SOCIAL CARE REVIEW

Mr Speaker, I wish to make a Statement to the Assembly today on the very important matter of the Review of Health and Social Care Services in Northern Ireland.
Health and Social Care is something which touches all of us in one way or another: every family in the Province interfaces with the sector.  I know that this report has been anxiously awaited by many.
I believe that this is the most important Statement that I have made - or am likely to make - to this House in respect of our Health and Social Care system.  It is something which is of relevance to every man, woman and child, and it is something in relation to which we as Members of the Executive and this Assembly are duty bound to act collectively and responsibly to ensure that we do the best we can with the resources available to us, to provide safe and effective Health and Social Care services for all the citizens of Northern Ireland.
The Report which has been distributed to Members today contains a compelling set of proposals for the future of Health and Social Care services in Northern Ireland.  At the outset I want to thank John Compton for leading the work, the independent panel members for their challenging and thoughtful contributions, the support team who have worked so hard to produce this Report in a very demanding timetable, and everyone who contributed comment or input through meetings, discussions and correspondence.   
Vision and Priorities
In setting my vision for the future of Health and Social Care services in Northern Ireland my over-riding concern is to drive up the quality of care for clients and patients, improve outcomes, and make sure that patients and clients of our services have the best possible experience in every aspect of their care.  A key aspect of that, of course, is to promote prevention and early intervention measures with the overarching objective of avoiding unnecessary hospital admissions in the first place.
I recognise fully the need for greater productivity from the resources available to us, particularly in these times of austerity, and it is in that context that I firmly believe that the greater involvement of frontline professionals in decision-making and service development is essential.  
Again, I have expressed from the outset my belief that local commissioning has a crucial and a powerful role to play in driving change and innovation, and that I want to see a shift in care currently carried out in hospitals into the community, with patients being treated in the right place, at the right time, by the right people.  
My priorities have also been clear.  We need to improve and protect health and well-being and reduce inequalities; through a focus on prevention and earlier intervention. I welcome the commitment that has been given to improving public health in the Executive’s draft Programme for Government.
We need to improve the quality of services and outcomes for patients, clients and carers. We need to be responsive to the modern world and develop more innovative, accessible and responsive services promoting choice and making more services available in the community.
We need to involve individuals, communities and the independent sector in the design, delivery and evaluation of Health and Social Care services through strengthened local commissioning.  We need to improve productivity by ensuring effective and efficient allocation and utilisation of all available resources, in line with priorities.
And we need to ensure that across all our services that the system looks after the most vulnerable in our society, and the children, the future for this country.  
To effect this, it is clear that we need to stop doing those things which don’t work – challenge out-of-date practices – and acknowledge that some of our services and their design are no longer fit for purpose.
I believe also that the voluntary and community sector has a very important role to play in providing services and improved service delivery, and we need to do all we can to remove barriers and blockages that may hinder the optimisation of that contribution.
The Case for Change
It was in the context of this vision and the need to secure safe and effective services for all parts of Northern Ireland, that I initiated a Review of Health and Social Care Services.  The purpose of the Review was to examine the future provision of services, including our acute hospital configuration; the development of primary healthcare services and social care; and the interface between sectors.  There were very real concerns that our system was not sustainable to continue to meet the priorities, with consequences for patient care and safety.  My intention was to set a new reform agenda, to give a stronger momentum for progress towards my vision and priorities for Health and Social Care services for Northern Ireland.
If the need for change wasn’t clear to some before the Review, I say to them to read the Review Report. It paints a compelling picture of the need to reform.  It makes clear, on the basis of evidence and analysis, that the full range of Health and Social Care services are unsustainable in their present form if we want to deliver the best outcomes for everyone, and maintain the highest levels of quality and safety in service provision.   In that respect, nothing has changed since I initiated this Review, except, if anything, the need for change is even starker and more critical.  
The evidence in the Report is clear.   As in other parts of the Western World we face a combination of: demographic change with a growing and ageing population; increased demand and over-reliance on hospital beds; advances in medicines and technology; and rising public expectations.  The projected demographic changes alone are striking.  Northern Ireland has a population of 1.8 million people.  It is the fastest growing population in the UK, and it is continuing to grow.  By 2020, the number of people over 75 years is expected to increase by 40% from that in 2009. The population of over 85 year olds is expected to increase by almost 20% by 2014, and by 58% by 2020. The system cannot stand still in the face of such change, particularly in the context of a very difficult financial and economic climate.   This Review is not and cannot be about cost-cutting; it is about quality, accessibility and safety of patient care.  However, as the financial situation tightens – as is obviously the case for all public services - there needs to be a radical shift in where and how that money is used. I will say more on that shortly.
In my Statement to this House on 27 September this year I said that I believed that this Assembly was committed to the three key principles of the NHS model of universal care, namely:
  • That it is generally free at the point of delivery;
  • Funded by taxation; and
  • With the promise that the best available cost-effective treatments or services will be provided.
I believe we can only continue to deliver on these principles, if those maintaining the Health Service as we know it support a radical programme of service change and reconfiguration and act strongly and corporately in the interests of all the people we serve, even if that means some difficult decisions.
I initiated this Review knowing that there would be difficult decisions to take in the context in which we are all operating.  However, I made it clear when I took the Health portfolio that I would not shy away from hard decisions where this meant a better service would be provided to the people of Northern Ireland.  Indeed, it would have been irresponsible of me not to do so in light of the very real issues facing our Health Service and the increasingly difficult economic context.  
The proposals in the Review Team’s Report “Transforming Your Care” represent a radical change to the way our Health and Social Care services are currently delivered.  It is change that is long overdue and change which I believe will be good and will provide a more citizen-focused, sustainable and effective Health Service.  The evidence collected by the Review Team through surveys speaks for itself.  The vast majority of our people feel that improvements are necessary.
Future Model for Health and Social Care
The Review has developed proposals on the shape of a future model for integrated Health and Social Care.    I believe that these proposals which I will outline provide the best model to allow us to continue to deliver on these core values of our Health Service.
On developing this model, the Review considered and assessed existing arrangements for delivery of Health and Social Care services here and looked at alternative models of delivery, and assessed these in the context of the specific requirements in Northern Ireland.  In line with my expressed wishes, the Review undertook an extensive programme of engagement with key stakeholders and the public in which more than 3,000 people contributed.  On the basis of this assessment, and taking account of the views of stakeholders, the Review concluded that there was an unassailable case for change.   I agree with that conclusion.
I believe the model which has been developed by the Review and which has been endorsed by the independent expert panel which I appointed to support the Review, is a sustainable model which will deliver a different, improved, citizen focused and safe service for us all.
The Review has identified opportunities that exist for doing things better.  We have an advantage over other parts of the UK in already having an integrated system of Health and Social Care.  The recommendations of the Review exploit that advantage to develop a new model of integrated Health and Social Care for the future.
The proposed future model puts the individual at the centre and not the institution, and supports the individual to care for themselves and make good health choices. For many, Health and Social Care services will be increasingly accessible in their local areas: this may not seem different, but it is the way in which health professionals work together to deliver those services which will be different.  They will work together in a much more integrated way to plan and deliver consistently high quality care for patients.  
It is proposed that Integrated Care Partnerships will be set up to join together the full range of Health and Social Care services in their area.   Patients will have to deal with fewer professionals and will be at the centre of decision-making about their treatment.  There will be a significant shift from provision of services in hospitals to provision of services in the community, in the GP surgery, closer to home, where it is safe and effective to do this.  Services will regard home as the hub, and be enabled to ensure that people can be cared for at home, including at the end of life. More support will also be available at home.
Where specialist hospital care is required it will be available, with patients being discharged into the care of local services as soon as their health and care needs permit.  The Review proposes that an urgent care model will be implemented in every area to provide 24/7 access to urgent care services.
Hospital Provision
One aspect of the Review, on which I know there will be significant interest, is in the current hospital provision and its future role.  In line with the basic objectives of the Review it is proposed that hospitals will work as a system with each facility contributing to the provision of a total service to its population.  
The approach to specifying a function for each hospital will be a bottom-up approach designed by local populations and professional practitioners within the parameters set by the Review.   The Review Team has commented that all current hospitals will have an integral role in the delivery of services to their localities.  They will be essential to contributing to what a local population requires from a hospital service. This would mean change in all sites over a five year period with the final functionality based on population need and the principles set out in the Report. The engagement at local level with the Local Commissioning Groups will inform the services provided in each area.  A key aspect of this approach is that clinical staff will be employed to work in a hospital system, and will be a resource for each population working as necessary across hospital services and facilities.
We have ten acute hospitals in Northern Ireland serving a population of 1.8 million.  This contrasts with other areas of the UK with similar-sized populations, for example in urban areas of Great Britain, which are supported by maybe fewer than half that number. Our aim must be the provision of resilient, sustainable and safe services. We need to have a focus on individuals, patient care and safety, not on buildings or institutions.  We should not be asking the public to accept services for which we cannot provide assurance that they will be safe, resilient and sustainable.   It is in that strategic context that the Review envisages that by 2016/17 the model of major acute hospitals for Northern Ireland’s more dispersed population would reconfigure to a more appropriate scale.  
Clearly this would mean changes at sites but the key test for any future service configuration has to be sustainability and resilience in clinical terms.  The Review recommends that each Local Commissioning Group should draw up specific proposals, and take account of the potential to provide services to the Republic of Ireland on the basis of the analyses in its report.  The Review Team concludes that it is only likely to be possible to provide resilient, sustainable major acute services on five to seven sites.  
That may well prove to be the case - I cannot say at this stage - but the test will be one of clinical sustainability and resilience, and patient safety.  It will be on that basis that we will be able to determine whether an acute hospital would be viable.  That test is something which is simply not optional in this new model of services, and something which in my view never should have been optional.
Older People
I understand that during the engagement on the Review with stakeholders, concerns for the future provision of services for older people were often raised. Older people are significant users of Health and Social Care services and almost a fifth of the budget is allocated to services for them. Our services need to adapt to the ageing population to ensure that we can provide an appropriate level of services into the future.    It is not surprising therefore that a significant section of the Report is devoted to improving services for older people, and for those with long-term conditions. The Report highlights that home should be the hub of care for older people, with more services provided at home and in the community. The Review makes a number of recommendations to encourage independence and avoid unnecessary hospital admissions;  the provision of a diverse choice of provision to meet their needs, and with appropriate regulation and safeguarding to ensure quality and protect the vulnerable.
Other Areas of Care
The Review contains a wide-ranging set of proposals across secondary, primary and community care, and as well as examining acute care, and services for older people, has also included proposals for improving services for those with a physical or learning disability; people using mental health services and maternity and child health; and family and child care.
Workforce   
The proposed changes would require staff to develop different skills and capacities.    Workforce planning and development is, and will be, a critical building block in ensuring that staff are appropriately trained and confident in their roles.  Our workforce planning needs to focus on demand signals from the local health economy and patients and clients rather than simply supply side inputs.    It needs to be linked to service planning, and underpinned by robust financial plans making it more robust and linked to patient needs.
Technology
The Review recognises the scope for greater use of technology as an enabler of the delivery of the new model of care.  This is something which resonates strongly with me and I believe there is considerable scope to exploit the opportunities which technology provides in the delivery of effective health care services. My Statement to the Assembly last week provided details on how we should develop  Connected Health to improve patient care, and also to help support the economy.
Resources
As I said earlier, this Review is not about cost-cutting. But in line with a shift of services closer to the home, it does envisage a significant shift in where funding is allocated, and it coincides with the greatest financial challenge the service has faced in many years. The days of increasing resources year-on-year are gone. The change in the model of delivery means that there will be a shift of care from hospital settings to the community, and there will be a shift in the resources as funds are reallocated in line with service delivery.  
It is envisaged that key changes would include:
  • more care delivered in the home;
  • changing care packages for people in nursing homes;
  • an increased role for the GP;
  • increased role of pharmacy in medicines management and prevention;
  • increased use of community and social care services to meet people’s needs; and
  • outreach of acute services into the community.
Taking account of these changes, it is envisaged that by 2014/15 the Review concludes that there would be a shift of funding of around 5%, or about £83 million, from the hospital services budget to other services. In this model there would be increases to Personal and Social Services of around £21 million, to Family Health Services and Primary Care of around £21 million and to Community Services of around £41 million by 2014/15. The figures provided by the Review Team are indicative, and clearly the proposed reallocations would be refined through detailed implementation planning work.
The changes will not be straightforward.  It will require fundamental changes to the way we deliver services and will require substantial re-training of staff.  It is in that context that the Review recommends that transitional funding of around £25 million; £25million; and £20 million will be required in each of the next three years respectively to enable the new model of service to be implemented.  The funding would help support Integrated Care Partnerships, service changes and a voluntary early release scheme.
It would be foolish of me, or indeed of any of us, to believe that change of this scale could be implemented without some cost.  But the costs identified are transitional - and time limited over three years.  After that there would be pay back in terms of the more effective and efficient use of the resources which have already been allocated to our health service.
Implementation
The Review Team have provided a wide-ranging set of proposals.  In the coming weeks and months they will need to be translated into more detailed plans setting out the specific changes to be taken forward.  It will also be necessary to develop engagement plans for these changes setting out how the changes will affect users, families and staff. The Review has recommended that implementation and stakeholder engagement plans are drawn up and published by June 2012. The plans will be based on population plans for each area drawn up by each of the Local Commissioning Groups with the HSC Trusts.  
Conclusion
Members, the proposals in this Report will mean different things to different people. That is to be expected.  These proposals have been developed in the context of the evidence that was presented in the course of this Review, and they provide a framework within which service reconfiguration can be taken forward.  
The challenge now is to ensure that we take forward the implementation of this Review for the health and well-being of the people of Northern Ireland.  This is the responsibility of all of us. I am determined that the Review Report does not sit on the shelf.  Whilst I carry the portfolio for Health - I have said before and I will say again - every local Minister is a Minister for Health.  It is not, nor should it be a sole responsibility for one Minister.  All of our constituents look to each and every one of us to deliver safe and effective Health and Social Care services.
The next steps will require leadership to be shown firstly by myself, but also by all of us as elected Members of this Assembly, and by the Health and Social Care sector. We need to chart, using the Review as the basis, a road map for sustainable, effective and efficient provision for Health and Social Care services into the future.
And so Members I look to you today to support me in my proposals for reforming and modernising our Health and Social care system, to ensure that we get the best from the resources available to us; to ensure that services are, where possible, brought closer to the patients home, and to ensure that patients are treated in the right place, at the right time, and by the right people.
I want to repeat my thanks again to John Compton and his Team, and to the five independent expert panel members, for producing this substantial piece of work in a demanding timescale. I would also like to pay tribute to every single person who gave off their time to contribute to this Review over the past few months.
I would ask Members, those in the Health and Social Care sector, and the public to read the Report carefully in the coming days and weeks. Change will need to be delivered through working together. It cannot be put off as the Review has set out clearly. We have had too many reviews in health and social care over recent years where little has happened. I am determined that we should not repeat the mistakes of the past and we need to move forward now if we are to have a sustainable future for our health and social care services.  
I commend this Statement to the House.
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