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Health and Social Care Needs in Fermanagh & West Tyrone Cliffs of Magho, County Fermanagh. Image © Northern Ireland Tourist Board Health and Social Care Needs in Fermanagh and West Tyrone Declan Bradley 15 November 2019 ii Contents Executive Summary 1 Acknowledgements 5 1 Introduction 7 2 People and Place 13 3 Health and Social Care Services Overview 21 4 Health and Social Wellbeing 27 5 Community and Travel 43 6 Domiciliary Care 51 7 Community Care 55 8 Mental Health 59 9 Primary Care 63 10 Hospital Care 69 iii iv CONTENTS 11 Working with Western Trust 85 12 Conclusions 93 References 95 Appendices 99 Executive Summary The Fermanagh and West Tyrone Pathfinder Project is a ‘Transformation’ Project that was developed in response to the recommendations of several important reviews, reports and policies about the need to meet the chal- lenges of delivering safe and sustainable Health and Social Care (HSC) services in Northern Ireland.1–5 The aim of this Health Needs Assessment report was to identify, and where possible, quantify, health and social care needs of the people who live in Fermanagh and West Tyrone (F&WT). The project used a combination of intelligence provided by members of the public and healthcare staff, routinely published information and analyses of data from HSC information systems. The F&WT area is the least densely populated part of NI, making up 25% of its geography but only 7% of its population. F&WT contains a small number of areas that are among the most deprived in NI. Most of the area, however, is in the most deprived 50% of NI. There is a trend towards increasing numbers of older people, and fewer young working age people in the area. This presents challenges for HSC. Some groups such as those with disabilities, Travellers, migrants and LGBT people, have specific 1 2 CONTENTS access, language, health or social needs about which further information will be required when services are being redesigned. For most measures, health in the more deprived parts of Fermanagh and Omagh (F&O) was worse than in the area overall. The most striking finding was a sharp drop in women’s life expectancy by four years in deprived parts of F&O. This appears to be have been caused by an increase in preventable mortality, at least partly due to a marked increase in incidence of, and death from, lung cancer. Alcohol, smoking and drug-associated hospital admissions, illness and death are all more common among people who live in the more deprived parts of F&O. The low vaccination rate of pregnant women in the area is in contrast to their relatively lower risk behaviours compared to the rest of NI. People in F&WT are faced with travelling longer distances on smaller roads because of the geography of the area and because specialist services are further away. Many of the issues raised by citizens and staff about travelling are not under the direct control of WHSCT. Advocacy and partnership working will be required to influence change. However, many of the issues relating to travel to too many appointments at inconvenient times and distant locations could be ameliorated by sympathetic scheduling and coordination of care. People who live in F&WT and domiciliary carers who look after them are often dissatisfied with the way that domiciliary care is organised. Access to domiciliary care is limited, there is unmet need, and citizens in the area believe that the carer workforce is being economically exploited while others who might work in domiciliary care choose not to because CONTENTS 3 of the poor pay and conditions. Exciting new changes to the design of community care are in development in other parts of NI through a regional transformation project. There is an opportunity now for people in the F&WT area to benefit from innovation in the delivery of community care. Community services such as nurses, social workers and health visitors are under pressure and feel that they are struggling to meet needs of the people in the area. Limitations in community care capacity might be putting pressure on hospital services. Some service users find navigating and negotiating for specific services (e.g. meals on wheels and direct payments) frustrating, dealing with lots of different healthcare workers draining and the variation in provision in different areas or at certain times to be a barrier to access. Service users value mental health services that build connections and skills, such as the Recovery College. Some staff in mental health services are worried that the design of their service is not suited to the needs of their patients and is allowing harm to happen while users wait on waiting lists. Alcohol and drug use cause concern in some areas, especially Omagh. People in F&WT are worried that GP services in the area are fragile and vul- nerable to retirements and recruitment problems. Some patients approved of some primary care services being delivered by other professionals who work with GPs. GPs are frustrated at administrative duties and a feeling that it is difficult to recruit new GPs to the area because they do not experi- ence working in F&WT during training. Patients are frustrated at barriers and delays to accessing in-hours and out-of-hours GP services, possibly causing some to go to emergency departments instead. 4 CONTENTS The South West Acute Hospital (SWAH) emergency department is experi- encing declining performance against the target to assess and discharge or admit patients within four hours. People in the area worry about having to wait for many hours in a stressful and frightening environment. SWAH has constantly high numbers of inpatients, many of whom are medically fit for discharge. Staff and patients say that waiting times for outpatient services are too long. Improving access to services will require a different approach to service design. Staff reported that there was a major, frustrating problem with the effec- tiveness and efficiency of recruitment to jobs within the Trust. WHSCT health and social care staff do not want to spend time on administrative tasks at the expense of time caring for patients, but some feel that the system makes them do this. Some staff worried the complaints process does not result in learning. Some staff may feel aggrieved at disparities in pay between people doing similar work, and worried that some staff groups are undervalued and treated unfairly. The Fermanagh and West Tyrone Pathfinder project presents exciting opportunities to redesign services to meet the needs of the people who live in the area, and the staff and carers who look after them. As well as highlighting many areas that concern citizens and healthcare workers, the report shows how citizens value the staff who work in the services, the high quality of care when they access services, the high quality of the physical environment in the two new hospitals, and how staff value eachother and are eager to improve the quality of the services they provide. Acknowledgements Thanks to the citizens, stakeholders and Western Trust staff who shared their stories, information and time. The cover image was used with per- mission of the Northern Ireland Tourist Board. Administrative boundaries were provided by The Northern Ireland Statistics and Research Agency (NISRA) and used under the Northern Ireland Mapping Agreement. Ge- olocations derived from postcodes were based on the NISRA Central Postcode Directory except for the locations of GP surgeries and commu- nity pharmacies, which were supplied by Business Services Organisa- tion. Map tiles showing roads are from Open Street Map. Open Street Maps are © OpenStreetMap contributors and licenced as CC BY-SA. See http://www.openstreetmap.org/copyright Satellite imagery is from ArcGIS basemaps. Sources: Esri, DigitalGlobe, GeoEye, i-cubed, USDA FSA, USGS, AEX, Getmapping, Aerogrid, IGN, IGP, swisstopo, and the GIS User Community. Created using ArcGIS® software by Esri. ArcGIS® and ArcMap™ are the intellectual property of Esri and are used herein under license. Copyright © Esri. All rights reserved. For more information about Esri® software, please visit www.esri.com. This report was written in Bookdown.6 5 6 CONTENTS Chapter 1 Introduction In late summer 2018, Western Health and Social Care Trust (WHSCT) began a project to improve the health and healthcare of people who live in Fermanagh and West Tyrone (F&WT). The reason for focusing on this area was that though there were two recently-constructed, modern hospitals in Omagh and Enniskillen, there were concerns held by some about problems recruiting staff to work in the hospitals, the impact of the recent closure of several general practices, and uncertainty about the resilience and sustainability of services in this area. The initiative came at a time when changes in the organisation of Health and Social Care (HSC) services in Northern Ireland (NI) had been recom- mended by a series of reviews, reports and policies.1–4 These documents recommended more focus on prevention and community care, with the aim of reducing the risk of hospitalisation for citizens. The Expert Panel review, Systems, not Structures aimed to bring about a shared vision of proactively 7 8 CHAPTER 1. INTRODUCTION managing health in the community rather than reacting to health crises after they arise with hospital care. It recommended working with citizens to design the system that would provide this preventive and supportive care.3 The report was the basis for the ten-year Department of Health (DOH) policy, Delivering Together 2026. The aims of the policy were that: • people are supported to keep well in the first place with the infor- mation, education and support to make informed choices and take control of their own health and wellbeing; • when they need care, people have access to safe, high quality care and are treated with dignity, respect and compassion; • staff are empowered and supported to do what they do best; and • our services are efficient and sustainable for the future.

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