Response to Proposals for Health and Social Services reform in Northern Ireland

Our reference: Cons - 903
May 2008

Response to Proposals for Health and Social Services reform in Northern Ireland

1.0 Background to NICVA

1.1 NICVA (the Northern Ireland Council for Voluntary Action) is the umbrella body for the voluntary and community sector in Northern Ireland. It provides over 1,000 members with information, advice, training and support services on a wide range of issues, together with representation for the sector as a whole.

1.2 NICVA works to achieve progressive social change, based on equality and equity, working through a community development approach, to empower local communities to pursue their own needs and agendas.

2.0 General comments

2.1 NICVA welcomes the opportunity to respond to this consultation. The process of the Review of Public Administration has been a long and uncertain one and we welcome a definitive set of proposals from a local health minister. We, together with CDHN, have held a series of six consultation events across Northern Ireland and the input from these has informed our response.

2.2 What NICVA is most keen to see from health and social services is a healthier population with a better quality of life. Since, according to the King’s Fund, 80% of illness is preventable, we have long advocated a switch from an ‘illness service’ to a policy environment that promotes health and wellbeing, enables the maintenance of good health and tackles health inequalities.

Whether structural changes will make any difference to outcomes is a moot point at this juncture. It should be ensured, at the very least, that disruptive change and new structures should not make the situation any worse. If a shift towards proactively maintaining health could genuinely take place under the proposed new system it would be a major achievement. However, this process must be about improved outcomes and reducing health inequalities. These are not often mentioned in the consultation document, so it is unclear where responsibility would lie.

2.3 Public services were conceived in a world of deference, whereas we now live in a world of autonomy where the benefits of active and informed involvement are clear. Structural changes in modern services such as health must take account of these wider societal changes. NICVA is particularly keen to see engagement at all levels of the new structures. We believe that the Wanless ‘fully engaged’ scenario is a desirable aim for Northern Ireland and recognise that structures alone cannot deliver this.

We welcome the increased democratic involvement proposed and would stress that this should be as well as, rather than instead of, widespread engagement, including the voluntary and community sector. Local political involvement is necessary but not sufficient to ensure real engagement. The consultation document states that: “Patients, clients and carers must be given the opportunity to voice their concerns and be sure that they are being listened to – dignity, respect, equality and fairness for patients, relatives and staff are at the core of the health and social care system.”

While a commitment to listen to the views of patients, clients and carers is welcome, we would also like to see some stronger references to actually involving them more proactively in the planning, commissioning and delivery of services. There is also no reference here to a desire to involve wider communities in planning and delivering services. This is important because the wider citizenry, not just those involved with the health system already due to ill health, has a vital role to play in improving health outcomes and tackling health inequalities.

2.4 We are disappointed to note that citizens and service users are referred to in the consultation document as ‘customers’ and ‘consumers’. The instrumental, transactional language of consumption misrepresents the relationships citizens have with public services, which is not directly comparable to the relationships they have as customers in the market. Research by the Open University (Clarke and Newman, 2005) with health service users found that only 6% viewed themselves as consumers/customers, most preferring terms denoting belonging such as service user, or member of the public.

2.5 Voluntary and community organisations are substantial providers of health and social care services in Northern Ireland, particularly to hard to reach and vulnerable groups. It is not clear exactly how these organisations will fit in to the structures. If they are service providers, it is unclear whether they will sub-contract from trusts, as many already do, or be directly commissioned. We appreciate that organisations providing services might be perceived as having a conflict of interest if they are also involved on commissioning bodies, however, it would be no more a conflict of interest than that of statutory service providers involved in the system. From the sector’s perspective, it is also important that during change processes there should be minimal disruption to those to whom they provide services. With some health bodies passing on their 3% efficiency savings as funding cuts to voluntary and community organisations, service provision is already under strain. The added tension of structural upheaval, staff changes and new relationships having to be established should not be allowed to impact on services.

2.6 While we welcome local commissioning, although it will in practice be hardly more local than current Boards, the new structures do need to safeguard the interests of dispersed populations who may not be well represented at local level. Thematic services such as mental health, learning disability and eating disorders will still require careful regional level planning. For example the health structures previously proposed included recognition of the need to plan holistically for children’s services. This is not mentioned anywhere in the proposed new structures.

2.7 The new structures and language in the consultation document seem to denote a very medical model of health. Current evidence suggests that wider determinants of health must be considered at the centre of health and social care provision.

2.8 In our consultations, voluntary and community organisations stressed the need to preserve what works well in the current structures and to share good practice throughout the system. Current partnerships such as Investing for Health and Health Action Zones are often working very well and have formed effective relationships and trust. Different aspects of the current system are working in different ways across the region and often the centre is unaware of good practice and effectiveness. It would be extremely undesirable if these were to be destroyed and replaced with something not substantially better.

2.9 Community development approaches need to be seen as a horizontal strand running throughout health structures. If a community development approach is not championed, and if existing good practice is lost in the proposed changes, it will inevitably remain tokenistic at commissioning and trust level.

2.10 The proposed new structures must ensure that long-term goals are not sacrificed to shorter-term agendas.

2.11 Links must be made to the community planning structures proposed under the Review of Public Administration. Health and wellbeing ought to be at the core of community planning outcomes and the new structures must have the ability to integrate with this new mechanism for priority setting and community involvement.

3.0 Regional Health and Social Care Board

3.1 NICVA welcomes the principles which are to underpin the Board’s constitution. It is unclear in the consultation document how users, carers and communities will be involved in the work of the Board or how ‘other officers’ might be appointed to it. We assume a public appointments process will be used. If the new structures are to be truly inclusive and involve people in the planning and delivering of services, then real engagement at Board level is important.

3.2 We welcome the Board’s role in driving forward change and accounting for outcomes in better heath and social care. In terms of its financial role, we are uncertain what ‘incentives and sanctions’ might mean in achieving best return on investment. Aligning resource allocation with performance would need to employ an extremely sophisticated system for disaggregating causality and would need to ensure that staff are working within well designed systems. Otherwise financial sanctions might be imposed where dysfunctional systems are to blame and not individual performance.

3.3 As mentioned above, we would be opposed to the funding relationships between the Department and strategic voluntary and community organisations being shifted to the new Board.

3.4 While welcoming the emphasis on prevention, early intervention and care management at the heart of the commissioning arrangements, voluntary and community organisations are also concerned that regional aspects of commissioning should be dealt with at a regional level so that the needs of dispersed populations are safeguarded.

3.5 It is not clear from the proposals exactly what decisions would be taken at what level as regards commissioning or what level of planning and performance management would lie with the Board and what with LCGs. It is also unclear whether the statutory Children’s Services Planning function would lie with the Board.

4.0 Local Commissioning Groups

4.1 NICVA members raised questions around use of the word ‘local’ in the proposed commissioning arrangements. It is not obvious how, after great upheaval, five LCGs will be substantially different to the existing four Boards. As there is no level proposed below these LCGs, there is some concern as to how close they will really be to need on the ground.

4.2 The proposals note that LCGs should have a “good spread of expertise with a bias, in terms of numbers, favouring those with close (preferably daily) contact with the local population but they should also not be too cumbersome”. Beyond this there is no rationale given for the suggested composition of LCGs.

4.3 Previously, the local commissioning bodies were to have two lay members, but an additional four local councillors have now been added in. While the involvement of locally elected representatives is welcome, there are important issues around how these representatives will be selected. It is reasonable to expect that all of the representatives on LCGs should have some background in health and wellbeing and this should apply to local councillors as well. We would therefore recommend that councillors go through a selection process to ensure that they have the necessary expertise. Our members have expressed some concern about the impact of party politics upon health decisions, where conflicts with party policy may arise, and the necessity of making unpopular decisions.

4.4 A background in health and wellbeing does not have to mean a clinical background. During the last round of appointments to LCGs the criteria stated that the lay representatives should have clinical experience. NICVA objected strongly to this at the time and wants to see a wider definition of health and wellbeing used to select both the lay and elected representatives for the new groups. We would also question the need to have four GPs on each Group.

4.5 Again, it is unclear who will have the final say on commissioning decisions – the LCGs or the RHSCB of which they are a part.

4.6 NICVA would recommend the maximum amount of co-terminosity in all the decisions surrounding the Review of Public Administration. There is clearly a balance to be struck between fit with the new council boundaries and additional numbers of structures which might be less cost-effective and lead to fears of a postcode lottery system in commissioning across Northern Ireland.

4.7 We welcome the continuing development of the Stakeholder Network if it is to play a meaningful role in designing and delivering services.

5.0 Department of Health, Social Services and Public Safety

5.1 NICVA welcomes the proposed streamlining of the Department. However, it is unclear how DHSSPS will relate to the new Regional Health and Social Care Board in practical terms; for example if the Department retains responsibility for cross cutting strategies, how will they inform the work of the RHSCB? Also, if the Department will take forward cross-cutting functions which are focused on ‘longer-term health and wellbeing outcomes’, what will be in place to ensure that all parts of the system are focused on delivering this?

5.2 It would be important that the research and analysis function should stay with the policy function in the Department. Although an element of research and analysis will be needed in the new Public Health Agency, it would not make sense to remove information and analysis from the Department.

5.3 DHSSPS has traditionally funded a number of voluntary and community organisations to undertake policy-related and innovative work. NICVA believes it would be appropriate for this link with the Department to remain, meaning that this funding role should not be passed to the new Regional Health and Social Care Board.

6.0 Regional Public Health Agency

6.1 This new body, if created, would ensure a welcome renewed and enhanced focus on public health. NICVA very much welcomes the statement: “Improved health and well being and reduced health inequalities are the yardsticks by which the success of that system will be measured.”

6.2 We welcome the key elements in principle:

• public health at the centre of policy and strategy;
• better co-ordination and delivery of interventions to protect and improve health and wellbeing;
• a stronger role for local government in shaping health improvement programmes and in tackling the underlying causes of poor health;
• robust arrangements to provide public health support to the RHSCB and its LCGs in developing their commissioning plans; and
• a continued role for HSC Trusts in developing and delivering health improvement and health protection programmes.

6.3 The new RPHA is to incorporate all of the public health functions and responsibilities that currently rest with Boards and Trusts. This means that responsibility for work on health improvement, health inequalities and community development will not lie with the organisations commissioning and providing services.

The LCGs and Trusts will have a responsibility to consult the RPHA on their plans but we would be concerned that this separation might weaken these areas of work because commissioners and providers will feel less obliged to mainstream health improvement and health inequalities issues into all their work. This would detract from, rather than strengthen, the public health agenda, especially at local level where good relationships and good practice currently exist.

Voluntary and community organisations feel that being a core part of health teams has ensured that public health is taken more seriously. Therefore we recommend that if the Agency is created it should not necessitate removal of public health staff from other parts of the system. Structures for collaboration will be necessary, possibly co-location or joint appointments. In addition we recommend that there should be a statutory duty on commissioners to pay due regard to the advice of the RPHA.

6.4 The RPHA, if it is formed, should be given a limited commissioning role, in co-ordination with or perhaps jointly with other commissioners, rather than only acting as public health delivery agent and advisor. It should continue the public health tradition of directly commissioning voluntary and community organisations to deliver services to hard-to-reach groups and communities.

6.5 It is not clear from the consultation document how the public health structures will actually translate into local functions. Progress has been made through Investing for Health in furthering understanding that health improvement is everyone’s business. Experience from Investing for Health Partnerships should be mainstreamed and built upon, not lost. The Regional Public Health Agency potentially needs both regional and local elements to ensure this.

6.6 Tackling health inequalities is not described as a key function of the RHPA and we would like to see this included. There should also be community development expertise contained within the RPHA and expertise on inequalities. Overall, there needs to be clear accountability for public health outcomes. We would like to see common, outcome-focused objectives for health and social care and public health, to ensure an integrated agenda.

6.7 The Agency should be a strategic resource for public health intelligence and research, drawing on academics when necessary and should attempt to transfer skills within the rest of the health and social care system. It should undertake evaluation and set standards of excellence.

7.0 Health and Social Services Councils

7.1 NICVA welcomes the fact that these structures would be funded directly by the department to maintain their independence.

7.2 The previous draft health legislation, now withdrawn, which was to underpin the last round of changes, included a statutory duty of engagement on health and social care organisations. This would have meant serious involvement of the public at all levels. It is essential that the HSS Councils do not become just a channel for complaints nor should they be the single route for citizens to engage with planning and decision making in the new system. They must be a voice for all citizens, whether current service users or not.

7.3 We note and welcome the important role played by the Councils in advocating for patients and users in terms of the health and social care services they receive. We also welcome Councils’ work to widen understanding of best practice user involvement in health and social care. A balance between a regional and local voice would appear to support the Councils in their work and so we would recommend one strong regional organisation which has a local presence through local offices as proposed in Option one.

8.0 Other health agencies

8.1 NICVA opposes the proposal to subsume the Mental Health Commission into the Regulation and Quality Improvement Authority, as this runs contrary to the Bamford Review recommendation of an independent Commission.

9.0 Equality Impacts

9.1 The information provided in the consultation document is inadequate and does not enable informed comment to be made. The draft EQIA appears to be mostly about staff and not about the full impact of the proposals on the population of Northern Ireland.

10.0 Conclusion

10.1 Since structures in themselves will not deliver anything different, a real change in culture will be needed to make these proposals work. There must also be good communication with all stakeholders during the period of change.