Official Report: Minutes of Evidence
Committee for Health, Social Services and Public Safety, meeting on Wednesday, 7 October 2015
Members present for all or part of the proceedings:
Ms M McLaughlin (Chairperson)
Mr Alex Easton (Deputy Chairperson)
Mrs Pam Cameron
Mrs J Dobson
Mr K McCarthy
Ms R McCorley
Mr M McGimpsey
Mr Fearghal McKinney
Mr George Robinson
Witnesses:
Mr Richard Pengelly, Department of Health
Key Issues in the Health Service: Mr Richard Pengelly, DHSSPS
The Chairperson (Ms Maeve McLaughlin): The permanent secretary, Mr Richard Pengelly, is here today to discuss the current position on key issues. No papers have been provided. You are welcome; thank you for attending, Richard. Do you want to make a few opening comments?
Mr Richard Pengelly (Department of Health, Social Services and Public Safety): I had not planned to, Chair. I thought you just wanted to go on to questions, if that suits you.
Mr R Pengelly: I will take your guidance, Chair. I am here on the back of a phone call that said that you wanted me to come along. I do not have a list of specific issues that you want to talk about. That is why there is no paper. I thought that you wanted to move into questions.
The Chairperson (Ms Maeve McLaughlin): OK. We will do it through questions, Richard; thank you. Thank you for agreeing to come along today. Obviously, we find ourselves in a hugely important position. Can I ask you this frankly, to begin with: is it currently business as usual?
Mr R Pengelly: In the absence of a very precise definition of "business as usual", it is as close to business as usual. None of us would pretend that we are in a perfect situation, but, in terms of operational issues, it absolutely is business as usual. The business of the health and social care sector continues, and patients continue to be seen. With regard to the key issue with the position of the Minister, his involvement is, clearly, on the high-level strategic issues. Since 10 September and the first resignation, I have had a good amount of time with the Minister every week, following the renomination. In those discussions, he has cleared some key issues. Certainly, we have had a longer discussion about the general direction of travel of some of the strategic issues, and he continues to give us that guidance. So, whilst it is not perfect, I certainly do not see anything in the strategic piece in which there is a fundamental flaw.
Mr R Pengelly: Think about the two key roles of the Minister, one of which is the strategic direction role. To the extent that there is absolute unfettered access, where, if an issue comes up, we can have a conversation, that does not happen. That is not the norm; it will happen from time to time. I can honestly say that, over the last three weeks, there has not been an issue on my desk of such strategic importance that I have thought that I needed to speak to the Minister about it but have been unable to do so. We have had some very good strategic discussions. Probably the bigger gap — important as it is, it is not anything like as significant as the strategic issue — is in the outward-facing duties that the Minister would perform on a very regular basis, such as engagement with the community, attending functions and events and meeting delegations of interest groups. I do not want to underplay the importance of that engagement and dialogue, but, if we are talking about a period of a couple of weeks in which that does not happen, it is not on the same seismic scale.
The Chairperson (Ms Maeve McLaughlin): You are saying that it is "as close to business as usual" but it is not perfect, and you have alluded to strategic decision-making. If there is a strategic decision to be made, are you in charge? Can you make that decision?
Mr R Pengelly: No, issues that need ministerial decision will always need ministerial decision.
Mr R Pengelly: In this session, it might be helpful to give examples of the issues that you have in mind. Over the past number of weeks, there has not been an issue on which we have had to absolutely slam the brakes on what we are doing because something needs a ministerial decision and we have not been able to get it. Ultimately, any Department operates at the direction of a Minister. The position that the Minister put in place before resignation sets our policy and strategic direction. I can take any and all decisions within that environment, but, if a decision lands on my desk, I cannot say, "This is not an issue that a Minister has given any consideration to, but my view is that the Minister would pick x or y". I cannot do that.
The Chairperson (Ms Maeve McLaughlin): If a Minister has made recommendations or there are recommendations on his desk, as it stands currently you cannot implement them. You cannot write the cheque.
Mr R Pengelly: If the Minister has agreed recommendations? If the Minister has agreed recommendations, we can carry on with their implementation.
Mr R Pengelly: There is no decision on the Minister's desk on the review of commissioning. We have captured a huge amount of evidence as a result of the dialogue that we have had, and we have engaged with colleagues across the sector. We are collating evidence and trying to formulate where we end up on that. As we do that, we have had regular discussions with the Minister, pre and post 10 September. That issue —
Mr R Pengelly: Yes, but that has not been completed —
Mr R Pengelly: No, but the report has not thus far been absolutely concluded. There is no report sitting on a Minister's desk waiting for sign-off by a Minister. We have continued to work on that. You talked about an aspiration: we had to engage much more deeply and much more widely than we first thought with colleagues across the system. We have had considerable ministerial input into that. I would say that we are very close to the finishing line on that, but where I sit right here and now, I have not put a final set of recommendations to the Minister for sign-off.
Mr R Pengelly: To a considerable extent, yes. However, I cannot take the place of a Minister and take decisions that are the preserve of Ministers. I can implement decisions that have already been taken by Ministers, I can authorise payment for the implementation of those decisions and we can progress those.
Mr R Pengelly: As I said, my assessment is that it is not a perfect situation. I do not believe that it is impacting across the service in operational terms, because the Minister does not get involved in operational issues.
Mr R Pengelly: We need to bear it in mind that, at the moment, we are talking about a situation that arose on 10 September, a few weeks after early August. The strategic agenda is one that will map out the direction of travel for the health and social care sector for the next five, 10 or 15 years. That will take a fair bit of time to implement. I absolutely do not believe that it has had a fundamental impact or that it will cause any significant delay in that work.
Mr R Pengelly: I do not want to get hung up on definitions. The system is in extreme difficulty. We can talk about the reasons for that, but the question is whether you could characterise that as a crisis. For someone who is on a waiting list and facing the prospect of a year or more's wait, I absolutely think that that individual would call this a crisis situation. However, we need to bear in mind that, in the normal run of health and social care, 30,000 outpatient appointments are conducted every week, and there are over 230,000 GP patient consultations. There is a huge amount of activity that continues to a very high standard and is delivered by hugely committed and professional staff.
Mr R Pengelly: Neither am I, Chairperson, and that is why I am struggling to completely agree that it is in crisis.
The Chairperson (Ms Maeve McLaughlin): In your opinion, are there instances where, potentially, if this continues, we will see public concern and potential crisis around the delivery of health? What are those?
Mr R Pengelly: I am not sure that there is any merit in trying to get into the space around what differentiates a crisis from an extreme difficulty. There is no doubt that there is a large measure of public concern and concern in the Assembly from elected representatives, and rightly so. By any measure it is, at minimum, an exceptionally difficult and challenging position that we face, but, to be frank, my job and my responsibility is to deal with that rather than spend too much time debating what label we attach to it.
Mr R Pengelly: I do not think, Chair, that anyone in Northern Ireland should be surprised about the position that we are in. It was clarified by the previous Minister in the Committee last October. He was clear about the direction of travel that we were taking with the funding envelope that we had for this year. It is not as if this has snuck up on us in some way.
Mr R Pengelly: I can see a situation developing in which the waiting times will continue to deteriorate, but — I suspect that we will come on to this — in the short term, the only way that we will address that issue is through securing additional funding.
The Chairperson (Ms Maeve McLaughlin): OK, so, what are you, as permanent secretary, as the person who is in charge, albeit loosely, doing to mitigate that? What actions are you taking? Is there an action plan? Is there a developing protocol around how we tackle that? If you are flagging this up today as a potentially deteriorating situation —
Mr R Pengelly: We have commissioned from the Health and Social Care Board, which remains the commissioner of the delivery of services, a medium- to long-term plan for addressing the problem of elective care. That is looking at how we can, over a period of years, get the position back in —
Mr R Pengelly: As far as the board is concerned, the commissioning plan is close to being agreed. The Minister wrote to the chair, and I wrote to the chief executive of the board some weeks ago to say that the Minister was largely content with the plan. There were a couple of minor caveats, so we asked the board to come back to us with some assurances. The assurance that it received is absolutely adequate for the board to get on with implementation of the plan, and we wait. I think that I saw last night in my inbox that the chief executive was —
The Chairperson (Ms Maeve McLaughlin): But, with respect, "close to being agreed" is not sufficient when that will be the format for the delivery of services, which would include, I assume, a key responsibility in and around waiting times. I suggest that "close to being agreed" does not wash.
Mr R Pengelly: I accept that, Chair, but your proposition is, then, that the Minister should agree something that he is not happy with. The commissioning plan was put to the Minister for approval, and there were a couple of additional assurances that he wanted from the board, as implementers of the plan. He wrote to the board a number of weeks ago, asking for those assurances. We await the board's detailed response on that. The Minister —
Mr R Pengelly: The Minister indicated, Chair, that he was broadly content with the plan. That was a sufficient steer for the board to get on with the plan.
Mr R Pengelly: Absolutely.
Mr R Pengelly: Absolutely.
The Chairperson (Ms Maeve McLaughlin): OK.
There are two pieces of legislation: the Health (Miscellaneous Provisions) Bill and the Health and Social Care Bill. Will the Health (Miscellaneous Provisions) Bill be introduced?
Mr R Pengelly: It will be introduced. At this stage, I cannot say precisely when it will be introduced.
Mr R Pengelly: I think — I would need to confirm this absolutely, Chair — but my memory is that, as long as it is introduced before the end of this month, it will not be at risk because of timing issues.
Mr R Pengelly: Yes. I will need to double-check that for you, Chair, but, from recollection, that is —
Mr R Pengelly: Of course there is a risk. For as long as it remains unintroduced, I cannot say that there is no risk. However, your question, I think, was, "Is it likely to fall because of time?", and, as long as it is introduced before the end of October, there is time for it to progress satisfactorily through the Assembly.
Mr R Pengelly: Off the top of my head, Chair, I am sorry. I cannot —
Mr R Pengelly: Absolutely, Chair.
The Chairperson (Ms Maeve McLaughlin): There is one more point that I want to raise; I know that the Deputy Chair wants to come in because he has another meeting to go to. This document — 'Changing the Culture of Care Provision in Northern Ireland' — which contains formal guidance to the Department from the Older People's Commissioner: where is it?
Mr R Pengelly: As I say, without advance notice of the specifics, I can say only that I will certainly check out the detail of that and get back to you.
Mr R Pengelly: I find concerning the assumption that I should have photographic recall of every issue that is live in the Department.
Mr R Pengelly: It is of fundamental importance that I make sure that answers I give the Committee are accurate. What I want to do is come back to you with an accurate articulation of our position on that.
The Chairperson (Ms Maeve McLaughlin): What I say back to you, Richard, is that this report, time out of number, referenced significant failings in the level of care provided, with formal advice to the Minister: four recommendations. It said:
"These proposals require consideration and action by the Minister for Health, Social Services and Public Safety."
That was in November. Very concerningly, it flagged up significant failings in how our older people and vulnerable people are cared for, and you say that you cannot respond. This was formal guidance to a Minister.
Mr R Pengelly: Chair, I can only apologise, but I cannot carry in my head the detail of every issue that is live in the Department and reproduce it. I am sorry.
Mr R Pengelly: Being in charge —
Mr R Pengelly: No, being in charge means leading other people. It means having good people around you and delegating; giving them authority and responsibility to take forward work on various things. I cannot do every piece of work in the Department myself.
The Chairperson (Ms Maeve McLaughlin): I find it irregular, Richard, that you come to the Committee to discuss the current situation in relation to health. What we want to know is this: who is in charge? Who is taking forward the key work? That report is a critical piece of work that highlighted major failings in our system.
Mr R Pengelly: With respect, Chair, I am here today because you phoned me at the end of last week and said, "Can you come along and talk about the Minister not being there?".
Mr R Pengelly: You are now extending it to talk about the specifics of other issues. I would like a little indulgence that maybe I cannot be forewarned —
The Chairperson (Ms Maeve McLaughlin): Richard, there were a number of issues last week. Yes, of course, we have asked you along today to address the fact that the Minister is not there, because that is leaving a gap that is well identified across our sector. Of course we will flag up the issues that are currently on the Minister's desk that can be actioned, and this is one of them. I assumed that, as permanent secretary, you would turn up today equipped with the details of that.
Mr R Pengelly: I am sorry, Chair: I turned up today to talk about the issue that you told me you wanted to talk about.
Mr R Pengelly: We have a clear mechanism whereby you highlight issues for agenda, and we produce papers. We come along and provide as much information as we can. If we get into a situation where we are invited along to talk about one thing and very specific points about other issues are dropped in, it is unfortunate, but it is difficult to respond to them with the accuracy that the Committee deserves.
The Chairperson (Ms Maeve McLaughlin): You are in charge, Richard, and I suggest to you again that there are a number of pieces there — I know that a number of members are looking to come in — but this is a key piece. This was not just a report that was produced by a sectoral organisation. This is the Commissioner for Older People giving formal guidance to the Minister in November 2014. Now, we have a situation where we do not have a Minister, and the permanent secretary is in front of us saying, "I do not know". I find that irregular.
Mr R Pengelly: I accept that that is a key piece, Chair, but I hope that you equally accept that it is not the only key piece of work in the Department.
Mr R Pengelly: There are numerous strands of work. I am trying to lead and keep the momentum going on a range of issues. The consequence of that is that I need to rely on the very capable and professional people around me to take forward bits and pieces of work. That means that, at any point in time, if I am suddenly asked a specific question about a piece of work, it may be that I cannot answer with graphic detail. I am sorry, but that is the way it is.
Mr R Pengelly: No. I think the Committee wants a detailed and specific answer, and I will provide that.
Mr R Pengelly: We will provide that to the Committee.
Mr R Pengelly: We will provide it to the Committee.
Mr Easton: Thank you, Chair. Richard, in your opinion, the day-to-day running of the health service has not been affected by the Minister's absence.
Mr R Pengelly: No. As I said to the Chair, I would define the day-to-day issues of the health service as activity that happens in GP practices, hospitals and community services. The Minister has no day-to-day role in that, and it continues under the guidance of the clinicians who lead that work and their very committed staff.
Mr Easton: There have been no major issues during this period that you have not been able to deal with?
Mr R Pengelly: The big issues that we are dealing with are things like Donaldson and the review of commissioning. There has been an opportunity for the Minister to give me his strategic direction on those on a weekly basis. They have not suffered. There are no decisions sitting on my desk that are burning at the edges waiting.
Mr Easton: So, you are in regular contact with the Health Minister, every week basically.
Mr R Pengelly: Every week after renomination.
Mr Easton: Obviously, waiting lists are getting worse: is that pretty much down to a lack of money?
Mr R Pengelly: The financial issue is the most significant issue just to be completed. The other big issue is demand. It is interesting if you look at it. Sometimes the public judge the performance of the health service by reference to metric of waiting times, and I can understand why that happens. However, the problem comes when you factor in rising demand, and there is increasing demand both in numbers and in the level of acuity of patients that come forward. There was more activity in the health service last month than there was in the same period last year. We are improving performance, but that increase in performance is not as sharp as the increase in demand. At one level, performance is improving. However, it is not improving quickly enough to keep up with demand. You have to factor that in along with the pressures in unscheduled care, which obviously have an impact on elective care. The single biggest issue is the availability of funding. Look at the use that we have made in previous years of the independent sector as a safety valve. The funding for that has been drastically reduced this year, so that remains a big issue.
Mr Easton: So, basically, you have been reliant on monitoring rounds to boost that activity in the independent sector.
Mr R Pengelly: We have been reliant on it to boost it. However, even within our baseline, we have had a measure of funding. This year, in the last Budget, we were grateful to get support from the Executive in real terms. The problem is that demand has grown greater than real terms, so we struggle to keep up. Even our baseline funding has been insufficient. It is not just that we are reliant on monitoring but that we are becoming ever more reliant on the monitoring system to receive funds to keep up activity.
Mr Easton: So, the arguments about welfare and the fact that we are getting fined £10 million every month have not been helpful to getting money down to the Department. That money could have gone into the health service and helped waiting lists.
Mr R Pengelly: I hope you appreciate that I do not want to stray into the politics. From my perspective, we made a significant bid in June monitoring that would have helped us to alleviate some of these issues. For issues that are outwith my area of responsibility, there was no June monitoring round, and we did not receive any allocation. From my perspective, that is the key cause of our difficulties.
Mr Easton: Getting welfare resolved would probably be helpful to you in the Department.
Mr R Pengelly: The Executive allocating additional funds to us would be very helpful from my perspective. What takes place in the political echelon to facilitate that is not an issue for me.
Mr McCarthy: I must say that I am very disappointed in your responses so far. First of all, you came in without a paper in front of you to give us an indication of things. You have gone on about availability of funding, baseline funding being insufficient etc. I have a document in front of me that says that your latest assessment is that the Department will live within its available budget. You go on to say that achieving financial balance will have service implications for patients and clients. In other words, you are saying what has been said in the Assembly week after week. Last week, it was waiting lists and cancer support, and this week it was autism. Yet, you also say that you will be able to live within your budget. Which is it?
You also mentioned that the health service is in "extreme difficulty": some people have said that the health service is in crisis. I would say that the health service is in a shambles. From what I hear from you this morning, we are going to continue with that shambles, whether there is a Minister there or not. Can you give me some idea about this? The last time that your officials came here — I do not know whether you were with us or not — you were looking for £98 million from the June monitoring round, which you have not got. You have not got one penny.
Mr R Pengelly: £89 million.
Mr McCarthy: Sorry, £89 million. Of that, £45 million was to overcome the waiting lists issue. You have not got that. Is that why we are on a downward spiral and why my constituents are waiting desperately to see a consultant or whomever to get them out of pain and suffering?
Chair, I could go on and on in relation to waiting lists. Cancer support is another issue. You know as well as I do that it is unbelievable that people have to wait to see what the next stage in their cancer treatment will be. Autism is another issue, which we spoke about yesterday. I have a list of questions, and I do not have time to discuss them this morning, but I will ask you take them with you. The Autism Act went through this House in 2011, and there is a lot of disappointment that a lot of stuff in that Act has not been implemented. For instance, funding for the awareness campaign in that Act has never happened. Can you comment on how things are measured? Can you confirm whether claimed progress will be independently scrutinised, validated or self-reported and regulated? This is all to do with the Autism Act. A lot of stuff in it has not been implemented. Do you agree that public confidence would be best served if the Departments did not police themselves? I will give you that list, Mr Pengelly, particularly about autism, and I expect that you can answer the Committee on that.
Can you see where we, as public representatives, are? Also, the Committee asked for an update on the Donaldson report. We got a letter back from the Department saying, "We can't give you that". Your Department cannot give this Committee a report on how the 99 recommendations are being taken forward. If that is —
Mr R Pengelly: Are you talking about Transforming Your Care?
Mr McCarthy: Yes, absolutely. You spoke about the Donaldson report on the back of Transforming Your Care, and you could not even give us an update on how those recommendations were being brought forward. That proves my point that the health service is not in crisis; it is in a shambles. Can you give us any explanation of where we are going simply because you did not get that £45 million for existing service pressures, elective care, diagnostics, Transforming Your Care, etc? You sit there and say that we are in extreme difficulties. As I said, I think that we are in a shambles.
Mr R Pengelly: I will try and pick up on the issues that you raised. First, a paper is being prepared for the session on the financial position, which Julie is coming to this afternoon. We are on course to break even because that is the fundamental responsibility on the Department to live within the budget that is set by the Executive and approved by the Assembly. I do not think that we have any other choice but to do that. The consequences of living within budget are that we cannot deliver as broad a range of services as we would want to. The point that would have been flagged up at the time of the June monitoring round, when the bid for £89 million was submitted, was that the consequences of not getting that funding will mean reduced levels of elective care activity.
Mr R Pengelly: Yes. The simple reality is — forgive me for stating the obvious — we cannot increase activity unless we have the funds to pay for it. Elective activity is not cheap. It is either done through extended opening and use of overtime in our trust facilities or use of the independent sector. So, if we do not have the money to pay for that, and we bid to the Executive for the money and that is not forthcoming, that activity cannot happen. The consequence of that is that our levels of activity cannot keep pace with demand, and, hence, waiting times will grow. Again, that is a point that has been flagged up on many occasions before today.
You touched on autism. I will take your questions and come back with comprehensive answers. The financial position on autism is that, between 2010 and last year, referrals increased from 1,500 to 2,900. We do not have the capacity in the system to keep pace with that. To create the additional capacity to deal with the diagnosis and the subsequent treatment would cost around £2·5 million a year. That, again, is a financial issue that we will press.
Parallel to that is the response. We have asked the clinicians to undertake a peer-led review of the clinical pathways and the ways in which we can reshape the service within current resources to get through those referrals more quickly
It is important to point out that, although we talked very much there about the clinical pathway and diagnosis through to treatment, at a very early stage in the referral process there are a number of other support services available for the families affected, which we certainly signpost, such as educational psychologists and speech and language therapists. It is not the case that the children and young people who are affected are left in isolation. There is some support, but absolutely not the level of support that any of us would want to give to them. Again, at the risk of repeating myself, unless and until we get the additional resources to put in place additional clinical support to deal with those numbers, which have virtually doubled in that four-year period, that will be a difficulty. There are over 800 people who are waiting for longer than 13 weeks.
Mr McCarthy: So you admit that there has been a breach of the Act. You said that there was an increase of some 60% in the number of youngsters with autism. There has not been a 60% increase in funding to cater for that, so there is a breach of the Act that was passed in 2011, which is totally unacceptable.
Mr R Pengelly: But we do not have the funding. There is a risk, if we take each of these issues in isolation, that we lose the bigger picture. The reality is that, with a fixed budget within which we have an absolute obligation to live, if we spend more money in any one area, we spend less in another area. Everywhere we look in the health service, services are of fundamental importance, particularly from the perspective of the patient or client who receives that service. There are very few easy choices here.
Mrs Dobson: Richard, you will no doubt be aware of the debate on the motion that most of us took part in on Monday in the Chamber. In the absence of a Minister to answer these crucial questions on behalf of cancer sufferers, I would like to focus my questions on cancer services. Of all the missed targets, the one that most concerned me was that only 27% of breast cancer sufferers in the Belfast Trust were seen within 14 days. Can you explain why that was, given that the Northern Trust met the target with a similar number of patients?
Mr R Pengelly: On the 14-day target, I will briefly try to cover the five trusts. Three trusts — the Northern Trust, the Southern Trust and the Western Trust — have a pretty high level of compliance with the target. The overall Northern Ireland target is currently being dragged down, mostly by performance in the Belfast Trust and, secondly, by the South Eastern Trust. The big issue with the Belfast Trust has been the inability to secure the necessary staff resources, particularly at consultant level. The one ray of optimism in this is that, from speaking to the Belfast Trust as recently as last week, I know that it has now secured the additional resource. The consequence of that has implications for the South Eastern Trust, the poor performance of which was in considerable measure due to the fact that, given the problems in Belfast, it had started taking patients from Belfast to treat because there were such difficulties. That pulled the performance of those two trusts down. The Belfast Trust is now confident that, by October, it will be back to 100% compliance with the target.
Mr R Pengelly: This month. It is confident that, when we report the figures for October, it will have the staff resource in place. It is also running additional evening clinics to try to catch up with the demand, so there is a clear recovery plan there. The big issue was securing that staff resource. Having said that it is good that it is getting back to 100%, it is hugely regrettable that vulnerable patients were put in the position of us not complying with that target. It is a fundamentally important target for us to comply with.
Mrs Dobson: It is simply shocking. I am sure you are aware that, yesterday, at the invitation of the Minister, most of us attended a Public Health Agency (PHA) event to promote the Be Cancer Aware campaign and Breast Cancer Awareness Month. At one end, the health service is encouraging women to come forward for breast cancer checks, and, at the other end, the health service cannot cope with the pressure. It is brilliant that more women are coming forward, and we are very much for that campaign, but, if they do not get the treatment or those urgent referrals —
Mr R Pengelly: Absolutely.
Mrs Dobson: As you said, it is one of the most treatable cancers if it is caught early enough. I am pleased that you are addressing that, and I hope that we are not in the same position where you talked about a consultant not being in place, because it was so shocking. Those figures are a total disgrace, you have to admit.
Mr R Pengelly: Performances at that level are not acceptable to us. I am not going to sit here and say that it is due to issues outside our control. One point I would make — I say this only to be fair to my colleagues on the front line who are delivering the service — is that it is important to reassure the public by saying that the recent European study showed that we in Northern Ireland have the best breast cancer survival rate across the United Kingdom and Ireland.
Mr R Pengelly: As we stand today, we have the best survival rate. That is an important point of reassurance, but that requires us —
Mr R Pengelly: I accept your point about performance, but that has improved. It is important to provide comfort to people and recognise the effort that has gone in.
Mrs Dobson: What is the backlog? If a consultant has now been appointed, what is the backlog in the Belfast Trust? Obviously, there are very many women waiting for treatment.
Mr R Pengelly: I am not sure. Again, there is an issue around increasing demand. From memory, I think that about 1,300 patients were seen in June, which was the high —
Mrs Dobson: Because of the campaign that we all supported yesterday.
Mr R Pengelly: We would expect to see that spike in demand in the latter part of this month and in November.
Mr R Pengelly: Yes. In terms of the outworking of that campaign, the trust plans to put in place some evening clinics in anticipation of a spike in demand, through the publicity of the PHA.
Mrs Dobson: Do you feel that women were coming to harm because of the 27% situation?
Mr R Pengelly: I cannot answer that; it is a clinical matter. The reality is that the target is there for a good reason. It is supported by clinicians, but the clinical dimension of it is outwith my area of competence.
Mrs Dobson: The Chair touched on my next point earlier. I ask this question just to satisfy myself and as it is something that I am constantly asked by constituents: who is ultimately accountable for our health service today? Is it you, Valerie Watts, the trusts or the absentee Minister? Who is accountable for all this?
Mr R Pengelly: The Minister is ultimately accountable. There are various strands. In terms of value-for-money issues and spending in the health service, I have a personal accountability to the Assembly. The Minister is accountable to the Assembly for the policy directions and choices.
Mr R Pengelly: He is, but just to follow up on that accountability thread, for practical purposes, outside the Assembly Chamber the main vehicle for discharging that accountability on the policy perspective is this Committee, and the reality is that —
Mrs Dobson: You can see the frustrations around the Committee, with the Chair trying to find out who on earth —
Mr R Pengelly: The only point I make is that the Committee's work continues and officials continue to come along every week, so it is not as though there is a complete vacuum.
Mr R Pengelly: Yes, but that is an issue of operational finance.
Mrs Dobson: As we sit now, today, who is in ultimate charge? We do not have a Minister.
Mr R Pengelly: Right now? The Minister.
Mr R Pengelly: The Minister is in post at the moment, yes.
Mr R Pengelly: I met the Minister this morning before the Committee meeting, and we talked through some strategic issues.
Mr R Pengelly: No, I would not.
Mr R Pengelly: As I said, the situation is not perfect. Is there a gap? I do not believe that there is. It is my role to provide a measure of strategic leadership. I am in post continually through this period, and I have a considerable period of time with the Minister on a weekly basis. Prior to the issue of resignations, the amount of time I spent with the Minister on strategic issues was not fundamentally different from the time I currently spend with him on a weekly basis.
Mrs Dobson: The Assembly unanimously passed Monday's motion on cancer waiting times: have you read up on that? We had a very good motion on autism from the SDLP yesterday as well. I take it that you have read up on those motions. Have you?
Mr R Pengelly: I saw the generality of them, but I have not read through every bit of them.
Mrs Dobson: You did not read through to see the concerns of individual MLAs.
Mr R Pengelly: With respect, I cannot. Is it the expectation that I read through the detail and I do not rely on —
Mrs Dobson: This is the Northern Ireland Assembly. This is the will —
Mr R Pengelly: I accept that it is the Assembly, but, with respect, is it unreasonable that, with 65,000 colleagues in the health service —
Mrs Dobson: We are the elected representatives, reflecting the views of our constituents on two motions.
Mr R Pengelly: Sorry, I have to deal with this point. An issue is being raised about who is providing strategic leadership. What I hear today from a number of members is the requirement on me to continue to provide strategic leadership. Strategic leadership is strategic by nature, so we cannot have it both ways. I cannot spend all my time in the trenches doing the operational detail and do the strategic —
Mr R Pengelly: I have an overview, Chair.
Mr McKinney: Thank you for letting me in, Chair and Jo-Anne. Do you understand that, had the Minister been in charge, he would have been present at the debates on those motions yesterday and on Monday to answer every point? Is Mr Pengelly making a different point in that sense that he, in fact, is not aware of the detail? Therefore, there is a gap in the knowledge at the top of the health service.
Mrs Dobson: I totally agree. The Minister should have been there for the debates on those motions. As part of our role as MLAs, we are there reflecting the views of our constituents. We had debates on cancer waiting times and autism, two vital motions. I was going to ask you what has been done and what planning has been made after those motions, but, if you are not even aware of what we said and have only a scant view of the motions, you have no plan of action.
Mr R Pengelly: With respect, I did not say —
Mrs Dobson: Does the work of the Assembly count for nothing? Is that totally disregarded? Does the work of the Health Committee count for nothing?
Mr R Pengelly: No, that is not what I am saying, Mr McKinney. Please.
Mr R Pengelly: You draw your own inference. What I have said and what, I think, I have illustrated is that we are working on trying to address the waiting times issue. We have a clear plan of action in terms of the operational issues. It is unfair to suggest that, because there was not an immediate response to a very important Assembly debate —
Mrs Dobson: We had no Minister. In the absence of a Minister, surely you would have gone through an overview, as the Chair said, of two vital motions that were being debated. How will we get action from those debates if you did not even —
Mr R Pengelly: I think it is unfair if the Committee does not recognise this, although it is the Committee's choice, but we need to differentiate between what any individual does and what the system does. The system comprises a lot of moving parts. If we are going to carry the strain and in any way seek to address the multitude of challenges that we face, we need to allow each of those moving parts to address the bit that is relevant to it. Forgive me if this has not been clear, but I am certainly not suggesting that, as a Department, we are not paying incredibly close attention to what the Assembly says on these matters. That is, of course, of fundamental importance, and we are looking at them as a Department, but that simply does not mean that I, personally, do every piece of work in the Department.
Mrs Dobson: There were two motions: the Ulster Unionist motion on cancer waiting times and the SDLP motion on autism. We were there on behalf of our constituents, putting those concerns across. I was going to ask you what you were going to do on foot of what was said. Does that mean that our motions here count for nothing, if you are not taking those concerns on board?
Mr R Pengelly: When you say —
Mrs Dobson: The motions were passed. We had no Minister, so he was not able to answer. You are the permanent secretary.
Mr R Pengelly: When you ask, "What are you doing?", do you mean what I, personally, am doing or what we as a system are doing? What the system does is more important. What the system does —
Mr R Pengelly: Because it is currently being analysed and its component parts drawn out for my attention. Sorry, it is physically impossible: I cannot be in every place at every time and monitor every piece.
Mr R Pengelly: Sorry, Chair, that is grossly unfair.
Mr R Pengelly: You asked me for a very specific point of information. I have given you an answer. On Thursday or Friday, when we had the phone call, it would have been the easiest thing in the world to give me a list of pieces of information —
Mr R Pengelly: If you want complete —
The Chairperson (Ms Maeve McLaughlin): You are the permanent secretary. You should have been coming here with an overview of the current gaps in the system and information on how they are being addressed.
Mr R Pengelly: I am incapable, as I think any individual is, of carrying every scrap of information about every issue in the health service.
Mr R Pengelly: Well, I disagree, Chair. I am sorry.
The Chairperson (Ms Maeve McLaughlin): That is disingenuous. It is not every scrap of information. We appreciate and respect the fact that there are professionals in the system who should be working with you and guiding you on this, but I would have expected you to come here today with at least an overview of where the gaps are and how they are being redressed. It is not just about the two motions.
Mr R Pengelly: I have done that, Chair. I have talked you through some of the issues. Is there a question about gaps that I have not responded to?
Mr R Pengelly: Chair, you used the word "disingenuous" —
Mr Pengelly: I think that is unfair.
Mr G Robinson: On a point of order. Quite honestly, I have listened intently, and I think that the official came to answer certain questions, not everything that you and other members have put to him. The official has done his best. I think that it is absolutely ridiculous.
The Chairperson (Ms Maeve McLaughlin): He is the person in charge, and we expected him today to address the current situation in the delivery of health and social care. That means there are key pieces that are sitting there, in my view, that could be actioned. We want to get a sense of your delivery around that.
Mr R Pengelly: Chair, I think that I have sought to address that, but it is not possible to distil the key pieces of health and social care into one paragraph. If we want to talk about waiting times, the only way that you can accurately do it is by breaking them down and analysing them at specialty level. There are different challenges for cancer treatment, for orthopaedics, for ENT etc. There is a range of issues.
I have sought to cover the points that you indicated to me that you wanted to address today. I apologise for your frustration that I cannot answer questions that I was not advised of or that I could not anticipate. I have said that I will come back to the Committee very quickly with a comprehensive response. I am genuinely not sure, beyond that, what I can do to help the Committee.
The Chairperson (Ms Maeve McLaughlin): I will just make this comment, because I know that there are a number of members who want to speak, and we are pushed for time. It is not just this Committee that is pointing up these issues: we have heard from a litany of sectors. Just last week, Nigel Edwards said that people would die. The College of Nursing, the College of GPs, trade unions and individual members of society — I could go on. This is not something that simply had to be flagged up by the Committee to give you a list of what the issues are. We would have expected you, Richard, to come here with that overview and how they are being rectified.
Mr R Pengelly: I think that I have done that, Chair.
Mr R Pengelly: I think that the points that you are frustrated about are specific points of detail that you sought to ask about.
Mrs Dobson: We brought forward the motions because we truly care about the health of the people that we represent. Now you are saying that you do not know the detail of them. We need a message to bring back. People are asking what the outcome was of the motions that we brought on cancer times and autism. No answers. We had no Minster to reply. You have no answers whatsoever; you do not even know the detail. What message does that send out to the general public?
Mr R Pengelly: The message that we send out to the general public, which I am trying to articulate, is about the action that we are taking in the system to address the issue of excessive waits. That is the fundamental issue. Important as the Assembly debate is, it is shining a spotlight —
Mrs Dobson: It is not that important; you did not know any detail on it.
Mr R Pengelly: It is shining a spotlight on an issue that we are working rapidly to address. That is the point that I am talking about today.
Ms McCorley: Go raibh maith agat, a Chathaoirligh. Thanks, Richard, for coming to the Committee today. I am also frustrated at the lack of information and the attitude. On one hand, you say that it is not perfect: do you think, then, that it is good? What does that mean?
Mr R Pengelly: It means that it could be better. Clearly, I do not think that anyone could argue that, if the choice was between having a Minister full time or having a Minister for certain periods of the week, the preference would clearly be to have the Minister full time. But the subtlety to that question is this: what are the practical implications of the Minister not being there full time? I am just trying to articulate that the practical implications are that he is still, in the limited time that he is available to the Department, focusing that time on directing the strategic movement of the Department towards a number of key issues, so those discussions continue.
Ms McCorley: Like other members of this Committee, I am really disappointed that the Minister cannot turn up to answer questions or to respond to things. Other Ministers who have resigned and gone back to their job seem to be able to do that. It is as though health is not an important enough issue, but other issues are. That is hugely disappointing.
Also, the Chair referred to the guidance from the Commissioner for Older People. It has been available for nearly a year, and you do not know anything about it. We will be speaking this afternoon to the commissioner. What I would like to know is this: have you had discussions with the Minister? Has he raised it with you? It is not on your table, obviously, because you said that there was nothing pressing on the desk. It is not even on the desk. Have you had discussions with the Minister?
Mr R Pengelly: It is an issue that has been discussed with the Minister. It is clearly an issue that the Department is alive to. That fact that, without any advance warning, the question is being thrown at me and I cannot provide an answer to it should not dilute or hide the fact that many colleagues in the Department are working proactively on this and taking it forward. That is the picture that I will convey to the Committee after this session when we provide more information.
Ms McCorley: I just find it amazing that on such a big issue and one that is never far from the headlines — residential homes, care for the elderly, how old people are treated, abuses and neglect — you cannot think of anything that the Minister might do.
Mr R Pengelly: With respect, that is not what I am saying; I am saying that there was a specific question about the Department's position on a report that covers — as you indicated in your question — a wide range of areas. To give proper service to the Committee, the response to that should be as comprehensive and as wide and cover all of those areas, and that is what we will provide for the Committee. The Committee deserves that and not some half-hearted attempt, as I said, by someone coming here not anticipating the question.
Chair, the lesson for us is that we need better notice about the issues. I genuinely want to work with the Committee and provide information, and I hope that no Committee member takes anything other than that. The reality is that, if we are going to properly cover issues in the detail that the Committee wants and deserves, we need some prior —
The Chairperson (Ms Maeve McLaughlin): With respect, Richard, I do not know how you can say that you need better notice. You are in charge of the system; you should know what the key issues are and their current status.
Mr R Pengelly: Chair, I think that the better notice point is accepted on both sides. I can recall that it was not too long ago that you would not let some of my colleagues into the room to discuss a paper because you felt that you had not received it in sufficient time. It is fair that that plays both ways.
The Chairperson (Ms Maeve McLaughlin): I will make the point again, Richard: it was formal guidance to the Department. There are sectors across society that know that document inside out, with four recommendations.
Mr R Pengelly: I take that point, Chair, but we are not a Department that is short of formal guidance on a range of very important and strategic issues for Northern Ireland.
Ms McCorley: You were nearly making the case earlier that you did not probably need a full-time Minister, because so much goes on —
Mr R Pengelly: I was not making that case.
Ms McCorley: It sounded a wee bit like it. You said that there were just some decisions that required the Minister but, generally, you can take decisions and keep things moving. Why, then, have our questions been rejected by the Department?
Mr R Pengelly: Do you mean Assembly questions?
Ms McCorley: Surely those are questions that can be pursued by the Department.
Mr R Pengelly: As I understand it, Assembly questions are an issue for the Assembly authorities to handle. My understanding is that the Assembly has decided not to accept questions.
Ms McCorley: So, if we write to the Department, we will be able to have those issues pursued.
Mr R Pengelly: We continue to respond to any correspondence that we receive, either from the public or from elected representatives. If the question is about factual information or an established position, we will answer that. If the question is about where the Minister might go on an issue, that will be held until the return of the Minister. I have received emails from elected representatives that we continue to process and answer.
Ms McCorley: So, if there is an urgent question — we could be without a Minister for who knows how long — that will not be resolved or dealt with because there is no Minister. If it requires the Minister, no matter how urgent it is, it will not go anywhere.
Mr R Pengelly: Sorry, do you mean an urgent Assembly question or just a general issue that is a matter of urgency?
Ms McCorley: If it is something that requires an urgent answer, anything could come up.
Mr R Pengelly: Any questions that come through to the Department that we are able to answer, be they requests for factual information or articulation of a current policy position, we will process and answer, and we will endeavour to meet any timetable that the questioner puts regarding urgency. There are issues that we cannot answer. For instance, a question asking us to speculate on where we might land in response to Donaldson and the review of commissioning is for the Minister and could not be answered. However, for example, if there is a question asking about the number of people waiting for certain procedures at a point in time, we will provide that information very rapidly.
Ms McCorley: That would be useful. That is not the way it was being presented. It was like it was a brick wall. That is helpful.
Can I ask you about the development of the children's heart services in Belfast? Where is that currently?
Mr R Pengelly: The work is ongoing. Is that the paediatric congenital cardiac services (PCCS)? Are you talking about the work in Dublin or the extension of the facilities in Belfast?
Mr R Pengelly: There is a huge amount of detail, and colleagues continue to explore that. They are working with clinical colleagues. There is a governance position in place to roll that out. I can come back to you with a comprehensive response, but it is not a question that I could have reasonably anticipated today.
Mr R Pengelly: We can come back to you with information on that.
Mr R Pengelly: There is one in progress.
Mr R Pengelly: No, it is just a question of work and effort. It is not being held up by the Minister.
Mr R Pengelly: We are working to get it done as quickly as possible. Again, off the top of my head, I am not sure of the exact date.
Mr R Pengelly: We will come back to you on that.
Mr R Pengelly: Yes, and that is the issue we are looking to work at, Chair: how best to serve those children.
Mr R Pengelly: We can rehearse every specific piece of information. I will come back to you with the information on it. I am not sure that it is unreasonable for me not to carry every date in my head. I can keep repeating that.
Ms McCorley: You probably know that some of us in the Committee are also involved in the Ad Hoc Committee on the Mental Capacity Bill. It is a heavy piece of work, and there is a huge volume to it. Issues are starting to arise, and we are seeking clarification from the Department. The response that we have had from the Health Department is that it cannot give ministerial assurances on all that. We heard earlier that there were two health Bills, and you sounded fairly optimistic that it would be possible to progress them within the required timelines. Here we have another Bill that could be held up because of lack of clarity and direction from the Department. The further we go down the road and as time goes on, those Bills look less likely to be able to complete their passage in the mandate. Can you respond to that?
Mr R Pengelly: We talked about the issues earlier. With the Mental Capacity Bill, there are issues that require ministerial attention, not just from our Minister but from our colleagues in DOJ.
Mr R Pengelly: There are issues with the legal construction of some of the clauses. That is complex work. I take your point that there is a risk.
Ms McCorley: We are saying that the lack of a Minister means that that hugely important Bill could fall.
Mr R Pengelly: There are many challenges with that legislation, about the technicalities of it, but some of them are outwith areas that require ministerial consideration. There is a whole range, but I take your point that it is clearly at risk.
Ms McCorley: It is hugely complex work and people are working hard at it, yet we have a Minister who is not at his desk. It is unreal that that work will be invested and will, potentially, fall by the wayside. It is not right.
Mr G Robinson: I have one question for Richard. As well as the present position we are in, do we need to take a longer-term look at how we want our elective care to be carried out to get the best value for money and the best performance?
Mr R Pengelly: That is one of the clearest issues that flow from the current position with waiting times. We commissioned work from the Health and Social Care Board on a medium- to-long-term strategy for the provision of elective care. Setting aside the issues of funding, given the way we provide elective care, it is impossible to separate the provision of elective care from the issues about commissioning and the response to Donaldson. If we look at Belfast and the 14-day cancer target, we see that there is a clear issue that, where we seek to replicate services in every part of Northern Ireland, each of those services would be, by extension, smaller than they would be with a regional approach. Therefore, it becomes inherently volatile, particularly when key staff fall ill or take periods of leave. I am not suggesting where we should look to on the spectrum, but, at one end, there are many small facilities and, at the other, there is one facility for Northern Ireland. The question is where; that is a key issue in the management of elective care.
There are also issues about how we forecast demand and the way we plan capacity. There is also a big issue about the extent to which we should use the independent sector in the future. There are quite different issues in the management of the existing problem. At the moment, where additional funds become available, we would have little choice but to use the independent sector to help in some way. To be clear, that is a completely separate issue from the longer-term issue. We could plan not to use the independent sector or make greater use of it. We have not had that debate yet.
That strategy work is needed. We need to reshape how we deliver elective care across the Province.
Mr G Robinson: I want to make a comment, Chair. I was in Altnagelvin Hospital with my wife last Friday. I want to commend, in particular, the gynaecological ward for the excellent treatment my wife received. It was unbelievable. I have been around quite a lot of the wards in the hospital, visiting people and so forth, and all the staff — doctors, nurses, everybody — are to be thoroughly commended for the excellent work they do.
We cannot wait until the new cancer unit is built. That is nearly in operation. That will be a terrific addition to the north-west of the Province.
Mr R Pengelly: Those are very kind comments; I will certainly pass them on. I know that there is a tangible buzz of excitement about the new radiotherapy unit in Altnagelvin.
Mr G Robinson: The health service gets knocked quite a bit, and I just wanted to add my comment about the experiences I have had recently.
Mr R Pengelly: One of the issues that surprised me about our system is that, if we are ever asked about the number of complaints, we can provide a quick and accurate answer, but if we are asked how many compliments the services receive — . This is one of the issues I have been pursuing, because I think about staff morale. We have a huge number of highly committed, highly professional staff.
Mr R Pengelly: It is surprising just how many compliments are received. We need to do a bit more to make the staff who have given rise to those compliments aware that people are grateful and still see the service that they provide.
Mr G Robinson: The work that the staff do is absolutely unbelievable. Every one of them does a brilliant job.
Mr R Pengelly: I will certainly pass that on.
Mr G Robinson: I am sure that the £2 million we are losing every week could be used to greater benefit.
Mr R Pengelly: That would be helpful.
Mr G Robinson: I know that you do not want to comment from a political point of view, but, at the same time, I know exactly what is happening. It is absolutely disgraceful. A lot of that money could be used to reduce waiting lists. I just wanted to make that comment.
The Chairperson (Ms Maeve McLaughlin): On the elective care issue, we took evidence from England, Scotland, Portugal and Italy and made five or six recommendations to the Department on waiting times. Are you progressing those? Can you?
Mr R Pengelly: The key issue is the refer-to-treat target. The then Minister concluded that, in concept, he would be supportive of a move towards that target, as they have done across the water. The reality is that, where they did it across the water, the movement to it was accompanied by additional investment. The view at the moment is that we need to improve our performance as opposed to just putting a new set of targets in place.
The Chairperson (Ms Maeve McLaughlin): There was more than referral to treatment. There were issues with the use of the independent and private sector as well. Are those recommendations being progressed?
Mr R Pengelly: We talked about the review of elective care and spending; that was part of the response. A key plank of the review of elective care is how we engage on a regular basis with the independent sector.
Mr R Pengelly: They have been considered by the Department. We need to do further analysis. We need to develop a strategy to deal with the elective care problem and the challenges we face. The Committee's work on that is very helpful in framing the strategic piece of work that we want to do on developing a new model for elective care. The RTT issue is partly about the use of the independent sector. These are fundamentally important issues. If we were just to jump to implementation in full, the Minister —
Mr R Pengelly: The review, as I said, has been commissioned. The board is working on it as we speak. The issue about the specific recommendations was that the Minister took the view, at the time, that he could not satisfactorily implement the recommendations without additional resources. He was grateful for the receipt of them. They will be factored into the further work, but, because of cost implications, they cannot —
Mr R Pengelly: That is particularly true of the RTT issue.
Mrs Cameron: Before I ask my questions to Richard, I, as a Committee member, have always been supportive when we, as a Committee, have decided that we did not receive the proper briefing or the information in a sufficient time for us to deal with whatever is on the table. That courtesy should be given back to the officials. I was not given very much information on what this meeting was about, either —
Mrs Cameron: — quite frankly. Health is a big issue. I am sure that I do not need to defend an official who comes before the Committee, but, if you want detailed answers to questions, it is common courtesy give some form of detail about what is going to be asked.
Richard, as far as the public and our constituents are concerned, the main gripe among my constituents and family members about the health service is waiting times. I do not get complaints about the treatment they receive when they get it; it is about the time they wait to get to that stage and the deterioration in their health while they are waiting. It is vitally important that the waiting times are reduced. We know that. I have personal experience of waiting for some attention from the health service. I am happy to do so, as everybody else has to be in Northern Ireland. My recent experience, just as George has had recently in the health service in different departments, was amazing. The treatment and how it was brought to us, as a family, was second to none once we got it. My gripe is about the wait to get there. I know that we, as a Committee, talk a lot about the use of independent providers. Is there opposition in the Department to the use of independent providers? If money were made available to bring the waiting lists down quickly and efficiently, could that be done?
Mr R Pengelly: There is no opposition in the Department to the use of the independent sector. Neither is there any dogma that it is the best way to address it. The reality is that, if we received additional money tomorrow, there would be a combination of increasing internal capacity through trying to open theatres at the weekend and bring staff in, particularly in the area of orthopaedics, hips and knees and things like that, and giving some money towards the independent sector for other procedures.
The easy answer to your question is that, for any additional money we get, we will work out how we can get the maximum number of patient treatments for it, be that in the independent sector or internally; we certainly do not favour one over the other.
That is very much the short-term issue. There is a longer-term issue. It strikes me that the model in the past has been that we broadly try to marry internal capacity to demand and that we leave the independent sector as a safety valve if demand increases above that for which we have capacity or if there are any issues with the ability to deliver capacity. I am not suggesting that this is the way forward, but it is an important question going forward: should we continue to do it that way, or should we aim to deliver 90% capacity and put a longer-term arrangement in place with the independent sector? It is worth asking ourselves that question. It is driven purely by value for money.
One of the points that the independent sector has made is that it does not know when, or how much, work it will get from us. There is a framework contract in place which allows us to send patients for different procedures. The sector has made the point to me repeatedly that if it had a contract in place for a certain period of time with the minimum number of volumes, then that would allow it to make some investment in its service and be able to deliver the service to us at a much lower cost. I think that that is worth exploring. From my perspective, it does not breach the principle of a national health service because I would look at that issue from the patient's perspective and whether, as a patient, you get healthcare at the same standard that is free at the point of delivery, rather than whether we chose to provide it. It is an important point to look at that as part of a medium- to long-term strategy, but in the short term, we will use any avenue open to us to accelerate treatment.
Mrs Cameron: You make a good point. Certainly, I have seen presentations from independent providers which were very impressive. They truly operate as a business. I suppose that that is a criticism we could gear towards our National Health Service: why can we not be a bit more like the independent sector and actually try to operate as a business and as through we were making a profit — we are not looking to make a profit — to maximise the value?
Mr R Pengelly: May I make one caveat, or my clinical colleagues would never forgive me? It is important to recognise, too, that it can be very difficult to make comparisons between the independent sector and trusts' performance. I think that, recently, one of the broadcasters was saying that, typically in an independent-sector setting, a consultant could get through six or seven procedures in a session whereas in a trust facility, that may be four or five. The point that the clinician would make — and it is very much a clinical point that I am passing on — is that the reality is that the more simple and straightforward procedures tend to go to the independent sector because a more complex or difficult procedure stays in the trust, so that there is the backup of all the other services that are available in the trust environment. There is also the fact that in the trust environment, in the orthopaedic setting, for example, a session can suddenly have to be halted because of an emergency trauma that comes in. It is difficult to make comparisons. We should make comparisons, but we need to be intelligent about making them on a proper basis.
Mrs Cameron: I think that is right. Again, from my constituents' point of view, I do not think that any of them would care where they got their treatment from as long as they get good treatment as quickly as is humanly possible.
Mr R Pengelly: No, sorry; the point that I made earlier, Chair, was that we have commissioned the board to produce for us a medium- to long-term strategy for addressing the problem of elective care. As part of that work, we want it to consider the optimum use of the independent sector in supporting our work on elective care.
Mr R Pengelly: It is part of that piece.
Mr R Pengelly: At this stage, it has given us a skeleton outline of the areas that it will look at. It has now started to work on that. I think that we will be looking for a progress report from it in the next couple of months to see how it is getting on with that.
Mrs Cameron: Chair, just for clarity, could I just ask one more small question? Do you believe, if the money were made available, that the Minister would be minded to put it towards reducing the waiting lists?
Mr R Pengelly: I do not really want to speak for the Minister, but I think that it is fair to say, certainly from what the Minister has said publicly, that, at the moment, he sees addressing the waiting challenge as being the number one priority for him. Without wanting to commit the Minister, which I cannot do, it would be my expectation that they key focus of any additional money that we receive would be to address waiting times.
Mr McKinney: Can I just address the issue around praise? Had the Minister been in the Chamber on Monday and Tuesday, he would have heard praise from Members about professionals in the autism sector and those involved in cancer services. Indeed, all of us made those points in all the debates. You do not have to look much further than the Assembly Chamber itself to see the praise that exists for the health service. I made that point in every meeting —
Mr R Pengelly: I take that point. I know that, in that past, you have been very complimentary about some of the services, Mr McKinney.
Mr McKinney: — and I make it again today at this Committee. It is a point that I continually reinforce. Would you accept that we are in highly unusual circumstances at present?
Mr R Pengelly: Absolutely.
Mr McKinney: I am interested in your responses because I really want to know whom you are representing here today.
Mr R Pengelly: I am representing the Department.
Mr R Pengelly: The institutions, the structure, the people.
Mr McKinney: I mean the public. I just notice that any criticism that you have of the absence of a Minister in these highly unusual circumstances is very constrained. Why is that?
Mr R Pengelly: Any what, sorry?
Mr R Pengelly: It is never my role or that of any civil servant to criticise Ministers. It is not part of our responsibilities to offer any sort of critique.
Mr McKinney: It is your role to question the circumstances that you find yourself in.
Mr R Pengelly: No, it is not: it is my role to get on with the job in whatever circumstances I find myself.
Mr McKinney: Are you constrained in getting on with your job in the absence of a Minister?
Mr R Pengelly: I think that we have addressed that point. As I said, it is not perfect but we are getting on to the very best of our abilities.
Mr McKinney: I found the intervention from Nigel Edwards very valuable. Did you read the report?
Mr R Pengelly: I saw the comments from Nigel Edwards. I think that points in it helpfully stated the position, which did not come as a surprise to anyone. I thought that, possibly, parts of his comments were made without a full and proper understanding of the issue in Northern Ireland. He seemed to conclude that any issue about excess waiting times was absolutely a performance issue, hence his comment, "Heads would roll". Were it absolutely a performance issue, that would be a valid comment. However, from the analysis that we have done, the biggest contributory factor is the lack of availability of finance. That is not an issue that, I think, individual chief executives can be held accountable for.
Mr McKinney: He may have said, "Heads would roll", but he did not say which heads, and you are making an assumption about which heads as a result of your comments just now.
Do you recognise what he said: those figures represent a very worrying situation for here? Do you accept that?
Mr R Pengelly: Of course they are worrying, yes.
Mr McKinney: And that they compare very badly with those in England.
Mr R Pengelly: At face value, but you need to drill beneath the detail on the level of funding in England in particular, which is a key component. Comparisons are at their most valid when you compare like with like, and I do not think that we always have a like-for-like comparison. Certainly, for any of our trusts, I pretty much guarantee you that I could find you a comparator somewhere in England on which we outperform them. I do not think that that would be a valid comparison, so I think that we need to tread carefully.
Mr McKinney: Do you accept his contention that the Northern Ireland waiting list situation requires immediate action?
Mr R Pengelly: Absolutely.
Mr McKinney: Does the absence of a Minister in any way frustrate that immediate action?
Mr R Pengelly: From my perspective, as I think I have sought to articulate today, the most important factor for us in terms of immediate action is to secure additional resources for the system.
Mr McKinney: The Minister is not in his position to argue for that resource: is that frustrating that ambition?
Mr R Pengelly: I cannot argue that it is not relevant, but, equally, when a Minister was in place and made a bid to June monitoring —.
We need to recognise the broader financial position. I will not sit here and argue that it would not be helpful to have a Minister to argue that case — of course it would — and to get the additional funding, but it is about funding.
Mr McKinney: The Minister not being in his post is not helpful for patients and the public.
Mr R Pengelly: In terms of securing additional resources, it certainly could be better.
Mr McKinney: But additional resources are the key in your argument about it.
Mr R Pengelly: Additional resources are the key, yes.
Mr McKinney: And the Minister is not there to argue for them.
Mr R Pengelly: As a statement of fact, the Minister, as we speak, is there.
Mr McKinney: Well, on the wider point, he is there for only a couple of hours a week, but he is not there to argue for them, and that is frustrating your ambition.
Mr R Pengelly: Well, I hesitate, Mr McKinney, because I will not be drawn into the business of criticising what Ministers do or do not do. What I would say is —
Mr McKinney: I am not asking you to criticise; I am asking you, against your measurement, to tell me whether your job on behalf of the people of Northern Ireland in dealing with waiting list times is being frustrated by the absence of the Minister. It is a yes or no question.
Mr R Pengelly: My response would be that my job and those of all my colleagues across the health service would be easier had we access to more resources.
Mr R Pengelly: I heard the question. That is my response to it.
Mr McKinney: And the Minister, if he were in his chair, would be able to argue for those resources more effectively.
Mr R Pengelly: That is your statement. It is not my role to offer a critique of what Ministers should or should not do. I am not going to be drawn into that.
Mr McKinney: I am not asking you to critique or criticise the Minister. Your job, as the permanent secretary in the Department, is to deal with these issues. You were brought in to do that job. Is your job being frustrated by the absence of a Minister, or is it not?
Mr R Pengelly: My job would be easier had I more resources, as is the case for all my colleagues across the health service.
Mr McKinney: So, the job that the Minister should be doing is arguing for those resources.
Mr R Pengelly: It is for others to talk about the job that the Minister should be doing.
Mr McKinney: What is the one thing that you would ask the Minister to do?
Mr R Pengelly: It is not anywhere in my job description to offer a critique of what Ministers should do. I operate absolutely at the direction of Ministers. I do not offer comments on —
Mr McKinney: What is the one job that the Minister should be doing on your behalf?
Mr R Pengelly: It is not for me to tell any Minister what he or she should do.
Mr R Pengelly: I do not think that it is appropriate for a civil servant to offer a view on what Ministers should or should not do.
Mr McKinney: I disagree; I think that it is entirely appropriate. I am not asking you for the detail of a report. I am not asking you for something that would not have been brought to this table in any event, even at short notice. I am asking you, as head of the Department in the absence of a Minister, how much the absence of that Minister affects your ability to get your hands on the money that you need to do the job.
Mr R Pengelly: My role before the Committee is to represent the Minister and help articulate his policy agenda. I have a Minister in post. It is never my job to offer a critique of what a Minister should be doing that he or she is not doing or of the validity of that. That is simply not a role for any civil servant. Any civil servant who sought to offer a view on ministerial action would be treading on very dangerous territory.
Mr McKinney: Can I just remind you of what you said on 22 October 2014? You told the Committee:
"The challenge that the Minister faces is of trying to bring all those individual strands together within a very difficult funding envelope and making those difficult choices."
You gave him advice then: is that position consistent with his absence today?
Mr R Pengelly: In what I said then, I was outlining the challenges that the Minister faced. I was not offering a view on the actions of the Minister.
"We have been speaking to clinicians and other health service staff on the front line, and there are passionate ideas and enthusiasm out there. So, it is about grabbing those ideas, moving forward and continuing on that trajectory."
Is the Minister's absence today consistent with that position?
Mr R Pengelly: The passion and drive of clinicians and other colleagues across the service is there. I spent some time out in the service last week, and it is tangible when you are out on the front line.
"I have done this a bit longer than the Minister, but, at the moment, I am still engaged in trying to understand what is a massively complex system".
That was the case even with your longevity in the post. Is Mr Hamilton's absence from his post consistent with your view on that?
Mr R Pengelly: On the complexity of the system?
Mr McKinney: Yes; in other words, being there to do the job.
Mr R Pengelly: The complexity of the system is not a function of a Minister; it is a function of the structure of the system, the colleagues in the system and the relationships across that system. That has not changed.
Mr McKinney: I turn now to the issue of questions and information-sharing between the Department, the public and the Assembly, which Rosie McCorley helpfully brought forward. You are aware of the ministerial code.
Mr R Pengelly: I am aware that it exists, but it is —
Mr R Pengelly: The ministerial code is not an issue for a civil servant. The ministerial code is an Assembly document. Ministers are accountable to the Assembly, not to civil servants.
Mr McKinney: Yes, but you are in the Department. In relation to information-sharing, paragraph 1.5(iii) of the ministerial code says that Ministers must:
"ensure that all reasonable requests for information from the Assembly, users of services and individual citizens are complied with; and that departments and their staff conduct their dealings with the public in an open and responsible way".
Your earlier evidence suggested that, in fact, you are not responding to the public in a complete way, and I am certainly not getting answers through the Assembly question system. Is that a breach of the ministerial code in your view?
Mr R Pengelly: First, they are Assembly questions. They go through the institutions of the Assembly. When the Assembly issues questions to the Department, they become a departmental issue. As I understand it, at the moment, the Assembly authorities are not accepting questions where there is ministerial absenteeism. That is an issue for the Assembly. As I think that I sought to make clear, we continue to respond proactively to any and all correspondence that we receive from the public, patients and elected representatives up to the point where it asks for a ministerial opinion, which we cannot give. We continue to provide that. The ministerial code is not an issue for the Civil Service; it is an issue for the Assembly authorities. I offer no views on the ministerial code.
Mr McKinney: I have just one final point on that. Evidentially, what is the size of the mailbag that is not getting answered?
Mr R Pengelly: It is limited because the vast majority of questions that we get at any point in a cycle are about factual information as opposed to ministerial views. It is very light.
Mr McKinney: One of the big issues for me — you will have heard this over the last number of years — is wastage in the system, particularly the bank and agency system, and I refer to the discussions earlier around workforce planning. Specifically on nurses, where are we on that?
Mr R Pengelly: As part of the review of administration structures, I have asked BSO to look at the possibility — there are two strands to it. At the moment, properly managing the use of agency and bank staff is done essentially on a trust-by-trust basis. We are looking at a way that we can better centralise that to provide a one-stop facility for the whole service. The broader point is the ongoing work on workforce planning issues and the amount of money we invest between Queen's and UUJ in training additional nurses. We are only ever in the space of using agency or bank nurses where there is a vacancy. Quite often, those vacancies arise through issues like staff illness, but there are issues —
Mr McKinney: Do you accept that it has grown now bloated beyond its —
Mr R Pengelly: It has grown to a point where I am deeply uncomfortable with it.
Mr McKinney: Has it grown to the point that it has corrupted the system in many ways, in that it has become a bit like what you were saying with the elective care stuff? Has it grown to a point where — corrupting might be too hard — it has become more attractive to bank at a much increased cost to us than it is to deliver?
Mr R Pengelly: I do not know whether we have crossed that line, but I acknowledge that it has a real risk that we need to address. Part of the issue is that we cannot dictate to individuals that they must take up paid employment with us. We have the same issues with locum medical staff. We need to continue that workforce planning. Part of the issue that has been made to me is that, for some colleagues, the bank position is a bit more attractive because you come in and out of situations, as opposed to being in one place where you feel under pressure. So, we need to address that, and we need to support colleagues properly to deliver the high service.
Mr McKinney: That is attractive for those who use the bank, whereas I am concerned with those who get the service.
Mr R Pengelly: Absolutely.
Mr McGimpsey: The questions are a key element of accountability as far as the Assembly is concerned. When I was in post, I answered something like 11,000 Assembly questions. You are saying that you do not get the questions, as the Assembly is not accepting them. If the Assembly was accepting them, they would go down to you in the normal manner, is that right?
Mr R Pengelly: If the Assembly accepted them, yes.
Mr McGimpsey: OK. Who would sign them when they reach the Department if the Minister is not there?
Mr R Pengelly: I would need to explore that because, I think, it is an issue that we would need to put to the Assembly authorities. Normally, the response to any question needs to be signed off at ministerial level before it can go back to an elected representative. In the absence of someone to sign off on that, it is fundamentally an issue for the Assembly authorities and whether they would be prepared to accept alternative sign-off on that.
Mr McGimpsey: So, in fact, the reason the Assembly authorities are holding the questions here and not sending them down is that the Minister is not available to sign them. What authority do you have to sign them?
Mr R Pengelly: I cannot sign Assembly questions because they need the signature of a Minister. For all other correspondence, the subtlety is that, where it is factual information or articulating a ministerial position that has already been made clear, we will answer that; if it is asking us to speculate about the future direction of travel or a policy agenda, we cannot answer that. That means that we are able to answer the vast majority of questions.
Mr McGimpsey: Effectively, then, there is that accountability question in the Minister's absence, which is having an important effect there. I am not asking you to comment on that.
I am interested in the here and now. We have this terrible situation, and I have to say that, when I was a Minister, if I had been presiding over this, there would have been mass hysteria.
I mean, George would be dancing on the table in reaction instead of being so —
Mr McGimpsey: Because I remember your performance in the Assembly, George.
Mr McGimpsey: I will not get into any arguments about what you see as your job. I know that you have issues to deal with.
Without getting into that situation, it is about the here and now. You have heard about the cancer waiting times and will be familiar with those. You get the high-level information, and you drill down. You may not feel capable of answering in detail here — I understand that — but you know the situation. You are aware of where we are with cancer, neurology, ophthalmology, orthopaedics and so on.
Mr McGimpsey: You have this major issue of a couple of hundred thousand people waiting for appointments and so on. There is the problem, and the question is this: what are we going to do about it? You are talking about operational issues and working rapidly to address them. There is a clear plan of action. It is constrained by the resource available, but I presume that you have a plan of action, and that is what I want to hear about from you. What will you do about it? What do you intend to do? Were the money situation to begin to ease, what would this plan of action start to look like? How would you deal, first, with meeting demand, and then the key element is of course the backlogs? What is that going to cost?
Mr R Pengelly: The plan of action is twofold. I will not labour this because I think that we have covered it. There is the medium- to long-term piece on the elective strategy. A lot of the short-term piece is, in many ways, more of a clinical than administrative response. As one member said earlier, being on a waiting list is not a pleasant place to be when you have a condition that needs treatment. There is an issue about the way that that is managed clinically.
At the moment, there are essentially two types of referral: urgent and routine. The urgent referral is subject to triage at the point of referral. Urgent referrals are then taken in order of clinical priority. Routine referrals are taken in chronological order. That is the flow that is happening. As I said earlier, there continues to be flow. I think that we spend about £28 million a week on acute care throughout the year. So that continues. We also look to the clinical community to constantly reassess and re-evaluate. We make it clear to patients on waiting lists that, should they feel that their condition has changed or deteriorated and they have not made it through the first stage of the process, they can go back to their GP, who may want to uplift their category from routine to urgent. That is how we manage the large cohort of patients on the lists.
Separately, the Health and Social Care Board — the commissioners — is doing a detailed piece of work with the trusts to ensure that they deliver on core capacity. There have been some issues about capacity. The two main issues where trusts have struggled to deliver core capacity have been through shortages of key staff and the growth in unscheduled care, which clearly has implications for elective procedures. We are trying to get a handle on getting the unscheduled care piece into a good place, and a lot of good work has been done there through the task force led by the Chief Medical Officer and Chief Nursing Officer. That has now transferred to the board and the PHA to take the strain of trying to work with colleagues, and many trusts are carrying out recruitment exercises to try to fill key posts. That is going to uplift our internal capacity. Besides that, it is about waiting and hoping that we get additional funding so that we can boost internal capacity through use of overtime and additional labour time and deploy some of the independent sector activity to help us.
Mr McGimpsey: I just want to get some idea of the money. You must have an idea of what, ideally, is needed, first, to get capacity up so that you are meeting demand and, secondly, to start dealing with the backlogs. If you are not hitting demand, those backlogs build and build. I have some knowledge of that because I have been there. The situation that I inherited from the direct rule Minister, although improving, was far from where we wanted to be, but we worked hard and got there. So, I know roughly what you need to do. It is a big task; your waiting lists are now the worst that they have been in 15 years. It is a resource issue, and it is a capacity issue. It is about getting that capacity up. It is the nature of the action plan. We can all talk about this, and go round the houses and so on; but you have an emergency situation. You have very large numbers of patients sitting in pain and distress, and some of them are coming to harm. There is no doubt about that. Patients will be in very severe situations. So, we need to deal with it. This is an emergency situation, and you are the one who would have to pull the plan together with the board and the trusts to deal with this. Give us some notion of what the shape of that plan looks like, of how long it is going to roll out, of the extra resources that you need, of what your in-year pressures are per annum — you estimate that you will have in-year pressures, anyhow. What is that plan looking like? How much is it costing? What is the argument, or what is the key issue that you will be taking to the Department of Finance and to the Executive?
Mr R Pengelly: I will separate, as you have done, the in-year issue from the forward position. As you will well recall, at this point in the year, the in-year issue is more, "How much would you be able to spend?", as opposed to, "How much do you need to spend?". Our estimate is that we could absorb additional funding in the region of £1·25 million or £1·5 million a week, if we were to uplift activity. We are constrained in the number of colleagues that we have employed by the trusts who can do additional work and the capacity of the independent sector. That would frame how much money we could take this year to address the problem. That would not address the problem in its totality. Going forward, the board has undertaken what is called a demand and capacity gap analysis. Its estimate is that there is a current gap, between demand for services and our capacity to deliver based on current baseline funding, of about £70 million a year.
Mr McGimpsey: That is the extra money that you would need just to hit demand.
Mr R Pengelly: That is what we would need in a steady state to hit demand. I think that we would also still need some transitional funding, because the first thing that we would want to do is to clear the backlog.
Mr McGimpsey: Is your underlying pressure not around £200 million or £200 million-plus? I mean the difference between the money you get from the Department of Finance and the money that you would actually need to provide the service. I am talking about more than waiting lists.
Mr R Pengelly: Yes, it is more than waiting lists. Plus, importantly, there are service developments that we want to do to actually improve the product on offer as opposed to just improve access to the product on offer. However, for this specific issue, we think that the gap between capacity and demand is about £70 million, plus an injection to get the current waiting times down to an acceptable level. That would allow us to go forward in a steady state.
Mr R Pengelly: The spending review at national level for the 2016-17 year, as we understand it, is due to be announced by the UK Government in about November. At that stage, Barnett consequentials will apply and colleagues in the Department of Finance will know the position. They have started a process now, and we are just initiating in the Department the actual planning process to look at what funding will be available and at demand across the whole range of areas beyond waiting times, to come up with the equivalent of the £200 million figure you raised; in other words, the nature of our proposal through Finance colleagues for the 2016-17 financial year.
Mr McGimpsey: You cannot depend on Barnett, because Finance will just snaffle it.
Mr McGimpsey: It is what they did with me and the Cameron money that was ring-fenced. Anyhow, I would like us to see the plan. You reckon that the board has that demand-gap analysis ready.
Mr McGimpsey: Chair, it would be important that we have a look at that, because they are actually there to manage the health service. The actual step-by-step is that, if I had been there, the Minister takes that to the Executive, argues his case and gets all the parties' support. That would be the next step.
So, if the Minister is in place, would you have that ready to hand to him to take to the Executive, whether they top-slice or the Finance Department finds the money or whether we can get some more out of Barnett or whatever?
Mr R Pengelly: In terms of 2016-17?
Mr McGimpsey: If you do not get money, this cannot be fixed. You cannot get the supply to hit demand nor can you begin to deal with the backlog.
Mr R Pengelly: We have started work for 2016-17 because colleagues in DFP have just recently indicated to us the timetable to which they will operate. The first stage in that process is that all Departments are invited to submit their proposals. We have now initiated a process in the Department to start working up our ask of the Executive for 2016-17.
Mr McGimpsey: That is for 2016-17, but right now, if you had it, you could spend £1·25 million to £1·5 million a week on this. That is a special emergency case to the Executive.
Mr R Pengelly: Yes. We would be ready to go with that any time.
Mr McKinney: I just want to come back in on this. I agree with Mr McGimpsey that it is a resource issue, but it is also about a continuing failure to deal with this at a strategic level. The finance package that was put in to help A&E services took away from elective care. This is a merry-go-round that is making us all dizzy, because it is a systemic failure. Where is the strategic issue, which is really about dealing with the long-term demand and the investment in the primary sector? That was part of TYC, which we have probably managed to collectively investigate to the extent that we do not know where it is.
Mr R Pengelly: Forgive me if I have misinterpreted you, Mr McKinney, but you are really getting into the territory of Donaldson and the review of commissioning and how we structure and deliver health and social care in Northern Ireland. That work is very well advanced. Sir Liam Donaldson delivered his report at the end of December last year. There was a period of public consultation that ran until the end of May, and 142 consultation responses were received, extending to 360 pages of text. There is a big bit of work to analyse the views in that. We have been going through that, and we have been having those discussions with the Minister.
Mr R Pengelly: We have been having those discussions on a weekly basis throughout the post-consultation period. We are now very close to the point where we will have a clear view of where we think the system should move to in the longer term. That encompasses the Donaldson issues and the response to the review of commissioning, which are two significant issues. We are virtually at the end of that analysis work and are drawing our conclusions from that.
Mr McKinney: It has been delayed, of course, by the absence of the Minister.
Mr R Pengelly: The work that we have had to do is the work that we have had to do.
Mr R Pengelly: Well, I am —
Mr McKinney: Just say yes. Has it been delayed or has it not?
Mr R Pengelly: I do not feel that it has been delayed by that.
Mr R Pengelly: I dealt with this issue. We were surprised by the sheer volume of evidence and analysis that we had to do before we got into the review of commissioning. This is a failure of officials, given the pace at which we have taken it forward. The original timescale was the end of August. We were not in a position at the end of August to put a set of decisions to a Minister to conclude on that. We continue to work on that. We have had those discussions, and we are very near the end point in being able to reach conclusions.
The Chairperson (Ms Maeve McLaughlin): Thank you, Richard. I know that we have gone slightly over time. I am certainly not assured today that what I have heard does not highlight what we have been saying collectively, which is that there is a gap, particularly in the strategic leadership and decision-making role, that impacts across the delivery of our health service and, therefore, on day-to-day lives.
We have raised a number of issues today. I expect that we will get responses to those, from the key pieces that are ongoing to the piece around the action plan and delivery. Thank you for your time today.
Mr G Robinson: I just want to make one small point from my point of view. I have alluded several times to the fact that we are haemorrhaging £2 million a week. Michael quoted a few stats there about how much money it takes to run the service every week. It would be a big plus to get that back again.
Ms McCorley: I just want to make the point that if we do not deal with the issue of welfare cuts and how they will affect severely disabled adults and children, those people will end up coming to the attention of the health service and will cost the health service more. We are all agreed that prevention is better, so I do not accept that argument. There is more to it.