Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): We have with us Clare Duffield, HR director at the Northern Health and Social Care Trust; Ann McConnell, HR director at the Western Trust; Damian McAlister, director of HR and organisational development at the Belfast Trust; Kieran Donaghy, director of HR and organisational development at the Southern Trust; and Eamonn Molloy, director of HR and corporate affairs at the South Eastern Trust. You are all very welcome. Thank you for attending. I invite you to make your opening comments.

Mr Damian McAlister (Belfast Health and Social Care Trust): Good afternoon, Chairperson and members of the Committee. Thank you for giving us the opportunity to address you as you continue to take evidence on your review of workforce planning within the context of Transforming Your Care (TYC).

Our provision of oral evidence is further to the written evidence that each of our organisations provided to your ongoing review in mid-May this year, and the subsequent request to each of the Health and Social Care (HSC) provider trust chief executives, which was received on 14 May. In that correspondence, the Committee specifically asked that, in our opening statement, the trusts provide evidence on the following: the progress that we have made to date on workforce planning in support of the implementation of Transforming Your Care; details of the strategic direction our trust is being given by the regional workforce planning group, the Department and the HSC board; investment made in retraining of staff to achieve an appropriate skills mix; investment in leadership and capability development; how the money shift from hospital-based settings to community-based settings under TYC — £25 million to date — has impacted on staff, and how trusts have dealt with that; whether our trust has been asked by the regional workforce planning group if the Health and Social Care Board is to do workforce planning to support a shift of services out of hospital settings into community and primary care settings; how trusts as employers are taking account of recruitment issues for particular geographical areas; the desirability of seven-day working; and the composition of the workforce with regard to gender mix and associated work patterns.

We will address each of those issues in turn, starting with the regional workforce planning group. Each of our organisations is represented by a HR director or deputy director. At least four members of that group are present today. As HSC trusts, we fully support the establishment and operation of the regional workforce planning group, and we believe that it has provided the necessary vehicle by which, first, the appropriate means of approaching workforce planning has been agreed. That will help us to achieve a workforce of the right size, with the right skills, to work in the right place at the right time. Secondly, we have secured a workforce planning approach which, while patient and client centred, is flexible and responsive to change in service demands. Thirdly and finally, facilitated workforce planning through appropriate training means that it can be based around programmes of care, while determining the impacts on single and multi-professional groups.

As provider organisations, we all have contributed to the development and agreement of the regional HSC workforce planning and framework document, which sets out in detail the methodology to support workforce planning and the key roles and responsibilities of key parties in the process, including the Health Department, the Health and Social Care Board (HSCB), the Public Health Agency and ourselves as trusts. However, we would like to assure the Committee that, while this document has only recently been agreed, all the trusts have had prior involvement in workforce planning initiatives at a local level.

In its most basic form, workforce planning is about modelling the workforce to meet demand. While arguably not adequately resourced to do that, each trust, through local managers, has considered workforce-needs planning in determining how service demand can be met or how new services, with the support of our local commissioning groups and the Health and Social Care Board, can be delivered.

The outworking of some of these initiatives has resulted in new service delivery models. We will shortly provide an example of each of those models from our organisations. There has been retraining for some staff in new activities or the creation of new or merged goals based on the concept of skill mix, some of which have worked across traditional professional workforce groups. On the latter, I want to highlight the development of the allied health professional support worker in the community, which has allowed a merged role to be created to support allied health professional staff who carry out home treatment plans. Previously, each allied health professional grouping had its own support worker but now one person works across physiotherapy, occupational therapy and speech and language therapy disciplines. We also point to the development of advanced nurse practitioners in HSC emergency departments, which, while not fully replacing hard-to-fill middle-grade medical posts, has allowed some of the shortfall to be addressed through extended nursing roles.

Having specifically described our role as trust representatives on the regional workforce planning group, it may be worth providing an overview of our role in workforce planning as trust directors of human resources. At a high level, by way of example, our roles and accountabilities for workforce planning locally include the following: the provision of workforce data and information for the organisation; the provision of recruitment and selection processes and initiatives to meet workforce needs; supporting the development and delivery of directorate and service improvement working plans through HR business partnering, which responds to forecasted workforce supply and demand and which are aligned to strategic direction; and the development and delivery of a strategy for learning and development to meet current and future skills and capability requirements in the organisation.

The Committee also asked for information on leadership and capability development. A range of initiatives have been undertaken in that regard across each of our organisations. For example, the HSC knowledge exchange is an actual and online forum that provides an opportunity for HSC employees to discuss, debate and address emerging issues in health and social care. It has provided access through the HSC leadership centre to a range of additional resources for HSC leaders and access to best practice from across the national and international markets.

As a result of workforce planning, regional and trust-led succession planning initiatives have analysed recruitment and turnover trends and determined that more needed to be done to grow future HSC leaders. We have also introduced formal coaching and mentoring strategies, which have assisted general and clinical leaders and managers to focus on performance, service delivery and productivity improvements. We also have regional and trust-led leadership and management development programmes, which are aimed at developing senior and middle-management health and social care staff to be able to practise and operate in a range of situational models, including distributive and collective leadership, applying organisational development methodologies, including Lean, Six Sigma and Institute for Healthcare Improvement (IHI) Triple Aim, and managing change programmes and their impact on staff and patients alike.

We will now turn, with your permission, to specific examples of service change initiatives that have resulted in new services being developed in the context of Transforming Your Care.

Ms Ann McConnell (Western Health and Social Care Trust): I will concentrate on an example of outpatient reform that has been implemented in the Western Trust area. My colleagues will give examples in other areas. It is important to note that outpatient reform is integral to the reform of pathways for long-term conditions and acute care reform. The current process for outpatients, as you are aware, is that the GP sees and assesses the patient and may or may not do investigations. In some cases, the GP may not have access to all the investigations that they would need without going through hospitals. The GP decides whether specialist advice is needed and makes a referral by letter or electronically, and the patient then attends an outpatient clinic. The average cost of that is £205 per outpatient appointment.

The opportunity to reform the process requires GPs and consultants to change their referral patterns and behaviours, and for referrals to be seen as requests for specialist advice. The change also requires the upskilling of the primary and community care staff to support the new models and ways of working. That is the workforce planning element of the service redesign.

The Western Trust aims to reduce outpatient attendances by 15% in the west in 2015-16.

An example of that that is already under way is the respiratory care service. A workforce plan was developed and the HSCB local commissioning group provided the funding to support the transition to a new model of service. The multidisciplinary model comprised a consultant, an oxygen specialist nurse, a respiratory pharmacist and a respiratory physiotherapist. The service was changed so that there was a consultant-led focus on the community. That involved outreach clinics being held, phone or virtual clinics, phone and email consultations, home oxygen assessment, drugs reviews and physiotherapy being available at home.

The outcome in one year has been a 38% reduction in the length of stay in the South West Acute Hospital for respiratory inpatients. There were 152 new referrals contacted, and 48 of those patients were discharged. Using phone and email consultations, 33 admissions and 89 review clinic appointments were averted. The waiting time for oxygen assessment reduced by 10 months and, while all of that undoubtedly reduced admissions, there have also been considerable savings on drugs. Five of the top six drugs prescribed in the Western Trust are respiratory drugs. In four months, there was a saving of approximately £70,000, and almost 100 admissions were prevented through physiotherapy interventions. From a performance perspective, that demonstrates real improvement. More importantly, from the patient perspective, it demonstrates improvements in the quality of care. Patients have reduced side effects from drugs, have interventions to avoid admission, are supported in a more timely fashion and, if admitted, have shorter hospital stays. Haematology in the west has also transformed outpatient services using similar approaches. That transformation in services can be replicated in other service areas. That work is under way in diabetes, cardiology, ENT and renal services.

Ms Clare Duffield (Northern Health and Social Care Trust): Good afternoon. I would like to provide you with an example of how workforce planning has contributed to and supported the implementation of reablement services in the Northern Trust.

The reablement ethos is a person-centred approach that promotes and maximises independence and allows people to remain in their own home for as long as possible. The reablement service is a planned short-term intervention, which provides support to a patient in their home. It is designed to enable people to gain or regain their confidence, ability and the necessary skills to remain independent after having experienced a health or social care crisis, such as an illness, a deterioration in health or, perhaps, an injury. The aim of the reablement service is to help people to perform their usual daily living skills, such as personal care, walking or preparing meals so that they can remain independent in their own home.

The Northern Trust has developed a reablement service from within its existing home-care resources. Anticipated demand was forecast from domiciliary care referrals and package requirements. Initially, the services were established through a dual-role approach. In other words, existing staff were trained for dual roles, supported by the redeployment of hours within in-house domiciliary care.

In the past year, the trust has developed specific reablement teams in line with the regional model by redeploying individual staff from core services into specific reablement teams across the trust. That has enabled a large percentage of new referrals to domiciliary care to be accepted through reablement. The service benefits also from the specialised focus provided by occupational therapists to maximise the overall effect to meet the individual's optimum level of independence. In the trust, the service comprises approximately 92 whole-time equivalent domiciliary care reablement staff who are supported by around 10 occupational therapists. Both workforce groups have a mix of skill level aligned to referral needs and demands.

The workforce plan to enable the development of the service included a comprehensive training programme for allied health professionals, occupational therapists, social workers and district nursing teams. The training was designed to address both skill and competency requirements and covered topics such as the values underpinning the service, reablement experiences, professional perspectives, person-centred planning, recording and reporting, and communication skills.

Most importantly, the staff training programme focused on developing behaviours and skills that would help make the shift and transition from an ethos of "doing for" to one of "doing with".

As previously described, the workforce plan also helped to identify the number of staff required and where they could be sourced from. From a workforce perspective, service change is also supported by a framework for the management of people change to ensure that employees affected are engaged and consulted as appropriate. The trust continues to develop and improve the service, and plans to integrate it into its locality multidisciplinary teams in the future.

Mr Kieran Donaghy (Southern Health and Social Care Trust): Chair, if you are content, I will continue with an example from the Southern Trust. In July 2009, the Health Minister approved proposals for the future provision of mental health and learning disability services. The implementation of that decision provides an example of how workforce planning works within the Southern Trust.

The changes were brought about through the Bamford review, which, as members know, required a fundamental shift in the balance from hospital-based to community settings. At that time, the trust had 108 mental health and learning disability beds at the St Luke's sites. Some 220 staff of various grades provided care to those patients. The current position is that all the staff have been redeployed, apart from a small number who requested voluntary early retirement (VER), and all the patients have been placed in community settings. The only thing that is left on the St Luke's sites is the Gillis Centre, which is a dementia ward.

As the Committee is aware, effective workforce planning can be introduced only when the model of service delivery has been developed and agreed through the commissioner and the Department. For that reason, I will concentrate on three examples of new service delivery models that we agreed within the Southern Trust in order to allow the move from St Luke's to happen. Those are supported living, assessment and treatment, and crisis response times.

The Southern Trust has now developed 13 homes for supported living within its area. The latest of those is Granville, which is a learning disability home in Dungannon. It provides for 25 tenants in five separate but connected houses. Each house has been assessed and required staffing levels have been assigned according to the complexity of patients' conditions. Each patient has been assessed according to needs. Staffing is on a 24-hour shift pattern, seven days a week and, within that home, 60 staff have been provided from St Luke's to provide that service. Each of those staff has undergone retraining.

The next example is the assessment and treatment unit, which was relocated to the Craigavon Area Hospital site in the summer of 2014. The trust recognised the need for a continuing level of inpatient assessment and treatment, and created the Dorsy unit at Craigavon Area Hospital, within the Bluestone unit, which has 10 beds. Some 25 staff now provide a service through that unit to learning disability clients.

The third example is the crisis and home support team. We had 30 staff within that area but, more recently, within learning disability, we have also created a crisis response and home treatment team which is the first of its kind for that particular client group. It provides services that are very effective in allowing clients to remain in their own home.

Many of the 120 staff who were formerly on the St Luke's site required retraining, and that was given by the trust. They have all now been redeployed into new areas of work, including the Bluestone mental health unit; supported living homes; support and recovery teams; home treatment and crisis response teams; primary mental health care; and community psychiatric liaison teams. Again, the trust was mindful of its decision about the St Luke's site. Working in partnership, we actually redeployed and centralised our support functions on that site to take account of the gap that was left by moving those clinical services. We re-provided up to 200 jobs through the replacement of HR services, finance services and some element of shared services.

Mr Eamonn Molloy (South Eastern Health and Social Care Trust): One of the biggest issues facing the delivery of health and social care is undoubtedly the forecasted increase in the prevalence of dementia in our population. In Northern Ireland, as you are well aware, we have one of the fastest growing elderly populations in the UK. Currently, over a quarter of a million men and women are of pensionable age, which is nearly one in six of our population. By 2028, that will have increased to nearly one in five, and I will be in those ranks. By 2050, the number will be almost one in four.

Demographic changes have a specific impact on demand for health and social care services; that is fairly obvious. As life expectancy increases, the number of people affected by conditions associated with old age will increase commensurately. Based on rates from across Europe, we may see dementia numbers rise from 19,000 currently in our trust population to around 60,000 by 2051. We must also remember that dementia does not only affect the elderly. There are a significant number of people who live with dementia who are under the age of 65. Early-onset dementia is especially difficult to diagnose, so the actual number is uncertain at present. However, estimates suggest that there could be as many as 1,000 people affected by early-onset dementia in Northern Ireland. Considering the specific needs of that group is another challenge that must be tackled.

I would like to tell you a little bit about a specific approach that has been piloted in the Lisburn sector of our trust. Although it is on a small scale, it is proving highly successful in meeting two of the stated objectives and recommendations of TYC, namely changing care packages for people in the residential and nursing home sector and, more importantly for our clients, avoiding unnecessary admission to acute hospitals.

Traditionally, care homes sought assistance for residents who had dementia and other unmanageable challenging behaviours from the already overstretched GP network. GPs would often refer those cases straight to acute psychiatry so as to cause no delay in the treatment plan for the patient, without full and proper assessment of any delirium or risk factors that they may be experiencing. That led to acute psychiatry receiving an increasing number of referrals and a poor response for the patient, as waiting lists grew longer. At one stage in that sector, whilst the waiting-time target was nine weeks, in reality it was extending to waiting times in excess of four months. As you can imagine, that could only lead to an unsatisfactory outcome for the patient, the safety of other patients being compromised and unacceptable levels of disturbance within the facility or home in which they were living.

With the help and expert assistance of a number of our staff, we sought to examine what we could do to respond to this situation, using TYC as the linchpin. Our aims were to improve the treatment of patients with delirium and dementia living in our care homes; reduce the number of referrals to acute psychiatry and admission of patients who have dementia being inappropriately admitted to the acute psychiatry unit; assist nursing and residential staff and general practice to become more aware of delirium and the impact that it can have on our patients; and reduce waiting list times.

On examination, our community psychiatric nursing (CPN) service came up with the simple solution of aligning itself with each of our care homes in order to provide the first response to the home in cases of delirium, rather than the GP. The community psychiatric nurses were willing to extend their role to undertake that range of functions and develop a new skill set in that service area. They developed a systematic checklist that standardised the approach of the CPN on examination of the patient. The commissioner has now recognised that this solution works and has allocated funding to support the initiative through the addition of five new CPN posts in that sector, with a social worker and two part-time posts with the new title of dementia navigators. Essentially, the job of the dementia navigator is to signpost people to particular services and specialties. The outcomes of this simple service model are a marked reduction in waiting times for patients with dementia who exhibit challenging behaviour from a four-month wait for an acute psychiatric referral or appointment to one week within our new CPN-aligned service; and a marked reduction in the number of straight referrals to the department of acute psychiatry by 26%. Care home staff have reported that they now feel more confident and supported in dealing with delirium and challenging behaviours, the CPNs have consolidated their knowledge and there is less chance of the symptoms of delirium being missed in the treatment of our patients.

As an offshoot or by-product of the CPNs consolidating their knowledge, they have now taken on responsibility for running nurse-led clinics in dealing with delirium and challenging behaviours. They act as liaison and triage points for the medical team. They now organise post-diagnostic support clinics, they are involved in anxiety management groups and they are participating in a new and innovative well-being hub in the Dunmurry and Stewartstown area. In summary, we used the ideas of our current staff group to shape a new service model that is responsive to our patient needs. We have extended the existing role of the CPN, which has provided us with a solution to a service need that is likely to increase over the foreseeable future. Our next steps are to share the evaluated outcomes of this approach with other CPNs, to begin further alignment of those staff with all homes in our geographical area, and to encourage the homes to use the checklist independently to identify and treat delirium at the earliest possible juncture.

The Chairperson (Ms Maeve McLaughlin): Thank you all for that. Damian, did you want to say more?

Mr D McAlister: Yes, Chair, just to finish off our presentation. The programme treatment unit was launched in the Belfast Trust during the 2010-11 financial year following receipt of comments from a patient who questioned the amount of downtime that they experienced while waiting for specialist clinical treatment as an inpatient within the hepatology service in the hospital. They queried why much of the clinical treatment could not be provided as an outpatient.

By way of background, the programme treatment unit falls under the traditional title of ambulatory care and offers care in the day predominately by a nurse-led team, which has been empowered to take the lead in pathway care. All nurses working in that area are educated to a level of practice to ensure that they are competent and safe in providing the specialised clinical treatments that are offered, and they are also supported by specialist nursing teams who work to the unit. Trust medical staff who traditionally provided that specialist clinical treatment before the service was created now offer a clinical advisory and support role to the unit which, in turn, has freed them to concentrate on other more highly specialised tasks. In addition to being supported by other specialist nurses and medical staff in the hospital, the nursing staff also receive support from pharmacy and allied health professional staff, and the patient pathway is now such that all patients receive their treatment, are discharged and booked for follow-up appointments all in one visit.

When launched as a trial, the service comprised of one nurse providing one specialist clinical treatment to 68 patients in a room off the main ward. While that was a very small launch of the service, it served to demonstrate the concept and, quickly, the service began to gain the confidence of the wider clinical team, for whom those 68 patients would have otherwise been admitted for the same care. Quickly, one nurse became two and the number of clinical treatments that were being offered grew, so much so that, by 2014-15, 6,800 patients were receiving 32 different clinical treatments in a larger but still relatively small location in the Royal Victoria Hospital — a unit comprising five day beds and five chairs from an enhanced team led by nursing. The results achieved have also been very significant. The average overall length of stay for patients in the hepatology service has fallen from 13 days in December 2011 to 10 days in December 2014, while the length of stay for a liver transplant patient has reduced from 11 days in hospital before transplant surgery to now not requiring any.

The service is now seeking to expand the range of clinical treatments that it can offer and to provide more clinical treatments to support the flow of patients to the unscheduled care pathway in the trust. Given the success gained to date in enhancing the safety and quality of the service provided and reducing the need for admissions and length of stay within the hepatology service, it is envisaged that, with a larger footprint area to work from, and with an increased nursing-led resource invested in the programme treatment unit, we could equally help improve patient outcomes and avoid some unnecessary admissions that may occur through the trust emergency departments. The trust is currently working with the Health and Social Care Board and the local commissioning group to seek the means of securing the resources needed to achieve this, recognising that, in the first instance, this will require some support and an initial financial investment to help the bigger unit to be established before any projected savings can be realised.

We hope that the examples we have offered provide reassurance to the Committee that workforce planning, often in its most simple form, is central to the development and delivery of services offered within all settings in health and social care.

I will turn briefly to the issues of our involvement in workforce planning led by the regional workforce planning group, the Health and Social Care Board and the Public Health Agency. We are all currently participating in the regional workforce planning group's approach to domiciliary care and the various speciality medical workforce plans that are being led by Dr Carolyn Harper from the Public Health Agency on behalf of the Department. The trust fully welcomed both of those approaches as, while each takes account of the regional service delivery model principles that pertain, they are also sensitive to local and specific service needs. For example, the workforce planning review of domiciliary care, which is being significantly influenced by the near-completed Health and Social Care Board-led review of domiciliary care services models, will, in our opinion, provide a regional overview of the workforce growth in numbers and the changes in skills that are needed to meet the increased demand brought about by the needs of an ageing population but will take into account demographic issues that each of the five trusts faces.

The current challenges that face health and social care are significant. There is a growing demand across a wide range of services in a context of reducing budgets. Specialties in the area of unscheduled care, including emergency medicine, acute medical care and surgical services, are now being challenged to move to full service provision across seven days. Setting aside the very evident financial challenges that growth and demand invariably bring, that also presents significant workforce challenges, particularly in view of the existing configuration and service delivery models.

Local service planning gives consideration to those workforce needs. Each trust has a range of posts, mostly medical, for which ongoing recruitment difficulties are being experienced. A number of our trusts have sought to address those difficulties through international recruitment through agencies, but that has had very limited success. The trust, with the support of the Health and Social Care Board as commissioners, is working collaboratively to explore solutions, including the establishment of clinical networks, targeted recruitment internationally in countries and regions where there may be an oversupply of workforce, and the creation of extended roles, such as physician's assistants.

Workforce planning plays a formal and informal role in how services are planned and delivered in health and social care in Northern Ireland. It involves many managers, staff, trades unions, our patients and clients and our stakeholders in those processes. It can be both complex and straightforward, and informed and informing in how we commission services to meet population needs, by how we commission university and educational places for our health and social professions, and by how we develop the roles and skills of our workforce.

We are pleased that the topic of workforce planning is under the consideration of the Committee. At a time of such challenge, the trusts appreciate the help that this focus will bring in supporting the continued development of services and the implementation of patient-centred Transforming Your Care initiatives through employee and workforce transformation and change, particularly in the constrained financial climates that we are operating in.

We again thank the Committee for the opportunity to address you on this critical function. We hope that this opening statement supports the written evidence that we have submitted as the provider organisations in health and social care.

The Chairperson (Ms Maeve McLaughlin): Thank you all for those opening comments. We have heard much about particular individual service delivery models from outpatients through to mental health, reablement and a number of fronts. We heard from professional organisations in our inquiry and review that they were unaware of the workforce implications of Transforming Your Care on their members because the service delivery models had not been established, or even designed, and certainly were not in place. Who is responsible for that? Is it the board, or is it a joint responsibility between the board and the trusts?

Mr D McAlister: I think that we all are, Chair, to be honest. There are local service delivery models that we develop locally and then seek the support of the commissioner to provide funding for. There are also regional service delivery models that are very much led by the Health and Social Care Board, as a commissioner, and influenced by the Department that we would be party to in terms of resolving the impacts that that might have on our workforce. In direct answer to your question, both of us are responsible.

The Chairperson (Ms Maeve McLaughlin): So, it is a joint responsibility.

Mr D McAlister: Yes.

The Chairperson (Ms Maeve McLaughlin): If there is a responsibility also on the board, do you, as trusts, feel that you are in any way being hampered if those responsibilities are not being actioned?

Mr D McAlister: I can speak only for the Belfast Trust; colleagues may want to speak on behalf of their trusts. We have a very healthy relationship with the Health and Social Care Board as a commissioner. There are often cases that we put to it that it does not support as a commission; it does not see them in the overall service delivery model. That is fine, but we are supported by it, and, equally, by the Department. I go back to the comments that we made in the opening statement: we are very supportive of the regional workforce planning group and the principles that it established. While we were probably displaying and putting in place many of the principles locally, having them now in the regional context of the regional workforce planning group and the workforce planning framework document only further enhances the ability of the service to respond to population need.

The Chairperson (Ms Maeve McLaughlin): I am watching others shaking their head in agreement. You think that it is joint responsibility and that there is a good working relationship.

Mr Molloy: Each one of us has a role to play. The role of the commissioner is important in assisting us to interpret strategic direction from the Health Department, but their primary responsibility is to assess the need of the population and to specify and design services to meet that need. From our perspective, it is up to us to try to ensure that we put the proper staffing model in place to deliver that care. I take it from what you said earlier that some of the representations that you received were from members of our trades unions and professional organisations. You may not necessarily see a direct link to TYC, but a lot of the workforce reform that we are involved in is done in partnership with our trades unions. They are very aware of what we are doing; they subscribe, in the main, to most of the things that we are trying to do. That is about trying to develop new roles, new skill sets and new ways of approaching problems that previously were intractable. Everyone has a role to play in this. The simple example that I was giving you was about asking our own staff because, on occasions, front-line staff have the best solutions to some of these problems because they are doing the job every day.

The Chairperson (Ms Maeve McLaughlin): Other sectors can speak for themselves, but I suggest that it was much more than a direct link. All the organisations that gave evidence felt that they were not participating in the process. They were not at the table, bar one.

Mr D McAlister: To reinforce what Eamonn has said, in the Belfast Trust, we very much take a partnership approach to service development and service delivery, and our trades unions locally are involved in it. That may not necessarily mean at all times that trades unions regionally will be intimately aware of what is going on in the local organisation, but our trades unions locally are very much involved in the process.

Mr Molloy: I think that that is potentially the answer. Many of our local trades unions are deeply involved in areas of service planning and development.

The Chairperson (Ms Maeve McLaughlin): Again, I am talking about the regional workforce planning group, which is not necessarily your responsibility, but every sector requested that it be an active participant in the process.

Mr Molloy: That issue is with the Department of Health at the minute.

Ms McConnell: I think that it is fair to say that, at the moment, the trades unions are not at the table at the regional workforce planning group, but they have been invited to nominate a representative to the regional domiciliary care working group, which is where the workforce planning is taking place for reshaping that model. As Damian said, the issue of representation at the regional workforce planning group is with the Department at the moment.

The Chairperson (Ms Maeve McLaughlin): Somebody mentioned recruitment and retention issues. That can be an issue in rural areas, but I know that it is also an issue, for example, in the Western Trust. That was acknowledged in your briefing paper today. Do you as trusts feel that, in relation to retention and recruitment, the Department could be doing more at a regional level?

Ms McConnell: Because you mentioned the Western Trust, perhaps I will speak first. One of our biggest challenges is our medical workforce, and the Department is very aware of the issues that we have there. We are working with the Health and Social Care Board and the Department to resolve some of the issues that we have. I think that the challenge is that the difficulties that we are experiencing are happening now and that the solutions are a little bit off in terms of the planning piece. Being able to deliver all the solutions that we need right now means that we are having to look at other things. We are looking to our cross-border colleagues; we met the Royal College of Surgeons in Ireland this week. We do training grades with it in the South West Acute Hospital. We are looking at whether we can get postgraduate level doctors onto our rotas to fill some of the middle grades. That would be a very welcome development. We are looking at solutions, and I suppose that the trust has to take some responsibility for trying to find some of the solutions. That is what we are doing.

The Chairperson (Ms Maeve McLaughlin): Equally, the example was given that there was a £10 million cost last year for locums in the Western Trust alone.

Ms Duffield: I can provide some examples or thoughts on whom we are looking at, medical workforce shortages in particular. First and foremost, as you mentioned, we have to ensure the continuation of services, so the short-term fix is, obviously, through the use of agency and locum doctors in the absence of a pipeline of candidates coming through. However, there is an example where the Northern Trust and the Western Trust have worked together and collaborated to look at how services are being delivered to take a more regional or geographical approach to address any shortages. We are also looking at attraction and recruitment strategies, and I think that it was Damian who mentioned the fact that we try to be creative and look at other ways of attracting candidates, whether through overseas recruitment or a different model. For example, in emergency medicine, we are looking at using physicians' assistants to account for the shortfall there.

The Chairperson (Ms Maeve McLaughlin): I absolutely understand that, and I know the work that a lot of the trusts are involved in, but, specifically, does the Department need to do more in relation to this issue?

Following on from that, Damian, when it comes to, for example, GP contracts, do the trusts have a view as to how those contracts are drawn up and how you could influence those contracts to ensure that doctors are retained here or deliver their service here?

Mr D McAlister: In answer to the latter question, we do not employ general practitioners, so we have no view on GP contracts per se, but we have a view on the contracts for hospital consultants and trainee-grade doctors. Our sponsor Department was involved in national negotiations that we, as trusts, joined in. The Department organised regular briefing sessions, and much of its approach on that policy was influenced by how we found things on the ground. We were giving them the reality of the situation and highlighting things about how we needed to incentivise productivity, for example.

To go back to the earlier question about whether we feel supported by the Department, we engage on a monthly basis with the HR director from the Department in its HR directors' forum, and medical workforce shortages have been on the agenda of nearly every meeting for the last six months. The Department gives us a listening ear. We sometimes have the ability to look at incentivisation under the terms and conditions.

I can quote an example that we used some years ago where we had real difficulty in a specialty in the Belfast Trust. We introduced a very highly specialised service, unique only to the Belfast Trust, and we brought forward a requirement for recruitment and retention premia. A case was made to the Department, which was ultimately approved by the Department of Finance and Personnel. For a time-limited period, we were able to offer those premia to attract the right people to the service and to retain them. That meant that stability was brought to a service that was so unique that it was going to have to stop being provided by the National Health Service.

The Department has those abilities if we approach it, but, as Ann said, there is a certain responsibility on us. Clare gave an example of clinical networking: the solutions are multifactorial; sometimes, it is not simply all about money. We need to do better to package what we have in Northern Ireland and the educational facilities that we have, through Queen's University, to offer research facilities. Sometimes, it is not just about adding more money but about being able to put together a better package to sell the idea of coming to work and live in Northern Ireland.

The Chairperson (Ms Maeve McLaughlin): I appreciate that detail, but do you have a view as to whether there should, if possible, be a requirement in the contracts of doctors and consultants that they must work here in the North or in a particular trust, for example?

Mr D McAlister: Do I believe that they should be?

Ms McConnell: We had that type of contract for clinical psychologists a number of years ago. The difficulty is that it is quite hard to enforce. These people have gone through specialist training, and if their life circumstance change, if they marry someone and that person, through their job, has to live in a different country, it is very hard for any employer to say that they need to stay here. Legally, it is hard to enforce. Even if you had that condition, it may be hard to make it stick.

Mr Molloy: Those individuals are now very highly sought after internationally. We find that it is extremely difficult to staff shifts in our rural hospitals; we have had to look at other models of service. Whilst we can include "Work with us for the next two years" in the contract, in reality, as Ann said, it is difficult to enforce. We are competing with the bright lights of Sydney and Auckland and the rest of the world; they want to get out and about and around the globe, and that is what they can do.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. Thanks very much to all of you for your presentations today. The Committee is interested in the relationships between the board, the trusts and the Department. In workforce planning, what is the key difference between those roles as you understand it?

Ms Duffield: I will respond initially by saying that we have found it very helpful in past months that, through the regional workforce planning group, a framework document has been created that helps to outline the roles and responsibilities of each stakeholder group represented. There is also a clear commitment by all those groups to the workforce planning methodology that has been agreed. That document helps to provide some clarification.

Mr Donaghy: I suppose that the roles have been fairly clearly set out in a document that was submitted to the Committee. The Department feels responsible for setting the strategic direction, ensuring commitment to a high-level workforce strategy to underpin the Department's wider policy objectives; the HSC is there to be the commissioner and to ensure that HS trusts and the practitioners have considered and identified the workforce needs for service delivery, through, for example, demand-and-capacity exercises. As Eamonn pointed out earlier, trusts are ensuring that we have the right people in the right place at the right time, trained to deliver services to our patients and clients.

Mr D McAlister: I often describe it as almost a "virtuous circle". We are sitting in one part of it, where we are delivering local services. We might identify a local service need, which we then push to the HSCB commissioner, who takes a view on it. It may ultimately end up with the Department, which may be required to commission more educational training places from universities for nursing, medicine or whatever. The securing of the funding then comes back round to the trusts, the Department funds the board and the board, as the commissioner, gives us the money to implement the service. I see it as a circular relationship as opposed to a hierarchical one.

Mr Molloy: In reality, the relationship can be fraught on occasions; it is not all sweetness and light, as you can imagine. When you deal with a scarcity of resources, particularly money, you will always compete with other priorities, and on occasions that brings tension into the relationship. Those are just the realities of the situation.

Ms McCorley: Do you feel that the model works?

Mr Molloy: I think that we alluded to this earlier on, but it is important that we keep close. The prize is trying to ensure that we use every pound that we spend in the most effective way possible, particularly in workforce. From our perspective, it is important that we have a clear definition of the type of service that we are trying to create, using the ideas of our existing workforce, and others, to shape service models. Workforce planning is not a black art by any stretch of the imagination; there is no real science to it. It is quite simple when it comes down to it, but some of the issues that we encounter daily are primarily about the competing yearning for additional resources. However, we know that there is no bottomless pit of resource.

Ms McCorley: In the document from the Belfast Trust, there was not very much reference to TYC, per se. Will the way in which you change how services are delivered be driven by the board, or will the trust take its own initiative?

Mr D McAlister: I think that there is a dual relationship. There is a lot going on on the ground in the trust. We have our own Transforming Your Care programme board, where a lot of our service development initiatives are brought and governed in the TYC framework. We have a very strong relationship with the local commissioning group, which is our conduit into the Health and Social Care Board. There is no one size fits all. There is very much a dual partnership relationship — between us, the LCG and the Health and Social Care Board — as to how services are being transformed. TYC provides the umbrella by which it is all being taken forward. It gives us leverage to secure bids that we can make to the board for the development of new services coming under the TYC banner. It is very much a partnership relationship between us, LCG and the board.

Ms McCorley: Is the reablement programme working successfully? People have that support for up to six weeks. Beyond that does it just cut off?

Ms Duffield: I do not want to speak on behalf of colleagues from that area or that service who are not here today, but the success is about it being integrated into broader locality teams that have access to specialists and clinical advice from across a whole range of professions. That is how we are developing the model at the moment.

Mr D McAlister: It is needs-assessed. We could all answer that.

Ms McConnell: I suppose the —

Mr Donaghy: Sorry, Ann. I will just add that I suppose, for reablement in the Southern Trust, it is about giving people the confidence to keep living at home. As a result of that, we have seen at least 50% stopped from going to residential homes or hospital beds. It is now beginning to reap the dividends, but it takes a considerable time. We have been implementing it for nearly two years, but now we are, hopefully, seeing the shoots coming up.

Ms McCorley: It is a really positive idea, but my concern is that it will just merge into normal domiciliary care. There are lots of issues being raised about that being inadequate.

Mr D McAlister: That might be the case, depending on what the individual client's needs are assessed as being. After the reablement process, it may be that they are assessed as needing ongoing domiciliary care to live at home, or it may be that there are other pathways that they need to go down. However, it does not just stop. Once reablement is completed, we do not just walk away and leave the client; there will be a continuum of care provided.

Ms McCorley: So you maintain that support.

Mr D McAlister: There will be an element of care maintained, yes.

Ms McCorley: Is that above and beyond what domiciliary care provides?

Mr D McAlister: Again, it depends what the individual client's needs are assessed as being. It may be that they only require domiciliary care, or it may be that there are needs over and above that, which can be met in another way. It is individually needs-assessed.

Ms McCorley: My concern is that we are hearing, from the other angle, that people are under threat. They are at risk of ending up in hospitals because domiciliary care has been reduced and, because of that, they end up in greater need. It is the other end that you are dealing with, but that is the aspect that would prevent people from going into hospital if that was better.

Mr Molloy: The primary objective of the service is to ensure that that very thing does not happen and that ending up in hospital is the last resort.

Mr D McAlister: That is what we have to avoid.

Ms McCorley: That is what we are all trying to do.

Mr D McAlister: Absolutely.

Mr McCarthy: Following on from Rosie's concern, the Committee has certainly voiced its concern about the lack of domiciliary care over a long period. I am delighted to hear that the reablement programme is working. At the back of that, the Committee's and my concern over a long time has been that the number of individuals, particularly elderly lonely people, entitled to community meals was vastly reduced. The reason given by the various trusts was the enabling process. Are you all confident that the vast reduction — you know what I am talking about — in people entitled to community meals is working? As Rosie said, those people are not being left behind. You are trying to get the enabling thing. We are all supportive, but we want to make sure that nobody is left behind when getting a decent meal each day.

Mr Molloy: That is right, Kieran. It is a very highly charged and contentious issue across the Province. We want to make sure that the services that need to be maintained in an individual's home are maintained at the appropriate level and to the appropriate needs that the individual has. In respect of the by-product of the supply of community meals, the biggest issue that has been drawn to our attention is the socialization aspect: that whoever calls gets an individual taking time to talk to them, seeing how they are and listening to the difficulties of the day. We are trying to replace a number of those things with targeted befriending services and by looking at how we can best support an individual living at home. Meals are fine for those individuals who need meals, but by the same token there are specific issues about ensuring that people's socialization and human contact is maintained during the day, without the necessity of a meals provider.

Mr McCarthy: Thanks very much for that. Your briefing papers and your contribution this afternoon are very welcome. I was encouraged by the enthusiasm of each of you about what we are talking about, and that you seem to be saying that you are making progress. That is to be very much welcomed. Keep it up.

Speaking as a constituent representative, another issue, apart from community meals, is waiting times to get into hospital or for treatment. I got a list of waiting times from the Portaferry health clinic. It was unbelievable. There was one person who had to wait 80 weeks for something in the hospital. Surely that is not acceptable.

The Chairperson (Ms Maeve McLaughlin): I will ask the trusts to deal with that separately afterwards, because I am conscious that we are straying into constituency matters. Important though that issue is, I want to keep us on workforce planning.

Mr McCarthy: I am being told off for standing up for my constituents, [Laughter.]

but, anyway, do you get my point?

Mr D McAlister: Yes. I do not think that anybody on this side of the table would accept that that is a position that we find acceptable. Absolutely not.

Mr McCarthy: Damian, you said that you were supportive of workforce planning. Can you give us an assessment of the progress of the regional workforce planning group?

Mr D McAlister: It is one of those things where progress will happen on an evolutionary basis. Going back to the statement that we made, one of the things where there has been the biggest progress is the regional agreement on what the approach should be to workforce planning at a regional level. When you previously had five organisations doing their own thing in respect of workforce planning, which may, in itself, have been successful, the fact that we now have a regionally agreed framework gives us a very clear direction of travel. Factoring it around programmes of care is very important, as opposed to focusing on uni-professional need.

There is absolutely no point in going away and doing a social work workforce plan or a nursing workforce plan for the provision of older people's services in the community. What you need to do first and foremost is assess the demand for older people's services in the community and, subsequently, look at the uni-professional and multi-professional requirements that fall out of that. What are the consequences of the demand that we face for older people's services in the community? How do we best meet that and work outside the traditional professional boundaries? It does not necessarily always need to be about the recruitment of more nurses or social workers. Really begin to look towards the development of new roles, such as we mentioned in the allied health profession or support role — an opportunity to modernise and innovate, as opposed to continuing to deliver the service in the traditional means by which it has always been delivered.

Mr McCarthy: OK. The Allied Health Professions Federation has stated that there seems to be an inconsistency in how the trusts review their workforce and plan. That association stated that it was not aware of the workforce planning happening at trust level. What is your response to that? Is it a communication problem?

Mr D McAlister: Who did you say it was?

Mr McCarthy: The Allied Health Professions Federation.

The Chairperson (Ms Maeve McLaughlin): And the Association of Social Workers.

Mr D McAlister: The Northern Ireland association?

Mr McCarthy: Yes, that is right.

Mr D McAlister: I must admit that I know the second group, but the first one is new on me. We deal locally with the Chartered Society of Physiotherapy and the Society of Radiographers, which are the recognised professional associations and trade unions for those allied health professionals. They pretty much are involved at a local level on a weekly, daily and monthly basis for how we approach the workforce in that regard.

I know that each trust is having discussions with the Northern Ireland Association of Social Workers. I recently had a meeting with it, and the Belfast Trust is now beginning to engage with it on our social work forum. The association has a vested interest in it, and we agree that it can be a key participant and make a contribution, and we are engaging with it in that regard. I will need to go and see who the previous group is and see how we engage with it if we need to.

Mr McCarthy: There is a lack of communication.

Mr Molloy: Kieran, I think that it might be another example of the regional level not necessarily knowing what is happening at the local level. I stress again that there is very high collaborative working between professional organisations at local level and trust level on the whole issue that we are talking about now. At the regional level, people might not necessarily recognise that that is the case.

Mr McCarthy: Finally, we probably have touched on this, but does the trust believe that the make-up of the regional workforce planning group is right? For example, would it be better served if education providers or training bodies were represented on it? Would it be enhanced if professional bodies and trade unions were represented on it? I think that we spoke about this earlier. There are gaps. What is your reaction to that?

Mr Molloy: Do you want me to answer that, Damian?

Mr D McAlister: Yes.

Mr Molloy: Our regional trade union colleagues I love dearly, but I think that they believe that there is something going on in the regional workforce planning group that actually is not. We had a very frank and open discussion with them over recent days, and it is really important that they engage with trusts at local level in the highest possible way that they can, because that is where this happens in reality. From our perspective, we have been saying to them that, whilst a seat at the table would be nice, they may find that, after a period of time, it is not necessarily where they can make the biggest input and impact. I think they have broadly accepted that as being the case, but, frankly, I have absolutely no difficulty with them being at that table. I do not see any issues for them at all. It is just where best they can play an active role.

Mr D McAlister: They currently have a request with the Department for membership.

Mr McCarthy: I wish you all the best; keep it up. Nobody knows who will need your services tomorrow or the next day.

Mr Easton: I was interested in the Western Trust. You were looking at doing different outpatient reductions, and you mentioned respiratory conditions and haematology. Are all the trusts doing the exact same thing?

Ms McConnell: There are four pillars of reform, and outpatients is one of them, so every trust is doing similar types of work. We are particularly being driven by things like our medical workforce shortages and working smarter within those disciplines. We have prioritised the disciplines. For instance, we have fewer haematologists than we would like, so we have a consultant who is inspirational in maximising his input, and we have designed the service around him, but, yes, everyone is doing that type of work.

Mr Easton: The Northern Trust paper states that it would like a greater leverage on the workforce planning in areas such as pharmacy and primary care. What do you mean by that?

Ms Duffield: As we have described already, it is about the opportunity to work in collaboration with all of the different stakeholders that impact our workforce or the pathway of care for a patient. Whether that patient accesses services initially through the GP or goes to the emergency department, it needs to be a clear journey for that individual depending on their requirements. That has an impact on the workforce, the skills and capabilities of the workforce and the required change in culture so that people work outside of silos and in particular directorates or areas so that there is more of an integrated approach to care for the individual. That demands and requires that we work across boundaries. Hopefully that describes what we were referring to. It is across boundaries, whether it is acute care, care in the community, primary care or building our relationships. You will be aware that we have integrated care partnerships. That is one way that we build those relationships and, hopefully, build the ways of working within our community workforce so that we have locality-based teams that work in partnership with GPs.

Mr Easton: I know that you are all working together and that you have all of those things to try to improve that, build relationships and all the rest of it. Would you say that the likes of pharmacies and different things are sort of holding you back a wee bit, because they are not all part of it? Obviously, you are building the relationships, but they are not part of it. Is that holding you back a wee bit in developing?

Ms Duffield: I am not sure that I am equipped to comment on that specifically, but, in the spirit of workforce planning, I think that, if there is any weakness in the cycle that affects the patient's journey, that will hold us back.

Mr D McAlister: Is it community pharmacy or hospital-based pharmacy? Community pharmacy? I do not think they would.

Mr Easton: This is my last question. Is the lack of finance for Transforming Your Care — the fact that you have not progressed it — holding you back quite a bit and you are not able to progress things as quickly as you want?

Mr D McAlister: Workforce planning?

Mr Easton: Yes.

Mr D McAlister: We have not been funded for workforce planning. Any workforce planning that we are doing is being done within our own resources locally. Of course, if there was funding available and it was invested in workforce planning to support local managers then, yes, it would be very welcome.

Mr Easton: Would that speed things up for you?

Mr D McAlister: I think Sir Liam Donaldson made particular reference to Transforming Your Care. I think the commentary that he received indicated that there was frustration on how to progress in that regard. I think the responses that have gone back to the Minister on that indicate that it could be given a bit of impetus with some resources, so, yes, we would welcome it.

Mrs Cameron: Thank you for your presentations. In relation to mental health and learning disability resettlement, I know that you mentioned the Southern Trust's point of view, Kieran. You have probably answered most of my questions, but I will ask again, and maybe ask each of you to answer the same question. What has that meant for each of the trusts in terms of the staff who were previously based in the hospital settings? Did they follow the clients to the new community settings, or were they redeployed to other areas?

Mr Donaghy: I will start, perhaps, and then my colleagues can come in again. In the model that we chose, we had one-to-one meetings with all of our staff to try to find out where they wanted to go. Some of them wanted to follow the clients. For instance, quite a number of our staff followed the clients within supported living, which required a great deal of retraining. Others, however, chose to go and work in Bluestone, which is a mental health facility. Home crisis response in the community was again an option that some others decided to go for. Of 220 staff, we had 14 who took voluntary early retirement; all the rest were redeployed within the trust to various roles, not just in mental health, but in the other programmes of care in the trust. That was again done with the agreement of trade union colleagues, particularly UNISON and NIPSA, which were very helpful in that whole process.

Mr Molloy: Almost 100% of ours have followed the patient. I am thinking specifically of recent times, of the closure of wards in Downshire Hospital and their replacement by places like Cedar Court. All the staff have moved with them. It is really important, particularly in the areas of mental health and learning disability, that the relationship that has been built up between the clinician and the patient is maintained.

Mrs Cameron: Was retraining required for staff?

Mr Molloy: Where it was, it was provided. These are very highly skilled, adaptable and flexible individuals.

Mr D McAlister: It is exactly the same story for us. We are moving people out of traditional institutions where they were cared for and resettling them, both in sheltered accommodation and supported living environments, as well as looking at home treatment teams. No staff have been made redundant; all staff have been redeployed. I would say, like Eamonn, that nearly 100% have followed. Probably all of them have stayed in their speciality area, but whether they have followed the individual patients they cared for is another thing. Certainly, they have stayed in their traditional professional area.

Mrs Cameron: And again —

Mr D McAlister: Again, where reskilling has been required, but very little has been, because this is more about where they are cared for. Once it was in an acute inpatient bed; then it is at home. There is little difference in the actual care.

Ms McConnell: I will not say anything very different. In the redeployments that we have been involved in, a core group go with the client. Some individuals may choose to stay in a hospital-based setting. As Damian said, they are qualified to work in the different settings, and it is more about changing the ethos of the care than having a lot of intensive retraining.

Mr McCarthy: My question is for you, Damian. How is Muckamore progressing? It is due for closure, or at least emptying, very shortly.

Mr D McAlister: The traditional institutions within it are emptying, but other services are now being provided on the Muckamore site — fantastic, leading-edge, first-class services. We are progressing very well, particularly with the resettlement from learning disability. We have a wee bit further to go, but we are working in partnership with families so that nobody feels they are being forced out of the institution. We are very much working in partnership with them to make this as seamless as we can for the client.

Mrs Cameron: I just wanted to get to the Northern Trust on the back of the Muckamore issue. I know that there have been issues in the community. Are you working with the community? I know that you do not have to, but nearby residents and stuff can be an issue and can have real concerns about who is moving in near or around them. I know that is a huge issue, certainly in parts of south Antrim, where resettlement is planned.

Mr D McAlister: I cannot comment specifically on the situation in south Antrim in respect of Muckamore, but our approach as an organisation is very much in fulfilment of our personal and public involvement (PPI) scheme, where we engage the population in those geographical areas as part of any consultation exercise around changes to the service delivery model. It would not just happen without community involvement. While I cannot comment specifically on that case, I would be surprised if that has not happened in respect of how we have approached it with the Belfast Trust and Muckamore.

Ms Duffield: I have not a great deal to add to what has already been said, but in the Northern Trust there has been a programme of resettlement of patients from the Holywell Hospital into community living services. From a workforce perspective, that has been about managing that change in line with our engagement and consultation framework for employees, retraining employees with the right and appropriate skills, but also, through individual meetings with them, finding out where their skills are best placed. There may be different individual decisions depending on the employee, with a large percentage obviously being deployed and following the patient as per the examples that my colleagues have given.

Mrs Dobson: I also thank you for your briefing. It is good to see Kieran here. I usually torture him with emails on a regular basis.

Now that we have heard that there are plans to resume permanent admissions to statutory homes and there has been a reversal of trusts' previous decisions — thanks goodness common sense has prevailed on that one — whose responsibility is it to provide adequate staff to cover those homes? Given trusts' reliance on the private sector for domiciliary care and nursing home placements, who is responsible for providing an adequate workforce to staff those homes?

Mr Donaghy: I will comment on that first. We work very closely with our service directorates. In this particular instance, Jo-Anne, having, as you know, been involved in it for the last two years, we are very comfortable that we are able to provide that level of service to those residents. As you know, the decision has been made to facilitate residents to stay in homes for as long as they wish. We are very comfortable that we will be able to meet those service needs and demands.

Mrs Dobson: Going forward with regard to the reversal of the trusts' previous position with certain homes and the reliance on the private sector, who is responsible for providing an adequate workforce? Is it you? There has been a reliance on the private sector.

Mr Donaghy: If I understand your question, we will look to the service directorates to identify any gaps, and support the service directorates in delivering that service, but it will be the —

Mrs Dobson: Does that go for whatever sector it is, whether it is private or otherwise?

Mr D McAlister: If it is a trust statutory residential home, it is our responsibility, as the employer, to staff it.

Mrs Dobson: And the domiciliary care too? Is that something that the regional workforce planning group is considering, given the fact that the homes will remain open and that it is something that you are responsible for?

Mr D McAlister: Yes.

Mrs Dobson: What impact does the gender mix in the workforce have on trusts' workforce modelling in terms of working patterns? I am thinking of females and part-time workers.

Mr Donaghy: I will allow one of our females to answer.

Ms McConnell: I am a female who works full time, but anyway. The reality is that lots of staff choose to avail themselves of flexible working options. That is an issue for workforce planning, and part of the challenges that we are finding with the medical workforce is the change in the gender group that is coming through. As lifestyle trends change, we learn more and more about how people are working and try to do what is called scenario planning, which looks at what people are likely to want in the future.

Mrs Dobson: Have you had initiatives to encourage more women back to work?

Ms McConnell: We have things like back-to-nursing courses and so on. We never close the door on people who are keen to work with us. We try to have routes to retrain people if they have taken a break. If they are having an employment break for a few years, we try to offer them refresher days or training days. It is the same with extended maternity periods and so on. They can come in and keep in touch. We continue to engage with them and keep them —

Mrs Dobson: Holistically, given the pressures that staff are under anyway, how do you work with them to encourage that when very valuable members of staff feel under pressure? We had an excellent presentation from representatives from Scotland, who told us that they have initiatives to work around women in particular to keep them in their careers and help with workforce planning. Do the trusts work together, or are there individual schemes? How do you plan?

Ms McConnell: I think that we all have our own internal management processes. Clare, do you want to say something about that?

Ms Duffield: I can maybe provide a bit more of an example and one specific thing in relation to the question that was asked. In the Northern Trust, there is obviously a much higher percentage of female employees. At the end of the day, however, we have to recognise that the changing demographics of the workforce in general mean that people want much more flexible working arrangements. They have different lifestyle choices, and we have to have working policies and procedures that can accommodate that so that people enjoy coming to work, whilst also not disrupting the continuity of the care and services that we provide. At a very basic level, that comes down to great rota and roster management at ward or service level. At a more corporate level, we provide a lot of workforce information an analysis to look at the trends and patterns in the workforce. For example —

Mrs Dobson: That would be, if people are leaving, on why they are leaving and what could have been done to —

Ms Duffield: Exactly: it is on labour turnover. We know, for example, that approximately 3% of the female workforce in the Northern Trust is on maternity leave at any one time. By knowing that, we can plan for it. It is about using workforce information and analytics to allow us to plan on a very local level, but also on a more strategic and corporate level.

Mrs Dobson: I note that you talk about hard-to-fill positions. Have you any indication of which ones you find the hardest to fill? Can you outline those and what you are doing to address that?

Mr D McAlister: We have a number of medical posts that, probably in common with all five provider trusts, are hard to fill; for example, consultants in emergency medicine or consultant surgeons. Particularly with specialisation now, it is no longer just a general surgeon that you are looking for but a breast surgeon, gastroenterologist, radiologist, urologist or dermatologist. You could almost name all the specialties. From our perspective, some of those are actually national shortages across the entirety of the United Kingdom. That is why predominantly we are having to push the boundaries of where we traditionally look for supply to beyond these shores and internationally. Recently, in the Belfast Trust, we advertised for consultants in emergency medicine. We ran specific campaigns in Australia, because we knew from people who had returned to work in the organisation after having spent two years in Australia that there were a number of indigenous Irish people there who could potentially come back. We did not have great success, but actually testing the boundaries of it at least gives us more evidence that, in the eventuality that we ever do need to engage the Department in a conversation about a hard-to-fill post, at least we can demonstrate that we have tried significantly to recruit and have been unsuccessful.

Mrs Dobson: Ann, you talked about different methods that you are using in the Western Trust and changes that you are making regarding outpatients. You mentioned work that was under way in renal services. You know my particular interest in renal services. Can you outline —

Ms McConnell: I am not aware of your particular interest, sorry. It is about more home dialysis and skilling up community nurses to support people at home so that there is less need for them to attend outpatient or day clinics.

Mrs Dobson: Will that be rolled out across the trusts?

Mr D McAlister: Yes.

Mrs Dobson: Is that given more significance due to the fact that more people need dialysis? Is that why you are trying to push the home dialysis route more?

Ms McConnell: Yes.

Mr McGimpsey: Thanks, folks, for your presentation. What interests me is actually the time frames and resources that are available, and the shift left in Transforming Your Care. Kieran, you gave us a good example from the Southern Trust of supported living for mental health and learning disability, the crisis in home support and crisis response. Eamonn, you gave us an example of dementia services in the South Eastern Trust. Those are good examples and show good progress. The issue for me, therefore, is this: across how many ranges are you making that sort of progress? You have other areas, obviously, like support services, domiciliary care, respiratory care or whatever. How many others are actually in place and making that sort of progress? First of all, you have the service delivery model, then you match the workforce, then you match the resource and then you match the time frame. You appear to have done that in those two examples in the Southern Trust and South Eastern Trust. Where are you across the further range of service deliveries? Where are the other trusts in this?

Are those they matching you? What we do not want, for example, is good service delivery in your trust but the Belfast Trust being nowhere. It is about making sure that there is coordination. There are also the financial implications. Damian hedged a bit on Liam, his report and the money, but you need money to make this work. If you are to move services into primary and community settings to dampen demand on secondary care, there will be a serious financial implication. Where are you with that? You have a good story to tell. There were two examples. Kieran, I take it that you are one of the Donaghy gang, are you, with Sean and Colm?

Mr Donaghy: Fortunately.

Mr McGimpsey: If you are Colm's brother, you can be sure that I will believe every word that you tell me.

Mr Molloy: How do you answer that? We picked the examples that we gave you today to give you a blend of the services. We are all doing similar things. We are all looking at reablement, how we run our outpatient clinics and various bits and pieces, and we learn from one another. So if there is a unique response or service model design in an organisation, we share that information so that we are not reinventing the wheel. I think that that is sensible. You asked how many more there are. The list is endless, Mr McGimpsey. In our organisation, we have 20 bids — investment proposal templates (IPTs) — under consideration between us and the board. Prioritisation will be important, but each has merit in its own right. When those 20 are complete — if they ever are; I will probably never see them in my lifetime — there will be another 20 to replace them. The environment in which we work is so dynamic that it is important that we always try to use our resources in the best possible way. As HR folk, that is when we come to the fore. It is about trying to ensure that we use our resources in the best possible way, allying that to patient need. There are examples of what we outlined to you today happening in each organisation, and I think that we will probably have another 20.

Mr McGimpsey: You gave dementia as an example, but could you have given me many more examples?

Mr Molloy: Yes. I used that example because the suggestion came from the staff group. We looked at this on the basis that we potentially need a new type of service. The community psychiatric nurse (CPN) workforce is normally a quiet lot, but those individuals said that they were willing to take it on. They knew that people were being referred directly to GPs, and they said that they could help.

Mr Donaghy: I will give another example in the Southern Trust that I think is fairly common in all the trusts. It relates to acute care at home. Basically, we are trying to prevent some of the elderly population going into acute beds. We set up an acute care team that provides cover for 36 nursing homes, which equates to 1,500 beds and 21 GP practices. Team members look at clients in the community setting and provide a plan to look after their needs. It is headed by a consultant geriatrician and comprises a number of professional staff who meet the needs of those clients on an ongoing basis. That takes pressure off the acute system and allows those people to be looked after in their own home, which is another good example of where we have gone with TYC. That is common to each of my colleagues.

Mr McGimpsey: So this is not ad hoc; there is a plan. We want to see the plan and the time frame, and we want to see those benchmarked against workforce and finances. Can you supply us with that?

Mr Molloy: I think that there will be a plan.

Mr McGimpsey: There will be a plan.

Mr Molloy: There will be a plan. To be honest with you, there will be a plan.

Mr McGimpsey: Kieran mentioned that his example dated back to 2009, which is way before TYC. We are not sceptical at all, but I believe firmly that, unless you have the money, you cannot do it. That is why we need to see the plan. We need to see what you want to do, benchmarked against workforce and money, and what resource is required to do it.

Mr Molloy: You will know this better than me, Mr McGimpsey, but it is important for us to have clarity about the commissioning direction of the service. It is about us trying to translate that into the workforce component. We take our lead from that.

Mr McGimpsey: Does it work better if all of you go together —

Mr Molloy: Precisely.

Mr McGimpsey: — and if you all want to do mental health and learning disability and to produce this together?

Mr Molloy: As Damian said, the issue in the past was that workforce planning was seen in professional lines and right down to uni-professional lines. We are now trying to ensure that that does not happen. All professions have a part to play, and we are trying to do this on the basis of what the service tells us we need, what our patients need and what professionals and individuals can supply.

Mr McGimpsey: It is about the demand that you see for the future and how you address that. You have a long way to go.

Mr D McAlister: Absolutely, but, to very clear, workforce planning is not the solution. It is a vehicle by which we could arrive at the solution. The solution is probably driven by commissioning, because commissioning has to meet population needs.

Mr McGimpsey: It is for the local commissioning group to determine the need and inform the board accordingly. As far as I can see, there appears to be a break there. In any case, that is the theory: the board commissions, and you provide.

Mr D McAlister: We provide.

Mr McGimpsey: As far as the regional workforce planning group is concerned, I think that it is a serious mistake not to include the staff side. That is a major blunder. I do not entirely buy the line that regional and local elements are not talking and that there is dysfunction. You are talking to the unions, UNISON or whatever, and they know exactly what is going on. I am sure that it is not meant, and it is not your decision. You just have to go along with it, but it sounds like this: "We are the bosses. We will tell you what to do, and you folks will do it". This is a team game. We are all on the one team.

Mr D McAlister: I want to reassure you that we did not intend any slight whatsoever against our regional trade union colleagues when we made our comments about local trade union officials. We are dealing on the ground with our trade union colleagues in delivering in partnership the services that we provide. We accept the regional position with the absence of trade union colleagues on the regional workforce planning group, but, as my colleague Ann said, they have been invited to sit on the domiciliary care regional workforce planning group, and I know that they are actively considering who can take that seat. It is very important. We are very much in the world of partnership working with trade unions. There is absolutely no question about that.

Mr McKinney: As you are probably aware, we are a bit sceptical from time to time. I will follow up on some of Michael's points. If you are following a plan, how come there is such a disparity between your written contributions today?

Ms McConnell: Can you give me an example?

Mr D McAlister: What do you mean by "disparity"?

Mr McKinney: Your paper, for example, is 15 pages long, and it is my understanding that it refers to TYC once. The South Eastern Trust's paper is about a page and a half long. In content alone, there are huge differences in what has been presented today. Is that consistent with a plan?

Mr D McAlister: As individual employers, we all have our own plan. I reflected the Belfast Trust plan. Obviously, I cannot speak for others. You comment that we mention TYC only once. We have had a service reform plan, which was a requirement, since 2008, when the first comprehensive spending review was put in place against the trust, and we have been carrying out that plan for the last seven years. When Transforming Your Care came along, it brought the plan together regionally and gave us a very strong direction. We would contend that we were on that path, but it certainly gave us very clear and credible evidence of where we needed to be. My response to the Committee was an attempt to be as full and frank as possible.

Mr McKinney: Yes, so is the South Eastern Trust operating to a different agenda that is much more bald?

Mr Molloy: No, not at all. I tend not to write long letters, unfortunately.

Mr D McAlister: I do.

Mr Molloy: From our perspective, as we have demonstrated this afternoon, we work across a broad canvas and have similar ideas and plans on what we are trying to do to put services in place.

Mr McKinney: Can you point me to the plan that Mr McGimpsey asked for? Where is the plan? Where are the timescales?

Mr Molloy: Ongoing work in the regional workforce planning group is to develop that plan. It is important that that group is given the opportunity to do so and to bring it forward in the way that we described.

Mr McKinney: What timescales are you operating to?

Mr Molloy: To be frank, that question is probably best addressed to the Department, which is leading the regional workforce planning group. We have an idea of what we would like to do in our organisation. We follow the commissioning direction and try to put in place the services that we believe our patients and clients need. If that is a plan, it is a plan. If you are looking at something that is more overarching in structure across all organisations, that, hopefully, will come sooner rather than later.

Mr McKinney: We are, however, four years into a process that was supposed to last five years. Are you reflecting that fact back up the line?

Mr D McAlister: To reassure the Committee, we have not been doing nothing in the last four years; we have been very busy reforming our services locally. I accept the point that the regional workforce planning group and the regional workforce planning framework document were agreed and established only recently. The document was agreed only in March. Now is the time to put significant impetus and energy behind them.

The work that we are doing on domiciliary care, which is complemented, as I mentioned in our opening statement, by the Health and Social Care Board's review of domiciliary care and the service delivery model, is the first attempt. We are very clear that that work needs to have significant energy and commitment behind it. As organisations, we are all committed to it, because we recognise that it is a fundamental part of the service we provide, particularly to our older population, so it has to be provided right.

Mr McKinney: Just recently, Julie Thompson told us that it was now an eight- to 10-year plan. Has that been reflected to you?

Mr D McAlister: Sorry — an eight- to 10-year plan in respect of what?

Mr McKinney: TYC.

Mr D McAlister: Locally, we all have our own TYC programme boards, and we each have a plan that we are working to. Our plan —

Mr McKinney: I am trying to work out what plan and timescales you are operating to. Are there any timescales?

Mr D McAlister: I have not seen an eight- to 10-year plan, but that is not to say that one does not exist.

Mr McKinney: Are you operating to the original five-year plan, then?

Mr D McAlister: We are operating locally, and we operate within our trust delivery plan, which is an annual document that reflects all that we undertake to do as an organisation.

Mr McKinney: I get that, but I am trying to work out where the Transforming Your Care initiative is at. It was a five-year plan. We are being told it could be an eight- to 10-year plan. What is being communicated to you about that?

Mr D McAlister: We understand that TYC is an iterative plan. I was here on 11 March with Heather Stevens from the Department when we talked about TYC. When TYC was launched in 2011, it was a document that put a stake in the ground and established a direction of travel. However, as we reflected that day, the service has developed and grown as well, and it has not just been about shifting things left. There has been a growth in our community staff, for example, but, equally, there has been a growth in those staff working in the acute hospital service, because service demand and service developments have occurred.

It is a rolling plan that you do not simply put time frames to and work to. It needs to be sensitive to the way in which services are commissioned and to how population need, health and well-being change. It is a stake in the ground, but it has to evolve. It does not just set down one direction of travel.

Mr McKinney: It is OK to say that in 2015, but that was not what was being said in 2011, and it is not what people bought into during the Executive's consideration of the business case.

Mr D McAlister: It set down very clear principles. Everybody would accept that it was about providing care, insofar as possible, in people's homes, and that is still the aspiration of each organisation in Health and Social Care. We want people in hospital only when they need to be there. As long as we can keep people out of hospitals and institutions, that has to be a good thing, and that is all that we are working towards.

Mr McKinney: How many of the cuts that you were asked to see through in the last while impacted the plan — if it exists — negatively?

Mr D McAlister: The efficiency savings that we have been required to make have been challenging. I do not necessarily believe that they have cut into any plan that we have. Indeed, they can be used as a force for good in expediting the plan.

Mr McKinney: At other levels, the defence has been an acceptance that it is counter-strategic. Do you accept that you have been forced into counter-strategic measures?

Mr Molloy: When possible, we try to avoid that. In reality — this has been well documented — the financial situation that we are working in is extremely difficult. It is as difficult as I have ever seen, and I have been around these parts for a long time. Over the last three to four years, it has been very challenging, and there is the potential for us to do things that are counter-strategic. We want to try to ensure that we do things that are strategically sound and relevant.

Mr McKinney: Do you accept that some of that counter-strategic approach has impacted older people more than in other areas, given the cutbacks in domiciliary care packages?

Mr D McAlister: No, I do not agree with that.

Ms McConnell: Our approach is to try to make those savings across the range of directorates and services. The reality is that there are some services that you intend to make savings in that you just cannot because, if people present themselves at the door of a hospital, they need treatment.

Mr McKinney: I get that, but, when you provide brief domiciliary care packages, with people potentially finding themselves malnourished as a result, those people who could be kept in their own homes are now presenting themselves at the very door where you are trying to cut costs and prevent them entering. I am looking for the strategic approach that puts the resource into the area that TYC recognised as being the biggest area of concern.

Mr D McAlister: That is exactly why I said that I think that we need to put a significant impetus and energy behind the ongoing review that is being led by the board on domiciliary care and the associated workforce planning that falls from it. I do not accept that we have salami-sliced older people's services, particularly in domiciliary care. It is still an assessed need, and we believe that we are providing an assessed need on that basis. The regional workforce plan will, hopefully, secure the agenda of clearly identifying future demand and the workforce that we require to meet such a demand. That cannot come soon enough.

Ms Duffield: The financial challenges that all the trusts are presented with means that we must have a more diverse approach to workforce planning, because we have to use resources in the most productive and efficient way. From a workforce perspective, the financial challenges mean retraining, diversification of skills, redeployment, productivity and ensuring that we retain and attract the best talent, because the pipeline of talent is not as available as it was. There are implications for the way in which we plan and use our workforce, but I believe that that could be argued in any organisation.

The Chairperson (Ms Maeve McLaughlin): One TYC assertion is that a 3% reduction in the workforce is required. As trusts, do you have a view on the actual requirement? We are now told that that was a working assumption.

Mr D McAlister: As I said, it was a working assumption in 2011, but, in 2015, the service is different to what it was in 2011. There has certainly been a growth in demand, and, while we gave examples of where the expected shift left, as it is called, of moving resources out of hospitals into community settings has occurred, it has now clearly been offset by a growth in hospital services. So it is difficult to say transparently that there has been a 3% reduction. There has been growth in both sectors.

The Chairperson (Ms Maeve McLaughlin): Are we now saying that what is in fact required is an increase in the workforce?

Mr D McAlister: Our demand is growing at 6% a year, yet the financial investment into the health service has been set at 2%. While there are productivity challenges for us to rise to, equally, the demands on service in our current configuration of service delivery model in the Health and Social Care family and environment is not only a challenge financially but a challenge for the workforce.

The Chairperson (Ms Maeve McLaughlin): What I am hearing and trying to tease out is that, to implement Transforming Your Care and the shift left, there would be a requirement to increase the current workforce.

Ms McConnell: I think that it is fair to say that, for a lot of the initiatives that we need to put on the ground in the community, we need transitional funding. I shared some examples of respiratory services making a real impact on admissions and so on. When they start to make a real impact, it means that, at some stage, we will no longer need the transitional funding and will be able to shift the money from one source to another. It is fair to say that quite a few of the initiatives need transitional funding.

The Chairperson (Ms Maeve McLaughlin): Does it also mean an increase in staff?

Mr D McAlister: It could do, temporarily.

Ms McConnell: Our funding is primarily spent on staffing.

Mr D McAlister: The example that I gave about ambulatory care is prime: we still have patients occupying beds who are admitted to the emergency department while we grow the ambulatory care service to try to prevent those things happening. It does not stop on a Friday and start on a Monday. There will be a potential need for investment funding at the start and an increase in the workforce.

Mr Molloy: The traditional workforce that we employed 10 or 15 years ago compared with the workforce that we now employ are poles apart.

The Chairperson (Ms Maeve McLaughlin): Yes, but do we have a sense of that overall? I know that this is the board's responsibility, but, as trusts, if it is not a 3% decrease, what is it? How much of an increase is it?

Mr Molloy: It is a different workforce. Our workforce numbers might increase, but they might be completely different to what they are now. I used the word "dynamic" earlier, and I really mean that in its truest sense. The individuals whom we now employ are the types that we mentioned in some of those examples, such as AHP support workers. There are people with a generic range of skills whom we would not have employed five or six years ago. A physician's assistant would not —

The Chairperson (Ms Maeve McLaughlin): Does the regional workforce planning group have that analysis?

Mr Molloy: It is important that we work together to try to ensure that we develop that thinking in a coalescent sense, right across the totality of everybody as a —

The Chairperson (Ms Maeve McLaughlin): OK, I will close there. I find it ironic that somebody, somewhere was able to calculate a 3% decrease in staff required to implement TYC, and we are now saying that that was a working assumption, but we do not have a figure. We know that it is an increase, but we do not know how much. That is part of the difficulty that we find ourselves in with this policy direction.

Thank you for your time and evidence today.