Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): You are very welcome.

Sir Liam Donaldson: Thank you.

The Chairperson (Ms Maeve McLaughlin): I am delighted that you could attend today. We have with us Liam Donaldson, the report author; Mr Richard Pengelly, the permanent secretary; Michael McBride, the Chief Medical Officer; and Charlotte McArdle, the Chief Nursing Officer.

We are talking about structuring this in two parts, if you like, in terms of the way forward. We want to begin by focusing on the report and directing questions to you, Liam, on that. We will then move on to discussing how the Department intends to respond to the report and direct our questions to the officials. At the outset, I want to say that, when we direct a question to the Department, it is our preference that one official answers. You may have to make a judgement among you of who is best placed to do that, but certainly, with regard to maximum detail and outcome, that is our preference.

You are welcome. I invite you to make your opening remarks, and then we will open it up to members' comments.

Mr Richard Pengelly (Department of Health, Social Services and Public Safety): Thanks very much, Chair. I just want to say something very briefly by way of introduction. I will then ask Sir Liam to say a couple of words and allow the Committee to move into questions. The only point that I wanted to make is one that risks being lost about yesterday. I am just taking us back to the early part of last year, when the report was commissioned. This was in specific response to difficulties at the Belfast Trust and Northern Trust that had been highlighted as serious adverse incidents. At that stage, there were many concerns about the transparency of the system and whether in fact there had been a cover-up around those issues. The important point — Sir Liam may want to say a bit more about this — is that Sir Liam provides us with the reassurance that he found no evidence of any form of cover-up. There is also clear evidence in the report of staff striving for transparency, notwithstanding the intense scrutiny that they are under. I just thought that that was an important contextual point to bring to the fore of our conversation today.

Sir Liam Donaldson: Thank you very much, Chair, for inviting me. It is a good opportunity for me to talk a little more about the report and answer your questions. Thank you.

As the permanent secretary said, the initial purpose was to provide an external view on the internal procedures that were used to investigate and report on some of the concerns about standards of care in particular trusts, but the terms of reference were wider than that. They were to look also at the quality and safety aspects of the health and social care system in Northern Ireland. It was in pursuit of a rounded view, not just on the specific issues where we were able, as the permanent secretary has said, to provide reassurance, that, in talking to a large number of staff, stakeholders and patient representatives, it was clear to us that quality and safety in the service was determined not only by matters to do with the investigation of and action on serious adverse incident reports but on the structure, processes and organisation of the health and social care system overall.

There was nothing shocking in this that you would not find to some extent in other parts of the UK. I felt a great surge of optimism as I concluded the work that the size of Northern Ireland and the dedication and commitment of the staff in the front line gives the opportunity to do something that would just not be possible in a larger, more complex health and social care system. There is an opportunity for Northern Ireland to move forward relatively quickly and address some of the things that other countries have not been able to solve.

I believe that the 10 recommendations — I deliberately kept the number small — are genuinely capable of being transformative if all of them are acted on. They come with my 30 years' experience of health care safety and quality, my leadership of a health care system in another part of the UK, my extensive knowledge of other health care systems across the world and my US adviser, also coming from a position of around 30 years' experience as a physician and quality and safety expert who presided over probably one of the most successful institutions in delivering health care to eight million people in the United States.

We have provided a diagnosis. Much of it you will recognise, but it is an externally validated diagnosis. We have also opened some doors and opportunities. As a person who has great goodwill towards the country of Northern Ireland, where I have some ancestral roots, I very strongly hope that you will take those opportunities and become a service that leads others rather than being in the middle-of-the-road position that, I believe, it is now in.

The Chairperson (Ms Maeve McLaughlin): Thank you for that. Thank you for your work; it is important to say that also. I think that you will find no fault around this table in trying to deliver the first-class service that we all strive to achieve, but we need to cut to the chase, particularly with regard to recommendation 1, which clearly recommends that:

What evidence was that based on?

Sir Liam Donaldson: It was based on a reading of previous documentation where others have made similar comments about the distribution of facilities in Northern Ireland. It was based on a universal message from the relatively large number of staff whom we talked to over a short space of time. They also felt that the current arrangement for the distribution of health facilities in Northern Ireland was not what the population needed. I think that there is a very strong feeling that, behind the scenes, everybody would do it if it did not cause any personal injury to their reputation and position. It is purely, in my view, a problem that I have seen elsewhere in the world where there are widely distributed populations. In particular, in one of the states of Australia where I did a review, exactly the same issues prevail. Local populations want the specialist services close to their doorstep, and local politicians are afraid of being voted out of office if they oppose changes — albeit evidence-based changes. The emotion and campaigning is all on the resistance side. On the evidence-based side, the clinicians and others who, behind the scenes, strongly advocate change are not prepared to go into campaigning mode and use some advocacy.

I would be reluctant to feel that this was the dominant feature of the report because I think that the nine other recommendations, particularly the ones on the voice of the patient, where I think Northern Ireland is in a very weak position and could strengthen it, are capable of transforming the quality and safety of care. Finally, if you were to say to me, in all honesty, as politicians, that you believe this problem is insoluble, I would have to stand back and say, "Well, maybe some problems are insoluble", but it would be very sad indeed for the population of Northern Ireland.

The Chairperson (Ms Maeve McLaughlin): There are a number of things in that. First, you have identified in your report that the system is not the one that we need. That is fine, and I have no difficulty with striving forward to take that head-on. I agree with you that the sector, medical professionals and staff will indicate that as well. However, the question I ask is this: have staff and medical professionals told you or accepted or advised you that an independent panel of experts will be commissioned without consultation that the public should agree with in advance?

Sir Liam Donaldson: No. The diagnosis that I made of the need for change was based partly on the discussion with staff, but the recommendations are my own, based on 30 years of experience and, particularly, 12 years of experience in major policy-making posts elsewhere in the UK, where I had to think a great deal about how to achieve change. This is a recommendation that is high-profile and, I admit, likely not to be accepted. I think that is a very great pity, because I would say, "Where is plan B?". If I were a gambling man, I would say, "Well, if there is no plan B, I would put a lot of money on this never happening". The implication, you are saying, is that a two-tier service in Northern Ireland is the standard that we want to set for our population's care and a solution that will take it to one tier of a high uniform standard is insoluble for political reasons. OK, but just come out and say it openly.

The Chairperson (Ms Maeve McLaughlin): Nobody is saying that.

Sir Liam Donaldson: But that is the implication.

The Chairperson (Ms Maeve McLaughlin): No. The important point in all of this is that I am asking you a direct question: have the public, the health sector and the professionals signed up to agreeing with recommendations in advance? You talk about plan A and plan B; we do not even know what plan A and plan B are. To sign up to those recommendations in advance harms, in my view, the whole process of active consultation and participation and making sure we have a strategic outcome to Transforming Your Care and looking at health inequalities and outcomes. We are effectively being asked here — it has been indicated here — that the public and medical professionals and people working in the field and the sector should agree in advance to recommendations from a panel of experts. I find it irregular.

Sir Liam Donaldson: What the recommendation is really saying is that the agreement should be that, if an evidence-based blueprint for the service in Northern Ireland that accords with best international practice is recommended, people would not shy away from that without good reason. Good reason is not an emotional perception that this would not be a good thing to do for a variety of reasons. We have seen the benefit, particularly, even though it is still controversial, of your review of paediatric cardiac services, which brought in an external panel. It may not have done the job, but it seems that people were willing to set aside some of their personal opinions on it when they saw a distinguished panel coming in. It was about recommending a similar approach to that. I accept that, ultimately, the decision has still got to be made by the Assembly to sign it off, but we should try to get people to agree in advance that they would take a reasoned approach and, by and large, if the evidence was strong, compelling and acceptable, would not find reasons to undermine it. That is basically the spirit of the recommendation.

The Chairperson (Ms Maeve McLaughlin): OK, but I take issue with the fact that what is being recommended should be accepted in advance. That is a step way too far. I accept what you are saying when you say that processes need to be evidence-based — of course they do — in getting the right outcome, but a recommendation such as this, in my view, is a step too far.

Sir Liam Donaldson: OK.

The Chairperson (Ms Maeve McLaughlin): Secondly, in terms of commissioning, just so I am clear, did your terms of reference specifically ask you to review or assess the commissioning process?

Sir Liam Donaldson: They asked us to look at systems for assuring quality and safety. As I say in the report, our view was that this has a very strong bearing on the quality and safety of care delivered. It needs to be right, and it needs to reinforce good care and safe care. At the moment, we cannot see how the commissioning service works.

The Chairperson (Ms Maeve McLaughlin): Is it not safe at the minute?

Sir Liam Donaldson: It probably is most of the time, but we cannot see how the commissioning process and decisions flow through to provide those assurances in a complex system that is very difficult to understand.

The Chairperson (Ms Maeve McLaughlin): On page 15 of your report you say:

Are you suggesting in that statement, by implication, that neither the local commissioning groups nor the Health and Social Care Board are assessing needs and planning services adequately?

Sir Liam Donaldson: No, I am saying that, if you make changes and simplify the process of commissioning or any other way of arranging care in Northern Ireland, then those are givens. You have to make sure that you can show that those things are being done properly.

The Chairperson (Ms Maeve McLaughlin): OK, I will finish at that point because I want to come back the Department on that review of commissioning. A number of members have indicated that they want to speak.

Mr McCarthy: Just to follow on from recommendation 1, I hear what you are saying, but what you are in fact saying is the closure of a number of hospitals.

Sir Liam Donaldson: I am not saying that at all, sir —

Mr McCarthy: No, you are not, but that is what you mean.

Sir Liam Donaldson: No, sir, I am not saying that at all. If you want me to be really honest, I will say that I am not sure these days you can get a consistent definition of what a hospital is. Can you define it?

Mr McCarthy: Well —

Sir Liam Donaldson: Would you like to give us a definition of a hospital, as you have raised the question?

Mr McCarthy: All I can say is that, when you talk about closing a hospital, you will have the fury of the population on our backs and on everyone's backs. The Minister, in his response to me yesterday on this very subject, said that we faced uncomfortable decisions. That was obviously meaning going on from Transforming Your Care to close some local hospitals. That is what I take out of recommendation 1.

Sir Liam Donaldson: I do not accept the concept of closing a hospital, because I do not understand —

Mr McCarthy: I like to hear that.

Sir Liam Donaldson: Well, the premise of your question is that, if something is going to close — you said it is a hospital; I would like to hear your definition of what a hospital is — in the modern world of healthcare, health facilities take all forms. There is no question but that what would replace anything that was changed in your system would be an advance and improvement on what had gone before.

Mr McCarthy: So we can relax: you are not suggesting the closure of small hospitals.

Sir Liam Donaldson: You will have to accept what I say: I will not be drawn into defining what a hospital is, because I do not think anyone can. What I will say is that the range of health facilities in Northern Ireland, including hospitals, would be the better for change.

Mr McCarthy: There appear to be findings in the report that are based on opinion rather than purely facts. For example, on page 10, you state:

On what evidence are you making the claim that the public would receive a better service if managers were paid more?

Sir Liam Donaldson: Having had extensive experience of management in healthcare and having been a chief executive in the north-east of England, I see a huge variation in the standard of managerial performance. These are people who are not running mobile phone companies; they are running organisations that determine whether people live or die. Therefore, I think that it is taking a short-sighted view to say that we should keep the cost of this down to the bare minimum. These are important, responsible jobs, and the rates of pay for them should be comparable with other public sector posts in other parts of the UK that serve the public in life-and-death and high-risk situations.

Mr McCarthy: So it is not an opinion; it is fact. You say that it is purely fact that, if we had better-paid people to do the job, we would have a better health service.

Sir Liam Donaldson: It is a skilled professional judgement; it is not an opinion.

Mr McGimpsey: Thanks, Liam. We have never met, but many's the time I sat in Cabinet Office Briefing Room A (COBRA) listening to you talk about swine flu. Swine flu was quite a challenge. Fortunately, it did not translate into what we once anticipated: 15,000 premature deaths in Northern Ireland alone. I have to say, Chair and colleagues, that Liam's advice was always carefully listened to, and he played a very important part in all that.

Am I right in thinking that you were involved in the Belfast City Hospital/Royal Maternity issue?

Sir Liam Donaldson: I was, yes.

Mr McGimpsey: I thought that you were part of that. I seem to remember that as well.

You started by asking whether the situation was insoluble and whether we were looking at a two-tier health service. I do not believe for a moment that the situation is insoluble. The system is under some stress. We do not appear to have enough beds manned to take sick patients or have anywhere for well patients to go once they have had their treatment. Under the new regime, which has been in for some time, most of our GPs do not work nights or weekends, and that, too, is promoting a lot of stress in the system. The fact is that the Northern Ireland health service is underfunded in comparison with England, Scotland and Wales. In fact, in 2009, we fell behind England; we have always been behind Wales and Scotland. I do not think that we are making that up. We are starting from way back.

It seems to me that — this is an observation working into questions — you have a system, and you need a certain amount of money to run that system. If the money is not there to run the system, you either up the money or you drop the system. I am concerned that you are getting involved in that. We are going to end up with a system that matches the budget, rather than what we need: a system that matches the need, which is where I think you are coming from. I am a great believer also in evolution, not revolution.

What sort of time frame do you think we are looking at? Say we meet all these recommendations. I must say that the first one, about how we will all sign up to it, frankly, in the real world, ain't going to happen. I know that you would like it to happen, but it is not going to. What sort of time frame do you think we are talking about to evolve and get ourselves a system that will meet the needs of people in Northern Ireland? I actually think that the health service here is a good one. I think that there are problems, but I think that they can be fixed. All right, the model is not quite what we want, but I am asking about the time frame. I have seen some of the fairly negative headlines you have been getting so far. What time frame are you looking at, and what sort of bill should we expect? What sort of money do we need? That is the key thing that we have to wrestle with.

Sir Liam Donaldson: Thank you very much for your comments. First of all, you are not alone. I am not able to judge the relative level of funding; maybe others can, but I cannot. I have not looked at that. Notwithstanding the 2008 financial crisis and the effect that that has had on public services across Europe, there was already a funding crisis before that. Most Health Ministers that I have encountered in developed countries around the world were concerned about how their service could be sustainable in the long term because of growing demand, the ageing of the population and all the factors that we know about. So there are two issues here: one is fixing problems, and the second is the whole question of sustainability for the future. My report was not asked to look at public health, but it would be wrong of me not to draw attention to the high levels of preventable disease in Northern Ireland and in many other parts of the UK as well. Those upstream factors will be major determinants of the sustainability of the health service.

As far as fixing the problems is concerned, I think that, as I said at the beginning, some of the recommendations are transformative potentially, and I think that, despite the question of funding needing to be resolved, there are things that can be done — innovations and creative ideas — that could make a service do more for the money that is available to it. Some of them are set out in the report. However, many of the recommendations will do one other big thing: they will make the service much more patient-centred, because at the moment it is not. I would say that the service in England is not either — I know that very well. It is not truly patient-centred, and, if some of those changes came in, that would, of anything, make everybody feel a lot more positive about the service.

Mr McGimpsey: Thank you for that. Another part of it, which I think is key and which we do not talk about an awful lot here, is the independent sector. The reality is that the service just does not have capacity in a whole number of areas — for example, orthopaedics and ophthalmology, and there are others. We have huge waits developing for some of these. Your journey time in England is 18 weeks; our journey time now can be over a year, and that is not acceptable. It seems to me that the only way that we can sort that out is in the independent sector, and we paused that six months ago. It means that when that unpauses in April, the first thing you have to do is take care of that lump — all those waits — before you get into the waits here, and you are probably talking about very large sums of money to get us back to where we were. Once you start to let this go, pulling it back is very expensive and very difficult. I take the point about what a hospital is and how it is defined, where our acute hospitals are and so on. What role do you see for the independent sector? In England, you are spending about 6%; over here we are down to about 1% or 2% in the independent sector. However, we are not going to get her back to where she should be without some money for the independent sector.

Sir Liam Donaldson: It can be successful if used in the right way. Obviously, the factors that need to be borne in mind are whether making a short-term commitment to buying in the independent sector will cause any difficulty for the infrastructure on the NHS side that may be needed in the long term — that is the first question. The second question is whether it is the same surgeons working in both sectors and whether there is any conflict of interest. The third issue — I heard anecdotal concerns about this expressed when I was going round — is that, in some of the crisis situations where a trust was under pressure to get its waiting times down quickly, they felt that they were paying over the odds and not really getting good prices for the services that they were buying. However, it has its place; it has been successfully used in England. Obviously, there are things that need to be taken into account.

Mr McGimpsey: Presumably you would operate within whatever the tariff was in the health service. Therefore, it is not costing the health service globally any more to do, say, a hip or a knee —

Sir Liam Donaldson: Yes, but you do not have a good tariff system here at the moment.

Mr Brady: Thank you for the presentation. My question relates to Transforming Your Care. Recommendation 3 states:

In evidence to the Committee last year, the Royal College of Nursing described Transforming Your Care as a vision without action. I think that you are recommending that that plan should be produced as quickly as possible. Were you asked to review the implementation so far of TYC?

My second question also relates to recommendation 3, where you have suggested that there should be expanded roles for two groups — pharmacists and paramedics. Is there any particular reason why those two groups were chosen?

Sir Liam Donaldson: Yes. In so far as I have gone into wider territory, it was purely because I found that there were several things, including this, which had a fundamental bearing on the quality and safety of care. In other words, if patients are flowing into the health service in high numbers and putting pressure on the system, the staff are less able to cope and deliver standards of care. If you take a step back, you can look at the root cause of that, which is a slow pace in developing the services that, upstream, would prevent the pressure that is causing doubts about the quality and safety of care. I was not asked to review Transforming Your Care, but I was asked to review quality. I thought that it had a contribution to and an important bearing on that.

Why did I choose those two examples? In my discussions with the ambulance trust, I asked about its innovations and what it was doing to improve the quality of care. It cited the number of diabetic patients admitted as emergencies to hospital: they went into hypoglycaemic coma or shock because their blood sugar fell, dialled 999, went into hospital, sat in the A&E department for a few hours until they were stabilised and then were sent home. The trust had the idea of extending the skills of its paramedics so that they would go to the patient's home in such a situation, take a blood sugar level, give the patient the glucose that they needed, wait half an hour before taking another blood sugar level and leave when they had stabilised. The paramedics would do exactly what is done in the A&E department, thus averting all those people from A&E. That was, I thought, a great idea. It was piloted and seemed to work. I asked, "Right, why don't you just do this permanently? You've changed the process of care for the better, so why not institutionalise it?" The response was, "We can't get cooperation from the trusts. We're not legally in a position to bear the risk of managing those patients on our own. We need the hospital to agree that we've done what we've done and arrange an outpatient appointment in the next week to review that patient." I asked whether that had been achieved and the answer was, "No, we can't get agreement between the trusts to do it, so we're contemplating abandoning the programme". I thought that this was a classic example of people working in silos instead of working together. I was being a bit provocative. I was saying, "If I recommend this and the Government accept it, they will have to confront the fact that these good ideas, which could help to release the pressure on hospitals, would have to be addressed, and people would have to confront the fact that they're not working together".

In one of the trusts that I visited, the duty pharmacist told me that four of the patients who had been discharged over the bank holiday weekend, when he had to dispense the prescriptions, had been given 20 drugs each. In medical terms, that is absolutely shocking: people should not be on regimes of that sort —their medicines should be reviewed. However, the pharmacist was powerless to do anything about that. He is not a doctor, so how can he do anything? I thought that this was another good example that will challenge those in the system to show how they can work together. I was being provocative, but I am pleased that I am provocative, because things need to change. These are good examples of people having great ideas that would be transformative and improve care, but they hit a brick wall because most people are working in silos.

Mr Brady: Thanks for that. Part of the ethos of Transforming Your Care was to do what you have described: to prevent people going into hospital and enable them to remain in the community instead. However, the infrastructure has to be there to deal with that. The funding of the shift left, from acute to primary, has not really happened. Originally, we were told that something like £83 million would move from acute to primary, but that has not happened. A costed and timetabled implementation would need to happen quickly, because Transforming Your Care has been trundling along since 2011 without any visible outcomes. That is, I think, part of the problem. When TYC came out, outcomes were not part of the overall plan, or at least that was the way it seemed. Most of the 99 recommendations, if you went through them one by one, seemed fine at the time, but they simply have not been implemented.

Sir Donaldson: That phrase, "shift left", was like a red rag to a bull for some of the people whom I talked to. I spoke to a very courageous woman who was a carer for her seriously disabled son. When I mentioned to her that this policy would improve, she went ballistic at the use of that term and even the term, "Transforming Your Care". I think that it is a great vision and a great policy, but people do not have confidence in it. The GPs were also very negative. Again, that was due to dysfunction in the system, because they said, "People are being discharged. We haven't got the referral letters. We don't know what medication they're on. We ring the hospital, but we can't get to speak to the consultant or even a junior doctor." Some were ringing a colleague general practitioner who happened to have sessions in the hospital and asking whether he or she could find someone for them to talk to. IT could help with that. The introduction of electronic communication could be a great help, but there are basic, practical problems about how the connections work in the system, how communication works and how the processes work. They are soluble, if people sit down, look at what is dysfunctional and address it. There were so many stories like this. I am sure that it would be no different in England, but, if you wanted me to put a label on the NHS across the UK, I would say that, at times, it is extremely disorganised and needs to be better organised.

Mr Brady: The problem with the term "shift left" was that it had political connotations for some people. Maybe that is where the problems arose.

Ms P Bradley: I hope that my voice holds up. Before I talk about recommendation 4, I want to follow on from what Mickey was talking about earlier. You mentioned that good ideas can release the pressures in hospitals. From personal experience and the experience of others in my household, we have some wonderful clinicians who are coming up with the most innovative ideas to discharge people from hospital to receive care in their own home. However, a lot of those clinicians do not feel supported. Somebody in my household was released from the infectious diseases ward last year on a fantastic acute-care-at-home programme, which saved weeks' worth of bed days in hospital. Quite often, the clinicians do not get the recognition that they should for the work that they are doing. We need to put on record that some people have fantastic ideas that will make a big difference to lengths of stay in hospital.

That takes me on to recommendation 4 and the self-management of chronic illness. Nobody would disagree with the recommendation that people be empowered to manage their illness. I worked in the respiratory ward in Antrim Area Hospital for three years, and we had a really high number of people with chronic obstructive pulmonary disease (COPD). They were revolving door patients — in week after week with the same problems that could have been dealt with in their home and thus avoided their admission to hospital. Are you aware that, under the Programme for Government, one of the Department's commitments — number 44 — is to enrol people who have chronic conditions on a condition management programme?

Sir Liam Donaldson: I did not know about that. I met a representative of Diabetes UK and representatives from other organisations. They were very well informed, but they did not mention that. They were not particularly involved in the commissioning process. When I was in England, I made a suggestion to Ministers that was not adopted. I think that it was probably too radical at the time. I suggested that, in some fields of care, voluntary organisations/charities should commission the care. Why shouldn't Diabetes UK commission diabetic care, obviously with professional advice? I have seen evidence elsewhere in the world of people getting the support and skill to manage their condition. They do not need much. I defy you to catch out the mother of a diabetic child on something that they do not know about diabetes or the management of their child, and that is what we need to tap into. One person who had been a diabetic for 40 years told me about a very different attitude. You would expect that, after that length of time, he would have eye complications and skin ulcers, but he had nothing — no complication. When in hospital for his annual visit, he proudly said to the consultant, "I just wanted to let you know that I've been an insulin-dependent diabetic since adolescence. I've controlled my condition myself and, after all this time, have no complications". The consultant said to him, "You're very good at following orders". That balance of power needs to change. It needs to be a partnership. It should not be the case that the patient is down at one level and the health-care professional is at a much higher level. That is what that recommendation is all about.

Ms P Bradley: It is also about giving patients the relevant information so that they have the ability to manage their condition at home and do not fear doing so. It is about giving the information to patients to empower them to make those decisions. We fail on both levels.

Sir Liam Donaldson: I am sorry to get excited about this, but I was brought up here by a taxi driver who recognised me from the recent attacks on me in the newspapers. He said, "You're reviewing the health service. I've something to tell you. I had a stomach problem and was treated for seven years with Zantac-type tablets. I saw a locum, who told me that I might have a more common cause of ulcer: Helicobacter pylori". He gave me a week's course of antibiotics, and I was cured". The point of the story is that he then advised three other taxi drivers who had similar symptoms for the same length of time, and all have been cured. So there you are — there is the expert patient for you.

Ms P Bradley: He must be one of our expert taxi drivers in Northern Ireland.

Sir Liam Donaldson: That is not a model to be recommended, but it is an interesting story nonetheless.

Ms P Bradley: Work is already being done by the Public Health Agency and the board on the management of chronic conditions.

Sir Liam Donaldson: We should build on that.

Ms P Bradley: It is about building on and working in tandem with that.

Sir Liam Donaldson: Definitely.

Ms P Bradley: It is not about building another tier; it is about working in line with what is already being done.

Sir Liam Donaldson: Yes, and bring the charities into it.

Ms P Bradley: As I said, I do not think that anyone would disagree with that.

Was it part of your terms of reference to look at that?

Sir Liam Donaldson: It was not to look at that, but it was to look at things that had a bearing on quality and safety. More or less every major report on quality around the world, including Don Berwick's one in England recently, emphasises the fact that direct engagement with patients and families on various aspects of their care is the bit of the health-care system that is not working well and has the potential to bring great benefit.

The Chairperson (Ms Maeve McLaughlin): I just want to be clear: are we now saying that recommendation 4 is no longer a recommendation? Work is ongoing, and there is a commitment in the Programme for Government, so we do not need to establish what you suggest to give people with long-term illness that opportunity to manage their condition. Liam, I absolutely agree in principle with what you say. Maybe Richard will come back on this when we move on to questions to the Department: a physiotherapy self-referral pilot was initiated, but then it was just pulled. You are absolutely right that this process is all part of the shift left, but we already have a commitment in the Programme for Government, so this is, potentially, duplication.

Sir Liam Donaldson: Do not forget that I have worked in a senior governmental role, and any report to government is responded to. The response can be to accept as recommended or to reject as recommended. Quite often, the response is, "We have something going on this. We will reshape and re-energise it, and we will meet your recommendation in that way".

That is the way the world works. In a very short time, we went over a lot of ground in a country of which we did not have detailed knowledge. We will have missed some things. I was not told about that particular initiative, but we came across hundreds of things. So, if there is something already going on, that fits into the final category of response. In that situation, I would expect an Executive or Government to respond by saying, "We are already doing something a bit like that, so let's bring it all together". What I have suggested, which is a sharper edge, is that there should be proper evaluation, a —

There is no point in empowering people to manage their condition if we do not then learn whether it is working and whether they are getting lower rates of complication and a higher quality of life than would have been the case had we left them to be dealt with in the old way.

The Chairperson (Ms Maeve McLaughlin): Particularly if it is a Programme for Government commitment as well, but those points are well made.

Ms McCorley: Thank you very much for the presentation. Generally, how problematic is the apparent failure in the system to think outside the box, look at new ideas or accept change?

Sir Liam Donaldson: It is a problem everywhere. Inherent in a lot of health services and social care systems are conservative with a small "c" elements, people who do not want to change. However, the whole movement for quality improvement, which is very strong in some places, tends to encourage people to have an appetite for change based on looking at opportunities for improving things. I would say that Northern Ireland is no worse than anywhere else, but, with no disrespect to my generation and age group, we should look to young doctors and nurses for the future. It is very important that we get them to realise that being a doctor or a nurse is not just about treating the patient in front of you; it is about thinking more widely about how you can make your service better. In my generation, that was not a professional value. The professional value was to do your very best for the patient in front of you, not to think any more widely than that. We know that people who think more widely make a contribution not only to the patient in front of them but, potentially, to dozens of patients in their care.

Ms McCorley: Recommendation 5 suggests that the Regulation and Quality Improvement Authority (RQIA) role could be replaced by outsourcing the function to, for example, the Scottish regulator. Will you provide more detail on the thinking behind that recommendation?

Sir Liam Donaldson: As I say elsewhere in the report, during our discussions, the RQIA was not mentioned once by anybody or any organisation. They did not mention it spontaneously or talk about it. In England or America, that would be unheard of. In England, the Care Quality Commission is a dominant feature, albeit not in an entirely positive way because it introduces a fear factor that is not always helpful. In the United States, the Joint Commission, which is the main accreditation organisation, can make or break a hospital in the market, and it is on everybody's lips. It was puzzling that, in Northern Ireland, the regulatory function in health was not spontaneously mentioned, though it was prominent in social care. The Minister at the time had just announced that he would bring in acute hospital inspection, which, I think, is a good move. However, that seemed to be an initiative that did not necessarily have a wider context to it. So, we felt that it would be time to look at the health side of regulation in the round and ask whether Northern Ireland feels that it is right. However, one or two people asked whether Northern Ireland was big enough for its own regulator. They suggested that there might be an advantage in looking to a regulator in another country that had been longer established and would have data with which Northern Ireland could compare itself. The Joint Commission in the United States, for example, has a branch called Joint Commission International that helps with regulation in quite a lot of countries, so it is a model that is in use worldwide. There are advantages to having the regulator in-house, but there are also advantages to an external regulator working but not based in the country.

Ms McCorley: Are you thinking of particular elements of the Scottish model? Are you very familiar with it, or is it just its proximity?

Sir Liam Donaldson: I am not deeply familiar with it, but people felt that it was relatively near at hand and seemed to be a mature and good organisation. If this recommendation is accepted, all the potential options need to be looked at, and that was just an illustration.

Ms McCorley: Will you elaborate a wee bit on recommendation 7 and the creation of an institute for patient safety?

Sir Liam Donaldson: Yes. I am pleased that you mentioned it. It has not been raised with me once in the past 36 hours. I feel that patient safety is one of the key areas that I have experience in. I have looked at it in the past few years since I stopped being Chief Medical Officer and spent a lot of time on it. I have read and analysed 10,000 incident reports in England. I have listened to descriptions of incident reports in all the trusts in Northern Ireland — in two of the trusts in depth — and discussed them with staff. I have looked at incident reports in several other countries. The two fundamental flaws in any system — I will not list them all — that I would say are directly relevant to your question are, first, that the quality of the investigation does not always lead you to the true cause. That is because expertise that is very valuable in other sectors, particularly the so-called human-factors element, tends not to be used a great deal in health care. If it were, you would, I think, get closer to the true causation. Secondly, I have seen no strong examples around the world, including England and Northern Ireland, of learning that leads to a definitive and sustained reduction in a risk. The same things are happening everywhere, and they are happening over and over again. I feel that this is sufficiently important, because some patients are seriously harmed and some are dying, that it needs to be somebody's day job. It needs to be taken very seriously. The data need to be analysed in a much more sophisticated way than is the case at the moment. We need to get people who can come up with solutions that will actually work, because, at the moment, there is a bit of a feeling that this is about documenting incidents, not finding solutions. Hard though everybody is trying, there is more to be done.

Ms McCorley: How confident are you that a more holistic approach, as per your diagnosis, will be adopted?

Sir Liam Donaldson: I cannot be confident that the recommendations will be adopted because I have seen the force against some of them, but I am confident that this would give you a much better chance of reducing harm and saving lives than the present way of doing things, which is basically several organisations working on it at once.

Ms McCorley: In effect, this would take over the function of serious adverse incidents.

Sir Liam Donaldson: Yes, it would.

The Chairperson (Ms Maeve McLaughlin): We will move on to questions to you, Richard.

Mr McCarthy: Just before we move on, I want to ask Liam about recommendation 10, which is to do with the Patient and Client Council. You do not say anything derogatory about the activities of the council, but you advise that more independence be given to it.

Sir Liam Donaldson: Yes.

Mr McCarthy: What is your thinking behind that? I would have thought that we had a fairly good Patient and Client Council and complaints department here.

Sir Liam Donaldson: I think that very good people run it. I did not feel that there was as much representation of actual patients and users of the service on the board as you would see elsewhere. The patients to whom we spoke — we spoke to some who had suffered harm and their families — were very respectful of the people who run the council and of the board, but they said that those people were inside the system. On the complaints side, you find that a lot of complainants are dissatisfied and do not feel that a truly independent view was taken of their complaint.

Mr McCarthy: So an independent voice would make a difference.

Sir Liam Donaldson: It would.

The Chairperson (Ms Maeve McLaughlin): There are a few more comments for you, Liam.

Mr McKinney: Thank you, Sir Liam, for your considered input. For me, the report illuminates the health landscape and, as a result, shines light on some areas and throws up shadows on dark areas elsewhere. You make some criticisms of constituents attached to the overall service and those who use it. Do you accept that you ascribe particular motivations and self-interest to the media, the public and politicians? Do you also accept that their other interest — perhaps their primary interest — is accountability and making sure that those who make decisions do so in their best interests?

Sir Liam Donaldson: I completely accept that. I certainly mean no disrespect to politicians. I worked with politicians extensively in England, and I understand politics. I understand how difficult it sometimes is to balance the needs and wishes of constituents against a wider policy debate that is controversial. I completely understand that.

Yesterday, I allowed a comment by one journalist — that I had criticised the media — to go unchecked. I did not criticise them: I said that the reporting was generally very negative. I see that in England as well, but it is not quite as negative there as it is here. Constant negative reporting gets to be a bit of a habit, and it can be very demoralising for staff. It can undermine public confidence. So it is not a criticism. When my colleagues in Whitehall, behind the scenes, used to criticise the 'Daily Mail' and say that it was terrible and so on, I was always the one who, internally in those discussions, would stand up and say, "I'm sorry, I have had a hard time with them as well, but, on balance, I would rather have a media that has no fear or favour". I definitely believe in that, but a balance has to be struck. In England, we would not see this level of imbalance in coverage. That is what I am talking about.

I have some quite subtle thoughts on this. In my experience of dealing with the media on health topics, the tendency is always to go to black and white. When I was in post, my job as a professional was to show that there are shades of grey, and you need to think about the shades of grey, not just the black and white. What I see here is that everything is painted in black and white. There are no shades. It is as if there is no colour grey in Northern Ireland, which is good in some ways — grey is not a great colour — but that is frustrating to me. I would be very frustrated if I were a doctor working in the health service — very, very frustrated. I do not mean to say that the media are at fault or that it is unhealthy to have media involved at all; I am just saying that the phrase was very carefully chosen — "a system under the microscope" — and it is. There are disadvantages to looking at things only through the microscope, because you do not see the big picture.

Mr McKinney: With respect, I would suggest that you are looking at the symptom and not the cause. We see it repeated because it is reacting to repeated actions that are taken at leadership level. Do you agree?

Sir Liam Donaldson: You have been looking at it for longer than I have. I could not comment on that. I do not often say that I cannot comment. I do not feel well enough informed to say that that is the root cause of the problem. I do not know.

Mr McKinney: You also point to failures in administration and things not being implemented, which has led to bigger questions about accountability. How could you be assured that those who failed the system in the past at managerial and high levels in the system are in any position to fulfil the ambitions that you want?

Sir Liam Donaldson: I think that some of the failure is due to an overcomplicated system for such a small country. I would like governance and accountability to be simplified and much more clarity about leadership. That is probably as far as I could go in my knowledge of the system.

Mr McKinney: Do you accept that this has been a strategic failure?

Sir Liam Donaldson: I do not think that I would use a phrase like that about it. As I say, I have seen other situations in the UK that have got bogged down in a similar way trying to make change in a very difficult environment and circumstances. It is very complex, and I think you should be looking forward, not looking back.

Mr McKinney: You, however, were the one who reached beyond the narrowness of the review terms and into TYC. Do you accept that the failure to measure, implement and fund TYC properly has led to some of the problems that we face today? You accept that it is a forward-looking programme.

Sir Liam Donaldson: I accept that it is a forward-looking programme. I went into that only because it ultimately had a direct bearing on the quality of care. Yesterday, the Minister said that he did not have the funds that he needed to do that. I do not know whether that is the case. As far as I can judge from talking to people about the implementation, it looks to me like a management solution is needed. There are lots of people involved. The leadership is not clear enough. Projects are being initiated all over the place. It needs to be gripped and driven forward in a much clearer way.

Mr McKinney: One thing that is also excluded from your report is the entirety of the patient journey, some GP issues and primary care aspects. It is clear, for example, that the health service here does not know in real time the length of GP waiting times. You refer to the data issue. If we do not have the whole picture and the information, how can change be effected?

Sir Liam Donaldson: One of my recommendations is about data. One of the quality gurus, Deming, said years ago:

I absolutely agree that we cannot run a service without good data. I hope that those holes in our knowledge will be closed.

Mr McKinney: You hope? We need more than hope.

Sir Liam Donaldson: I have given you recommendations; I can only hope that you have the good sense to implement them.

Mr McKinney: The ultimate ambition of the report — it should be welcomed — is the patient-centred focus. Given the absence of data and the absence of money to put the patient first, how can that ambition be achieved?

Sir Liam Donaldson: I have recommended that you should do what they do in the United States, which is to have an annual validated patient experience survey, and funding should be determined by the results of that. That would concentrate the minds of the system very well.

Mr McKinney: Funding, however, has to be key to this so that money is ultimately shifted to the patient.

Sir Liam Donaldson: Absolutely, yes.

Mr McKinney: How do we arrive at that point? This goes back to accountability. How can the public be assured that this does not just become a review or analysis that allows cuts and does not put the patient first?

Sir Liam Donaldson: The whole thrust of the report is away from the question of cuts towards providing a better service in the future. That is the clear philosophy running right through it.

Mr G Robinson: First and foremost, I commend the very professional consultants, doctors, nursing staff and health workers throughout our health service in Northern Ireland. That comes from the heart.

Thank you for your presentation, Liam. You have probably answered many of the questions that I was going to ask you, which were about the media. Perhaps my question is more for the departmental officials: it is about how they handle the media from time to time. I know that the media have a job to do, but they can be very negative, day to day and week to week, particularly in Northern Ireland; Sir Liam mentioned that. From the Department's point of view, how do you handle it on a day-to-day basis? It cannot be easy.

Mr Pengelly: No, it is not easy. As Sir Liam said, one of the prices worth paying for a free media is that, from time to time, they land the odd blow on you. We engage with the media; when we have failed, it was partly due to the fact we did not do enough preparatory work with the media to help them to understand. When it comes to an issue such as Sir Liam's report, you can drift into it and easily miss its subtleties and nuances. We need to do more to highlight that and signpost it without in any way trying to handcuff the media. It is a process of engagement and being mature enough to understand that we cannot ever expect the media to be a PR outlet for us. It is right that we are subject to scrutiny and critique from them, but, as we have both said, it is a price worth paying.

Mr Givan: Thank you very much, Liam, for the work that you carried out. On recommendation 1, I share some of the views that, ultimately, it should be for politicians to rubber-stamp —

Sir Liam Donaldson: I hope that you will take the spirit of it, if not the letter.

Mr Givan: I agree with the spirit. I think that you should have a little bit more hope in some politicians to be responsible about this. I have had public meetings in my constituency at which I have said that Lagan Valley Hospital cannot be the Royal Victoria, the Ulster or Craigavon, that it would be wrong to pursue that agenda because you cannot spread the resources and that outcomes are better if there are specialists in specialist centres. When that is explained to people, they start to buy into it.

Some politicians — not all, but some — will be responsible. Some will politicise the NHS — Ed Miliband wants to weaponise it — so I am not surprised that there are politicians here who will want to use it to have a go at a Minister. I used to do it to Michael, so that is par for the course, but it is about how you insulate the system from being buffeted so that short-term incidents do not alter the long-term objectives. That is where we need to try to build in resilience so that the professionals and the management who have to deliver do not get distracted by short-term situations.

I noted your commentary on the media. To be fair to UTV, it usually adopts a balanced approach. Others would do well to read your report and give a better understanding of what is happening.

I want to ask about a point relating to the permanent secretary. Your report states that, statutorily, he is chief executive of the health service, but what that means for policymaking is not widely understood and communicated. How should that look? How should we expect the permanent secretary of the Department of Health to run the health service as chief executive?

Sir Liam Donaldson: This chief executive is relatively new, I think, so he has an opportunity to look at everything afresh. It is difficult for somebody to be chief executive of something as important as the health and social care service of Northern Ireland without being relatively hands-on so that he is seen to be directing the system and inspiring the staff and is also visible and public. He has to let the public see him explaining, promoting and championing the policies and praising, encouraging and motivating staff. That is the classic job of a chief executive in a big organisation. The governance, however, is written slightly differently. The chief executive is the chief executive in overall accountability terms, but it is a behind-the-scenes form of accountability. That lies behind my earlier reflections, and, to a certain extent, I picked it up from people's uncertainly about who is in overall charge. This is not so much a criticism as a feeling that you have to make your mind up about the model that you want. You can do it in all sorts of ways, but there are attractions to having a visible champion who explains and motivates, and that is more difficult, given the way in which the governance structure is currently written.

Mr Givan: My final question is about TYC in the context of budget reality. We do not have a bottomless pit of funding, and that will not change — in fact, it will probably get worse. Can the change in TYC be delivered? Obviously, funding is always an element, but you touched on the need for management processes to get behind TYC. Is there an opportunity to advance TYC by putting in place clear management processes to drive forward some of that change? How much of it is dependent on funding the delivery of the management processes?

Sir Liam Donaldson: I almost said something in response to questions about that yesterday. This will probably mess up all their thoughts about leadership and management. If I were in charge, I would put in a supremo for at least a year to really get this going. I would have one person accountable to the permanent secretary in overall charge and say, "Right, get this going". Hospitals will suck in all the money in any health-care system until you start to put down some red lines and innovating, as in some of the examples that I gave you. You have to start to build up that infrastructure to stop the tide flowing into hospitals, or it will overwhelm the opportunity to implement this policy. The media reported me saying a "rocket boost" — maybe that is not the right turn of phrase — but it needs to be gripped and moved forward quickly in a very authoritative way. My management solution would be to put somebody good in overall charge. I once chaired a visit to my region by Margaret Thatcher — she kept calling me Mr Speaker for most of the meeting — and she asked one of the clinicians what she should do about a particular area of policy. All he said to her was "Put your best people on it". She seemed to quite like that answer. That is what is needed here. Put your best people on it and get them to drive it forward managerially.

The Chairperson (Ms Maeve McLaughlin): That is an important point. It brings up the challenge of why it is not driven by "your best people", as you said. Why did that not appear as a recommendation?

Sir Liam Donaldson: It is not for me to interfere by suggesting detailed solutions for the governance and overall leadership of the programme. I have mentioned the areas that need to be looked at, but the solutions need to come from within, not from outside. If they come up with solutions, they will have ownership and feel that they have to deliver. I do not know what you think.

The Chairperson (Ms Maeve McLaughlin): We will move on because members have questions that they wish to ask you directly, Richard. Let us go back to recommendation 1. I do not need to rehearse it:

How serious is the Department about that?

Mr Pengelly: In many ways, it is slightly premature to talk about the Department's view, because the Minister published the report only yesterday. He has called for evidence from the community at large up to 30 April, when he will formulate his formal response based on all the inputs received. He has still to invest the time and energy reflecting on it and looking at the responses. Certainly, we see the intellectual rigour of the recommendation as Sir Liam outlined it, but it is a political issue for the Minister to take forward. He also indicated yesterday that he would want to engage with Executive colleagues on the issue, but it is premature to outline a definitive response by the Department at this stage.

The Chairperson (Ms Maeve McLaughlin): Would you not accept, Richard, even given what you have heard today, that this turns processes on their head?

Mr Pengelly: I certainly accept that I have heard that today, Chair. Ultimately, however, it is for the Minister to respond, and he has not concluded on his position yet. I cannot advise the Committee on his position.

The Chairperson (Ms Maeve McLaughlin): There is no departmental view at this stage that recommendation 1 is a non-starter.

Mr Pengelly: Chair, the report was published yesterday. It resonates with the very point that you are making. The Minister has said that, before he concludes on the way forward, he wants to receive inputs from as many parts of the community and the profession as possible. To cut that off would very much reflect the point that you are making. The Minister is not in a position to do that. As I say, he has just published the report.

The Chairperson (Ms Maeve McLaughlin): I do not know how long the Department has had the report.

Mr Pengelly: We received it at the end of December.

The Chairperson (Ms Maeve McLaughlin): Sir Liam made the point that this recommendation did not necessarily come from staff or patients. Do you accept that?

Mr Pengelly: I absolutely accept that it is Sir Liam's recommendation, as he has outlined today.

The Chairperson (Ms Maeve McLaughlin): Do you accept, however, that this is not based on a clear request or recommendation from the consultation?

Mr Pengelly: Yes.

The Chairperson (Ms Maeve McLaughlin): You accept that. Quite a few pieces of work in the report will have to be resourced, Richard. The Minister has now committed to a range of reviews, consultations and even legislative change. The report refers to a review of commissioning; a review of whistle-blowing; the conclusion of the morbidity and mortality review; a new system to review deaths; changes to the serious adverse incident system; the introduction of a new events list; an RQIA programme of unannounced inspections; a review of the Health and Personal Social Services (Quality, Improvement and Regulation) Order 2003; and new legislative proposals for changing non-acute services. We also have to design a new framework to measure patient experience.

How and where does the capacity come from in the Department to do that?

Mr Pengelly: Some of the issues you talk about are not particularly resource intensive to take forward. Some of them are more so. Fundamentally, it is an issue of prioritisation. We can all too often default to the position that we do not have a lot of spare money. The reality is that we have the thick end of £5 billion available a year, so it is about the prioritisation of that money. All the issues you talk about fundamentally go to the heart of improving the quality and safety of the system, so that is money well spent. A hard-nosed look at the prioritisation by which we deploy our resources is never more appropriate than in the context of the issues that have been highlighted in the report.

The Chairperson (Ms Maeve McLaughlin): How do we start to prioritise those, then? Is it the review of whistle-blowing? Is it the commissioning piece? How does that process work?

Mr Pengelly: Without getting into the absolute detail of it, various elements of them fall to various bits of the Department, so they can be taken forward together. It is not as if the burden will fall on one small team in the Department to take all the issues forward. Obviously, we work with our partners and colleagues throughout the wider health and social care sector. It is an issue about taking them forward with all possible pace, making sensible, reasonable, pragmatic and prioritised choices, and moving them forward. We cannot deny the importance of taking them forward with pace.

The Chairperson (Ms Maeve McLaughlin): So, all of those I listed will be taken forward. Is that what I am hearing?

Mr Pengelly: Yes. Absolutely.

The Chairperson (Ms Maeve McLaughlin): All of them?

Mr Pengelly: Yes.

The Chairperson (Ms Maeve McLaughlin): OK.

Mrs Cameron: First of all, Sir Liam, thank you very much for coming today. It was very interesting. You will be glad to know that I do not have questions for you. You are very easy to listen to; I could probably listen to you all day. It was fascinating. My question is for the Department in relation to recommendation 6 and the duty of candour. Has duty-of-candour legislation been introduced in any other part of the UK?

Dr Michael McBride (Department of Health, Social Services and Public Safety): Proposals in relation to the introduction of the duty of candour have been taken forward in England. It is probably worth stating that there is already a professional duty on health professionals, such as doctors, nurses and other professionals, in relation to candour with patients and clients. The recommendation around a statutory duty of candour was one of the recommendations that came out of the Francis report. Undoubtedly, candour is at the heart of quality and safety and quality improvement. Sir Liam mentioned the importance of that, particularly in relation to engagement with patients and clients and the trust that they have in the service provided. Undoubtedly, in all healthcare systems, things sometimes go wrong. That is deeply regrettable. Sometimes, patients are harmed, but it is absolutely essential that the population and those who use our services have absolute confidence that, when such things happen, the healthcare system and the professionals working in it will be absolutely open and transparent in relation to what those shortcomings were, where the failings were and the process by which they were identified. As Sir Liam mentioned, it is about the learning of lessons, as a system and as professionals, to ensure that those issues do not occur again.

As I was listening to Sir Liam, I was reminded of a quotation that I use often that he used in 2005 at the World Alliance for Patient Safety: to err is human. To cover up is inexcusable, but to fail to learn is absolutely unforgivable. It is only by being absolutely upfront, open and honest with those who use our services that we, as a system, can truly learn and truly improve the quality of health and social care. Our patients and clients who use our services need to be absolutely confident.

Mrs Cameron: Will you give us an indication of any timeline for the introduction of that legislation?

Dr McBride: Obviously, as the Minister indicated in his statement yesterday, the preparatory work in relation to that has already commenced. He has tasked us with beginning the initial stages of that. Obviously, it will require the introduction of primary legislation, which, as you know, goes through the normal process and takes time, but there is now a clear commitment to that. As I said, that will run its natural course, but legislation can take nine to 12 months or more, depending on its complexity.

Mrs Cameron: From your response, I take it that the Department is convinced that legislation is the way to go to encourage more openness and transparency in the system. Is there a danger that the introduction of legislation might give the appearance of having dealt with the problems, when, in fact, there are cultural and systemic issues around openness that will need ongoing work?

Dr McBride: I can certainly comment on that, but I would be interested to hear Sir Liam's views as well. I think that you are absolutely correct: some have a view that a statutory duty of candour may be a very blunt and legalistic instrument to ensure and safeguard that, as health professionals and as a system, we are doing what we should be doing anyway in any event; there are those who have concerns that it may be counterproductive in terms of creating a system more under the microscope, as Sir Liam alluded to earlier; and some are concerned that it might be less open and transparent, as was previously the case.

I think that it provides a legislative framework that reinforces and underpins what is absolutely the right thing to do in those circumstances. We should be absolutely ambitious to ensure that not only do we encourage all those involved in healthcare professionally to be open and transparent — Sir Liam's report provides significant assurances on staff commitment to openness and transparency, including the SAI process — but that we also underpin that in legislation, because I think that it gives comfort to those who experience it, including patients and carers, in the behaviours and actions of staff and it gives comfort that it is a statutory obligation on healthcare organisations and workers.

Sir Liam, you may have a —

Sir Liam Donaldson: No, I think that you have explained it very well. I agree with that.

The Chairperson (Ms Maeve McLaughlin): Section 3 of the report states that:

There is a big gap between 3% and 25%. Why is that?

Dr McBride: Again, Sir Liam quoted those figures in his report. However, we know from studies right across the world that there is significant variability in the assessment of the scale of avoidable harm. The truth of the matter is that, as healthcare becomes more complex and there is more technology, we are treating patients for conditions from which they would previously have died, as Liam said, because, at times, it is a life-and-death business. However, the downside of that complexity, that technology and the multidisciplinary nature of the engagement of teams of individuals is that sometimes patients do come to harm. That can be for a variety of reasons, and, in his report, Sir Liam highlighted some things that are almost unthinkable in terms of wrong-site surgery, prescribing errors etc. The academic literature that looks at the frequency of that provides a fairly wide

The most important and telling point there is the 50% that is estimated to be avoidable. That a system that is about providing healthcare should cause harm to those who come in contact with it is somehow or other almost unconscionable, but that is the realty of modern health and social care.

Sir Liam, I do not know whether you want to comment on that.

Sir Liam Donaldson: Yes, very briefly. The figures come from all the research studies that have been done around the world to investigate the number of adverse incidents in hospitals, both major and minor. The 3% came from the first study in the United States, and it used a very tight definition, which was akin to medical negligence really, so the threshold for calling something an incident was very high. The 25% came from one that looked at everything, even the most minor. However, when people look at all the studies that have been carried out, and there have been something like 20 or so around the world, they will see that they usually cite a ballpark figure of one in 10 hospital admissions resulting in some form of error of which 50% or so are avoidable.

Mr McCarthy: I want to follow on from your comments, Chair, on the number of reviews. I mentioned that when the Minister presented his statement yesterday. First, I want to complain. Richard, did you say that you had that report in December?

Mr Pengelly: Yes, 31 December.

Mr McCarthy: We are nearly at 31 January, and we only got that in our pigeonhole a few minutes before 10.30 am yesterday, along with the statement. I think that that is an atrocious way to treat a Health Committee and, indeed, to treat the whole of the Assembly. We got it 10 minutes before the statement, and you have had that lying from December. I think that that is crazy stuff. The Minister did seem to be, rightly, embarrassed yesterday when he was challenged on why we got it only two or three minutes before we went into the Chamber to ask questions and debate it. Maybe you will answer that some other time, and, in future, we will get better timing on it.

In relation to that, I said to the Minister yesterday that we have reviews and reports coming out of our ears, and here we have 11 from your report, Sir Liam. I have no doubt that there is probably a dozen lying somewhere else in the Department. I think that I will table a question to ask the Minister how many reviews or reports he has on his desk. Every time that there is a mess made or something happens in the health service, we say, "Oh, we will have another review and another report". It builds up and builds up. There is something wrong there.

Anyway, let us go on to what I want to ask. Sir Liam, you might want to close your ears to this one. This is to the officials. Does the Department believe that Sir Liam and the review team went beyond the terms of reference that they were set?

Mr Pengelly: I will start, and Michael might want to come in. First, the statement not being available yesterday was an administrative mistake. It was planned to be available more than an hour or so earlier. The Minister apologised yesterday on his own behalf, and I certainly apologise on behalf of officials to Members. It should not have happened, and it is unacceptable.

Mr McCarthy: It is not the first time.

Mr Pengelly: As I say, I apologise for that.

Mr McCarthy: It does seem that it is maybe deliberate to avoid the Members having real questions prepared. I wanted to ask questions yesterday, and I think that the Speaker shot me down because I was asking too many. It is not right that we get it two or three minutes before the time. The question is this: did Sir Liam overstep the mark?

Mr Pengelly: From my perspective, I absolutely believe that he did not go beyond that. I think that, as Sir Liam has alluded to on a few occasions, when you are dealing with issues of quality and safety, virtually everything in our system has a ripple effect that at some point drifts into those issues. I think that he has taken the review to some very pertinent points. I think that Sir Liam could have extended the review and covered a lot more ground, and it would have had a relevance. So, I think that he has focused on the big issues. I see all of it as being germane to the challenge that was placed when the review was commissioned last year. It is fundamentally at that quality and safety point.

Dr McBride: Very briefly, obviously, Sir Liam was asked to look at the governance of the HSC in the context of openness and transparency and planning and learning and redress in the context of the SAI reports and concerns around that process. You will remember the then Minister's statement on 8 April about establishing Sir Liam's review and his team at that time. The fact that Sir Liam felt so compelled, in looking at the quality of safety of health and social care in Northern Ireland, to comment on the second theme that the design of our health and social care system is the greatest challenge that we have in maintaining the quality of care was very telling. The fact that he also commented that that is causing the major stress on staff working on the front line, often feeling that they are not able to deliver of their best to the patients who they are providing care to, is also very telling. I think that we need to reflect on that, and I think that it is certainly entirely apt that Sir Liam, as Richard said, commented on all relevant elements of the quality and safety of health and social care in Northern Ireland.

Mr McCarthy: You are happy that what we have before us is what Sir Liam was asked to do and that he has taken everything into consideration?

Mr Pengelly: I am happy that what he has presented to us is a very good analysis of the core issues and their impact on the quality and safety of our system, which is precisely what we had asked for.

Mr Brady: I go back to Transforming Your Care. In a statement yesterday, the Minister said:

When the Minister gave evidence to the Committee on the 2015-16 budget, he identified the implementation of TYC as his number 2 strategic priority. There was a lack of clarity on how TYC ranks in comparison with other areas of discretionary spend, such as elective care and pharmacy. I would like the Department to clarify that TYC is the top priority for discretionary spend. When the Minister and officials gave evidence to the Committee in October of last year, the plan was to spend £15 million to £17 million on the implementation of TYC in the coming financial year. Is that still the plan? Also, in November 2014, in the approach to the 2015-16 budget, we were told that the Department is not in a position to advise of the projected shift in funding from hospital services to community primary services for 2015-16. Could you please clarify what that figure will be?

Finally, in a statement issued yesterday on TYC the Minister said that:

How does the Department expect front-line staff to implement TYC when the resources are not committed? There is a number of questions there.

Mr Pengelly: There is. I will have a go, and you can come back to me if I do not pick any of the points up.

Firstly, I cannot give you a definitive number yet for the planned 2015-16 spend. We are still working through our financial planning processes. As you are aware, we face very significant challenges. We have an opening pressure of about £320 million. Next year, we have about £160 million additional funding and about £160 million of efficiencies to deliver. We are still doing the numbers in that context.

I come to your point about operational staff. One thing has struck me during my relatively short time of seven months here. I have tried to get out and spend a fair bit of time in various facilities, and the knowledge, passion and enthusiasm of front-line staff and the innovative capability of people on the front line is awe-inspiring at times. At times, the best thing that managers can do is capture that effort and innovation rather than try to bring a huge amount of quality to the game themselves. There is so much already there.

That is very much true of our approach to TYC. We will need some additional funding for TYC; we have said that consistently. The 2011 report talked about £70 million in transitional funding. Thus far, we have received something in the region of half that, so more remains to be done. Sir Liam made the point very well that we need to focus our energy and attention on this, because, notwithstanding a shortfall in transitional funding, we can make progress through focusing attention on it, building capacity and motivating staff on the ground. There is a lot that can be done.

We need to reflect going into 2015-16, which is probably the most challenging financial year thus far. It would be deeply frustrating if all our energy and attention went into achieving a balanced financial position and avoiding the extreme contingency measures that we had to take at the tail end of 2014. The reality is that, if we do nothing but stand still and do not actually find the space to intervene and change the system, every year will be the same: we will have to deal with crisis and find more and more extreme ways of managing pain. We need to start changing the direction of the oil tanker.

Mr Brady: I absolutely commend front-line staff in the health service. If I may be purely parochial for a moment, I visited Daisy Hill before Christmas to meet front-line staff, and their commitment to and enthusiasm for the work that they continue to do under extremely pressurised circumstances can only be commended. The support that they need must be found. As I said, we have been told that Transforming Your Care is a vision without action. It is time the action was put into place.

Mr Pengelly: I take your criticism of TYC, because it is not where we want it to be. There has, nonetheless, been a fair amount of action on the ground. I think we need to capture and collate that and, as Sir Liam said, maybe think about having a much more visible driving force behind it to bring it home.

The Chairperson (Ms Maeve McLaughlin): Can you clarify now that TYC will be the priority for discretionary spend?

Mr Pengelly: Nothing has changed. Mr Brady quoted the Minister's comments. Nothing has changed from when he talked about TYC being a clear priority for him.

The Chairperson (Ms Maeve McLaughlin): But it was a number 2 priority.

Mr Pengelly: That was the position he articulated on the day. Within the financial position, there is a difference between discretionary spend and the statutory obligations on us to provide services.

The Chairperson (Ms Maeve McLaughlin): We cannot clarify at this point if TYC will have priority for discretionary spend?

Mr Pengelly: There has been no change since the Minister outlined his position before the Committee. How that manifests itself in the funding allocations depends on the outworking of the overall financial position, because it is still discretionary spend. We have debated before, Chair, the difference between prioritisation and obligation. Something can be the number 1 priority, but if there is no statutory obligation to do it, and there are statutory obligations to do other things —

The Chairperson (Ms Maeve McLaughlin): We have all signed up to the strategic policy direction of Transforming Your Care. We were told it would be the policy piece that would address some of the issues that Sir Liam has reflected in his report.

Mr Pengelly: I am not suggesting that TYC will not be taken forward: the issue is the pace. The reality is that, with a budget that is clearly less than the Minister feels he needs for health and social care next year and given the range of statutory obligations upon him, these have to be discharged before he can find any funding for discretionary priorities. That is the simple reality.

The Chairperson (Ms Maeve McLaughlin): I accept that there are constraints in the system, that we need to deal with those constraints and that we have done what we can to protect the Department. My clear question is about the discretionary spend. What assurance can we get that TYC will have priority, for example, over elective care? How do we know?

Mr Pengelly: The Minister sat in front of the Committee and said it was a priority.

The Chairperson (Ms Maeve McLaughlin): It was the number 2 overall priority.

Mr Pengelly: I am sorry, Chair, but I do not have the authority to change the Minister's priorities. The Minister indicated that that was the nature of his priorities, and that remains the position.

Ms McCorley: Go raibh maith agat, a Cathaoirligh. I want to explore some thinking about how things can be done better with our resources. Diabetes was mentioned earlier. Liam, you outlined an example of how things might be done better. Failure to learn from that example might fall into your unforgivable bracket, Michael. We all know that diabetes is a big and increasing threat and that it is going to be the biggest burden on the health system. A lot of it is very manageable and avoidable with good education. Reference was made to how some people are very good at just obeying the rules. There are simple rules for people with diabetes that might be easy for some people to follow and not for others. Some people are just better than others at doing the right thing, because people are all different.

My question to Michael is this: have you looked at or thought of any other ways of getting the message through to people, given that people hear advice, accept advice or learn in very different ways, that a one-size-fits-all scenario does not work? I would also be interested in Liam's views on that. Given the nature of diabetes and the big threat that it is, it is important that we try our very best to get the message out in as many different ways as possible so that as many people as possible learn the lessons and, hopefully, avoid it or manage it successfully.

Dr McBride: That is a very good question and a good example of a long-term condition that is going to be around for quite some time, and Sir Liam gave an example of the importance of patients being empowered in relation to self-management. As you will recall, the then Minister requested that I undertake a review of diabetes services in Northern Ireland, which has been completed. It involved working with the Northern Ireland branch of Diabetes UK and a range of health professionals in Northern Ireland. It looked at a range of issues, including the public health messaging in relation to avoiding diabetes, particularly type 2 diabetes; what we are doing around public health; the new public health framework Making Life Better; the obesity prevention strategy; the standardising patient education programme; self-management programmes; looking at novel interventions and treatments for the management of diabetes; making recommendations for the development of a register for all people in Northern Ireland with diabetes; and the establishment of a diabetes network along the same lines that Sir Liam outlined, with a focused leadership working and advising the Health and Social Care Board and the Public Health Agency around the appropriate models to commission for diabetes care across Northern Ireland that will improve the quality of those services and the outcomes for the patients using them and the experience of those services for people living with diabetes. That report has been completed and has been shared.

In terms of taking it forward through to implementation, I go back to the point that the Chair made earlier about capacity. The same officials who were involved in that work have been involved in the response to and the development of planning around Ebola, for example, and that has been slightly delayed. I am happy to share with the Committee, in due course, the outworkings of that and the plans to take it forward.

It is a crucial area in terms of improving the outcomes for people living with diabetes in Northern Ireland and it is a major cost to the health and social care sector in Northern Ireland and the UK. I think that it is estimated that around 12% of health-care expenditure relates to dealing with diabetes and some of the complications, whether that is end-stage renal disease or retinopathy — problems with eye sight and vision. Again, through better control, better self-management and better support of people living with diabetes, there will be significant savings to individuals in terms of complications and significant savings in health-care costs, but that requires a different model. As Sir Liam alluded to in his report, it requires a model that involves bringing patients and users of the service into the tent in terms of how we design and commission those services so that they co-produce those models with them and we have that more mature relationship that is not the big doctor up there and the patient down there. It has to be that partnership.

Mr McGimpsey: First, I want to make a comment about the panel. I know that it is an international panel of experts, but it seems to me that you need input to that. I do not think that an international panel of experts, brilliant as they may be, will be sufficiently connected. The other plea that I would make is that you must involve the staff side. You have 70,000 people working in the system; this ain't going to go without them, so they need to be very much involved in all of this.

Richard, when we were talking about TYC, I think that Mickey asked a question about the money, and you said that we have to prioritise out of £5 billion. I understood that your DEL was £4·6 billion.

Mr Pengelly: Sorry, I think I said the thick end of £5 billion.

Mr McGimpsey: I did not hear "the thick end".

Mr Pengelly: Sorry.

Mr McGimpsey: When I heard £5 billion, I thought, "Somebody is not telling us something here. Has someone worked out that we need to write a cheque?".

Mr Pengelly: Sorry.

Mr McGimpsey: We have the worst four-hour waits in the UK. We also have waits as far as a number of specialities are concerned. As I understand it, we are going to get the figures again in mid-February, but, in the last ones, I think that about 16,000 were waiting beyond what they should have been. When people are waiting too long, they come to harm. We know that; they are in distress. How are you going to fix that? As I said four years ago, as Edwin Poots eventually said and as Jim Wells is now saying, there is not enough money in the system to run the system, so how are you going to fix it? How are you going to make it right? How are you going to do TYC and evolve along the direction that Liam says we should go and, at the same time, fix the stress in the system? There is clear stress. I know that you were brought in because you were the money man in DFP, as was your predecessor. He was not able to get a printing press. When I heard £5 billion, I thought, "Aha; there is" —

Mr Pengelly: If only.

Mr McGimpsey: Somebody has to work out the pure politics of this; somebody has to write a cheque.

Mr Pengelly: The point you make is very true: the waits that you refer to are not going to improve unless we change something; they are going to continue to decline. From my perspective, as much as additional money would be very welcome, additional money without systemic change is the wrong way to go. We need both: we need some investment, and we need to find a new and better way of doing things. There is a huge amount in the report that offers us a road map to do things differently. There are some points that the Committee may or may not accept. There is a process of challenge for us to reflect on how we currently do things: the acceptance that what we have been doing up to today is not working as well as it could be. There is a process of challenge, reflection and change, but we must drive change. Those waits will just continue to erode throughout the rest of this year and next year.

Dr McBride: Absolutely. You made points around waits for electives. There is not the capacity or capability in the health service at present. The fact is that we had to turn off the independent sector. As we outlined to the Committee when we were here previously around the implication of living within our budget, it will be very profound in terms of people waiting at home; in many cases, waiting at home in pain and discomfort.

Your point around unscheduled care was also well made. We went through the details of that when we last gave evidence to the Committee. The system, certainly over the winter period, has been under a significant amount of pressure. We saw a 7·5% increase in emergency department attendances. We then saw a dip, which you referred to in the last session in which we gave evidence; ED four-hour performance dipped below 80% to 79·8%. However, in the context of a 7·5% increase in demand, one might have expected that dip to have been more than that. That, again, is disappointing. Last year saw the lowest number of people in the last five-year period waiting for more than 12 hours, but that should not be our benchmark; absolutely not. I anticipate that the figures will increase given the pressures that we have seen even in the first number of weeks in March. We have had a further 6% increase in emergency department attendances and a further 3·5% increase in relation to ambulance attendances, which generally convert more into admissions because, by and large, they are sicker patients. We have also had a 5·9% increase in people coming directly into hospitals, who might be our frail elderly people or patients with acute MIs etc. I suspect that we are unlikely to see a significant improvement or change in the four-hour target in the latest statistics that, as you say, will be released shortly.

Richard is absolutely right: it is about a combination of us doing things differently. I am taking forward work with Charlotte that involves engaging with the rest of the health and social care system in Northern Ireland. Through the unscheduled care task group, we are looking at different models and putting them in place. On Monday of this week, we had a fascinating presentation from the Northern Ireland Ambulance Service in relation to the example that Sir Liam referred to: hypoglycaemia and diabetics. It proposed a different model for the management of frail elderly people who fall at home. A significant proportion of frail elderly people attend our EDs. We can get a different model in place that allows us to manage those patients at home rather than having them coming to our emergency departments. It is a about a combination of using our resource to the best of our ability, and, if there is more resource to be had, yes we can use it. Also, as Richard said, that systemic change that Sir Liam has pointed to in his report is required.

Mr McGimpsey: I understand that you have stopped elective spinal surgery, for example. Is that right? You are dealing with emergencies only.

Dr McBride: I think that there has been a pause on a number of —

Mr McGimpsey: You have lost four orthopaedic surgeons. Is that right?

Dr McBride: I am the Chief Medical Officer. The detail of that will be with the Health and Social Care Board and the specific trusts.

Mr McGimpsey: How long will those patients who are sitting waiting in pain and distress have to wait? They cannot wait for systemic change, and they cannot wait for all the different ways of working and whatever. What you need is somebody to write a cheque to allow you to buy the procedure to sort them out. Is that not right? You have thousands of folks like that waiting.

Dr McBride: I have given evidence to the Committee before about the pressures on health care in Northern Ireland and my concerns. Indeed, I communicated my concerns to the then Minister about the consequences of the challenges that we face around our budget. I have those concerns, and we are seeing the manifestation of that, but, as Richard has indicated, we have the resource that we have. Our challenge and task is to live within that resource and provide the best service that we possibly can and, at the same time, continue to seek to improve that service by using that resource ever more efficiently. I think that is a big ask and a big challenge, and, unfortunately, as the Minister alluded to at the start of January, the issue that will dominate health and social care over this year will be the resource allocation and the budget that we have to deliver. There will be some tough choices, and you highlighted some of them. Earlier, you alluded to the direct access physiotherapy. It is not that it has been abandoned, but, if we have excessive numbers of people waiting for physiotherapy, we need to prioritise access to resource. That is deeply regrettable. It is not abandoned, but we had to pause that whilst we deal with the demand and the backlog of patients requiring physiotherapy.

The Chairperson (Ms Maeve McLaughlin): Sorry to come in here, Michael. Is that not counter-strategic? You are talking about doing things differently, and then we pull a project that —

Dr McBride: I am on the record from when I was at the Committee previously in relation to my concerns about some of the implications. Richard is on the record saying that the decisions that we made are the decisions that we needed to make in relation to the flexibility that we had with uncommitted resource. To say that all of these decisions at that time were strategic or what we would have wished to have done in a different budgetary situation is not correct. Clearly, in a different budgetary situation, those would not have been the decisions.

Mr McKinney: Richard, we talked earlier about this illuminating the landscape, if you like, and identifying various constituencies, some of which are transitory with people taking an interest or campaigning around hospital closure or whatever it happens to be. If you discount those, that leaves you, the Department, with the responsibility. So, how do you react to what, in my view and the view of considered audiences out there, is a damning indictment of the Department's stewardship of the health service?

Mr Pengelly: Forgive me, but can you help me to understand what bit you think is a damning indictment?

Mr McKinney: There is a question in here that I think is fascinating. On page 16, it states:

Is the fact that that question appears in this report not a damning indictment in itself?

Mr Pengelly: I am not sure that it is a fundamental question that appears in the report as opposed to Sir Liam highlighting something that is, by any analysis, suboptimal in the system. In a system this large, there is a lack of clarity. I think that it is a valid critique. I do not accept that it is a damning indictment. I think that it is worth having a much longer debate on what the implication is of that perceived lack of people knowing who is in charge. One of the issues that I have inherited, and I think that I have mentioned to the Committee before —

Mr McKinney: Sorry, can I just remove the inherence aspect to this? I am asking about the Department's ongoing and long-term stewardship of a system that is clearly failing the public, not your most recent appointment.

Mr Givan: The report does not say that either.

Mr McKinney: Pardon?

Mr Givan: It does not say that it is failing the people of Northern Ireland.

Mr McKinney: All right. It states:

You might not find those specific words, but —

Mr Givan: Read the conclusion.

Mr McKinney: — overall —

The Chairperson (Ms Maeve McLaughlin): Through the Chair, please.

Mr McKinney: Sorry, Chair.

Mr Givan: If he would let people finish when they make their point, rather than headline-grabbing —

Mr McKinney: Sorry, Paul, it was you who interrupted me. So learn your own lessons, please. Sorry, Chair.

Could you address the point?

Mr Pengelly: The point is in terms of the system and about this lack of who is in charge, I am not sure that, expressed in those terms, it is a fundamental issue for the day-to-day provision of health care. I think that it is a challenge for us in terms of leading us through a process of transformation of the health-care system. The reality is that our health-care system operates — as Sir Liam recognises, and it is a very astute analysis — with far too many silos. Within each of those individual silos in our health-care system, people are in absolutely no doubt about who is in charge of their world as they know it. It is the chief executive of the organisation that they operate. The challenge for us, and it comes through not specifically in what Sir Liam said, is that, if we want a whole-system approach to a range of issues, we need to break down those boundaries and we need to act and behave as an integrated health and social care system with clear leadership of the system. I think that is the point that Sir Liam highlighted: we need leadership of the system, not individually.

Mr McKinney: Yes, but how does the Department react to the fact that Sir Liam has been able to arrive at those conclusions? This is not a system —

Mr Pengelly: You ask me how I react. I tried to explain what I was doing, and you cut me off because you said that you did not want to know.

Mr McKinney: No, No. Continue.

Mr Pengelly: As a first step, we have created a senior management team of the health and social care system in Northern Ireland, which has not happened in many years, where all trust chief executives, the chief executive of the PHA, the board, and I meet in that forum not as representatives of our individual organisations but as the senior management team of the health and social care system. That is a group that I chair and give leadership to, but with joint leadership from my colleagues at trust, board and PHA level, who are also giving very clear and decisive leadership together with me and separately in their individual organisations. It is difficult for me to make an assessment of that, and Michael might want to add something. Since those meetings started, trust chief executives have told me that there is a better sense of the whole-systems approach to the issues.

Sir Liam made a point about the review of commissioning. With regard to the review of administrative structures that the Minister announced before Christmas, we are looking at how our structures within the system interact with each other to remove duplication. I think that all those issues are starting to get traction, and that is how we will address the issue.

Mr McKinney: With respect, I do not think that you have actually answered the point. If a man with Sir Liam Donaldson's authority has been able to ask a question simply about who is running this system, it obviously points to long-term flaws in the system. He is able to point to a TYC plan that has not been measured, implemented or funded, and you are not able to tell us today that that will change.

Mr Pengelly: No, I do not accept that I am not telling you. I am outlining for you exactly how we are seeking to change that. Your introduction to this was that it was a damning indictment of the Department, and one of the points that you make is that TYC has not been properly funded. That is an Executive decision. The Department can deal only with the resources allocated to it. We expressed previously our frustration, and the Minister is on record with his frustration. The leadership point is absolutely valid, but I do not think that it is the fundamental plank on which all these other issues are built.

Mr McKinney: With respect, Mr McGimpsey pointed out at the time that the system needed more money, and he is here to represent that point, although he may not want to. The TYC plan was developed outside of a budget and was to be funded only out of monitoring rounds, so it was flawed from the start.

Mr Pengelly: Sorry, I did not get a question.

Mr McKinney: I am making a point, contrary to the point that you are making. I will make it into a question: would you agree that that is the case and that that was the case?

Mr Pengelly: I was not in the Department at the time of the TYC report. I do not think that that report specified that it was to be funded out of in-year monitoring. The TYC report recommended that it would need £70 million of transformational funding to fully implement it over a three- to five-year period. I have not checked precisely, but I suspect that the words "monitoring round" are not used anywhere in the report.

Mr McKinney: It was conceived and came after the Budget, so it could get money only out of other sources, which was the monitoring rounds. It never had a chance; it has never been properly funded out of monitoring rounds ever since. Did you apply for funding for TYC in the January monitoring round?

Mr Pengelly: I do not think that we did in the January monitoring round because you are constrained in that monitoring round by your capacity to spend money, and there are only a couple of months left in the year. Notwithstanding that, there was a clear signal that no money would be available.

Mr McKinney: So, it did not get any money.

Mr Pengelly: Money was not allocated to TYC not just because we did not bid for it.

Mr McKinney: OK, I will turn to another issue. It is about the system to review deaths to complement the role of the coroner. Do we not already have a system? Should deaths not be referred to the coroner in cases where it is deemed necessary?

Dr McBride: Yes. There is a statutory responsibility in section 7 of the Coroners Act. As the then Minister announced back in April, there was a look-back exercise of all SAIs between 2009 and the end of 2013. The purpose of that was to look at the read-across between those SAIs and the complaints process and also to ascertain the involvement of families and carers in relation to that process and to provide assurances in relation to the information being conveyed to the coroner. That review has been completed, and it will be published in February. Sir Liam had an opportunity to consider the findings of that RQIA assurance of the process, and he commented on it in his report.

Mr McKinney: Would what you are proposing require new legislation?

Dr McBride: No.

Mr McKinney: Did you take any consideration of the proposal of the Attorney General, John Larkin, to have outside scrutiny through his offices?

Dr McBride: I am aware of the Attorney General's comments on that. Indeed, I have met the Attorney General in the past in relation to that.

Mr McKinney: Will there be any need for legislation, primary or secondary, in relation to a quality improvement and regulation order in relation to the regulation of acute health-care providers?

Dr McBride: There will be.

Mr McKinney: Which? Primary or secondary?

Dr McBride: It will probably require primary legislation. Obviously, the underpinning regulations will have to be developed from that as well.

Mr McKinney: What will be the situation in relation to non-acute services?

Dr McBride: My understanding is that that will also require some changes. I am not precise on that point, but I think that changes to secondary legislation and regulations will be required. I am happy to confirm that with the member.

The Chairperson (Ms Maeve McLaughlin): OK, members. Thank you for your time, particularly you, Liam, and for sharing this with us. Obviously, there are a number of questions. We expect, Richard, to hear from the Department on what it will implement of the recommendations that have been made. Thank you for your time today.