The shocking truth about Transforming Your Care

When its authors published Transforming Your Care they went to great lengths to stress that its central objective - shifting patient care away from acute hospitals and into the community - was the only way to preserve the Health Service and prevent long term collapse: there was no Plan B. 

Yet almost by the day further evidence is emerging of how, despite all the fine words, the reality on the ground is that Health Trusts are cutting back on the very services they need to expand as a short-term fix to comply with budgetary pressures. This is perversely leading to still higher costs for the service, creating massive strains on already overstretched A&E departments which in turn is putting patient safety at risk. 

Admission statistics demonstrate that between December 2013 and December 2014, the total number of attendances at the major acute hospital emergency departments in Northern Ireland increased by 6%, from 45,842 to 48,867. Across all emergency departments the increase was 3%. 

We can expect that trend to worsen. Last Autumn the five HSC trusts announced the closure of a number of minor injury units, respite facilities and rehabilitation beds, thus funnelling even more patients through an acute hospital system already close to breaking point. 

But surely this is just a short term blip, and investment is being made for the future? Again there is bad news, both in terms of spending and planning. 

Let's start with the numbers. In September 2014, the former health minister Jim Wells told the Assembly that a total of £28.49 million had been spent on the implementation of TYC since 2012-2013. However one third of that sum was deployed on voluntary redundancies and early retirements, with just £5.67 million allocated to associated service changes. 

In January of this year Mr Wells confirmed that just £2.53 million of a projected budget of £27.53 million had been deployed during 2014-2015 on core TYC services such as community dementia care, home dialysis and the relocation into the community of mental health and learning disability services. 

Planning for the future also appears to be in disarray. The Royal College of Nursing recently submitted a paper to the Assembly Health Committee on "workforce planning" - the process by which the DHSSPS makes sure it has the right staff, with appropriate training, in place to meet present and future needs, presumably in the light of a transformational change programme which will revolutionise the Health Service. 

You might have expected that the department's Workforce Planning Directorate would have been hard at work on this, the day the department endorsed TYC. Perhaps it was. However a new workforce plan was not produced until late last year. The last workforce strategy to be produced was in 2002. 

The lack of an up to date strategy and plan might explain why the nursing and midwifery education and training budgets have been severely cut over the past five years, during a period when radical impending change would suggest they should have increased. The pre-registration education and training budget and expenditure for nursing and midwifery has decreased by 9% and the post registration education and training budget has gone down by 19%. 

According to the RCN the DHSSPS includes salary costs within commissioning arrangements for some post-registration programmes, but not others. If HSC trusts commission programmes for which the DHSSPS does not support salary costs, then the trusts have to pick up the salary tab themselves. Trusts, already struggling to make cost savings argue that they do not have the funds to support staff through these programmes with the result that training often does not take place. 

Even more concerning is the escalating nursing shortage in Northern Ireland. Many nurses trained here are moving away because of the tendency of trusts to offer temporary contracts. This, in turn, is leading to increasing numbers of unfilled vacancies. 

The reduction in training, coupled with the nursing brain drain is hitting trusts hard because it leads to an increasing reliance on far more expensive agency or "bank" staff. Last year the Belfast Telegraph reported that annual agency staff costs were running at £70 million, a 60% increase over five years. Some nurses were being paid £87 per hour. 

The shortage is also hitting the independent care sector, another vital plank of Transforming Your Care, with problems so acute in some homes that their future viability is at risk. 

Despite this gathering crisis and the obvious future need, Northern Ireland is the only part of the UK not to be increasing the number of pre-registration nurses it currently trains. 

If incoming Health Minister Simon Hamilton is as serious as he appears to be about making TYC work, he is going to have to knock quite a few heads together in both the department and the trusts, and fast.