“An 80-year-old waiting five to seven years for a hip will not get that hip replacement. A child on a waiting list waits so long that they are transferred to the adult waiting list.” This is why the Assembly must come back – now

photo: Royal Victoria Hospital Belfast

When so much comment has been preoccupied with squeezing out yet another fine point about the council election results, rumbling on in the background has been another squeeze, the Barnett squeeze which has the effect of reducing the funding for Northern Ireland at the worst possible time.  (explanation later). Breaths are being held for a Westminster bailout of up to a £1billion more or less, to fill a budgetary black hole, on condition that the DUP return to the Assembly and regional government resumes. That in itself will prove no miracle solution. But it could be better than a start if they are forced to begin taking long overdue well identified decisions at last.  The state of the budget crisis is hardly news. But when the full picture is revealed in a single session, I suggest the effect is stunning to all but the case hardened or cynical.

Political obsessives privately find this stuff quite boring and head back quickly to their political games.  So why don’t you see if you can stick it out with my edited versions of last Thursday in a Westminster committee room on the state of crisis in Northern Ireland’s funding and governance?  The crisis is not hopeless. Surgical hubs can be introduced quite quickly.  The  Westminster subvention based on entirely measurable  need has been agreed with the Welsh government and as East Belfast  MP Gavin Robinson has argued, should be applied to Northern Ireland.  The words, as it were, speak for themselves.  The local media should be giving  these hearings decent coverage. Shameful that they virtually ignore them. .

Time  to squeeze hard on the politicians.

  NORTHERN IRELAND AFFAIRS COMMITTEE

Oral evidence: The funding and delivery of public services in Northern Ireland, HC 1165 Wednesday 24 May 2023 Ordered by the House of Commons to be published on 24 May 2023.

Health

Witnesses I: Dr Tom Black, Northern Ireland Council Chair, British Medical Association; Dolores McCormick, Associate Director, Employment Relations and Member Services, Royal College of Nursing; Professor Mark Taylor, Northern Ireland Director, Royal College of Surgeons.

Nursing crisis

Dolores McCormick: Thank you for the opportunity to provide this evidence today. As a thumbnail sketch, I would not be overdramatising it if I said that the state of our health service in Northern Ireland is beyond crisis. I would absolutely say that we have fallen off the cliff edge from the front door of our hospitals to the back, right out to our community primary care. We are facing incredible pressures. I am here today speaking from the Royal College of Nursing. Nurses are facing moral distress daily as they strive to deliver care, which they feel, on many occasions, sadly, is not the level of care that they want to be delivering. They are unable to meet the needs of patients. To me, that is where we are at. We are underfunded, with a workforce that is stretched and broken, and with an inability to do what it is that we came into the profession to do…: We have approximately 3,000 vacancies among nursing staff and, to plug those gaps, this culture of using agency staff has crept in and spiralled. It has now spiralled to absolutely scandalous hourly rates that are being used for off-contract agency staff

Surgery crisis

Professor Taylor: Thank you all very much for the opportunity to come here today. To set the scene, we have 122,000 patients waiting for surgery in Northern Ireland. We have 378,400 patients waiting to see a consultant for the first time. That is over 500,000 people in Northern Ireland currently waiting either to see a clinician or to have treatment. That is one in four of our population. We know from the time of Bengoa that there was a situation where we had to transform our health service but realised that we had a massive backlog. The difficulty with this current budget, and particularly reducing money that was addressing waiting list initiative work, is that all that that will do is simply add to the burden.

To set the context, our orthopaedic surgeons are seeing people whom they know they will never be able to give the treatment that they are designed to give them. An 80-year-old person waiting five to seven years for a hip will not get that hip replacement. A child on a waiting list waits so long that they are transferred to the adult waiting list, due to the length of time that they have waited. Every single day, vascular surgeons are making decisions around, “Is it the person who needs the lifesaving aneurysm operation?” which is an operation in the abdomen, “or is it the person who needs their leg taken off?”

Dr Black: We do not need to tell you what the funding is like. You have seen the documents that came to you. The funding is the situation. You cannot run a health service on that funding. We have heard about the workload and the waits. Just to put it into context, in England they are working very hard on their 18-month waiting lists. That is the focus in England at the moment. We are working very hard on our eight-year waiting lists, which is 96 months. In terms of comparison, how bad is it in England in terms of outpatients? 7 million patients are waiting. The equivalent number, when you take into account the population in Northern Ireland, would be in excess of 20 million.  In June 2022, the BMA held a press conference and said that we felt that, at that stage, the NHS in Northern Ireland was broken. We felt that there were 20 GP practices in crisis. We described the situation in terms of outpatient and inpatient waits. Since then, 16 of those 20 practices have closed. They have handed back their contracts. At this moment in time, we have 30 practices in crisis. How many of those will close? Which service is next to close? Is it going to be a surgical service in that hospital? Is it going to be medical or paediatric?

…we said in Bengoa that the stark option facing Northern Ireland’s health service was to resist change and see services collapse. We see that in emergency general surgery in the South West Acute Hospital, we see that in emergency general surgery in Daisy Hill Hospital, and it will not be long before other hospitals are the same. The difficulty is that my counterparts and friends in England, Scotland and Wales have made some of the decisions that we should have made a decade ago.

.Surgery The Solution – Surgical hubs

Professor Taylor   … elective surgery is always the casualty, whereas, in the infrastructure of Northern Ireland—forgive me for coming back to buildings—we have the opportunity for hospitals that are so precious to their local communities to stay open, not close, but under a different identity. That identity is surgical hubs that do not need to worry about the pressures of emergencies. That will build up the capacity to meet the ever-rising demand that we currently find ourselves with. We have seen examples of that in Omagh and Lagan Valley. We are now seeing it in South West Acute Hospital and Daisy Hill Hospital. They were hospitals that were feeling vulnerable because the word “closure” was always close by…

The important thing about surgical hubs is that they will allow elective surgery to take place seven days a week. That surgical presence in a building called a hospital will still allow that hospital to function as a hospital. While emergency general surgery or emergency surgical practice may come away from it, the fact that there is elective practice in there will keep the hospital open, as well as their ED (ANE) and their acute medical departments. The success of creating these hubs is that we do not have to face the question, “Do we close hospitals?” Remember that 60% of our waiting list is ambulatory. It is day care surgery. It is only 40% that is the big, complex stuff, and that is why these surgical hubs could really revolutionise the capacity that is needed. We are also going to need the independent sector and waiting list initiative work to deal with a backlog. We cannot use a new, transformed system to start off first with this massive backlog and then start to try to develop capacity

GP Crisis  

Dr Black I have fewer doctors now than I did 30 years ago when I started. We provide twice as many appointments per head of population. The average number of consultations is now seven per patient per year. When I started, it was 3.5. I have fewer GPs. How do I cope with that? We have a real problem at the moment. I am from the BMA, and my members expect services. My medical students have said to me, “Could you please develop guidance for applications for intern posts?” Interns is the name for F1s in the Republic of Ireland. My medical students want to go to the Republic, where they will be better paid and better treated. My consultants have asked me for guidance on how to apply for jobs in the Republic of Ireland. They want to move to the Republic of Ireland, where wages are twice as high. I declined both of their offers, on the basis that not only would they be outside the NHS, which would not be in the interests of the United Kingdom, but they would also no longer need to be BMA members if they moved to the Republic of Ireland. That is the problem that we have at the moment. It is not so much the funding. You are quite right, Carla, that we do not have enough funding to fix this at the moment. We need more funding, but it is not just the funding. We need more workforce. If our workforce is moving out of the jurisdiction, we have a real problem in the future.

Cross border operations – gone because of Brexit  

Claire Hanna MP You mentioned a cross-border dimension. A scheme that previously ran allowed for relatively minor procedures under an EU directive that appears to be gone now.

Dr Black: It was brilliant, Claire.  If you needed a hip replacement in Northern Ireland and the capacity was not there in the system—while we have only three private hospitals in Northern Ireland, there are 18 in the Republic of Ireland—you could go to the Republic and get your hip done in Dublin, Navan or wherever, and come back up. You paid half the price yourself and they covered the other half of the price. Some of my patients went to other European Union countries. That is no longer the case. They would go to Latvia and come back the next day with their knee replacement. I do not know how they managed it, but they did it. That is not available now. What my consultant colleagues tell me is that we do not have the capacity to mop up the 600,000 people who are on waiting lists. We simply do not have the capacity in the private sector or the public sector in Northern Ireland. Doctors in the UK would tell you that 30% to 35% pay cuts across the board—junior doctors, consultants and GPs—have arrived. You understand the Barnett consequentials better than I do, but it is very clear that, if you are telling healthcare workers of all sorts in Northern Ireland that there will be no pay rise now because of the politics—let us call it that, for shorthand—what do you think the workforce is going to do? They are going to move to places, be it Australia for junior doctors or the Republic of Ireland for more senior doctors. They are going to leave the system, because they have lost hope in the system in Northern Ireland. We have a very difficult year ahead of us. We are going to see GP collapses and hospital service collapses, and they are going to happen every month, if not every week.

FUNDING

Written evidence

BMA

We note the Secretary of State’s reference to a £660m black hole[] in Northern Ireland’s public finances. A recent briefing[2] from the Department of Health stated that the best-case scenario for 2023/24 is currently ‘Flat Cash’ i.e. no increase on 22/23 funding. It says that even with a sustained productivity and efficiency drive, the 23/24 budget will be £300m short of estimated funding requirements and that bridging this gap will require medium and high impact savings, with adverse consequences for an already highly pressurised health and care system…

 

Continuing to operate in crisis mode, which is the worst of all worlds with high costs and poor patient outcomes, has already begun to take its toll on staff and patients.

The lack of an Executive has a clear detrimental impact on the management of the budget and strategic planning within the Department of Health, with civil servants placed in unenviable situations where they are unable to make decisions necessary to improve services.

 The most obvious example of this impact is on the development of multi-year budgets. BMA NI was disappointed in February 2022 to respond the Department of Finance budget consultation which, while outlining such a budget, knew it could not be implemented due the collapse of the Executive.

The BMA Northern Ireland response stated:

Single year budgets do not allow for the planning to transform the HSC in the ways identified as necessary. Or to sufficiently plan a rebuild of services as we hopefully transition to a post-pandemic world.

 Additionally, single year budgets are given as the reason departments cannot commit to multi-year pay deals, which led to significant issues during the negotiations of the 2021 Specialty and Specialist doctor contracts and a lower uptake of the contracts in Northern Ireland

 These issues remain and highlight the deficiencies in short term planning and funding. Ultimately, no serious action can be taken to improve long term recruitment and retentions issues that are central to the current challenges within the health service.

EDUCATION

Mark Baker, Chief Executive, Controlled Schools’ Support Council; Sara Long, Chief Executive, Education Authority; Liam McGuckin, President, National Association of Headteachers (Northern Ireland)

Sarah Long   We are very deeply concerned about where we find ourselves in terms of education. This year, the Education Authority, which is the funding authority for all schools, finds itself with a funding gap of somewhere in the region of £200 million. The key elements of that funding gap relate mostly to pressures in our schools and our school deficits that will carry forward into the EA block, and also to pressures relating to rising demand and the services provided to children with special educational needs. As you will know, these are some of our most vulnerable children. In addition to that, we know that there have been significant reductions in a number of earmarked funds targeted and directed to those children most vulnerable and most in need, which facilitate learning for those children. These include the Engage programme, which was put in place in terms of the pandemic, Healthy Happy Minds, some of our Shared Education work and our Holiday Hunger payments as well. We are very concerned about the financial position, where we find ourselves and the impact that that will have….  In addition, it would be fair to say that over 85% of the costs in relation to education are staff. We employ all the non-teaching staff within maintained and controlled schools and the teaching staff within controlled schools, and we know what our colleagues are facing in other sectors. We do not yet have a pay deal for teachers for 2021-22, never mind a settlement for 2022-23, and we are facing into 2023-24. We know that this year, after a successful resolution of industrial action, we have returned to industrial action.

Mark Baker

Why the Barnett squeeze has to be replaced by funding by parity with England on the basis of need

One thing I wanted to pull out was the recent Institute for Fiscal Studies report. The headline says, “It is all okay now. Northern Ireland is the same as England and Wales”. That report covers the covid period when there was a functioning Northern Ireland Executive making good decisions and putting £800 per pupil into education. England put in £300. That has now been reversed. In reversing that, Northern Ireland is now again £500 behind compatriots in England. When you then add on top of that the £2.3 billion that the Chancellor announced last November for schools in England, for which Barnett consequentials will not come through to Northern Ireland, that further puts Northern Ireland children and young people £230 back. This is a significant amount of money. If you compare a child in Northern Ireland with a child in Scotland, we predict that £2,000 extra will be spent this year in Scotland compared to Northern Ireland. Over a child’s life, that is £30,000 in education. It is vital that there is parity of investment in our young people. That impacts the services and the decisions that Sara has to make and that a permanent secretary has to make.

Chair: Is parity vital? Mark Baker: No. What is vital is need.  What is vital is parity that addresses the need. English education could potentially manage at a lower level of funding. The difference is that Northern Ireland is a fundamentally different jurisdiction to England: 18% of the population of Northern Ireland are of school age, compared with 15% in England. If it was the same, there would be 2.5 million more children in schools in England

The effect of the Barnett Squeeze

NI needs public spending per head to be 24% higher than in England to deliver comparable public services. It’s now at 23% & the Squeeze will take it to below 20% by the end of the decade. Wales have already done this with a guarantee that the Block Grant there would not fall below the 15% needs premium.

 

Northern Ireland Fiscal Council Report

The Executive’s spending on public services is largely financed by a core Block Grant from Westminster, which evolves according to the Barnett Formula. Put simply, this ensures that when the UK Government increases spending in the rest of the UK on services for which the Executive is responsible in NI, the Block Grant rises by broadly the same amount in pounds per head. But spending per head was much higher in NI than England when the formula was introduced, so this produces a ‘Barnett squeeze’ with the percentage premium of the Block Grant over equivalent UK government spending shrinking over time. As result of the formula and lower ‘non-Barnett additions’ from political agreements and other sources, the Block Grant per head is set to fall from 38 per cent above equivalent UK Government spending in 2017-18 to 25 per cent above at the end of the current UK Spending Review period in 2024-25.

This would confront the Executive with several choices, and it would presumably combine a number of them: • simply to accept a lower quality and quality of services than England. • to try to increase the efficiency with which NI services are provided. • to cease or reduce the provision of lowest priority services. • to make additional ‘fiscal effort’ (raising Regional Rates and/or fees and charges, with domestic water charges most frequently suggested). • to seek greater tax raising or borrowing powers from the Treasury. • to seek additional funding from the UK Government. Additional funding from the UK Government could be attached to another political agreement designed to restore or sustain the Stormont institutions, like the New Decade New Approach agreement of 2020. But financial support of this type is typically time-limited and earmarked for particular purposes, which is not conducive to long-term planning and reform. A more durable option would be to seek a similar agreement with the UK Government to that reached by the Welsh Government in 2016, setting a floor under the Block Grant premium at an agreed estimate of relative need (15 per cent in that case, based on analysis by the Holtham Commission) and an additional uplift to Barnett formula increases (5 per cent in this case) to slow the rate at which the premium approaches the floor. In addition to assessing the sustainability of the Executive’s finances, the report notes that the UK Office for Budget Responsibility has recently (and not for the first time) concluded that the UK public finances are on an unsustainable trajectory as population ageing and rising costs in health put upward pressure on spending and the loss of fuel duty from the transition to electric vehicles puts downward pressure on tax revenues. This implies a need for fiscal tightening at some point that would affect people in NI through some combination of higher taxes, reduced welfare or pension payments, or lower public services spending (relative to the projected upward trend) that would feed through to the Block Grant via the Barnett formula.

In this regard, the Barnett formula implies a Barnett paradox. The more rapidly the UK Government increases its spending on public services, the more rapidly the NI Block Grant rises in absolute terms but the quicker the premium between the Block Grant and equivalent UK Government spending shrinks in relative terms. Equivalently, a programme of spending cuts at the UK level – which many commentators expect – would reduce the absolute level of the Block Grant and the Executive’s spending but would ease the Barnett squeeze


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