Analysis: healthcare's potentially fatal paradox

5 Jan 2015 Ryan Miller    Last updated: 7 Jan 2015

Local health and social care reform is based on moving provision closer to home - but are cuts to both emergency and domiciliary care causing a spiralling crisis?

Local Health and Social Care is under strain. Despite the DHSSPS budget treading water while most other departments face savage cuts, demand is shooting upwards, stretching all services.

The latest palpitation sees reports of chaos at the Royal Victoria Hospital’s emergency department – with a 73-year-old woman with suspected pneumonia waiting eight hours on a trolley and 11 ambulances backed up outside the entrance.

This followed a Belfast Trust u-turn just before Christmas when an announced reduction in domiciliary care services was shelved.

Plans to end home help services for 550 older people were reversed almost immediately. The climbdown followed a cackhanded bid to bury bad news that led to an inevitable public relations nightmare, with the service users receiving their Dear John letters in the week before Christmas.

Of course it is great to hear that the people in question will continue to receive this service – but what about the long term?

It seems very unlikely senior officials at Belfast Trust are Scrooges revelling in making cuts to valuable services. Indeed, their reversal came with the following quotation:

"This was a decision we took with great reluctance and it was based solely on our need to live within the resources available to us in the current financial year.

"Since the announcement was made there has been many representations made to Belfast Trust from individuals, families and others, all concerned about our decision.

"As a result, we have decided not to proceed with these changes at this time. We regret any distress or anxiety we may have caused.”

This boils down to: the reason for the cut was because we can’t afford the service, the reason for the climbdown is because everyone was angry at the cut.

At the heart of this issue is the major fault line in local health and social care reform.

Transforming Your Care

In 2011 then-minister Edwin Poots ordered a review of HSC. The result was Transforming Your Care (TYC), a bold policy call to arms which concluded there is “an unassailable case for change” of our care model.

In short, a growing and ageing population means poorer health with more frequent and longer-running health issues which, without reform, would ultimately destabilise the entire service, culminating in failures both for the local population and also staff within our agencies.

The solution suggested was a greater focus on preventative care and also services being based closer to home – with the idea that these strands would dovetail.

If successful, these measures will allow people to be healthier for longer, and also to spend a maximum amount of time in their homes and in the community, two positive developments that would actually result in savings for HSC, when compared with equivalent costs under the older model.

Demand continues to rise, and the more we don’t spend on changes now the more it will cost us in the future.

So goes the theory.

In 2013, Independent Health and Care Providers – the umbrella body for nursing homes, domiciliary and community care provision in Northern Ireland – published Can We Trust The Trusts? alongside their English equivalent the UK Home Care Association (UKHCA).

IHCP members are supposed to be in the vanguard of Transforming Your Care, but two years into the reform they felt the need to publish a call-to-arms saying their services, which cater for around 24,000 older and vulnerable people across Northern Ireland, are in danger of collapse.

The group accused health trusts, who commission this care, of “undermining” the reforms pursued by politicians. The paper says: “The Health and Social Care Board wishes to see an expansion of community based care delivered by independent and voluntary sector providers, yet at the same time the Trusts are implementing short-term financial savings which threaten the quality and sustainability of these providers, bringing the industry to the brink of crisis.”

The trusts stand accused of fiddling eligibility criteria to save money and leave many people who have genuine needs without help, and also reducing the quality of the services that are provided to the point where they are inadequate.

Necessary changes suggested by IHCP includes respect for the dignity and human rights of its members’ clients, reversal of trust cuts to domiciliary care services, implementation of a value-for-money audit of the sector, and for politicians and care commissioners to work together to ensure planned reforms are adequately supported.

The focus of IHCP ire was the trusts – but they receive their budgets from Stormont (which itself is beholden to Westminster). What if there really is not enough money?

Budgets are what they are and, barring great improvement in the local economy or major savings made elsewhere in public spending, it is unlikely TYC will be funded to a more complete degree.

Bids made for essential delivery of the reforms have come up short in recent monitoring rounds, while Finance Minister Simon Hamilton even saw fit to publicly criticise his party colleague Edwin Poots for poor budget management in the past few years.


This problem is not unique to Northern Ireland. Shadow Secretary of State for Health Andy Burnham said last month that the NHS in England is “on the brink”, with a collapse in community provision leaving emergency departments stretched.

Burnham said providing domiciliary services is cheaper than hospital care but the current system in England is incapable of delivering that and, during this Westminster mandate, around a quarter of a million older people had lost social care support in the home, with services increasing absent in certain parts of the country. He stated that hospitals are accordingly spending more money on agency staff.

Prime Minister David Cameron has accepted the strain on health services and told MPs that, in one week in November, 429,000 people attended A&E units across England, around 3,000 more patients every day than under the previous government.

On Tuesday NHS England announced its worst week since records began in 2004 for A&E pressures. Just 83.1% of patients were seen within the four-hour waiting target in the week before Christmas, coinciding with the week that a record number of people – 289,530 – attended emergency departments.

The relationship between domiciliary care and demand levels for emergency departments is generally accepted across our politics. NI is different from England in that health and social care locally are already integrated.

However, the dynamic between community provision and hospital care remains the same.

Jonathon Holmes, policy officer for the UKHCA, spoke with Scope and said domiciliary care services in England are also suffering, being asked to do more for less.

“The single biggest thing for our members is the workforce requirement – finding them, hiring them and retaining them.”

He said a high turnover of staff was related to the general pressures on the sector, and adds yet another pressure on provision – high turnover in any firm or industry leads to lower productivity, as staff constantly have less experience and require more training than in businesses who retain their workers, who therefore get to know their roles and become increasingly proficient.

“Another growing issue, although this remains anecdotal for the minute, is a growing mistrust of GPs amongst service users, and growing waiting times for GPs as well. This again puts further strain on other areas of health and social care provision.”

Bleak homecare

Given that England’s problems mirror our own, we have to ask whether there is some inevitable crisis looming on the horizons.

Unless more money is found to provide for local health and social care – which could mean increased funding to buttress secondary services as well as comprehensive support for the TYC remodelling – then it seems inevitable cracks will begin to show and grow on all fronts.

The miserable truth might be that ascending to the position of DHSSPS Minister is simply receiving a hospital pass. If there is not enough money to sustain services under the current model and not enough money to properly implement a new system that may resolve growing issues then services will suffer and nothing can be done about this.

Of course, Jim Wells’ announcements as he settles into his brief do not strike that tone; he remains fully committed to TYC and positive about its progression.

If this is the case then domiciliary care services must receive investment that, the argument goes, will save more and more money the further we go into the future. It is in everyone’s interests that Mr Wells’ positivity proves well founded.

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