Reshaping the System: Implications for Northern Irelands Health and Social Care Services of the 2010 Spending

Review
Introduction This document provides the Minister for Health, Social Services and Public Safety with possible plans that would deliver high quality, cost effective health and social care services for Northern Ireland in the coming years taking account of the likely reduced funding levels anticipated in the Current Spending Review. It sets out:
The Departments assessment of the funding required to maintain Health and

Social Care in Northern Ireland (HSCNI) in its present form over the coming years
High-level estimates of the cost saving potential of a far-reaching and

integrated programme to improve productivity and quality

A vision for a reformed health and social care service for Northern Ireland

arising from and necessary for these improvements

What it will take to successfully make the transition to this future system.

The analysis underpinning this document is top-down in nature 1 , making assumptions about the overall system and drawing on the experiences of other, equivalent systems elsewhere in the UK and beyond. It does not therefore include an impact analysis on a local basis, nor does it provide a final, comprehensive perspective on the future shape of health and social care services. Much remains uncertain, not least the political decision-making process and the level of support from the public, professionals and managers to implement the reforms described. This document is therefore intended to provide the foundation for a constructive discussion between DFP, the Minister for Health, Social Services and Public Safety and DHSSPS on the size and nature of the challenge and the changes required to ensure the service is fit for purpose for the 21st century.

1 Conducted over a 5 week period during August 2010

This document frequently refers to quality and productivity. A high-quality service is effective, safe, ensures people from all sections of society who need care can easily access it, and is patient or user centred, providing a good user experience. A productive service makes efficient use of all resources, including facilities, staff and supplies. Productivity covers both allocative efficiency (i.e., the right services being provided in the right setting) and technical efficiency (i.e., right people working effectively in the right place at the right time within each setting of care). Executive Summary Northern Irelands health and social care (HSC) service has made improvements in the quality of care for our population, as well as in productivity, over recent years. There has been innovation, focused on keeping people well and independent, and reducing reliance on hospital based care once they are unwell. These are achievements we should be proud of, especially when taking into account the fact that our regions HSC system spends between 7% and 16% less per head than Englands, once our higher levels of deprivation and social need are taken into account. (Ref: page 13). However, there is now a clear imperative for us to make improvements in both productivity and quality. Not only are we falling short in some areas, such as smoking prevalence and circulatory disease mortality rates but we face increasing pressure on the system now and in the future. The pattern of need in NI, in common with other developed countries, is changing. Growing demand for care, inflating costs, and constraints in the growth of health and social care spend could result in a significant shortfall in funding by 2014/15 if health and social care continues to be provided in the same way as now.

EXHIBIT 1
Demographic change, residual demand growth and cost inflation, unmanaged, would increase spend by ~6% p.a.
b per annum, nominal, total DHSSPS allocation
7
Historical/ forecast spend Forecast do nothing spend x Spend gap

6 5.4

2010/11 savings

3 2006/07

2010/11

2014/15

SOURCE: SRF; DHSSPS; various Northern Ireland historical activity sources for residual growth (see appendix for details)

The HSC could continue to improve quality of care and productivity to reduce this financial gap by implementing a number of improvements:
We estimate the 2014/15 funding requirement could be reduced by ~0.1

billion by optimising the quantity and type of care provided (for instance, through better management of long-term conditions to improve overall health and reduce need for costly treatment)
The 2014/15 funding requirement could be further reduced by an estimated

0.5 billion by bringing down the unit cost of care provided (for instance, by reducing length of stay in hospitals and increasing staff productivity across all settings), subject to acceptance of all the changes needed to secure such savings In addition to these improvement opportunities, required future funding could be further reduced by several hundred million if it was possible to make some centrally-led changes to income and costs, for instance by introducing user copayment for services, or centrally controlling staff pay inflation. However, these ideas could only be progressed if there were to be significant change from current policy and principles. Capturing these opportunities will involve a transformational, structural change: we need to go further than simply improving our current model to meet the scale

of challenge we face. We will need to create a health and social care system that looks and feels very different from today:
Enhanced and more effective services in home and community settings will

improve health and well-being and require greater integration and consolidation of primary and community health and social care, while reducing activity in hospitals
Better quality acute care will require concentration of some services to ensure

minimum clinical critical mass and maximum efficiency

All of this will result in a different service provision landscape, e.g., primary

care centres acting as hubs for integrated community health and social care; fewer acute hospitals, supported by local hospitals providing local access to urgent care services; revised ambulance and transportation services that support these reconfigurations. Implementing change on this scale will be challenging and will require strong political, professional and managerial leadership across the system. Indeed, without the political will to make these changes, the current HSC system is likely to become unaffordable within the next five years. We will also need to invest in: the capacity and capability needed to manage the transformation programme; effective communication with and engagement of all stakeholders including public, patients and clients; acquiring the IT and other technology required to improve productivity; and redeploying staff. We estimate the one-off transition cost of the necessary changes at ~0.3 billion in total between now and 2014/15 plus additional on-going investment in necessary enablers (e.g., ~0.1 billion p.a. in IT).

Key points
HSCNI is not resource-rich. We spend between 7% and 16% less per

head than England when deprivation is taken into account equivalent to between 250 million and 600 million less per annum.
Despite this, HSCNI has improved the populations well-being and the

quality of care they can access in large part by increasing productivity, including delivering RPA. However, more needs to be done to match English standards of well-being and care quality.
Growth in need for care and in unit costs, if not managed, will increase

DHSSPS required funding from ~4.3 billion in 2010/11 to ~5.4 billion in 2014/15.
By undertaking a stretching programme of quality and productivity

improvement, HSCNI could reduce 2014/15 required funding by ~0.6 billion. Doing so will involve a strategic, evolutionary transformation of our system. This will not be easy, and will require:
Significant political, professional and managerial leadership. For each

month we delay, the 2014/15 saving that could be delivered reduces by 5 million.
Effective communication and engagement with stakeholders including

communities, patients, clients, carers, their local political representatives, partners such as GPs, staff and staff bodies.
Investment in capacity, capability, technology, facilities, and staff

redeployment including one-off transition costs of ~0.3 billion over the years to 2014/15.
A further reduction of several hundred million pounds in 2014/15 required

funding could be secured by introducing co-payment for some services by the service user (e.g., bringing protocols in line with the rest of the UK).
Any required reduction in funding beyond this will involve freezing staff

pay costs and/ or rationing access to services thereby threatening the fundamental integrity of our system.

The remainder of this document sets out in more detail where we stand and what we need to do, over the following seven sections:
1. Where we stand today: describes how well the current service is meeting the

needs and expectations of the people of Northern Ireland.

2. The trends in health and social care needs and implications for funding:

outlines the level of funding that would be required for the future if services do not change.
3. Reshaping the system: describes the opportunities we have identified to

improve productivity and quality in the system, and the impact of these.
4. Implications for the system: what a new, higher quality and more efficient

service could look like: explains what capturing the productivity and quality opportunities will mean for the health and social care system.
5. What it will take to secure the necessary changes: describes what needs to

be in place for us to implement the changes we need to make, including our estimates of the transition costs involved.
6. The pace of delivery: sets out our plan to deliver the improvements we need to

make, describing our stretch ambitions, our assessment of what can realistically be delivered in the next four years, and additional steps we could take to further reduce growth in spend.
7. Implementation plan: outlines our current (early-stage) plans for

implementation.

1. WHERE WE STAND TODAY

People in Northern Ireland deserve and increasingly expect a health and social care service that provides high quality, cost-effective care, on a par with the other regions of the United Kingdom. They also have reason to expect an effective, joined-up service (e.g., for long-term conditions or for frail, older people) given that in Northern Ireland our hospital- and community-based health and social care are integrated (and have been, under various organisational constructs, for a long time). The current system has made strides towards meeting our populations needs and expectations. It has done this while spending less than England per needweighted head of population, by driving up productivity alongside quality. But more remains to be done to match the higher standards of health, well-being and care quality accessible by people in England and to optimise how and where we spend available funding. Quality and productivity improvement delivered to date Recent improvements in the quality of care delivered, detailed in Exhibits 2 and 3, include:
Overall health outcomes in a number of areas have improved. Life

expectancy, although still lower than in England, has increased for both males and females. Contributors to this increase include reductions in mortality rates from many conditions including cancer and reducing infant mortality rates.
We are reducing disadvantage in our society. The gap in mortality rates

between Northern Ireland as a whole and the regions deprived areas is reducing.
We are doing more to maximise peoples health and well-being. More

mothers are breastfeeding, more children are being immunised, more people are being screened for disease, more smokers are trying to quit and there are fewer births to mothers under 17 years old.
Rates of healthcare acquired infections are falling. Incidence of MRSA, C-

Difficile and surgical site infections have all declined.

 Care is increasingly effective. For example, in 2008 56% of stroke patients

received a brain scan within 24 hours, which was higher than Wales (54%) although lower than England and Scotland (both 59%) 2 .
People who use our services are increasingly satisfied by their experience,

as demonstrated by improvements in patient/ client survey results.

EXHIBIT 2

Quality of care in Northern Ireland has improved in recent years (1/2)

CAGR (average annual % change)
Signs of good quality are increasing . . . Outcomes a. Life expectancy at birth, males b. Life expectancy at birth, females Prevention c. % breastfeeding at discharge from hospital d. Number of smokers setting a quit date e. Immunisation uptake 0.3% 0.2% . . . and signs of poor quality are reducing i. Infant mortality rate ii. Cancer mortality rate Iii. Rate of births to mothers under <17 years old -1.3% -1.4%

3.0% 9.0% 0.3%

-3.4%

Safety in care

iv. MRSA episodes v. C-Difficile reports, inpatients >65 years old vi. Surgical site infection rate, orthopaedics -19.4%

-8.8%

-17.8%

Years (signs of good quality): a, b: 1991-93 to 2005-07; c: 2004 to 2008; d: 2008/09 to 2009/10; e: 2000 to 2009 Years (signs of poor quality): (i), (ii) 1997-01 to 2004-08; (iii) 2001 to 2008; (iv) 2003 to 2009; (v) 2006 to 2009; (vi) 2004 to 2008 * Average of Dip3, Tet3, Pert3, Pol (IPV)3, Hib3 SOURCE: DHSSPS; PHA; Communicable Disease Surveillance Centre Northern Ireland

2 SOURCE: Royal College of Physicians National Sentinel Stroke Audit Phase II (clinical audit) 2008

EXHIBIT 3

Quality of care in Northern Ireland has improved in recent years (2/2)

CAGR (average annual % change)
Signs of good quality are increasing . . . Clinical effectiveness f. % thrombolysis g. Stroke scan 24h h. Primary angioplasty 1.9% 1.6% 5.9% vi. % patients waiting >13 weeks for inpatient care vii. % patients waiting >13 weeks for outpatient care viii. % patients waiting >13 weeks for diagnostics1 User experience Inequality -9.0% 470.0% 16.0% . . . and signs of poor quality are reducing

Access

i. Patient and client survey

TBC

ix. Person in deprived area more likely to die2 x. Infant in deprived area more likely to die

-0.3% -2.1%

Years (signs of good quality): f, g, h: 2004/05 to 2008/09 Years (signs of poor quality): (vi), (vii) 2007 (quarters 2-4) to 2010 (quarters 1-2); (viii) 2008 to 2010 (quarters 1-2); (ix), (x) 1997-01 to 2004-08 1 16 tests: Audiology - pure tone audiometry, barium studies; cardiology echocardiography; cardiology - perfusion studies; colonoscopy; computerised tomography; cystoscopy; dexa scan; flexi sigmoidoscopy; gastroscopy; magnetic resonance imaging; neurophysiology - peripheral neurophysiology; non-obstetric ultrasound; radionuclide imaging; respiratory physiology - sleep studies; urodynamics - pressures and flows; 2 Standardised mortality rate for under 75 years old, deprived areas relative to NI as a whole

SOURCE: DHSSPS; PHA; QOF

While delivering these improvements in quality, the system has also improved productivity, as illustrated in Exhibit 4.

EXHIBIT 4

Many aspects of Northern Irelands productivity have also increased

CAGR (average annual % change)
Signs of productivity are increasing . . . Inpatient 1. % all admissions done as day case . . . and signs of inefficiency are reducing 4. Average length of stay -4.5%

1.0%

2. Throughput per bed

4.0%

3. Day of surgery admissions %

11.0%

Primary care

5. Growth in primary care prescribing spend1

-3.0%

Years (signs of productivity): 1, 2. 2003/04 to 2008/09; 3. 2008/09 to 2010/11 Years (signs of inefficiency): 4. 2003/04 to 2008/09; 5. 2004/05 to 2009/10 1 Relative to expected 2 % of complex discharges delayed by more than 48 hours SOURCE: DHSSPS; PHA; TOR

Achieving these quality and productivity improvements has involved a number of innovations in service provision. For instance,
Innovative models of telemedicine have been established in pilots and roll-

out is beginning for patients with long term conditions such as lung disease and diabetes. This approach has avoided the need for inpatient treatment, reduced length of stay for unavoidable inpatient spells and received very positive feedback from patients.
Community rehabilitation teams have been established and have

successfully prevented admissions to hospital and to nursing care, reducing patients length of stay in hospital and helping them maintain their independence and well-being.
GP Out of Hours services: The introduction of nurse triage of patient calls,

cross cover of periods of high demand with staff in A&E departments, installation of GPS and toughbooks (networked laptops) in on-call cars, have significantly reduced the number of GPs on call in the early hours.

10

 The Virtual Ward model of providing care in the home rather than in

hospital has been set up. This avoids patients needing to go to hospital, reduces length of stay and results in a very positive user experience.
An enhanced intermediate care service has reduced bed blockages (beds

being taken up by people waiting to be discharged) and reduced average length of stay (ALOS).
A new Pharmaceutical Clinical Effectiveness programme has reduced

growth in primary care drug spend by engaging primary, secondary and tertiary care clinical experts in the development of prescribing guidelines.
Diabetes Inpatient Specialist Nurses have been introduced and has resulted

in a reduction in admissions and ALOS, and improved quality of care and clinical effectiveness.
Emergency ambulance response: The training and equipping of local

citizens as first contact responders has released ambulance capacity contributing to a significant improvement in emergency ambulance response times across the area. There have been many other examples of innovation, e.g., Productive Ward, Hospital at Home, Supporting People, carer support, Local Area Co-ordination, specialty networks (e.g., intensive care, cancer), specialist community care teams (e.g., respiratory).

11

EXHIBIT 5
NI CASE STUDY

Pharmaceutical Clinical Effectiveness program controlled primary care drug spend

Expenses for primary care drugs, in m 500 450 400 350 300 250 200 150 100 50 0 2000/ 01/ 01 02 02/ 03 03/ 04 04/ 05 05/ 06 +9% p.a.

Actual Expenses Original Budget Plan1

+3% p.a.

Pharmaceutical Clinical Effectiveness Program Effort started in April 2005 Strategic principles are Rationality Safety Individuality Economy Equity Consistency Continuity Innovation Engagement of Primary / Secondary / Tertiary Care clinical experts in developing guidelines on prescribing

06/ 07

07/ 08

08/ 2009/ 09 10 Fiscal Year

1 Prior to Pharmaceutical Clinical Effectiveness Program started in April 2005 SOURCE: DHSSPS Northern Ireland

In addition to operational productivity improvements, DHSSPS has reduced management overhead staff as part of the Review of Public Administration (RPA). Savings to the end of 2010/11 will amount to a reduction in spend of ~48 million relative to the 2007/08 management overhead baseline. Senior executives in HSCNI have reduced from 188 to 79. The system-wide administrative staff body has reduced by ~1,500. Commissioning Boards have merged from 4 into 1, provider Trusts from 19 to 6 and the establishment of a shared Business Services Organisation. Through all of these improvements in quality and productivity, HSCNI has continued to fulfil its other responsibilities such as research and the education and development of high-quality professionals.

The funding context within which this improvement has been delivered Until 2009/10, Northern Irelands spend per capita on health and social care was in line with, or above, UK average and higher than England. From 2008/09 to

12

2009/10, it grew at a slower rate than other regions and now stands at 1,881 per head for health care (below England, Wales and Scotland), and 519 per head for social care (54 more per head than in England, but below the UK average and 105 lower than in Scotland).
EXHIBIT 6

In 2009/10, Northern Irelands per capita spend on health care has dropped below that of other regions
per capita, not weighted for need
2007/08 North East England 1.79 n/ a 0.44 2008/09 1.95 n/ a 0.46 1.90 2009/10

Healthcare Social services Northern Ireland

2.08 n/a

Englan

1.63

1.75

0.47

Wale

1.89

0.54

1.97

0.58

2.07

0.60

Scotlan

1.76

0.64

1.86

0.64

1.96

0.62

Northern

1.68

0.46

1.86

0.47

1.88

0.52

UK

1.66

0.46

1.78

0.48

1.91

0.49

SOURCE: HM Treasury Public Expenditure Statistical Analyses 2010

However, levels of deprivation and need for health and social care are higher in Northern Ireland than in England. For example, 1 in 10 people in Northern Ireland is in receipt of a disability living allowance, compared with 1 in 20 people in England 3 . In his report, Independent Review of Health and Social Services Care in Northern Ireland (Kings Fund, 2005), Professor John Appleby stated, "The judgement of this Review (to be confirmed or denied in the light of any subsequent results arising from a UK-wide allocation model) is that a reasonable need differential between England and Northern Ireland should be around 7%." Subsequent, unpublished work by a joint DFP-DHSSPS committee estimated a

3 Another illustration of Northern Irelands relative deprivation is that life expectancy in Northern Ireland is shorter than in England, by ~1.5 years for males, ~0.5 years for females

13

need differential of 14-17% for all care 4 . Analysis done in this document uses a range of 7-16% overall need weighting and 16-36% social care need weighting. When our regions higher levels of deprivation and social need are taken into account, Northern Irelands health and social care system spends 7-16% less than England on health and social care equivalent to between ~250 million and ~600 million in 2009/105 . In particular we spend less than half of Englands per capita spend on supporting people with mental health problems and learning disabilities.
EXHIBIT 7

HSCNI spends less than England when need is taken into account
per capita spend on health and social care, 2009/10

-3% -12% 2,293 2,069 England Funding gap NI unweighted NI 7% weighted 226m NI 16% weighted 606m

2,361

2,400

SOURCE: HM Treasury

In the current economic environment we cannot expect funding to rise to close the gap to English levels. Rather, as we plan the future of HSCNI, we need to recognise that given we spend less per need-weighted head of population, we have less room than other regions for simple cutbacks of non-essential services.

4 33-36% for social care specifically; 14-16% for health care specifically 5 Using the 14-17% need weighting this gap increases to ~540 million to ~670 million

14

Instead, we will need to look to fundamental reforms to ensure we deliver value for money without harming the existing quality of care: a crash diet of emergency cost cuts will not be enough to create a service fit for the long-term future. Further improvement required to match other regions quality standards and to optimize productivity As described in the preceding sections, HSCNI has improved quality in a context of lower funding than England, by driving up productivity. However, there are challenges in replicating the pockets of innovation and good practice across the whole system and there are still critical areas where our service falls short of the quality we should be delivering. For example,
Outcomes. Life expectancy is lower than England. Mortality rates from

circulatory disease are higher than in England, as is the prevalence of coronary heart disease in our population.
Inequality. Deprivation is high both within NI (e.g., life expectancy varies

by several years between the most and least deprived quintiles of society) as well as in comparison to England (e.g., more people on Disability Living Allowances).
Prevention. Some health behaviour indicators are poor, e.g., the number of

smokers and obese adults in our population is higher than in England and Wales.

15

EXHIBIT 8
NI mortality rates are higher than comparators, except for cancer
All circulatory disease mortality age standardised, 2004- 08 # per 100,000 population 265.5

Age standardised death rate 2003 -07 # per 100,000 population Northern Ireland 837.6

Cancer mortality European age standardised, 2004 -08 # per 100,000 population 179.2

England

581.9

183.7

173.9

North East SHA

660.0

201.8

203.9

Wales

614.7

Unknown

190.9

Scotland

Unknown

Unknown

206.8

SOURCE: Northern Ireland Neighbourhood Information Service, NASCIS 2008/09, Northern Ireland Cancer Registry, Information Service Division Scotland (ISD), StasWales, Welsh Cancer Intelligence and Surveillance Unit

16

EXHIBIT 9

Smoking and poor diet could be among the causes of NIs lower life expectancy and higher mortality rates
Smoking prevalence (2008) % Northern Ireland 24 Adult obesity, 16+, (2007)1 % 24.0 Adults eating recommended 5 fruit or veg a day (2006) %

27

England

22

22.0

29

Wales

21

21.0

Unknown

Scotland

25

25.6

21

1 Data for Scotland is 2004 (the latest), Obese is defined as BMI>30Kg/m2 SOURCE: Northern Ireland Neighbourhood Information Service, Information Service Division Scotland (ISD), StasWales ,Cancer Research UK, Public Health Observatory for Wales, International comparisons of Obesity 2008

Clinical effectiveness: The 'bar' for clinical effectiveness is constantly being

raised and sometimes at a rate quicker than is being implemented in NI. For example, clinical evidence now points towards ensuring brain scans for all stroke patients within 3 hours - and the English NHS is rapidly moving towards doing that.
Access. Waiting times for diagnostics and outpatient care have increased.

This is a natural and difficult consequence of attempting to reduce spend without reshaping the system and, without action, waiting times are likely to worsen as will be discussed further later in this document.

There are considerable variations in productivity in our system. We intend to particularly target hospital care and community prescribing for reform as these areas, even on a needs-weighted basis, have greater spend than both England and the North East Strategic Health Authority (a comparable region in terms of social deprivation). We have identified an opportunity to reduce performance variation

17

across the five Northern Ireland HSC Trusts, by bringing Trusts with poorer performance into line with the better performers, e.g., on hospital admission rates.
EXHIBIT 10
Comparison of per capita spend across UK
spend on services (including supplies), 2008/09
Hospital Community Social care Primary care

Spend per capita across types of care per capita

2,206 2,254 2,066 1,901 969 905 1,090 835 1,078 227 157 2,051

Breakdown of Spend % of total spend (total spend, m) 100% = 3,946 95,311 6,759

44%

51%

48%

264

246

12%

227

7%

10%

552

516 399
Northern Ireland (7% weighting)

476 363

399 417

472

25%

22%

21%

421
Northern Ireland

464
Wales

19%
Northern Ireland

20%
England

21%
Wales

Northern England Ireland (16% weighting)

SOURCE: HSCNI; Information Service Division Scotland; Wales StatsWales; England Laing and Buisson 2008/09

18

EXHIBIT 11
High-level benchmarking suggests the largest productivity opportunities lie in hospital spend and community prescribing . . .
per need-weighted population
% % reduction opportunity from NI 16% weighting to England Northern Ireland (7% weighting) Northern Ireland (16% weighting) England North East SHA

Hospital spend by category -12% (61m) -26% (54m)

110 101 258 238 208 211 86 79

-18% (30m) 65
64

-18% (53m)
154 142 116 104 42

75

75

-7% (6m) 39 36 30 A&E

Elective inpatient

Non-elective inpatient

Daycases

Outpatient Prescribing cost

205 189 145

Mental health and learning disabilities spend

Primary care spend

189 197 85 79 33 30 Mental health 56 64

-23% (91m)
125

140 126 116 107 35 32 48 50 GP Dental

54 50 Community Prescribing

64 N/A

Learning disabilities

Hospital Prescribing

SOURCE: Laing & Buisson 2008/09, NHS Information Centre Prescribing Data, HES 2008/09, HSCNI data

EXHIBIT 12
And significant variations in performance across NI highlight potential for internal productivity improvements
2009
Standardised Admissions Ratio Emergency Admissions 100 = NI Standardised Admissions Ratio All Admissions (including daycases) 100 = NI

95

99

91

108

111

Higher admissions in the Northern Trusts appear to be driven by higher elective admissions In the Southern Trust the higher ratio is driven by emergency admissions For the Western Trust higher ratios for both elective and emergency are seen

Belfast

95

100

98

104

104

Northern

South SouthEastern ern

Western

Belfast

Northern

South SouthEastern ern

Western

Standardised Admissions Ratio Elective Admissions (excluding daycase) 100 = NI 114 106 99 89 88

Belfast

Northern

South SouthEastern ern

Western

Note: SARs information is based on the home address of the patient and will not give an accurate reflection of the over- or under-usage of hospital facilities within a Trust Area, as patients can attend hospitals outside their immediate home areas. The SAR is indirectly standardised and compares the ratio of observed admissions in an area to those that might have been expected had the area experienced the age specific admission rates of the NI population. SOURCE: Northern Ireland Neighborhood Information Service 2009; Department of Health; Social Services and Public Safety

19

We describe the opportunities to improve productivity in these areas, along with other productivity and quality improvement initiatives, in more detail in section 3.
2. THE TRENDS IN HEALTH AND SOCIAL CARE NEED AND IMPLICATIONS FOR FUNDING

Demand for health and social care is growing quickly in Northern Ireland, in line with the trends elsewhere in the UK. Four separate trends will combine to place pressure on the system in the coming years:
First, our population is both growing and ageing. There will be ~50,000 more

people in Northern Ireland in 2014 than there are today and more than half of these will be over 65. The overall proportion of people aged over 65 will grow from 14% today, to 17% by 2014. Our larger, older population will place more demands on the system.
EXHIBIT 13
NIs population is ageing
Population growth by age group in Northern Ireland 100 = 2008 population 125 120 115 60-79 110 105 100 0
2008 2009 2010 2011 2012 2013 2014

80+

40-59 20-39 0-19

2015

SOURCE: Northern Ireland Neighbourhood Information Service

Second, social, behavioural and other factors are increasing the incidence of

need. There are increasing numbers of people with chronic conditions such as hypertension, diabetes, obesity and asthma. Family structures are changing, meaning people are less often able to rely on family for their care. Drug and

20

alcohol use is increasing. All of this increases need for public health and social care.
Third, health and social care technology and clinical and professional practice

have changed. While some innovations reduce activity (e.g., the shift from open heart surgery to angioplasty), many more increase it.
New drugs, other treatments and equipment now exist that were not

previously available, such as the use of thrombolysis for treating stroke patients.
New professional and management guidelines on what is required to

provide high quality services exist to improve care, but can result in extra costs. An example of this has been the implementation of the European Working Time Directive, which increased costs by reducing the hours worked per frontline member of staff. It is sometimes the case that implementing new guidelines from the National Institute for Health and Clinical Excellence (NICE) involves additional cost, at least at the beginning. Another example is the greater scrutiny of child protection, resulting in more referrals to social services.
Professionals are becoming better at identifying need that may previously

have gone undetected. For example, long-term conditions such as hypertension and diabetes go undiagnosed less frequently nowadays. Autism diagnoses are made more frequently and at an earlier age. Such change is highly beneficial for the patients and clients concerned but often leads to additional activity to care for them.
Fourth, individuals expectations of the service they receive have risen.

People expect an ever-safer, more effective service, an ever-better experience of it, and an even greater say in their care. For example, more people are consulting their doctor nowadays about their health concerns, often for new conditions such as food sensitivities. Long-term historical activity trends demonstrate the impact of the second, third and fourth of these factors on demand for services, but we cannot be certain of their precise impact in the future. However, responsible planning must take account of these residual, non-demographic drivers of growth. Other UK and international systems are including substantial residual growth figures in their planning (see below exhibit) and we have calculated a similar figure for Northern Ireland using local data.

21

EXHIBIT 14
Other regions have assumed residual activity demand growth above demographic which has been similarly calculated for NI
Compound annual growth rate; 2010/11-2013/14 (England SHA A), 2007/08-2016/17 (England SHA B) or 2010/11-2014/15 (all other) High case Base case Low case

Demographic growth3
Wales2 Northern Ireland Scotland

Residual growth1 0.9% 1.3%

Unit price inflation 1.2% 1.8%

Total do-nothing growth in spend 2.6

3.9%

0.5% 0.8%

1.5%

2.2%

1.9%

5.7%

1+

1.3%

1+

1.8%

1+

N/A

-1

N/A

England SHA A2

1.9%

1.8%

2.2%

6.0%

England SHA B2

0.3% 0.9%

0.8%

2.7%

2.5%

3.5

6.2%

1 Residual growth representing increasing expectations and demand for services, improving access to care, changes in care technology, changes to clinical practice, changes in disease profile and all other factors which increase demand for care, other than demographics. Details of calculation for Northern Ireland in appendix; calculated at 2.4% incorporating ageing factor and excluding prescribing (which were then deducted and added respectively to give figure shown above); 2.4% comprises ~4% for acute, ~1% for social care, ~0% for community and primary healthcare, based on 04/05 08/09 CAGRs; ~0.8% ageing factor and ~0.6% impact of prescribing volume increase are based on DHSSPS assumptions 2 Healthcare only, excludes social care 3 Accounts for growth of whole population (0.7% CAGR for NI, source NISRA) and changes in age profile (0.8% CAGR for NI, source DHSSPS) NOTE: Total growth in spend CAGR for comparators is accurate; constituent CAGRs are approximate representations of the aggregation of CAGRs applied at service line and organisation level and then compounded in each year. Differences in methodology mean that figures for different regions are approximately but not precisely comparable SOURCE: Expert interviews; DHSSPS; Welsh and English SHA QIPP plans

We expect growth in demand for health and social care activity to drive costs up by ~3.7% p.a., of which ~1.5% p.a. will be caused by demographic factors (population growing and ageing) and ~2.2% p.a. by residual factors. At the same time, unit costs are inflating. We expect inflation to increase overall costs by ~1.9% p.a., as a result of rises in:
Staff pay and grade inflation protected under Agenda for Change The cost of supplies, especially drugs caused by external market factors Inflating cost of contracts with external service providers (primarily private

nursing homes and family health service practices such as GPs, dentists, community pharmacists, and ophthalmologists). If we were to continue providing health and social care in the same way as we do today, we estimate that we would need ~5.4 billion of funding by 2014/15 to cope with this combination of growing demand for care and inflating costs. Given that we expect funding to be below this, we are faced with a substantial funding gap if we do nothing to change the configuration and delivery of our services.

22

Doing nothing is clearly not an option; neither is responding by leaving services as they are and assuming (in line with popular perceptions) that funding shortages could be addressed by reducing senior management pay, reducing the number of managers, or targeting managerial expenses. While such actions may have a symbolic value in signalling a culture of cost-consciousness, they will not solve the funding gap. HSCNI spends ~300 million on administrative staff at all levels, including ~140 million on managers (~7% and 3% of total annual spend, respectively). Most of the significant management, administrative and overhead efficiency savings potential has already been captured through RPA and the potential for further savings is limited. Instead, fundamental change is required where most funding is spent the services we deliver. It is clear that we need to act now both to improve our systems productivity and to manage down the demand on our services while driving up quality. As we mentioned in the previous section, we believe fundamental reform will be necessary to achieve both of these. 3. RESHAPING THE SYSTEM: OPPORTUNITIES TO IMPROVE BOTH QUALITY AND PRODUCTIVITY In the previous section, we described the need to improve both the quality and productivity of our health and social care system. In this section, we set out ways of doing this, and the potential impact. Improvements in quality and productivity can, and often do, go together. In this review, we have considered only opportunities that have both a positive effect on productivity and a positive or neutral effect on quality. Section 6 describes some further, more radical opportunities to make savings, such as the introduction of co-payment for services. In looking for opportunities to improve, we have compared the different parts of our health and social care system with each other, and compared our whole system with comparators in England and elsewhere. These comparisons suggest two main types of opportunities with a neutral or positive effect on quality: actions that optimise the quantity/ type of care provided, and actions that reduce the unit cost of that care. We have assessed the 14 main such opportunities, described below, split into two groups:
Opportunities 1-6a optimise the quantity or type of care Opportunities 6b-14 reduce unit costs

23

1. Better management of long-term conditions. We could reduce demand for

additional, sometimes costly treatment by providing more proactive, effective and co-ordinated community-based care. This would improve quality of life and health status, prevent complications, extend life expectancy and prevent hospital admissions. This would include offering greater support for self-care and carers.
2. Decommissioning clinically ineffective or non-essential treatments. We

could cease providing treatments that are relatively ineffective (e.g., insertion of grommets), potentially cosmetic (e.g., aesthetic ear/ nose/ throat surgery), treatments for which there is a more cost-effective alternative (e.g., hysterectomy for menorrhagia) or which have a close risk-benefit ratio (e.g., Cochlear implants).
3. Preventing illness. We could prevent illness in the long term by promoting

healthy lifestyles for the whole population (e.g., smoking cessation, breastfeeding, healthy eating, healthy weight, reducing alcohol intake, immunisation, screening, safer sexual behaviour). This would have a minimal short-medium-term financial impact but potentially more substantial longerterm impact.
4. Managing referrals/reducing variation in assessment. We could control

activity levels through a more managed system of practice in areas of healthcare where a given patient is sometimes referred for more treatment, and sometimes not specifically targeting GP referrals to hospital consultants and A&E admissions to hospital.
5. Optimising urgent care. We could reduce the number of urgent admissions to

hospital by preventing people needing urgent care in the first place (e.g., falls prevention support for older people), and by managing them better once they do need it (e.g., making better use of minor injuries units instead of A&E, or by improving care in A&E). This opportunity goes beyond the improvement potential already identified through better management of long-term conditions (listed as 1, above).
6. Social care improvements include two main types of opportunity: 6a. We could reduce the number of clients receiving care by:

More consistently applying assessment protocols that govern whether or

not a client receives social care

Allowing a few weeks intensive rehabilitation, for instance after a fall or

operation, before assessing the client for ongoing social care instead of

24

assessing them while they are still acutely unwell and therefore more likely to appear to require more intensive ongoing care.
6b. We could reduce the unit cost of social care through:

Improved procurement of externally-provided services Greater operational efficiency of HSCNI-provided services Greater use of individual budgets, which incentivise the service user to

optimise the care they use by allowing them to choose and procure it, with support
Delivering more social care in peoples own homes rather than in nursing

and residential homes. There is also significant scope for cost reduction if we were to match English protocols for user payment and/or co-payment for domiciliary care. This is described along with other co-payment opportunities in section 6.
7. Shifting to lower cost settings. Some patients could be treated as well, if not

better, outside of hospital and at lower cost. Clinicians in NI and elsewhere say about a quarter of outpatient appointments are for issues that could be treated by a GP (with sufficient specialist support).
8. Productivity improvements that would reduce unit cost include:

Reducing average length of stay (ALOS) in hospital, through more

intensive therapeutic care while in hospital, more efficient hospital operations, and better out of hospital services to accelerate appropriate discharge.
Increasing staff productivity by improving working processes (such as

planning and scheduling), management systems (e.g., performance management), changing staff mindsets (e.g., adopting a culture of always taking the patient/client perspective, by asking, What is best for Esther? 6 ) and raising capabilities (e.g., in process mapping, customer service). Specific areas we could target include

6 "Esther" is a fictional, ailing, but competent elderly woman with a chronic condition and occasional acute needs. She was invented by a team of physicians, nurses, and other providers who joined together to improve patient flow and coordination of care for elderly patients in Hglandet, Sweden. She, or equivalent fictional patients/ clients, have been used to drive collaboration and improvement in several regions. Another example is Torbay Care Trusts Mrs Smith, used to drive full integration of frontline multi-disciplinary teams. Source: Institute for Healthcare Improvement

25

Acute staff productivity for example reducing the time surgical theatre teams spend waiting for the patient or variability in practice between consultants for the same condition Community-based health and social care staff productivity for example reducing time spent on admin by introducing better technology and streamlining processes GPs productivity for example, reducing the time wasted as a result of people not attending pre-booked GP appointments or reducing the down-time between appointments.

9. Optimising prescribing and procurement of pharmacy. We could reduce

the unit cost of drugs prescribed by increasing the use of generic drugs and therapeutic substitutes, by controlling therapeutic creep 7 and through better negotiation during the procurement of drugs. We could also reduce the quantity of drugs used by introducing more clinical protocols that set clear guidance on prescribing amounts (which could also help reduce medication errors).
10. Optimising procurement of other supplies. We could reduce the cost of

supplies other than pharmacy by making our procurement approach more costeffective, e.g., reviewing standards for the products used, reducing waste, and consolidating our spend on fewer product variations and a smaller number of suppliers to get the best price.
11. Making better use of our estates. We could reduce estates costs by

minimising the amount of vacant and under-used space in our system; in the short-term possibly leading to vacating leased space, in the longer term a review of our estates footprint.
12. Improving management of patient flows to and from other regions. We

could introduce more cost-effective procurement of services provided outside of Northern Ireland (e.g., eating disorder services) and better management of two-way reimbursement for patients who cross the border (in either direction) with the Republic of Ireland for treatment.
13. Renegotiating unit prices or re-procuring services. We could introduce

more cost-effective procurement of services provided by third parties within Northern Ireland primarily private nursing home care and family health services practices (GP, dentistry, community pharmacy and ophthalmology).

7 The use of more expensive drugs for conditions that could be treated by a less expensive drug

26

14. Optimising management and other administrative overhead costs. We

could review the structures and activities of HSC Trust management, the Health and Social Care Board (HSCB) and the Public Health Authority (PHA), to reduce any duplication and waste. (Some or all of this opportunity may already have been captured through RPA.) The diagram below shows a high level assessment of the relative potential impact of these improvement initiatives, drawing on a combination of benchmarking analysis and a review of changes made in other parts of the UK and other health and social care systems worldwide.
EXHIBIT 15
Improvement opportunities can be prioritised according to quality and financial impact and ease of implementation
Quality impact Low 1 2 LTC management, early intervention Decommissioning Prevention Referral management, variation in assessment Optimise urgent care Social care Shift to lower cost settings Productivity (staff productivity, inpatient ALOS) Prescribing and Procurement of Pharmacy High Financial impact Low High

INDICATIVE
High Priority Medium Priority Lower Priority Ease of implementation Low High

3 4 5
6 7

8 9

10 Procurement of other supplies

11 Estates better use of space 12 Patient flows to/ from other regions

13 Renegotiate unit price or reprocure services 14 Reduce management costs and other administrative overheads
SOURCE: Workshop 16 August 2010 (70 participants), NI interviews, experience of similar initiatives in England

If we can match the highest performing 25% of English organisations or equivalent benchmark in each of these 14 areas of opportunity, we will improve quality and reduce required funding in 2014/5 by ~15% (compared to the do nothing scenario and excluding transition costs). However, achieving these improvements will not be easy as will be discussed in more detail later in this document:
Implementing high quality, efficient services would require and result in

major changes to the way our services are configured (see section 4): this

27

transformation of the health and social care system in Northern Ireland would require some supporting policy and legislation changes as well as strong political and clinical leadership to make the case for public support.
Few healthcare organisations have achieved this level of improvement across

all parts of the system simultaneously.

70% of organisational transformations, across a wide number of different

regions and industries, fail 8 . Typical reasons include lack of leadership will and capacity, lack of organisational capabilities and knowledge, poor accountability and ownership of performance by relevant staff, and misalignment between organisation-wide aspirations and individual/team goals and targets. Many of these statements are true of Northern Ireland right now (see section 5); success would require substantial changes in our culture and ways of working.
Transition costs (e.g., redeploying or reducing staff, acquiring new

technology, running duplicated services through the transition, refurbishing buildings) could amount to ~0.3 billion in total over the 4 years 2010/112013/14. (Section 5 provides a breakdown of estimated transition costs.) It is unclear whether the identified productivity and quality improvement opportunities will suffice to close future funding gaps. If not, then there are other actions which can be taken to reduce required funding in future, which do not fundamentally improve (and may worsen) quality and the systems allocative and technical efficiency. These include: co-payment by the service user; controlling staff wage inflation; and restricting access to services. These are discussed in more detail in section 6 of this document. 4. IMPLICATIONS FOR THE SYSTEM: WHAT A NEW, HIGHER QUALITY AND MORE EFFICIENT SERVICE COULD LOOK LIKE Our vision for health and social care in the future capturing the identified opportunities to improve quality and productivity will require, and result in, a system that looks and feels very different from today.
Optimising the quantity and type of care required will depend on higher

quality services in the home and community that play a more central role in peoples care and actively improve health and wellbeing. This will result in
8 Beer and Nohria (2000); Cameron and Quinn (1997); CSC Index; Caldewell (1994); Gross et al (1993); Kotter and Heskett (1992); Hickings (1988); Fortune 500 interviews; Conference Board Report; press analysis

28

reduced activity in hospitals and while introducing: greater integration of primary and community health and social care; 12-16 hours a day, 7 days a week access to out-of-hospital and urgent care services; multi-disciplinary teams; and increasing scale of out-of-hospital care to ensure these standards of service are possible.
Reducing unit costs will require a step-change in productivity across all

settings, by taking actions such as improving appointment scheduling, making greater use of a mix of skills, adopting care protocols and reducing length of stay in hospitals. All of these will also result in higher quality of care. In addition, we will need to consolidate services so they operate at greater scale particularly within the acute sector to ensure the minimum levels of activity required for clinical quality while at the same time maintaining local access to urgent care services. These changes will substantially impact current services. As an example, the diagram below shows how a network of organisations spanning major acute hospitals through to integrated primary, community and social care centres could effectively provide care to the population of Northern Ireland.
EXHIBIT 16
SERVICE CONFIGURATION OVERALL

Ideally, health and social care will be delivered by a network of organisations

Integrated care centre Local hospital

ILLUSTRATIVE AND HIGHLY PRELIMINARY

Major acute hospital

Description

Integrated primary, community and social care, possibly including outpatients and day cases

Range of acute services including ICU Urgent medicine and PATS1

Comprehensive acute services including Level 3 ICU Neurosurgery, (cardiology, trauma)

1 Paediatric Ambulatory Treatment Services

29

Over the coming months, Northern Ireland led primarily by health and social care professionals will need to develop and implement a new model of service configuration that includes:
Fewer acute hospital sites, reflecting the need to consolidate services for

quality and productivity reasons, as well as the impact that reducing length of stay and acute activity will have on smaller local hospitals ability to cover their fixed and semi-fixed costs
Development of local hospitals that provide local access to urgent care

services, complex and urgent medicine, intensive care units (ICU), and paediatric ambulatory treatment service (PATs)
Integrated care centres that support multi-disciplinary team working across

primary, community and social care, and offer 12-16 hour, 7 day a week urgent care services, diagnostics, assessments and access to outpatient services
Ambulance and transportation services that support the new service

configuration
Reconfigured mental health and learning disabilities services that provide

greater care in the community, less in inpatient settings. The scale of the change that is likely to be needed should not be underestimated. For example, within out-of-hospital care, the system will need to move from an individualised GP practice-based system with a high fixed cost base and low utilisation of assets to a consolidated model which offers efficient, integrated, and ideally co-located provision. Whichever model of out-of-hospital care that is implemented in each region whether that be networked provision, hub and spoke, or fully co-located services changes will be needed across all services.

30

EXHIBIT 17
SERVICE CONFIGURATION OUT OF HOSPITAL

Within out-of-hospital care, changes will be needed across all services

From To

ILLUSTRATIVE

Urgent care

Diagnostics

Some current A&E activity is unnecessary, with suboptimal care and resulting unnecessary admissions into hospital, Restricted primary and community care out-of-hours access (requiring travel to alternative acute locations) Duplication of services such as minor injuries units, GP out-of hours and A&E Duplication of diagnostics due to poor communication between GP and/or consultants Indicative cost of diagnostics bundled with other procedures, resulting in poor equipment utilisation rates Primary care contracts based on per capita criteria Non-itemized community services contracts Variable access to services Disconnected and / or unintegrated social care delivery Outpatient consultations delivered almost exclusively by consultants Minor procedures often delivered in hospital with unnecessary admissions Series of uncoordinated visits for LTC treatments managed by the patient Inconsistent adherence to protocols/guidelines Admissions into hospital for treatment of poorly managed LTC conditions

Min. 12x7 access to local urgent care services based around primary care easily accessible with the lights on and the doors open and diagnostics on site GPs have easy access to expert advice

Direct access for GPs, ideally through provision of diagnostics in enhanced primary care centres Integration of services into one centre with electronic results accessible throughout the integrated care centre (IT enabled) Tariff based on true cost of diagnostics, requiring a high equipment utilisation rate Fully integrated teams of primary care, community care and social care workers easily available at least 12x7 Primary contracts based on GP performance and staff and space utilisation Monitoring of community and social services activity, with tariffs based on performance Outpatient consultations delivered by a mix of consultants, GPs, nurse practitioners and other health professionals Day care procedures with minimum time spent in network Limited emergency hospital admission thanks to greater prevention, coordinated care, adherence to guidelines and GPs relying on easy access to expert advice Care pathway coordinated by the patients doctors (GP and specialists) Single organisations consisting of primary care, community care, social care which operate efficiently and seamlessly

Primary and community care

Social care

Planned care (OP, minor procedures) LTC and case management

Although these changes are significant, they have been advocated by professional and managerial leaders in Northern Ireland for many years as a means to improve services with some innovations already in train, as outlined in section 1. Whatever final shape our service configuration may take, what is not in doubt is that changes of this magnitude will be needed in order to meet the current financial and quality challenges. Reconfiguring the model of service provision to improve quality and productivity also affects how much capacity is needed in each type of care. In some areas, some current capacity will need to be reduced. However, in many areas, the task is less to reduce current capacity than to avoid the introduction of unnecessary additional capacity in future years through more productive use of existing capacity. In the do-nothing scenario, considerable additional capacity would need to be added to deal with the increasing levels of demand. Much of our effort will need to focus on changing the way services are delivered, increasing throughput and flow of activity so that we can do more with the capacity we have.

31

EXHIBIT 18

Some savings involve removal of capacity; others making better use of current capacity to avoid adding more in coming years
Reduction in 2014/15 required funding2, m
Main improvement levers 1 Optimise the care delivered (allocative efficiency) 2 3 4 5 Decommissioning Prevention Referral management Optimise urgent care
1

Required change to capacity/ cost (relative to 2008/09) Greater productivity to remove Greater productivity to avoid existing capacity adding capacity

LTC management, early intervention

6a Social care activity - later assessment for care 6b Social care activity - eligibility for care; type of care 6c Social care unit cost reduction 7 Shift to lower cost settings 8a 8b 8c 8d 9 10 11 12 13 14 Productivity - inpatient ALOS Productivity - acute staff Productivity - community-based health/ social staff Productivity - GP Prescribing and pharmacy procurement Procurement of other supplies Estates - better use of space Patient flows to/from other regions Rengotiate/ reprocure externally-provided services Reduce administrative overheads
0 50 100 150 200 0 50 100 150 200

Reduce the unit cost of required care (technical efficiency)

1 Social care is one area of application of several improvement levers, but for practical reasons, all social care improvements included in social care levers (6a-c) and omitted from relevant other levers (e.g., 13) 2 Relative to do-nothing scenario; gross of opportunities captured in 2009/10 or planned for capture in 2010/11; excludes transition costs; assumes 16% population need weighting for NI relative to England; quartile performance; includes annual residual growth 3 Split between removal and non-addition of capacity/ cost based on activity changes except inpatients (based on change in number of required acute inpatient beds) and primary care drugs (based on change in spend) SOURCE: Various

The overall impact on activity of the new model of care described above varies by the different settings of care:
Less hospital capacity will be needed, e.g., ~350 fewer hospital beds and

~30% fewer hospital outpatient appointments than were required in 2008/09. This equates to ~1,150 fewer hospital beds and ~40% fewer hospital outpatient appointments than needed in the do nothing 2014/15 scenario.
Greater capacity will be needed in community-based services, e.g., ~20%

more general practice consultations and ~15% more community healthcare contacts than were required in 2008/09 (5% and 1% more, respectively, than needed in the do nothing 2014/15 scenario). The planned increases in community-based service productivity will contribute to these increases in capacity.

32

EXHIBIT 19
Required capacity will change - differently for each type of care
Required capacity
10.3 1.5 11.9 0.6 12.5

2008/09 to Do nothing managed to managed 2014/15 2014/15 21% 5%

General practice consultations

Community healthcare contacts

4.1

0.6

4.7

0.1

4.7

15%

0%

54.1

11.6

65.7

12.6

53.1

Staff

-2%

-19%

5,406

807

6,213

1,165

5,048

Acute beds 2008/09 Impact of Do nothing demographics, 2014/15 residual growth Impact of Managed improvement 2014/15 opportunities

-7%

-19%

These changes to capacity will have particular implications for workforce. Overall, our very preliminary estimates are a net reduction of ~1,000 staff relative to 2008/09 levels a reduction that is likely to be more than adequately covered by 2014/15 through natural attrition and retirement. However, this headline figure masks the scale of the workforce change required. If we continued to provide services as we do now (the do nothing scenario), we would need an additional 10,000 or more staff by 2014/15. To avoid this, we need to help our workforce operate in very different ways, and shift the workforce skills mix towards delivering more care out of hospital. Fewer staff will be needed in hospitals and residential facilities, while more staff in some professions may be needed in the community. Over the coming months, a substantial amount of work will be required to derive the specific, local implications of our new vision for health and social care, including the optimal location of capacity and the detail of our estates and workforce strategies.

33

5. WHAT IT WILL TAKE TO TRANSFORM Implementing the structural and other changes described above will be challenging. To succeed, a number of enablers must be put in place: political, professional and managerial leadership across the system; capability and capacity to implement the changes; the right supporting infrastructure and systems; and compelling communication of the case for change and our vision for the future. We describe each in more detail below. Leadership We need to ensure:
Strong political, professional and managerial leadership across the system Local leadership of required changes by professionals, managers, and local

political and community leaders. Unless there is alignment across a broad group of leaders on the need to change and the approach to take, we will not be able to implement improvements at scale in the required timeframe. It will therefore be vital to get together a group of leaders who will work together to champion the reforms, pioneer and support innovation, speed up decision making and ensure that actions across the system are coherent and aligned. Such leaders are likely to be, at system level: Ministers, HSCB, PHA, DHSPSS, HSC Trusts, senior health and social care professionals, Patient and Client Council, Trade Unions, staff and professional representative bodies; and at local level, local professional, managerial and community leaders, and MLAs. It will also be important that leaders from all professional groups are at the heart of designing improved models of care. They must be given a clear remit and responsibilities to lead implementation in their organisations and communities, and will need the training, data and managerial support to do so. Capability and capacity We must put in place:
Sufficient leadership capacity and capability both professional and

managerial, especially for programme management and delivery of improvement initiatives

Mechanisms to make the most of scarce skills and resources (including

central support and ways to share learning and innovation between organisations)

34

 A workforce pipeline and talent management process that is aligned to the

strategy. The level of capacity and capability that exists to drive change in our system varies greatly across organisations and localities. We will need to identify and nurture the high calibre leaders we have, and put in place programmes to develop the implementation skills of HSC Trusts, LCGs and other professionals, and the commissioning skills and capabilities of the HSCB/ PHA and LCGs. We cannot afford to wait for innovation and clinical/ professional breakthroughs to trickle slowly through the system, or to have organisations attempting to reinvent the wheel. We therefore plan to assess opportunities via test-bed pilots that can be rapidly rolled out to other Trusts once completed. Finally, we must not wait until reconfiguration of services is complete before turning attention to workforce issues. We will need to make proactive and immediate changes to our workforce pipeline and deployment of staff to reflect the future delivery of services for instance by influencing graduates to apply for roles that will be of growing importance in future, and by developing training that reflects new roles and/or helps individuals to switch between roles. Supporting infrastructure and systems Implementing changes to the system on this scale will require:
A robust transformation programme architecture and an effective on-

going performance management system. We need to establish clear lines of accountability for delivery, and incentives for individuals, teams and organisations that are aligned to our strategy. For example, we will need to introduce incentives for staff and partners (e.g., midwives, nurses, social care professionals, GPs, consultants) to improve productivity across the system not just in their own part of it.
Investment in technology to improve our ability to: Generate useful data on performance on both quality and productivity

across NI
Support new delivery models (e.g., a single electronic health record that

would allow multi-disciplinary teams to work together seamlessly; telemedicine equipment to allow patients/clients to monitor their conditions at home with support from teams of professionals).
An estimated 0.3 billion transition funding over the 4 years 2010/11 to

2013/14. We have begun to estimate the costs of implementing the changes

35

described in chapters 3 and 4 (e.g., workforce transition, acquiring new technology). The exhibit below illustrates the breakdown and phasing of these cost estimates.
EXHIBIT 20
TRANSITION COSTS

Main transition costs could amount to several hundred million pounds

m, rounded to nearest 5m
2010/11 Capital Investment 2011/12 45 2012/13 2013/14 2014/15 Assumption made

ILLUSTRATIVE ONLY FURTHER WORK NEEDED TO CALCULATE

Each new primary care partnership and associated integrated care centre would require ~2.5m refurbishment1 No net reduction in total workforce above natural attrition Acute staff impacted by shift of activity into home/ community must be either made redundant (and replaced by communitybased staff) at a cost of average 08/09 wage of 44k and one month payment for each of 15.64 years of service, split 60:30 over years 1 and 2 or retrained at similar cost Unit productivity savings and switches to care have half a year lag in achievement due to time to shift staff/ activity and/or close wards/ sites Telemedicine; hardware (e.g., laptops); etc (One-off) introduction of new IT systems Very rough estimate of ~0.5% of total spend in 2011/12-2012/13 and half that in 2010/11 Estimated based on experience at 2% of yearly savings opportunity; front-loaded to recognise time to implement and capture savings Increased need for effective communications teams both internally and externally

Workforce transition

65

30

Double Running

30

15

Acquisition of new technology

10

20

20

Project mgt and external support Communications

10

10

Total one-off transition costs

17

147

92

22

~280m in total

Note: Assumes 16% population weighting for NI relative to England; includes annual residual growth 1 Healthcare for London work scaled up to reflect larger footprint / population served and inclusion of social care; assuming mixture of new build, refurbishment and reuse. Note excludes ongoing capital investments

Communication and engagement We need to communicate the case for change and the vision for future services effectively, and involve stakeholders in making change happen. We will need to begin this process soon, to engage communities, patients, clients 9 , professionals and all staff in shaping and supporting system-wide changes such as individual budgets and home-based care before implementation, as well as effectively engaging opinion formers (e.g., the press, unions) in the rationale and direction of change. We will also need to establish a robust clinical and professional rationale for changes very clearly early on, if we are to successfully engage health and social care professionals themselves in driving the changes. Finally, we must think carefully about who tells this change story to partners, staff, managers and local professional leaders across the system, and how. Without a coherent narrative to explain why and how the system needs to change,
9 Fulfilling, but not limited to just fulfilling, our legal Personal and Public Involvement (PPI) responsibilities

36

staff and partners will find it difficult to remain focused on providing consistently high quality, efficient service delivery, or to plan effectively during the changes.

The absence of any one of these enablers will reduce our ability to deliver the identified improvement opportunities thereby increasing the funding the system will require. Any delay in putting these enablers in place, or any decisions which do not acknowledge or permit strategic change, will reduce our ability to generate the savings we believe are possible. We estimate that for each month of delay, the feasible reduction in 2014/15 required funding will reduce by at least ~5 million. (See below exhibits)
EXHIBIT 21

Enablers will take some time to put fully in place

Broader enabler Effective senior professional, managerial and political (Minister and broader political body) leadership of required changes Effective local professional, managerial and political leadership of required changes Sufficient leadership and managerial capacity and capability (including central support, learning from other organisations) Access to required transition funding including capex Workforce pipeline aligned to strategy Effective communication of required changes Robust transformation programme architecture with clear, single point accountabilities for each programme area; sufficient capacity and capability; good information Effective on-going performance management system with incentives for individuals, teams and organisations aligned to strategy Technology-enabled: Performance information (NI-wide, consistent for quality and productivity)

Of particular concern in Northern Ireland

Months required to put fully in place Likely to be led by 6-9 3-6 12 3 12-24 2 6-12 HSCNI, DHSSPS HSCNI, DHSSPS HSCNI, DFP DFP DHSSPS, Edu orgs HSCNI, DHSSPS HSCNI

18

HSCNI HSCNI, DFP

24 24 18 HSCNI, Professional orgs

Productivity (e.g., referral management, distance medicine, self-care)

NI-wide best practice care protocols

SOURCE: HSCB Director interviews

37

EXHIBIT 22

Decisions which do not permit strategic change will reduce the improvement that can be delivered within 4 years
Reduction in required funding1, billion

If implementation begins now 0.6

If implementation is prevented from beginning by 6 months 0.6

0.4 0.59 0.2

~5m per month of delay2

0.4 0.56 0.2

0 2011/12

2014/15

0 2011/12

2014/15

1 Relative to do-nothing scenario; net of opportunities captured in 2009/10 or planned for capture in 2010/11 all of which are assumed to be not dependent on legal process; excludes transition costs; assumes 16% population need weighting for NI relative to England; quartile performance; includes annual residual growth 2 For first 6 months; per-month cost of delay will be greater for delays more than 6 months SOURCE: Various, see previous analyses

We will need to work with other departments and stakeholders to enable the changes we need to make. Specifically, we believe we must:
Work to secure political support from Ministers and MLAs. Work with professional bodies and senior professionals to engage local

professionals in owning and implementing the required changes, across the HSC Trusts and family health services such as General Practice
Begin to communicate with staff and staff bodies about the case and vision

for change
Work with the Patient and Client Council to engage and involve community

leaders, patients and clients in the case and vision for change
Work with DFP to invest in required technology Work with DHSSPS Workforce to develop a detailed workforce plan,

engaging all relevant stakeholders in this, through the HSC Partnership Board

38

 Work with DFP to review remuneration scales of senior roles so as to access

the required talent.

Establish a programme management and transformation communication

office within HSCNI. 6. THE PACE OF DELIVERY By increasing quality and productivity as described in the preceding sections, and contingent on the necessary enablers being in place, we believe it is feasible for DHSSPS to reduce its 2014/15 required funding by 0.6 billion relative to the 5.4 billion do-nothing scenario. If more than this 0.6 billion is needed, a further ~0.1-0.3 billion could be achieved through the introduction of copayment and further savings through a freeze in staff pay costs. Any further savings will involve reducing quality by restricting access to services risking the integrity of the health and social care system. This is illustrated in the exhibit below:
EXHIBIT 23

To address the funding gap, HSCNI will need to increase productivity, and possibly also introduce co-payments, control pay and restrict access
2014/15, billion, potential impact on funds available for services, net of associated incremental re-provisioning costs but not of transition costs, assuming performance of best 25% of English organisations or equivalent Optimise the quantity and type of care provided Reduce the unit cost of required care
Range

0.2 0.8 1.1 0.3 0.1 0.1 0.6 0.1 0.2 0.3 TBC

Productivity and quality increases

Total possible productivity savings, as at 2008/09

Captured 2009/10 and 2010/11 Deliverable after 2014/15 Fixed and indirect costs

Total deliverable by 2014/15

Copayment by service user

Other quality neutral Other quality reducing

Control staff cost inflation

Total 2014/15 impact

Restrict access to services

TBC TBC TBC

Total 2014/15 impact

SOURCE: HSCNI analysis using 16% population need weighting for NI relative to England, and including annual residual growth

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Savings achievable through quality and productivity improvement

The 0.6 billion reduction in required funding is estimated as follows:

Evidence from three different assessments both local and international -

suggests ~3% improvement p.a. would be a stretching but feasible pace of change for HSCNI:
1. About half of the total quality and productivity improvement opportunity

will be subject to legal process. This will delay implementation and the capture of savings by 6-36 months, depending on the specific opportunity, and the point at which related savings can begin to ramp up (see below exhibit). Taking this into account, a reduction in required funding of ~3.03.5% p.a. to 2014/15 should be possible, assuming the enablers discussed in section 4 are in place.
2. In Northern Ireland, DHSSPS delivered ~3% CSR efficiency savings per

year over 2008/09 and 2009/10, and plans to deliver a similar percentage in 2010/11. These savings were measured against 2007/08 spend. Of the 3% savings, ~2% were recurrent savings delivered by HSCNI.
EXHIBIT 24

Opportunity-specific process will require up to ~3 years, depending on the opportunity

May vary by opportunity After this, it will take further time for opportunities to rampup to full potential impact Must be led by DHSSPS Executive DHSSPS Health Estates HSCNI HSCNI, DHSSPS, Edu orgs Executive, DHSSPS, HSCNI DHSSPS, HSCNI HSCNI HSCNI Parallel or sequential Sequential Sequential Parallel Parallel Parallel Sequential Parallel Parallel Sequential

Opportunity-specific process Change policy Public consultation1

Months 618 36 1018 6 12 2 6 6 3

Building refurb/ repurpose Staged rollout2

Staff transitioning/retraining Redundancy notice Bringing all key stakeholders on board Recontracting/reprocurement Planning

1 Including drafting the consultation document, considering responses and getting approval 2 Assumes change is not a groundbreaking pilot requiring evidence-based evaluation, rather the localisation of an approach already proven elsewhere SOURCE: HSCB Director interviews

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EXHIBIT 25
NIs identified improvements requiring legal process will be delayed in commencing ramp-up
Reduction in required funding1, m
Subject to legal process Not subject to legal process

Theoretical ramp-up, before legal process accounted for 4% p.a. improvement

Possible ramp-up, taking legal process into account 3% p.a. improvement

1,000 800 600 400 200 0 2011/12

Necessary legal and practical process

1,000 800 600 400 200 0 2011/12

2014/15

2014/15

1 Relative to do-nothing scenario; net of opportunities captured in 2009/10 or planned for capture in 2010/11 all of which are assumed to be not dependent on legal process; excludes transition costs; assumes 16% population need weighting for NI relative to England; quartile performance; includes annual residual growth SOURCE: Various, see previous analyses

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EXHIBIT 26
DHSSPS actual spend

DHSSPS has delivered ~3% p.a. improvement; HSCNI 2%

billion, nominal

DHSSPS spend on existing services after efficiency savings HSCNI spend on existing services after efficiency savings DHSSPS Investment

5 4

CAGR 2007/082010/11, % +4 p.a. -3 p.a.

-2 p.a.
2 1 0 2007/08
SOURCE: HSCB Finance; DHSSPS

2008/09

2009/10

2010/11

3. Experience in private and public healthcare and non-healthcare sectors in

the UK and other countries suggests that an organisation can typically deliver 2-5% improvement p.a. but that within public healthcare, it is difficult for the payor/ commissioner to deliver more than 2.5-3.0% p.a.
Taking a stretch target of ~3% p.a. suggests a maximum ~700 million

reduction in 2014/15 required funding is theoretically possible for HSCNI, assuming all enablers are in place.
Fixed and indirect costs will limit the spend that can be released where

existing capacity is being reduced (see exhibit 29 below). For example, if one ward on a site is closed, the cost of keeping the entire site open and of managing the HSC Trust will not be proportionately reduced.

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EXHIBIT 27
Improvement elsewhere has achieved 3-8% p.a.
% change p.a.
Time Years ALOS Number of beds Number of staff Cost per patient
Public healthcare Private healthcare Public non-healthcare Private non-healthcare

Country Organisation

Cases Procureper employee ment

Budget

England NHS England Primary Care Trust USA USA Regional hospital system Veterans Association

10-21 3 2 6

-3 -8

-3

-4 -6 -5 4 4 5 -8 -6 5

Germany German payor Germany Vivantes Canadian province Government 268 Manufacturing firms

10 2

Canada Canada Mostly America

2 2 4

SOURCE: See overleaf

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EXHIBIT 28

For improvements involving removal of inpatient capacity, full cost may not be releasable
Current cost breakdown, 2008/09
100% = m
Day-Cases 77% 5% 18% 150

Trust overheads Indirect costs Direct costs

Acute hospital

Inpatient

67%

11%

23%

989

There may be ways of releasing part of the indirect costs without a full site closure, e.g., close a large section of the site; rationalise support functions in line with reduction in activity Opportunities to reduce Trust overhead will likely be identified, which would facilitate release of some part of those costs captured in opportunity number 14 To be conservative, for the purpose of this analysis, we assume only direct costs are releasable without site closure

Outpatient and A&E

50%

28%

22%

364

Social care

76%

13% 11% 987

SOURCE: TFR

This is however not the case where the saving comes from avoiding the

addition of new capacity (as described in section 4 of this document). As a result, at least ~90% of productivity savings should be cash-releasable or cash-avoidable, i.e., ~0.6 billion reduction in required 2014/15 funding is possible.

Further savings achievable without necessarily reducing quality

In addition to the opportunities to improve productivity and quality identified above, there may be additional ways to reduce required funding without damaging quality by making regionally- and/or nationally-led changes to income and costs. Such changes would require decisions by political leaders and challenge the principle that the NHS is free at the point of delivery. However, the content suggests that such options may need to be considered.
We could generate revenue through co-payment by the service user, an

opportunity estimated to be worth 0.1 billion -0.3 billion p.a. by 2014/15.

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 Bringing co-payment protocols into line with the rest of the UK could be

worth ~50-80 million by 2014/15.

In addition to this, other co-payments such as are used in other European

countries or beyond that could potentially be introduced, if there was need and will. For example, people could pay for attending A&E (as in Republic of Ireland); for access to primary care (as in Germany); for inpatient stays (as in France).
Co-payments have a demand management effect as well as generating

revenue. They would therefore need to be carefully designed to ensure they do not discourage people who need care from accessing it. Models for doing this exist elsewhere and could be localised and further developed in Northern Ireland.
The decision on whether and to what extent to introduce co-payment would

be a regional one for the Executive, dependant on the relative merits and risks when compared to other options for closing any funding gaps.
EXHIBIT 29
NI-SPECIFIC ANALYSIS

Revenue generated by co-payments on services could be between 140 302m

Range

2014/15, million, potential impact on funds available for services, net of associated incremental running costs
Ranges are used to illustrate the potential scale of opportunity. More work will need to be done to ratify the assumptions made within the model
35

A Align fees/ funding thresholds to rest of UK B Fees additional to the rest of the UK C Potential other methods of charging

Prescription Charges Dental Social Care (Community care services) Outpatient DNAs and CNAs Primary Care Consultation Fees Fixed daily payment for Inpatient stays >24hrs Imaging Diagnostics A&E attendances Patient Transportation Car Parking
Total

17 22 39
2

47

79

20

12

49

20

39 3

11

38 5

8 13 140
302

SOURCE: GEK-Report 2008; Ameli; Northern Ireland Hospital Statistics 2008/09; Northern Ireland Neighbourhood Information Service; Prescription Charges in Northern Ireland Report, dhsspsni, Dec 2007; Department for Health

We could also control costs by keeping staff pay costs flat (i.e., preclude or

neutralise the impact of pay inflation and grade inflation): this could save

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~0.1 billion p.a. by 2014/15. However, such a change would likely need to be addressed at national level, and so is not explored in detail here.

Savings achievable by reducing quality

If further reductions in funding were to prove necessary, beyond the identified improvements in productivity and quality, and the changes to income and staff costs described above, then quality of care and the integrity of the HSC system would be put at serious risk. We would need to restrict access to services and treatments, for example by:
Enforcing tougher eligibility criteria for treatments, e.g., hip replacements

only for the over 80s, social care packages only for the acutely-ill, asking people who need it to buy their own equipment
Introducing means-testing, i.e., making people pay for care if they can afford

to
Denying treatments that are high cost per Quality-Adjusted Life Year

(QALY), e.g., high-cost end of life treatments such as chemotherapy

Reducing funding of services seen as non-core, e.g., voluntary and

community groups which currently substitute and/or prevent need for statutory care. Such actions would risk legal challenge, for example on the basis of equal access. They would involve further bed closures and workforce reductions, of ~150 beds and ~1,200 staff per 0.1 billion further reduction in 2014/15 funding. Such changes would also undermine the integrated, preventive management of peoples well-being, resulting in them needing more urgent and other acute care, thereby indirectly increasing costs.
7. IMPLEMENTATION PLAN

As described in section 5, we are working to develop a robust and comprehensive implementation plan that will marshal support from professionals and political leaders, engage the workforce and the public, and put the right resource in place to implement the changes we need. This plan will set out how we will deliver, in the first instance, our 2011/12 productivity and quality improvement priorities, and how we will test and roll out

46

improvements for the longer term. It will incorporate local, tailored plans for delivery, building off best practices and successes both locally and beyond NI/the rest of the UK, and describe the governance and programme architecture we will use to manage implementation. To implement successfully, we will need to generate and maintain a level of momentum for change over and above what is currently within the system. There will inevitably be uncertainties surrounding political leadership and the implications that may have on health and social care in the run-up to the election. However, a significant number of the changes proposed are ones that any health and social care system should implement as guardians of quality, health and wellbeing outcomes, regardless of the political or financial context. A key first step will be to put in place the transformation architecture and programme management to support the necessary changes. This will be important to create accountability at all levels on delivery and ensure that implementation is coordinated and learnings are shared. We will need to dedicate sufficient capability and capacity to programme management to ensure successful delivery in both the short-and long-term.
EXHIBIT 30

Setting up a clear implementation organisational structure will be critical to ensure co-ordination and accountability at all levels on delivery

Transformation Steering Group

DHSSPS Perm Sec, HSCB and PHA CEs, HSC Trust CEs, LCG Chairs, relevant Chief Professional Officers, Patient & Client Council Monthly meetings to monitor progress, challenge plans, remove road-blocks Central coordinator of overall transformation planning and delivery including: Developing and aligning the vision Creating communications Setting overall transformation and specific programmes objectives and metrics Providing LCGs/Trusts guidance on what makes a good plan Acting as a connector to share best practices across localities Develop local plans to execute the specific opportunities, with clear and detailed actions, accountabilities, and timelines Define, consult and implement specific future model of care delivery within own region, in line with overall NI vision Accountable for specific test-beds within own region (before subsequent roll-out to other regions) Nationally led programmes consisting of cross-NI working groups encompassing clinical and professional leaders, Trust senior managers, LCGs, DHSSPS and HSCB/PHA members Responsible for identifying: The objectives for the programme and specific performance/delivery measures (in tandem with the PMO) What will be required to implement the programme and how to implement Barriers to implementation and mitigators Oversee regional test-beds, where set-up and appropriate Convene regular all-region workshops in each opportunity/enabler area to help share content, measure progress, share learnings and create friendly competition to maximise impact

Staff: 510 people

Programme Management Office

Specific opportunity programmes

Enabler programmes

Trust

Trust

1, 4. LTC and referral management

A.B.C.D. Transformation architecture, leadership and comms

Trust

Trust

Trust

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Implementing such major change will depend upon a cadre of both professional and managerial leaders, at all levels, across the system. We need to identify them, support them and give them the tools and capabilities that they will need to deliver successfully. In addition, we will need to put significant effort into our communications with the system as a whole, providing stakeholders with a clear, consistent, and compelling narrative for change and ensuring that we have sufficient communications capabilities both centrally and regionally. Although some actions to make savings will require legislation and policy changes, many can be started immediately. This includes actions that we can take as no-regrets moves (those that can be enacted before the expected election in mid-2011, such as continuing work on prescribing and procurement). In addition, we will need to start piloting, testing and implementing some of the longer-term initiatives, such as long-term condition management, reducing average length of stay and staff productivity. While we may not capture the full savings potential until necessary legislation and consultation is enacted (e.g., for reconfiguration), we can start to develop the new ways of working and protocols that will underpin future savings, and can start to make some structural changes if we have the discipline to not fill up freed-up capacity. This will be critically important where we need to test and pilot changes.

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EXHIBIT 31
Although all programmes will be led by cross-NI teams, some opportunities may need local test-bed verification before roll-out
Opportunity programmes

Likely to require locally-driven test-beds by 1 specific Trust/LCG before wider-rollout Centrally-driven by programme working group

6. Social care

7. Shifts to lower cost settings

8a. Productivity out-of-hospital

8b. Productivity in-hospital

9. Prescribing

14. Admin/OH reduction

1, 4. LTC and referral management

2. Decommissioning

3. Prevention

10, 12, 13 Procurement of external services and supplies

15. Co-payment

Enablers

A, B, C, D Transformation architecture, leadership and comms E. F, G. H. I, 11. 5 Incentives Information and IT systems Care pathway protocols Reconfig, service overlaps and estates strategy Capacity/capability building Workforce strategy and pay

J, K. L, 16.

We will also need to start planning for and understanding the implications of proposed changes on both estates and workforce so that we can take action over the next 6 months to start rebalancing current capacity towards areas where assets and skills will be needed in the future. While the savings opportunity may be limited in the next 6-12 months, we urgently need to start taking action now. There are some symbolic no returns actions we can take that will clearly signal the nature of the reform we will be undertaking, and help to maintain momentum for example, create a forum for the 5 HSC Trusts to take collaborative action to improve quality and productivity. Below we set out the current outline of what our overall implementation plan may look like.

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EXHIBIT 32
Main actions to capture the quality and productivity opportunities
2010 2011 Action Agree key drivers of change and future vision with Executive and other key system players Develop locally tailored plans to deliver opportunities Aggregate individual Trust plans into overall implementation and accountabilities framework Set up central governance (e.g., PMO) and support structure Manage 2010/11 quality and productivity improvement requirements Agree approach to no-regrets opportunities (e.g., fees, decommissioning) Roll-out no-regrets initiatives (e.g., fees, decommissioning, etc) Identify and start implementation of no-returns actions (e.g., removal of capacity) Agree policy approaches / responses to longer-term initiatives and their implications (e.g., reconfiguration) Start pilots in longer-term initiatives in specific Trust areas Rapidly roll-out and implement longer-term initiatives to other Trust areas Coordinated communications cascaded within and outside the system Implement national support programmes 2012 2013 Responsible Steering group plus Executive, DHSSPS, HSCB/PHA, LCGs, HSC Trusts HSC Trusts, LCGs PMO and steering group HSCB, DHSSPS Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Includes workforce and estates transition planning

Plan for success

Deliver 2010/11

HSCB/PHA, HSC Trusts

Start noregrets implementation

T e s t

Implement

Executive, DHSSPS, Minister, HSCB/PHA, LCGs, HSC Trusts HSCB, LCGs, HSC Trusts HSCB/PHA, LCGs, HSC Trusts

Pilot longerterm initiatives

HSCB/PHA, LCGs, HSC Trusts HSCB/PHA, HSC Trusts, LCGs

Roll-out longerterm initiatives

HSCB/PHA, HSC Trusts, LCGs

DHSSPS, HSCB/PHA, HSC Trusts DHSSPS, HSCB/PHA

Comms and support

We hope that this document sets out clearly the choices facing us and what it will take to ensure the people of Northern Ireland have a safe, high quality, costeffective health and social care service in the future. The changes ahead will be complex and challenging. We look forward to discussing our plans with DFP and working together as Departments to make them happen.

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