Human Rights Inquiry Emergency Health Care Contact us If you would like to know more about the work of the Commission, or any of the services we provide, please contact us. Northern Ireland Human Rights Commission Temple Court 39 North Street Belfast Northern Ireland BT1 1NA Telephone: +44 (0) 28 9024 3987 Fax: +44 (0) 28 9024 7844 Email: [email protected] www.nihrc.org ISBN 9781910219492 Follow us on: 9 781910 219492 CDS 119941 119941_NIHRC Emergency Health Care Inq Rpt_A4_10mm spine Cover/Back_V7.indd 1 18/05/2015 14:56 119941_NIHRC Emergency Health Care Inq Rpt_A4_10mm spine Cover/Back_V7.indd 2 18/05/2015 14:56 Human Rights Inquiry – Emergency Health Care Foreword This is the first national human right inquiry into The Inquiry seeks to use international human rights health care in emergency departments undertaken standards including the right to health as a lens anywhere in the world. The Inquiry builds on an through which to view emergency department international model of human rights inquiries to health care. In turn, this incorporates human rights ensure the process was rigorous. The choice of an concepts including the right to respect for dignity, Inquiry into health care in emergency departments responsiveness to need particularly among the reflected the focus on the issue both politically and most vulnerable, participation and the involvement publicly. With around 700,000 visits to emergency of people receiving care and treatment in planning departments in hospitals in Northern Ireland it is an and delivery of services. issue which touches almost everyone’s life here. The Inquiry found examples of human rights The Inquiry has been wide-ranging taking evidence violations though we did not receive evidence from ministers, the Department, the Health to suggest such violations were systemic. The and Social Care Board, health and social care Inquiry also wanted to look forward and the report trust managers, clinicians and trade unions, key outlines how a human rights based approach to voluntary organisations dealing with complaints and emergency care could assist health and social care providing advice alongside patients and families trusts in delivering emergency care services. The who are at the receiving end of the service. We conclusions and recommendations aim to support wanted to hear good stories as well as bad and and assist those who set policy, commission what was working well alongside what needed services and deliver the care, carry their work to improve. The Commission was conscious that forward. emergency care departments are a vital part of The Inquiry relied on the evidence given to us in a much wider health care system. To that end, writing and in person at the eleven public hearings. we know that the emergency department relies We are immensely indebted to everyone who significantly on other parts of the health service participated in the Inquiry. The evidence at the including out of hours GP services, minor injury public hearings can be viewed on the Commission’s units, and availability of community care services website at www.nihrc.org. and beds elsewhere within hospitals. Moreover, the setting of policy from within the Department Finally, I would particularly like to thank my and how services are commissioned and funded colleagues on the panel Marion Reynolds and Paul both through regional and local mechanisms Hunt, fellow Commissioners and Commission staff has a significant influence on how emergency for so ably organising and steering the Inquiry to departments work in practice. The Inquiry also fruition. examined spending patterns on emergency care Les Allamby and transition monies for the Transforming Your Chief Commissioner Care initiative to help us understand how money is allocated and spent. The references to documents and other materials in the report cover the period up to completion of the Inquiry but, it is recognised that additional material has been produced since the completion of the report. 1 Human Rights Inquiry – Emergency Health Care Contents Introduction 5 What is a human rights inquiry? 5 Why investigate emergency health care? 5 Human rights framework 8 The right to health 9 The health system in Northern Ireland 11 The current framework for providing emergency care services 11 Service standards 13 Accessing emergency health care 14 How was the Inquiry conducted? 15 1. Quality 17 Human rights laws and standards framework 17 Dignity 17 Information and participation (including consent) 18 Timeliness 19 The provision of appropriately skilled health care staff 20 Domestic framework 21 Domestic laws and standards 21 Regional strategies and plans 24 HSC trusts and institution specific policies, education and training 25 Findings: Domestic framework 26 Quality in practice – Inquiry evidence 27 Dignity 27 Findings: Dignity 31 Information and participation (including consent) 32 Findings: Information and participation (including consent) 34 Timeliness 34 Findings: Timeliness 39 The provision of appropriately skilled health care staff 40 Findings: The provision of appropriately skilled health care staff 43 2 Human Rights Inquiry – Emergency Health Care 2. Accessibility 44 Human rights laws and standards framework 44 Non-discrimination and equality 44 Domestic framework 47 Domestic laws and standards 47 Regional strategies and plans 51 HSC trusts and institution specific policies, education and training 52 Findings: Domestic framework 54 Accessibility in practice – Inquiry evidence 54 Refraining from discrimination 54 Findings: Refraining from discrimination 62 Eliminating and preventing discrimination 63 Findings: Eliminating and preventing discrimination 67 Monitoring inequality 68 Findings: Monitoring inequality 70 Training to ensure awareness and responsiveness by health care staff 71 Findings: Training to ensure awareness and responsiveness by health care staff 72 3. Governance 74 Human rights laws and standards framework 74 Legislation, strategies, codes of conduct etc. 74 Participation, information and transparency 75 Accountability 77 Domestic framework 79 Legal recognition of the right to health 79 A national health strategy and action plan 80 A regulatory framework to ensure effective system functioning 82 A Patient Safety Policy Framework 85 Mechanisms to ensure public participation 86 An effective accountability framework 88 Findings: Domestic framework 93 Governance in practice – Inquiry evidence 94 Integration of right to health / human rights-based approach 94 Findings: Integration of right to health / human rights-based approach 95 Quality Improvement and Patient Safety 96 Findings: Quality Improvement and Patient Safety – mechanisms 97 3 Human Rights Inquiry – Emergency Health Care Findings: Quality Improvement and Patient Safety – mechanisms – culture 100 Findings: Quality Improvement and Patient Safety – mechanisms – leadership 101 Effective functioning of the system 101 Findings: Effective functioning of the system – protocols, including escalation 102 Findings: Effective functioning of the system – resource planning 106 Participation in health decision-making 106 Findings: Participation in health decision-making 108 Accountability 108 Findings: Accountability – monitoring 109 Findings: Accountability – review 112 Findings: Accountability – remedial action 115 4. Developing a human rights-based approach to 117 emergency health care in Northern Ireland Three steps towards an operational human rights-based approach to 119 emergency health care 5. Conclusions 123 6. Recommendations 128 Appendix 1 Terms of Reference 131 Appendix 2 Witness list 134 4 Human Rights Inquiry – Emergency Health Care Introduction “[T]he enjoyment of the highest attainable standard broad community, offering an analysis based in of health is one of the fundamental rights of every human rights law and providing recommendations human being…without distinction of race, religion, for systemic responses”.3 political belief, economic or social condition.”1 This Internationally, human rights inquiries are endorsed right is guaranteed in a number of international by the United Nations as a method of investigation human rights instruments. The Universal by NHRIs. The method has been developed over Declaration of Human Rights (UDHR), Article 25 (1) the past twenty years largely in the Asia Pacific states that “[e]veryone has the right to a standard region. Human rights inquiries involve evidence of living adequate for the health and well-being of gathering; investigation (much of which is carried himself and his family, including…medical care...” out in a public forum); analyses of the evidence; and the International Covenant on Economic, Social and reporting which includes recommendations and Cultural Rights (ICESCR), Article 12 guarantees for action. An Inquiry also has an educative role the right of everyone to the enjoyment of the raising public awareness of the subject matter and highest, attainable standard of physical and mental the human rights engaged. health. In accordance with the Northern Ireland Act On 3 June 2014 the Northern Ireland Human 1998, Section 69, the NIHRC “shall keep under Rights Commission (NIHRC) launched a Human review the adequacy and effectiveness in Rights Inquiry into Emergency Health Care (the Northern Ireland of law and practice relating to the Inquiry). The Inquiry aimed to investigate, and protection of human rights”.4 For the purpose of make recommendations on the extent to which exercising this function the NIHRC may conduct the Northern Ireland Executive and other