The Department of Health should order the Southern Trust to conduct a ‘value for money’ study on spending on home care provision amid claims it is “out of kilter” with other areas across Northern Ireland.
For it has been claimed around £11 million could be saved which would “help alleviate a lot of problems” in the Southern Trust area if things were done differently.
The claims come from Independent Health & Care Providers (IHCP) chief executive Pauline Shepherd, who outlined serious concerns about the Trust’s performance, following on the heels of a letter to Department of Health Permanent Secretary Mike Farrar.
It comes after figures quoted at an ABC Council meeting on Monday reported over 800 people waiting on full-time domiciliary care in the Southern area, with hospital beds taken up because patients were unable to be sent home with no package in place.
Ms Shepherd spoke to Armagh I this week and highlighted her concerns that the Trust was spending too much on its in-house home care service, when real savings could be made by making more use of external providers.
She said: “For the Southern Trust, their internal service costs twice as much as commissioning it from outside. So other Trusts have a balance of 70/30. The Southern Trust commissions 60% from the independent sector and obviously is spending an awful lot more money internally, where if they commissioned it from the independent sector, they would be able to make considerable savings. So really, it’s about value for money, basically, that’s what it’s about.”
Independent Health & Care Providers is a representative body of employers, covering care homes, domiciliary care and supported living, representing private sector, not for-profit charities and faith-based providers.
“We’ve got about 300 members across northern Ireland and our membership covers about 70% of the larger care home groups. Any care home group that has three care homes and above, we would have 70%, so we’ve quite a high membership,” said Ms Shepherd.
By making more use of independent providers, the chief executive believes there could be real benefits and differences which could be made in other areas.
“If they saved money in the Southern Trust, there’d be more money to commission more packages, so there wouldn’t be the delays from the hospitals. There wouldn’t be so many people,” added Ms Shepherd.
“If we’re going to pay twice as much for an internal service, if you reduce that, you’ve got £11m probably that would go to commissioning and reducing waiting lists, reducing people that are waiting for months or whatever for a care package. Basically there’d be more money to go around. It’s more about efficiencies.
“What they need to do now is a value for money exercise and actually look at their internal costs against commissioning from independent providers. The Department is constantly asking for us to save money.
“We think the Trusts are saving money by not providing as much medical care packages as they could. So if they recycle the money from their in-house teams to commissioning outside, they would be able to spread that money much further and they’d be able to commission more packages for more people.”
Care workers, meanwhile, like everyone else, are being hit by the rising cost of living, hikes in fuel and other increases to every day necessities.
Ms Shepherd says morale, therefore, was “very low”, with Health Minister Mike Nesbitt “making a u-turn” on a “commitment to pay social care and workers in the independent sector the real living wage” because he insists he “couldn’t afford it”.
Said the chief executive: “There was a promise, there was an expectation, that the staff would get an uplift last September and obviously that didn’t come through, and I suppose it’s more that people see decisions being made for the likes of the MLAs and other money being spent.
“Social care workers feel that they’re at the bottom of the pile. Morale’s not good. Staff turnover’s very high. I’ve got some of the larger home care providers saying that the staff turnover is as high as 40%.
“So people will go and work in hospitality, retail, where they can earn the same amount of money or more and obviously have a less stressful job because, doing social care, particularly in people’s own homes, visiting lots of people every day, it’s very stressful. They’ll move elsewhere and find a job elsewhere for an easier way of earning a living.”
Ms Shepherd believes that the Southern Trust must urgently address how it operates its care commissioning when compared to the other four Trust areas in Northern Ireland.
“The cost per hour for Southern Trust delivering home care must be considerably higher than other Trusts per hour,” she said. “So they’re out of kilter with the other Trusts.”
So what then, does she feel, must happen?
“I would go as far as saying the Department should be asking the Southern Trust to actually look at their value for money for their own care service and split between in-house and services from the independent sector,” said Ms Shepherd. “There should be a value for money exercise done and that compared with other Trusts.”
Claiming around £11 million could be saved, money which could be spent in other ways, she added: “It would have a big impact. It would alleviate a lot of problems in that Trust area.”
Much of what has been said has been based on information provided by the Trust in response to Freedom of Information (FOI) requests.
The IHCP has recently written to Permanent Secretary Mike Farrar “concerning the structure, cost and workforce profile” of the Southern Trust’s internal domiciliary care service.
While one FOI response was described as “materially incomplete and subject to further clarification”, information which had been disclosed raised “issues of such seriousness in relation to cost efficiency, workforce sustainability and operational capacity that we believe urgent departmental consideration is now required”.
That letter to the Permanent Secretary goes further: “The Trust’s own published data indicates that its internally delivered domiciliary care service operated in 2023/24 at a unit cost of £39.74 per hour. This compares with a highest independent sector commissioning rate in the same period of £20.01 per hour. In practical terms, this means the Trust is delivering care internally at a cost approximately £19.73 per hour higher than independent provision — almost double the external rate.
“At the same time, the Trust continues to operate a delivery model in which roughly 40% of domiciliary care is internally provided and 60% outsourced, whereas the established pattern across other Northern Ireland Trusts is materially closer to an 80% outsourced / 20% internal balance.
“Based on the Trust’s own activity volumes, alignment with the regional delivery profile would indicate a potential annual system saving in the order of approximately £11–£12 million within this Trust alone.
“The Trust will likely attempt to argue the need to move to a 40% insourced model was due to Independent Providers leaving the Trust area – our members have confirmed directly this was due to the manner of engagement by the Trust over the last number of years. Equally, it is fully apparent, the current model is failing.
“This is not a theoretical observation. It goes directly to the Department’s repeated position in ongoing engagement with providers that insufficient funding exists within the system to support commissioning rates capable of absorbing statutory cost pressures.
“The scale of potential efficiency identified within a single Trust is such that, were equivalent structural alignment applied regionally, the resulting headroom would be sufficient to increase the Northern Ireland domiciliary care rate by approximately £1 per hour.
“When combined with the recently proposed wholly insufficient 78p uplift, this would materially alter the sector’s ability to absorb unavoidable statutory pressures, including minimum wage uplifts, the 2025 National Insurance changes, and the forthcoming statutory sick pay reforms in April 2026 — all of which the Department has acknowledged represent unavoidable cost drivers which must be funded if services are to remain viable.
“Beyond the fundamental cost differential, the workforce and operational data disclosed by the Trust also points to deeper structural fragility within the internal service model. The Trust reports more than 41,000 sickness days in a single year, representing over £2.5 million in direct absence cost and the equivalent of well over one hundred staff absent on any given day.
“When distributed across delivered hours, absence alone appears to add more than £2 per hour to the cost of provision. The Trust simultaneously reports an internal workforce of 1,187 staff, while continuing to record hundreds of vacancies across the service, suggesting that recruitment challenges are both persistent and likely to intensify rather than stabilise.
“Almost half of the workforce is reported to be on zero-hours contracts despite the substantially higher unit cost of internal provision. Operational resilience indicators are also concerning: delivered care hours fall rather than increase during peak winter months, new package assessments reduce sharply during the same period, and virtually all assessed patients are deemed eligible for services, demonstrating that the primary constraint within the system is not eligibility policy but delivery capacity.
“The Trust also records hundreds of missed homecare visits during the reporting year, reinforcing the operational implications of workforce instability.”
Taken together, the IHCP says the figures “suggest a position in which one of the largest domiciliary care systems in Northern Ireland is operating a model that is simultaneously materially more expensive, structurally less workforce-stable, and less operationally responsive during peak demand periods than the independent sector delivering the majority of regional provision”.
The letter continues: “IHCP members are repeatedly advised in commissioning discussions that public finances cannot sustain higher independent sector rates. However, the Trust’s own disclosed financial and workforce data now raises a legitimate and unavoidable question as to whether the issue facing the system is one of absolute funding shortage, or of how existing resources are structurally deployed within delivery models.
“Given the magnitude of the figures involved, and the potential implications for regional commissioning policy, value-for-money assurance, winter capacity planning, and long-term workforce sustainability, we believe this matter now requires formal departmental review rather than remaining solely at Trust operational level.”
It is therefore calling for the Department to confirm what steps it intends to take to review the cost structure and deployment model of the Southern Trust domiciliary care service; assure itself that current resource allocation within domiciliary care maximises patient access, service stability and financial efficiency; and ensure that decisions affecting the sustainability of the independent sector – which continues to deliver the majority of homecare hours across Northern Ireland – are taken with “full regard to the comparative financial evidence now available”.
The letter states: “Given the seriousness of the issues emerging, and the incomplete nature of one of the FOI responses, IHCP will continue to seek clarification through the appropriate statutory channels where required. We would, however, strongly prefer to engage constructively with the Department at an early stage to ensure that these matters can be addressed transparently and systemically.
“You may also wish to note that, given the scale of the financial differentials now evidenced and the potential implications for regional commissioning policy, we would reasonably assume the Department will wish to satisfy itself that the current position would withstand external value-for-money scrutiny, including by the Northern Ireland Audit Office or other oversight bodies, should the underlying delivery model or funding decisions come under formal examination.
“IHCP would be happy to assist constructively in providing any additional sectoral data which may support that assurance process. We would welcome the opportunity to discuss this with officials at your earliest convenience.”
