Northern Ireland Affairs Committee
Oral evidence: Funding Priorities for the 2018-19 Budget: Health, HC 1447
Wednesday 17 October 2018
Ordered by the House of Commons to be published on Wednesday 17 October 2018.
Members present: Dr Andrew Murrison (Chair); Mr Gregory Campbell; Mr Robert Goodwill; John Grogan; Lady Hermon; Nigel Mills; Jim Shannon.
Questions 85 - 120
Witnesses
I: Lynda Wilson, Director, Barnardo's Northern Ireland; Carolyn Ewart, National Director, British Association of Social Workers Northern Ireland; Joan McEwan, Head of Policy and Public Affairs, Marie Curie Northern Ireland.
Written evidence from witnesses:
- British Association of Social Workers Northern Ireland
- Marie Curie Northern Ireland
Examination of Witnesses
Witnesses: Lynda Wilson, Carolyn Ewart and Joan McEwan
Q85 Chair: Good morning and welcome. Thank you for coming all this way on such a miserable day. Your evidence is very important to us. We as a Committee are interested in health and social care in Northern Ireland and our remit is the setting of a budget here at Westminster, as a result of the fact that Stormont is in abeyance. We have interpreted that as meaning that we should be investigating things like health and social care, which previously would have been exclusively the province of Stormont, rather than Westminster. I am sure you would agree it is important that, in this interregnum, we continue to have some sort of democratic involvement and investigation into what are very important public policy areas. That is the background and why you are here.
We will be preparing our report on these very important subjects shortly, but we thought it was important to hear from you as practitioners about the situation currently, how things are not working and how they can work better. I wonder if, briefly, before we get to the questions, you could perhaps introduce yourselves and give us a little thumbnail sketch to illustrate and explain the written evidence that you have already submitted. Perhaps we can start with Carolyn.
Carolyn Ewart: Thank you for the invitation today. We are very happy to be here and have a chance to talk to you this morning. I am Carolyn Ewart and I am the national director for BASW Northern Ireland. That is the British Association of Social Workers. We are a UK organisation and we have offices in London, Birmingham, Edinburgh, Cardiff and Belfast, where I am based. I head up a small team and our role is to represent the profession. We are a member organisation; all our members are practising social workers, right through from students to practitioners at baseline, through the different management scales, up to directors of social work, so we have a really wide reach.
We meet regularly with our members; we consult and hear from them first hand about the challenges and opportunities within the health and social care system in Northern Ireland. As I say, we speak uniquely with a UK voice, in that I have colleagues across the whole of the UK, and we link internationally. That is who we are, as BASW. We have over 21,000 members, so we speak with some authority and can give you lots of good insights into the system, and the challenges and opportunities in the system at the moment.
Lynda Wilson: I am Lynda Wilson. I am director of Barnardo’s in Northern Ireland. I would like to thank the Committee for inviting us here today, and hope that our contribution will assist you in your inquiries, in conjunction with our written submission. Barnardo’s is the largest children’s charity working in Northern Ireland. Last year, we worked with over 14,000 children and young people. We are currently delivering over 50 services. Additionally, we deliver programmes and interventions in over 200 schools, and that will increase by the end of the year.
We support children and families right across the continuum. We do a lot of early intervention and prevention work, and family support, but we also deliver intensive interventions to children who require protection, who have suffered various forms of abuse, trauma and neglect. We work right across the continuum and have a very strong interest in how that total system works, or does not work on some occasions.
The two areas that we gave particular concern to in our written submission were young people’s mental health and emotional wellbeing, and the functioning of the system to address those needs at the moment; and children who are subject to corporate parenting, in other words children who are in the care system, on the edge of the care system or leaving care. We have concerns about service delivery, investment, policy and strategy in all those areas.
Joan McEwan: Good morning. I am Joan McEwan. I am the head of policy and public affairs for Marie Curie in Northern Ireland. Like my colleagues here, I am very grateful for the opportunity to be here today. I am part of the wider UK organisation of Marie Curie and, in Northern Ireland, we provide help and support to people impacted by terminal illness. Every year, we provide clinical, practical and emotional support to around 4,000 people, and they include patients, carers and families. We do that through a range of services, primarily our hospice based in Belfast, which is made up of an 18-bed in-patient unit. There are other auxiliary services that operate from the hospice. We also have a nursing service that provides hands-on care for patients in their own homes throughout all five trusts, and we have a helper service that provides practical non-clinical support for patients and their families.
It is important to say that we provide support for people with any terminal illness, not just cancer. We are seeing an increasing demand and need from people who have terminal illness. We also campaign, and that is the reason I am here today: to campaign to provide information on the issues affecting people who have been impacted by terminal illness.
In terms of our submission, we wanted to highlight the importance of social care and the role it plays in facilitating palliative care for people at end of life and throughout their palliative journey, particularly around discharge and areas where people have delayed discharge, whether from a hospice or an acute setting, to get back home. You can imagine the importance of that, particularly when it is at end of life, and how crucial it is for people to get back home. The role of social care is critical in helping to facilitate that, and one of the things we want to talk about today is how important that is, the impact it has for patients, but also the substantial impact on the system, in terms of the cost and resource it takes up.
Q86 Chair: I am very glad you have raised delayed discharge, because it is something I have been involved with in the 17 years I have been a Member of Parliament, and we do not seem to be very much further forward, so we will come back to that in a minute, if we may. Can I start with adult social care and the report “Power to People”, which made some far-reaching recommendations, which it seems have perhaps been put on ice as a result of the political developments, or lack of them, in Northern Ireland? Since they are far reaching, a Minister is probably required to progress them much further. I wonder if you could talk to that report and say whether, broadly speaking, you agree with its recommendations. I am guessing you probably do. What are the key points in it that need to be rolled out? In particular, what do you think the consequences of the impasse at the moment are, in relation to developing and improving social care in Northern Ireland? I suspect, Carolyn, that is one for you to kick off on.
Carolyn Ewart: It is something on which we have put together some information for you, in our submission. Life expectancy is increasing across the piece and that issue is not particular to Northern Ireland. We know that our populating is ageing. The projections are that, by 2041, there will be a 107% increase in the number of people alive who are over 85. With that comes increased need for service provision. “Power to People” looked at how our system might be able to meet that increased need. In times of financial constraint, there is always a challenge of how you continue to meet increased need within a system where money is finite. We are fully aware that money cannot simply continue to be presented to a service, but there are particular issues within Northern Ireland. We know, for example, that by 2040 the number of people aged over 85 in Northern Ireland will be significantly higher than anywhere else in the UK and that our birth rate is lower. That will bring particular challenges for a very aged population without those younger people coming through and paying into the tax system.
We also know from our social workers that it will be an issue of not only increased age, but also increased complexity. We know already that older people, like the rest of us in society, present with a plethora of difficulties and challenges. We know, for example, that addiction services are increasingly seeing people who are older, and that will continue to be a need. It is not simply looking at traditional services around packages of care and support for personal care, but looking at someone’s needs in a holistic way, so their mental health needs, whether addictions, a diagnosed mental illness that someone ages with or increases in the number of people presenting with dementia. Those present a huge range of challenges and they present challenges at the moment. We know from members that older people are already waiting for assessments for services. We have members who tell us that, in some areas, people are already waiting up to four months for an assessment of their need. In a sense, we know the system is heading towards crisis point at present, so, without something radically different, it will not be able to continue to meet that need.
“Power to People” is a document to be welcomed. It took a holistic view of the services we have and is quite a challenging document, in many ways. It sets out some new, innovative and exciting ideas around how we might develop services for our whole community. While BASW on the whole welcomes the suggestions around that move, in some ways it is nothing new. We have heard about the need to move from a hospital-based model to a community-care-based model in Donaldson and in Bengoa. We know there is a move from putting lots of money into services and into a building, towards putting that money and those staff into delivering good-quality, high-quality care in someone’s home, at the point they need it. For us, one of the challenges is—you are right to mention it—that a lot of the recommendations are stalling now because of the lack of a Minister to make those decisions.
Interestingly for us, and we have been quite vocal about it, the one and only recommendation that is getting lots of discussion is the one around beginning to charge for social care. We have been quite vocal in our opposition to that. As an association, we are acutely aware of the impact of poverty. We know the number of older people who are living in poverty already. Older people have to make really tough decisions: “Do I buy food this week? Do I heat my house? Do I buy clothes?” To push the responsibility of paying for care services on to those people would be something that, as an association, we would not support.
We need a much wider debate, so discussions like this are particularly helpful, but we need a whole-society debate around the type of care we want for ourselves, because we will probably all end up as users of services. What kind of services do we want for our family members and for our society? There are lots of good suggestions within “Power to People” about how to work more closely with community groups and carers to deliver those services.
Q87 Chair: You speak in your evidence of bureaucracy bedevilling social work in Northern Ireland. I wonder what you really mean by that and how it differs in Northern Ireland from the rest of the United Kingdom. It certainly comes across from what you have written that you believe this is peculiar to or more acute in Northern Ireland.
Carolyn Ewart: I do not know that I would say that. We know that in social work in particular bureaucracy is a major issue and I know colleagues in England experience similar challenges to us. I do not know if it is unique to our profession, but the level of bureaucracy within social work is really challenging. Often, when I mention bureaucracy, people roll their eyes and think, “What’s that about?” I cannot stress enough to this Committee the importance of the issue of bureaucracy to social workers.
Q88 Chair: Can I ask you what it is about? In a social worker’s day-to-day existence, where in that day’s work is bureaucracy causing a problem and how can we eschew it?
Carolyn Ewart: I will say to start with that we, as an association, are not recommending that there should not be bureaucracy in social work. There should. Good-quality recording and report writing are integral and should be a cornerstone of good social work practice. For governance and accountability, there must be clear records. Within social work over the last couple of decades, and this was very evident in the Munro review in England, services have become overly bureaucratised. For example, a survey we did some years ago pointed out that social workers spend 70% of their working week in administrative and bureaucratic tasks. Now, we say that is completely unacceptable. It is a complete waste of that valuable resource.
You have a social worker who is highly skilled, has gone through university, is skilled, trained and ready to do a job working with people. To expect them to spend 70% of their working day and week filling out paper forms, duplicating those forms by putting them on to a computer system and inputting data is just unacceptable. We would not accept that of other professional jobs. We would not accept, for example, our GPs spending 70% of their clinic time filling in a form. We should not accept it in social work.
The one thing I cannot stress enough is that, if you want to transform social work services and the experience for service users of social work services, by reducing the bureaucracy in our system you will transform their experience. Service users tell us repeatedly that the one thing they want is to have more time with their social workers. They get stressed when they phone and cannot get a hold of a social worker or social workers do not have time to go and visit. Lynda, I am sure your staff are well aware of the sheer level of paperwork that must be completed around social work tasks: the processes around looked-after children, child protection and referral, UNOCINI. The response to practically every single inquiry where there has been a death or serious injury of a child, over the last two or three decades, has resulted in increased bureaucracy, so increased forms.
There is a notion that having a piece of paper, having someone fill in a form and tick a box, or do an increasingly lengthy assessment, is the solution to that and we say it is not. Allowing social workers the time to go and spend with their service users, to build a relationship and see that relationship they have with the child, their family, an older person or a person with a mental health problem, is how you will fundamentally get a change. That will be the service and, at the moment, a lot of social work tasks are unnecessarily bureaucratic.
Chair: At that point, I am going to move on to Robert Goodwill, because he has the advantage of having been a Minister in this particular area, so we can perhaps blame Robert.
Q89 Mr Goodwill: In terms of bureaucracy, I agree, having been responsible for children’s social care in England. Is this not being driven by two factors? One is that, when there is an issue like the Victoria Climbié death, the social workers always feel, “If the paperwork is in order, at least I am covered.” I remember one case when a child had been dead in the house because the mother had a medical incident and the child had died of starvation. There was a long record of social workers calling at the house and knocking on the door, but there was no reply. They had ticked that box.
The second reason is that we often have parents complain about the lack of continuity, where agency workers are used and staff turnover is very high. Therefore, while I understand the point you make about needing to have a relationship with a social worker, if that social worker changes regularly, does that force more bureaucracy on the system? Then they need that file for the new social worker to pick up and carry forward.
Carolyn Ewart: You are right on both those points. A culture has grown up and you often hear the mantra, “If it’s not recorded, it didn’t happen.” There is a fear about social workers not recording. Go into social workers’ offices. Imagine, in your working day, having to make a record of every time you speak to someone, either in person or on the phone, and every email that you send. You record in a paper file “spoke to” and the detail of that conversation. That is the level of recording that has grown up within the system, so the culture of that needs to change.
I have to say that, in Northern Ireland, we have a social work strategy headed by our chief social worker Sean Holland. In the first three years of that strategy, we have been trying to tackle the issue of bureaucracy. While there was great intent with that and a lot of effort, unfortunately, there has been a minimal impact, in terms of how much bureaucracy has been taken out of the system. There has been a sense of covering oneself that has grown up. That has become an embedded culture now, so there is a need for a real shift on that and permission not to have to record every detail. That journey has to be gone on.
The issue you raise of agency staff and throughput of social workers is one that we hear about all the time. We are increasingly reliant on agency social workers in Northern Ireland. We know that most jobs that come up for newly qualified social work staff will be in children’s services, because that is where the throughput is. People tend to move into mental health and older people services, and stay there. We know there is more churn within children’s services.
Q90 Mr Goodwill: Can I interrupt? How does the situation in Northern Ireland differ from that in England? There are local authorities, like my own in North Yorkshire, that have virtually no agency staff, which get amazing reports from Ofsted. You have other local authorities with massive turnover, because they are failing in many cases. What are the differences between Northern Ireland and England, and where would Northern Ireland be on the league table of delivery of children’s social care?
Carolyn Ewart: I have to say I do not know where we would be on that league table. There are fundamental differences between social work in Northern Ireland and the rest of the UK, in that we are part of an integrated health and social care system. For example, in England your social work staff are employed by the council; in Northern Ireland, they are all employed within the integrated health and social care system, so, in a sense, they are all part of the NHS family. That changes things somewhat.
Q91 Mr Goodwill: Does Ofsted inspect on the same basis that it inspects local authorities in England?
Carolyn Ewart: No, we have RQIA, the Regulation and Quality Improvement Authority, which inspects and then the social work profession is regulated by NISCC, the Northern Ireland Social Care Council. All social workers are required to be registered and to maintain our registration, and social worker is a protected title in that sense. You are only allowed to call yourself a social worker if you have gained the qualification and have the appropriate standards.
Agency staff, if I can go back to that point, has not been as big an issue within Northern Ireland as it has been in England, and I think there has been a subtle change in that. We know from members that there is an increasing reliance on agency staff, due probably to a number of factors. The budget has an impact on that. At this stage, trusts are not clear what their budgets are. They are all telling us they are in overspend.
Q92 Mr Goodwill: Is that the annualisation or just general underfunding?
Carolyn Ewart: We have had a long period of underfunding now and that has been recognised. We have been falling behind inflation in the budget that is allocated through the Department to the trust to deliver services. There has been a huge impact in the voluntary sector of late from having no Assembly. One of those things is that lots of money that would have gone through the voluntary community third sector is not there now, so there is an anxiety around creating full‑time posts within that sector. The statutory sector is where most social workers are employed: 70% of social workers are employed within the statutory health and social care trusts and the majority, 60% of them, are employed in children’s services.
The Business Services Organisation has taken over recruitment of all social workers now across the piece in Northern Ireland. Any statutory agency that has a social work vacancy recruits through this one agency, and that has led to some challenges with delay in the system. We know from the directors of social work and employers that there is a real lag between posts becoming vacant and getting them filled, so most posts are being recruited as temporary posts now and they are being recruited through agencies, so there has been a shift, based on that short-term funding, to an increase in agency staff.
Q93 Mr Goodwill: What is typically the difference in cost between an agency worker and somebody on the payroll?
Carolyn Ewart: I am not specialist enough to tell you. I know an agency social worker, for example, will be paid through their banding, so all social workers in Northern Ireland are on the Agenda for Change pay scale. When you first qualify, you are at band 5 until you complete your assessed year in employment, usually within one year. Then you move to band 6, team leader and band 7 beyond. The average through an agency for a band 6 post, which is most likely what you will get, is about £13.75 an hour. I am afraid I do not have information about how that translates to costs for the trusts. I can find that out for you, if it would be helpful.
Q94 Mr Goodwill: There can be quite big discrepancies in the cost, certainly in England. What happens if children’s social care in a particular part of Northern Ireland falls over? In England, the Department for Education would come in. It would either pair them up with another local authority if that would help them, or it would take over and intervene. What about when that happens in Northern Ireland? It is already run by the Government, so who could intervene then? Lynda, you are shaking your head.
Lynda Wilson: It is a very good question. Because I am one of eight directors across the UK, I have an opportunity to work in parts of England, Scotland and Wales, as well as Northern Ireland. I have not seen anything like the post-Ofsted inspection experiences that local authorities have in England. Very often, organisations like Barnardo’s are asked to come in. At the moment, we are in Norfolk, helping it turn around after quite a negative set of inspections. We were talking about this yesterday: I have never seen RQIA go public on a failing trust or, as very often happens in England, the director or management team in that local authority go and bring in some other arrangements. That sometimes gives great opportunities for quite radical turnarounds and for putting in strategic partnerships, which can lead to innovation and improved effectiveness. I have never seen that from my experience in Northern Ireland. We would not even hear if a trust was being inspected and had particular difficulties.
Carolyn Ewart: RQIA produced a report towards the start of the summer on the inspection of children’s services. The issues they highlighted at that stage—and, again, they did not go into naming and shaming trusts—were around the number of unallocated cases, so the cases of children who had been referred who were awaiting allocation. They also identified the issue of what they termed “unattended cases”, which we really welcomed. Unallocated cases are, as you would expect, referrals going into the service that are not able to be allocated; there is no worker available, due to demands on time. Unattended cases are something quite different. The RQIA has called for the directors of social work to audit the number of unallocated cases and to report back, and we would really welcome that.
Unattended cases are, for example, when a social worker is on long-term sick leave, has gone on temporary secondment or is on maternity leave. Their caseload is not able to be simply divvied up among everyone else in the team, so it tends to be that the highest-priority cases, where there is extreme risk, would be allocated, but other cases might sit and wait. The manager or senior social worker would keep a watchful eye, so they are unattended. No one is regularly visiting and they might just get their monthly or statutory requirements. We almost hope that those cases do not need any attention until someone comes back. It was very helpful of RQIA to highlight that issue and, as I say, to request that it is reported back on.
That chimes with the experience we hear from members, that social workers are incredibly busy. Although we now have more social workers in the system than we have had, referrals continue to increase. The complexity of cases is something that members strongly report and, therefore, the time required to work with a case, and the resources needed continue to increase. We hear from members of extreme pressures in the system and that they are struggling to cope. Most social workers come into the job as a vocation; they want to help people and make a difference. They struggle with ending up in what is quite a bureaucratic system, where they do not get the time they would like and need to work with families to effect change.
If you can imagine a system where you are struggling to cope with the sheer volume of your own caseload, struggling with this real burden of bureaucracy, as I have described, if someone goes off and is not replaced, there is a limit to what you can naturally and safely absorb. As we see it, there is a need for additional investment within core services. We did a report the year before last called “Above and Beyond”, where we highlighted the sheer volume of additional hours that social workers are working for free, above and beyond their contracted hours, simply to get their job done, to do a good job and to see the people they need to see. We did some calculations around the number of hours that social workers are contributing to the system, and it equates to about £11.5 million saved to the service every year through the additional hours they currently work just to get their job done.
Q95 Mr Goodwill: Can I ask how much this is down to money and how much it is down to poor leadership and management? If you look at English local authorities, it costs more to deliver bad children’s care than it does to deliver good children’s care. If there is not an intervention system in place to identify failure and fix it quickly, are children in Northern Ireland losing out compared to their peers in England, who at least have that fire engine approach? At its worse, the chief executive of the council, the director of children’s services and the leader of the council would be sat in front of a Minister in the Department for Education, having the riot act read to them.
Carolyn Ewart: I think children are getting a good service, but they could probably get a better service. They are not getting a bad or failing service. Those people who are engaged with and involved in services are having a good experience. Those people waiting for a service obviously should not be waiting; they should be able to access the help they need. They could have a better service; they could have a much more personalised service; they could have more time. There may be discrete areas, such as mental health, where there is a real need for investment, both in children’s and adult’s services across the piece in Northern Ireland. There are certainly areas of real need, where we could improve and transform things.
Some of the confidence-and-supply money has come through, the £100 million for innovations. I have a list of how that money is broken down but, unfortunately, I do not have any detail of where that money has gone to support the service. We know that all the money is geared to transformation and transformative projects, but that money has to be spent by the end of March next year. How realistic that is, and how it is going to bring about actual transformative change within six months, when there are quite fundamental issues with core services, we would question. I would suggest that none of that money, that £100 million, has been targeted towards a real task force to reduce bureaucracy. There was an opportunity to bid for money, and it would have been great to do something radical to the system and try to effect a change. It is disappointing that no money is targeted at that. As you rightly say, there is a root and branch review and change needed. To have targeted some money directly at that problem would have made a huge difference.
Q96 Mr Goodwill: Would Lynda like to comment on the particular way that we could target money?
Lynda Wilson: Carolyn is absolutely right, in particular in reference to children and young people’s mental health services. There is something we could definitely change. I am very confident that we could change that. At the moment, we are only spending 7.8% of the Northern Ireland mental health budget on young people’s mental health services. The Health and Social Care Board did a comparison with what is happening in England, and the percentage that really should be spent is 10%. That would be an extra £4.6 million. There really would be no point in giving us that extra £4.6 million if we continued to spend it in the way that we are spending it at the moment.
Earlier this month, the Commissioner for Children and Young People published her report into young people’s mental health. It is called “Still Waiting” and I would commend it to the Committee. It is difficult and sad reading, but her recommendations are excellent. She points out a number of opportunities where we could bring about real practical change very quickly, and a mechanism to do that, through a transformation fund and transformation board. She has done a good analysis of the budgetary position on mental health services. I have seen excellent examples, such as the Solar work in Solihull, which has brought together clinical practitioners along with children’s social workers in one location. They have completely turned around their waiting lists. Fewer children are having to go on to tier 4 CAMHS. Young people are getting services more quickly. There is less stigmatisation. Young people, commissioners and families are very happy with that service.
The thing about the commissioner’s report is that it has great support from the child welfare world, people like myself, but it was crafted with a lot of participation and input from young people who have had mental health difficulties and their families, who have found the system wanting in meeting their needs. I would commend that report as a source of both analysis and recommendations. You could call it a blueprint for action. We could turn around our children and young people’s mental health system very easily or we could waste a lot of money on it.
Mr Goodwill: Thank you very much indeed. By the way, I want to put on record my thanks to Barnardo’s, which brought up my father-in-law when his mother died and, it is widely accepted, saved his life at that point, so thank you.
Lynda Wilson: I hope we did a good job.
Q97 Jim Shannon: It is nice to see you and have you at the Committee. I have a number of questions. First of all, can I thank the three of your organisations for what you do? Being on the frontline of health issues in my constituency, we are well aware of the magnificent contribution that you make. The first question is to you, Joan, and is in relation to your response to budgeting. I am just going to quote what it says here, to get your thoughts on it. Your organisation refers to a short-sighted approach to budgeting that has led, according to Marie Curie, to counter-strategic decisions that ignored long-term problems. Could you perhaps elaborate on that?
Joan McEwan: I would echo Carolyn’s point about transformation. We know that our health and social care system absolutely needs transformation, but the funds that have been allotted for that transformation are on a one-year budget. First of all, it is almost impossible to make any sort of transformation within that timeframe. We see, for example, that the pressures already building in the system are not being addressed, so a chunk of that money, I think £30 million, was taken out of transformation to deal specifically with the waiting lists. That diminishes the pot for transformation funds as well.
We are seeing a lack of investment, specifically when it comes to social care. We need a sustainable, stable service that supports and enables the delivery of palliative care. When it comes to social care, it supports the patient in so many ways, from diagnosis right through their journey and periods of crisis, but particularly at discharge. That is evident in the responses we have received from freedom of information requests, which we sent out in advance of our opportunity to speak today. We know that there are a number of people—two trusts have responded to us, Belfast Trust and Western Trust—currently waiting for domiciliary care packages in order to get back in their homes, to be cared for at home. At the minute, there are over 600 people waiting for a care package in Belfast Trust and over 100 people in the Western Trust, so we know that the support and the domiciliary care packages are not there.
It is not just about money. Sometimes we know that the money is there, but the staff resource is not there, so it is about staffing, resourcing and having a stable workforce there to do it. Another reason cited is that there are no nursing home spaces available. We know that available beds in nursing and residential homes have fallen by about 2%. That may not seem like a large number, but you need to take it into context against the point that Carolyn made earlier about the increasing demographic of our ageing population, the number of people aged over 65 and over 85 in 20 years’ time and the huge volumes that will bring about, and that deaths are set to increase in just over 20 years by just over 30%. That is a factor as well.
There are also concerns around the quality of care in nursing homes. Part of that is down to the inquiry into Dunmurry and the findings of poor standards that residents received in that nursing home. There are concerns around that too. The Northern Ireland Social Care Council did a survey of social care workers, and only 51% held vocational training. That echoes Carolyn’s point that not only are people living longer, but they are living longer with one or more chronic or complex conditions, so their needs are becoming more complex. We need to have a highly skilled, supported and trained workforce to deal with the complexity of their needs. There is another point around the delay in people being discharged due to the bureaucracy in the system. We hear of delays in getting very simple things like equipment, which has to be done with the trust, which can add delays of a number of days to getting somebody discharged and being cared for back at home. Days is a long time when somebody has a finite amount of time left.
Q98 Jim Shannon: I agree wholeheartedly with your synopsis of people who have not just one problem. They have complex problems, and really that is the issue. I have knowledge of that primarily through my contact with people usually to do with benefits issues, but you get a feel for people and what they have. There is an increasing number of those with dementia and Alzheimer’s, which unfortunately comes with old age, and diabetes, of which the carers coming in need knowledge to deal with it. Can I ask you quickly about end-of-life care? That is something that your organisation is very involved in. I was saying to Lady Sylvia beforehand that, just in the last three weeks, one of my friends and constituents went into end-of-life care. The work you do is great. Do you feel that the social care system that we have in Northern Ireland is dealing with end of life in the way it should? I know your organisation does, but what about the DOH in Northern Ireland?
Joan McEwan: Again, it is the fact that social care plays a critical role in supporting and facilitating us as the palliative care provider and the other providers that exist. We are seeing a massive impact on people at end of life. For example, in a 15-month period in our in-patient unit, which is an 18-bed unit, 17 patients were delayed from getting back home. You can imagine not only the stress that that puts on the family at such a critical time, but also the knock-on impact. It is not only getting those people home, but allowing people to come in, so there is a double impact there. That is where I ran through the underlying issues around what delayed discharge is about.
In an acute setting, we know there are 600 people in Belfast Trust and over 100 in the Western Trust, and these are just two trusts that we know of. When people are delayed in a hospital setting, they are at greater risk of their condition deteriorating and it no longer being safe for them to be discharged. The chances increase that they may have to stay in hospital and possibly even die in hospital, against their wishes. There is also an increasing chance that they might contract a hospital-acquired illness.
It is important to highlight the impact on resources and how they could be better spent. To take the case of 17 patients in Marie Curie hospice alone, if you put some very high-level numbers around that to give you an indication of how that money could be better spent, 17 patients were delayed for approximately a week. Delay of a week, or even several weeks, is not unusual. If we calculated 17 patients and the cost of running our hospice for a day, it equates to 99 days of 24-hour nursing care, which is massive when you think of the value of nursing care in someone’s own home, especially at end of life, when that is paramount. The support is immense. Those are a lot of days that could be put into the community, transferred and put to better use.
In the hospital setting, we know there are 17,000 emergency bed days in Northern Ireland per 1,000 deaths, and there are roughly 15,000 deaths every year. On the back of the FOIs that we got from Belfast Trust and Western Trust, we know there are respectively over 3,000 and over 10,000 lost bed days from delayed discharge alone. There are significant costs in caring for those people in an acute setting. Any investment to help support social care in caring for people and getting them back into their own homes would release significant funding that could be put to better use.
Q99 Jim Shannon: Lynda, as I said to you earlier on, outside, we have contact with your organisation Barnardo’s on a regular basis. We recognise the tremendously good work you do. I want to ask you a question in relation to something you have mentioned, which was in my mind before I came here, by the way, because it is something I have contact with on a regular basis, unfortunately. That is the mental health of children. The mental health of adults is something you have direct contact with across the table, but the mental health of children, more often than not, comes through parents telling you stories.
You also mentioned something that intrigued and interested me. You referred to early prevention for the family. Could you tell us what you would like to see? Maybe I could also ask if you saw any of the £100 million transformation fund that came in to address the mental health of children.
Lynda Wilson: For 50% of mental health problems, there are normally indications before a young person is about 14. For about 75%, we have indications before they are 24. Barnardo’s would certainly want to see more investment in early intervention and prevention. We deliver programmes to build children’s mental and emotional health and wellbeing, and their resilience, in a whole-school, whole-classroom way. That has a very good investment return, based on the evidence-based programmes. We can look at whole-school impact. The number of suspensions drops and the amount of self-regulation improves, so you are building more resilient children.
Similarly, if you move up the tiers, we are talking about schools counselling and looking after your mental health being just a normal thing. There is a door to knock on, you go in and you take your friend, because your friend has a problem. Some of those services are funded through the Department of Education in secondary school at the moment, but we do not have them in primary school. I now have experience of talking to two previous Education Ministers who said that this would definitely be happening and it has never happened, so we do not have schools counselling in primary school. Some schools will buy it off us, but not other than that. Yet that is something that we could roll out universally, because we cannot afford the intensive interventions that are required when young people get to the other end of the line.
We cannot afford the loss of life either, because the suicide rate for young people in Northern Ireland is way higher than it is in the rest of the UK. I see that in my own leaving-care services. We need to look at the total system and have a system that allows young people to step up and step down, to get intensive interventions when they need them quickly and to be seen quickly, so we know what pathway they need to be directed to, so they have somebody who is there with them early on.
It is the stuff that Carolyn was talking about earlier. We did research two or three years ago into multiple adversities and service users were clearly saying, “If there had been one person who was there for me and helped me through the system, it would have worked for me”. We need a multi-system, integrated, easily accessible approach right across our mental health services. Some of it is about making mental health everybody’s business. I was at a PATHS conference, Promoting Alternative Thinking Strategies, in Derry/Londonderry last Monday, and I heard eight-year-olds talking about not only looking after their own mental health, but looking after the mental health of other children in the playground. That is where you have to build it, because CAMHS is too expensive and it is not really working.
Q100 Jim Shannon: I agree with you. We need to do more educationally and to go from secondary to primary schools. You have to remember as well that children come from homes—and I need to be careful what I say—that may be dysfunctional, if I can use that terminology. Therefore, you do not know what has happened. This is very important.
I just want to ask a question to Carolyn. One of the greatest jobs that I have as an elected representative, which certainly recurs with regularity, is about home care packages. An organisation that was looking after the Ards peninsula was, this year, no longer able to complete its contract and had to withdraw from it, whatever those reasons were. It put great pressure on the trust in the area to try to deliver care for all those homes and people, at short notice. Those are just some of the things that are happening. They asked a care worker to go into a home of a person who may have complex needs and deal with that person in 15 minutes, as they would deal with me, Lady Sylvia or you. It is not possible, in 15 minutes, to get a person out of bed, give them a cup of tea and a bit of toast, and then leave. It just does not work. I am wondering what your thoughts are when it comes to realism in the contracts.
I am also mindful of the background information that you sent to us. It was very clear. You said that you also see, I think, 4,050 new packages that will be needed before 2020. That is only a short time away, so what would you like to see for this system to be more responsive? By the way, I will just tell you what my advice was when some of my constituents came to me and said, “I’ve been told that I have to go home.” I said, “Have you got a care package?” The answer was, “No, we do not have it yet.” I said, “I tell you what then. You tell the doctor that you are not leaving until you have it.” That is my advice to every person when they are in hospital before they are sent home with an unknown package in place. Make sure that it is in place and do not go until it is. I just wanted to get your opinion in relation to that.
I have one other quick question, which is on the actual job itself. How would you make the job of a social worker or care worker more attractive? I know pay would be a start, but what can we do to make it more attractive to people?
Carolyn Ewart: The issue you raise around care packages is critical. The sad reality is that there is not sufficient money in the system to purchase the packages of care that people need. Unfortunately, when we see cuts being made in services, they are frequently made first to mental health services and to older people’s services. Last year, all five trusts were presented with the need to save £150 million, and the first place that all of them looked was to cut back on their home care packages. There was a campaign against that and those cuts were reduced.
There is no easy answer to this. “Power to People” begins to open that debate. The challenge for you as politicians is to think about where care needs to be funded. A care or support package to have an older person at home should not just be seen as a cheap alternative to hospital care. It is about someone’s wellbeing and about them functioning well as a human being in their community, within their family, for as long as they can. That requires funding. Good community care is not a cheaper option to hospital care. It is about moving the money and deciding that that is where you want the services to be placed. They are as valuable as and need equal funding to your hospital services.
It is very difficult. We talk about being an integrated health and care system. We are, but, when it comes down to hard decisions about where services are prioritised, hospital-based care services are frequently prioritised over domiciliary care services. There is a challenge for you to help shape that debate and have an honest discussion about the kinds of services we want to see developed. “Power to People” gives you some good suggestions around that and it will be interesting to see how we can progress them.
Chair: It is worthwhile pointing out that hospital care is murderously expensive and we have to consider the money side of things, so part of your argument really has to be around the cost-effectiveness of what you do, notwithstanding the need to put quality in prime position. We need to make the economic case too, and particularly the point you touched upon earlier, Joan, that keeping people in the acute sector unnecessarily is wrong for them and wrong for the bean counters.
Q101 Mr Campbell: You are very welcome, ladies. I wanted to ask Carolyn a question on the comment that you made at the start, when you said 70% of the time of most social workers was spent on bureaucracy. I understand that you put in the caveat that there is a requirement for it and, given the small numbers of quite extreme cases that sometimes get the headlines, it is perfectly understandable that people want to be clear that they have done their job properly and appropriately. I understand all that, but where did the 70% figure come from?
Carolyn Ewart: It came from a survey that we did, which we published in a report called “Social Work Not Paperwork”. We have referenced it and I can send you a copy of that. We surveyed social workers across all of Northern Ireland—not just our members, but all social workers. We specifically asked about the amount of time they spend, so it was a self‑assessment in that sense. It has been repeated in various other parts of the UK, most recently in England, where it came out at 80% and 20%, so the figure has some rigour. It continues to be the biggest issue. Any time we engage with social workers, the single biggest issue they talk to us about is bureaucracy and paperwork.
Q102 Mr Campbell: Chairman, it seems to me that if a social worker was employed, just working out the stats, on a 36 or 37-hour basis over a full working week, it would mean about 10 hours are spent doing what they are trained to do. On a five-day week basis that means two hours a day doing what they have been trained to do, rather than significantly the reverse, which one would hope was the case.
Carolyn Ewart: Absolutely. We know that social workers do lots of extra hours. They all do extra unpaid hours. You will find, on any given day or week, that they are doing more of the stuff above and beyond their paid time at work, so they can spend more time with service users. It is very routine. Our most recent survey was around the amount of extra hours that social workers are giving to the system unpaid.
Mr Campbell: They should not have to do that.
Carolyn Ewart: They should not have to, but they are doing it and they are doing it because they need to do it. They want to provide a good‑quality service and the value they get from their job, the benefit and sense of worth, is from doing the job of seeing people. From my point of view, it is an entirely broken system in that sense. We would love to see that flipped. We would love to see service workers spend 70% of their time with service users and 30% on paperwork. That would seem a much fairer balance and a more efficient use of social workers’ time. Although social workers are not tremendously well paid, they are too well paid to spend their time and work on administrative tasks.
Q103 Mr Campbell: In answer to somebody’s question earlier, you alluded to the £100 million that came through from the confidence and supply arrangement. I do not want to put words in your mouth, but I got the impression that you were hoping for—I do not want to use the grandiose term, but I cannot see another way of saying it—some sort of Bengoa‑style review of the whole issue of how social work can be streamlined and delivered in a better way. Is that a fair assessment?
Carolyn Ewart: There was a missed opportunity in this sense. An awful lot of work has already been done around what we need to do to strip away some of the layers of bureaucracy. The social work strategy set off with the very ambitious aim to do that. For lots of reasons, it has not been able to deliver the reductions that we would all like to see. There was an opportunity with new money coming through, specifically aimed at transformation, to say, “Let’s take six months. We do not need lots of working groups or to establish a whole bureaucratic system around it, but let’s get a task force of a number of people and look at what we can strip out of the system, keeping all of the stuff that we need, the good governance stuff we have to have there, but looking at IT solutions and the number of administrative staff supporting social work teams.”
Under the review of public administration back in 2006, the number of administrative posts in social work teams was slashed and there was a very direct result. While those administrative posts that supported the functioning of teams were lost, social workers have taken on those jobs. A social worker should not be spending their time doing filing. They should be doing the job of a social worker and, actually, there are very real solutions that would have a huge impact.
This is a very simple example that would not cost a lot of money. There is a plethora of organisations that a social worker refers to for services. They all have different referral forms. A social worker might have to fill in the same form for the same service user, or a different form for the same service user, five, six or seven times. There could be one referral form that social services agree, which is sent out to the other agencies, and that would be a sea change for social workers, instead of duplicating all the information.
Q104 Mr Campbell: My final question is on the issue of missed opportunity, which was the term you used. If it were possible to roll that out into the next financial year, would you think that is a good idea? Would it be at the top of your priority list?
Carolyn Ewart: It absolutely would. It would be at the top of social workers’ wish lists.
Q105 Lady Hermon: It is very good of you all to travel over to give us evidence here. I do not know which particular order to go in, so I will just ask the question. The evidence has been really interesting, so thank you all very much indeed for contributing to it. Which areas are in most urgent need of investment, from your point of view?
Carolyn Ewart: Mental health.
Lynda Wilson: Mental health.
Joan McEwan: We are in the palliative care world, so there are a number of areas. I know we are talking about social care here today, but there is a palliative care partnership workstream looking at the nuts and bolts and the blocks in place. Keep that funded; keep it going. The social care world is critical in supporting the delivery of palliative care, especially in people’s own homes. I would also look to a public health approach to palliative and end-of-life care, where you are seeking the engagement of the wider community. Community planning has a big role to play in that, to provide more practical and non-clinical support to people. That is empowering the public to have those open conversations, to be better informed and to be more in control of support within their community.
In relation to “Power to People”, there was a recommendation around carers, which is about putting carers’ rights on a legal footing, along with other parts of the UK. The lack of support in social care has a big knock‑on impact on carers. Especially when you are talking about people who have terminal illness, a lot of them are older carers.
Q106 Lady Hermon: I should say I have had a long involvement with the North Down support group for Marie Curie, and you do tremendous work at what is a very difficult time for many families, so thank you so much for that. We are talking about funding and budgets being overstretched. There is a key issue when it comes to hospices, which has been there for many years. That is the fact that hospices pay VAT. The Marie Curie hospice, Children’s Hospice and other hospices all pay VAT. We were told when we tried to get an exemption from the VAT for hospices right across the United Kingdom that, because of EU directives, we could not have an exemption. Are you aware of this issue? Have you any idea how much VAT the Marie Curie hospice pays to the Government every year?
Joan McEwan: No, I am not aware of that amount, but I can go away and get an answer for you on that one.
Q107 Lady Hermon: I can tell you it is a huge amount of money. It is a huge amount of money. It strikes me that when we have so many supporters, fundraising right across the country, and then the money is taken out of the hospice by the Government charging VAT, it is quite scandalous. Now that we are going to Brexit, we should not have this argument about EU directives, so perhaps you would like write to as many MPs as you can think of and start a campaign, so that all hospices are exempt from VAT.
Lynda, people do not have a clear idea of what Barnardo’s does nowadays. Perhaps 40 or 50 years ago, they might have had a clearer idea. How many people work for Barnardo’s in Northern Ireland?
Lynda Wilson: At the moment I have about 570 staff.
Q108 Lady Hermon: There are 570 staff in Barnardo’s in Northern Ireland alone. Are they spread geographically?
Lynda Wilson: They are spread geographically. Actually—and this is quite different for Barnardo’s Northern Ireland compared to other parts of Barnardo’s—I deliver services in Scotland, Cymru and England as well. I have services in Birmingham, London and a couple of other parts of England, predominantly the schools programmes.
Lady Hermon: When you say you deliver those programmes, you mean you go there yourself.
Lynda Wilson: No, I have teams in Renfrewshire, Wales, London and Birmingham. We are about to put in two workers, one in Birmingham and one in Glasgow, to do the British Red Cross reuniting families work, because we carry the Syrian refugee contract for the Home Office in Northern Ireland. We have an intake tomorrow and, by that stage, we will have taken 1,400 Syrian refugees.
Q109 Lady Hermon: In what timescale have those 1,400 Syrian refugees come to Northern Ireland?
Lynda Wilson: In December 2016, we took our first group.[i] We are more than half way through. We also hold the independent guardianship for unaccompanied and trafficked children, which has a different legal status from the rest of the UK. We have 33 young people who are subject to that status at the moment, plus we have a number of internally trafficked young people. Those are some of the newer pieces of work, but, over the last 10 to 15 years, we have moved to a much stronger focus on early intervention, prevention and system change. We are very interested in strategic partnerships. For example, there is a strategic partnership just starting with South Eastern Trust, where we are putting in a significant level of funding, as is the South Eastern Trust, to change its infant mental health provision. We will be co-located and co-managed, with common outcomes, accountability and governance, bringing the statutory and voluntary together to improve the system. We are increasingly doing that kind of work.
Q110 Lady Hermon: Before we come to partnerships with charitable and voluntary organisations, and social care, can we go back, because I am very curious? Barnardo’s has the contract with the Home Office for the location of Syrian refugees coming to Northern Ireland. What does that mean? Does Barnardo’s find accommodation, look after the services and the families? What does it actually mean?
Lynda Wilson: It is a complete package and it is a very interesting initiative, because it is a consortium. It is a collaborative exercise between a number of bodies, and I have to commend the Department for Communities, which commissioned this. They took quite an innovative approach. They pulled us together as a small group of voluntary organisations—the British Red Cross, Extern, Bryson and Barnardo’s—as statutory partners, and basically said we have a week. This was in November 2016, and we were getting the first intake on 16 December. They said, “Can you pull yourselves together as a collaboration?”
We managed that by having a clear focus on outcomes. We said, “What are the outcomes that we can all agree to here? What are our different areas of expertise? How can we jointly commission them and create governance?” We were able to do that and the Department for Communities commissioned on that basis. It is an exceptional consortium. When I look at the Syrian refugee distribution policies throughout the UK, they are not as effective as what we are delivering in Northern Ireland.
Lady Hermon: We have a good-news story from Northern Ireland about Syrian refugees being homed and integrated.
Lynda Wilson: The first thing they want to know is when they can get into school. Some of them have been out of school; some of them have never been in school; some of them have been in camps for four years. They get into school. We have had some exceptional young people do extremely well very quickly. I have to say our communities have been very responsive and kind, sometimes too kind. The good-news story is the collaboration. Before each family comes, we have a dossier eight weeks in advance, and we sit down with the midwives, the paediatricians, housing, the police, the Department and education. We have a plan for each of those families. Some of those children are coming in terminally ill. We have women coming in with brand new babies or just about to give birth to babies, so it is a very collaborative exercise.
Q111 Lady Hermon: May I follow up on that? Has the Home Office recognised the success of Barnardo’s?
Lynda Wilson: Yes, very much. We are visited by the Home Office.
Lady Hermon: Home Office officials come to Northern Ireland to learn from your good experience. That is wonderful; we have a good-news story from Northern Ireland.
Lynda Wilson: I have to commend the Department for Communities on this, because it has been excellent.
Q112 Lady Hermon: It is very encouraging to hear that. Thank you so much indeed. I said we would come back to this, because it strikes me that we could be doing a great deal more, where voluntary and charitable organisations come together to support social care. Is that correct? Do we have a strategy to work more closely with social care, the charitable sector and the voluntary sector? Do we have a strategy? Has there been any thinking put in place?
Lynda Wilson: There have certainly been a lot of demonstration projects. Barnardo’s has been very fortunate in that we were funded significantly by the Atlantic Philanthropies, which was American money, before they departed. I have a number of collective impact initiatives that are taking a whole locality, and we are not there to deliver services; we are there to build the capacity of schools, community groups and small voluntaries, to share knowledge, support them, act as a backbone organisation. Similarly for ex-combatants in the Lisburn area, we are working with groups to facilitate their governance and evidence-based interventions supporting them. At the end of the day, there is a lot to do and organisations like Barnardo’s cannot always be in the rescue mode of picking up the pieces at the end. It is about being constructive and building resilience and capacity in communities and families, as much as doing.
Joan McEwan: As a charity, Marie Curie does a lot of partnership working, but we mainly do it where we see a need driven by a group of patients, whether in dementia or a day hospice service in a certain locality. We do it on that basis and there would be elements of social care within those partnership arrangements. It is driven by patient need and where that is, rather than coming at it from the other side. Your question was around specific partnerships in social care and the charity area. That is definitely something we could look at. When the three of us came here today we thought we were quite a different group together, but there is certainly a common thread.
Lady Hermon: That came through in your earlier evidence, which is why I am thinking that there is more to be done. Where there is a will, maybe there is a way.
Carolyn Ewart: There is a very strong experience within Northern Ireland of working collaboratively. I know that seems at odds, but, at one level, at the delivery-of-service level, we work well across health and social care. There are some strong examples of that, in terms of voluntary, community, third-sector and statutory services working collaboratively to develop services. We have family support hubs that are groups of those organisations that come together to look at the referral of a child, for example, who may well not need to be referred to child protection services, but who may need support within their community. You have voluntary groups, nursery groups and all the services that might be in that community meeting to say what they could offer or do. That is a very real example of what you are describing.
Belfast Trust is developing a mental health hub. That is the same idea of all the different groups that might offer services within a community area talking collaboratively about what they can offer to a particular group of people. Likewise, in two of the trusts, and there are plans to expand this, there are community care hubs, which are looking at that same model, particularly in dementia care.
Q113 Lady Hermon: In the absence of a functioning Assembly, there is a lot of very good work going on, on the ground. If I were to ask you again to identify the main difficulties and challenges caused by the absence of a Health Minister, a functioning Assembly and devolved Government, what would you identify?
Joan McEwan: In relation to what we are talking about today, I would go back to the “Power to People” report, the outcomes of that and how they are going to be implemented. At the minute, we are waiting for the Department to consult on its response to the recommendations in spring next year, which will be welcomed. How that is progressed will be up to a Minister, in terms of how it is put out. We absolutely need to see recommendations in that paper progressed.
Lynda Wilson: There are a number of very important strategies sitting at the moment. Departments are working away. The looked-after children’s strategy has been sitting on the shelf for a long time now. The system needs to be completely overhauled. We are not getting good outcomes for our children in care.
Q114 Lady Hermon: How many children are we talking about, Lynda? I am sorry to interrupt you.
Lynda Wilson: There are 31,000 children in the care system.[ii] That was published last week. It is the highest number we have had since the Children Order came in, in 1995. The little ones we are getting at the moment, the under-eights, are coming in with very, very complex needs and multiple moves. Sometimes there is nowhere for them to go. I have seen children kept for a week or two in outdoor pursuits centres, because there just is nowhere for them to go. A number are going out of jurisdiction, predominantly to Scotland, which is very expensive and not necessarily a good thing. That really has big repercussions on children’s lives at the moment, in our looked-after system.
Lady Hermon: That is about the number of younger children going into care.
Lynda Wilson: The children coming in are younger and more traumatised. They have had more moves and there is domestic violence, hidden harm, substance, alcohol, parental, mental health, neglect and a range of abuse. We are no longer just employing social workers. I am employing psychologists, neuro physiotherapists and sensory experts, because that is the way that you reach these children. Strategies are stuck, and innovation is a bit stagnant, because we have our duty to co-operate. We could really be pulling Departments together to bring about significant change across the piece, such as in mental health and education. That would definitely be a way to go. We have an understanding of what needs to be done.
Carolyn Ewart: I would absolutely support what Lynda has said.
Lady Hermon: We need decisions about the strategies.
Carolyn Ewart: Yes. We could probably list them. I am thinking of a couple I could name. Protect Life 2, the suicide strategy, is sitting waiting. We know that mental health is a huge issue within Northern Ireland. Our incidence or prevalence of mental health is significantly higher than anywhere else across the UK, and that is directly related to our history of conflict and violence. We are only really beginning to look at the intergenerational impact of trauma now, and that is an area that needs a huge amount of work. Our Protect Life 2 strategy is sitting, waiting, ready to go, but we need a Minister to get that out and working. Our adoption and children’s services legislation has been a long time awaited. We have got to the point where it has been written and consulted on, but again it is now sitting and waiting, and cannot be progressed without a Minister.
Lady Hermon: That is unless we are able to persuade the Secretary of State for Northern Ireland that, in fact, we could legislate here at Westminster in the continuing absence of an Assembly. That may be a way forward.
Carolyn Ewart: Another thing that continues to be a frustration is the lack of an ability to plan long term. We are planning and talking about short-term innovations, without an eye to the future and what we need to be planning for the long term.
Lady Hermon: Long-term funding is essential as well.
Carolyn Ewart: Absolutely, and there are some exciting innovations. One I will mention is the roll-out of social workers, mental health workers, occupational therapists and physios co-located with GPs in primary care. That is a great example of a really innovative new model, to make health and social care more accessible, and meet the needs of people at that very frontline service.
Q115 Lady Hermon: Is that being piloted?
Carolyn Ewart: It is being funded and piloted. We have £5 million to roll out the project across 40 GP practices. It is a great pilot.
Q116 Lady Hermon: Did that come out of the transformation fund?
Carolyn Ewart: It did; there was £15 million within the transformation fund to roll out that project and £5.5 million specifically to staff the project. The Department has been very clear that it sees this not as a pilot, but as an initial launch. It wants this to be continued. Obviously the impact will be evaluated, but, if it is to continue, to fund the social work service alone would require a £12.2 million increase annually. We do not know if that is going to be available, at any stage, in the coming budgets.
The other impact we notice links into the figures that Lynda has highlighted around the increased number of children in care, which is working in a society and culture with the impact of austerity. The welfare reform agenda has hit a lot of families particularly hard. Among the families we are working with in social work, we are seeing real impacts, particularly from the roll-out of universal credit. There is strong research that suggests 200,000 children across the UK will be forced into poverty; that is an additional 200,000 children as a result of the roll-out of universal credit. There has been a lot of publicity this week about the implementation and roll-out across England. There are real impacts, and children and families are really struggling.
Q117 Lady Hermon: How many would it be if those figures were translated into Northern Ireland?
Carolyn Ewart: I am afraid I do not have that. They have not looked at Northern Ireland specifics, because we are in the very early stages of roll-out, so we just do not have it. Currently, 15% of children in Northern Ireland live in absolute poverty.
Lady Hermon: That is not just poverty, but absolute poverty, which has a definition.
Carolyn Ewart: It has a definition, which is that they are struggling to buy food, shelter, clothing, warmth and access to education information. It is very profound. To be forcing more children into that situation is shocking.
Lady Hermon: It is absolutely shocking and appalling in 2018.
Carolyn Ewart: It is. We have been very vocal about universal credit and particularly the impact of the dreadfully named rape clause. To have a benefit that requires a woman to disclose and prove that a child was conceived as a result of rape is an unacceptable social policy in 2018.
Lady Hermon: I totally agree. Thank you. That is a very sobering thought to end with.
Q118 Chair: Can I ask what you think might be done to deal with this bureaucracy issue? You have each mentioned it in various ways and you have provided one or two solutions. One was specific, which is the form that is not common to the various agencies that you use, two of which are represented here today. I am wondering what other practical solutions you might have to deal with this obvious problem around bureaucracy. We can all argue about the money and the money will always be short, but bureaucracy really is unacceptable and remediable. I am wondering what practical solutions you might have, other than the one you have helpfully suggested, which could assist with this.
Lynda Wilson: I do not know the specific detail on this initiative, but I am aware that it is happening in Wales. The Welsh Government are looking at rolling out a new framework for social work and they are using the phrase “proportionate assessment”. At the moment in the social work profession—I hope you agree with me—we have gone too far in the wrong direction on assessment, with the sense that, if we have done the assessment, we are okay. Service users are fed up with being assessed, so we could definitely take knowledge and learning from other parts of the UK, as to how they are addressing that.
Mr Goodwill: I remember one parent saying to me, “If case conferences had solved my child’s problems, we’d have solved them a long time ago.” We have 12 people sitting in a room for an hour discussing a child’s case, when more time spent with the family might have helped.
Lynda Wilson: There is also the judiciary. We have a very conservative judiciary in Northern Ireland and children move slowly from one court situation to another, while their future is determined. We are talking, in the case of some of our services, about a child of six, seven or eight. They do not have time for that in terms of permanency and attachment.
Joan McEwan: Part of the problem is the perfect storm for Northern Ireland. We are in this situation where we have no Minister. Permanent Secretaries are reluctant to make decisions in the absence of a Minister being in place, so we have this perfect storm where a lot of practical things could be resolved, but there are procedures and processes that must always be adhered to and a real reluctance not to adhere to the process and procedure. That is definitely part of it. The transformation and the short-term budgeting and planning are definitely other factors within that.
Look at the size of Northern Ireland; it is small enough, so we should be able to fix a lot of these issues. You can see where it works in some of the examples Lynda was talking about. Through collaboration, when everyone gets in the room, things can be addressed and be done. Some of the issues we see are around simple things that delay people being discharged, such as having advanced care planning conversations or getting equipment. These are very simple things that could be addressed and resolved, and we should be able to do that. It is about getting the right people in the room and having an open discussion to work out the solutions together, putting the processes and procedures aside for a moment, and looking at the best outcome for the patients.
Carolyn Ewart: I will forward to the Committee for information a report that we did, “Social Work Not Paperwork”. In that we detail some specific and real recommendations that could make a significant change. I will highlight a few for you. I have already mentioned that there needs to be a Department of Health-led task force that is time bound and time limited, with a clear remit and the authority to purposely take out unnecessary and duplicative paperwork as a start.
We need proper and adequate IT systems. For example, in a day a social worker might do five or six home visits. They are going out to a family’s home, to an older person’s home or to someone who has a mental health problem. They have to record. We have paper forms and files, so we have to go back to the office manually to record, “Visited Mr A. Presented as A, B and C.” You usually come back to the office at the end of the day. You write up your running records. If you have some kind of IT solution that you can use in your car, to log in and do that as you go through the day, you will not have to scribble your notes on a jotter or a file while you are out doing it, and then come back and duplicate that work. If you have appropriate IT support, you can do it there and then.
If you have properly skilled and resourced admin staff, who can input the data that needs inputting and file the material that needs filing, rather than relying on social workers who may not be particularly IT-literate to input that data, it would make a huge difference. There are a few pieces of paperwork that are troublesome and irksome to social workers. One is the Northern Ireland Single Assessment Tool, called the NISAT. If I had had an extra bag to bring with me, I could have brought you some of the paperwork to demonstrate its volume. It is an assessment form of 30-plus pages. The idea behind it was a good one, which is that you have one assessment that all the different professionals involved in someone’s life will input to. In reality, it is a social work-only assessment tool. Social workers fill it in. As a result, the social worker has to capture all the information. The other professional groups that are meant to input into it do not do it, and see it as a social work task.
Lady Hermon: Maybe we should see that. Can you put it in the post?
Carolyn Ewart: We can forward that, absolutely. It is a huge piece of work.
Chair: I would be very interested in the document and very grateful if you could send that to us. It would be helpful.
Carolyn Ewart: I can give you one more brief example of something that we hope is being progressed, but unfortunately now seems to have stalled through the lack of a Minister. We made a recommendation around looked-after children. As a very real example, again, there are huge amounts of paperwork that start when a child becomes looked after, and rightly so. There should be good processes around documentation, but the documentation is excessive. Each child in a family, if there are six or 10 children, has to have this set of documents, 50-plus pages of documents, which are required at different points of time for review processes. Child protection processes often run at the same time. There is different documentation for the child protection process, and there is a UNOCINI, which is a single assessment for children’s services. All this different documentation runs at the same time.
This is our question: why are there three different requirements for forms that all relate to the one child and assessing their needs? As a real example of that, for children who have a disability, if they require one night’s respite care in a year, they automatically become looked-after children. That gives them a certain legal status. They are then required to become subject to the full looked-after process, so all the forms I am talking about have to be completed for that one child, for one night. It is unacceptable. It should not be happening. They already have a UNOCINI assessment, so the documentation that you need to look at their needs and their family already exists. It is about being bold and brave, and making some big decisions.
Q119 Lady Hermon: This is just a quick clarification, Lynda, because I am so intrigued and taken aback by what you said. You described the judiciary in Northern Ireland as conservative. Do you mean the judges are conservative or the judicial system is cumbersome and that is why things move slowly for a child? Which is it?
Lynda Wilson: It is probably a bit of both. Children are moved around the system. Quite rightly, there is a strong emphasis on trying to support families to care for children and try everything they can in their best interests.
Lady Hermon: The judge has a very difficult decision.
Lynda Wilson: Yes, but, very often, all that is happening is that judges are referring children to other bodies for expert assessments. A lot of my facilities would predominantly do expert assessments on parenting capacity or protective factors for the child, for the court, rather than doing any real work. We talk about early authoritative intervention; I do not quite know how the system is delivering to that ambition, but we have an increasing number of very small ones coming in, who have multiple and complex problems, and big attachment problems.
Q120 Lady Hermon: Is this an issue that you have raised with the Lord Chief Justice?
Lynda Wilson: No, although I know it has been raised.
Lady Hermon: Perhaps that is a suggestion to leave you with.
Carolyn Ewart: We have raised that issue of delay in the process in courts. Long delay can be caused by the continuous assessment and the notion of needing to refer on for a specialist assessment, which can take a significant period of time. We would argue strongly that the social worker in the case is the expert opinion. They know the family, have worked with the family and spent time with the child. They are presenting an assessment and that should be enough for the court.
Lady Hermon: That is very interesting. It may be something we could come back to. Thank you so much for your fascinating evidence.
Chair: Thank you very much indeed. That was quite a marathon. We have gone through a lot of very complicated issues, and we are very conscious of that. Thank you for your written evidence, and thank you for being here today. It has been exceptionally helpful.