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How strained health care system can be improved

By John Simpson

Published 26/01/2016

Nursing home support is capped
Nursing home support is capped

Health and social services in Northern Ireland have a unique organisational structure that should allow good integration of health and social services for people who need these services. Two key starting points: first, money is not the only factor in decision making but it is a necessary real constraint. Second, the oft quoted ambition to offer services 'free, at the time of need' is misleading. It applies to acute services but not to the wider range of care and non-acute services (and never has done).

At least part of the causation of crises in providing acute hospital services is the inadequacy of non-acute provision and its organisation. Increasingly, because funds are limited, services are being constrained by delays and queues, even when seeking a GP appointment. Beyond the immediate impact of waiting (queuing) some services are subject to rationing and/or means testing, occasionally to the point of near exclusion.

With no comfort to those disadvantaged, health and social services are moving to a regime where they are constrained not on the basis of personal perceived need, but on the relative degree of professionally assessed urgency.

There remains an overriding need to provide better health and social services effectively and efficiently. In part this calls for better organisational working arrangements. Excessive optimism that 'moving the furniture' will make the necessary improvements merits caution.

The special advisory group now following up on the Donaldson report should look beyond the 'furniture moving' organisational remit.

There is a major distortion of the use of health services resources evidenced by the blocked bed syndrome. People who are no longer in need of an acute hospital bed should be transferring to appropriate support whether from domestic support services at their home (community support packages) or residential or nursing home care.

The transfer from acute care is not working seamlessly. The reasons are both logistical (making joined up arrangements) and financial. The financial difficulties come in differing ways.

Residential or nursing home care for many people is not 'free at the time of need'. Part of the process affects the allocation of pension and social security entitlements which then become a source of private contribution to care costs. Much more significantly, since nursing home care comes from private sector organisations, each has a structure of care charges to be met.

The official health and social services contribute to these charges but this is constrained by two factors.

First, official support is constrained by means testing where, if the patient has personal funds (capital) of over £14,250, a partial weekly contribution is expected and if those personal funds exceed £23,250 then the full cost is charged.

A second constraint is that, regardless of the available personal funds, the official support to a nursing home is capped (2015-16) at £593 per week. If the home charges more than this, as many do, the excess must come from the patient's and their family's resources.

Without going into greater detail, the significance of the charging and contribution arrangements is that when a patient moves into continuing nursing care (or assisted home care) health needs become subject to financial constraints. There is no surprise that sometimes timidly or obscurely a move to non-acute care can be delayed by these complications.

Blocked beds impose an extra cost on acute care, but they also delay acute care for those who are waiting.

A proposal: Northern Ireland could use its devolved authority to use funds to make the transfer to non-acute care 'free at the time of need' for the first (say) three months of non-acute care? This would mean a better use of the acute hospital services along with a better targeted allocation of an agreed budget.

The current systems operate with a disincentive to sensible care planning. It could be improved. Is Simon Hamilton, as minister, ready to consider this type of organisational and financial change?

Company report: Budget Energy

Budget Energy is a relatively new locally owned business supplying electricity to domestic and other electricity users. The company has its registered office in Springtown Industrial Estate in Londonderry. 

With no inherited links to the energy sector and no inherited energy customer base, the company has signed up over 61,000 account-holders in less than four years.

Several years ago, the initiators of Budget Energy met the conditions to obtain a licence to sell electricity in Northern Ireland. Using a successful marketing effort emphasising its comparative tariff advantages, the company has generated a rapid increase in its customer base.

As a privately owned competitive business, the company determines its own charges. To succeed, tariffs have continuously been significantly lower than the regulated tariffs of the largest supplier, Power NI.

With its expertise in operating arrangements for pre-payments of accounts — built up in an earlier business — Budget Energy has a significant proportion of its accounts using pre-payment arrangements.

Only in the trading year to June 2014 did the company first record appreciable trading profits. In the two most recent trading years, the company has been able to offset the initial trading losses and is now reporting acceptable levels of pre-tax profits.

Employment in the company has increased to an average of 42 people.

No dividends have been allocated to the shareholders and post-tax profits have been retained in the company. As a consequence, the value of shareholders’ funds as at the year-end increased by over £3m to reach £8.8m.

Belfast Telegraph

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