Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): Welcome to the meeting. Julie, I assume you will make the opening comments, and then we will open it up for questions. There has been a link in relation to the Programme for Government commitments that we have just come through, so I ask members to bear that in mind and try to be as specific as possible around June monitoring. Julie, I will hand over to you.

Ms Julie Thompson (Department of Health, Social Services and Public Safety): Thank you for the opportunity to provide evidence to the Committee today on the Department's proposed approach to current and capital expenditure investment in the June monitoring round. The Committee also asked for information on 2014-15 and 2015-16 savings.

In respect of current expenditure bids, we have considered a range of factors, the most significant of which continues to be the financial context for 2015-16. At this stage, our latest assessment is that there is an unresolved gap of £30 million to £40 million for 2015-16. As previously outlined to the Committee, this assumes that there are no new service developments able to be funded in 2015-16. However, it is acknowledged that the availability of funding in this monitoring round may be limited in light of the wider constrained funding environment and the challenges facing the Executive.

Notwithstanding that, we are proposing that four revenue bids should be submitted. Some £23 million is proposed to be allocated for a range of priority pressures across existing service areas such as learning disability, resettlement, public health initiatives, unscheduled care, patient flow and the revenue consequences of a number of capital schemes that are due to open in 2015-16. A further £45 million would be used to deliver additional elective care capacity across a range of specialties. It is anticipated that that level of funding would allow a further 58,000 assessments and 13,000 treatments by the end of March 2016. There are bids for £5 million for a range of Transforming Your Care (TYC) reforms and £16 million to be directed at a number of prioritised service developments, such as specialist services and mental health around disability and children's services. Members will note that bids have also been prioritised in line with DFP requirements. As previously advised to the Committee, additional funding will be required by the Department through monitoring rounds in order to avoid unacceptable service consequences.

Turning to capital expenditure, any bids must be for projects that can be fully spent in 2015-16 and must not carry a tail into 2016-17. We are, therefore, proposing to bid for £45 million for a range of capital projects, including maintaining essential services, medical equipment, estates works, fleet, ICT and invest to save.

Turning to savings in 2014-15, the Department was committed to delivering £170 million of savings, and this target has been achieved. We are currently working through, and reviewing, progress in each area as part of our annual reporting process to DFP. For 2015-16, savings opportunities and cost reductions of £157 million have been identified at this stage. This includes opportunities of £105 million at the trusts, £25 million in relation to prescribing and family health services and £30 million in relation to departmental and arm's-length body (ALB) savings opportunities. Trust boards approved the savings plans a few weeks ago, and trusts are moving forward to implement their plans. This will include consideration of consultation processes as appropriate. We strongly commend that the Department's bids be considered favourably by the Committee. I am happy to take any questions from members on any of the issues raised.

The Chairperson (Ms Maeve McLaughlin): Thank you, Julie. I suppose it is hard for me to understand, given that the backdrop for monitoring, in terms of the Department's agreement, is for major and unforeseeable circumstances.

Ms Thompson: Yes, and I think that this is a subject that we have had a discussion about with the Committee. It is exactly the scenario that we are in, but, equally, because of the scale of the pressures in the health service, DFP has not precluded us in the past, and has certainly not indicated, that a bid, or bids, in this monitoring round would be unacceptable to it. Obviously, it will then be a matter for the Executive to consider alongside all the other pressures put forward by other Departments.

The Chairperson (Ms Maeve McLaughlin): You can stand over that these bids are major and unforeseeable at this point?

Ms Thompson: They are there in the context of the entire financial position being, I guess, considerably worse than it might otherwise have been. Therefore, we need to put in bids to reflect that.

The Chairperson (Ms Maeve McLaughlin): I will use the example of waiting lists. You cannot say that this is unforeseeable.

Ms Thompson: What we can say is that we have considerable numbers of people and patients on waiting lists and that, if that money becomes available to the Department, it would make a difference to those individuals. Hence, the bids are going into the system. Obviously, the Executive can consider them against other Departments' priorities.

The Chairperson (Ms Maeve McLaughlin): The total bid is £89 million.

Ms Thompson: That is right.

The Chairperson (Ms Maeve McLaughlin): Julie, I think you alluded to the fact that the bids have been prioritised as per a DFP request. Transforming Your Care is number 3, again. Does this mean that it is the third-highest priority?

Ms Thompson: It means that we have to ensure that the existing service base is fully funded and that we work forward on the back of the monitoring rounds. These are the bids that have been put at the top of the pile. The ones that are, effectively, the existing service pressures reflect the fact that we have a £30 million to £40 million funding gap at this stage. That has to be resolved before we put additional money into TYC. Money is being invested into TYC, and I am not sure whether you have already had that bit of the conversation. The £5 million that we are bidding for would go on top of the funding that is already assumed for TYC going into 2015-16, so it is not that nothing would be happening there. This is going on top. The other bids are taking priority because they are reflecting the expenditure gap that we currently have, and we have to sort that out before we can look at the wide range of service priorities that we wish to invest in.

The Chairperson (Ms Maeve McLaughlin): I just do not get that. Again, the policy context, the vision and the aspiration were the widened framework of TYC to address those service issues and gaps, yet it is priority 3. I do not get that logic. It suggests to me that it is down the pecking order and has reduced in significance.

Ms Thompson: We cannot put money into new services until we have resolved the funding gap that exists in our current base, and priority has been given to the funding needed to sort out the baseline issue, if you like, and the gap that currently exists. When we have sorted that out, we can then move to looking at other service developments, such as putting further money into TYC or into other service developments. Elective care has been put in as a priority given the number of people currently sitting on waiting lists and the need to make progress for the people who are currently waiting for their treatments.

The Chairperson (Ms Maeve McLaughlin): You told us previously that £15 million was planned to be spent on TYC. Now, this £5 million that you are bidding for is in addition to that.

I am going to come back because there are a number of things that jump out at me. I will point out one before I move on to the other members. You indicated the, almost, shift in relation to domiciliary and residential care, and you talked about a further move of services from the statutory sector to the independent sector.

Ms Thompson: I think that what you are referring to is within the trusts' savings plans. They are looking at a range of social care opportunities. I am not sure whether Seán wants to comment in detail on that. The trusts are looking at how they can consider their domiciliary care provision and how it can best be provided. Each trust is considering that. You know that the independent sector is very active in the domiciliary care arena and it may be that more use is made of independent sector provision. It is different within different trusts across Northern Ireland as well, so it is reflecting that difference. We will be putting additional money into domiciliary care but, equally, we want the money that is there to have as great an effect as possible.

The Chairperson (Ms Maeve McLaughlin): Has there been a cost analysis of services within the system as opposed to those done independently? Has the Department done that piece of work or is it likely to do it?

Mr Seán Holland (Department of Health, Social Services and Public Safety): Individual trusts do that piece of work when they are delivering their savings plans. The Northern Trust has put a particular emphasis on shifting commissioning, or provision, of domiciliary care from in-house provision to the independent and third sectors. The Northern Trust specifies that it can deliver savings by doing so. They are the people who have done the analysis to say that, if we move from in-house provision to the independent and third sector for that particular service, we can deliver a saving. I do not have the exact figure for the saving in front of me but it certainly features, most predominantly, in the savings plans of the Northern Trust.

The Chairperson (Ms Maeve McLaughlin): OK. In relation to the general issue, I hold this view as to where money currently goes. It is important to be able to stand over that process and say, hand on heart, that money is going in the right direction. There was a DFP proposal, last year, that there should be additional oversight of the Department. Where is that at now?

Ms Thompson: They are looking at where the money goes. It will be reflected in our database reports. We report to DFP on an ongoing basis, and it will be picked up by DFP reviewing the figure work that we supply to the database, and confirm that that expenditure within trusts is increasing as intended. That is where they will go with that.

The other element was an OECD review. Part of the work around that was to consider our provision on how that sits. I am not sure whether Deborah wants to comment further on that particular aspect. So, there are two aspects: one will be checked by DFP looking at how the figure work presents itself, and the other by the OECD review.

The Chairperson (Ms Maeve McLaughlin): What are the findings?

Ms Thompson: We are so early in the financial year that there are no findings, as yet, on that one.

The Chairperson (Ms Maeve McLaughlin): There is no indication of how that additional oversight is impacting?

Ms Thompson: No, because it has to report through, if you like.

The Chairperson (Ms Maeve McLaughlin): But you have done an initial report for DFP.

Ms Thompson: We have looked at it. We know that there are considerable pressures on trusts, which are way over the £200 million we were currently allocated, less the savings that were to be achieved. We know that there are over £300 million of costs which need to be put in to address the pressures that are out there. We are happy enough in that we know that the pressures are there and that savings, far more than the £49 million in the budget document, will come in. We are assuming that savings of up to £160 million will come through. However, that all takes time to work its way through to spend levels, forecasts and whatever. DFP will come back to that when we are sufficiently through the year. However, because it is so early in the financial year, we are in set-up mode with that.

Mr McCarthy: Thanks for your presentation, Julie. Can we get this clear? Last year, you were in the same position. You put in for money, I forget what the figure was, for the September monitoring round or maybe it was in October. You did not get all you wanted; I do not know what the figure was. You mentioned that there is a £30 million to £40 million gap in the year 2015-16. Is that where we sit at the moment? Is there a £30 million to £40 million gap before we start off?

Ms Thompson: Yes, in 2015-16, we have a £30 million to £40 million gap. That sets aside anything to do with new service development. So, having looked across the piece of our existing service provision and having identified savings and plans and where all the cost pressures are, we are £30 million to £40 million short. You may recall that this was the case when I talked to the Committee in March. The figure work has not moved an awful lot since then.

Mr McCarthy: So, if you had £40 million, the Department would be up to date and you could provide all the stuff we are talking about such as the reduction in waiting lists, the cancelled operations and all the rest.

Ms Thompson: The £40 million would bring us into a balanced financial position with our existing services. It would not address service developments. Those also need to be looked at. That is what a lot of the June monitoring round bids are about. For example, they are about money to invest further in children's services, mental health, NICE drugs or whatever.

Mr McCarthy: If you get your £40 million — hopefully, you will also get your £89 million — will that bring you up to the point where you would eradicate the sort of stuff you are talking about and stop lives being put at risk? That is what we want to hear. We want to hear that this will happen if you can get that. We will support you wholeheartedly to get the £89 million to bring us up to where we want to be for our constituents.

Ms Thompson: I guess it will mean us looking across the piece, prioritising service developments and working through the investments we could make in 2015-16 — you also have to be able to spend the money. That would allow us to move forward on a range of initiatives, including the £45 million for elective care, which would make a considerable difference to those patients.

Mr McCarthy: The other thing that concerns me — and the Chair mentioned it — are the savings. You mentioned domiciliary care, and that scares me. We know that we will need more funding for domiciliary care to keep people in their homes for as long as possible. You are looking at further savings in that area. That means that some people will go wanting.

Ms Thompson: There are two things going on in domiciliary care. One is that additional funding will be provided. You are right: people are getting older and require more packages, and money is going in to enable that to happen. At the same time, work is going on to ensure that that provision is as efficient and effective as possible. That is where the savings side come in, so that both happen at the same time.

Money will go in for new packages, and I am sure that Seán can talk more about the intensive levels of some of those packages that will go in to keep people in their homes. We also have to ensure that we are making savings in that area and that it is done as effectively as possible. The two can go hand in hand to ensure that we are dealing with that need.

Mr Holland: The point was made earlier. If trusts believe that they can get more value for money by changing the provider of their domiciliary care and make savings in doing so, we are identifying the savings that can be achieved from that. We also realise that the number of people who require domiciliary care is rising, particularly in the level of complexity, so we are simultaneously increasing our investment to meet that demand.

Mr McCarthy: As long as the people who require domiciliary care can get it when they need it; that is the thing. You are talking about savings, but that sometimes means cuts. It worries me that some people will not get the care that they should get and are entitled to.

Moving on, there are £23 million of existing pressures plus the £45 million. You then have the £16 million for prioritised service development and the £5 million for Transforming Your Care. As the Chair said, £5 million does not seem very much to bring us to where we want to be with Transforming Your Care.

Given the current uncertainty with the Executive and departmental budgets, particularly the very wide range of financial scenarios, what financial planning is currently under way in the Department?

Ms Thompson: We are looking at all the funds that are uncommitted and, in theory, could be stopped. Those are wide-ranging. For example, there is some money in the elective care space that is intended to be spent, and the money that we are bidding for would be on top of that. We know that all the domiciliary care packages are obviously not all invested yet and some will come in in the later part of the year. There will be moneys that would be intended to be invested in ICT. We keep a record of anything that is planned to come in later in the year to understand what that looks like.

The amounts are not huge. If money does not become available, the main way that it would translate is that elective care waiting lists would go out further, which would be of significant concern to us. We are looking at what our options are with moneys that we had labelled for certain things and whether they could be stopped, but there is not a huge volume of those. Trusts are spending money on an ongoing basis. We are a demand-led service, which means that people have to be treated as they turn up, and that will continue to be the case. None of the planning relates to not treating people or not keeping them safe. That has to be very much part of how we move forward. It must have primacy. So, we are looking more at areas where, potentially, there is an element of choice. Even in elective care, we want people to continue to be treated and to keep waiting lists as short as we can. It is challenging, but the Department has considerable stops and checks in place for when money can and cannot be spent.

On the back of the June monitoring round, we will need to understand where we are and make sure that we have a viable plan to live within the available resources.

Mr McCarthy: I hope that you get the £89 million, because we want the whole Department and the entire health facility to be brought up. We want to cancel all the waiting lists, delays and all the rest of it. What happens if you do not get it? Last year, you did not get what you applied for. If you do not get £89 million, where will the health provision for our constituents be?

Ms Thompson: That will be a matter for the Minister to reflect on after the June monitoring round. As I said, you cannot invest money that you do not have. Therefore, service developments could not ahead.

To deal with a £30 million to £40 million gap, the uncommitted funds that I talked about would have to remain uncommitted, but it would be up to the Minister to decide exactly how that would work its way through. There is absolutely no doubt that it would have an impact on waiting times, further extending them. It could also mean that existing capital schemes were unable to open on time. The Minister would have to make those types of choices and consider how we could maintain patient and client safety, meet the demands out there and live within our resources.

Mr McCarthy: So, the Minister knows exactly what is required, and you are telling us that, if he can get that finance into the Department, we should be in the position that we all want to be. When would that funding be in place?

Ms Thompson: The June monitoring round is due to be agreed by the Executive towards the end of June. Getting the £89 million would make a big difference to us. It would allow us to move forward and put the investment that we are bidding for on the ground.

Mr McCarthy: So, you would not come back in six months' time looking for another whack of money in the September monitoring round. You should be on an even keel throughout.

Ms Thompson: It will be about understanding where we are at that point. I cannot say that we would never come back. It depends on what we get now and how service demands change in the interim. That would be a matter to reflect on. The £89 million would help the outlook for 2015-16 considerably.

The Chairperson (Ms Maeve McLaughlin): If you do not get £89 million, which of the four bids will be your top priority?

Ms Thompson: The top priority is to balance the books and maintain patient safety. So, the ones labelled existing service pressures in the briefing paper —

The Chairperson (Ms Maeve McLaughlin): Is that within existing service pressures?

Ms Thompson: Yes, those are the ones that are already on the ground and need to be properly financed to enable them to continue.

The Chairperson (Ms Maeve McLaughlin): So, that becomes the top priority.

Ms Thompson: Absolutely.

The Chairperson (Ms Maeve McLaughlin): So, Transforming Your Care is obviously not a priority.

Ms Thompson: We have to deal with our existing service provision and ensure that it is fully funded. If we do not do that, something else will have to give. We have to sort that out before we can put new money on the ground for new things.

Mrs Deborah McNeilly (Department of Health, Social Services and Public Safety): There is a single bid of £5 million for TYC, which is focused on the transitional work streams and innovative pieces of work. However, as Seán and Julie mentioned earlier, increased domiciliary care packages are being provided. They are being funded, and they are part of the bigger TYC picture.

Of the £23 million bid, £6 million is to assist with unscheduled care and patient flow. Part of that is to increase capacity in community nursing and have more rapid response clinics in community hospitals. The £5 million TYC bid is for the transitional, pump-priming stuff. However, in the day and daily stuff, TYC is part of the existing services as well. I do not want you to think that the only thing that we are doing on TYC is the £5 million under the TYC transitional funding banner.

The Chairperson (Ms Maeve McLaughlin): I accept that, but we also asked about the scoping exercise for services that were being shifted left, and I make that point again.

Mr McKinney: May I further interrogate the £89 million? Do you recall the amounts that you bid for in January and last October?

Ms Thompson: Last October, we bid for £130 million. Last January — I do not have that figure, but, if you give me a minute, I can get it.

The Chairperson (Ms Maeve McLaughlin): I think that it went from £160 million to £140 million.

Ms Thompson: I think that the £160 million went to £130 million and then — I will be able to get it, if you would just keep talking.

Mr McKinney: If you scale it down percentage-wise, what is the realistic amount —

Ms Thompson: Sorry, in answer to your question, we bid for £23 million in January.

Mr McKinney: Yes, I knew that there was £23 million. I think that you got £3 million. Did you?

Ms Thompson: We got nothing.

Mr McKinney: You got nothing. Anyway, you can see where I am going here. You have a bid in for £90 million. What is the likelihood that you will get £90 million?

Ms Thompson: Given the challenges across the Executive, £90 million will be a challenge. Nonetheless, all that we can do is put forward the bids and priorities as the Minister wants them to go forward. The Executive will then decide. We do not know what will happen. You are absolutely right in saying that, in recent times, we did not get the full amounts that we bid for. If that happens this time, decisions will have to be taken on priorities. As I said, addressing the existing service priorities will have to be the first call on any money before we can move forward into new spending.

Mr McKinney: How will you deal, for example, with the existing backlog in elective care and the fact that you are not funding that externally?

Ms Thompson: It is not that we are not doing anything on elective care. It is a bit like what Deborah was saying about TYC. We will put around £60 million into elective care. Our bid for the further £45 million would bring us up to where we believe that we need to be moving forward. It also reflects what is spendable in the currency of the year. It has to reflect a kick-off position from July as opposed to a run rate from April.

Mr McKinney: What are the specific implications if you do not get the money that you are after?

Ms Thompson: The implication is that the 58,000 assessments and 13,000 treatments will not happen. The impact on those patients, therefore, will be that they have to wait longer, in line with clinical priority and chronological order, as that falls with the clinical priority.

Mr McKinney: Do you recognise the story about savings in 'The Irish News' today as accurate?

Ms Thompson: The story is more about the service developments that cannot happen as opposed to savings, cuts or reductions. The word "cuts" is used, but it is more about the fact that we will not be able to invest in particular areas, whether in reducing waiting times or in the areas that we are bidding for, such as specialist services, National Institute for Health and Care Excellence (NICE) drugs, children's services or whatever. I recognise the concept that, as Mr McCarthy said, unless we get the money through these bids, we will not be able to do those things. The story, as I understand it, is not about savings plans but more about lack of service development —

Mr McCarthy: Julie, the headlines are here. I have the paper. It is a two-page story.

Ms Thompson: Yes, I understand.

Mr McCarthy: It is unbelievable, as Fearghal said.

Mr McKinney: You mentioned NICE a couple of times. Up to this point, the NICE issue has been non-approved drugs and dealing with the individual funding request (IFR) process. Are you now saying that NICE-approved drugs and processes that could be available here will not be available?

That is where we sit currently and where we have been in previous conversations with the Committee. We can continue to give existing NICE treatments to new patients. However, looking ahead, newly approved NICE drugs that are coming on stream in 2015-16 are what the bid in June monitoring would resolve for us.

Mr McKinney: Do you understand that that would present a difficulty for professionals?

Ms Thompson: It will present a difficulty for professionals and patients —

Mr McKinney: A professional, knowing that a treatment is now available under national government and could make a difference to a patient's life, might not be allowed to administer that drug, even though it is available elsewhere in the UK.

Ms Thompson: You could make that statement about the fact that clinicians know that they could treat people who are on a waiting list for an operation but are not able to do so. It is the same concept as criteria being applied in domiciliary care. When you have a demand-led system, as we have, clinicians want, of course, to give the best possible treatment. We want that, too, as does the Minister. However, we have to live within the resources that we have, and, currently, the money for that does not exist. It is in the bid that we are putting forward. It would be a significant concern if we were unable to allow those NICE drugs to move forward.

Mr McKinney: Can you say that you are dealing comprehensively with wastage in the health service?

Ms Thompson: What I can say is that, as you know, we are taking a considerable look at efficiencies on an ongoing basis. We have challenging and ongoing efficiency targets right across the system, in the trusts and our arm's-length bodies. We are looking to ensure that those savings come out, and we have done so in recent years. Does that mean that we have captured absolutely every ounce and every element of wastage? No, I cannot advise of that. However, what I do know is that we continue to look at everything, from administration costs, management costs, procurement and estates right the way through to length of stay and day-case rates. It goes from back office-type work right through to looking at how we can work on the front line more effectively. We are looking right across the piece and will continue to do so. I am sure that more efficiencies will come out in 2016-17 and 2017-18.

Mr McKinney: I assume from your earlier comments that the story in 'The Irish News' is, in fact, accurate. It refers to the inability to provide safe, high-quality and accessible care going forward. Given what Seán was saying earlier about reaching out for even cheaper care, how can we be assured that that process, particularly in domiciliary care, will provide safe, quality and accessible care?

Ms Thompson: I need to point out that the safety of patients and clients is the priority in the system. All the trust chief executives are fully aware of that. That needs to be and will remain the priority moving ahead. I am not sure about domiciliary care specifically, but we absolutely need to maintain safety as a priority.

Mr Holland: We assure ourselves of the safety of services through a number of mechanisms. Services provided directly by trusts are provided within a governance framework that the trust operates to make sure that services are operated safely. There are mechanisms to identify where there are errors or mistakes and systems in place to learn from those. There is a responsibility on both the board and the trust when they commission services to be assured that they are of an acceptable and appropriate standard. Other specific services are regulated by the Regulation and Quality Improvement Authority. That involves standards being published and organisations and services being inspected against those standards to ensure that they are of an acceptable, safe standard. All of those mechanisms do not eliminate the possibility of error in services, but that is true of all activity.

Mr McKinney: Do you accept that the downward spiral of cost is placing huge pressure on all providers, particularly some of the independent and third-sector providers, in the delivery of proper care?

Mr Holland: The pressure on cost puts pressure on people who are trying to provide services safely within the cost envelope.

Mr McKinney: That is a structural issue. It is your decision to commission at that cost. That is before anything happens. You have not commissioned yet, but that is a threat to quality and safety.

Mr Holland: Our decision is to try to ensure that we get the very best value for money for the limited resources available to us to meet the health and social care needs of the population of Northern Ireland within the boundaries of safe practice.

Mr McKinney: Just to balance up the two sides —

Mr Holland: If someone comes to us and says, "We can do this for that price", and we say, "No, you can't. That's clearly not safe", we do not buy it.

Mr McKinney: You will have heard how independent providers and others feel that this is so constraining that it questions their ability to provide a safe service.

Mr Holland: There are times when, inevitably, people who are running businesses will face a challenge in how they manage to provide a service to the appropriate standards and make the profit that they need to make. There is a marketplace, and people are in the market. If they were not able to provide the services safely at the prices being charged — there are methods to assure safety — they would not still be in business.

Mr Easton: I know that everything that you are looking for in the June monitoring round is vital, but do you agree with me that it is particularly important that you get the money for elective care and diagnosis?

Ms Thompson: I am sure that members will support and recognise the import of all the bids on the table. There is absolutely no doubt that elective care is important to us, but the other bids on the table are equally important. The elective care bid will make a difference to individuals and mean that they do not have to wait as long, but the other bids are also compelling. The Executive have to put these bids alongside all the other bids and figure out, from there, what can be funded. We believe that we have put forward some very compelling bids and that those services are absolutely needed.

Mr Easton: In your briefing, you mentioned identified uncommitted expenditure. Should you have to go down that route, how much money have you identified?

Ms Thompson: The moneys that are held back, for want of a better phrase, are in the order of £30 million to £40 million. For elective care, further money could add to that. The amount is in double figures of millions as opposed to hundreds of millions. If you then say that you have to stop and do something more radical, agency spend, locum spend and things like that are not necessarily contractual commitments. However, if we took those away, there would be a horrendous problem in how the service would look. We are looking at the areas where resources are not on the table. That will help to inform where we go after the June monitoring round. However, none of it is without implication, and there is no doubt that it would put us in a very difficult position. The moneys definitely need to go to where they are supposed to go.

Mr Givan: You are very welcome to the Committee. Did the Minister sign off on the prioritisation of the bids submitted?

Ms Thompson: He did.

Mr Givan: Did the Minister change any of the priorities that officials advised him of?

Ms Thompson: No.

Mr Givan: That is important because, sometimes, we have a go at officials, but, ultimately, these are the Minister's priorities, and we can challenge him on why he signs off on things in the way that he does. Officials will do as the Minister says, and that is the way it should be. For the record, I support the prioritisation and the rationale that you have provided to the Committee for the priority being given to the bids that you have made.

Mr McCarthy touched on the contingency plans, and you touched on them briefly. The DFP paper suggested that, if there is a 5·9% reduction applied to all Departments in the absence of welfare reform being agreed, resulting in the Budget having to be changed to deal with that, there could be a potential £279 million of cuts. What would £279 million worth of cuts mean?

Ms Thompson: It is very difficult to contemplate how you would take £279 million of cuts out, in all honestly. You would be stopping elective care and have a silting up of the hospitals because of A&Es working through: you would not be able to provide domiciliary care packages at the other end. You would end up with delayed discharges, which would back the hospitals up. I am not even sure whether you would physically be able to do it, in that people would continue to arrive in need of vital treatment. As I said to Mr Easton, due to the issues around what you can actually control, you would be talking about taking out agency nurses and locum doctors. That would have significant implications, particularly for smaller sites, because that is where a lot of the spend is. You would effectively be collapsing into the bigger area hospitals, and even they would not be able to operate effectively. It would be exceptionally difficult. It is very difficult even to contemplate what that would look like in the health service in a context that we have on the table with a £30 million to £40 million gap. A £279 million gap would change the pattern of services completely.

Mr Givan: Would it still be safe?

Ms Thompson: That would have to be looked at, but because of safety — back to Mr McKinney's point — it would be very difficult for doctors not to treat people. Would any clinician or professional find themselves in a place where they would not treat a person who had turned up and get them into a safe place? Would somebody be left as a vulnerable person in their own home in a vulnerable state? I suspect that it would therefore lead to safety remains, but we cannot take the £279 million out. I suspect that the professional side of the equation would mean that safety would have to continue, and it would be very difficult for people to live within the budgets that they have. You would end up with deficits and an overspend. From the professional side, that is how it would end up.

Mr Holland: In the realm of social care, safety is slightly different, in that you are often working in situations where you accept that there is risk all the time and you try to manage it. Under those circumstances, the risk would rise dramatically — the risk to vulnerable adults living in the community and the risk to children requiring protection. You can never guarantee 100% safety, and in any of those circumstances you manage risk. Under those circumstances, I would envisage the risk changing significantly.

Mr Givan: You really cannot make an overspend, and there are consequences if that is where we go.

You will do well to get a small fraction of the £89 million, if you get anything at all. Given that you have made a bid for £89 million, and that there is uncertainty around the Budget, even if the Budget is put through based on welfare reform, and we put it up — when I say "we", I mean my party — to the Treasury and the British Government to intervene and legislate on welfare reform to make it a reality, is there a point at which officials make the political call that this is not going to get sorted and you are potentially looking at serious cuts of £279 million to your budget — or indeed more? Maybe officials are not allowed to make that call.

Ms Thompson: What you are weighing up is effectively the role of the accounting officer versus the role of the political and of the Minister. At the moment, we can get the books to balance off the back of our current budget by holding back on a range of commitments, and with the consequences that I have already described. If, out of the back of June monitoring, we do not get any further funds, or we get insufficient funds, the Minister will have to reflect on what that means, looking ahead. As we have already debated, the £279 million cut to our budget would put our current position in a completely different place.

Mr Givan: You have no plans —

Ms Thompson: The role of the accounting officer is to ensure that he or she lives within the budget; you are absolutely right. The accounting officer can ask for a ministerial direction. He or she would be saying that the Department cannot live within the available resources and that the Minister will have to direct him or her to do so. Ministerial directions have to go to DFP, however, which would come back to the fact that there is not enough money to live within the resources available. You end up in a position whereby you cannot overspend, which is the point that you are making.

In health and social care in particular, getting those two things to match in the context of a £279 million cut would be exceptionally challenging, but the accounting officer's discussions with the Minister is where that gets resolved. DFP would have its concerns about that, which is a different conversation about how it deals with Departments that are struggling to live within the resources that they have. In answering previous questions, I have identified where money effectively is uncommitted at this point, but as I said, those moneys all have implications if they do not go where they were intended. We need to look out the back of June monitoring and work with the Minister on the priorities that he would want to reflect.

Mr Givan: I do not envy you. It seems, from my point of view, that we are having quite a surreal conversation about bidding for £89 million in the context of the financial realities that we are looking at as a result of the failure of others to live up to the Stormont House Agreement.

Finally, on the subject of capital projects, and from a purely parochial point of view, I wanted to ask you about the co-location of the out-of-hours facility and the emergency department at Lagan Valley Hospital. You may not be across the detail of that issue; it is just that I did not see it cited. There is an ongoing piece of work to facilitate the reopening of the 24-hour facility, which will cost around £1 million, according to the business case. Do you have any updates on that?

Ms Thompson: That project is contractually committed, so it is among the projects that will go ahead.

Mr McKinney: I just wanted to make a smaller, but still significant, point. It is conceivable that some of the new NICE treatments that are now approved will be cheaper than the existing treatments. What is your consideration there?

Ms Thompson: You are absolutely right to point that out. If it is cheaper than what we currently have, that would be able to be [Inaudible.]

I was describing a situation in which there are ones that have additional resource consequences. You are quite right; if there are no additional resource consequences, or there is a saving, we would expect those to continue to go through as normal. What I am describing is a difficulty where significant additional costs are incurred on new NICE drugs.

Mr McKinney: There could be arguments in the margins there.

Ms Thompson: There could be arguments in the margins; equally, however, it would be for the commissioner to work through with the provider what that looks like. We do not have significant funds to put into new NICE drugs, looking ahead.

Mr McKinney: How is that being communicated to clinicians and front-line staff?

Ms Thompson: We have had discussions with the regional board about it and about the fact that we understand and realise that, given the situation that we are in, those new NICE drugs cannot be funded. It is then for the commissioner to liaise with the providers because they commission from them. It would up to them to advise the trusts accordingly.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. Most of the issues have already been discussed. If you were not to get the £89 million bid, what would it mean in real terms?

Ms Thompson: In its simplest terms, it would mean that waiting times would continue to increase and people would not be able to be treated. It would mean that we would not be able to invest further in Transforming Your Care on top of what we have already planned. It would mean that we cannot invest in children's services, mental health, new NICE drugs and the range of bids that we have on the table. Effectively, it would mean a difficult scenario that would get worse through 2015-16 rather than moving forward.

Ms McCorley: Is it possible to survive within that or would you see that as walking into a crisis?

Ms Thompson: We need to ensure that, as I have already pointed out, safety is the prime concern and ensuring that patients and clients are safe, that they are treated in clinical priority order, and that we make the best use of the resources that we have. That is all part of it. What would happen, though, is that waiting times continue to increase, and that will get more and more difficult for patients and doctors to deal with. It certainly would put considerable pressure on the system. However, we still have £4·7 billion. We need to ensure that that money continues to be used wisely as we look ahead.

Ms McCorley: Let us presume that you will get some of the £80 million. Would you cut each of the figures that you outlined or would you see some of them as being of such priority that everything that you laid out — for instance, £23 million for one — would be taken out of whatever you get or would you top-slice everything to move everything along?

Ms Thompson: That would be a decision for the Minister on the back of June monitoring. I could not answer that. I guess that it would depend on the level of money that he gets. Certainly, with regard to existing service pressures, as I have already explained, we need to ensure that those things continue to be supported; if they are not, there are further implications elsewhere in the system. Ultimately, that is for the Minister to decide. As I said in previous answers, he has advised on these priorities. I suspect that he would wish to remain broadly in line with them, but whether he would carve out some money to move it further down the piece, I do not know. That is ultimately for him to decide.

Ms McCorley: Presumably, you would recommend that you would continue in some shape or form to support each of those priorities.

Ms Thompson: I am sure that he would wish us to ensure that we can live within the funds that we have and he would absolutely ensure that that is the case. That means that we need to deal with the existing service pressures that are presenting first before we turned to the rest. Equally, I know that he would wish to support all those areas if he could. However, it depends on what level of resource he is given and therefore how he wants to move that ahead. Fundamentally, it is up to him to make that decision.

Ms McCorley: With regard to what you consider to present the greatest risk at a given time, we know that there are some conditions that, if they are dealt with early, will not become a risk at a later stage because of intervention. Do you look at that when working it out or do you just deal with current pressures as they arise? You have all the big risks, like diabetes, obesity and all the issues that can be serious in some degree or other, but, at a point further down the road, you know that they could be fatal. Do you take that into account or do you just say, "Here is the current priority today."

Ms Thompson: You try as best you can to look at both. We have a public health bid for £4 million, which is in the first tranche. It can be very challenging to do that because, as you say, demands are presenting on an ongoing basis, and therefore putting money into the preventative piece is a difficulty. That said, looking at how we deal with diabetes or obesity, for example, is where Transforming Your Care would want us to move forward or propose that that is the case. There is a diabetes bid in that as well that would hopefully allow that to happen. You are trying to bring all that together. It is wrong to say that we are not doing anything in public health. We most definitely are.

The PHA has resources of over £90 million in that public health space, never mind the ongoing preventative work that clinicians and GPs do. The bids are a mixture of dealing with the here and now, such as unscheduled care and patient-flow, and the future, which is the public health bid, and we have tried to ensure that we reflect all that in our bids. You are also talking about the use of money that we already have in ensuring that that is happening. The Minister wants us to continue to reform the service and move things forward on preventative measures, our lifestyles and all that because if we can crack that particular problem, move it or improve it, that would help considerably, but it may take many years before you see the benefit of that. They are both there.

Mr Holland: It is also worth noting that we are looking at a very challenging scenario, but we have already been in a very challenging scenario. Unfortunately, we did not get time to reference these points when we were talking about our Programme for Government commitments. We have made significant progress, and that is reflected in our Programme for Government commitments on increasing the investment in public health, specifically in obesity prevention programmes. We are also investing significantly in the issues that I think you were referring to: chronic condition management programmes, whereby you attempt to assist people to manage their condition before it becomes acute.

If you look at the material that we supplied under the Programme for Government achievements, you will see that we have, through a very difficult period, continued to invest in that activity, and have achieved our targets very successfully. It is a very difficult balance, but, as Julie said, it is about trying to deal with the immediate acute need that you have to respond to when it is in front of you while, at the same time, trying to hold on to investing in longer-term preventative measures. So, the Programme for Government picture beyond the discussion that we had reflects great progress in that area.

The Chairperson (Ms Maeve McLaughlin): There are a couple of points to clarify before we finish. What is the £2·5 million under the prioritised service developments, which is under other departmental priorities?

Mrs McNeilly: The £2·5 million includes £1 million provision to allow additional education and training. It would also support the General Dental Council recommendations on the training of dentists and making sure that they get more training in a community setting so that they can deal with more patients in a community setting. There is also £1 million for developing non-specialist acute services, including the delivery of more programmes for long-term conditions. It includes work on the early identification of patients in palliative and end-of-life care so that they can get earlier support and can have wrap-around services.

It also includes money for the commissioning of a community pulmonary fibrosis service and a community non-invasive ventilation service. Other pressures are in and around — it is back to some of the inspection and safety work — additional health and social care inspectors, for example. The others that I mentioned for the specialist acute services are being bid for under other departmental priorities. They are TYC-consistent but are not being bid for under transitional TYC funding as part of the £5 million. We do that because of how the funds are managed in different programmes of care and so on. That is another £1 million that is consistent with TYC.

The Chairperson (Ms Maeve McLaughlin): I want some clarity on this: a yes or no. Given the 5·5% reduction in the Fire Service budget, what analysis has been done on the impact and risk to the service?

Ms Thompson: We are awaiting receipt of its final savings plan, which we understand will come to us very shortly. The Fire Service has been looking at managing risk, and that is what you would expect it to do. It operates a risk-management plan that — it is back to the safety issue — means that firefighter and public safety is the absolute priority. So, risks will be considered, identified and then managed as it implements those savings plans.

The Chairperson (Ms Maeve McLaughlin): You must have a view at this point that the £4 million reduction will not present a risk.

Ms Thompson: As it implements those plans, the Fire Service is saying that it will look at the risks and manage them and that firefighter and public safety will be the absolute priority.

The Chairperson (Ms Maeve McLaughlin): There is obviously a risk.

Ms Thompson: In the same way as there is a risk in any service change. It is saying that risks will be managed and that public and firefighter safety is the priority.

The Chairperson (Ms Maeve McLaughlin): Finally, there is £16 million savings on departmental running costs. One person's saving is another person's cut. Is there a split? You talk about admin and programmes. Which is it? Is it both?

Ms Thompson: There is an element of both. The £16 million is coming off departmental resources. We have internal Department administration, and just over £1 million, if I can recall the numbers, of the £16 million is coming from our Department having to live within a reduced level. The remainder is looking at our programme budgets and trying to identify what we could reduce. The problem with all these things is that, although savings are a challenge, if we do not achieve those savings, the position becomes even worse on the other side. The £16 million has been worked through on that —

The Chairperson (Ms Maeve McLaughlin): It is £1 million for admin and £15 million for the programme budget. Can you furnish the Committee with that list?

Ms Thompson: I am sure that we can get it.

The Chairperson (Ms Maeve McLaughlin): Folks, thank you for your time today. I appreciate the clarity and clarification. There are issues that we will want to reflect on.