Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): Folks, you are very welcome. We have Mr Mark Lee, director of health care transformation: Ms Fiona Hamill, director of service delivery; and Ms Jennifer Mooney from the health care transformation directorate. I hand over to you to make some opening comments, and we will then open up the meeting to questions.

Mr Mark Lee (Department of Health, Social Services and Public Safety): Thank you, Chair. Good afternoon to everyone. I will take the opportunity to make a few comments on the approach that we have taken to the draft commissioning plan direction, which we have shared with you, and to summarise the key changes to the standards and targets. In doing so, it is important to think about the financial context in which we will operate, and I know that the Committee will keep that in mind. The Committee is very well aware that 2014-15 was a particularly challenging year for Health and Social Care (HSC) and that 2015-16 will continue in the same vein. As a consequence, we have had to think very carefully about the targets and standards set in the commissioning plan direction. Although a plan to secure financial balance has been developed — the finding of substantial savings by the Department and its arm's-length bodies — it means that the Department's budget for 2015-16 does not allow for the funding of any new service developments. In that context, we have always had to be realistic but remain challenging in what we ask the health and social care system to deliver. The draft commissioning plan reflects that and the fact that we have had to scale back some targets and remove others. Even having done so, I think that it will remain challenging for the health and social care sector to deliver the targets and standards set out in the direction.

I have a few comments on the detail of the draft direction. You will notice that it is considerably shorter than usual — we have helped to minimise your reading load — but the detail on the key services to be delivered regionally and across each of the five local commissioning group (LCG) areas is still there, and there is still a requirement to demonstrate that it will meet the assessed needs of populations and how ministerial targets and standards will be met.

The 2014-15 commissioning plan direction had seven strategic priorities, and we have now combined these into three core themes: improving and protecting population health and well-being and reducing health inequalities; providing high-quality, safe and effective care, listening to and learning from patient and client experiences and ensuring high levels of patient and client satisfaction; and ensuring that services are resilient and provide value for money.

As the letter from the Minister highlights, 14 targets have been rolled forward from last year's commissioning plan direction, 12 have been revised and there are four new targets that we propose to add or are considering adding. A total of 10 targets from the previous year have been removed. As the Committee will have noted, a small number of targets have no number attached, and we are still working on the exact detail of those numbers. I hope to finalise that detail by the end of this week or certainly early next week. The targets that continue to roll forward are doing so because we continue to place a lot of importance on achieving them, and the Minister wants real progress in achieving targets on, for example, emergency department waiting times and cancer access times. We have pushed up some of the targets that we revised. We think, for instance, that performance is strong on direct payments and stroke, and that we can go further. The Minister is also very keen to see a significant reduction in the number of cancelled outpatient appointments.

In other areas, we had to recognise the budget constraints. As the Minister's letter sets out, target levels for outpatient assessment, inpatient and day-case treatment and access to allied health professional services has had to be reduced to reflect that. None of us would wish to take that approach, but we need to set realistic targets for the financial context in which we find ourselves. Similarly, I should point out that the lack of funding meant that it was necessary to remove the current target for access to specialist therapies. We will, of course, keep that under review, as with all of the targets, and, if additional funding becomes available in-year, we will look at whether we can change that position.

We have continued to have a focus on Transforming Your Care (TYC) and reform in the system, which becomes even more important in financially constrained times, as does the focus on moving upstream to population health and well-being, for which we include targets. Good progress has been made on the integrated care partnerships (ICPs). We removed them from the direction to focus on the outcomes that they are trying to achieve rather than the process of creating them.

The only other thing that I want to flag is that, given the financial challenges, we set some targets to try to ease some of the pressures. We are very clear that we want further reductions in the length of hospital stays, significant reductions in the number of hospital cancelled appointments and the delivery of at least £20 million in efficiencies from prescriptions. Those are challenging targets to try to make health and social care and the system more efficient.

Finally, I remind the Committee that, as well the commissioning plan direction, there is an indicators of performance direction, which sets out the data that we will continue to collect. Even where we have removed targets from the commissioning plan direction, we will continue to monitor performance through the indicators of performance direction.

I hope that that was useful as a brief summary of the approach that we have taken, and Fiona, Jennifer and I will do our best to answer any questions that you have.

The Chairperson (Ms Maeve McLaughlin): Thank you, Mark. How much exactly has been shifted left through Transforming Your Care?

Mr Lee: Do you mean the quantum of funding?

The Chairperson (Ms Maeve McLaughlin): The amount of money.

Mr Lee: We wrote to the Committee on that previously, setting out the figures on the shift left and the agreed elements of TYC, one of which is the services that have been stopped in hospitals and moved to communities: for instance, mental health services. There are also areas where we have created new services in the community or invested in community services rather than hospital services. I do not have the figures in front of me, but we provided them to the Committee before.

The Chairperson (Ms Maeve McLaughlin): The last time that you were in front of us, we were told that it was £25 million, but I think that you had indicated that that might not be accurate.

Mr Lee: The correspondence said that I thought that there might be more to say about how much had shifted left. It gave the figure — you say that it was £25 million — from stopping hospital services and provided the broader picture of additional investment in community rather than hospital facilities. I do not have the figures in front of me, but we were attempting to demonstrate a broader shift left than the figure of £25 million would suggest.

The Chairperson (Ms Maeve McLaughlin): That £25 million was identified for 2013-14. What amount has been identified for 2015-16?

Mr Lee: I am working from my memory of what the letter said. I think that it suggested that a few services had been shifted and that there were continuing savings from the move of mental health services.

The Chairperson (Ms Maeve McLaughlin): Do you not agree that it is really irregular to be discussing a commissioning plan and setting targets when we do not even know what has been shifted to date on the key policy direction?

Mr Lee: That letter set out what has been shifted to date.

The Chairperson (Ms Maeve McLaughlin): It said that there was £25 million in 2013-14, so the question now is this: what is the anticipated shift left? I have to say, Mark, that I find it really irregular that we cannot get an accurate figure. How are we supposed to set policy direction for the key policy that we all collectively signed off when we do not know how much has been shifted?

Mr Lee: I am sorry. I do not have the letter in front of me because I was not expecting to have this particular discussion now, but it provides all the detail. Obviously, until we get to the end of the current financial year, we cannot give you a clear position on —

The Chairperson (Ms Maeve McLaughlin): Mark, Transforming Your Care is critical to the commissioning plan direction.

Mr Lee: Absolutely, yes.

The Chairperson (Ms Maeve McLaughlin): The obvious question is this: how much have we transferred?

Mr Lee: The broad answer to that is not enough, which is why there is still a target in the direction to continue to transfer money from the acute side into primary and community services. I do not have the figures in front of me, I am afraid.

The Chairperson (Ms Maeve McLaughlin): The Department is in charge of this. You should have a figure. You should have come to us with that figure. We are discussing the strategic direction going forward, and we cannot even get an accurate figure on how much is being shifted.

Mr Lee: The accurate figures are those that we provided in writing previously. For the current year, we will not have a final figure until we are at year end and can take stock. I can go away and provide further written information, but I am not sure that there is much more to say than what was in our previous letter.

The Chairperson (Ms Maeve McLaughlin): Right, OK. You are in charge here. Is it £25 million? Is it more than £25 million? Is it less than £25 million? Who, if it is not you, has the figure?

Mr Lee: The position is as it was set out in the correspondence to you.

The Chairperson (Ms Maeve McLaughlin): That was £25 million, Mark, and it was for 2013-14. We asked what was anticipated in this budgetary round. We are asking for an accurate figure, and we are not getting it.

Mr Lee: Are you asking for the figure for 2015-16?

The Chairperson (Ms Maeve McLaughlin): Yes. I am asking you this: to date, how much of the £83 million, to which everybody signed up, and the £70 million of transitional funding needed to do that has been shifted left? To date, the only figure that we have received is £25 million. Then, we were told that it might not be accurate. I ask this question: in Transforming Your Care, how much has been shifted from acute to community or primary services?

Mr Lee: For the end of 2014-15, I think that the current figures suggest that it will be around £27·5 million.

The Chairperson (Ms Maeve McLaughlin): That is for 2014-15.

Mr Lee: Yes. We will not be able to finalise that until the end of the year. That is the cumulative figure over the entire period, so, up to 2014-15, there will have been a total shift of £27·53 million.

The Chairperson (Ms Maeve McLaughlin): Are we really saying that only £2·5 million will have been shifted left in this current budgetary round?

Mr Lee: That is correct about the shift out of hospitals into communities. As the Committee knows, that reflects the unsuccessful in-year bids for additional funding for moving services across to a primary setting.

The Chairperson (Ms Maeve McLaughlin): How are we supposed to have confidence in a system that is about shifting, keeping people out of hospitals and focusing on primary and community services if only £2·5 million has been shifted in this budgetary round?

Mr Lee: That is a reflection of the financial circumstances in which we find ourselves. The Department will continue to do everything that it can to find funding to move services safely into a community and primary setting, but, as the Minister said, we must have the transitional funding to allow us to do that safely. If the transitional funding is not available to do so, we will not make decisions that put safety at risk.

The Chairperson (Ms Maeve McLaughlin): It is about prioritising. All of us have collectively signed up to this concept of shifting left. As far as I can see, it is not delivered in the commissioning plan. You are telling us that only £2·5 million has been shifted, so it is no wonder that we have a crisis in emergency departments, GPs are struggling, and there are all the struggles and pressures on the system.

Mr Lee: I can only reiterate that the financial challenges are key, but the Department remains focused on delivering that shift left.

The Chairperson (Ms Maeve McLaughlin): We talked about money that was allocated towards a new service delivery model, but you talk about the availability of transitional funding. Who is responsible for making that available? Where does it come from?

Mr Lee: Either the Department has to find it from its own budget, or it has to bid for it, which has been the previous approach, through the monitoring rounds from central finances. We have made bids for money over the past financial year that have not been successful.

The Chairperson (Ms Maeve McLaughlin): I reiterate that I do not think that it generates any great confidence in the system and the priority of its strategic direction if all that we have seen shifting is £2·4 million. I really do not. I will move on.

Mr McCarthy: I must say that I am disappointed, because, if that is the rate at which Transforming Your Care is going, we will never get it delivered. Patients will lag behind and suffer. What you have been saying to the Chair is very disappointing.

My question relates to the target drops for 2014, particularly the target for mental health and learning disability resettlement, which was to resettle all clients by March 2015. You state that it has been removed from the commissioning plan. The Department's briefing paper states that the majority of clients have been resettled. Perhaps you could tell the Committee how many or the precise percentage of clients who have been resettled and how many are left. What are your plans to get them resettled in the way that everybody wants?

Mr Lee: The remaining number will be resettled as soon as possible.

Mr McCarthy: Do you know what that number is?

Mr Lee: The Health and Social Care Board is finalising the number at the minute. My sense is that it would be between 20 and 30 individuals. There is still work to be done to finalise that number.

Mr McCarthy: Are the people who have already been resettled happy and content in their new surroundings? There were a lot of concerns that people may have been forced out of Muckamore to somewhere they did not want to go. On more than one occasion, we had assurances here that that would not happen and that people would remain in Muckamore as their permanent home if that is what they wanted. What is the situation?

Mr Lee: As far as I know, there are no issues with those who have been moved. I do not know whether my colleagues know more than I do. We could write to you with any further detail that we have about the status of people who have been moved and whether they are happy with the care that they now receive.

Mr McCarthy: That is important. It is vital that those who remain will not be pushed out somewhere against their will because you have a target date of March 2015. It has always been my concern and certainly that of the Committee that that would happen. You can let us know how many remain and how long it will take for them to be resettled properly. We do not want to be pushing them out to somewhere that they do not want to go. It is as simple as that.

Mr Lee: Absolutely.

Ms Fiona Hamill (Department of Health, Social Services and Public Safety): To reassure you, Mr McCarthy, the HSCB is clear that there is a small remaining number of patients in this group for whom, for a variety of reasons, resettlement is not suitable or is more complex, and they are now being looked at individually. I think that they include the group about whom you are concerned.

Mr McCarthy: Will you let the Committee know precisely what the position is and give us a time frame?

What plans are there to address the structural underfunding of mental health services in general in Northern Ireland? Only today, the lead news story was the shortfall in psychiatric beds. There are not enough services there. Mental health has always been the Cinderella of the health service. All your bosses have said that they want to put that right. Will you be able to do that with the commissioning plans that you have given us?

Mr Lee: We have certainly kept a target in the commissioning plan direction for access to mental health services, which we continue to view as critical. We are working with the Health and Social Care Board and the trusts to try to ensure that that target is met. I do not know whether Jennifer has anything specific to say about the work that is going on.

Ms Jennifer Mooney (Department of Health, Social Services and Public Safety): The board has provided additional funding to some of the trusts to build capacity in that area. I do not know the precise details of how much, but I can certainly —

Mr McCarthy: That would be useful. Are you aware of the crisis in psychiatric services? People simply cannot get beds.

Mr Lee: We know. We are very aware that that area is under pressure, and the board and the Department are focusing on it. We have kept it in the commissioning plan direction, so there is a focus on those targets and on delivering the service that should be provided.

Mr McGimpsey: As a follow-up to that, the deal for learning disability patients was that nobody would have a hospital as their permanent address. It looks like you have missed that target. I assume that you have plans to deal with it. I do not want to get into too much detail, and Kieran made a number of very good points.

Mr McCarthy: The target was supposed to be March this year.

Mr McGimpsey: Right. The key thing for mental health services was Bamford, which was rolled out in 2010. Bamford was taken through the Executive, all parties signed up to it, and a number of recommendations came out of it. How many of those recommendations have been actioned, and how many are there still to go? Where are we with what is the blueprint for future mental health services? Where are we with the Bamford review of mental health services?

Mr Lee: The key thing has been resettlement in communities, on which we have —

Mr McGimpsey: That is just one of the targets. I cannot remember how many targets there were — 28 or maybe more.

Ms Mooney: We would have to check the —

Mr Lee: We will have to come back to you on that.

Mr McGimpsey: I understand that. You are at a higher level.

Let me make a number of other comments. It is tragic that there are no service developments. Medicine and health provision are evolving, and we are not catching any of those developments through new services. That is a fundamental indictment of where we are and what we are about. As I recollect, the process is that there is a certain amount of money to spend. You hand over your commissioning plan, together with the money, to the Health and Social Care Board. The Health and Social Care Board delivers according to departmental and ministerial high-level priorities, as illustrated here.

My concern, and the point that Liam Donaldson raised with us last week, is that you go to the Health and Social Care Board and perhaps give it £2·5 billion to buy health services, £1 billion to buy social services and money to buy health in the community. You know how this is done: so many hubs get so much, so many heart services get so much and so many domiciliary care packages get whatever the money is. However, Liam Donaldson was fairly scathing about the tariffs and roll-out. There does not appear to be uniformity across the trusts, and it does not seem to match the UK Health Service in general. When you hand over the money to the board, and the board goes to spend it, the board should know exactly what it is getting for its money. It should know how many units of whatever service it is ordering, that it gets it, that it is on time, that it is on the money, that it is up to standard and all the rest. What are your plans to look at that? As I understand it, and if Liam Donaldson is right, the board appears to have dropped the ball in that area. That is very serious because the board is the organisation that spends the money for you. Is that not right? Is it spending over £3 billion? If it is not getting its tariffs right when it goes to buy, even if it gets it wrong by 0·5%, where are we with that?

Mr Lee: You raise a number of points. In response to the Donaldson recommendations, the Minister has announced a review of the commissioning process. We will look at Sir Liam Donaldson's comments about complexity and scale in Northern Ireland and whether and how a commissioning process is appropriate, and we will start work on that review soon.

When we are working on this, we have to make the best of the process that we have. The commissioning plan direction is focused more on improvements in quality, productivity, efficiency and effectiveness, so we would expect even more of a focus from the board in it demonstrating value for money and unit costs. We will work with it on its detailed commissioning plan, which previously set out the units that it is buying and the price that it is buying them for. It may be that we need to increase the level of detail in some of those areas in response to Sir Liam Donaldson's comments. We will work with the board to see how best we can respond to those comments in the current process.

Mr McGimpsey: That is very important. It is about careful management of the resource — the money — which is the key ingredient to make the whole thing tick. We cannot simply go down with a cheque and say, "Give that to the boys". When do you think that the commissioning review will see daylight? Presumably, we will have the board up here, and it can take us a bit further with the matter, but do you have any idea?

Mr Lee: I think that the Minister announced that the review will be completed this summer.

Mr McGimpsey: For the next commissioning plan, not this one.

Mr Lee: That is correct.

Mr McGimpsey: I will not keep you too long, but you are restating a number of targets — for example, outpatients, diagnostics, inpatients, cancer targets, A&E, ambulance category A responses. We have had all those for a number of years. Is that right?

Mr Lee: Yes.

Mr McGimpsey: You are restating them, and that is good. Where those targets are being missed — a number of them are being seriously missed, and cancer targets are on the slide — do you plan to prioritise the money with the board? As you are aware, patients who are waiting for cancer treatment can come to harm. There are targets for urgent breast cancer referral at 14 days, 98% of patients to be seen within 31 days for first treatment or 95% within 62 days for patients who have an urgent referral, and, if you are missing those targets substantially, patients are coming to harm. Are you getting any strategic direction for where to target money in those areas?

Mr Lee: The way that the money is used —

Mr McGimpsey: Those targets are picked for a reason, as you know. There is a four-hour target for A&E. There is a special reason for the target of 95% in four hours. That is the key target.

Mr Lee: We obviously monitor performance against those targets, and we are working closely with the board to improve that performance. I do not know whether Fiona will be able to say a bit more about that.

Ms Hamill: I will pick up on the cancer-related targets that the board has been working on over the past year. The targets for breast cancer are reasonably close on performance, but the targets for other cancers can vary quite a bit from trust to trust.

The board looked at the waiting list by tumour groupings. It took the six main tumour groups — upper GI, lower GI, urology, lungs, skin and obstetrics — and got working teams together across all the trusts to look at where the best practice was, to share best practice and try to bring a more consistent standard.

The provisional evidence on, for example, the 62-day path, which is the GP referral path, shows that all those performances, for example, in urology, are coming into line together, so the performance is now more consistent. The board is working to bring in the best standard of performance across all trusts to ensure equality of access. That, rather than funding, is the approach being taken.

Mr McGimpsey: Yes, that is good, but, if the funding is not there, it will not happen. It is the funding that drives it. Do you expect to get back to the targets?

Ms Hamill: Yes. The board is monitoring, is pleased with the response and envisages more improvement. The board is looking at work being piloted in Wales that tries to be more specific on the target pathways for individual tumour groups and to refine that a bit more. They are doing a lot of work in that area because, as you say, these are exceptionally vulnerable patients.

Mr McGimpsey: The stroke strategy is to be rolled out, and you say that, from April 2015, 13% of patients are to receive thrombolysis. Is that lower or higher than was originally planned for by now? The figure of 13% does not ring a bell with me. I thought that a much higher uptake was hoped for.

Mr Lee: That figure is correct.

Mr McGimpsey: Should it not be higher?

Mr Lee: One of the challenges with this form of treatment is that it is not suitable for everyone.

Mr McGimpsey: No, you have to screen and scan.

Mr Lee: We had to have a conversation with the medics, who are clinically qualified to say what is a sensible target to aim for without incentivising behaviour that might cause people harm. The target last year was 12%. We have upped that to 13% because we think that that is still clinically reasonable, but —

Mr McGimpsey: What is it in Scotland, do you know?

Mr Lee: I do not. I am not even aware that Scotland has a target on this, but we could certainly check.

Mr McGimpsey: OK, great. Thanks very much.

Ms P Bradley: You spoke about the targets that were altered from 2014 to now. I want to ask you about two of those. The target for access to allied health professional was nine weeks. It has now been changed to 13 weeks. Do you see that as being achievable? Where did 13 weeks instead of nine weeks come from?

Mr Lee: As with all these targets, we looked at performance over the past year. We spoke to a range of experts within and without the Department — for instance, the board — to get a sense of what we think should be achievable by the system if it is working as effectively as it should.

The performance on access to allied health professional has not been good over the past year. It would be an awfully long road to the nine-week target. However, we think that there are things that the trusts can do to improve their performance. The board is working with them on that, and 13 weeks should be an achievable target.

I do not know whether there is anything else you want to say on performance by way of context, Fiona.

Ms Hamill: We are moving the target to 13 weeks because we want there to be achievement, but we also recognise that there is a data problem in the background that we need to address. We need to clean the data to get an accurate figure. Extending the target to 13 weeks is seen as providing time to do some housekeeping and make sure that everything is calculated accurately. Our aspiration in the longer term is, perhaps, to be able to revise that target and get it back to nine weeks.

Ms P Bradley: Do you know what percentage of appointments was within nine weeks over the past year?

Ms Hamill: No. We do not have percentages. Unfortunately, at the moment, because there are data problems, the figures are very out of date and provisional. The number of people waiting is increasing quite significantly.

Ms P Bradley: Are many of those going over 13 weeks?

Ms Hamill: I do not know, but they are certainly going over nine weeks.

Ms P Bradley: Do you see 13 weeks as being achievable?

Mr Lee: We see it as challenging. It will be hard for the health and social care sector to achieve that, but we think that it is possible if it does everything that it needs to do.

Ms P Bradley: Most of us get queries through our office on outpatient appointments. That target, which was that 80% would wait no longer than nine weeks, has also been changed and is now down to 60%. I take it that you do not have any figures to substantiate why that had to change from last year.

Mr Lee: Current performance is some way off the targets in the current commissioning plan direction. The change partly reflects the difficulties this year because of the lack of access to funding for buying additional capacity in the system. That creates a backlog moving into the new year, and, because of the financial position, there is limited external capacity that we can buy in for elective procedures from the private sector. That limits our ability to keep the targets as high as last year's level. I do not know whether there is anything more detailed to say.

Ms Hamill: There is. The waiting times for outpatient appointments are increasing because of a number of factors, including, first, the fact that demand in the system exceeds capacity. Normally, some of that excess demand would have been addressed by the independent sector. That is no longer possible, so the number of those patients in the system is building. The second issue, in the background, is a natural increase in demand. The third issue is that some of the trusts, in certain key specialities, are failing to deliver the core capacity that the board commissioned. That can be for a range of reasons, including being able to retain clinical staff in a certain regional area. A combination of all those factors has led to a significant increase in the number of people waiting for outpatient appointments this year.

Ms P Bradley: What is the difference between first outpatient appointments and follow-up outpatient appointments when it comes to targets?

Ms Hamill: We do not hold that data. We look at the first outpatient appointment, which is almost the triage point. I will be very clear with the Committee that these are our performance figures. They are not our published figures and are subject to change and data clarification. From September 2013 to September 2014, the number of people waiting increased from just under 30,000 to 73,000. That is a material jump, and the delays are throughout the system. There are delays in people waiting for a diagnostic test, but, thankfully, not in the waiting for their diagnostic test to be reported. People are waiting to get in, so it is about volume. The board is working with the trusts to ensure that they get to their core capacity and to help them in every way to do so. We have to expect that the pressure created this year through the reduction in independent sector appointments will build again next year. We are trying to set more realistic targets but still keep them tight.

Ms P Bradley: It is extremely worrying when patient targets are extended. People who come in and out of all our offices wait for over a year before they finally get a diagnosis. They have had to wait for an initial appointment, for follow-up appointments, radiography, diagnostics and allied health professionals. It goes on and on and on, and, a year down the line, they may still not have a diagnosis.

Mr McKinney: Thanks, Paula, for letting me in on this. What is tight about a 60% target?

Mr Lee: When we say that, we are saying that it will still be a very challenging target for the health and social care sector to meet.

We have not reduced it to a level that would be easy to achieve and allow us to simply tick a box and say that the target has been met.

Mr McKinney: Is the 60% target not poor?

Ms Hamill: A 60% target reflects what we know to be their core capacity and the number of patients waiting.

Mr McKinney: What is it about reducing a target that incentivises or encourages the system to work better? You can come back next year and say that you met your target.

Mr Lee: If we have a target that is clearly unachievable, there is no incentive for people in the system to work towards that because they know that they cannot get there. We need to set targets that people find challenging and difficult and have to work extremely hard to meet. It will not necessarily mean —

Mr McKinney: I am suggesting that 60% is a poor figure to aim to achieve.

Ms Hamill: If demand and capacity were balanced, it would be a poor figure, yes. They are not balanced; our demand exceeds our capacity. Therefore, the target that people will be seen within nine weeks is the target when demand and capacity are balanced. Where we now know that our demand outstrips our capacity, that target is unachievable. We are trying to set a target that we believe is more achievable and will allow trusts to work at their capacity.

Mr McKinney: At their core capacity?

Ms Hamill: At their core capacity.

Mr McKinney: Should there not be a system whereby people are encouraged to work better to achieve a target? What worries me about shifting targets is that the problem appears to disappear even though it still exists.

Mr Lee: We are not trying to suggest by changing the target that there is no problem. We are not suggesting that we would not like performance to be higher. We are setting a target that reflects the absolute best that we think can be achieved by the system through fully utilising the resources that we have. It is a question of the resources that are available to us. If more funding becomes available in-year, as with some of the other targets here, we may return to it and see whether that will allow us to —

Mr McKinney: You said earlier that there was a limited amount of money for elective care. You have factored in now that you do not have the money for this. You agree at this point that there is limited money, so you are changing the targets. By next year, we will be told that you met your target, but 40% of the patients will still have waited longer than we would have expected them to wait this year.

Mr Lee: Absolutely. The target is about getting the best out of the system.

Mr McKinney: Yes, but it is almost a mirage. It did not happen.

Mr Lee: That is certainly not what we are trying to achieve. The numbers are the numbers, and you will be able to hold us to account on —

Mr McKinney: On 60% targets.

Mr Lee: And on the total numbers.

Mr McKinney: As opposed to 80% targets.

Ms Hamill: The target is that 60% will be seen within nine days and nobody waits longer than 18 —

Mr McKinney: Nine weeks.

Ms Hamill: I am sorry — nine weeks — and nobody waits longer than 18 weeks. That has moved from 80% within nine weeks and nobody waiting for longer than 15 weeks. We are saying that the target of 60% within nine weeks and nobody waiting longer than 18 weeks, hopefully, reflects our system working well and at capacity.

Mr McKinney: I just see goalposts being moved. I understand what you are doing, but there is an issue of perception, and, in your post-match analysis, when you come back next year having met the 60% target, it will look like there was no problem.

Ms Hamill: From my point of view, I suggest looking at these targets from my performance management role in the Department and with the board and trusts. I want to see them working to achieve something. I do not want targets that are so far away from being deliverable that they are a disincentive. I believe that the targets we have come to now are ones that the trusts can focus on and hope to achieve. That way, we get the best, clinically, out of the system.

Mr McKinney: I beg to differ.

Mr McGimpsey: That is an important point, Chair. We are at nine, nine and 13 weeks, and that is where we should be. That is slipping, and it is useful to recall that it has slipped quite a bit in the last few years. That is a barometer of the system, and it is purely down to the fact that there is not enough resource going into the health service to maintain the service that is required.

Ms P Bradley: I have one final question, which is to do with district nursing. We know that, last year, it was within the targets. As no district nursing targets are included this year, I can only assume that they have been met.

Ms Mooney: Again, because of the budget position, normative staffing ranges have not progressed as far as we expected, so it is a question of what can realistically be achieved within the resources available. Unfortunately, I do not think that district nursing has progressed as far as we hoped.

Ms P Bradley: If it has not progressed, why has it been taken out completely?

Ms Mooney: The available resources mean that the funding is not available to progress the range of staffing in district nursing

In the text of the commissioning plan direction itself, to keep the focus on the application of normative staffing arrangements, there is a requirement for the board to demonstrate how it will deliver the normative staffing ranges.

Mr Lee: The plan sets out how progress will be made towards the Delivering Care framework, which is to do with normative staffing. We do not have the funding to set a particular target for how far we can get, but we have said that we want the board to demonstrate how it can get as far as it possibly can within the overall context in which it is working on those issues.

Ms P Bradley: I will come back on that.

The Chairperson (Ms Maeve McLaughlin): Mark, what you are saying to us today is that you have put forward new targets for acute care, but you have de-prioritised things like district nursing. You have removed that target.

Mr Lee: We can put in only those targets that we can afford. Some of the new targets that we have put in are about saving money or about the balance between safety at the weekend and during the week, which we do not think requires new funding to achieve because it is just about ways of working, whereas the move to normative nursing comes with a price tag attached, and, unfortunately, there is not the funding for it.

The Chairperson (Ms Maeve McLaughlin): There has to be a process of prioritisation. You would prioritise on the basis of your strategic direction, and your strategic direction tells you that you need to focus on primary and community care.

Mr Lee: Absolutely.

The Chairperson (Ms Maeve McLaughlin): It would not take a genius to work out that part of that is an increase in areas like health visitors and district nursing. So, we have removed that as a target and put in four new ones about dealing with emergency departments.

Ms Mooney: They are not all about dealing with emergency departments.

The Chairperson (Ms Maeve McLaughlin): They deal with acute, as opposed to community or primary, care

Mr Lee: Some are about stopping people going into acute care.

Ms Mooney: Yes, there is a new target for dealing with acute conditions in the primary and community sector and trying to prevent hospital admissions. There is a patient safety one that relates to death rates and one for efficiencies in pharmacies.

The Chairperson (Ms Maeve McLaughlin): It is about the strategic fit. At what point or in what assessment was it decided to remove a target that you did not get near to? The Deputy Chair asked that question, and that is the only sense of it that we have

Mr Lee: Sorry, what was the question?

The Chairperson (Ms Maeve McLaughlin): Previously, there was a target in the plan for nursing levels. It was not met, but it has been removed. Somebody somewhere made an assessment that it should come out and something else should go in.

Mr Lee: We made an assessment that we could not afford to achieve that. Some of the other targets may not have specific new funding requirements associated with them.

The Chairperson (Ms Maeve McLaughlin): Is the assessment always on the basis of affordability?

Mr Lee: The overall commissioning plan direction has to be affordable, but, obviously —

The Chairperson (Ms Maeve McLaughlin): We accept that, but where does the strategic policy direction come in in an assessment?

Mr Lee: In deciding the total balance of the targets. That is why we have new targets about ensuring that there are fewer unplanned hospital admissions so that more people are dealt with in the community. That is why we have targets for safety and efficiencies.

We have tried to focus our indicators more on stopping people being admitted to hospital when they do not necessarily need to be in hospital and making the savings in the system that will allow —

The Chairperson (Ms Maeve McLaughlin): With respect, I suggest that part of that is to do with district nursing and levels of care in the community.

I will close on this question: has there been or is there an assessment of need? Does the Department do that before it sets a commissioning plan?

Mr Lee: The way in which the commissioning process works is that the Department sets key standards. The need, which includes population levels etc, is then set through the board's commissioning process, working with the LCGs. We will set standards for Northern Ireland that we think are achievable and meet the need on a broad regional level within our budget. The board will then do more detailed assessments of what that means in figures, quantums and need for the different trusts.

The Chairperson (Ms Maeve McLaughlin): The Department said that one of the three targets this time is to:

Where is the analysis to show that, on the basis of need and the increasing health inequalities and levels of poverty, doing x, y and z in a commissioning plan will have the right outcome? Where is that analysis? Who owns it? Who does it?

Mr Lee: There is not normally an individual analysis that underpins each commissioning plan direction. We rely on the analysis provided in, for instance, Transforming Your Care, the recent Donaldson report or other ongoing work on behalf of and without the Department.

The Chairperson (Ms Maeve McLaughlin): OK. A number of members are waiting.

Mr Brady: My question is on the integrated care partnerships. One of the main planks of Transforming Your Care was to ensure that pressure was taken off the acute sector, yet the targets relating to integrated care partnerships have been removed. Last year, the target was, I think, that 95% of people in that category — the frail and elderly, and those with arthritis, diabetes and respiratory problems — should have been placed on that care pathway. Have those targets been achieved? If you do not have integrated care partnerships, you cannot set targets for them. In my constituency, we were told that there would be an integrated care centre in Newry. Three to three and a half years ago, Mr Poots told us that £50 million had been set aside, and I think that £59 million had been set aside for Lisburn. That has not happened. If the idea is to take the pressure off the acute sector — you talked about care in the community, particularly primary care — that simply has not happened, yet you have removed the targets from the commissioning plan direction. Was last year's target — the 95% — even achieved? What will happen as we go along and integrated care partnerships are not in place? It will put more and more pressure on the acute sector.

Mr Lee: We still support integrated care partnerships, and we think that they are doing very good work. As to whether the 95% will be achieved, the ICPs have certainly done good work: the work on the identification of relevant patients is largely complete, and they are working with GPs and others to work through putting them on care pathways. I do not know whether we have current figures on the progress.

Ms Mooney: I do not think that we have precise figures. Progress has been good, and the target for this year has been a process-type target to ensure that ICPs are up and running. The indications from the board are that good progress is being made. This year, we intend to try to monitor the impact and outcomes of those ICPs. There is, for example, the target for trying to reduce unplanned admissions to hospital for people with long-term conditions, which is an indication of how well ICPs are working. We will also continue to monitor the number of people being managed through the indicators of performance direction.

Mr Brady: Do you have any information on where ICPs are in situ?

Mr Lee: All 17 of the proposed ICPs have been established.

Mr Brady: They were proposed, but one of those 17 was supposed to be in Newry, and it has not been established.

Mr Lee: Do you mean an integrated care partnership?

Mr Brady: The actual centre. The partnerships may be there, but we do not have the facility. We were told that the allied health professionals would be under that one roof to take some of the pressure. We were told that there would be, for instance, minor foot surgery, podiatrists and all sorts of specialist professionals there. You can have the partnership in theory, but, if you do not have the facilities in practice, it is quite difficult to ensure that they will work.

Mr Lee: Absolutely. The partnership is established. I do not know where we are with the new primary care centres in Lisburn and Newry, but I understand that they are progressing at the expected rate. We can write to you with a detailed update on when we expect them to be completed.

Mr Brady: Thank you.

Ms McCorley: Go raibh maith agat, a Cathaoirleach. Thanks for the presentation. On a general note, given the way that the plan is designed, it might be more useful if it focused on health needs and desired health outcomes rather than departmental needs. It sounds to me as though it is about making the Department look good. For instance, could you not set realistic waiting times that are reasonable, realisable and practical but mostly focused on health needs? You could say that eight weeks is long enough to wait and just deal with the fact that you cannot meet that. That would be an honest picture, rather than moving the goalposts so that you still look good to the general public, and only when somebody digs deeper do they see the real picture. Would it not be better and more honest to deal with that honest picture — this is how long we think that people should have to wait, but this is all that we are capable of achieving at this time?

Mr Lee: This is part of the commissioning process. We are trying to set the framework for the services that we think we can buy, which is why the targets are as they are. They need to be the best that we can achieve within the quantum of money in the system. It is about buying those services off the system, if you see what I mean. That is why this is not set as we would like to be the case if money were no object. It is about setting out what the system needs to achieve with the quantum of money that it has. That is why the targets are set as they are. Certainly, we could think further about whether there is more that we could say about clinical best practice and the like. Separate care quality standards set out in various places are more focused on care being the best that it can be. This is a slightly different process that is, effectively, focused on buying services.

Ms McCorley: Yes, but you can still buy services and be honest about the outcome.

Mr Lee: Just setting out what we would ultimately like to be the case, none of which may be achievable within the financial constraints, would leave it to the board to prioritise within that. If none of the targets can be met, it is entirely for the board to prioritise how far it can get against each of those targets. That is why it is important for us to set targets that the board can meet but which are still challenging for it. That sets the prioritisation in the system and the balance between different areas. If we just set broad ambitions, we do not end up influencing the way the board buys services, if that makes sense.

Ms McCorley: I am not sure that my question has been answered properly. The focus should be on health needs.

Ms Hamill: I understand what you are saying. You are saying that the targets should be what people understand are —

Ms McCorley: It sounds as though there is something inherently dishonest. I am not accusing anybody of being dishonest; it is the way it is set up.

Ms Hamill: What Mark is trying to explain is that these are not targets that we are setting specifically as what we would like to be achieved for the public. These are the parameters that we are setting with the HSCB on where we believe, given the limited amount of money that we can provide, they should deliver a good service. You are absolutely right. We would like to be able to say to the public that we would like you to be seen within this amount of time at these stages. However, in terms of buying a service from the board, we are saying, "This is where we expect you to get to. We recognise that we are not giving you all the resources that you require to deliver a service to meet demand and match capacity, but this is what we consider to be the right standard of service." There are two sides to it. As they are understood by the public, I can understand your concern.

Ms McCorley: OK. I will move on to one of my other questions, which is on one of the items removed from the target list. There had been a target for a person to be on a course of specialist drugs within three months, but that has now been dropped. Has that just been dropped and there is no target any more, or could you have thought about making it six months so that there would still be a target to aim for? It has just dropped off the list. Where does that sit?

Mr Lee: It is still being monitored through the indicators of performance direction. We will still look at how long it is taking people to be given those drugs. We removed it principally on the basis that there is no additional funding available for new drugs that are recommended by NICE. It is really about not being able to afford new drugs coming in. If additional funding were to be found or become available within the year, we would probably return to that and see whether we could reinstate that target in some way. However, we have taken it out because of the lack of funding for new drugs coming online.

Ms Mooney: As Mark said, the intention is to keep that under review and, should more funding become available for that, look at whether it would be appropriate to set a target at six months rather than three. It is just a matter of keeping that under review.

Ms McCorley: It is as bad as can be; it really is. The drugs are just not going to be forthcoming.

Ms Hamill: There was a target for when you would receive the drugs for specific, described conditions. The performance data — again, it is performance data and is not validated — shows that everybody was meeting that target. The question is whether, when you are under budgetary pressure for drugs, you carry it for one particular set of drugs. We need to make it balance across everything. However, it does not mean that the drugs will not be available.

Ms McCorley: It sounds like that to me. Does it mean that they will be available?

Mr Lee: The existing drugs that are being prescribed will continue to be available.

Ms Hamill: Just not within three months.

Ms McCorley: But you do not know when. It could be five years, because you just do not know when.

Mr Lee: We expect performance on existing drugs to maintain close to that level. Given the difficulties with new drugs that NICE is prescribing, it is not clear how we would fund and support those and how long it would take to get people onto them. That is the challenge in setting a target for some drugs but not new drugs. We have not set a particular target against it because of the difficulty in distinguishing between the existing drugs that people are on and new drugs that may be recommended by NICE, but we will continue to monitor it through the indicators of performance.

Ms McCorley: OK. I am just coming at it from the point of view of someone who was heartened by that target and was waiting for a specialist drug but now does not know when they are going to get it. That is the reality for some people.

Ms Hamill: Yes, but that was a specialist drug for a number of very specific conditions.

Ms McCorley: Yes, but the needs of those people have dropped off the radar.

Mr Lee: I would not say that they have dropped off the radar. As I mentioned in my opening remarks, even where we no longer have set targets, we continue to monitor performance. Where we have concerns around where performance is going, we will engage with the Health and Social Care Board, the trusts etc. If we see performance in access to the drugs that are available taking a real dip, we will work with the board and others to take action on that. I do not want to leave you with the impression that setting a target is the be-all and end-all. We still expect a good service to be provided to people in access to those drugs.

Ms Hamill: Access remains an indicator of performance. If access to drugs for those conditions starts to fall, that is something to be picked up and discussed. We are removing a specific target for a specific group of drugs because, as Mark says, there are new drugs coming on all the time. Arguably, in terms of equality for all, you should then be adding and adding and adding to that list. We will watch it, and, if there appears to be any deterioration for those groups of patients, that will be addressed.

Ms McCorley: In the commissioning plan direction, which of the 30 targets are concerned with statutory spend and which relate to discretionary spend?

Mr Lee: I do not think that we have done that analysis. We will probably need to take that one away and write back to you to give you an answer that we are absolutely confident in.

Ms McCorley: OK; thank you.

The Chairperson (Ms Maeve McLaughlin): It is important that we get that, Mark. We also asked the permanent secretary, a number of weeks ago, to clarify where the discretionary spend would be made. For budgetary planning, we need to know how much of this is statutory and how much is discretionary.

Mr Lee: OK.

Mrs Cameron: Thank you. In relation to the links between the services that are commissioned and the 2015-16 Budget, has the Department made a decision on how much to cut from the smaller arm's-length bodies? If it has, how much will that amount to?

Mr Lee: I do not think that there has yet been a final decision on the administrative savings to be made across the arm's-length bodies. That work is still continuing in the Department.

Mrs Dobson: I will start by focusing on the removal of the target for substance misuse services. Surely the alcohol and drug commissioning framework 2013-16 should have been published by now. If I am correct, the consultation ended in April 2013. Why has this been delayed?

Mr Lee: Are you asking why the target has been removed?

Mrs Dobson: Initially, and then I am asking for more detail around the framework, given that the consultation ended in April 2013. Why has this been delayed?

Ms Mooney: The public health framework has been published. The consultation on that is completed, and it is published.

Mrs Dobson: Why then has the target been removed?

Mr Lee: Again, it is the simple issue around our ability to fund the level of that target. As with all these targets, we have had to think about whether we reduce or remove the targets and continue to track them through the indicators of performance direction. On this one, it was felt that there was not a significant enough quantum of money to develop the service in any way, and that we could not, therefore, set a meaningful target against that, but that we should continue to monitor performance through the indicators of performance and intervene if we see a particular deterioration in that service.

Mrs Dobson: I have read through the 10 targets that were removed, and it is very worrying. I see that, after specialist drugs, that is the second one on the list. In a written answer in November 2014, the Minister told me that the health board and the PHA were working on a procurement plan to tender for services, that this had "gone live", and that new services were to be in place by April 2015. Is that now not happening?

Ms Mooney: There are new services in place. There have been some developments against that target, but it is just that the extent to which the coverage has been rolled out is not as we would have expected and that the funding is not available to progress it any further.

Mrs Dobson: Could you provide me with details of what has been rolled out? This is such an important issue. As I said, I was told in November 2014 that it had "gone live" and would be rolled out in April. Can you clarify that for me? Is it still going to be rolled out in April? There are so many people affected by substance misuse, and I am very concerned that, as Rosie said earlier, it has fallen off the radar. Will you come back to me with details about that service?

Ms Mooney: Yes.

Mrs Dobson: OK. I have read through the four new targets for 2015. Could you explain to me the rationale behind target 25 regarding patient safety, which is to:

It just seems incredible that this target exists at all. Where has the 0·1 percentage points come from?

Mr Lee: At the minute, the death rate in hospitals is worse for those admitted at the weekend than for those admitted during the week. There may be a number of factors contributing to that. It is a phenomenon seen not just in the health service here but more widely. It relates to the availability of doctors and services at the weekend and all those factors. It is something that we have wanted to address and is a key focus in patient safety. We have looked at the death rate of those admitted on weekdays and those admitted at the weekend. There is a gap between those. I am not sure whether the figures are public.

Mrs Dobson: Where did you get the 0·1 percentage points?

Mr Lee: We looked at the difference between the two and thought about how we could converge those figures, and 0·1% is a convergence target for the two death rates. If we had the figures to provide to you, it would make it slightly clearer. Are we able to provide them?

Ms Mooney: The provisional figures for unplanned admissions for 2013-14 show that there is a 0·2 percentage points difference between the death rates of —

Mr Lee: At the weekend, there is a death rate of, say, 3·2%, and, during the week, it is 3%. We want to see that converged. So, we have said to cut that gap, which is currently 0·2 percentage points to 0·1 percentage points. We will look at that again next year and see if we can push for a further convergence there.

Mrs Dobson: It just seems very cold to have a target for death rates; it was quite alarming to read that.

New target 11 is to:

Why has this target yet to be set?

Mr Lee: We are still combing through the data and checking, first, that we have data of the right quality and, secondly, that it tells us what current performance is and could be used alongside clinical judgements to set a target that would be stretching but realistic for the trusts. Essentially, it is just because we are working through some of the data issues that we have not yet been able to put a figure to it.

Mrs Dobson: What do you envisage the target minutes being?

Ms Hamill: We do not know yet. As Mark said, it is about understanding the data and how robust the data is, before we bring in a target. For example, we understood that, in England, there was a 15-minute target until we looked at it in detail and realised that it was 15 minutes only for those arriving by ambulance, which is a small part of the population visiting an emergency room. So, 15 minutes is not appropriate because patients arriving by ambulance are brought straight in.

We need to look at it. If we are convinced that the data is strong enough this year, we will bring it in as a target. If not, we will be very keen to get the data cleaned up as quickly as possible and have it there. It will provide an opportunity to give an assurance that, whilst people may have to wait to have their treatment completed at the emergency room, they will be seen, triaged and assessed for the urgency of their medical care within a very reasonable period. That is very important.

Mrs Dobson: When will we know that the target has been set? You talked about it being set this year, but we are going to have to wait until next year to find out. It would be useful, Chair, to have the Committee informed as soon as possible on that target. It just seems incredible that no time has been put on it.

Mr Lee: There are a couple of gaps in it, alongside that one. We will finalise that in the next few days.

Mrs Dobson: OK.

Mr Lee: I am happy to write to the Committee with the final position, filling in the two or three gaps in the targets that we shared with you. We were keen to speak to the Committee sooner rather than later. We were hoping to bring some final figures with us today, but we have not quite got to where we would have liked with the analysis of those figures.

Mrs Dobson: So, we could be in a position to have those details with the Committee next week, if it is going to take you only a few days.

Mr Lee: Potentially. We need to finish the data work, check that the Minister is content with that position and finalise it. We would write to the Committee off the back of that with the final information.

Mrs Dobson: I look forward to receiving those. Thank you.

Mrs Cameron: I am just reading down the list, in the Minister's letter, of targets that have been removed. One is on pressure ulcers. I will read what it says:

You could spend 10 minutes trying to decipher that paragraph. Does that mean that the target was not met?

Mr Lee: It means that the way the information was being reported was not consistent across trusts, so it is hard to tell. The performance data that we have is probably not true, fair and complete across the trusts.

Ms Hamill: The process of clinical coding of incidence and stages of treatment within hospitals is extremely complex. There can be differences in how things are recorded. Sometimes, we have to go back to first principles and clean the data through again to establish a baseline. That is the challenge of so many patients moving through a system, and the incidents that happen around them and treatments they receive being coded through in a way that we can understand in data.

Ms Mooney: We are proposing that that be included in the indicators of performance direction to ensure that performance continues to be monitored but, at the same time, to make sure that it is being recorded and encoded correctly.

Mr Lee: It may be, once we have a full year of data that we are happy and confident in, that we can set a target for future years with more confidence.

Mrs Cameron: Are you saying that you are not happy with the results that came back?

Mr Lee: No, what we are —

Mrs Dobson: They are being queried and the target is being removed because you cannot trust the data. This is really serious. This is talking about pressure ulcers in hospitals. It seems bizarre in 2015 that we cannot collect that data, and that the data is differing from trust to trust. It seems completely bizarre. Northern Ireland is a small place. I do not understand why this is such a difficult target to report on.

Ms Hamill: There is a pressure within the health service here in relation to clinical coding. We are short of clinical coders. Clinical coders take three years to train, and then they have to work with clinicians for each patient to code in everything and agree those codings. Because that is done by individuals, that can lead to anomalies in the data that is recorded.

Our statisticians and the board's statisticians look at that and can spot things that look incorrect. They then express concern about what they are seeing if it is not being reported. The important thing for us is that we see accurate reports of pressure ulcers. Basically, we are stepping back from a target into keeping an eye on it in the indicators of performance, putting the pressure on to clean it up and making an accurate report. It is important to say that the indicators of performance are really important because they are the more detailed characteristics that sit below each of these targets. For performance and monitoring, they are as important as these headline targets that we are discussing today.

Mrs Cameron: I am very confused here. I do not know how you scrutinise these issues when you cannot see anything from it.

Ms P Bradley: I just want to come in on the back of what Pam is saying. I worked on a hospital ward, and I can see the bit of paperwork, the drawing, the photographs and how pressure ulcers were monitored on the ward I worked on. They were monitored very efficiently. It is about how we have such discrepancies in trusts around how they record these and how they cannot give that information. As Pam said, this is 2015, and surely by this stage we should have the same generic paperwork and procedures across all the trusts. This shows us that that is definitely not happening.

On the issue of pressure ulcers, are these people who come into hospital with pressure ulcers or, more worryingly, are these people whose length of stay in hospital has resulted in pressure ulcers? Is there a difference or is it all one?

Ms Mooney: No. As far as I know, the target is aimed at hospital-acquired pressure ulcers.

Ms P Bradley: That is even more worrying, then.

Ms Mooney: That is why we are continuing to monitor this. No one is saying that, by removing this as a target for this year, it is any less important. We all appreciate that it is a really key safety issue and that is why it is there. That is why we are trying to focus on it, and it is just a matter of ensuring that we are getting accurate information and that it is monitored properly.

Ms P Bradley: I would definitely like to see the outcome of that, even at the end of the year to see what is being done about it. It is extremely worrying that trusts were not able to provide that information on people who have developed pressure ulcers because of the care that they have received as patients in hospital beds. It is very concerning.

The Chairperson (Ms Maeve McLaughlin): OK. I thank all three of you for your attendance today.

Mr McCarthy: I have one more question, Chairperson.

The Chairperson (Ms Maeve McLaughlin): Go ahead, Kieran, I will be lenient.

Mr McCarthy: To what extent do the targets in the commissioning plan direction document take account of increases in forecast demand in care and predicted health service inflation?

Mr Lee: That is part of the process of us looking at the budget and deciding, with the budget we have got, what we can reasonably set indicators for. The draft Budget process has included consideration of increases in population and demand alongside that. We have fed that into the process for setting these indicators so that they take account of that. That is partly why it is so challenging to set some of these at the level that we would like.

The Chairperson (Ms Maeve McLaughlin): OK, folks, thank you. Most of the members today have requested further details. I am concerned about the strategic point of the transfer to Transforming Your Care of the £2·5 million last year. How we are supposed to encourage a policy shift that keeps people out of hospital on the basis of that money is beyond me. I have been really disappointed; I have not heard anything in what you have said today about a needs analysis. That analysis should be the key starting point to direct commissioning. It just does not seem to be there.

I will go further and say this: if we googled Hansard, we would find that what we have heard more times than enough today is "I do not know" or "We do not know". That is not acceptable. The Committee is attempting to scrutinise and deal with the commissioning plan in the proper manner, and we have not had any of the detail that we required today.

Mr McCarthy: There have certainly been a lot of questions that need answers to come back.

The Chairperson (Ms Maeve McLaughlin): I suggest that we submit our questions to the Minister and the Department and have a written response to them. All the members today have asked questions that were not answered. Thank you for your time today.