Official Report: Tuesday 27 January 2015
The Assembly met at 10:30 am (Mr Speaker in the Chair).
Members observed two minutes' silence.
Mr Allister: On a point of order, Mr Speaker. Why is it that, yet again, when we are about to have quite an important statement on health, the statement is not put in Members' pigeonholes until after 10.15 am, giving us a wholly inadequate opportunity to consider the points that are to be raised? I thought that there was guidance of at least 30 minutes, which has yet again been breached.
Mr Speaker: Ministers are required to ensure that Members get statements in sufficient time. There may be issues, which, I am sure, reflect on what the Member has just drawn to our attention. I am sure that the Minister will address those in his statement.
Mr Wells (The Minister of Health, Social Services and Public Safety): At the outset, I will take up the Member for North Antrim's point. My understanding is that the statement was to have been in Members' pigeonholes by 9.00 am. Given the importance of the statement, I think that it is essential that Members get proper notification.
Last year, my predecessor commissioned an examination of governance arrangements for ensuring the quality of health and social care provision in Northern Ireland. That examination was led by Professor Sir Liam Donaldson. It is now complete, and the report is published today.
I am sure that other Members will wish to join me in paying tribute to the commitment and efforts of all those working in our health and social care system. I thank Sir Liam and his team for completing the review in such a short time. I also thank all those who met his team, including clinicians, managers, patients and members of the public. All of them contributed evidence to inform the team's work and findings.
Sir Liam is a world-renowned expert. The report is far-reaching in its implications, and I agree with Sir Liam's main conclusions. That said, I will need to take more time, as should others, to consider the specifics of some of the associated recommendations.
I want to highlight a quote from Sir Liam's report. He concludes that our health-care system:
"is likely to be no more or less safe than any other part of the United Kingdom, or indeed any comparable country globally."
That statement should be of some comfort and reassurance to those in our community who rely on our health service.
The report makes 10 recommendations. While some focus on specialist areas of quality and safety improvement, such as maximising learning from incident reporting, others are broader and focus on our health system. Members will be aware that I have already asked my permanent secretary to look at administrative structures in the health and social care system and the organisations that support it. The purpose of that review is to ensure that the structures in place to support the delivery of health and social care are working, individually and collectively, as effectively and efficiently as possible. That work will feed into future planning cycles, including for 2015-16.
It is clear that, on a number of the recommendations, there is a need to hear the views of other stakeholders, many of whom contributed evidence to Sir Liam and his team but will not have had sight of the recommendations before this morning. There are clearly recommendations that need to be considered by the Executive, and Members will also understand that, in respect of some of the recommendations, we will need to take account of the findings of the inquiry into hyponatraemia-related deaths, which will, hopefully, become available shortly. Despite that, there are a number of recommendations that should be progressed, and I am determined that that should happen as quickly as possible, particularly those that point to opportunities for improving the quality and safety of our services.
My predecessor and I have highlighted issues with commissioning, and this is reflected in Sir Liam's report. My officials have been asked to undertake a review of the existing commissioning arrangements to ensure that they are effective. The review will also take into account the recommendations set out in Sir Liam's report. A copy of the terms of reference for the review is attached to my statement.
A key point made by Sir Liam is that, in the Northern Ireland and broader UK context, the health and social care system that we have is not the one that we need. However, while acknowledging Transforming Your Care (TYC) as a strong forward-thinking piece of work designed to address this issue, he notes that progress has been slow. I wholeheartedly agree with that assessment, but we need to be clear that it does not reflect a lack of ambition or effort. In December 2011, the TYC report set out a change vision that would take three to five years to achieve and require some £70 million of additional transitional funding. Due to a change in the wider financial context, the Executive have been unable to provide that funding to my Department. That said, TYC remains a priority. It directly addresses the challenges facing our hard-pressed health and social care system. By working to safely introduce services in primary and community care, and supporting people to make good health decisions and manage their own conditions with appropriate assistance, we will be able to ensure that service users and patients are treated in the right place, at the right time and by the right people. We need to enthuse our front-line staff and empower them to make the changes that they can make in support of the aspiration for the highest-quality health and social care service. I am determined, even though we are working in a constrained financial context, that we must redouble our efforts to speed up the implementation of TYC. The best change comes from the ground up, and I want to facilitate those at the coalface to play a fuller role in delivering transformation.
I note that Sir Liam's review recognises the potential for pharmacists to expand their role in the provision of community services, and I can confirm that I will shortly announce details of an implementation plan to guide the execution of the Making it Better Through Pharmacy in the Community strategy. That will set out the strategic direction and enhanced role of pharmacists in the community for the next five years.
In addition, I can advise that my Department will be issuing a medicines optimisation quality framework for consultation later this year. This framework complements existing policies and TYC and aims to support better health and well-being outcomes for our population by improving the appropriate, safe and effective use of medicines throughout Health and Social Care (HSC).
I wish to confirm that a statutory duty of candour will be introduced in Northern Ireland. There should be no ambiguity in respect of my expectation regarding the crucial elements of patient safety, which are openness and transparency. I recognise that despite the best efforts of doctors, nurses, social workers, other staff and managers, mistakes can and do happen. Patients, service users and the public have a right to expect that, when they do, they will be communicated with in an honest and respectful manner and that every effort will be made to correct errors or omissions and to learn from them to prevent reoccurrence. I have asked my officials to begin the process to create a statutory duty of candour in Northern Ireland, so that, supported by professional codes of conduct that already exist, we might bring about the strongest possible form of openness and transparency in Northern Ireland.
The serious adverse incident (SAI) system has been the subject of a great deal of focus over the last 12 to 18 months. Sir Liam highlights that the SAI process needs to be strengthened. I agree with that assessment. However, I want to remind everyone that it is a system for learning, and it should not be used as a source of information to attack the service or to sensationalise issues which affect people at a very difficult time in their life. Such an approach can only serve to undermine the extent to which we are open about and seek to learn from mistakes that occur. The Health and Social Care Board and the Public Health Agency (PHA) jointly manage the operation of the SAI system. I have instructed them to consider the recommendations made in this report, prioritise changes that can be made now and set out the direction of travel for recommendations that will take longer to bring about.
Shortly, I will publish the details of a look-back exercise into SAIs, which was commissioned in 2014. The look-back report will confirm the desire of professionals to involve people, but highlights how hard it can be to get this right, because people want to receive information in a manner of their choosing, which may be unique to them. It will show that reporting of deaths in hospitals to the coroner is generally carried out appropriately. Sir Liam Donaldson and his team have however highlighted that improvements could be made.
I want to reiterate today my commitment to progress to a conclusion work that was previously announced by my predecessor, which was to introduce a regional morbidity and mortality review system as well as the development of proposals, in conjunction with the Department of Finance and Personnel and the Department of Justice, to introduce a new independent system to review deaths in Northern Ireland, complementing the role of and working with the coroner.
A "never events" list will also be developed for Northern Ireland. Never events are serious, largely preventable patient safety incidents that should not occur if available preventative measures have been implemented. They include incidents such as wrong-site surgery, misidentification of patients and dosing errors. Some of these events are already dealt with in Northern Ireland in the context of existing SAI learning letters and other guidance issued. I have instructed my officials, as an interim measure, to urgently consider the list of never events for England and to determine its applicability to Northern Ireland.
Sir Liam restates the need to use expertise and guidance from regulators in other countries. The Regulation and Quality Improvement Authority (RQIA) already uses and will continue to use experienced professionals from other UK countries in review work and will build on those existing arrangements appropriately in future review work.
Members will recall the announcement made by my predecessor that RQIA will begin a series of unannounced inspections of acute hospitals in April 2015. Members will agree with me that unannounced inspections are often of more value than announced inspections. Best practice from other regulators is already being incorporated in that work, and it will be shaped going forward on an analysis of key trends in the HSC in Northern Ireland on a rolling basis.
I have asked my officials to investigate with the RQIA the possibility of speeding up the roll-out of this programme of unannounced inspections. My officials will also begin work on new policy proposals to review the Health and Personal Social Services (Quality, Improvement and Regulation) Order 2003 with a view to introducing a stronger system of regulation of acute health-care providers. These changes need to be taken forward alongside changes to the current system of regulation. My Department will bring forward proposals to the Executive for changes to that system of regulation of non-acute services, with the aim of issuing the proposals for consultation later this year.
I say again: openness and transparency are vital to ensuring a system that is focused on maintaining quality and continuous improvement. The system must learn to listen to the voices of people who use it and who work in it and to make sure that those voices are heard. It is often those voices that highlight poor standards. The effectiveness of whistle-blowing arrangements in the health and social care system continues to be a cause for concern. As part of the 2015-18 RQIA review programme, I have directed that RQIA should undertake a review of the operation of whistle-blowing in health and social care bodies and make recommendations on how we can improve its effectiveness.
I am conscious of the general conclusions in the report about how the health and care service is both reported and perceived. Focusing on reviews, complaints and "never events" is important. This focus can, however, skew everyone’s perceptions about these services. I want more work to be done to measure and report patient and client experience. With this express intention, I have asked my officials to review the current arrangements for measuring patient/client experience to ensure we take the best available worldwide evidence and design a framework to strengthen the voice of patients at every level from the front line up to the Department. Monitoring patient and client experience, good and bad, is a much more effective way of driving improvements in the quality of our services. It is also an approach that will give a much more balanced view of the quality of the services being provided.
This is a time for those who are committed to the delivery of high-quality health and social care services to engage in open, honest, intelligent debate about how we move forward. The report should force us collectively to raise the standard of our debate on health and care and to focus on the prize, which is a world-class health and care service. We need to recognise the realities that we face and to arrive at the right decisions, beginning by ensuring that we are asking the right questions. Too often, discussion about the health service can be overly simplistic and focused on a simple choice between closing or keeping open a particular facility. In this context, the reaction of the local community is understandable and instinctive: a save-our-service mentality. In reality, though, it is not about saving a service, but saving a structure. The real choice that we face is an uncomfortable one for us all, including political representatives. It is this: do we want a world-class service or a service on our doorstep, which, while convenient, may be sub-optimal and compromise quality and safety? The discussion about the right structure for our services and hospitals has been going on for many years under different administrations and under the leadership of Ministers from different political parties.
The message from Sir Liam is clear — I need to emphasise this point — we now need a mature debate and we need to strive for political consensus to empower us collectively to make the right choice. Borne out of a desire for that mature debate, I have chosen to place this report in the public domain and to address the Assembly at an early stage in the interests of openness and transparency. I want to allow a wide range of stakeholders the earliest possible opportunity to reflect on the report and to begin to formulate solutions to meet the challenges in it. These solutions can only be informed by openness and honesty about where we are now and what has to be done to deliver the changes needed.
Whilst we are moving ahead with some of the recommendations that I have outlined today, I am also asking for written comments on the recommendations to be submitted to the Department by the end of April 2015. That gives an opportunity for stakeholders to reflect and engage with one another, political representatives and the Department.
I recognise that the analysis of the report will take some time and that it will need to be given careful, measured consideration. Inevitably, some of the recommendations will have financial implications, and some may require legislative change and Executive approval. Sir Liam, through his report, challenges us on what is best for the people we serve.
The report highlights specific issues on innovation, silo working and standardisation. As part of my approach to addressing those issues, I have specifically asked the six trusts to work with each other, their staff and other stakeholders to develop a combined response to the report and its recommendations. Their response should reflect the views of all front-line staff in particular. It should also focus on their ideas for improving collaboration, ending silos, increasing standardisation and promoting innovation. Front-line staff must be empowered not only as a result of that work but as part of it. In short, they hold the key to delivering on the change that is needed.
The trusts, along with other stakeholders, will be asked to provide their views and comments to the Department, again by April 2015. I accept that that is quite a challenging deadline for all concerned.
Mr Speaker, in the light of the challenges posed in the report, we must all contemplate the tough choices on improving health and social care that face the Executive. I propose to ask Sir Liam to return next year to advise me of his views on the progress made.
I will conclude by highlighting another quote from Sir Liam’s report. He said:
"the leaders of the Northern Ireland health and social care system should be clear in their ambition, which is in our view realistic, of making Northern Ireland a world leader in the quality and safety of its care. Northern Ireland is the right place for such a transformation, and now is the right time."
In summary, Sir Liam has concluded that we have a real opportunity to transform our health service into a world leader. I believe that that is an ambition that we should cherish. I look forward to the debate ahead.
Mr Speaker: Before I call the Member who will ask the first question, I inform the House that a large number of Members have put their name down to ask questions. I am sure Members will agree with me that as many as possible should be allowed to do that. For that reason, I ask Members to ensure that their questions are brief, not multi-question comments, and that they relate to the ministerial statement.
Ms Maeve McLaughlin (The Chairperson of the Committee for Health, Social Services and Public Safety): Go raibh maith agat, a Cheann Comhairle. I thank the Minister for his statement. However, I suggest that there is little in the report that heralds the new dawn, if you like, for our health and social care service.
The Minister said that we need a mature debate. That is absolutely no problem. However, the report cost £116,000 for eight months' work. It has effectively told us that Transforming Your Care is too slow; that there are concerns about commissioning, but it does not outline what those concerns are or, indeed, how they could be rectified; that the health and social care system is not the one we need; that there will be a statutory duty of candour; that there will be a direction for pharmacy; and that there is a need to strengthen the serious adverse incident system. So, how, exactly, Minister, will these 10 recommendations be taken forward by the direct actions that are required to bring our health service into the 21st century and to provide that world-class service that we all strive for?
Mr Wells: The lady is absolutely correct. I intended to reveal this anyhow: although not all the invoices are in, we think that the report cost roughly £116,000. That has to be seen in the context of an overall expenditure for 2015-16 of over £5 billion. I believe that, if properly implemented, Sir Liam's report will certainly make us much more cost-effective in many respects.
Where the mature debate is concerned, I remind her that three parties in the Assembly have had the opportunity, or the pleasure, of holding the health service portfolio and that all three have struggled with initiating the debate that Sir Liam clearly flags up, which is that, if Northern Ireland came into existence today, we would not start our health service provision from where we are now. I hope that his first recommendation will encourage us all to have that mature debate.
Although we had our concerns about issues surrounding Transforming Your Care, commissioning and SAIs, it was very helpful to have a totally independent, detached voice come in, look at the situation and confirm that our reading of that situation and our concerns were correct. That reassures me, and it incentivises me to try to ensure that we deliver what Sir Liam is saying. To some extent, at least the report is saying that Transforming Your Care is the right direction and that, strategically, it is the correct way forward. However, we need to put more resources into it. We can all agree on that.
Some of the recommendations will be implemented almost immediately. I mentioned the end of this financial year, which is quite a challenge. Some recommendations cannot be implemented without Executive support, while others cannot be implemented without changes to legislation. The Chairperson will understand that that is a long-term process. I am very keen to have a public, open and transparent debate on all Sir Liam's findings to get a sense of the support or otherwise among the medical community, service users and the general community, all of whom have a view on health and social care.
Some of this is very challenging and some of it is uncomfortable. I accept that. However, there is not much sense in our having a report that does not challenge us all. I will also be relying on the Committee to provide a sounding board for many of the views on it. I see the report as an extremely important document for the future of health in Northern Ireland.
Mrs Cameron: I thank the Minister for his statement on the quality of care in Northern Ireland, which is of utmost importance. What will his review of commissioning examine?
Mr Wells: It is important that we distinguish the two reviews. First, Richard Pengelly, the permanent secretary, has initiated a review of administrative structures in the trusts, the board and other aspects of health care to see whether we can make more cost-effective decisions. I know that many Members have expressed their concerns about admin costs. Mr Pengelly's role — it is a challenging one, because he has to report by the end of this financial year — is to examine every aspect of administration to determine whether there is overlapping administration and whether there are ways in which to take costs out of the system.
In addition, attached to the statement are the terms of reference for the review of commissioning arrangements, which focus particularly on the role of the board. The review will have a number of tasks. It will assess the health and social well-being needs of the population of Northern Ireland and assess strategic planning to prioritise needs within the available resources, including the use of financial and other levers to reshape services to meet future needs. It will engage with patients, users, carers, families and other key stakeholders at a local level in the commissioning of health and social care. It will secure, procure, incentivise and agree high-quality, value-for-money service provision to meet the assessed and prioritised needs of the population. It will ensure the delivery of outcomes from services commissioned and evaluate the impact of health and social care services, feeding back into the commissioning process how needs have changed. It will bring recommended options to improve the effectiveness of the delivery of health and social care in Northern Ireland. We expect that report by the summer of 2015.
Therefore, there are two ongoing processes here that affect commissioning. Of course, we acknowledge Sir Liam's comment that Northern Ireland could be in a position in which we have all the bureaucracy and administrative demands of a commissioning service without any of the real, tangible benefits that commissioning should be yielding. We need to examine that, but, again, that is something that I and my officials realised was an issue before we saw the text of Sir Liam's report. At least it is good to have that independent corroboration that we need to look at this very important issue.
Mr McKinney: I am reluctant to say, "I told you so", but does this report not represent a vindication of those who have been rightly critical of a service that has not been delivering, up to and including criticism of who runs the system. I remind the House that this Minister and his predecessor have robustly and at all costs defended that system. In that light, is it not now