Frontline First - Northern Ireland

In Northern Ireland, the Health and Social Care service faces a bleak financial outlook during a time of continuing unprecedented change for health and social care services in Northern Ireland. Between 2007 and 2011, the service underwent the profound restructuring brought about by the Review of Public Administration [RPA] in 2007 and 2009, as well as achieving the associated financial savings. The service also delivered the £700 million in “efficiency savings” required under the previous Comprehensive Spending Review [CSR], as well as absorbing a £105 million (recurrent) budget cut imposed by the Department of Finance and Personnel in 2010-2011. No other Northern Ireland Executive Department has been required to make the full cost savings associated with the RPA and the 2008-2011 CSR.

At the same time, the service is undergoing substantial further restructuring and reconfiguration as the focus of care shifts away from traditional institutional settings, such as hospitals and care homes, in favour of treating people, wherever possible, in their own homes and communities. This has taken place against a historic background of the under-funding of health and social care in Northern Ireland.

The service is already struggling to cope with escalating demand. Between 2007 and 2009, for example, demand for elective services increased by 19%. Some 13,000 more elective operations were performed over the two years and 19,000 more accident and emergency attendances recorded. Out-patient referrals increased by 86,000 and 6000 more emergency admissions were made. This increased activity took place during a period when funding grew by less than 1%.

The Department of Health, Social Services and Public Safety [DHSSPS] forecasts that demographic growth and demand will increase by 15.2% between 2011 and 2015. Despite this, the 2011 Northern Ireland Executive Budget provides for current expenditure funding increases of just 1%, 1.8%, 2.6% and 1.9% over the four years and reductions in the capital programme of 33.7% in year three and 11.7% in year four. Based upon an inflation assumption of 2%, the DHSSPS has estimated that the 2011-2012 allocation represents a 1% real terms funding decrease, equating to £45 million. It is clear, therefore, that there is now a huge and growing mismatch between demand and resources in health and social care in Northern Ireland. Indeed, the funding gap will continue to widen, from £346 million in year one to £2.3 billion in year four. The RCN believes that this is unsustainable.

This shortfall must be viewed alongside the incontestably higher level of health and social care need in Northern Ireland. This has most recently been documented in Reshaping the system: implications for Northern Ireland’s health and social care services of the 2010 spending review, prepared by McKinsey and Company on behalf of the Health and Social Care Board.. On the basis of these considerations, McKinsey and Company estimate Northern Ireland’s additional need, compared with England, as 7-16% overall and 16-36% in social care.

The HSC workforce quarterly cost analysis reports, published by the DHSSPS, reveal that the qualified nursing workforce in Northern Ireland, measured by whole time equivalent with pay, has declined by 3% during the last eighteen months, from 13760.53 in December 2009 to 13401.26 in June 2011. The health care assistant (or “other nursing”) workforce also declined by 3% over the same period, from 4061.23 to 3954.62. The contraction has been particularly severe in the Belfast Health and Social Care Trust (4% and 6% respectively) and the Northern Health and Social Care Trust (6% and 6% respectively).

The RCN believes that the nursing workforce needs to be designed and developed in order to meet demand and provide timely and appropriate services to patients. Critical services such as diagnostics, senior medical cover, community services (including social services), AHP services and GP out-of-hours services are currently not meeting demand because they are not being appropriately designed. This, in turn, creates significant waste and inefficiencies, for example through inappropriate admissions, duplication of tests, and longer lengths of stay in acute hospitals.

The HSC staff survey, published by the DHSSPS in June 2010, highlights some of the inevitable consequences of the pressures deriving from this conjunction of a diminishing workforce and escalating demand. For example, 51% of HSC staff work without pay beyond their contracted hours each week, the vast majority (89%) because they want to be able to provide the best level of patient care they can. Over half (52%) of all staff feel that they are unable to meet all the competing demands upon them and less than a quarter (24%) believe that there are enough staff for them to be able to do their job properly. More than half (56%) say that they are overloaded because of staff shortages and more than one-third (36%) suffered work-related stress during the preceding twelve months. Handovers between shifts, when nurses report on the condition and treatment of each patient to those nurses about to come on duty and who will be responsible for providing safe and effective care during their shift,  have been reduced to as little as 15 minutes. The RCN regards this as thoroughly inadequate and a significant risk to patient safety.

These findings are broadly similar to the conclusions drawn from the RCN’s 2009 survey of the nursing workforce in Northern Ireland. This determined that just 50% of nurses working in the HSC believe that the nursing establishment where they work is sufficient to meet patient needs. Some 47% of nurses working in the HSC say that patient safety is compromised at least once or twice each week and only one-third (36%) say that patient safety is rarely or never compromised. It is worth bearing in mind that these results derive from the period before nurse staffing levels in Northern Ireland substantially started to decline.

Given current projections about further job losses in the HSC, with the Belfast Health and Social Care Trust alone predicting the axing of 500 whole time equivalent posts, it is clear that the current allocation for health and social care is widening the existing mismatch between demand and resources and increasing immeasurably the already intolerable pressures on nursing staff.