Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): Good afternoon, Minister. You are very welcome to the meeting, as is Richard. Obviously, we want to look specifically at your announcement last week and at the reform proposals generally. We will perhaps have an opportunity to drill down to get more of a sense of the detail. I will hand over to you, and we will then open the meeting to members' questions.

Mr Hamilton (The Minister of Health, Social Services and Public Safety): Thank you very much. I am glad to be here to take the opportunity to expand a little further than we were able to yesterday in the Chamber. I am sure that members have many questions in respect of the various aspects of the speech that I gave last week at the Northern Health and Social Care Trust's leadership conference in Ballymena, where I outlined wide-ranging, ambitious and radical plans for reforming and transforming our health and social care system. I think that, if not everybody around this table, every party represented here certainly encouraged me to take decisions on transforming and reforming our health and social care system, particularly in respect of responding formally to some of the key aspects of the Donaldson review.

I have to say that I am pleased with the response so far to the proposals. Yesterday, I acknowledged your response, Chair. There has been reasonably broad — what constitutes broad in this place — support for the proposals or at least the principles behind the proposals, which I will touch on in a minute or two. However, while I am enthused by the political response so far, what has encouraged us much more is the response of many clinicians who have informally contacted me directly or through the Department to welcome the proposals and tell us what it means for them and their ability to deliver the highest standard of health and social care.

We all know that we need to reform. We face a myriad of large challenges. Some are here already, and some loom down the line. There are challenges around having a growing and ageing population and what unhealthy lifestyles will mean now and into the future. Even good things like the advances in technology, medicine and drugs increase demand and cost. All these challenges come at a time when money is at its tightest. We have also had report after report telling us that we need to change and reform, indicating the general direction in which reform needs to go, and warning us that, if we fail to reform, our health service will fail and the NHS that we all know and love will be at risk.

There are several important principles that underpin the proposals that I made last week. They are improving quality of care, enhancing patient safety, removing bureaucracy and establishing clear accountability. It is my view that, when you are faced with the challenges of unhealthy lifestyles and a growing and ageing population and the pressures of technology and limited finances, the NHS in Northern Ireland will not survive unless we focus on achieving the highest quality and safety of care. We need to configure our services properly and have an appropriate administrative structure, and that is what the proposals that I outlined are aimed at achieving.

I made proposals in three broad areas, and there are obviously different elements in each. I do not want to go back over what I said last week. Members will probably want to pick up aspects that they are interested in through their questions. However, I will perhaps just give you a little more detail about where I see some of the key aspects of each of those three areas going. I will talk first about our administrative structures, which has been focused most on what I plan to do with the board, namely to close down the Health and Social Care Board and take out that layer of bureaucracy.

While the focus has been on the board, this will result in change right across our system. As I indicated, the responsibilities of and staff from the board will head in various directions. Some will go down to our trusts, which will become responsible for planning for care in their areas, and some will go up towards the Department and the Public Health Agency (PHA). There will be change for everyone across the system even though, perhaps understandably, most of the focus has been on the plans for the board itself.

Robin Swann said that the board was a "stumbling block" in one particular policy area. I can understand that type of comment. It perhaps sounds and could be construed as being a little unfair to the staff in the board, but I understand the point being made; it is a point that has been made to me by many people over the last number of months since I have been in post. There is an additional layer of bureaucracy that is not needed for a small region like ours. That was certainly the feedback coming through from stakeholders in respect of the commissioning review that the Department undertook after the publication of the Donaldson review. If you have a stumbling block, a barricade or a barrier in your system, you do well to get rid of it.

I will give you a flavour of where I see the work in respect of the proposals on the board and the administrative structure. The Department is undertaking some scoping work to identify all the work that needs to be done to make a reality of what the proposals said last week. There will be a consultation, and we aim to get that out as quickly as we can. The board was created by legislation. Legislation will be required to make some but not all of the changes that we aspire to. Obviously, that will have to come through proper processes in the Assembly, more likely in a new Assembly term after the election. Given the realities of how long it takes to get legislation through and the fact that there is an election coming up, I see this probably as more or less an 18-month process from here and an aim, with a fair wind and everything going the right way, to implement the proposed changes around 1 April 2017, the start of that financial year.

There will be business as usual in the board. However, that does not mean that we should not look to make some of the changes that we want in taking away bureaucracy and not having barriers to innovation. The scoping exercise will pinpoint anything that we can do to give effect to the proposals in the meantime, if there is support for them through a consultation, rather than waiting an additional year for the formal legislative process to go through. If there are things that we can do in the interim to give effect to the changes, we will do them.

On the second aspect of the announcement around the appointment of a panel, you know that I rejected the full implementation of recommendation 1 of the Donaldson report, which was a completely international panel where we would all agree in advance all the recommendations that came out of it. I did not think that that was living in the real world. I did not think that it was recognising the considerable expertise that there is in the Northern Ireland health and social care system, which has an important role to play in advising us on the future configuration of services. I do think that we need a panel to look very carefully at the configuration of services, and that is why I indicated that I would appoint a panel. We have not had a clear view. Whilst the Donaldson report says that we need to reconfigure our services, it did not go into any detail as to how they should be configured. It is important that we see exactly how they would be configured to achieve, on the basis of evidence, a world-class health and social care system.

I will give some detail of how I envisage the panel working and the process around it. I see a panel of around half a dozen people. It could be smaller than that or a little bit bigger than that; it depends on the people who might be available to work on it. I say six, but I am amenable to seven or five to get a good panel. I want them to come from different backgrounds. I indicated that I wanted it to be a clinically led conversation. There is an important role on it for clinicians but not exclusively clinicians; we need to have representation for people who have experience of transforming health and social care systems. Even though I rejected a fully international panel, I think that there is merit in having some people from outside Northern Ireland, but not the balance. I see us appointing the chair.

I mentioned in my speech last week that I wanted to convene a political summit to discuss the panel's work and perhaps, if successful, set out a broad vision for the future of health and social care in Northern Ireland. I said that I would convene it but it would be better for the panel, when appointed, to convene that. As I said last week, I want the panel to lead the debate. I envisage the panel, once appointed, setting out a series of questions or broad principles for political parties to consider and then come to a summit and discuss and, if possible, agree. It is incredibly important for any panel, as it does or sets out on its work, to know the political parameters within which it operates. It is important that it knows as clearly as we can make it what we as political parties are up for and, equally, what we are not up for. That means that the report that you will get back will be more likely to be agreed by us. It will also not have proposals that it knows instantly will not fly or work. It is incredibly important that we set out the clear political parameters of what is possible for any panel that is appointed. I said that I wanted it to be a panel-led debate, and that is a way in which that can happen. I want it to do its work without telling it what to do, but I want it to base it very much on evidence and for it to be data-driven.

Finally, the third aspect of what I announced last week was my hope to create a health and social care transformation fund. I will be very brief in respect of it. My ability to do that will depend on the extent of an overall uplift in funding for the Department of Health, Social Services and Public Safety in the next Budget. However, it is an incredibly important thing to do. If we are to achieve the transformation and reform that we know is needed to stave off and conquer the challenges that our health and social care system faces, it is incredibly important that we ring-fence a portion of additional funding to make that a reality. I had some experience of that in my previous post as Finance Minister: I ensured that £30 million was set aside for a change fund. The Health Department benefited from that change fund. Three projects benefited from that funding. In retrospect, I wish that we had funded more projects in the Health Department. Those are very innovative and creative projects that are delivering really good outcomes. It is incredibly important that, using that experience, we look at the challenge that we face and the need to innovate and reform. Tremendous innovation is already going on in our system, but, to take that up a couple of levels, we need to ring-fence a portion of funding to make the transformation that we know we need.

As I said, we all know that reform and transformation are needed. These proposals are a big step forward on the journey. I said last week that this is an enterprise that will not be complete by the end of this Assembly term; it will probably not be complete even by the end of the next Assembly term. This is a journey that could take us as much as two Assembly terms or 10 years to get the world-class health and social care system that I hope we all aspire to. The next phase is the important work of taking time to consider and begin the work of designing the best health and social care system that Northern Ireland can have. I look forward to having your support, Chair, and the Committee's support for bringing the reforms forward, getting them implemented and starting on the journey of creating a world-class health and social care system.

The Chairperson (Ms Maeve McLaughlin): Thank you, Minister. I think that you know my views and, more or less, those of the Committee in relation to the requirement to reform a system that is overly bureaucratic and complex and in which there is duplication. There can often be a public confidence issue as a result of that. There is no doubt that, if we are about reform, we are in the right direction. I am interested in what you said around legislative change. You said that this could take 10 years to deliver: is that not a risk?

Mr Hamilton: A risk in what sense?

The Chairperson (Ms Maeve McLaughlin): A risk in the sense that, potentially, you have similar structures in place, that public confidence may erode over such a lengthy period and that the staff in the new structures may not know what the next step is. Ten years is a considerable period. I note that you said that some changes could be made without legislation: I would be interested to hear examples of those changes.

Mr Hamilton: I understand the point that you make. The scoping exercise will identify clearly where we can make changes that will have the more immediate effect that I aim for. I do not want to create the impression that all of this relies on legislation. If a board was created through legislation, we are going to have to dismantle it, for want of a better word, through legislation. Legislation will also be required to give effect to some of the more substantial changes, but that does not mean that work cannot start or continue throughout that process to bring into effect some of the changes that do not require legislation. We would be wrong to wait for legislation to start those changes.

I understand your point about 10 years. What I mean by referring to a 10-year enterprise is that the implementation of all the reforms that are required could take that long. It is not just a matter of closing down the board and taking out that layer of bureaucracy; that can be done in a shorter period. However, the bigger piece of work to configure our services properly — doing what we should do locally locally and doing what we need to do regionally regionally — may take longer. Those changes will require timetabling and, in some cases, investment, which is dependent on budgets moving forward. Clearly, we want to make those changes as quickly as we can, but we need to go into this with our eyes wide open, in the understanding that the changes might take some time. That is why I talked in my speech last week about a political summit. I took some criticism in the media for doing so, on the grounds that it would somehow slow things down, get in the way and that we would never be able to agree on anything. In reality, if this is to take a considerable period — I think that most people inside the system agree that it will — there could be as many as three Ministers from three different parties holding the position over that period. Therefore, it is incredibly important, I believe, to get the broadest political buy-in for the direction possible.

On your point about losing people along the way, I think that the merit in what I have set out about the panel — guided by the political realities that I have spoken about but also the principles of highest quality and safety of care — is that it will sketch for us the direction of travel and what we need to do. If we can agree and we all agree that it is for the right reasons, then, whilst it may take five, seven or 10 years to make it all a reality, people will at least know for the first time what we are doing and where we are heading with those big reforms and big changes.

You hear sometimes people saying that we should just implement Donaldson and all will be fine. Well, Donaldson does not go into precise detail on how services are to be configured. That is the work of the panel that he recommended. I propose a slightly different panel, but it will set out in much greater detail what we need to do and the tough choices that will be involved in that. There will be tough choices, but we will also see the benefit of those tough choices, and we will see, as well, for the first time, much more clearly the negative consequences of not making those tough choices.

The Chairperson (Ms Maeve McLaughlin): Thanks, but I am a bit confused. I support the need for reform absolutely, but surely the first stage should be the legislative change. The difficulty that we have here are the structural issues. I am just a bit concerned about what we can do in advance of legislation being changed.

Mr Hamilton: You are right. I do not think that you and I are in disagreement on this point. Legislative change is required, and it will be the first product of all the reforms. I am not saying that legislation will be passed immediately; obviously, there are processes to go through. However, the process of, as you say, taking out those layers that get in the way and dealing with the structural problems that inhibit reform and innovation will start very soon. We cannot think, however, that money alone will solve all the problems in our health and social care system and prepare us to properly meet the challenges that I was talking about. Even if we get out of our public spending difficulties and there is more money available for all public services, including the Health Department, throwing more money at it will not solve all our problems. You have got another wave of big challenges coming over the next decade or longer, which we need to ready ourselves for, and that is why we, yes, need to get the administrative structures right — that work will come first chronologically — but also to configure our services properly.

The Chairperson (Ms Maeve McLaughlin): I would like to drill down a wee bit more into this. You said in your correspondence last week and in your speech that allocating additional money at this point within the current system would mean that we would fall further behind.

Mr Hamilton: There are some people who seem to think that more money in and of itself would solve all the problems that our health and social care system faces: I do not believe that. The appropriate administrative structure is required to take bureaucracy out of the system. We have to configure our services properly to ensure that we get the highest standard and safety of care and use expenditure to deliver transformation. Do not get me wrong: we need more money in the short term and in the longer term, but we cannot just put more money into a system that is not operating efficiently, which I think is your point and one that I would agree with. We have to take out unnecessary layers of bureaucracy. At the minute, the Department has a budget of £4·7 billion, and I want to ensure that we get the most out of that £4·7 billion. I do not believe that we are currently, because we do not have the most efficient system. We need to change the system to prepare for the coming challenges. Sometimes, we do not understand the sheer size and scale of the challenges that are coming down the track. They will cause huge problems, and just throwing money at them is not in and of itself going to conquer them or solve the other problems that we face.

The Chairperson (Ms Maeve McLaughlin): Yes. I want to elaborate on this point a bit. You talk about the requirement for a huge uplift in the budget and about a transformation fund, which I can see the logic for. My concern is that there will be a huge uplift through a transformation fund to a system that is seriously flawed and may, as you indicate, take up to 10 years to reform. That is a very real concern.

I listened today to stakeholders at the international conference on suicide prevention. They are very supportive of what is on the table but say that review after review can leave a system in paralysis, where no one knows who is making the decisions and there is no clarity on the role of the Health and Social Care Board. My point is that we need to be clear on the timescales. My worry, much though I advocate what you suggest, is that, if we have no legislative change, we are simply putting additional money into a system that is flawed and will not have the outcomes that are desired.

Mr Hamilton: I do not think that we are in disagreement on the destination. I have no desire to let this drift in any way. As I have said to Richard, if the consultation document were put before me tomorrow, I would sign it off and get it out, so that is putting a bit of pressure on this man. I want to start moving on this; I am not holding back. We all get frustrated by processes. If I told Richard that I wanted to do exactly what you said and clicked my fingers to make it happen, he would tell me that there were a million reasons why I could not do that.

The Chairperson (Ms Maeve McLaughlin): Can you, as Minister, effect legislative change earlier?

Mr Hamilton: We have to face up to the realities of this place in getting that through. We would need to get a consultation out and consider the responses. You know about that; you do it all the time. Even if I were to introduce it — I am looking at Richard to correct me if I am wrong — this would require primary legislation. I do not think that we can do this by regulation or anything like that. If there are things that could be done in that way — I am not saying that there are — I will not do anything that will stop this. The important thing is that I have asked Richard and officials to identify areas where we can effect change as quickly as possible in the way in which we talked about and have agreed on without the need for legislation. That is probably the better way to do it. Then, if legislation is required, unfortunately we will have to go through the processes. Even if I were able to introduce that after a consultation — obviously, we would need to do a consultation — there is no way that we would get it through any of the stages this side of the election. However, all of the work will be done to ensure its early introduction in the new term so that a new Minister will have no hesitation in bringing it in as quickly as possible after the election.

The Chairperson (Ms Maeve McLaughlin): When will the panel be established, and is there a timeline for a panel report?

Mr Hamilton: We are busily working to identify suitable individuals to go on the panel. As I said, I want the panel to be small and to have a clinician-led conversation. I want clinicians to be very involved — people with clinical experience — and people with experience of transforming within the health and social care system. We are identifying individuals who have the experience, the time and the willingness to take part. Much like launching the consultation, I will not hesitate in appointing those people and getting the panel up and running. Obviously, I have to speak to them, ask them and make sure that everybody that we want and need is in place, but I do not see that taking much longer than a couple of weeks. Obviously, they will have to meet and consider how they can lead the debate, but my advice or instruction to them will be to convene the political summit that I talked about pretty quickly, because that is an essential building block for moving forward on their work so that they know the clear political parameters within which they have to work.

There will be logistical issues around getting people appointed, but I do not see that taking an inordinate amount of time. Then, they will have to carefully go about the work of getting the evidence and the data that they require and analyse it. I am not going to tell them what they should do, but they will probably have to go out into the field and talk to stakeholders and probably talk to the Committee. I do not see their work taking any longer than four to six months and a report being in place early in the new mandate.

The Chairperson (Ms Maeve McLaughlin): So, we are talking about a couple of weeks for the panel to be set up and four to six months for a report.

Mr Hamilton: Yes. It might take a couple more days than that to get it right and to get the right people. We are trying to identify and approach people who are maybe not international but are of international standard and quality and get them appointed to the panel.

I would be happy to wait a day or two to get a sixth person who would add to the thing. I do not want to be pinned down on whether it will be two weeks precisely; it might take another week to get everybody.

The Chairperson (Ms Maeve McLaughlin): That is fair enough. I am just trying to get a sense.

Mr Hamilton: It will be weeks rather than months.

The Chairperson (Ms Maeve McLaughlin): Finally from me, where does this proposal leave Transforming Your Care?

Mr Hamilton: I am acutely aware of the criticism of Transforming Your Care and its implementation. Very shortly, I will publish a progress report on our implementation of Transforming Your Care's 99 recommendations. For me, Transforming Your Care was always a journey and something that was more cultural than anything else. If you look at a lot of the recommendations, as I have done — even in recent times I have gone back over them — you will see that a lot of them are, as I say, quite cultural. They are not 99 specific recommendations; very few of them are specifically, "You will do x". It is a cultural thing. I think that you are starting to see that culture — as I do when I travel around the health and social care system — embed itself across health and social care. I have seen some incredible examples of Transforming Your Care in action. Lots of really good work is going on at the front line, which is the very essence of Transforming Your Care, as well as on some of the few recommendations that are quite specific.

Transforming Your Care is very much still there. It is still alive. It is something that we seek to increasingly ingrain in the system in which we operate. There have been challenges with funding, but that which has gone in has had the effect of shifting funding left. Around £45 million has been shifted left. Those are the latest figures that we have. It is starting to work, and it is starting to have an impact. There are lots of projects that we can point at, lots that I have been to and lots, I am sure, that the Committee has seen or heard of that are, as I say, the very essence of Transforming Your Care. It is something that is still there. In my view, it is one aspect of the reforms that are required, along with administrative bureaucracy and getting the right configuration of services. It is not the final —

The Chairperson (Ms Maeve McLaughlin): Is it a policy direction for the Department?

Mr Hamilton: Transforming Your Care? Yes, very much so. It is departmental policy. It was signed off completely just over two years ago. It has been implemented, as I said, since then depending obviously on finances, which have not always been available to do it on the scale that we would want to do it.

The Chairperson (Ms Maeve McLaughlin): Sorry, Minister, I must tell you that I think there needs to be clarity of intent around this. Transforming Your Care was actually over three years ago and has gone from being —

Mr Hamilton: It was announced two years ago, I think.

The Chairperson (Ms Maeve McLaughlin): It has gone from being the plan, the policy, to being a vision and, now, a journey and a cultural thing.

Mr Hamilton: None of those are necessarily mutually exclusive, are they?

The Chairperson (Ms Maeve McLaughlin): You are right to point out that £44 million has been shifted in three-plus years; it was supposed to be £83 million in order to do this. There are big question marks around the focus of Transforming Your Care. It became apparent when we looked at monitoring rounds. Richard and I have had this conversation many times. It certainly felt like it was down the pecking order. There is a need to say that this is the intent and policy direction of the Department and that you clarify that. If it is not, you need to say that it is not.

Mr Hamilton: I can say clearly that it is. You will see, when the progress report is published, that not only is it the policy intent and direction of the Department, it is exactly where we have been going over those two to three years. You will see significant progress being made on the vast bulk of the recommendations. Many have already been implemented. Many are in progress, and very few are not. I can say, absolutely, that it is the policy intent and direction of the Department, but it is only one part of the reforms that I believe we require.

I am happy to say that I fully support Transforming Your Care, and I accept and have accepted previously the points around funding. You will appreciate, when monitoring rounds come before the Committee and you are asked whether you support them, that you see that, particularly in a Department like Health, trying to pick and choose between bids is difficult. In circumstances where money is tight and there is huge pressure on the front-line services, to have not sought money for those, particularly in the current circumstances, and sought money for Transforming Your Care would have been difficult. That is why I acknowledged last week the need to create something like a transformation fund so that there is ring-fenced money. I firmly believe that, if you take money and ring-fence it for particular purposes like innovation, you will see a lot of great ideas coming forward. That fund is needed to encourage the development of projects like those envisaged in Transforming Your Care and, indeed, those that probably were not envisaged by Transforming Your Care but will have to be envisaged to meet the challenges I was talking about earlier.

The Chairperson (Ms Maeve McLaughlin): I said "finally" a minute ago, but I will ask another question. In the uplift that you referred to, how much are you talking about?

Mr Hamilton: As you know, there are discussions ongoing elsewhere in the estate involving all the parties around this table to try and ensure that devolution remains here and that we are able to set a budget for future years. Until we resolve the series of issues facing us, which I hope we will do and am optimistic that we will do, we will not be in a position to know — the Finance Minister will not be in a position to tell us all — how much money we will have in-year, potentially, to spend. I hope that a resolution to our issues around welfare reform can mean that there will be an injection of cash into this Department to deal with things like waiting lists and get ourselves ready for the pressures we will face in the winter. Also, clearly, we will not know what our financial circumstances will be going into a Budget. We know that times remain tough and that there will not be much additional spending, if any, in the overall block going into next year.

As I said, there is a need to continue to invest in health, not least to fund the transformation we have been talking about. In doing that, a situation where there is basically flat cash across the budget will mean sacrifices and difficult decisions elsewhere. Obviously, I will bid very strongly. There have been no directions or discussions initiated by DFP, not least because of the lack of resolution on all the other issues. When they are resolved, I am sure that there will be a quick flurry of activity to finalise what bids there might be. We will do that, and we will bid very strongly. We will be realistic with our bids and conscious of the difficulties other Departments face and of the overall pressures they face. We will bid for additional resources, and, as I said, I am committed to —

The Chairperson (Ms Maeve McLaughlin): You must have a kind of ballpark figure. If it were in your gift at the minute —

Mr Hamilton: It used to be in my gift, of course. Partially.

The Chairperson (Ms Maeve McLaughlin): What would your ask be, not to simply stand still but to do this reform agenda?

Mr Hamilton: Tempted as I am to play this game, I will not do so. I will make a very strong case to ministerial colleagues for a substantial uplift in Health's budget because I believe that we need to get that investment to deal with the challenges we face in the short term, ready ourselves, make those reforms and start the transformation that we have been talking about. I will have discussions with the Finance Minister. I used to play this game on the other side of the net, and it would not be advantageous to me, my Department or the services we will deliver if I started revealing my hand now.

The Chairperson (Ms Maeve McLaughlin): OK, so you are not telling me.

Mr Hamilton: It is a nice way of saying no.

The Chairperson (Ms Maeve McLaughlin): Yes, that is what it was.

Mr McCarthy: Minister, you can take your ease for a minute; I want to congratulate Richard. The last time he was here, he came in for some criticism, but I want to thank him for his prompt response to me in relation to autism problems. I did just fire a question at you, Richard, before you left and you responded quite quickly, so thank you very much. I do not know whether I agree with all that was said, but at least you responded quickly.

I now go to you, Minister. It scares the hell out of me when you say it will take another 10 years. Our constituents will be listening to every word you utter today because it is our constituents and families who are on the huge waiting lists.

I was glad to hear you say that you, as Minister, were in charge of running the health service. In recent times, we have heard, even on the Committee, people asking who runs the place and who is in charge. At least we now know that you run the place, you run the health service and the buck stops with you. That is a plus. You have told the community that.

You will know that the health service is undoubtedly at breaking point as regards waiting times. I was at a gathering of surgeons in this Building the other night, and the guy beside me said, "My patients are waiting up to 88 weeks for a second appointment". That is absolutely shocking. You would not like it if it was any of your family, and neither would I. We expect you to do something to get on top of that as quickly as possible, not within 10 years. The appalling waiting lists must be tackled. There are answers. You said in your introduction that you were listening to clinicians, for instance. The problems can be overcome if you listen and act on what clinicians and professionals tell you. At gatherings like that, we all hear, "If the Department does such and such a thing, we can overcome". We hear that from GPs, clinicians etc, so it is up to you to listen and then act.

We mentioned Transforming Your Care. The activity of GPs is paramount to Transforming Your Care because it placed a lot of emphasis on them. They published a document recently — in September, I think — that has five actions. They suggest that, if those actions were implemented, we could largely overcome the huge waiting lists and reduce costs. It is as simple as that. You said that you were listening, so you could act on what the GPs are telling you.

Donaldson came out about this time last year.

Mr Hamilton: It was earlier this year. It was about February time, I think.

Mr McCarthy: No, no, no, no. I have got it down here. That is the actual document that I got.

Mr Hamilton: It was TYC.

Mr McCarthy: Is that not Donaldson's response?

The Chairperson (Ms Maeve McLaughlin): Donaldson's response came after that.

Mr McCarthy: I have got it here: on 17 September 2014, the Liam Donaldson review.

Mr Hamilton: It was not published until February.

Mr McCarthy: Anyway, what I am trying to say is about the delay. You are coming here only now. You made that speech only this week, so if it is to take a year for you to do three actions — I think there are 10 recommendations — we will be a hell of a long time getting through that. I cannot understand why it takes so long to even make a statement on the thing.

The Health and Social Care Board, as you know and have said, will be abolished. Four hundred staff are involved, I understand. Where will they go to? Will they be simply dumped? What savings are coming back into the Department from abolishing the board?

You say in your statement in relation to Donaldson that closing hospitals is not on your agenda. Donaldson said clearly that we had 10 hospitals and needed only four. If you are not going to close hospitals, how do you come together with Donaldson and that review? He clearly says — indeed, it is common knowledge — that most people say that hospitals should be closed. I do not necessarily agree with that, but how do you reconcile closure from Donaldson and non-closure from you? I will leave it at that for the minute.

Mr Hamilton: I am not sure that there are any questions left.

Mr McCarthy: There are loads.

Mr Hamilton: I suspect you are right, Kieran.

You are conflating a few issues. On the issue of time, you talked about the overall package of reform that I and I hope all of us believe is required to create a world-class health and social care system and meet the big challenges that we are talking about. Unfortunately, that is not something that we can click our fingers and make happen very quickly, and there are lots of reasons why that is the case. You are conflating that issue with the current difficulties we face with waiting lists.

I am not saying that it will take 10 years to deal with the issues. There are lots of factors as to why there have been increases in waiting times; there has been a huge increase in demand. Primarily, it is an issue of resources. The last time I was before the Committee, I think we had a conversation about the money that is being lost to the Executive overall in welfare reform penalties. I do not want to dwell on that issue because, obviously, work is going on to resolve all the issues. I hope that their resolution, albeit late in the year, will allow some resources to be freed up in-year. I will bid, if there is the opportunity to do so, for more resources for health.

I can tell you, Kieran, and the Committee and anybody who cares to listen that the vast bulk of that money, if I get it, will go towards addressing waiting list problems. Whatever I get, if I get anything, will not resolve all the waiting list problems we face, but your constituents and mine and the constituents of others will start to see movement on waiting lists and see times coming down. It will need a concerted effort over subsequent years as well. Whilst it is not going to take 10 years, it will not be done in two or three months; it will take longer than that. Again, one of the reasons why I need to seek a significant uplift for the budget is the deterioration in waiting lists caused by pressures as a result of welfare reform. We had been getting to grips with waiting lists; they had been improving. It is interesting to note the correlation between the problems around welfare reform and the loss of money in penalties and the deterioration in waiting lists.

You mentioned several other things. You used the term "breaking point": I know there are pressures and difficulties. I get a lot of stories, and I am sure that members get constituents speaking to them about the problems they face. Describing the health service as being at breaking point sometimes does a disservice to the fantastic work that goes on across our service. We have excellent staff, but there are also some excellent projects that they are involved in. In my speech, I cited one in the South Eastern Trust area, where 700 diabetes sufferers use new technology to deal with their issues in a way that is far better than going to outpatient appointments. Loads of really good projects are going on. I know that there are challenges, but let us not do down the service by talking about it being at breaking point.

I understand the pressures that GPs, general practice and primary care are under. That is why, a number of weeks ago, I established a task force that will have departmental officials and people from general practice and primary care involved. It was welcomed by the Royal College of General Practitioners and the BMA at the time. We look forward to the task force undertaking some work around dealing with pressures, not just the pressures now but those that will come down the line because of GP retirements and the difficulties we have had in recruiting new people.

Your final point was around closing hospitals. I said in my speech last week and have said before that, for me, closing hospitals is not on the agenda. I think that that is what you said; I am not sure. You were challenging me; you were sort of being devil's advocate.

Mr McCarthy: You said that.

Mr Hamilton: Yes, I have said that, and I believe that. As I said last week and I repeat now, there is a role for our smaller local hospitals. In the future, it will be a different role in many cases to the one they have played traditionally. The role they have played has changed over the last number of years. Some people would say that that role has not changed or should not change or is not going to change, and I think that that is wrong. There are services that can be and should be delivered locally. Smaller local hospitals can take pressure off the bigger acute hospitals, and we need to maximise those opportunities, including dealing with things like waiting lists if resources are available.

I see a role for smaller local hospitals, and it is important that we make it clear. I am sure that others will agree, when we are working with the panel, that closure is something that we do not want to see happen. That does not mean that we should not centralise or regionalise key services where appropriate, where it can be done and where it can be resourced, so that the people we are elected to serve and whom our health service serves on a day-to-day basis get the highest standard and quality of care and the safest care. Sometimes, that will require things to be done regionally, but sometimes it can be done locally as well. I see it as very much a mixture of the two, and it is important to put down that marker. I imagine that others will agree with that, but saying that they will not close does not mean that there will not be change or that there should not be change.

Mr McCarthy: I am glad to hear you say that. How soon can you come out and say publicly what the changes will be? That will give confidence to the people who work in those hospitals. Donaldson said that up to six hospitals should not be there, and we do not agree with that. I do not agree with that. You, as Minister, or your Department must come out and say that the Downe Hospital or some other hospital will provide these services, rather than having the possibility that a hospital will close hanging over it. That cannot be right.

Mr Hamilton: That is what I hope. That is the intention of the panel. As Donaldson recommended, we have a panel with independent clinical expert advice. I have gone against some aspects of that recommendation, but I have maintained the essence of it.

This is a conversation between politicians, but it is much more about the public having a conversation and being involved in it. I want the panel to show all of us that something better is possible and the changes required to achieve that. As I said, I want it to show us, importantly, the consequences of not making those changes. The panel will do that on the basis of clinical evidence, and I hope that the multitude of data that is there will drive those conclusions. The public will see what changes are required. As I said, it is up to us, as politicians reflecting public view, and I think that we should lead the public view in the direction that change is required or the health service that we know and love will not be there for future generations to benefit from, if we do not make some changes. Those may require what may look on the face of it difficult decisions, but it will ultimately be for the benefit of the people we serve because they will get the safest care they can get and the highest standard and highest quality of care.

Mr McCarthy: Finally, you mentioned the extra funding, and we know about that. However, I think you had applied for £45 million to come out of the June monitoring round, which would have helped to alleviate the waiting lists. You did not get one penny of that. What guarantee are you giving to the Committee that you will get one penny from some other pot?

Mr Hamilton: Nobody got a penny of any money in the June monitoring round because, in the end, there was no June monitoring.

Mr McCarthy: So much depends on that £45 million.

Mr Hamilton: Kieran, you are preaching to the choir. I wanted there to be a June monitoring round, and other Departments wanted there to be a June monitoring round, because we all face pressures and need to get more money to at least try to alleviate those pressures.

You know as well as I do that, without a resolution to welfare reform, and that having a positive impact on our Budget, the Finance Minister could not engage in a June monitoring round because she did not know whether she had enough money to balance the books at the end of the year, never mind giving out more money in June.

I hope, from the monitoring round in the autumn, whenever that might be concluded, that we will have a resolution through the talks process to the welfare reform issues that has the potential to help to balance the books and free up some cash in-year that could go to Health, DRD or wherever it might be. I have absolutely no guarantee, but I think that that is what we should all be hoping for: that we get a resolution to the talks that resolves all those budgetary and financial issues and allows money to get to the front line in various Departments.

Mr McCarthy: I talked about breaking point. I maintain that there are breaking points: the nurses and doctors are at breaking point because they are overworked. They really are, and I want to pay tribute to the work that they do, as you did. I support you in that excellent work and in the provision of the professional people that we have in Northern Ireland. What is your relationship with other Departments and universities in creating and providing more professionals — the doctors, GPs and nurses whom we desperately need?

Mr Hamilton: Relationships are good. Richard will correct me if I am wrong, but we continue to work on workforce planning. We have to acknowledge certain areas have fewer people than we need. There are fewer than we need now, and, projecting further, we will continue to have issues. I mentioned general practice. There have been issues in the past, and there continue to be issues with getting consultants for emergency departments. Last week, I met representatives of the Royal College of Emergency Medicine, and they acknowledged some of the good work that has been going on in trying to address those challenges. We acknowledge the problems that are there and that not all have been solved. There are issues with retaining people, not only retaining them but losing them to outside Northern Ireland.

Mr McCarthy: Somewhere on your desk is the GP contract that is coming up, and it is worrying us all. What about the junior doctors?

Mr Hamilton: I want a fair contract for junior doctors in the same way as I want a fair contract for anybody working in our health and social care system. Let me make it very clear that I will not do or support anything that compromises patient safety or the quality of care. I encourage representatives of junior doctors to re-engage in discussions with the Department of Health in London to see whether we can agree a UK-wide contract to replace the current one, which, I think, all sides acknowledge is not fit for purpose.

Mr McKinney: Thank you, Minister and Richard, for coming in. Just for clarity, I remind the Committee that TYC was published in 2011. It will be four years old in December, which is next month. Before we get to your speech and your plan, Minister, I wonder whether, given the consensus on TYC at the time — that it was the correct diagnosis, if you like, of what was wrong in the system — would you agree that a lot of time has been wasted in the interim, in terms of advancing the ambition, or however you want to characterise it, of that plan?

Mr Hamilton: I think that it would be unfair to say that the time has been wasted. We had this conversation at length the last time I was at the Committee, if I recall rightly. I will not be churlish and say that everything has gone the way that you would want it to in implementing TYC. Earlier, we discussed the financing of it and, therefore, the ability to shift funding left. I would not say that it had is all been hunky-dory by any means. However, I do not think that we should say that it is all duck or no dinner — that it has been a resounding success or a complete failure. I am not arguing that it has been a resounding success, and I hope that you would not argue that it has been a complete failure.

There are lots of examples — I can go through a few if you want me to — of where specifics, or the vision, of TYC have been implemented and are in action. Not long after coming into the Department, I said to officials, "You want to get out and about to understand the system. You best understand the system by meeting people and talking to your staff on the front line." I wanted to see those projects and initiatives, which are the very essence of TYC, being implemented. If the report is not published today, it will be published very soon and available for people to see. I hope that you will see then that we are making tremendous progress in achieving those targets. As I said before, a lot of the targets in TYC are not very specific targets that you could point at and say, "That is that done." Only a few have been like that.

Mr McKinney: Yes, but was it not the job of those in charge of the system to take that framework, which I agree that TYC was, and start to put action points, targets and finance against it?

Mr Hamilton: They have.

Mr McKinney: This would not have been published in the form that it has if that were the case and there had been, for example, a five-year plan for TYC.

Mr Hamilton: It said that there would be implementation over a period and could be quicker or slower depending on resources. I have acknowledged the issues around resources and the challenge of any Minister in juggling competing priorities at a time of pressure between the front line — it is a very serious and important front line that we have in Health and Social Care — versus a transformation project or programme. I have acknowledged that by identifying, I hope, a better way forward and saying that I support the creation of, and will create, a Health and Social Care transformation fund from next year's budget to ensure that there is a ring-fenced pot of money to develop projects, such as those envisaged in TYC and other innovation, collaboration and early intervention projects, that will produce better outcomes and benefit people.

Mr McKinney: How can you realistically expect to get extra money for your budget given the identified waste in health at present?

Mr Hamilton: What waste have you identified?

Mr McKinney: I would expect you to be aware of it, but there is £50 million in bank and agency staff, £40 million in fraud, 360,000 appointments cancelled by patients and clinicians and the waiting list situation where, until cancelled, elective care operations were being paid for twice. All of that amounts to roughly £200 million.

Mr Hamilton: I am not sure whether the Chair would indulge me, but we could go into all of those and have a discussion about whether some of them are a waste of money or not. We could have a discussion about previous Ministers having to cancel contracts with the independent sector to tackle our waiting list because of the shortage of money across the system, due in no small part to of the failure of some parties to proceed with welfare reform. We can have that discussion if you want.

Mr McKinney: We could. We could also have a discussion about how the health budget was ring-fenced and England gave extra money to the system. In your Ballymena speech, you said:

I am just raising a question mark over whether your Executive colleagues would provide that extra funding given —

Mr Hamilton: Do you want me to address that, or do you want to move on to something else? I have not answered that.

Mr McKinney: Go ahead.

Mr Hamilton: I will look to others to support it, and I hope that they will. Take the premise of your question on waste — to use your word — in the system. That is precisely why I have outlined a vision that is tackling bureaucracy. If there is unnecessary duplication and bureaucracy in the system, I would be happy to concur that that was waste. The very fact that I am outlining an ambitious, radical plan for reforming administrative structures gives all of us, I hope, the sense that this is reform that is heading in the right direction and that we are planning to and will get to grips with so that, by the time that we are crafting, finalising and forging a budget, we will have seen some progress along that line. I was chatting to the Chair earlier about doing things in advance of all of that, such as moving to a consultation and getting legislation ready. We will have started that process.

The whole idea of configuring services in a more appropriate way is about using whatever there is in the system, whether it is £4·7 billion, £4·8 billion or £4·9 billion, as efficiently as we can, and that is what I am focusing on. Whatever the outcome of the Budget, whether there is the same or more money for health, I have a duty to try to maximise the output from that. That is one of the motivations and principles behind the speech that I made last week. We need to reconfigure services and streamline bureaucracy to ensure that whatever quantum of cash there is in health is used as efficiently as possible.

Mr McKinney: I think that we are all agreed that, if anything held up TYC, it was money. In Ballymena, you said that you want to take a sizeable amount of any additional funding and put it into a Health and Social Care transformation fund. However, last night, your remarks were much more cautious.

Mr Hamilton: I am realistic.

Mr McKinney: I will read out how realistic you are:

Mr Hamilton: I would be foolish to presume that there will be any more money, as any Minister would be. I would be wrong to say that I expect it. I will make a good fight of it, and I hope that the Committee will be behind me in doing that. You quoted my answer to a specific question.

Mr McKinney: It was, but it was also very clear, and it related to the transformation fund. I could say that I would like a transformation fund. However, I can tell you that, if transformation is linked to the fund, and there is no money, there will be no transformation.

Mr Hamilton: So you are not criticising the principle of a transformation fund.

Mr McKinney: No.

Mr Hamilton: You are having a go on the hypothetical basis of my not getting money in a Budget monitoring round that has not even started. We should all agree that a transformation fund is a good thing and a good idea, and that ring-fencing money for innovation, collaboration, early intervention and so on is a good thing that we should do. We should support additional funding coming into the health service so that we can do that. If there is any caution, it is on the basis that I know — I think that you and the Committee also know — the extent of the other challenges that the health service is facing. The fund is absolutely something that I want to do and that we need to do, but I am realistic about budgets moving forward. I know the challenges that the Finance Minister faces, and I will not be presumptuous in any way, shape or form about what I might or might not get.

Mr McKinney: I get that. Chair, I would just like to draw your attention to the Minister's remarks about me "having a go". My role on the Committee is to scrutinise decision-making by the Minister and the Department, not to have a go.

Mr Hamilton: I am sorry if my comments offended you and your sensibilities in any way.

Mr McKinney: The record will show whether that was meant or not. I am not here to have a go. I have spent two years asking questions about a TYC system that I was told at the outset was being implemented. That period of asking questions proved that, in fact, that did not happen. I am here, as a public representative, to ask questions on behalf of the public about accountability, transparency and the good use of public funds. I would like you to respect that, please.

Who will pick the panel?

Mr Hamilton: I will appoint the panel.

Mr McKinney: Have you any idea at this point of the individuals who will be involved?

Mr Hamilton: At the risk of repeating myself and taking up more of the Committee's time than is necessary, we are intensively seeking to identify people. I hope that, after looking through a list of potential candidates, spoken to them and ensured that they are keen to take part, we will be able, as I said to the Chair earlier, to announce who will be on the panel in the next number of weeks.

Mr McKinney: Will they be employees of the health system?

Mr Hamilton: What do you mean by employees? Do you mean people who are working inside Health and Social Care?

Mr McKinney: I mean people under your charge, if you like, now that you are in charge.

Mr Hamilton: As I made clear last week, one reason for rejecting the full implementation of recommendation 1 of the Donaldson report, which was to appoint an international panel and agree to its recommendations up front, is that I think that there is ample expertise inside our system. I think that we would be absolutely wrong to appoint a panel to look at the best configuration of hospital services in Northern Ireland without listening to people working in our system and taking their advice, experience and expertise.

Mr McKinney: As you can probably gather, the issue that I am thinking about is transparency and accountability.

Mr Hamilton: Yes, I understand your point. I have not found so far, and I am sure that my predecessors would say the same, a lack of willingness from clinicians on the front line to tell me what they think, to disagree with the Department and the Minister, and to challenge. You may have concerns, but I do not have concerns about the ability of our clinicians to give it to us straight and give us the best advice. We will always look at the politics of all of these things, and it is our job to do that. My view, based on their advice to me to date, is that they are pretty straight.

Mr McKinney: Will you consider having union representation on the panel?

Mr Hamilton: I want to get the best people with the appropriate skill sets. I do not want to get into having every sector, organisation and interest group represented, because it would be a very large panel.

Mr McKinney: Yes, but —

Mr Hamilton: Sorry, let me finish.

If I said that we would have union representation, others would ask whether we could also have this group or that group. The result would be a very large panel that would most likely be unable to do the job of work that we want it to do. Even if individuals or groups do not believe that they are represented, it does not mean that they will not have an input into the process. I do not envisage a process in which the panel does not engage with stakeholders. In fact, if that did not happen, I would expect the Committee to raise a flag very quickly and say that it was not right to have a process that did not engage with stakeholders. I do not believe that there is no role for unions, or whatever sector, group or organisation, in the overall process — far from it.

Mr McKinney: I hope that you take this question the right way. It seems to me that you are falling into the trap of seeing all health's problems as being related to health. There are also a lot of issues in, if you like, the business of health — patient flow and how you run systems — that are not necessarily linked to health or, specifically, clinicians. Do you have anybody in mind with that expertise for the panel?

Mr Hamilton: I hope that I picked you up right. I said that I want it to be a clinically led conversation, but I do not think that it should involve clinicians exclusively. I want people who have experience in exactly the area that you are talking about and people with a good CV showing experience in making transformation happen. Fundamentally, we are talking about the major transformation of our health and social care system for however long that takes and well into the future. I do not think that we should ignore that experience. You are right to raise that, and, if it is a trap that I have fallen into, I will try to get myself out of it.

Mr McKinney: It is not a trap.

Mr Hamilton: It is not all about poor health; a lot of it is systemic, and I think that there is an absolute need for that input into a panel on the question of how we can make the system work better.

Mr McKinney: If you zoomed right out, you would see that this is not a health problem and that your health budget will never solve it. This is a societal and economic problem. The earliest intervention will be on jobs, which will make a difference.

Mr Hamilton: I first spoke about these issues back in May, and, last week, I talked about those broader challenges. Putting lots more money into the system that we have, which is not as efficient as it should be, will not, in and of itself, solve the problem. It is about unhealthy lifestyles and bad choices. It is also about good things, such as an ageing population, and the challenges that that brings. You are absolutely right: it is a massive societal problem rather than purely a health one.

Mr McKinney: I have lots of questions and we could go on all day, but I will not.

Mr Hamilton: You might go on all day, not me.

Mr McKinney: No, no. I am trying to keep my questions short.

I worry that we have ended up with a board that became inflated over four years, and now we will spend time deflating it. We will spend time on a panel and a summit. To me, Minister, all of that is kicking the ball up the road. It is all activity disguised as movement. We are not getting the results that we thought we would get when the original report was published in 2011 and the subsequent critique was published last year. We are getting more process and not enough product.

Mr Hamilton: I encourage you, Fearghal, not to be so cynical. There is nothing to be gained by any of us around this table seeing this as an opportunity to score political points. We are all citizens of Northern Ireland, so we recognise the huge challenges that we face in health and social care, as well as other societal problems and challenges.

We could pick over what happened, when and who did or did not do this, but that would not get us any further down the line, and it would not get us a world-class health and social care system or solve the problems in the short or longer term. We all have to invest time and effort into this, and, because it is such a huge enterprise and undertaking, we all need to get behind it and do our best to make a positive contribution.

Mr McGimpsey: Thanks, Simon. I listened carefully to what you said, and two or three things bother me, but I will come to those in a moment.

You have a view on the question of reform. I, too, had a view, and I introduced radical reform, reducing the number of trusts and health boards from four to one, which is what we are talking about. I set up the Public Health Agency, the Business Services Organisation and so on.

Fearghal made a point about the board. When I left, the Health and Social Care Board had 335 members of staff. I understand that the number now is closer to 600. Why, do you think, was it allowed to get as fat as that? It was supposed to be the lean machine, the efficient organisation that the Minister could use to run the health service, particularly the trusts. Each trust had commissioning groups for each area, heavily loaded with doctors and health professionals to determine the health needs in each area, because you cannot leave it solely to the trusts to deliver according to their view. There have to be other views, particularly from GPs.

You are now looking at that board — I have some sympathy for your views — and saying, "This thing has got so big, we need to get rid of it". I caution you because my experience is that civil servants cannot run the health service. That was a very important lesson that I learned. It sounds to me as though you intend to move a lot of these folk back into the Civil Service and go back to where we started.

To see a real bureaucratic nightmare, you should have a wee look at the plans that I was presented with — those from the direct rule days. If you want an efficient management tool, it is a mistake to move it back into the Department. Keep it out of the Department. That is for your benefit, too, although I will not go into that at the minute. It is about determining need, and that is what the board is there to do. The board effectively addresses the need through the trusts and their hospitals.

The other side — primary care, community care and social care — also has to be addressed. We are inclined to say "health and social care" but talk only about hospitals, yet there is social care provision, too. I ask you to think carefully about that because I am not quite clear on what you will do, who will commission, who will determine the need and who will demand from trusts that they deliver their bit.

In primary care, there is the issue of the number of GPs. I addressed that by training an extra 70 GPs per annum at Queen's. I was shocked when Jim Wells told me that, last year, 50 GPs trained and graduated, at a cost of £600,000 each, only to go off to Canada and Australia. That is a major issue for you as well. TYC is all about the shift left to community care, but that appears to have seriously stalled as well.

Someone will have to the jobs that the board does now. It may be that two or three people are doing a job that one person could do, but that job still has to be done. Who will do it?

Mr Hamilton: Let me just unpack some of that. There is quite a lot there, so may I miss some of it, but I will try my best.

Mr McGimpsey: You do not have to go through all of it. Obviously, I was hoping for some comment because I am as passionate about this as anybody. This is all about the function of determining where the need is and how you address it. The key thing is that we are not really talking that much about patient need and outcomes today. You have healthcare staff who, by and large, are overwhelmingly dedicated to meeting that need, looking after patients and giving them the very best care. We are looking to give them the support to allow them to do that.

Mr Hamilton: Let me start with your assertion on the size of the board. You said that perhaps it was an easy target, given its size, and asked how it got to its current size. I read your interview in the 'Belfast Telegraph' earlier in the week, in which you said that your vision for the board was a lean organisation of 250 staff, but that there was some wailing and whining — I cannot remember the tem that you used, but it was something like that, and —

Mr McGimpsey: Senior civil servants complained that they needed more staff.

Mr Hamilton: You listened to the wailing, you listened to the whining and you conceded —

Mr McGimpsey: I listened to a lot of that whining and wailing, I can tell you. I heard plenty of it.

Mr Hamilton: Let me finish my point.

You conceded that, instead of being a 250-strong organisation, the staff count could rise to — I think that the number quoted in the paper was 325 — and you now ask how it could have grown and grown. Perhaps, if it had not been conceded at the start that the number could go from the original vision of 250 to 325, that growth would not have happened.

Mr McGimpsey: So it is my fault. Sorry, I missed that.

Mr Hamilton: Look, you have made the proposition, and I am responding to it. I looked at the numbers, and, in 2010, there were 390 whole-time equivalents. The headcount in 2010, the first full year of operation, was 436. Michael, it was never a small organisation. It was always a big beast, and I think that the risk is —

Mr McGimpsey: How did it get so fat, to the point that you have to abolish it?

Mr Hamilton: I want to make this point. I tried to make it last week, again yesterday and I will make it again now: I did not take the decision on the basis of the organisation's size. It was nothing to do with how big it was. The problem was that, as the Chair said, the additional layer of bureaucracy that the board created was impacting on operational delivery and inhibiting innovation.

Sorry, I did not pick up on Kieran's point earlier when he mentioned all the other recommendations in Donaldson. Many of them have been adopted and are being taken forward. Donaldson himself was critical about our commissioning process and, when Jim was in post, we agreed to a review of commissioning, and that is where the conclusions about the board have largely flowed from. The findings of the review said that the current commissioning complex and, indeed, wider health and social care structures were too complex, with too many layers of bureaucracy and authority; there was a lack of clarity regarding the roles and responsibilities of various health and social care organisations and the chains of accountability between them; things were transactional, rather than transformational. There was a myriad of criticism about the system.

My focus — and the objective of what I said last week — was not about a number of people. Quite frankly, it would not matter to me whether the Health and Social Care Board was an organisation of 200 or 2,000 people. The criticism coming back is that we have a system that is too complex, with too many layers of bureaucracy, and there are issues around authority and accountability. Clinicians on the front line say that they have no idea — bearing in mind that these are not stupid people — how the system works or what benefit that additional layer of bureaucracy brings, and they feel that whenever they want to do things that are innovative, that additional layer of bureaucracy gets in their way. That is not a nice commentary about the system that was created. I hope that, no matter who was in post — whether it was you or me — if you heard those criticisms, you would want to take action. No matter what impression you want to create, for me, it was not about the fact that there were 600 people in the board and, therefore, it was an easy target that I just wanted to take away; it was about the barrier that it was creating and the fact that there was that acknowledged additional and unnecessary layer of bureaucracy. That was the objective. It was not about —

Mr McGimpsey: OK.

Mr Hamilton: To follow on to your point around what happened to people in —

Mr McGimpsey: No, it was not the point about people.

Mr Hamilton: You made that point yesterday.

Mr McGimpsey: No, I asked a simple question yesterday, and you were not able to answer. The question that I am asking you today is this: who is actually going to be doing this now? How is this, directed inside the Department, going to differ from the board as it sits? You talked about other people going off into trusts and so on. How is that new model going to work? That is what I am trying to find out.

Mr Hamilton: I made it clear what I see happening. You talked about planning for need and about that going down to our trusts. You mentioned general practice, GPs and primary care. I want to see a very clear role for GPs working with our trusts to plan for need in their particular areas. I believe that they know best the needs of the people in their area, and I want to see them both working very closely on planning for need. They will be directly accountable to the Department. Another criticism that you hear within the system is that there are too many opportunities to pass the buck when things go wrong. Trusts will point the finger of blame at the board, the board will point the finger of blame at the trusts, the trusts will maybe point the finger of blame back at the Department — maybe everybody points the finger of blame at the Department. I want to make it absolutely crystal clear where accountability lies. I will be looking to the trusts to deliver on meeting their performance targets and their financial management targets. I want them to do all of those things that they need to do, and they will be held accountable to me. There is a point that Richard has made to me in the past that highlights the confusion —

Mr McGimpsey: Again, I understand that that is the vision. How is it actually going to work?

Mr Hamilton: I was in the middle of a sentence there.

Mr McGimpsey: I understand that, but you have a lot of sentences. I am not having a go, but I am just trying to get firm —

Mr Hamilton: I appreciate that.

Mr McGimpsey: We are trying to just tease this out, because this came out of the blue during a speech in Ballymena.

Mr Hamilton: I do not think that it came out of the blue that something had to be said. The work was being done; you knew that.

Mr McGimpsey: I thought that it came out of the blue, and I have to say —

Mr Hamilton: Sorry, you are saying that it came out of the blue that a response to Donaldson had been made that there would be a conclusion to the review of commissioning.

Mr McGimpsey: No, the announcement about abolishing the board came out of the blue. That is what we are talking about. We will get on to Donaldson in a minute.

Mr Hamilton: Maybe you thought that it was out of the blue. I do not think that anybody who knew that a review of commissioning was going on would find that that was something that was out of the blue.

Mr McGimpsey: All right. It was out of the blue as far as I was concerned. I did not see that coming. I knew that there was a discussion going on, but I never imagined that the Health Minister would go to Ballymena and make the announcement. I thought that he would have come to the Assembly. What I am trying to get from you is what this looks like. What is this model that you have? A directorate inside the Department that will do all of these things that you say it is going to do? How many people will be there? What are they actually going to do? Who is doing the commissioning plans? Are they being done in the Department? Will they be done in the trusts? Remember, they are hospital trusts. How does primary care and community care fit into all of this? TYC and the shift left is a key part of primary and community for the future.

Mr Hamilton: On the point around the social care side of the house, there will need to be a form of commissioning still done for that. I have been consistent in saying, to use the phrase that I used last week, that this is an end to the current way in which healthcare is commissioned. On social care, there has been no significant criticism that I am aware of about how social care has been commissioned, and we will continue with some form of commissioning for social care. I reiterate the point that I made before that the objective here was not to make savings or efficiencies around people. There are many good people in the board doing good work, and that work will continue, where it is required. That may be at trust level on work around planning. If it is work around accountability, that is more likely to head in the direction of the Department.

You made the criticism that civil servants are not good at running the health service, but I think that the problem at the minute with the system that we have with these additional layers of bureaucracy is that the current system is not working great as it is. In circumstances where you get those sorts of criticisms that I outlined, I think that action is required, and I think that, as Donaldson highlighted and Kieran mentioned, there are issues around who is in control and where accountability rests. It is, comparatively speaking, a very, very small region of 1·8 million people. It has a very elaborate and complicated structure of administration, and you do look at examples elsewhere, particularly the likes of the other devolved regions of Scotland and Wales, that have very much moved away from the sort of system of commissioning that operated in England and operated here to some similar degree. As I said, this is about getting the system working as efficiently as possible. It is not about making savings by getting rid of staff from the board. There will be jobs that they will need to do, and they will be going in different directions depending on what function they are performing.

Mr McGimpsey: You are going to have a directorate inside the Department. How many people will be in that?

Mr Hamilton: That is a bit like Maeve's question about how much money I am going to bid for. We will do a piece of work that will examine how many. Because we do not have a precise answer on how many staff —

Mr McGimpsey: You do not know. You have not worked it out. Just say that you do not know.

Mr Hamilton: You thought that the board would have 250 people, and you let it have 325.

Mr McGimpsey: And it ended up with 600.

Mr Hamilton: Yes, you created the big beast to start off with.

Mr McGimpsey: It was not a big beast. It was all right when I left.

Mr Hamilton: It had 436 headcount in your first full year of operation.

Mr McGimpsey: I got that sorted.

Mr Hamilton: You got it sorted. Right, OK. How did you sort it?

Mr McGimpsey: You cannot tell us how many people will be on this directorate right now. You have not worked it out.

Mr Hamilton: There will be as many people in the directorate as required. I do not see this as being a big department or a boost in the size of the Department by any means.

Mr McGimpsey: Can we go on to the panel? You are going to set up this panel. I do not want to go through all the process, but are you going to give it your blueprint and ask it to look at that and to prove the blueprint? Have you got a blueprint for the future for the Donaldson plan on hospital services, or are you just going to throw it to the panel? What are you going to do?

Mr Hamilton: I am not sure if you picked up what was said around —

Mr McGimpsey: I think I did, but you just go on. If you could answer the question, it would be helpful.

Mr Hamilton: I will say it again, then.

Mr McGimpsey: Yes, OK, if you have to.

Mr Hamilton: There are, to use your term, blueprints, plans or policies in place like Transforming Your Care that will inform the panel's work. I want them to look at evidence that is there and to develop their own evidence around the best configuration of services. I want them to inform. I want it to be a clinically led conversation, where clinicians and, as I said to Fearghal, those who have experience in transforming the health and social care system tell us the best configuration of services, and the benefits of making those changes. Also, importantly, and something that we have not had before, telling us the consequences of not taking those decisions. It will then be for us to choose whether that is the direction in which we want to go.

Mr McGimpsey: So are you giving them a plan or not? Are you letting them know your blueprint — what you think is the ideal?

Mr Hamilton: If it was a matter of what I thought should be done —

Mr McGimpsey: Do you have a plan or an ideal?

Mr Hamilton: If it was a matter of what I thought it should be, I would just go ahead and do it myself. The recommendation of Donaldson was that we hand this to an international panel of experts and that we all agreed their recommendations up front even before we saw them. I am not prepared to do that. He was right in his aim and objective but not in the way that he proposed they were executed. What Donaldson said about having a panel look at the best configuration of services is a good thing to do. I have just decided to configure it slightly differently than he proposed.

Mr McGimpsey: So I take it that there is no blueprint.

Mr Hamilton: What would be the benefit of me giving a blueprint that might then become the outcome that the panel reached? The benefit of having the panel, which is what Sir Liam was attempting to do, was that it would be independent and look at the evidence. We should be informing them politically of what the parameters should be of the work that they will be undertaking, whether around the role of small local hospitals or whatever. They need to be cognisant of the political realities. However, it is not for me to tell them, "This is what I think you should be doing. Go away on and confirm that." I want to get their independent expert advice as to the best configuration of services.

Mr McGimpsey: So you do not have a blueprint.

Mr Hamilton: Could I have a blueprint? Yes, I could, but the point is getting that independent advice.

Mr McGimpsey: It is a yes or no. Do you have one? Yes or no.

Mr Hamilton: Do you have a blueprint?

Mr McGimpsey: I am asking you the question, Simon.

Mr Hamilton: The point here is —

Mr McGimpsey: Does the Department have a blueprint?

Mr Hamilton: No, we do not have a blueprint about what the future configuration of services should be. After having asked Sir Liam Donaldson to produce a report, we have been reflecting upon that key recommendation. I have proposed a way forward that will get a blueprint for the best configuration of hospital services that ensures that safety and quality of care are paramount.

Mr McGimpsey: Can I just get the chronology? Ten years was mentioned as a roll-out, but how long is the panel process going to take? You are going to set up a panel, it is going to deliberate, it is going to produce a plan, and you are going to look at that and, I do not know, have a forum or something you talked about. What is the chronology? What is the time frame for that — setting up the panel, panel given a certain amount of time to deliberate, than a plan and then a forum, presumably?

Mr Hamilton: Again, for perhaps a third time, Chair —

Mr McGimpsey: We can do it for four times, if you wish, Simon. I do not mind.

Mr Hamilton: If you do not listen to the answer the first time, we might have to go for two, three or four times.

Mr McGimpsey: I listened carefully. Now, easy. It is all right. We will get there.

Mr Hamilton: We will appoint a panel in the next number of weeks. We are seeking to identify people to be on that panel. If I could do that in the next number of days, I would. There is nothing holding that up other than identifying the right people who are available and willing to do the work. We will do that in the next number of weeks. As I said to the Chair initially, and to others, I want the panel to deliberate on questions that it wants to pose to us as political parties. That will be brought to the summit that I talked about, and it will then be for all of us to participate in that. I hope that parties will participate in that.

Mr McGimpsey: When do you plan to have that summit?

Mr Hamilton: I do not see this taking a terribly long time. As I said to the Chair, there are logistical issues around getting people appointed and in place. I hope that we will be able to do it before Christmas or shortly thereafter.

Mr McGimpsey: You mean that you want to get the panel in place before Christmas.

Mr Hamilton: I mean getting the panel in place and having the summit quickly thereafter, possibly this side of Christmas, as I said, or shortly after.

Mr McGimpsey: I am talking about the panel producing this plan or blueprint that you do not have.

Mr Hamilton: And then it will —

Mr McGimpsey: When are we going to see it?

Mr Hamilton: The panel will then go ahead and do that work. I do not see that taking any longer than four to six months.

Mr McGimpsey: If the panel is in place by Christmas, gets together for a chat and takes four to six months, you are talking about July.

Mr Hamilton: Yes, some time in June or July, or something like that.

Mr McGimpsey: That is the next mandate.

Mr Hamilton: Realistically it is, yes.

Mr McGimpsey: Where does the 10 years come in? You talked about 10 years.

Mr Hamilton: The point that I made in response to Kieran was that — I imagine, because, of course, I do not know what the conclusions of the panel will be — these will be far-reaching reforms and changes to our health and social care system. I do not expect that they will be the sort of reforms that can be implemented very quickly in many cases. It may be that some can — indeed, I would expect that some will be able to be implemented very quickly, but others will take a lot longer. I made the point about 10 years to be realistic and to emphasise our sense of the gravity of the challenges facing us. They are not things that can be addressed as rapidly as we would like. The reforms will, in some cases, be difficult and take time. In many cases, they will require some investment, particularly capital investment, to make them a reality. That said, it is reasonable to say that this will be a five- to 10-year project.

Mr McGimpsey: All right. Five to 10 years; that is fine. That is basically your hospitals plan. We talked about TYC. I am not 100% clear where we are going with that now or how we boost primary care. You have said that there are no problems with commissioning social care.

Mr Hamilton: I think that the feedback from the review was that there were no —

Mr McGimpsey: Would you say that the Older People's Commissioner, who has just left post, was in agreement with that?

Mr Hamilton: I am not sure what she would say.

Mr McGimpsey: She published a report. I think that she was quite clear.

Mr Hamilton: A report that I only saw after the various media outlets were given copies.

Mr McGimpsey: Did you read it?

Mr Hamilton: I have looked at it, yes.

Mr McGimpsey: You have read it.

Mr Hamilton: I am well aware of it.

Mr McGimpsey: I am surprised at you saying that there are no issues with social care commissioning.

Mr Hamilton: I am not saying that there are no issues.

Mr McGimpsey: Then I am not hearing what you said.

Mr Hamilton: What I said was about the review of commissioning. It proved that any problems were not to the same degree as those on the health care side, in terms of complexity and barriers and so forth. Certainly, we want to take forward the best from social care commissioning in the past and improve it. It is not that we will not have an agenda to improve it, by any means. There are clearly current and looming challenges in social care.

The Chairperson (Ms Maeve McLaughlin): I would like to ask about the panel, if I may, for clarity. Will you set the panel's terms of reference, or will the panel set them itself?

Mr Hamilton: Actually, I had not considered that point of detail. I think that we will want to craft the terms of reference along the lines of what has been outlined in the speech. I will obviously consult with the panel members when they are in place. It will be important to listen to their views on what is possible and where they see it going, even at the outset before commencing, and work with them to craft terms of reference that are appropriate.

The Chairperson (Ms Maeve McLaughlin): Secondly, do you consider that the panel should have open sessions to seek wider societal views on any amount of key issues?

Mr Hamilton: I do not want to box the panel into a particular format all the time, or anything like that. I want to appoint the members and speak to them first about how that might work operationally. I am not against the panel going around and speaking to stakeholders in different parts of Northern Ireland. In fact, as I said before, it is pretty essential that the panel does get out and about to meet people. Many of the panel members will be from Northern Ireland and will already have a flavour of what is happening. It is important that they get out and speak to people from all backgrounds, stakeholders and those who have a role in health and social care.

Mrs Dobson: Minister, I thank you for your answers. It has been quite a lengthy session. I was in the hot seat last week, so I appreciate what it is like to be on the receiving end.

Michael touched on this earlier, and I touched on it again yesterday evening: the board's administrative staffing level. I know we are focused on the figures here, but in an answer to a question for written answer in January, you explained that in March 2012 the board had a headcount of 405, a whole-time equivalent of 380. Little had changed by March 2013, when there was a headcount of 400 and 377 whole-time equivalent. Then, by March 2014, it was 472 and 446. Last night, in answer to Mr McGimpsey, you said that in March the figures were 584 and 544 whole-time equivalent. This cannot all be blamed on Michael. How did it get so big? Who was overseeing it?

Mr Hamilton: As the figures show, this was a big organisation from the start. According to my figures, in 2010 there were 390 whole-time equivalents in post, considerably higher than 250. I think it was large from the outset.

Mrs Dobson: It got very big very quickly.

Mr Hamilton: A range of additional functions were given to the board. That is the sort of thing that tends to happen when you create a big, powerful organisation at the centre. When additional responsibilities come along, it will attract those responsibilities, and coming with those responsibilities often come additional staff.

Mrs Dobson: And duplication of roles.

Mr Hamilton: I am not able to say categorically whether the additional functions produced duplication. Certainly, there is valid criticism that the additional layer has at times created additional bureaucracy. That is why I want to address the criticism by doing away with the board.

Mrs Dobson: But the figures were readily available.

Mr Hamilton: I am not denying that it is a larger organisation than it was. I am simply making the point that it was a large organisation to start with. It was not an organisation of 250 to begin with; it was much larger than that, and, yes, it grew. I accept that. I appreciate why you may want to style my proposal as "because it is a big, bloated organisation, and therefore easy to do away with, or a target to do away with". That was not the purpose. The purpose is to make our system work as efficiently as possible, and the criticism that came back through the commissioning review and from front-line staff was that we have, as the Chair said, too many layers of bureaucracy getting in the way of innovation and the best operational delivery.

Mrs Dobson: I appreciate that, and the fact that it rose to 584 shows that. Who ultimately oversaw that? I was easily able to get the answers about how it has grown. Who ultimately had responsibility for it becoming so big and so bloated that we are now at the decision you have taken?

Mr Hamilton: Again, I do not accept the premise that, because it is big and bloated, to use your phrase, that is why the decision was taken. That is not why it was taken. As I made the point, it would not matter, in my view, if it were an organisation of 200 or 2,000. The decision was taken because of the fact there is an additional layer of bureaucracy that many would say is unnecessary. I agree that it is unnecessary and that it is getting in the way of the most effective delivery of health and social care services. That is why I have made the proposal that I have made, and I hope that people will support it.

Mrs Dobson: We certainly welcome it. I have figures here, and I can give you a copy, but they are from your office anyway. It does not appear that the trusts are reducing administrative jobs. Last night, when you appeared in the Chamber to take questions, you gave me a sort of warning not to go down some route that you felt I was going down. As Fearghal said earlier, is it not legitimate for a Member to ask these questions about why the board had ballooned so much at a time when waiting times were so high, domiciliary care was being cut back and front-line staff were at breaking point? Surely it is legitimate, and you can appreciate, based on the figures that have been provided to us, why we ask these questions.

Mr Hamilton: Absolutely, on the general questions. I think that, on the basis of what you have said, you have agreed and acknowledged that getting rid of bureaucracy is a good thing and is an objective that we should all share. Where there are opportunities to get rid of bureaucracy, we should seize those opportunities. That is certainly something that I can support.

Mrs Dobson: You can appreciate —

Mr Hamilton: Absolutely, yes, I appreciate that. You are right. We all hear, I hear and you hear people say that too much bureaucracy gets in the way and that we need to get money into the front line. That is exactly what I hope we can do. That is what I am proposing, and that is what I want to do with the proposals that I have made. As I pointed out to Michael and others, there are staff in the board who are doing good work. We want to ensure that they continue to do that good work. They may do that in different destinations, but, at this time, their talents, their abilities and their skills are not being exploited to the maximum, because they are not operating in a system that is as efficient as it should be.

Mrs Dobson: At the start of your presentation, you referred to business as usual and things that we can do in the interim period. In responses yesterday, you said that the 584 staff still had important work to do. What assurances can you give us that this plan does not involve simply changing the nameplate on the door, with a 'Yes Minister'-like shift of staff from one board into a Department? Can you assure us that that will not happen?

Mr Hamilton: That is very clearly not the objective of what I am putting forward. It is to create a system that gets the best from our staff, and I do not believe that the system that was created in the recent past has shown evidence of being able to do that. That is why I have proposed the changes that I have. It would be a failure of the reforms that I have proposed if it were just the same but in a different way. I repeat that this is about making the system that we have, which has £4·7 billion going into it, operating and functioning —

Mrs Dobson: So, you can assure us, Minister, that that will not happen. We do not want to see a nameplate and, as I said, a 'Yes Minister' approach.

Mr Hamilton: This is about getting rid of nameplates actually and getting rid of that additional layer of bureaucracy to get more money into, as you alluded to, the front-line services to use the talents of the people who are doing a good job on the board but to get a more effective output from it.

Mr McCarthy: Simon, I asked how much money you would save by doing this, and I do not know that you gave me an answer.

Mr Hamilton: No, I did not, and it was not that I ignored it. I made the point that the objective was not to save money from doing away with the board. That was never, ever a part of any discussion that I had in coming to my view on this that, if we do away with the board, we will save a lot of money, not least because there are functions and roles that those staff are performing that will have to be performed in the future as well, albeit in a different place and in a more efficient way. There will be some savings. Any savings that are made will go into the front line, I hope. The board has a budget of about £29 million this year, so if we were able to save even 10% as a result of changes, that would be close to £3 million. That is a lot of money but not a huge amount in the context of a £4·7 billion budget, but it is a lot of knee and hip operations and other procedures that could be delivered if we can make anywhere near that saving.

Mrs Dobson: What do you see as the future vision for commissioning once the board goes?

Mr Hamilton: I want to see responsibility for planning going to trusts. I want to see trusts working closely with general practitioners in their area to plan for need in those areas. Each trust area will have different needs. For example, the South Eastern Health and Social Care Trust has an older population than other trust areas, and that produces different needs and requirements. I want them to tailor their planning accordingly. The Department and whoever the Minister is will have a clearer line of sight in keeping those trusts accountable for meeting their targets and delivering on financial and performance management.

Mrs Dobson: For clarity again, Simon, how long will the board continue, and is it still recruiting admin staff?

Mr Hamilton: As I said in response to the Chair, it will require legislation to finally do away with the board. With the fairest of winds behind that and support from the Committee and Assembly, that legislation could be introduced early in the new term, passed quickly and be in place at the start of the 2017 financial year. You are talking 18 months for all of it. I am keen that, where changes can be made in the interim, they will be.

Mrs Dobson: During that period, will the board still be recruiting staff? Will we be coming back for more figures?

Mr Hamilton: I do not know what its recruitment policy is or whether there is a recruitment freeze. I do not know whether you know that.

Mr Richard Pengelly (Department of Health, Social Services and Public Safety): At the moment, it has a number of temporary or agency staff. That is the model we would see them going down. The one line we do not want to cross is that, until the board dissolves, they will still be undertaking important work.

Mrs Dobson: You do not want to bloat it further, though.

Mr R Pengelly: No, we do not want to bloat it further, but we want to make sure that it continues in its role until we reposition that. The point you make is valid. They are not going to be recruiting staff, but that leaves us with an issue to resolve after the board —

Mrs Dobson: So, you will not be recruiting additional staff.

Mr R Pengelly: As the Minister indicated, some of the functions of the board will be moved to another part of the system because this is about system redesigning. If, at an early point in the design phase, it is decided that a function remains important, there is no reason why permanent staff could not be recruited in those circumstances. We would need to take account of other staff in the Department and keep people within the system. The point that you make would be a guiding principle for us, but I would not want to get into making black-and-white rules at this stage.

Mrs Dobson: Can you guarantee that in 18 months' time it will not become even bigger?

Mr Hamilton: It should not become bigger over that period, precisely for the reasons that Richard outlined. However, let us not forget that in the intervening 18 months, there is still a job for the board until such time as it ends, and it will require people to do that.

Mrs Dobson: I appreciated your talk yesterday about the important role of administrative staff. Given their rise in number, has there been an equivalent rise in front-line staff, especially given the trusts' attitude towards domiciliary care in particular?

Mr Hamilton: Yes, there has been a rise in the size of the board, but we have quite a small Department, which, I think, went down in size after the board was created. Has there been an increase in the number of people on the front line? Yes, there has, and I am proud of that.

Mrs Dobson: An equivalent rise?

Mr Hamilton: There has been an increase in the number of staff on the front line. I am proud that, over the last four years, there has been around 1,000 more nurses employed, which is up around 7%; 430 —

Mrs Dobson: Is it equivalent to the admin rise?

Mr Hamilton: I have not looked at the two side by side, but there have been 430. You are saying that there is an increase. We would need to —

Mrs Dobson: It is just that we hear every day about front-line staff stretched to breaking point.

Mr Hamilton: Allow me to make the point that there are nearly 1,000 more nurses, over 400 more allied health professionals, nearly 240 more consultants, nearly 100 more middle-grade doctors, 28 more paramedics. So there has been an increase in front-line staff. You are talking about an increase in the size of the board as an increase in admin staff. You would obviously have to then —

Mrs Dobson: No, you earlier referred to bureaucracy and doubling up.

Mr Hamilton: — compare that with, perhaps, decreases in departmental staff and whatever is happening in trusts as well. Yes, the board has increased, but we would need to look at other figures to see whether there has been an overall increase or to what extent there has been an overall increase in administration staff. You asked whether there had been an increase in front-line staff.

Mrs Dobson: An equivalent rise.

Mr Hamilton: There are about 1,000 more nurses, more allied health professionals, more consultants, more middle-grade doctors and more paramedics. I am proud of the fact that that is the case.

Mrs Dobson: Still, they are under extreme pressure. Chair, it would be useful to get that comparison — the equivalent rise — with front-line staff.

The Chairperson (Ms Maeve McLaughlin): Another five members have indicated that they have questions. I am very conscious of the time, so I ask members and the Minister to be succinct. Let us not go over points that have been made.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. Thank you very much, Minister, for coming today. I am not going to go over stuff that you have already covered. It is all about change and the structures. I imagine that people looking on today will want to know how it will affect them, because ultimately that is what it is about. What assurances can you give people that the changeover or any restructuring will not make things worse? We heard again today about the horrendous cases of people on waiting lists and what that means. What would you say to people who are on those waiting lists about how it is going to affect them?

Mr Hamilton: Clearly, we do not want to engage in administrative reforms that ultimately make things worse for people. That would be absolutely against what we are trying to do. Yes, there are long waiting lists, and I hear the same stories as you do. My own constituents and people from across Northern Ireland write to me about their waiting times, and I want to address that as quickly as I can. As I said to Kieran, I am not going to be able to do that by waving a magic wand at it. I need an injection of resources in the short term, and then I need to continue that focus on waiting lists over the next number of years to get them back down to a more manageable or acceptable level. I do not think that we will ever eliminate them or get them down to where we would really want them to be, but I want to get them back to what we had a number of years ago, when we really started to make some headway and progress against them.

I do not want to be political about some of the causes behind some of those pressures and why we have not been able to spend as much money on waiting lists as we would like. As I said before, I hope that a resolution to the various political difficulties that we have had will give an opportunity for a new start in many respects and also a new start in getting some money into health and social care. If I can persuade the Finance Minister and her Executive colleagues to give me some more money, you can rest assured that the bulk of that money — the lion's share — will go to addressing need on our waiting lists.

Ms McCorley: The issue of mental health comes up frequently, and we know the connection between that and people on waiting lists; it is compounded, and people develop mental health issues as a result. It can become quite complex. In the view of some people, mental health has been poorly served by the health system, and it is like the poor relation. There are holistic ways of dealing with it, not just medical. What are your views on that? I am not trying to pin you down on anything, but are you looking to address mental health in a more comprehensive way?

Mr Hamilton: Your conclusions and views are right. You are correct that we often look at a waiting list problem and see it just as a waiting list problem and do not see how it can sometimes manifest itself in some of the pressures that we are experiencing in emergency departments, for example, or, as you say, with people's mental health. I accept that point. I agree, too, that mental health is, and has been, a poor relation of physical health. That is not just in this part of the world. It is a fair criticism everywhere. We could go into why that is the case, but one of the positive developments over the last number of years is much more acceptance of mental ill health as a condition and trying to deal with stigma around it. It is still very challenging and difficult, and we are not quite there yet.

In terms of what the Department has done, the Bamford report marked a bit of a sea change in our understanding of, and the way in which we tackle, mental health problems in Northern Ireland. There has been a significant increase in spend on mental health. Just short of £50 million additional per year is spent on mental health. More is being spent, and the balance of that spend is also better, with more being spent in the community. It was 60:40 hospital:community, and now it is the other way around. We have seen a move towards closing down some of the far-from-suitable institutions and moving people into much more suitable accommodation, very often in the community that they are from and where their families are.

Another thing that I have been pushing for, and I have spoken to party colleagues of the member about, is the issue of focusing on mental trauma. It would be a fitting legacy to those who have experienced severe mental trauma issues as a result of the Troubles if we were to use the fantastic experience that we have in mental trauma — we also have wonderful expertise in physical trauma — to develop a world-class service in dealing with mental trauma. That will benefit people who experienced mental trauma in the Troubles but also other people, irrespective of where their mental health problems came from.

I mentioned Bamford. Richard has just pointed out to me that the vast bulk of Bamford action points, 73 of 86, are being implemented or are recognised as green in the red/amber/green system. We are starting to see that change. It will clearly take some time for that to manifest itself in a positive way, but we are starting to embrace that much more than we did in the past and to take some positive action to deliver on the vision in Bamford.

Mrs Cameron: Thank you, Minister and permanent secretary, for your time today. It has been quite a long session, so you will be glad to know that I will not ask you to go over questions that you have already answered once, twice, three times or four times.

Mr Hamilton: I thought that you were going to start a song there. [Laughter.]

Mrs Cameron: What contribution has the review of administrative structures carried out by your permanent secretary made to your decisions around health and social care?

Mr Hamilton: You are right. Just before Christmas, Richard embarked on a review on administration. That was different and distinct from administrative structures like the board. Jump in to correct me and shout at me if I am wrong, but this was about looking at scope for further efficiencies in how our health service is organised. We have some very good examples. The Business Services Organisation (BSO) is generally operating to a very high standard in its delivery, and it has consolidated under one roof a lot of core corporate functions that would have been spread across trusts, the board and others. The administrative review was to look at where we could expand and do some more of that. The closure of the board will have something of an impact on that. We will want to come forward in the not-too-distant future other things that we want to do around an admin review, as distinct from an administrative structure review or changes to that.

Mr R Pengelly: We were very clear at the start of the process that this would not be a review that would result in a traditional report with some recommendations. It was basically about trying to work in real time for people to become more efficient. We identified, at an early stage, a number of areas where we have a proliferation of arm's-length bodies in the health sector touching on common issues that we thought better worked together. Of more importance and where there is more scope, as the Minister indicated, we have identified a number of areas where BSO, which is a very successful organisation in our world in terms of shared service centre processes and transaction processing, can look at further scope to extend the shared service model.

Interestingly, the use of bank staff has already been mentioned today. Each trust tends to manage its own bank. There may be a way of bringing that together and managing it centrally. BSO is currently undertaking business cases to try to roll out the use of IT and business intelligence. We hope that there will be both efficiency gains and qualitative gains, particularly in the business intelligence area. We are using the data that is available to us in a smarter way to focus our attention on patient care.

Mrs Cameron: That is very welcome. I had some other questions, but you touched on them before, so I will not prolong it.

Mr Easton: Thanks, Minister, for your presentation, and thanks, Richard. Under the proposed new model, can we expect trust chief executives and chairs to be more visible and accountable?

Mr Hamilton: Yes.

Mr Easton: Is that the answer?

Mr Hamilton: Yes. [Laughter.]

That is what I want to see. I read earlier, when I was responding to Michael, the criticism in Sir Liam's report about whether it is clear who is in charge. Kieran talked about that point earlier. Some of the feedback in the commissioning review was about a lack of clarity regarding the roles and responsibilities of various organisations. I do not want to get into the gory details of some of the examples. However, I have not been in post that long, and I have seen plenty of examples where, as an outsider coming into the system, I would have expected trusts and trust chief executives to take more visible responsibility for decisions or on the issues that appear from time to time where things are not so good, but they have not. There has been a lack of clarity about whether it is their responsibility. I may think that it is their responsibility, but they would say, "No, it is the board", and the board might say, "It is the Department". That creates an impression of a lack of clarity about who is in charge. If it is a trust matter but the trusts are not taking visible responsibility for it, that is not right.

As a result of the conclusion of this process, I would expect to see our chief executives in the trusts taking a much more visible role and being responsible for decisions that are taken. They are going to get a lot more responsibility, so we will have to hold them to account a lot more. I think that they would acknowledge that there is a degree of risk for them in taking on that responsibility. The feedback from the chief executives that I have spoken to so far is that they recognise the risk but are up for that. They also see huge opportunities for them in the new configuration of administrative structures.

You are right that we will want to see them stepping forward and taking more responsibility for what they do or do not do. That is not meant to be a criticism of any chief executive in any trust, and I know that they do step forward. However, I want to see it done a lot more and much more clearly. I have some experience of talking to others in the system, and I get the sense that the way that it is configured at the minute, with an additional layer of bureaucracy, means that people can pass the buck. That is not acceptable.

Mr Easton: I am keen to see chief executives being more accountable, to be honest with you. Is it your expectation that political parties will engage seriously and constructively in the summit? From what I have seen, you are already getting a hard time even before you have started or have any meat on the bones, which is a bit unfortunate. What is your view on that?

Mr Hamilton: It is probably not unexpected. I do not come here, go into the Chamber or go on the media and expect people not to have a go, if I can use that phrase. I expect that.

It would not matter who is in this chair, and anybody around this table could be in this chair after the election. The fact is that the Minister of Health, whoever that may be, is subject to criticism. That is all fair and legitimate in politics, but it is also a reflection of the importance of the Department to our people. It spends nearly half our budget. It touches everybody's life directly or indirectly day to day. It is understandable that there is a bit of passion about it and that people will be critical of me or whoever is doing my job after me. You have to accept that: it is part of the game.

That should not cloud the fact that we need to reform the health and social care system. Yes, there are deficiencies in the system. There are things that are far from perfect, absolutely. If we do not correct those things that are wrong with the system, given the challenges that are facing us now and those that are coming down the line big time in the years ahead, we have absolutely no chance. There will still be some criticism, and some will wish to be inside the room or outside the room criticising. You expect that. However, that should not stop me or any of us trying to build as broad a political consensus as we can, because I think that, in essence, we all want what is best. We all want the best health and social care system that Northern Ireland can have. That is going to require some difficult decisions that there may be disagreement about, but I think that there is a broad vision that we share and can agree on. You are right: there will be some who will criticise, snipe, have a go and all of that. We have to appreciate that there are certain political realities, so we have to try to agree as broad a vision as we can. If we do not, there will be serious consequences for the NHS in Northern Ireland.

Mr Easton: I have one final, slightly off-track question. In an answer to a question for written answer to the Finance Minister, it was revealed to me that £114 million was handed back to Westminster in welfare fines. What could you have done with that money if it had come to you?

Mr Hamilton: A lot of money has been lost, and I hope that we can resolve very quickly the issues that led to that loss. It would have been slightly greedy of us to have expected to get the entire £114 million, although there might have been an argument for that, but, if we had got even our 47% share, that would have meant a lot of assessments and procedures. It would not have eliminated problems with waiting lists, but it certainly would have dealt with a number of them significantly and allowed the system to start moving again as we made some headway. We have not been able to do that, however, and it is a significant explanation for some of our problems with waiting lists.

I am focused on a successful resolution to the talks process to keep devolution going, which is good for all of us in Northern Ireland and allows us to take decisions on health and social care instead of some direct rule Minister, while ensuring that money will be freed up this year and allowing us to strike a Budget next year and get resources to the front line as quickly as possible. That money is lost. We could look back and say that tens of thousands of this and thousands of that could have been done. That has not happened, and there are consequences. A lot of vulnerable people have not got the services or the operations that they needed, but let us redouble our efforts for a resolution and hope that, even though we are close to the end of the year, we can still get some money to the front line and start to give people the care that they need.

Mr Easton: Absolutely. Thank you.

Mr McKay: Minister, the Agriculture Minister has the Rural Needs Bill before the Assembly at the moment, and the Department will take a more strategic, hands-on approach. The Bill provides for policies, strategies and plans to be rural-proofed, and not tick-the-box rural-proofed but put on a statutory footing. Will the challenges that that presents to your Department change your approach to policy and strategy?

Mr Hamilton: To be perfectly frank, I have not considered its full implications. The Bill is up for Second Stage next week. I understand where the Minister wants to go with it, and I do not disagree with the intent. We need to be careful about being too prescriptive. I understand the points that she is making. It is one of the challenges that we face, although it is maybe not at as high a level as our growing and ageing population or unhealthy lifestyles. This is a small region, of 1·8 million people, but they are dispersed across Northern Ireland. We have a very rural population base, and that clearly has an impact on health and social care services. That is something that the panel in its work will have to acknowledge.

Our dispersed population is one of the reasons that I do not believe that we should be looking at wholesale closures. Some commentators pop up on the radio, and it is easy for them to say, "Close several hospitals". We have a rural population, and there is a need for some services to be delivered locally. It will not be all services. As I said last week, I do not think that our people expect us to have world-class cancer, coronary or stroke services in every hospital in Northern Ireland, as much as we might like that to be the case. We know that that cannot happen. As we have seen in the evidence, people are prepared to travel a little bit further to get the service that they need. When someone's life is hanging in the balance, that person is prepared to travel a little bit further to get the best care. There are clearly balances to be struck in healthcare delivery, given our rural, dispersed population.

Mr McKay: I am glad that some of the buzzwords that you used to use when in the Department of Finance have followed you to the Department of Health.

Mr Hamilton: There is nothing new under the sun, Daithí, I am afraid.

Mr McKay: Innovation, collaboration, prevention — we have heard them all before, although they are welcome. Your decision to retain the PHA is common sense, as far as I am concerned.

When you were Finance Minister, we had a lot of discussions about health and well-being. Health is one of those things that does not belong just to the Department of Health. If we want to make savings over the next 10 or 20 years, you will need certain strategic decisions to be taken by the Department for Regional Development, the Department of the Environment and the Department of Education in order to realise some of the savings and some of the prevention that is envisaged in the transformation fund. How will you engage with other Departments on a strategic approach to help deliver on public health?

Mr Hamilton: There is engagement with other Departments, such as the Department for Social Development. We were talking about Bamford earlier and developing appropriate housing and accommodation for people of all ages and with various conditions. I have worked very closely with that Department and have had the privilege of being at a couple of sod-cuttings and openings of new accommodation around Northern Ireland. There are challenges in that relationship, too. All Departments are facing pressures and demands on their budget, and collaborative work across Departments can unfortunately be seen as an easy target. When things are tight, Departments will go back to their core responsibilities, with other stuff being seen as more of a luxury. I think that we all understand, and I know that we have had this conversation before, that it is in that space that we have the biggest impact. It is when the Department of Health works with, for example, the Department of Justice, the Department of Education or DSD that you get the biggest outcomes and the most impact. It is certainly something that we are up for and that we do.

We are challenged because of our resources. I see the transformation fund as being about transforming health and social care in trusts and with others, and I am in the process of setting up an innovation fund for the community and voluntary sector. Through that sector, you may get more collaboration between Departments and different areas of responsibility. The change fund that I put in place when I was Finance Minister was a small amount of money, and it was massively oversubscribed. It was coveted by every Minister. All Ministers wanted all that money for themselves, and we resisted that, but it was absolutely the right thing to do, because one of the criteria for it was collaboration.

Particularly where there is innovation or a risk involved, and you want that collaboration between Departments on the Executive, that is where the Department of Finance has a role to play with its budget to use that change fund type of device. This will not affect the Health Department significantly, but the fact that we are consolidating the number of Departments should help a little — maybe more than a little, I hope — with some of the sorts of issues that you are talking about, such as eliminating some of those areas in which there are two Departments responsible for various issues.

Mr McKay: I have one final question. I am concerned that, at the moment, a few complaints are coming in about the paediatric unit and the emergency department in Antrim Area Hospital. It appears that the majority of staff are worried that there is a risk because there is no appropriate paediatric nurse cover and because nurses there do not have the appropriate training. There is not only a risk to patients but a risk of staff being put in an uncertain position. I know that that is slightly off-topic, but I wanted to raise it with you to see whether work is under way to resolve the situation.

Mr Hamilton: You did me the courtesy of mentioning it last night, and you did say that you would raise it today. I was aware of the issue, but I went away and looked at it again.

There are almost two separate issues there. The model of care that Antrim Area Hospital has tried to establish in its emergency department is a very good and commendable one. There is a paediatric emergency department in the emergency department. Thankfully, I have not had too much experience of it, but, having taken some of my own children to an emergency department, I know that, no matter the time of the day or the day of the week, it is not a great place to be taking young children to, particularly if they are in distress, because it only heightens that distress. The idea of having a separate ED for children and young people is a great idea. The model of care is a very good one. I think that it operates in Craigavon Area Hospital as well. I am not sure whether we do it in any other EDs. I imagine that, in new builds elsewhere, it may be the sort of thing that can be introduced further.

I appreciate the concerns that are there. As I said before, we do not want to do anything that has a negative impact on patient safety, staff safety or the high standards of quality of care. I know that there has been some threat of strike action, but I do not want to see that happening. I do not think that anybody wants to see that happening. We want to try to avert that and work with the staff there, and we will look to the trust to do that. The staff should also bear in mind that this is a different model of care, which is about improving standards of care. We do not want to do anything that impacts negatively on safety. We want to see a resolution, and I am happy to take the matter up with the trust to ensure that it can be resolved successfully as quickly as possible.

Mr Middleton: I apologise for being late, although it seems some time ago now. [Laughter.]

Mr Hamilton: The clocks have gone forward again.

Mr Middleton: I have two very quick questions for the Minister. The first is about staffing and bringing staff along. Of course, people tend not to like change. It is about how to get that message out to staff on the ground so that it filters right through and so that people know exactly what is going on. I respect the fact that that is not going to happen overnight as it is a longer process.

My second question is about your intention to retain the PHA, which you mentioned in your speech. That has to be welcomed, as the PHA will now have a renewed focus on early intervention and prevention. You mentioned the closure of the board and said that some functions will go back to the Department and others to the PHA. Do you have any idea at this stage of which functions will go to the PHA? In my constituency, we have a particular interest in how we deal with the high levels of suicide and with mental health awareness. Do you have any thoughts on that?

Mr Hamilton: The PHA performs an incredibly important function in our health and social care system. As I mentioned before, many of the big challenges that are looming or hitting us already are challenges that the core work of the PHA is targeted at, and I do not want to see that work lost in any reconfiguration of its administrative system. In fact, I want to see the PHA doing much more of that core work. It does it really well, and I want to see that being its bread and butter, instead of it being alongside the board as part of another additional layer of bureaucracy. I want to see those elements of what the PHA does change and for it to renew its focus on early intervention and prevention. We are not clear yet exactly what functions may move to it. Some may move from the board to it, but I do not see those being a huge volume. It will be a renewed PHA, working alongside rather than between the Department and the trusts. It will be working alongside the Department to focus on those important issues of early intervention and prevention and on work around suicide prevention and raising awareness of unhealthy lifestyles — that critical work that it does.

Mr Middleton: That is fine.

Mr Hamilton: Sorry, you mentioned bringing staff along. As with any change, this will impact on staff. I understand that, if you are a member of staff in the board, you will be wondering what this means for you. We have to be sympathetic and sensitive to those members of staff who will be most directly affected. I hope that, in communicating what it means, I do not see any compulsory redundancies as part of the process, and that may offer some comfort to staff. Yes, they may move, and they may not be working for the board. They may be working for the Department, the trusts or whatever, but we want to use their talents in the best possible way. One of the things that I have found is that, for most people working in health and social care, it is more than a job, and that does not matter whether they are clinicians on the front line or administrators. That sounds a bit trite, but they know that they are making a much bigger and broader societal contribution. Yes, we are making some changes that may have an impact on them, and they may be uncertain about that impact, but it is our job to show that it is for the greater good of trying to create a world-class health and social care system in Northern Ireland. I hope that that is something that we agree with and aspire to, something that our clinicians agree with and aspire to, and something that our staff on the administrative side of things agree with. Even if that means some degree of upheaval for them personally, I hope that they see that this is about improving the system that they work in and are a valuable part of.

The Chairperson (Ms Maeve McLaughlin): Thank you, Minister.

Mr Hamilton: You have some real work to do now.

The Chairperson (Ms Maeve McLaughlin): I think that you have as well, in fairness. [Laughter.]

Thank you for your time. You have been very generous with it. If you take anything from this, it should be the fact that we need reform of the system. Reform, in my view, is overdue. In going forward, we need to get a clear sense of the impact of the reform and of timescales. I suggest that most of the members around the table feel that the reform should be done within the proper remit and should happen as soon as is practicably possible. We do not need a system that is already perceived to be failing continuing to do so.

We look forward to getting an update on the panel as it is established, its terms of reference and remit, and how it all links to Transforming Your Care. How it can deliver patient outcomes is critical. Thank you both for your time.

Mr McCarthy: Chair, before they go, I want to ask a question about the draft Health (Miscellaneous Provisions) Bill. I do not know whether you can answer this, but does it include anything on the sale of e-cigarettes to young people and a ban on smoking in cars carrying young people?

Mr Hamilton: We will come back to you on that. In fact, we should be corresponding with the Committee anyway around trying to progress that legislation through the House. I think that some aspects of it deal with e-cigarettes, although I stand to be corrected if I am wrong. However, the Bill does not contain a clause on smoking in cars.

Mr McCarthy: It does not.

Mr Hamilton: No.

The Chairperson (Ms Maeve McLaughlin): Is it your intention to bring forward a clause?

Mr Hamilton: Nothing was put in, either because the time had run out or there was some issue with the consultation. I do not want to commit myself to saying something and it not being right.

It is something that I know there is a lot of support for. Clearly, the Bill can be amended after it is introduced, and I am open to looking at an amendment along those lines. It is probably worth saying that I appreciate that, as a Committee, you have a very heavy legislative workload. I know that you have a private Member's Bill and that the next piece of work that you are doing is on the Health and Social Care (Control of Data Processing) Bill. There is also the miscellaneous provisions Bill and an amendment Bill. There are several pieces of legislation, and it is perhaps a consideration for you in your work that, if that is the sort of amendment that we want to make, there is a lot of work for you to do, and that is a factor as much as anything in getting all the work done. On the substantive point, I am happy to look at the idea of an amendment, and I am keen to work with the Committee to do something that all folk might be able to agree on.

The Chairperson (Ms Maeve McLaughlin): I thank you both again for your time.