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Should Northern Ireland's health and social care budget be ring-fenced?

If politicians decide to protect it, other departments such as education and the environment will have to take the extra hit.

So why should health be more highly valued than some other services?

����ý NI health correspondent Marie-Louise Connolly looks at the tough questions and some possible answers.

Northern Ireland's population is growing fast - and the number of pensioners is expected to grow by 11% in the next five years.

And with new drugs and enhanced hospital procedures available, we are also living longer.

All of which means there is a greater demand on a health service that is now expected to make considerable cuts - potentially £758m worth.

The Health and Social Care Board decides which services to commission

Its chief executive John Compton admits that if the budget is not ring fenced, there will be tough times ahead.

He adds: "Clearly, there would be fewer people working for us and people would have to wait longer on services and there would be an element of rationing."

'Responsible change'

Some are calling for clinical rather than political arguments to shape the health service.

It would be a bold move to close or merge hospitals, but if the health budget is going to be hit hard then the health minister may have to make some bold moves.

However, if it creates a more efficient service, others might call those moves brave.

It has, for example, been argued that there are too many A&E departments and it would be more efficient to reduce them.

But that would mean closing smaller hospitals such as Whiteabbey and the Tyrone County.

John Compton says that regardless of the budget, maintaining the status quo is not sustainable and there must be "responsible change" because "nothing is static".

If nothing is static, then the health service needs to make better use of its resources.

For example, the £19m saved by closing the Mid-Ulster Hospital could be ploughed back into the system.

At least £13m of that money could go towards paying for a much needed extension to Antrim Area Hospital.

There could be another 150 hip operations performed locally at a cost of £1m.

Another £1m could go to coronary artery bypass grafts.

As Health Minister Michael McGimpsey wants to deliver more care in the community, £2m could pay for additional home helps and community services.

Finally, 100 additional nursing posts would be about £2m.

Gap

Even if the health budget is protected, some believe it will not go far enough.

John Appleby is the chief economist with the King's Fund in London and in 2005, he carried out an independent review into the health service here.

He explains: "If Northern Ireland receives a small real rise - that is if it is protected - the sort of gap between the money it gets and the money it would like to receive could be about 20% of its current budget. That is quite a large gap."

With so much focus on services, others believe it should be quangos which are under scrutiny.

"I think there is still fat in the system," says Professor Deirdre Heenan of the University of Ulster.

"If you take the Health and Social Care Board, it was set up to commission services from the trust.

"However the trusts deal directly with the health department. Therefore we could ask the question, do we really need this?

"The Patient and Client Council was set up to be an independent voice for patients. But, in recent health care debates about centralisation and cuts and waiting lists, the council has been notable by its absence."

Everyone is waiting with baited breath for the chancellor's Comprehensive Spending Review announcement on 20 October.

For a time, building projects on hospital sites will be rare to the point of non-existent. What money is available will be used to meet the growing demands and costs.

All in all, quite a gloomy prognosis for a health service that is already experiencing considerable pain.