Written evidence submitted by the Royal College of Paediatrics and Child Health (RCPCH), relating to the funding and delivery of public services in Northern Ireland inquiry (FPC0021)

Concerns have been raised across health, education and the third sector about how the tight budgetary settlement will impact the delivery of public services. It has also been reported that public services in NI will face cuts of at least £500 million in the new financial year.

The Secretary of State setting a Budget again for 2023/24 is not a tolerable or sustainable position.

In this context, the RCPCH submits evidence to the Committee on the following two terms of reference.

1)      The impact of the lack of a functioning Executive on budgetary management and strategic decision-making across Northern Ireland Departments.

1.1) Paediatric Strategy for Hospitals and the Community

Possibly the most obvious impact to strategic delivery, planning and funding of paediatrics lies in the inability to progress the regional Paediatric Strategy for Hospitals and the Community (‘The Strategy’).[1] The Strategy was published in 2016 (following consultation in 2012) followed almost immediately by political collapse in January 2017. During its’ lifespan, the political institutions have been functioning for 2 of 6 years, a timespan covering the response to the COVID 19 pandemic. Upon publication, no budget was assigned to the Strategy and the statement that funding was against a backdrop of ‘competing priorities’ remains unacceptable. It is understood that some recurrent funding has been found for age-appropriate care and palliative care, but it not understood how the reminder of the outputs expected by completion of the Strategy will be executed or how it fits in to the developing commissioning and transformation agenda/s.

Unfortunately, even straightforward initiatives are difficult to progress in a government department in crisis and without ministerial direction – while open to recommendations, there has been no opportunity to influence policy due to democratic deficit to create the structures to fully deliver on the commitments made by the then Health Minister who launched the Strategy, and demonstrate the absolute need and value in harnessing the dynamism of paediatricians and the whole child health workforce, in pushing this up the political agenda.

The Department’s own mid-year review of the strategy[2] reflected that little progress had been made, and why that was, as did the 2021 NICCY More Than a Number report[3] and follow-up in 2022[4]. We know that officials at the Department are working hard in increasingly difficult circumstances, and we definitely know those working to deliver paediatric and child health services are working hard to improve outcomes in intolerable circumstances in many cases.

Given the fraught landscape, it is difficult for those responsible for planning and delivery of public services however, with clear opportunities available to link up clinical networks and from there, community networks available and actionable and the HSC (NI) Act 2022[5] granting virtue to lay new statutory framework to deliver on commissioning and more in a range of areas, more work can be done.

1.1.1)       Programme Board for the Child Health Partnership

It is often stated that the Child Health Partnership are the vehicle with which to deliver the Paediatric Strategy, however, at this late juncture and during political dissolution, (while Ministers continued under caretaking duties) a consultation took place with Clinical Leads who identified the need for a review of the commissioning of children’s services given the current complex tiers of commissioning and the shift in modelling taking place at Departmental level. This point was reiterated by the Children’s Commissioner in her update to The More Than a Number Report in October 2022[6] – at this time, Departmental Officials made clear that given the uncertain budget envelope and political landscape, it would not be possible to fulfil this recommendation. We understand that senior civil servants are under undue stress and scrutiny to make decisions which otherwise would warrant the democratic accountability of ministerial portfolio holder and parliamentarians, our current structures should not impact good sense recommendations in the public interest.

1.1.2) A Senior Medical Officer for Children

The Departmental response (October 2022)[7] to the NICCY More Than a Number update report detailed that recommendation 3a i.e., appointment of a senior medical officer with responsibility for child health was underway. Regarding recommendation 3b, the Department recognised the extent of reform needed across many areas of child health, however stated that these do not reside within a single policy area and that policy leads are in place across the relevant parts of the Department who work collaboratively as required.[8] Again, if the promised Senior Medical Officer for Children is forthcoming, then the unifying office would indeed work more efficiently for health where multiple policy issues are interlinked and appointed policy leads could work more fluidly within the developing structures. Until a SMO post is created and empowered and lines of accountability are established back to CMO level, children may continue to be less than visible in the Department.

A ‘golden thread’ both empowered and accountable based on other models across the UK, an SMO if not a DCMO (as per Justice O’Hara’s recommendation)[9] is needed ASAP.

Our NI Executive CYP Strategy (DE sponsor) for example is a tenement to NI’s well-intended commitment to children, however, the reality is, in health services are unnecessarily complicated – planning and commissioning is far from clear and the Department must build in space, with or without Ministerial direction to deliver on recommendations to review, explore, empower and change. Given the operational nature of the position an Executive could easily be extracted from the expertise which already exists within paediatrics with support from SPPG.

1.1.3         Service delivery transformation

Innovation and change in terms of a framework for a fragmented system under immense pressure, a picture shared with the rest of the UK is apparent, acutely so in paediatric emergency medicine and Community Paediatrics.[10] The Hewtit Review clarified that to give every child the best start in life, ICSs should ensure that both their partnerships and integrated care strategy include a clear articulation of the needs of child should include children and young people and how those needs will be met through collaboration across the system.[11] Accountability for these developing structures in NI is needed, growing policy shines a light on our democratic deficit.

1.2) The Children and Young People’s Strategy 2020-30

This Strategy,[12] delayed by 3 years then launched against a backdrop of two successive short-term emergency budgets set by Westminster, is cited as the PfG for CYP. However, it’s delivery will be decimated against a background of cold education cuts across vital services delivered in schools (or by way of the education budget). Ultimately it is unlikely to meet objectives in its’ lifespan unless the spending trajectory changes and political leadership be reinstalled. Outcomes and indicators need refining in long strategies, inadequate reporting to the legislature due to dissolution is not optimal.

2)      The financial situation facing Northern Ireland’s public services, including the police, health, education and children’s social care, and the consequences of budgetary pressures on the delivery of those public services.

2.1) Proportion of health budget and delivery of Paediatric services

Given the proportion of the population of u18s,[13] the health spending is not commensurate, poor planning hampers successful pathways and funding tier applications. The need identified in the last NI Affairs Committee review reflected in ‘Health funding in Northern Ireland First Report of Session 2019’ for improving paediatrics within the £30 million sum carved out for the confidence and supply deal remains. Those on wait lists,[14] presenting in EDs[15] with majors or minors are having poor experiences. Post-COVID, the problems appear more pronounced with more numbers waiting than before and a burned out workforce.

2.2) Education budget

Recently, the budget for a range of additional support services have been axed due to the shortfall in the temporary WM budget. Despite much evidence[16] to the effect that front loading services for children results in savings and better experiences and outcomes for children and families does not appear to be important. Not intervening early costs more.

Ministerial direction and sustainable multi-year funding and linkage with the voluntary and community sector as per the ICS advice in the Hewitt Review should come in to play here. However, the ICS development is taking place in isolation within health, civil servants work hard to align services, but this is difficult in a fragmented system where children’s issues are dispersed.

2.3) Rights

Currently, the position of Children’s Commissioner is unfilled – it is unclear how the Executive Office will appoint a successor to the recently vacated seat.[17] At this time of brutal cuts to children’s services and the shortfall in the sum granted via consolidated funds for delivery of children’s services, including, Extended Schools, Holiday Food Grants, Healthy Happy Minds and more, effectively putting the most vulnerable at the sharp end of cuts, an advocate is needed. Child Rights Impact Assessments[18] need to be utilised if this series of cuts due to the temporary budget, which appears to disproportionately effect children, is to be identified and rectified.

The recent look at rights for the UNCRC Committee’s periodic review led by the Children’s Law Centre and contributed to by RCPCH, details a range of impacts to the plethora of children’s services which deliver the party state’s obligations toward UNCRC rights. The impact of political dissolution is clear in these papers. A re-organisation of government departments in Northern Ireland was conducted in 2016. Previously, two junior Ministers within the (then) Office of the First Minister and Deputy Minister held overall responsibility for children. However, currently no Minister has overall responsibility for children. This has weakened oversight and accountability for issues relating to children and the implementation of children’s rights.[19] Moving with progress like this cannot be considered in a system in perpetual fire-fighting mode.

2.4) Poverty and Health Inequality

Progressing an anti-poverty strategy was not possible by the Department of Communities as the NI lead before full dissolution, a child poverty strategy was in place until May 2022. We welcome a strong roadmap setting the trajectory for ameliorating poverty for children, families and communities. Of course, a Minister needs the Assembly to work in tandem with them to refine and implement said strategy. However, this important piece has stagnated. Issues are becoming more complex and the effect of poverty more at risk of becoming entrenched, indeed, the new strategy should now make provision for a lot of recovery following the cost of living crisis (CPI recorded food inflation at 18.2% in February 2023) and to undo the cold cuts impacting our disadvantaged communities through the education budget. Devolved government can better make provision for NI’s poorest households, nuances of life here and how we differ and compare to the rest of the UK, for example, it is vital for quantifying and understanding the impacts of rising prices[20] among other things.

3. Conclusions

It is uncertain to say what may have been different in policy outcomes without political dissolution, or indeed what could be achieved when faced with a global pandemic. Nonetheless, what is clear, political impasse is catastrophic for a tax funded and publicly run health service. Paediatrics has not fully implemented the recovery post-COVID plan for example. Tasked with managing crisis and severe, almost impossible budget cuts, senior civil servants cannot continue to be asked to do the untenable. A budget which allows for at least some slack for transformation in paediatrics and children’s services, with the support of the SPPG and Department, the Child Health Partnership can deliver on outputs in the remaining time of the current Paediatric Strategy and inform the development of the next one. In the meantime, sharp cuts in programmes which support children coupled with no investment in the improvement or cohesiveness in paediatric services until fairly recently within HSC creates a perfect storm for unmet need. In any case, it is not unfair to observe, that ongoing political impasse and successive Westminster set short-term budgets has and will continue to impact the delivery of public services in health and wellbeing for our infants, children and young people.

April 2023