Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): We have with us from the Department Deborah McNeilly, deputy secretary, health-care policy group; and Alison Jeynes, principal officer, Health and Social Care (HSC) performance unit. We also have with us Dean Sullivan, director of commissioning at the Health and Social Care Board (HSCB). Fiona Hamill has sent her apologies. You are very welcome. I will hand over to you to make your presentation, and we will then open up the meeting to Committee members' comments and questions.

Mrs Deborah McNeilly (Department of Health, Social Services and Public Safety): Thank you very much, Chair.

Good afternoon and thank you for the opportunity to provide an update on the commitments made by the Department in response to the recommendations arising from the Committee's report on the review of waiting times. We provided a briefing paper, which hopefully is in your folders, that outlines our position on the report's five recommendations. We hope that you find the paper useful for context and background.

Before I go through each of the recommendations in turn — I do not intend to go through them in detail, you will be glad to know — I will say a few words about waiting times in general. I recognise the Committee's concern over the length of time that people are waiting for elective care, which is obviously the reason that the issue was one of your strategic priorities for the 2013-14 Assembly session.

Whether we like it or not, waiting lists are seen as a measure of the state of the health service and an indicator of its performance. When they lengthen, that affects the public's confidence in the health service. They become concerned about whether they will be able to get help when they need it.

We are acutely aware of rising demand and of the financial pressures that the service is under, both of which mean that some patients are waiting longer. Those whose cases are urgent and of the highest clinical priority will always be seen more quickly, but others will be confounded by how long they will have to wait. I wish to assure you that the health service here will continue to do its utmost with the resources that it has available to it to ensure that the clinical needs of patients are met, that patient safety is maintained and that patients do not wait any longer than they have to.

The report's first recommendation — recommendation a — was that the Department introduce a system to measure referral-to-treatment (RTT) times for elective care and set corresponding targets. The Minister gave a commitment that we would review the experience of other parts of the United Kingdom in introducing referral-to-treatment targets to understand better the scale of the investment required to do so and the potential benefits, in order to see whether such an investment could be justified at the present time. That has now been done, and the details are in the briefing paper.

I wish to highlight, and make a few observations about, the findings from the review that are in the briefing paper. We remain of the view that the referral-to-treatment targets represent a better approach than the one that we have. That should be the direction of travel, because they provide a clear picture of the complete patient journey time and stop patients from being lost in the system, as they are tracked. They also reduce clinical risk. In the evidence put before you, clinicians clearly supported those types of targets.

Although we recognise the benefits of having such targets, the question has always been, and remains, whether we will be able to introduce them in practice. From considering the key aspects of the approaches taken by England, Scotland and Wales in introducing referral-to-treatment targets in their area — the policies that are in place that define how the reductions in waiting times will be delivered; whether there are sufficient funds to enable them to deliver such policies; the success on the ground in delivering reductions in waiting times; whether there is sufficient capacity to meet demand to deliver RTT targets, including the use of the independent sector when necessary; and the ability to measure in practice the complete patient pathways — we have concluded that the existing financial pressures and lack of any assurance on future funding do not put the Department in a position in which we could realistically take similar action at this time. I know that that will come as a disappointment to the Committee. We share that disappointment, but we cannot realistically give any commitment to introduce referral-to-treatment targets when, significantly because of the financial constraints that we are facing at this time, we have no means of putting them in place in practice.

Even simply to measure complete patient journey times without setting any form of target presents significant difficulties. We have looked at the approach taken in Wales to measure its targets. We estimate that to do something here would require us to collect information at an individual patient level for outpatients, diagnostics and referrals and to link the diagnostic data on local systems. On the positive side, we are taking steps as part of the electronic care record to link and aggregate systems, but that in itself will not provide the silver bullet necessary to get to a full referral-to-treatment ICT target, although it is a positive step, as is the recent introduction of e-referrals.

Recommendations b and c are that the introduction of referral-to-treatment targets be accompanied by new arrangements for managing performance and by a clearly defined policy on how compliance will be enforced. We advised that both recommendations be taken forward through the ongoing review of administration. Work to date has included an exercise to identify any duplication of key functions between the Department and other regional bodies. The Department is also liaising with the Health and Social Care Board on engagement among trusts, the board and the Department to ensure consistency in the reporting of performance, because different reporting is going on at the minute. It is important that we streamline our processes to avoid duplication and that we build on that process.

We are also expecting to refocus the monthly performance management reports that the Department receives from the HSCB by focusing more on the trajectories for change in improvement and the actions taken to deliver better outcomes for the elective targets.

Recommendation d is that the Department produce an action plan detailing how it will increase spend on private-sector elective care over the next three to five years by making better use of in-house health service-based solutions. That has always been the stated aim of the board, where the use of the independent sector has always been intended as a short- to medium-term measure to bridge the gap between funded capacity and patient demand. Unfortunately, by circumstance more than design, the current financial position will result in a significant fall in the use of the independent sector in 2015-16. I think that that is something that we covered a few weeks ago, when we were here with Julie to discuss the Budget. There is expected to be a small increase in recurrent investment in in-house elective care next year. That is reflected in the papers that you have received, but, compared with previous years, that investment will in no way be sufficient to address the significant shortfall in resources for elective activity. The Minister is on record about the funding constraints and their detrimental impact on services. Services cannot continue to be delivered as they are being delivered currently. Even if there were additional funding available through new monitoring rounds, we would not be able to get the elective lists back to where we would expect them to be in this financial year. In the meantime, the board is focusing on ensuring that trusts deliver their commissioned volumes of core activity in all specialties, along with strict chronological management of waiting lists to maintain existing waiting times.

Recommendation e is that the Department develop policies that proactively mitigate the potential conflicts of interest that exist for doctors who carry out private work as well as work in the health service. As you are aware, the potential for that conflict of interest has long been recognised and was addressed by the introduction of a code of practice for private practice in November 2003. You will also be aware of the Department's guidance on the management of private practice in health service hospitals in Northern Ireland. It sets out key principles, including that consultants and their employing organisation should work to prevent any conflict of interest. At this stage, as we have made clear before, the Department has no evidence that consultants seek to divert patients to private health care or to underperform in the public sector in order to maintain long waiting times. Nonetheless, we are meeting the Patient and Client Council (PCC) with a view to seeing whether it can undertake research along the lines suggested by the Committee. That meeting is scheduled to take place next week.

That concludes my opening remarks. We are happy to take questions.

The Chairperson (Ms Maeve McLaughlin): Thank you Deborah. Suffice it to say, that is disappointing. Certainly, from my reading of this, the five recommendations that came out of the inquiry have all been rejected.

Mrs McNeilly: At this time, the biggest impediment to us implementing them is resourcing. You are aware of the waiting-list statistics for elective care that were published recently, covering the period until the end of December. The statistics show the deterioration in the position until that period. In some large measure, that is down to the fact that there are now paused patients for elective care and the fact that, in 2014-15, we were not able to spend the money that we would have liked to on the independent sector.

Going into 2015-16, the financial position is increasingly difficult. That in itself is the biggest impediment for us to introducing a referral-to-treatment target. The most important aspect of one of the key requirements highlighted in the NHS guidance is that, to get an RTT target to work, you have sufficient capacity to meet existing demand — that you manage your capacity in a way that meets demand. At this time, because of the resource position, we just do not have the core capacity to meet demand. That is our biggest impediment to implementing a referral-to-treatment target. We would be measuring something that is inherently difficult, because patients are already waiting too long at the minute. Adding up the time for the three parts of the journey shows that. Patients are still going to be waiting that length of time, and it is not going to improve performance for the patient's journey at this time. We are unable to make inroads into the waiting lists as they stand.

The Chairperson (Ms Maeve McLaughlin): Is the reduction in waiting times for elective care a departmental priority?

Mrs McNeilly: Of course it is, but it is done within the confines of the budget that we have. There are numerous departmental priorities. That is a departmental priority, you are quite right, but, nonetheless, we have been given only a certain amount of money to spend. Even at that, you will be aware that we are having trouble balancing our budget for 2015-16. We had not quite got there, and we still have not quite got there. Therefore, even given all the work that has gone on, there is clearly unmet need out there, and we are short on resources to be able to make significant inroads into addressing that.

The Chairperson (Ms Maeve McLaughlin): However, it would fit clearly with the policy direction of Transforming Your Care (TYC).

Mrs McNeilly: On the policy direction of Transforming Your Care, in the context of keeping people out of hospital, treating them in the community and avoiding them having to get either unscheduled care or elective care, yes, all of it sits together as part of the holistic journey. Therefore, you have all those joined-up priorities. It does fit together, but, again, to take forward all the different work streams, there is only a certain amount of money to go around.

The Chairperson (Ms Maeve McLaughlin): What I do not get in this at all, Deborah, is that paragraphs 32 and 33 of your paper talk about the lead-in times that would be required for measuring referral-to-treatment times. The whole emphasis of the inquiry into waiting times was on the need to look at the entire patient journey. You keep referring to there being no overarching policy in place. There is an overarching policy: TYC.

Mrs McNeilly: You are quite right that there is an overarching policy for the direction of travel, as in we want to keep as many people healthy in the community for as long as possible and to treat them when that is required. As for there being no overarching policy for referral-to-treatment, the policy in England is about which pathways are measured, how they are measured and what the priorities are. I think that I am right in saying that that is how England has described its referral-to-treatment policy. However, if you are talking strategically, the policy is TYC.

The Chairperson (Ms Maeve McLaughlin): Yes, but why does your paper then state:

Miss Alison Jeynes (Department of Health, Social Services and Public Safety): I will explain that. For England, Scotland and Wales, we looked at the referral-to-treatment targets that they had put in place and tracked them back to see where they had come from. Around 2000, a 10-year policy was developed in England, and a clear focus of that policy was a reduction in waiting times. Likewise, Scotland and Wales introduced similar policies, with the primary focus being on reducing waiting times. Those policies set out how they planned to go about it on the ground.

Although it is quite similar to the policy in Scotland and Wales, where they were looking to shift services into the community as a means of reducing waiting times, Transforming Your Care does not have a specific focus on reducing waiting times. It is more about delivering services in a better way. I checked at the time, and there is no explicit reference in Transforming Your Care reducing waiting times, nor is there any explicit focus on doing so. TYC should contribute to a reduction in waiting times when it is implemented — there is no doubt about that — but we were stating in the briefing paper that, if we were to consider setting a target for reducing waiting times, specifically to the degree that you require for referral-to-treatment, which would be quite a significant drop, you would really have to work out on the ground how you achieve that. England, Scotland and Wales took different approaches to that.

The Chairperson (Ms Maeve McLaughlin): We have been setting targets for quite a number of years.

Miss Jeynes: We have been setting targets through the commissioning plan direction and priorities for action every year, and those targets followed on from what England had in place before it introduced its referral-to-treatment targets.

The Chairperson (Ms Maeve McLaughlin): Therefore, we are saying that we have a policy direction into which reducing waiting times for elective care fits but that there is something missing. What is the policy bit that is missing?

Miss Jeynes: We need to sit down and think about exactly what we would need to do to reduce waiting times significantly. From the policies elsewhere, you can see that there are different approaches to doing it.

Mr Dean Sullivan (Health and Social Care Board): There is a risk of us having a range of discussions in the corner of a room. In simple terms, there are patients waiting far too long to be assessed following referral by their GP, far too long to have a diagnostic test and far too long to be treated.

I would be the first supporter of a referral-to-treatment target — I see the benefit of it — but, as Deborah alluded to in her introductory remarks, there would be no value at all in having it unless, in parallel, we had a plan in place that was appropriately resourced for an appropriate period to bring the waiting times down for the assessment period, the diagnostic period and the treatment period; otherwise, all that you would be doing is adding up a series of increasingly long waiting times for the three elements.

From my perspective, the prime issue is not the referral-to-treatment target, although that is a place that we might want to get to in the longer term. The far more immediate issue, as we come out of March and into April 2015, is the ridiculously long waiting times that we have for assessment, diagnostics and treatment, and those will get longer in 2015-16 in the context of the resources currently available to us.

The Chairperson (Ms Maeve McLaughlin): OK. I have two direct questions. Could the Minister simply make a policy decision to introduce a referral-to-treatment target?

Mrs McNeilly: The Minister could take a policy decision to introduce referral-to-treatment —

The Chairperson (Ms Maeve McLaughlin): It goes back to this point, which leads on to my second question. Your paper states that the board has indicated that the estimated cost of addressing the demand/capacity gap is £61 million. Given the long-term benefits, the human cost and the length of time that people are waiting, why does the Department not consider it a priority?

Mrs McNeilly: Do you want to explain the £61 million first, Dean?

Mr Sullivan: Yes. We are talking about tens of thousands of patients, and there is a cost associated with the delivery of care for the gap today between demand and capacity. That cost varies according to whether you delivered that activity through the five trusts in Northern Ireland or through the independent sector.

So, there is a cost for that. The issue that it is important for the Committee to understand is that we have done this before. As I said when I was here the time before last, we have a track record of delivery. From where we are now, we are back to where we were in 2005 with patients waiting much longer than a year just for an initial routine assessment following a GP referral. This will not be something that we can fix by March 2016; it will take three or four years minimum to get back to anything remotely like the sort of service that we would wish to have for the population of Northern Ireland for timely access, to see a consultant when they need to see one, and to get an inpatient or day-case procedure when they need to.

The Chairperson (Ms Maeve McLaughlin): You talked about the benefits of this; you said yourself that you would introduce referral to treatment. However, I am still not clear because you have not answered why, then, the Department would not prioritise this.

Mr Sullivan: There are two separate things, with respect, Chairperson. There is the prioritisation of the concept of the referral-to-treatment target. If we thought that we had an end point in place, say, in 2020, that no patient would wait longer from referral to treatment than, say, 20 weeks — insert period of choice — then as part of a process to get to that by all means we should introduce it; however, there would be no value at all in introducing a referral-to-treatment target with the target itself being undefined. The hard bit is not the target.

The Chairperson (Ms Maeve McLaughlin): Why is the reduction of waiting times for elective care not a priority for the Department? Is it likely to become one?

Mrs McNeilly: It is a priority for the Department, but the Department has a number of priorities and it has financial commitments. As we discussed at the Budget 2015-16 session, there was a gap of £31 million, which is still a funding gap. That remains. We have consistently relied on in-year monitoring to supplement our funding. Whether we get any funding this year is in doubt. Therefore, we have to cut our coat according to our cloth and share the money out among different priorities.

Elective care is one of a number of priorities, as are Transforming Your Care (TYC) and unscheduled care, yet we are sitting here with a position for our budget for this year where we do not have the funding to provide new National Institute for Health and Care Excellence (NICE) drugs that come on stream in 2015-16. Providing new NICE drugs would be a priority for us, yet we do not have the money to fund them. We are in a very difficult position and face very difficult decisions, and we have to balance all those competing issues. There is the core capacity aspect of elective care, and £31 million has been going in recurrently in 2015-16 to help core capacity. We need ongoing sustainable recurrent funding to allow us to develop and sustain appropriate core capacity in the medium to long term. We just do not have that at the moment, primarily because of resource constraints and the heavy reliance on in-year monitoring, which is akin to drip-feeding.

The Chairperson (Ms Maeve McLaughlin): OK. If someone was to ask you to name your top three priorities for Transforming Your Care, what would they be?

Mrs McNeilly: I am not sure that I am best placed to name them ahead of the Minister. We have mentioned the importance of TYC in keeping the population healthy in the community and in providing care in the community.

The Chairperson (Ms Maeve McLaughlin): TYC is your overarching policy. What are the three key pieces that need to fall underneath that?

Mrs McNeilly: If you asked me what keeps me awake at night, maybe, rather than thinking of the Minister's priorities, it is elective care waiting lists, community care and unscheduled care. Those are the three things in my —

The Chairperson (Ms Maeve McLaughlin): You mentioned elective care waiting lists, but we are saying that we do not have a policy direction —

Mr Sullivan: I am not sure that we are saying that. What everyone — and, I imagine, most people around the Committee table — is saying is that we would all wish that the population of Northern Ireland was not waiting for an unreasonable period to be assessed, diagnosed or treated, insofar as that is the policy. It is a priority for the Department and for the board. Deborah just gave an example of the reality of the situation. If a new NICE drug is introduced in July 2015 for the treatment of cancer, as it stands at the minute, with the budget settlement that we have, there is no funding for it in Northern Ireland.

I make the point only to highlight the starkness. It is not as though we are sitting on all sorts of soft opportunities to spend money differently, or that we could prioritise the several tens of millions that would be required. It is the stark reality of where we are. Every sofa has had a hand put down the back of it; every pair of trousers has been shaken out, and we are still not at a balanced position.

The Chairperson (Ms Maeve McLaughlin): I absolutely accept the constraints, but I go back to my point, because the briefing paper said that there is no overarching policy direction. There is an issue there. Who is in charge of policy? Who sets it?

Mrs McNeilly: Policy is set by the Department and the Minister. Reducing waiting lists for elective care is a priority. It is mentioned further on in one of the recommendations that we need a plan to move away from reliance on the independent sector. The plan, to my mind, and Dean will comment on this, is to build up core capacity. We need to look at what more we need to do to build up core capacity, but that of itself will cost resource, and we will have constraints due to the need for new theatres and things.

We also, then, in parallel, need to get to the position of having sustainable elective care performance, instead of this up/down, "Here's some money in year to do it" approach. We need certainty and assurance from a five-year plan so that we know what we have for the next five years, and that nobody is going to take money away — we might not get any more, but no one is going to take away what we have. Then we can say: "Here is where we are going to get to, and here are the steps we are going to take." At the minute, because of the budget position, we are see-sawing, but we cannot move forward without the money. If you do not have certainty in your funding, you are constantly see-sawing.

The Chairperson (Ms Maeve McLaughlin): I will finish on this point. I go back to the evidence that the Committee took recently from various sectors, including academics, who said that the separation of policy from the budget allocation is frightening — "disturbing" is the word that was used. So, I go back to the point: if we know what the overarching policy is and what the key planks beneath it are, they should be protected to deliver the policy. I do not get the fact that we have TYC, and the reduction of waiting times for elective care is a part of that, yet we are saying that we have no policy for it. And now we have no plan to do it.

Mrs McNeilly: We have a policy to reduce elective care, and work continues to reduce elective care waiting times and to enhance core capacity; that has been coming through. Overall, yes, resources are allocated, but we have to meet our contractual commitments first. Then it is a question of how much is left and how we share it out to keep the priorities going forward, because, inevitably, we have to turn off a tap in one place before we can turn it on in another. That is part of the wider discussion on how we deliver and reconfigure services and on the Donaldson issues, which are out to consultation at the minute. The policy is there: when decisions are made on the commissioning and planning direction, they are linked to priorities in Quality 2020 and TYC and so on. So, there is a connection. I suppose that your question is: "Well, if those are your top three, give the money to the top three", namely, elective care, unscheduled care, and care in the community.

The Chairperson (Ms Maeve McLaughlin): It is not about turning the tap off; it is about where the tap needs to be redirected.

Mrs McNeilly: Inevitably that means that you have to turn it off somewhere else.

Mr McKinney: Thank you for your presentation. I want to get into the thinking behind the work that you have done. I think that the clue comes from — for me anyway — the end of paragraph 3 on page 1:

Can you take me through that? I get the sense that you changed the goal posts from what the Committee was saying into a financial argument.

Miss Jeynes: I can respond to that. Our approach was to look at the experience of England, Scotland and Wales. Each area had introduced referral-to-treatment targets and worked back to the very source of how they did that, how they planned for it and how they delivered it. So, the starting point for where the targets came from was their policy documents.

Mr McKinney: Yes, but the first paragraph on progress states that:

by the Minister, but you went on to reference it through to what scale of investment would be required as opposed to a core analysis of the value of RTT.

Miss Jeynes: We know what the value of RTT is; we know that it is a better way of measuring elective waiting times because it gives you a complete picture of patient waits. It means that a patient is tracked through the hospital system, so we know where they are and it also reduces clinical risk.

Mr McKinney: Yes, but when I read this, I take this as an argument or justification for not doing —

Miss Jeynes: No, I do not agree with that. I was coming at it with a completely open mind and saying, "OK. What did they do in England, Scotland and Wales to introduce it?", and the question in my mind is, "Can we not do the same here?"

Mr McKinney: The reality is that we will not arrive at new directions and different strategies unless we argue for them. If we are referencing it through simply saying that we do not have the money, we will not go there.

Mr Sullivan: Is it fair to say, Alison, that the Department is absolutely supportive of the principle of introducing a referral-to-treatment target?

Miss Jeynes: Yes, absolutely. If we could, we would.

Mr Sullivan: I think that that position is clear. It is just that there is no point in pursuing that unless we —

Mr McKinney: That is where we differ. I think that there is a point in going there because if you do not argue for it, it sits on the shelf as something that is not being done, whereas we need to present in all documents what would be the right way to do it. We understand that there is financial constraint, if you understand where I am coming from; that is there.

Mr Sullivan: I do, but perhaps the nuance is — maybe to describe it more from my point of view — I see no value at all in doing it unless it is part of a wider plan to reduce waiting times. If it is part of a wider plan to reduce waiting times in the way that Deborah has described, it is appropriately resourced, with sufficient certainty over a sufficiently long period, then, absolutely, it is the right thing to do, but not on its own.

Mr McKinney: This affects some of the conversation that we will have later about workforce planning and data, for example, and understanding what the flows are through the system. We are looking at bits and pieces of the problem and referencing it through lack of finance. That becomes a blockage in the thinking, as I see it. I would have preferred to see a document saying, "We accept the provisions", whereas we have ended up with, "The answer is no" because of the money. We should have an argument advanced about the answer being yes because it is the right thing to do in the context of x, y and z.

That is the document that I would like to have seen, notwithstanding the fact that we do not have the money there. There could be arguments and discussions elsewhere about how we would resource that. In other words, how do we get our thinking on to that positive track — not vainly positive, I urge you to understand — but the right and appropriate thing to do in a well-run health service. That is what you would do. At least, that gives strength to the politicians to argue the case for the money that you need, but I do not have that here.

Miss Jeynes: What was set out in that briefing paper is almost like a road map. If we were to go down that road here and introduce a referral-to-treatment target, looking at the experience of England, Scotland and Wales, the first thing that you would need to do is work out how you are going to deliver it. You would need to be able to afford to do it and to deliver the extra investment that you need to deliver the extra activity. In introducing a referral-to-treatment target and getting waiting times down, you have to be able to maintain that; in other words, you have to be in a position where you have sufficient ability to maintain your capacity against demand.

Mr McKinney: The document that I would like to have seen should be one that suggests what best practice would be against what we have. That gives me an argument for making a case. Well, on the money potentially.

Mr McGimpsey: Thousands of waits. That is a good argument.

Mr McKinney: That is another argument, but then we get hit with, "We have no money".

Mr McGimpsey: That is a Budget question, and that is the Assembly holding —

Mr McKinney: That is a Budget question, but none of this moves us forward.

Mrs McNeilly: I apologise if it is not clear in the paper that the Department is supportive of the concept of referral to treatment.

Mr McKinney: It is not about apologising.

Mrs McNeilly: I suppose it is the journey and the constraint at the minute. You are quite right: we agree that the destination is a referral-to-treatment target. At the minute, the difficulty, to my mind, is not even the IT systems; that is something that we can work at. We are working at and joining up IT systems. Electronic care records are an example of that, as are e-referrals. Our aspiration, beyond 2020, is a single system for your electronic health that follows you as a patient. At the minute, the e-care record is an aggregation of multiple systems, but our aspiration is to have a single system. We would be looking at that single system.

At the minute, when we look at our current systems and try to link them, we are very conscious of the need to link the data. We are looking at the metadata. Just doing that work would help us from an IT perspective on referral-to-treatment targets by having the data available. So, I would not like you to think that we are not doing anything on our IT systems that might help this agenda. I suppose that it goes back to the point about the destination. I absolutely agree that it is a referral-to-treatment target. At this point, it is, realistically, that piece about, "Here's where we are at the minute". When it was discussed in 2008, it was agreed not to introduce it then as a PSA target, simply because of the difficult resource position at that time. We are in a worse resource position now. Whether the destination would have been right and have got you there —

Mr McKinney: Yes, but that is back to the argument of, "Where does this fit in as a strategic priority?" I accept that it fits in with other strategic priorities. I would have liked to have seen an attitude of, "This is a gold standard; this is where we need to go". Then there is one paragraph at the end that states that we do not have the money. The substantive material should, at least, be about the gold standard and what we should be aiming for.

Mr McGimpsey: I will follow on from that, because we have standards that have already been set. They are about outpatients, diagnostics and then inpatients. We used to talk about nine, nine, 13, which was the travel time — your referral to treatment, when you add them all up. Where are we now with that? It used to be 65% at various waits. It is to get us an indication of where the system is because it seems to me that if we are not in an emergency situation, we are getting close to it. We have huge waits here across many specialities. I understand that we are now developing waits in and around cancers, which is a major concern. The first thing that we have to do is stabilise the system rather than see it deteriorate.

You talk about going back to 2005 waits. We are going to hear from the BMA, as there are serious concerns there about the number of GPs. In June, Chair, if you remember, the Minister told us that 50 graduate doctors went to Australia and Canada last year. We cannot sustain doctors voting with their feet; we cannot sustain that sort of punishment. Recently, we had industrial action for the first time in living memory. That gives an indication of staff morale and where staff think we are. Patients and the Patient and Client Council tell a similar story.

We need to stabilise the system quickly. How do we do that? What are the steps that need to be taken? How do you get back to your nine, nine, 13, or whatever your current standards are? They are set every year; I do not know exactly what they are at the minute. How do we do that? What do you need to do that? Parties around the Executive table have to agree a reallocation. We need emergency money into the health service.

Mr Sullivan: You mentioned, Mr McGimpsey, the nine, nine and 13. I thought that it might be interesting for members to see the unvalidated figures for the end of March. Again, there are the usual health warnings in that they will be refined going forward. At the end of March, more than 100,000 people in Northern Ireland had been waiting more than nine weeks for an outpatient appointment, and 28,000 — again, that is unvalidated — waiting for inpatient or day-case treatment. That is approximately half the total number of inpatient and day-case waiters at 58,000 and quite a lot more than half of the total outpatient waiters at 188,000.

Whether the system is in balance or not, we are going into next year with that, and we came into this year with that as our starting position. There are already 100,000 outpatients waiting longer than a reasonable period and 28,000 inpatients and day cases waiting longer than 13 weeks. The gap between funded capacity in trusts and expected demand for next year is about 60,000 outpatients and about 16,000 treatments. Those numbers can only go one way during the year in the context of the funding available.

You referenced the potential knock-on impacts. The main impact is on patients who are waiting for routine assessment or routine treatment assessed in that way. It may not feel routine for them, I am sure. A routine hip replacement, as it might be described, would not be routine in any way for many of us around the table, as people wait in a lot pain and all the rest of it. The main impact is on those patients, but it inevitably begins to creep and wander towards the more urgent categories, particularly those specialties on which the pressure is greatest.

The short-term solution would be exactly as you say and to, at the very least, get a degree of stability back into the system. That would be in part by funding additional non-recurrent activity in trusts during the year and in part by funding additional independent sector work during the year, but that will not be switch-onable at a moment's notice either. As the Committee is aware, that has been turned off, with the exception of a very small number of patients who were already in the independent sector, since September last year. We need to get control back into the system and then gradually, as I said, have a wider plan where we have certainty on funding, join up the dots on the capital budget for additional theatre capacity and on the staffing budget, where it is very problematic for the Department, who lead on workforce planning, to expand the workforce at all. That is just not happening at the minute.

We need to have a plan that joins up all the dots to land something in three, four or five years' time whereby the combination of short-term additional investments in trusts non-recurrently plus further investment in the independent sector allows time for that additional investment in trusts to come over the hill and the system to be in balance and to deliver the short waiting times that we all want. However, from where we are now, it is not. Moreover, I would not be delivering what you expect of me if I left you with the impression that we if receive £x million in June monitoring, my colleagues and I can have this sorted by Christmas. It has got far too far away from that. This was years of work between 2005 and 2010 to reduce the number of waiters.

I thought that this might be interesting. In March 2006, there were 180,000 patients on the outpatient list. That had reduced to 68,000 by March 2009. That is back up to 188,000 now. In March 2009, there were 488 patients waiting more than nine weeks for assessment. As I say, the unvalidated numbers suggest that it is over 100,000 now. In March 2009, there were 387 patients waiting more than 13 weeks for treatment; again, the unvalidated number is 27,000 now. That is what I mean about the challenge. This cannot be fixed by a £500,000 reprioritisation. We could work between ourselves and with the Department and the trust to identify things such as maternity, children at risk or unscheduled care or things that we see as a low priority and could switch off. Even if we could do that, it would be at the margins. This involves several tens of millions of pounds over a sustainable period. All these numbers, hopefully, give you some reassurance. As I said at the session before last, we can do this; I am absolutely confident that we can. However, we cannot do it when we are living from hand to mouth on the resource side. There needs to be additional resources with certainty around that for a sustained period.

Mr McGimpsey: We did it before and we can do it again, but it is very expensive. What you need is to get some sense of what size the emergency fund needs to be in order to get yourself back on a stable footing. What is the time frame? Is it one year, two or three? I know that this cannot be done overnight because I was there when all this was going on before. Things have changed.

There are other issues floating about: workforce morale, and the situation in the workforce; primary care; and community care. We were looking at Transforming Your Care. If primary care and community care are not right, it is very hard to see how you will get Transforming Your Care to work. It is to get some notion of the sums involved. Because Health and Social Care has been seriously underfunded over the last few years, how do we get that back? What is the amount of money that we actually need? That is what everybody understands. I am not saying: just do it now, tell us now. However, I think that you need to come back to us with some sort of step-by-step plan of what you need. I am just talking about stabilising the service; not about gold standards, Rolls-Royces and all the rest of it. We will get all those in due course.

Mr Sullivan: I guess that there are two separate things, though, Mr McGimpsey. You alluded to the wider resource context, and I am happy to provide what that might look like. However, there is a more immediate issue. If it were helpful, and departmental colleagues were happy for us to do so, we could produce something that would tie back into the discussion on referral-to-treatment times , as to a phased, costed, deliverable plan to get from where we are now to some reasonable end point over a reasonable period.

Mr McGimpsey: We all understand that that is just one step and that lots more needs to be done. You keep referring to Transforming Your Care, and that is primary and community care. In the immediate situation, all of us are getting pressure from constituents who have family members in pain and distress, possibly coming to harm because they are not getting the treatment that they should be getting when they should be getting it.

Mrs McNeilly: May I pick up on some of those issues? We have focused on the road map that you would have in place to improve elective care, stabilise it, get to a standard and then aspire to the refer-to-treatment target. However, in terms of the whole system, we know that what happens in elective care can get knocked off-track by what happens in unscheduled care, and what happens in unscheduled care can get knocked off-track by what happens in primary and community care. We need to have sight of the holistic piece as well. It is not just a simple fix: throwing a lot of money at elective care. We also need to look at how we need to invest in community care and primary care, for example. This is so that it is not just a silo piece, and we are not throwing it all in there —

Mr McGimpsey: I understand, but you need to stabilise the system because every month your waiting times get bigger and you do not have the capacity in the system to fix them. You need the independent sector to help. So this is about pressing that button and getting that rolling again. And that is just one —

Mrs McNeilly: Pump-priming. Yes, you are going for that aspect.

Mrs Dobson: My point follows on from Michael's comments. I have been writing down some of your comments and Michael's. We are getting close to an emergency. Michael touched on that as well, in respect of workforce morale. With the election in full swing, we are chatting to people on their doorsteps. I have been astounded by the number of community staff, nurses and doctors who are literally at breaking point. They are in tears on the doorstep; their morale is the lowest that I have seen. It is unbelievable to see that when you are knocking on people's doors. That is unsustainable, because they cannot cope with that pressure, and they are almost feeling guilty about it.

It is a ticking time bomb, and it is right up there with the biggest issues that we are hearing about. Something needs to be done sooner rather than later.

I appreciate your honesty, Dean. The figures that you have released are startling and alarming. As Michael said, we need to stabilise the system quickly because we are running out of time. We are talking about people's lives here.

What cost is put on people's pain? I have so many constituents whose lives have been put on hold when they are told that they have to wait 10 months for a new hip. They and all their family are under such pain. They cannot return to work, and there are cost implications for the Northern Ireland economy as a whole when those people are out of work as well as being in terrible pain. How do you factor that in? We are talking about budgets, but there is the pain that those people are enduring and the financial cost. I am concerned about the effect that that is having on the economy as a whole.

You touched on the cost of surgery being undertaken in other regions of the UK. That is being wound down to a certain extent, and Michael mentioned the use of external services. I will use Scotland as an example and the cost of families going there with their loved ones when they are waiting on surgery because demand is unable to be met here. The cost of sending someone to Scotland far outweighs the cost of doing it here. Realistically, what are you doing to address that and the fact that people are waiting in agony for months?

This cannot go on, and the workforce is under pressure. I will hear that again tonight on the doorsteps. It is too much to see people whom we rely on at breaking point and in tears. There is also the strain on families. Will you speak about that?

Mr Sullivan: I will speak about it and tell you what is being done today. The budget is still an issue of live discussion. As I understand it — I am reasonably close to the details of those discussions — it is not yet a final position. The detail is still being worked through between the Department and the relevant stakeholder bodies, including the HSCB.

In the second half of the year, we spent only a small amount of money in the independent sector, and nearly all of that was spent in Northern Ireland. Patients will always go across to GB, but, in the vast majority of cases, that tends to be for things that cannot be done straightforwardly in Northern Ireland, even in the statutory sector, such as some of the more complex procedures for kids and adults. The cost for that is the cost for that.

Your point about the disruption to family lives by having to go across the water is often made about paediatric cardiac surgery.

Mrs Dobson: It is often very young patients or more complex cases.

Mr Sullivan: That is right. That said, if you asked any of the thousands of patients currently waiting and gave them the choice of having their hip replacement in Blackpool next week or waiting in Northern Ireland to get it in 2017 —

Mrs Dobson: Of course anyone would take that.

Mr Sullivan: — I know what the answer would be, which comes back to the same issues we faced in 2006, 2007, 2008 and 2009, and people voted with their feet. Back then, no one was forced to be treated by any particular provider, but, for the vast majority of people and, I am sure, for most of our family members, whilst you might ideally prefer to have care locally to the required standard, if that is not possible, you will take it across the water or in the Republic of Ireland.

Mrs Dobson: The cost, however, of sending people, when it can be done —

Mr Sullivan: If that is a straightforward choice. The point that I am making is that I would not ask a patient to go across the water if it could be done —

Mrs Dobson: — here.

Mr Sullivan: Yes. So you work to the required quality standards and all the rest of it.

Particularly at election time, you all know that people will tell you about the pain they suffer. We certainly know that. I know that because I am out in the service speaking to patients daily. We know it more immediately from family members. We probably all have relatives who have reason to have had an orthopaedic procedure and so on. I speak with some authority, because I have had direct experience of a family member being affected. I know what that looks like, because I have a family member who has been on both sides of that 2005-06 divide: from GP referral, the family member waited three to four years for the left knee to be treated, yet the time from referral to treatment for the right knee was less than six months. That is the difference, and you cannot put a price on that. That may sound simply as if Mrs Smith needs a knee replacement, but Mrs Smith is not at the stage of a surgeon replacing her knee because there is a bit of a twinge: she can barely walk. That is the problem, and that is the place we are in.

Consultants, GPs, nurses and other professionals are seeing those cases far more than I am; they are seeing them daily. They are the individuals who have to tell people what the waiting times will be. Whilst some people may be able to buy their own procedure, that is very much the exception in a Northern Ireland context, and it is not what we are about in the HSC. We are about being free at the point of use and having reasonable waiting times for everybody, but that is just not possible within the resources that we have available to us.

I do not want to leave the discussion in too downbeat a fashion, but we are in a very grave position. We could be sitting here, as we might have been 10 years ago, with no idea as to whether we could fix the situation, but we know that we can fix it. We had long waiting times in Northern Ireland for over 10 years with no prospect of that being fixed. We showed that we can turn things around with a really concerted effort involving everyone, from the Minister to the Health Committee, the Department, commissioners and providers of primary care. We can turn it around, but it will not be done with a little nudge at the side. You can all insert your adjectives of choice, but it will require top-of-the-shop direction and prioritisation to get this to where it needs to be.

Mrs Dobson: In the meantime, workforce morale is dire. People who want to remain anonymous are crying on the doorsteps, but they care so much for their patients, and when someone goes off —

The Chairperson (Ms Maeve McLaughlin): I am very conscious that we are not here to reflect an election campaign or what is happening on the doorsteps. We are all well aware of the pain that people are enduring. I am attempting to be positive, Dean, and I heard you say that we need a top-of-the-shop approach. Are we suggesting that we do not have that?

Mr Sullivan: No.

The Chairperson (Ms Maeve McLaughlin): When can we see that top-of-the-shop approach to deliver on this issue?

Mr Sullivan: I maybe have a little more freedom than departmental colleagues in this regard. This is a priority for the Department, for the board and for trusts: fact. It has been a top priority for us for donkey's years and remains so. The resources that we have mean that there are plenty of other priorities — new NICE drugs, for example — that cannot be funded either. So when I say "top of the shop" — I hope that I am not speaking out of turn — I mean it: it is a priority for everyone, right the way to the Executive, to consider prioritisation of funding towards health. Exactly the same challenges exist elsewhere, in that there are competing priorities on very scarce resources. I am happy that someone else will reach a view that more could be done within the resource that we have. However, on the basis of the resource that we have today, we are not even remotely close to being able to turn this around in a way that we would all expect it to be turned around.

The Chairperson (Ms Maeve McLaughlin): At what point will we see the road map that Michael and others referred to? You say that this is a priority policy area, so when will we see a demonstration of getting to the destination that you spoke about?

Mr Sullivan: In the resource context that we face now and in the future, I am happy to work with departmental colleagues on picking up the important issues that Deborah talked about to share with you what a road map might look like, what the interactions with other service areas and the assumptions might be and what the resource requirements would be. However, it needs to be resourced. I am saying that, from my perspective, it is impossible, within the current resource settlement, to resource something on that scale. There was a very different resource context in 2005-06 and through the years. It was much more benign then than it is now.

Mrs McNeilly: We can certainly work on a road map over the next couple of months, because there are so many strands to it, and see what we can come back to. We will take that back to the Minister and see how we can prioritise the road map.

Mr G Robinson: I appreciate the situation that the officials refer to from a financial point of view. I suppose that we all have to look back and say that, a few years ago, there was a £1·4 billion cut in the block grant, and we are now just beginning to see some of the consequences of that. We also have the welfare reform issue. We are losing about £2 million every week in fines and so forth, so there is bound to be a knock-on effect somewhere. Unfortunately, as Jo-Anne mentioned, people out there are suffering.

At the same time, I do not want to turn this into an election meeting, but we all have to be realistic. There is pain, and there are cuts, and it is about how we manage all that. The officials have been very candid, frank and honest with us. As far as the Assembly is concerned, all the parties have to work together. The big one for me at present is welfare reform. The longer we go along without the implementation of welfare reform, the more pain — Jo-Anne mentioned that — we will get on the doorsteps. My contribution is more a comment than a question, but, as I said, we have to be candid, honest and frank. We all need to gear ourselves up for that.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. I refer to what you said about people having to cross the water to get treatment. What percentage of people have to go overseas to get treatment? I am trying to look at the drain on resources, because not only is there that aspect but there are the implications and the impact on people who are suffering already.

Mr Sullivan: Patients are going across the water for treatment because we physically cannot provide the treatment in Northern Ireland. As I said, a lot of the issues associated with that were rehearsed through the paediatric cardiac surgery consultations, so when we cannot safely and sustainably deliver a service in Northern Ireland because of our population of 1·8 million, it is entirely appropriate that we seek to commission that service from a provider that meets all the extant quality requirements.

The number of patients who go across the water in that context — in the context of the numbers that we are talking about today, anyway — is vanishingly small. Even when spending in the independent sector was at the levels that it had been at historically — around £60 million a year — and most of that was being spent in Northern Ireland, even that was only 3% or 4% of total acute spend, so, to reassure members, it would be vanishingly small. We keep records of all the transfers across the water, so I can certainly get you details of that. I would be surprised if, in the last year, more than a handful of those patients had been sent across the water for reasons other than that the care that they required was simply not available straightforwardly in Northern Ireland. It was not because the waiting times were too long or anything like that. It was simply that they required a particular type of access to a specialist or to a treatment that was not available in Northern Ireland.

Ms McCorley: You do not foresee creating capacity for those cases to be dealt with here. It is a better use of resources to take people across.

Mr Sullivan: Most of the time, that is right. However, over time, we look for some things. There are a couple of issues at the minute, and, initially, we sent patients across the water, but, over time, we saw opportunities to put in place a safe service locally, when there is sufficient critical mass. However, for the vast majority of patients, you are right.

Ms McCorley: You talked about a knee operation. Was that an exception? Knee operations are carried out here.

Mr Sullivan: That is going back several years. Back in the day, we were sending patients across the water for knee operations because we had capacity constraints in Northern Ireland. Certainly, in the last six months, there will not have been any patients like that. All the patients who were seen in the independent sector were seen by local independent sector providers, and we have not been sending away any patients at all.

Ms McCorley: I was just trying to get a sense of whether that was the resource issue. From what you say, it clearly is not.

Mr Sullivan: It is not. Subject to discussion with Deborah and colleagues, the plan that we might be sharing with you might include elements of accessing independent sector or other NHS capacity outside Northern Ireland. We need to work through the detail of that.

Mrs McNeilly: That would be to get us to a sustainable position in advance of establishing a sustainable long-term capacity. We might need to do that to pump-prime or to get us up again.

Mr Sullivan: The position of the Department and the board is clear. I have no desire to use the independent sector any more than is necessary as a short-term response to particular capacity/demand pressures. From where we are today, at the end of March 2015, you could, theoretically, avoid using the independent sector, but you would be doubling or trebling, or even making longer, the length of time it would take to get things back to what you would want. The workforce is simply not there in Northern Ireland. Urology is the example that I often trot out. We continue to have huge difficulties in that and other areas simply in recruiting staff. The money may be there, and we can get the anaesthetists, the nurses and secure other key members of the professional team, but, if we cannot get all members of the professional team, we cannot expand outpatient capacity and treatment.

The Chairperson (Ms Maeve McLaughlin): Do you accept that simply putting money into the private or independent sector does not resolve the issue?

Mr Sullivan: It depends on what issue we seek to resolve, Chair.

The Chairperson (Ms Maeve McLaughlin): We are talking about waiting times for elective care.

Mr Sullivan: With respect, it has reduced waiting times. If I am a patient waiting for a hip replacement, and I go to the independent sector, I get my hip replaced. I would argue that it has resolved that issue. What it has not done is put in place a sustainable increase in capacity in Northern Ireland. I have been investing as straightforwardly as I can in trusts in Northern Ireland when I am confident, and they are confident, that they can expand their capacity within all the constraints that I talked about. If they do not think that they have the extra theatre capacity that they need or that they cannot appoint the consultant staff that they need, why would they wish to take the money for capacity that they will not be able to provide?

The Chairperson (Ms Maeve McLaughlin): Has the Audit Office ever looked at this in terms of value for money?

Mr Sullivan: Yes.

The Chairperson (Ms Maeve McLaughlin): It has? Has work been completed on that?

Mr Sullivan: Yes. There was a Public Accounts Committee (PAC) review.

The Chairperson (Ms Maeve McLaughlin): Was it specifically on waiting times?

Mr Sullivan: Yes.

The Chairperson (Ms Maeve McLaughlin): I will ask to access a copy of that because it is an important issue. The independent or private sector will indicate that it can carry out five-plus procedures in a day and suggest that some trusts and hospitals can carry out only two or three. There is a challenge to that in terms of value for money. Did the PAC make recommendations?

Mr Sullivan: The PAC work will be available straightforwardly. As I recall, it was about the general departmental approach to the management of waiting times, and it also considered the use of the independent sector. The PAC also looked at the review rates of patients who did not attend (DNA) and cannot attend (CNA) and so on.

Mrs McNeilly: The report predates me, which is why I am sitting silently. I was not around when the PAC did that, but I will read the report.

Mr Sullivan: The independent sector will argue that it can be more efficient and productive than the statutory sector, and that may be right in certain cases. The independent sector is not, for example, trying to train junior doctors at the same time. It may be doing a different case mix than the statutory sector, which is why we continue, when appropriate, to use the independent sector. It sometimes appears to be a more expensive route than putting money into the statutory sector, but it is often a case of six and two threes. The Committee's expressed desire is to move away from the independent sector. That is also my expressed desire, but, in the short term, if we want to turn the challenging position that I described today around within any reasonable period and with any momentum, there will be a need to access external capacity from somewhere, and, if it is not from the independent sector, it will be from the statutory sector outside Northern Ireland.

The Chairperson (Ms Maeve McLaughlin): The Committee specifically asked to look at how you decrease spend in the private sector over the next three to five years and the best use of in-house provision. It is not as simple as saying, "Take it all immediately from there". We were looking for a plan to do that. My understanding is that that work was stopped, but I visited a local independent clinic last week, and the work has started again.

Mr Sullivan: No, it has not. To be clear, because there is a risk of confusion with this, there were still 4,000 people in the independent sector in September 2014 when the financial position for 2014-15 became clear. Authorisation was given to allow the urgent patients among those 4,000 to proceed in the balance of 2014-15. There was no authorisation to proceed with the non-urgent patients, because we did not have the financial cover last year. Those paused patients — the non-urgent and routine ones — are being proceeded with. There are no plans within the financial settlement, subject to further discussion —

The Chairperson (Ms Maeve McLaughlin): I will pick that up with you afterwards.

Folks, thank you. You have heard the views of the Committee. I expect, at the very least, that we will get that road map clearly demonstrated. If I am to take what was said today at face value and there is a priority for a general reduction in waiting times, it should be demonstrated to us how you get there. You should share that with the Committee as it evolves through the Minister and the Department.

Mrs McNeilly: We are certainly happy to work with the board. We will take that back to the Minister to see whether he will endorse it as a priority.

The Chairperson (Ms Maeve McLaughlin): Thank you for your time.