Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): You are very welcome to the meeting. In no pecking order, we have Mrs Elaine Way, chief executive of the Western Health and Social Care Trust; Dr Tony Stevens, chief executive of the Northern Trust, Mr Hugh McCaughey, chief executive of the South Eastern Trust; Ms Paula Clarke, chief executive of the Southern Trust; and Dr Michael McBride, chief executive of the Belfast Trust. I will invite the chief executives to make their opening remarks, and then we will open up the meeting to questions or comments.

Mrs Elaine Way (Western Health and Social Care Trust): Chair, in which order would you like people to speak? You made the comment about the pecking order, and, since I am the elder statesman, maybe I should go first.

The Chairperson (Ms Maeve McLaughlin): That is a good call.

Dr Michael McBride (Belfast Health and Social Care Trust): I could not argue, Chair.

Mrs Way: You are much younger, Michael.

We have provided briefing notes for members, and perhaps I will take a few minutes to go through those and add to them. I will also take away from some of the detail that is in the paper, because you can read that in your own time.

We have been asked to look at two issues — one is the savings plan and the other is our priorities. The savings plan for the Western Trust for 2015-16 is £11·4 million. That £11·4 million cash came out of the budget on 1 April 2015, and we are putting plans in place to try to deliver it all recurringly by 31 March 2016. This is extremely challenging, because we have already taken £66 million of savings from the organisation since the trust was established. I make that point because, given the challenging financial targets, it means that we have already looked at areas such as admin savings, procurement and so on to try to deliver savings in earlier years. At the moment, in procurement, the major area that we are still looking at is pharmacy procurement. As you all know, while the budget has reduced, demand and need is rising, and that has driven a requirement for us to do things differently. That is why, in my briefing to the Committee, I referred to the reform plan as well as the savings plan, because the reform plan spells out in greater detail how we will do things differently. A lot of the reforms are being clinically led; our senior doctors and nurses and other allied health professionals are telling us how we could do things better.

As for the detail of the plan, as with most other trusts, we have our main areas. First, we have acute care reform, where we are trying to look at reducing the length of stay in our hospitals. That is not necessarily so that we can get lots of beds out of the hospitals, because our beds are extremely busy; it is because we have a tendency to put up escalation beds and pay for expensive agency and locum staff to keep our patients safe. We are trying to deliver more within the same budget — in other words, increase productivity — make best use of all our buildings across the geography and, particularly working in partnership with GPs, we are also delivering services that look at providing acute care in the community and at home. In acute care reform, we are working across trust boundaries. Tony and I are neighbours, and we work together in a number of service areas and cross-border with our colleagues in the Health and Safety Executive (HSE) around radiotherapy and primary percutaneous coronary intervention (PCI). Finally, again in partnership with primary care, we have developed a whole series of patient pathways to keep our services safer for patients and to keep them from numerous admissions to acute hospitals, and an example is the respiratory care pathway.

In social care reform, the second pillar of our savings plan, we are trying to maximise the benefits of having an integrated health and social care system, and we have established an excellence in community care project. This is about integrating hospital and community reforms. There are a number of specific reforms detailed on domiciliary care, looked-after children's services, residential care for learning disabled adults and reform of day-care services. I mention that, Chairman, because I know that this is an area of particular concern in west Tyrone and Fermanagh. Again, we are working closely with our colleagues in primary care and, indeed, community and voluntary organisations to reform social care.

As our biggest area of spend, we are trying to tighten how much we spend on our workforce. In our plan, we are using vacancy control to reduce our spend on staff. We have also established a project to reduce absence in the organisation. However, I make the point, Chair, and I have made it to local politicians, that our attempts to control our workforce costs are somewhat undermined because of our unique difficulties in attracting and retaining staff due to the fact that we are on the periphery. You are well aware of the additional medical locum costs and so on that we pay. However, we do not see ourselves as hopeless, and in our plan we describe a very ambitious international doctor recruitment programme. By December, we will have 22 overseas doctors working in our organisation as we try to reduce spend in this area.

We have a number of miscellaneous and other productivity measures, which I will not go into now. They are detailed in our paper. All our proposals were equality screened. No equality impact assessments (EQIAs) were deemed to be required, and we are taking forward consultation in a number of areas.

The context for our key priorities remains the Quality 2020 and Making Life Better policy initiatives from the Department. The reform plan that I referred to earlier is very much anchored in that context and details service priorities in line with it. I genuinely believe that unless we work well with our colleagues in the community and voluntary sector we will not make a lot of progress. You will see details on children's services and, indeed, Big Lottery Fund programmes, where we are making great progress in the community. Our immediate priorities, in this year and at this point in time, include elective care, and I am delighted to hear the news today of additional money to reduce waiting lists. Reducing waiting lists is a big priority for us. Unscheduled care and planning for the winter is another priority for us, as is dealing with our workforce pressures, both medical and nursing — I could employ more nurses if more were available in the marketplace.

In capital terms, there is the radiotherapy unit, which is due to open next year; Omagh hospital and primary care complex, which will be handed over to us at the end of next year and open early in 2017; the redevelopment of Altnagelvin, which is ongoing and requires capital investment; and the acute mental health unit in Omagh, which is a £35 million facility.

My final priority — again, local politicians who are regularly briefed by me will be aware that we have particular financial challenges in the west — is that I am working closely with the Health and Social Care Board to get to recurrent balance by the end of this year.

The Chairperson (Ms Maeve McLaughlin): Thank you for that. We will take the contributions, first. I am looking at you, Michael, because you are sitting at the end.

Dr McBride: I am happy to go next. Thank you. I will try to keep my comments to the five minutes allocated. As Elaine indicated, the detail is in the briefing paper for you.

Our trust savings plan is set, as are the other trust plans, within the overarching budget for the Department and the financial plan for Health and Social Care right across Northern Ireland. The additional funding allocation of £150 million from DFP was very welcome, but, as we have heard and you know, it was not sufficient to deal with the pressures carried forward from 2014-15 and the new inflationary pressures in 2015-16. Some £157 million of savings are required from all of us to contribute to achieving financial break-even. Our contribution in the Belfast Trust is some £20·4 million. We have a well-established governance framework for delivering efficiency savings. We have adopted a number of key principles, which have been reinforced by the Department: the safety of services must be protected and maintained; service volumes must be sustained in line with the health board's commissioning levels; and primary and community care capacity must be there for any downturn or proposed downturn in acute capacity. Sixty individual projects were developed in the programme under the four overarching themes of non-pay savings, staff productivity, acute reform and social care reform. As Elaine indicated, all of our 60 proposals have been equality screened. Equality impact assessments have been developed where appropriate. All of our proposals have been supported by the Health and Social Care Board and the Public Health Agency, and they have been in the public domain through our websites since 4 April.

I will give you a high-level flavour of the projects. We are planning to deliver almost a third of our savings through a non-pay saving work stream. The main focus is on procurement, which will make up two fifths of the total under non-pay. We will also reduce a wide range of discretionary areas, including travel, print, stationery, training, record storage and general waste, which will make up a quarter of the non-pay element of the savings. The staff productivity work stream aims to deliver a third of our savings of the £20·4 million total. We are focusing on savings in management and administration. That will account for over a third of our total savings in the staff productivity work stream. We are looking at lowering sickness absence levels and reducing expensive backfill and agency costs. Each of those will contribute just under a third. In acute reform, we aim to deliver £1·5 million by switching to less expensive but equally effective generic drugs. We will also bear down in relation to drug costs in negotiation with drug companies. In addition, we are targeting efficiencies in laboratory services.

Reform, as you know, Chair and members, continues in social care as we shift from institutional models to care delivered in clients' homes and community settings. The social care reform work stream is an important area, but it will deliver less than a tenth of our total savings. This is more about the reform of how we do things than delivering savings. In children's services, we have created a new multidisciplinary resource team, a specialist front-line fostering service and additional foster carers. That will enable us to look after more children by allowing them to stay at home or in family environments rather than reverting to a traditional children's home setting. As for the older people's service, we have recently expanded capacity in our new therapy-led service, which will reduce demand and dependency on long-term domiciliary care. In mental health, we are moving from ward-based care in Knockbracken to care and supported living in the community. Lastly, we have worked and successfully negotiated with the community and voluntary sector, in line with our equality and our personal and public involvement (PPI) statutory duties, to ensure that savings are delivered.

Our mental health proposals, which are outlined in the paper, are fully in line with the Bamford review of mental health and learning disability and You in Mind, the new regional mental health care pathway. It is a fact that an increasing number of our service users are using the flexibility of the packages provided by the community and voluntary sector. That leaves significant gaps in terms of the underutilisation of our day centres, with fewer than half of the available spaces being used across Belfast. Our proposal is to move from the current day-centre model in operation in Everton and Whiterock two days per week to a day opportunities model that promotes recovery, integration and social inclusion on one site at Ravenhill. As part of that, we propose, ultimately, to reconfigure the building to a recovery centre, which will allow for the co-location of other mental health services. Over the medium to longer term, subject to the consultation responses, our vision is to move to a truly integrated community outreach model based in a central location, one bus ride away for all service users.

Our learning disability proposal concerns the implementation of the regional learning disability day opportunities model in Belfast, which was approved following extensive public consultation back in April 2014. Again, it is in line with Equal Lives and the Bamford review. This proposal is our first step in implementing that regional model. Based on the pre-consultation review, we propose to provide more day opportunities for the service users who would benefit from such an approach. That will follow a detailed and person-centred assessment of all those who are using our services and, indeed, their carers. As a consequence, the proposal is that we will merge three day centres to two in west Belfast, with Fallswater merging with Mica and Suffolk day centres.

As we have indicated in the paper, we have engaged very proactively with service users, carers, staff and trade unions at a series of meetings and briefing sessions. We have actively engaged with the local community and political representatives, convening public meetings and offering briefings to interested parties. I am aware that a number of members have attended those events.

Finally, it is very important to mention that no decision has been made on those proposals. Our decision will be fully informed by the views expressed during the consultation process, which runs until 10 December. It will then be considered at our trust board on 14 January, but, obviously, any decision or recommendation emerging out of that will require the Minister's approval ultimately.

Moving to a conclusion, I say that our key priorities need to be set in the wider context of the Department's priorities for transformation, reform, innovation and change, as Elaine has already indicated. We have identified three key areas for delivery in 2015-16: to further improve unscheduled flow through our hospital; to maximise elective capacity; and to enhance community capacity. These three priorities together obviously will help us to ensure safe and effective care. Key improvements delivered to date include the successful delivery of the new emergency department on the Royal Victoria site and the new model of clinical assessment to improve patient experience and outcomes. We have invested some £8 million since 2011, and this has allowed us to significantly increase the numbers of medical nursing staff in our ED and provide additional capacity in our wards and other clinical areas to reduce the pressures on emergency departments, to extend working hours and to aid community services and discharge. As you know, we have also increased investment in reablement, domiciliary care and the new acute-care-at-home model, which many of us across the trusts have invested in.

Our key priorities will remain a focus in year on new models of hospital discharge and improved theatre output, making best use of the additional moneys announced today. At a more strategic level, again, we continue to have a process that is medically led, clinically collaborative and supported by skilled managers in bringing about the improvements in the three areas that I mentioned. We have delivered, I think, innovative new ways of working, which I hope will continue to benefit patients and staff working across the service. There is a range of very new services and, I think, exciting and innovative approaches to our emergency department. There is our new ambulatory care facility. Again, we will continue to focus on research and innovation and translating that into benefits for patients. We have over 800 active research studies under way at any one time, 200 each year. Again, I have outlined the major capital programmes in the paper, and, in the interests of time, I will not say anything further on that now. I am happy to take any questions.

Dr Tony Stevens (Northern Health and Social Care Trust): I think that everybody will have seen our submission, and what I will say are highlights or key points from that. The trust's savings target this year was £12·1 million, and that is set against an overall budget of £650 million. We sought to take a strategic approach to delivering savings this year through reform and modernisation rather than relying simply on short-term cost reduction. In developing our savings proposals, the trust adopted a number of key principles. They are set out in our submission, but principally, we sought to maintain clinical and social care priorities according to need; to more effectively utilise our community resources, particularly where that would allow us to protect our limited secondary care resources; and to protect as far as possible the front line by looking at back-office functions, if you like, as much as possible. Michael set out in his presentation a focus on productivity and procurement and suchlike. Again, we have taken a similar approach, with more than half our savings coming from those areas rather than from the front line, from acute reform or social care reform.

Like Elaine and Michael, we have four key areas of focus: acute reform, social care reform, staff productivity and a range of other productivity measures. We are doing a number of things in acute reform, and I will come back to some of those. However, the highlights include trying to find a different way of working, particularly in our community hospitals. We are blessed with a number of those. They are relatively expensive to run, and we have been successfully rolling out a GP model of care in those hospitals. We are extending that to Mid Ulster Hospital. The saving opportunities that come from utilising general practitioners rather than secondary care doctors gives us an extra advantage, in that those secondary care doctors are then available to work in our acute hospitals. As you know, the trust has gone out to consultation on the permanent closure of Whiteabbey Hospital's minor injuries unit. That consultation is coming to a close. We are also, and have been, seeking to flex beds in acute care and community/intermediate care according to the season, to try to match demand and reduce cost.

On the social care side, we have sought to manage domiciliary care costs in what is at present a very challenging environment. We are doing that in two ways. First, by continuing to support and engage with the independent sector to maximise its capacity and maintain its reliability, but also to recruit to our own permanent home care staffing cohort, which allows us to reduce our overtime payments. We are having to do that within the context of not destabilising the independent sector, but we are working very carefully on that. We are also seeking to reduce spends on non-statutory transport, and we are carrying out a review of how we spend money within the community and voluntary sector. That, again, has gone out to consultation, which is ongoing. I will be quick to say that that is not necessarily about cutting the voluntary and community sector but about working with them to try and drive productivity, as we are required to do by our own auditors.

In the staff productivity work stream, we have been focusing on savings within administration and management, as well as dealing with sundry items such as staff travel costs. We have been having some success there. We have also had a sustained focus on supporting staff to be in work and reducing sickness absence; again, we have been having some success. The advantage of that is that it reduces our locum and agency costs. We have also been working very hard on recruitment of our medical staff, as Elaine said, and we are beginning to see some benefits from a reduction in locum costs in Causeway and Antrim hospitals.

We plan to deliver non-pay savings in a number of ways. Others have gone through much of this already, but they include in areas around procurement, particularly within medicines management, printing, stationery, training, records storage and general waste. We are also pursuing, very effectively, energy efficiency. We have an ongoing programme of estates rationalisation, trying to deal effectively with the 330 buildings that the Northern Trust manages or owns.

Our 2015-16 savings plan is part of our wider strategic approach to modernising services and delivering cost-effective, high-quality care. The trust moved out of turnaround in April of this year, and we have now put in place and agreed with the Department a reform and modernisation programme that encapsulates key regional strategies, including Transforming Your Care, Quality 2020 and Making Life Better. We have prioritised initiatives to reduce pressures on acute hospital beds; for example, the further development of direct access for general practitioners to the assessment of patients and diagnostics. We have improvements in seven-day working, reablement in the community and rapid-response nursing in the community. We have also successfully progressed network solutions in secondary care between Antrim and Causeway, which is absolutely crucial to the future viability of both hospitals. Importantly, also, as Elaine said, we are developing effective networks with Altnagelvin Area Hospital and Belfast hospitals. That will allow for more cost-effective working and will sustain key services. The trust is also implementing an early intervention model to support families, with the aim of reducing the number of looked-after children, again with some success. That is reducing costs. In social care, we are also taking forward models of self-directed support for adults with a variety of disabilities, allowing them to live more independently but also more cost-effectively. All those initiatives offer the potential to meet demand while avoiding cost.

Our immediate priorities for the coming months also include delivering an agreed winter plan; continuing to deliver our core elective activity capacity; and making effective use of the additional funding that has very recently been announced. We continue to recruit to our clinical workforce. That said, there are real challenges with that, but it is essential if we are to continue to reduce locums and deal with agency costs. We are ensuring delivery of our 2015-16 savings plan as a priority in year and recurrently.

The trust continues to work with local clinicians and primary care colleagues in taking forward Transforming Your Care, by taking forward a range of initiatives including reablement and resettlement and working very closely with our integrated care partnership. Examples of good practice are psychiatric rapid access, which is proving effective and, hopefully, reducing length of stay; nursing home in-reach to support nursing homes in keeping the elderly in particular in the nursing home, rather than going through the hospital cycle; an education programme for people with diabetes; other diabetes programmes; and community initiatives in respiratory care. Those are essential to our shift left. So, the trust remains committed to the delivery of excellent integrated services in partnership with our community and within the resources that are available to us.

Ms Paula Clarke (Southern Health and Social Care Trust): In the interests of time, I will try not to repeat too much of what others have alluded to, but I want to do my trust justice in giving some key examples. The Southern Trust's savings target for 2015-16 is £13 million. The trust has been very open in the development of our plans and making those available to the public on our website and ensuring that we have informed and engaged staff in their development and delivery. Like others, we have equality impact assessed, where required, and undertaken a number of public consultations. Our key savings are in the same four areas of focus that others have alluded to and that you have in your briefing.

I want to stress that our plans were very much developed in the wider context of our continuous quality improvement and innovation approach, through which we seek to support our staff to come forward and identify opportunities where they can deliver better care that can equally deliver better value or more efficient care.

Michael has set out some of the key principles within which we developed our plans. Again, I will stress that we have had a clear focus on providing safe, quality care, and where service change is required and where it is indicated on the basis of strong evidence, we build public confidence by putting in place the alternatives before we make the actual service change. We also aim to give staff stability by trying to secure our savings as far as possible through recurrent measures, so that we are avoiding the constant churn of in-year contingency actions. However, our recurrent plans will take some time to fully deliver out. So, in 2015-16, we continue to have a number of contingency actions.

There are a few key examples under the four key areas. Under staff productivity and workforce, like others, our focus is on managing the flexible workforce, improving productivity through better absence management and promoting staff well-being. We are also targeting savings for management administration, and, over the last two years, we have secured a 2·8% reduction in our admin staffing levels, while significantly increasing our professional staffing levels by over 4·2%.

We believe that our plans for social care reform are progressing well. I firmly believe that they are demonstrating that, where we can support people to have more choice about and control over their care, that improves their experience of care and can equally be more efficient. Some examples include the development of front-line and intensive foster care and outreach services for children and young people. As a result, we have reduced the need for placements in residential facilities and have just closed a residential facility in Dungannon, with full support from children, young people and the wider stakeholders.

We have also fully rolled out the reablement approach across the trust, alongside a redesign of domiciliary care, and we have evidence now that almost 60% of those who have received reablement do not need a full domiciliary care package at the end of the six-week reablement period.

Equally, we have continued to extend the day-opportunity choices that are available to our service users to allow us to concentrate our specialist day care provision on those with more complex needs.

On acute care reform, we have undertaken a significant number of public consultations on strategic change that were completely underpinned by clinical and professional evidence. There is a clear opportunity to improve safety and outcomes, make the best use of scarce public funding and ensure that our specialist staff resources are in the right place. These plans include modernising our inpatient, acute and rehabilitation stroke services, consolidating all our inpatient hospital services for older people at our two acute sites at Daisy Hill Hospital and Craigavon Area Hospital, developing a new, fit-for-purpose dementia assessment unit at Craigavon Area Hospital in line with the Bamford vision, and increasing access to emergency nurse practitioners at our busiest units by closing the Armagh minor injuries unit, where attendance has remained very low over recent years. A number of these changes will take time to fully deliver because some of them rely on capital developments, but we are progressing as much as we can now. A very clear example of that, which is also an example of Transforming Your Care in action, is our consultant-led acute-care-at-home service. We have a team in place that is led by a consultant geriatrician. In just one locality over the last year, the team has already reduced acute admissions by over 400 and facilitated 100 earlier discharges. All our feedback from carers and patients is extremely positive.

On non-pay expenditure, others have outlined some areas of savings in travel, books and publications, etc. At this stage in 2015-16, we believe that we are making satisfactory progress with our savings plans and are on track to break even.

On the Southern Trust's key priorities, we very recently concluded a wide-ranging consultation on our strategic priorities for the next three years — our Improving Through Change plan. In that, we set out our key priorities and themes, which are very much in line with the departmental strategies of Making Life Better and Quality 2020 in particular. We have a focus on promoting early intervention, prevention and wellness, supporting people to live more independently, better and more accessible care outside hospital, enhancing and modernising our hospital network, and continuously improving our safety and quality. I have a number of examples of how we are doing that, and I am happy to address them. Members have the briefing under questions. I will just draw your attention to the very welcome capital investment that the Southern Trust has received, which will allow us to progress two key paediatric service developments at Daisy Hill and Craigavon over the next 18 months and will significantly enhance our ambulatory care. We will also open a community care and treatment centre hub in Banbridge and, hopefully, another one in Newry shortly following thereafter. We have submitted a phased business case for the redevelopment of Craigavon Area Hospital, which underpins a number of our strategic plans.

Our immediate priorities are, obviously, the same as others: delivering safe, responsive care over the challenging winter period; improving seven-day working, not just in hospitals but across our community settings; maximising our elective capacity and ensuring that we manage those who are on waiting lists compassionately and fairly — like Elaine, I thoroughly welcome the announcement of the additional funds today; continuing to seek to work collaboratively to address workforce pressures, particularly in certain medical specialties and in the nursing workforce; and delivering our savings plans, both recurrently and non-recurrently.

Mr Hugh McCaughey (South Eastern Health and Social Care Trust): I do not want to repeat some of the things that have been said, so I will focus on some of the key issues in the paper that has been submitted to you. The South Eastern Trust had to save £8·4 million this year. Our plans were approved by the trust board in March and we followed a similar process to all the other trusts, so I will not repeat any of that.

We were looking for savings in four main areas. The first was in what I would call acute reform, which I suppose is really targeting making better use of our acute infrastructure and facilities. That is about reducing length of stay, seeing the same number of patients through fewer beds or more patients through the same number of beds. We have reduced the number of beds in the Downe Hospital, the Lagan Valley Hospital and the Bangor Community Hospital as a consequence of those plans and that acute reform.

In terms of social care reform, we looked at a lot of our voluntary service contracts and community arrangements. We looked at things like consolidation of contracts, better performance through those contracts and an alternative provision for either voluntary contracts or community care provision. We also looked at our use of agency in the community as well.

The third area is staff productivity. As others have said, we are continuing the trend of trying to reduce the use of and dependency on temporary or flexible staffing, particularly around locums, agency and bank staff, and overtime. We have seen a continued downward trend and saving in the temporary workforce, although, as others have said, there are areas in which we have workforce shortages, and that makes it difficult to deliver the service without the use of agency or bank staff or locums.

The fourth area is the catch-all of miscellaneous things. Like others, that includes better arrangements for travel, reducing the admin function and looking at areas like our use of other buildings and leases, and we were able to make some savings through those areas as well. More detail is available in our trust delivery plan and our savings plan.

I will turn to the priorities for 2015-16. I have grouped them into three areas. The first is priorities associated with growing demand and pressure. The second is around reform and modernisation and how we change and improve the model of care delivery. The third is focusing on how we assure ourselves about the safety, the quality and the user's experience. In the first area, we are no different to other trusts and, indeed, other countries in terms of the pressures that healthcare systems are facing. Typically, we are all facing rising demand. That is often in the region of 3% to 4% per annum and is associated with an ageing population, but also other things in the advancement of clinical care. When you add in 1% for inflation and 1% or 2% for new things, we are typically facing a pressure of 5% to 6% each year. Few economies can afford to invest at that level, and that is at the core of some of the pressure that we are experiencing. That is why we are continually looking for increased productivity. Staff and services certainly feel and absorb some of that pressure, and that is one of the drivers. Where does that manifest itself in our priorities in unscheduled care, particularly that pressure of growth? We see particular capacity and pressure at the Ulster Hospital. We are working on our plans, as we have done previously, to try to improve the flow through the hospital and to ensure quicker discharge and a better system and better flow through the system. We are also working with the board on how we can address some of those capacity problems and issues.

The second area, which others have talked about, is elective care. Like others, I welcome today's announcement of the additional £40 million of investment. This year, and in the latter part of last year, there was less money available for waiting list initiatives and for spend in the independent sector, and, consequently, we have seen our waiting times grow over the last period of time. We all want to get an opportunity to reverse that again; it is a priority for us. Like others, we have issues around workforce, particularly in a number of areas where we have shortages or recruitment difficulties. As others have mentioned, those are typically in nursing, some areas of medicine and allied health professionals.

Another area of pressure is in and around some of our capital developments, particularly the Ulster phase B. We have the new Ulster Hospital coming and the new bed block, which will be open in spring 2017, and that will be followed by the acute services block. Another capital priority for us is to bring our three mental health inpatient units together into one unit. That would give us the opportunity to make savings and to improve and consolidate the service. The second area that I want to talk about is reform and modernisation. As I have outlined in the paper, we have a tradition and history of reforming our services and making changes. Quite a number of things are outlined there, particularly within the area of growing our community services, trying to do better prevention and providing alternatives to hospital care, which is very much in line with Transforming Your Care and Making Life Better. There are a number of examples. I will not go through and list them; I am sure that you have had the opportunity to look at them.

The final area is, I suppose, a priority for us. The third area that I want to mention is around how we ensure the safety and quality of the user's experience. It is something that we have been doing a fair bit of work on in the past three or four years, building the capability of the organisation, particularly front-line staff, to lead safety projects or quality improvement projects. We have trained over 400 staff now through our own in-house programme so that they have the opportunity to deliver improvements at the coalface and within their own services. That has been a particular priority for us, and one we are continuing to invest time and resource in.

The Chairperson (Ms Maeve McLaughlin): Thank you all for that. Obviously, the chief executive of each trust has outlined the amounts in the savings plan that has been agreed. A number of members have indicated. My question to each of you is this: will the trust break even this year and, if not, what will be the deficit? I will start with you, Michael.

Dr McBride: I suppose that the straightforward answer to that is that we all have a statutory responsibility to break even. We are acutely aware of that. We are responsible to the chairs and boards of our respective organisations. As accounting officers within the respective organisations, we are clearly accountable to the Department for ensuring that that is the case. As Hugh has highlighted, that has become increasingly challenging in all health economies. We see the increase in demand, the inflationary pressures of the costs of new treatments and demographic trends of some 6% a year, and we put that in context. Others have spoken about the savings that have been generated in previous years, but in the case of Belfast, it has been 3% per year since 2008-09, which is a cumulative saving of some 20%. Again, as Elaine and Hugh have indicated, that is increasingly challenging.

Really, what we now need, and what Sir Liam Donaldson mentioned in his report, is a radical transformation of how we provide health and social care services. There are many good examples, certainly in the Belfast Trust; in the Southern Trust, as Paula has already indicated; and, as Hugh has indicated, with regard to different ways of working that can provide better-quality care and better experience of care, but actually provide that care at less cost. That is the challenge and the vision that the Minister has outlined in his recent announcements. There is no poverty of ambition or slackening of pace in the need to innovate and transform how we do things. The task for us — and this is a challenge for us all — is to communicate effectively to the population whom we serve — obviously, you all will be acutely aware of that — that doing things as we currently do them and providing services as we currently provide them is not an option. If we do that, we will have failed the population that we serve. We will have failed to meet changing needs. We will have failed to address demographic pressures. We will have failed to adopt new ways of working and innovative treatments, and ultimately we will not be able to live within the budget. It is a requirement. We will be working hard to do so, and we will work very closely with the board and indeed the Department in achieving financial break-even.

The Chairperson (Ms Maeve McLaughlin): OK, there is a requirement; I get that. You are also saying that it is increasingly difficult.

Dr McBride: It is increasingly difficult.

The Chairperson (Ms Maeve McLaughlin): Is there a figure on that — a deficit or shortfall?

Dr McBride: Not at this point in time, no. We have a pressure this year. We recognise that. Again, we have regular discussions and meetings with Health and Social Care Board colleagues on our anticipated income against the funding that they have available. Those are ongoing, live discussions and debates that we all have with board colleagues.

The Chairperson (Ms Maeve McLaughlin): So that I am clear, when is that figure likely to become clearer?

Dr McBride: As I say, these are very active and ongoing discussions. I am confident that the Belfast Trust will work to ensure that it achieves a financial balance position this year. That is a statutory requirement, and I must work to achieve that. I am very acutely aware of that. The greater challenge for all of us going forward is how we ensure that we maintain recurrent financial balance and, at the same time, provide the level of service — and there is an increasing level of demand, as Hugh has indicated — with reducing resource. That is the task that we face.

The Chairperson (Ms Maeve McLaughlin): OK. What about the other trust areas' shortfalls and deficits? Is there a calculation at this point?

Dr Stevens: For the Northern Trust, our expectation, based on our position at this stage, is that we will deliver a balanced budget. The real challenge for us is delivering the recurrent savings. In-year, a percentage of the savings that all the trusts are making are one-offs — non-recurrent — and the challenge that we all carry is making them recurrent. At this point in time, the Northern Trust anticipates and expects to balance its budget.

Mrs Way: Mine is a slightly more complicated answer, but the answer is yes, I expect to get to a break-even position. Why it is complicated is that, on the last occasion when I met my MLAs locally, I had said that we were projecting a £3·8 million deficit at the end of this year. Last year, we spent about £600 million in the Western Trust, and we ended with a deficit. Although the overall system in Northern Ireland balanced, we had a deficit of just over £6·6 million. There was a very detailed discussion with the Health and Social Care Board about what was a reasonable ask of the Western Trust. This year, the anticipation was that there would be a £3·8 million deficit. As I have briefed Members locally, my single biggest financial pressure in the Western Trust is the cost of medical locums to keep services safe. Last year, we spent over £10·6 million on medical locums, and that cost is rising this year. I think that there has now been an acceptance regionally that that is an exceptional pressure on the Western Trust. As a result of that — I have not had the opportunity to brief you; we will meet again in December — the permanent secretary has asked the board to look at whether we can have an additional allocation to enable us to reach a break-even position like others, but on the clear understanding that we must develop a recurring break-even plan going forward.

Ms P Clarke: As I indicated, at this stage in the year, the Southern Trust is on target to break even. Like others said, the challenge is to deliver it in a sustainable way, but the majority of our plans this year are predicated on a recurrent position at a future point in time.

The Chairperson (Ms Maeve McLaughlin): OK. Hugh, are you in a similar position?

Mr McCaughey: Simply, the answer is yes. We expect to break even, without any deficit. As Michael said, we are seeing that cumulative effect of absorbing the growth in demand over a number of years. I think that there are lots of signs of strain in the system, with our staff and services absorbing that rising demand. We can all see examples of that.

The Chairperson (Ms Maeve McLaughlin): OK. My next question is about the reform proposals that the Minister has announced and their potential impact. One of the key challenges and, in fact, needs is to radically reform the system, given the levels of bureaucracy and duplication in the system. One of the issues is bringing the trusts more within the remit of the Department. It was suggested that that would increase accountability. I am just wondering where that leaves your current proposals. If that is about increasing accountability, has there been a lack of accountability to date? Where does that leave current proposals? Can they be advanced, given the fact that we are all collectively facing a huge shift in the system?

Mrs Way: I do not think it will have an impact on the proposals that we have described today. All of us have said that our key priorities are already driven by the Department's priority documents and the Minister's requirements. We do have very strong accountability mechanisms at the moment. As a trust chief executive, I am accountable to the permanent secretary for everything, but I am also accountable to the Health and Social Care Board on issues such as financial management. The two things are very closely linked.

Finally, in relation to the proposals around reform, it was a very open process. The Department engaged with front-line staff, who expressed some frustration about how you develop business cases, get approval and get it on the ground. That de-layering that the Minister described is very much welcomed by the staff who work on the front line. We have an opportunity to shorten lines of accountability and strengthen accountability. I say quite clearly that, when I responded to the review of public administration many years ago, back in my days as chief executive of Altnagelvin, we suggested that accountability should be direct from the trust to the Department, without there being a regional board. We felt that commissioning should be handled within the local geography so that people like me could be accountable for some of the proposals around investments and priorities.

The Chairperson (Ms Maeve McLaughlin): But, collectively, you do not see any issues for current decisions around saving plans.

Mrs Way: No, I do not.

Dr McBride: Just to add to Elaine's point, there has been much achieved over the last number of years by the current system and way of working, but anything that is perceived as reducing bureaucracy or de-layering the system, whilst at the same time having that strong sense of absolute accountability for trusts through to the Department for delivery of key priorities, implementation of policy areas and ensuring that standards are maintained, is to be welcomed. However, there is no ideal system. It is about keeping that balance between accountability, ensuring performance and delivery, and the freedom to innovate and change.

The other thing that the Minister indicated was the fact that trusts will have a greater and more accountable role for the community and population they serve. It is as much about how we develop our role. Obviously, we will work with the Department on how that is to be shaped and informed and how we take more of a population health approach to the community that we serve. We have also heard from Elaine and Paula. We, as organisations, are more than sickness services. It is about what we do with the community that we serve to improve health, reduce health inequalities and reduce access issues in relation to health inequalities and access to care, and improve the health of the population that we have a responsibility for. In how that is developed over the next number of months, I think there is a real opportunity for us to do something radically different in Northern Ireland — something that realises the ambition that the Minister indicated in his statement.

The Chairperson (Ms Maeve McLaughlin): We hope so.

Mrs Dobson: Thank you all for your presentations. My first question is to you, Michael. I have read your briefing on your savings plan and overarching principle. Those should obviously ensure that patient safety and service must at all times be protected and maintained. With that in mind, can you explain why it was necessary for your trust to purchase 650 electronic tablets at an average spend of £1,000 each over the last two years?

Dr McBride: First, I do not have the detail of that, but I have no doubt that it is an accurate position. Increasingly, as we look to innovate in how we deliver services, we also need to recognise that Belfast provides not only acute services but care in the community. That is a range of healthcare workers who work in the community and remotely. All of us are involved in looking at innovative ways whereby we can facilitate individual practitioners entering information directly and using that innovatively, rather than returning to base — spending more time out in front-line services, delivering services and using modern technology to provide that service more efficiently, maximising the front-line engagement with patients. Good examples of that include the fact that we have invested moneys — I do not know the specific details of the spend — in portable ultrasound scanners for our community midwives.

Mrs Dobson: That is not comparable with 650 —

Dr McBride: I think it is, because this is about how we use technology and innovation to maximise the productivity of the workforce so that we ensure that the workforce spends more real time in patient contact and also, if the detail of this spend is not in front-line staff, it is also about how we, as an organisation, ensure that those who have responsibility for managing services effectively can absolutely ensure that the performance of the service is where it should be. The health service in Northern Ireland will have to invest significantly more in mobile technology —

Mrs Dobson: So you do not think that this is excessive.

Dr McBride: Jo-Anne, I honestly do not. As a healthcare system, we need to embrace innovation and what information technology can offer us to keep people well in the community. When I was in the Cleveland Clinic a year ago, they handed out portable tablets — I mean PC tablets — to patients with long-term conditions to manage their long-term condition and provide them with advice and support as to how they could best manage their care. That was to ensure those individual patients living with long-term conditions were involved in the self-management of their care. That is the future of healthcare. Innovation, technology and the new areas of genomics and big data will drive the transformation that we have discussed already and that all of us have highlighted. It will deliver the quality of care much more effectively. It will give a better patient experience and create a more empowered patient, at a lower cost.

Mrs Dobson: I fail to see how 650 electronic tablets at £1,000 each will benefit patient care. That is why —

Dr McBride: I do not have the detail.

Mrs Dobson: Well, maybe you can provide the detail.

Dr McBride: I am happy to provide the detail.

Mrs Dobson: Will you commit now to —

Dr McBride: Absolutely delighted to.

Mrs Dobson: That is why I think it is useful to have you all here. By comparison, other trusts have purchased a fraction of that number, often at reduced cost.

Dr McBride: The only other thing that I would add in relation to that is that the Belfast Trust is the largest employer in Northern Ireland. We are the second largest trust in the UK. We employ 22,000 staff, so, in relative terms, you would expect our spend on that type of technology to be greater.

Mrs Dobson: Not to that degree.

Dr McBride: Again, I do not have the figures, Jo-Anne.

Mr McCaughey: Can I just add to that? I could not tell you what our figures are without checking either, but we have been introducing mobile devices similar to those introduced in Belfast.

Mrs Dobson: It would be useful, Chair —

Mr McCaughey: They enable staff to work more quickly. If you are a member of community staff and you are out there and have access to a mobile device, you can access information, check things and even look up previous records. You can access information about conditions or services. Also, we are trying to press down on the number of administrative and clerical staff. We have an example of this where, in some of our children's services, by using mobile devices in real time, they have been able to reduce the amount of transcribing and speed up the outcome from minutes, meetings and childcare or case conferences.

Mrs Dobson: Chair, would it be useful?

The Chairperson (Ms Maeve McLaughlin): Yes, it would be useful to get that overview from the trusts. I also make the point that, when we took evidence from representatives of the Association of Social Workers, they pointed up some of the challenges around the need for IT equipment, particularly when it comes to having to go back to the office to write up reports. I suppose that this is about getting value for money and meeting the innovation that is required as well. That was a very specific ask from the social workers, but we should seek the views from each of the trusts.

Mrs Dobson: I totally agree with that because I am mindful of the fact that a lot of the people who provide valuable domiciliary care do not even have a mobile phone. That is why, from that perspective, it would be useful to tease that out.

Dr McBride: We will be happy to do that, Chair.

Mrs Dobson: To me it seems — I know that you are not going to agree with it — to go against the overriding principle of the savings plan at a time when, as we all know, front-line services and waiting times are out of control.

Again, I refer to the Chair's comments. Domiciliary care teams are doing that vital work without even a mobile phone. To me, the comparison seems very excessive. So, you will undertake to provide that information, Michael.

Dr McBride: I am very happy to do that, Jo-Anne — very happy to provide that through the Chair.

Mrs Dobson: Last week, I secured information that the number of administration staff in the health service earning between £100,000 and £125,000 has doubled in three years. Indeed, some are earning over £125,000. What is your view of that, and how many of them work in your trust?

Dr McBride: The overall management cost of the Belfast Trust, as of last year, was 3%. I know that if that is not the lowest, then it is among the lowest for all the trusts in Northern Ireland. It compares extremely favourably with similar-sized organisations across the UK, bearing in mind that Belfast is probably the second largest trust in Northern Ireland. I think there are in the region of 404 individuals earning over £100,000 in the Belfast Trust. Of those, 398 are consultant medical staff. Indeed, the numbers —

Mrs Dobson: Just for clarity, the figures I was referring to were for administration staff.

Dr McBride: I do not know if you are referring to the report that had some recent publicity. I do not have the figures that are in front of you, but administrative and management costs are 3% — that is factually accurate — in the Belfast Trust, which compares extremely favourably with other trusts. There are 404 people earning over £100,000 in the Belfast Trust. Three hundred and ninety eight are consultants. Just to confirm, 398 of those earning over £100,000 employed by the Belfast Trust are consultant medical staff.

Mrs Dobson: My question was not about consultants; it was about administrative positions. Could you come back to me on that?

Dr McBride: Would you please clarify the question? Maybe I misunderstood.

Mrs Dobson: The information I received last week was that the number of administration staff in the health service in general earning between £100,000 and £125,000 had doubled in three years.

Dr McBride: Four hundred and four minus 398 equals six. The six earning over £100,000, who are not medical staff, are me, the deputy chief executive and other professional heads of service. That is the answer, but, if you want it broken down, I am happy to get back to you.

Mrs Dobson: I would.

Mrs Way: May I add something, Chair? Obviously, we have been watching the reports in the media about pay. It was clear from the response that what happened was that some people have quite properly gone up their pay scale, which tips them into a different level. There are senior managers at that level, such as directors of pharmacy, and although those are management posts, they are clinical posts as well. You have to be a very experienced pharmacist to drive that forward.

From my perspective and to be absolutely straight with you, I make no apology for what I earn. I assure you that I earn my salary. I am now 20 years a trust chief executive, and I have just got to the top of my salary scale. I can assure you that, for the size and complexity of the organisation, there will not be another chief executive in the United Kingdom paid less than me.

Mrs Dobson: I was not referring to you specifically, Elaine, as you know.

Mrs Way: No, but I know that this has been a running issue for the Health Committee and, who knows, this could be my last opportunity to say something on behalf of my colleagues. [Laughter.]

I really feel that it is a bit of a red herring. We are working so hard to transform services, and I assure you that our salaries are the lowest in the United Kingdom. Despite what the 'Irish News' said a couple of weeks ago, our pensions are identical to those of other staff. Any midwife who started in the health service in 1977, as I did, will have a pension under exactly the same rules as mine.

Mrs Dobson: I understand that, but, with respect, you are the heads of the five trusts. I am talking in general about that alarming rise. Surely, you can see that the public are concerned at a time when one in five is on a waiting list? We are here, today, specifically to talk about savings plans. I am not referring to you; I am talking about that alarming rise. I am interested in teasing out details of whatever strategy has been employed by the trusts that has led to staff earning such large salaries in administration; salaries that have doubled or more.

Mrs Way: About 99% of our staff are on national terms and conditions. Doctors are on national terms and conditions. In response to the message about high earners that came out recently from the Taxpayers' Alliance and so on, I can tell you that there are about 1,500 people in the health service in Northern Ireland who earn over £100,000, and the vast majority, as Dr McBride has explained, are consultants. About 99% of staff are on Agenda for Change or they are on medical terms and conditions.

Mrs Dobson: I did not ask about consultants; I referred specifically to admin.

Mrs Way: The 1% who are not on national terms and conditions are the people at this end of the table, and these two are doctors. For the people at this end of the table, our salaries, relative to the three other countries, are lower.

Mrs Dobson: My point was about administration; it was nothing to do with consultants.

Mrs Way: But it is us.

Dr McBride: That is the point, Jo-Anne. Apologies if I did not make that clear, Chair, but that is the point, and Elaine has emphasised it: a significant number of the individuals who would be regarded as being in administrative roles are actually in those roles as the head of social services, head of pharmacy, medical director in the organisations —

Mrs Dobson: That is why it would be so useful to have that breakdown.

Dr McBride: That is the point I was trying to make: of those 404 people, 398 are medical staff; four are heads of profession and, of the other two, one is me and the other is the deputy chief executive. I am happy to provide that information, but it is important to understand that these individuals are holding dual roles by dint and virtue of their professional training and background. Sometimes, the headline figures that make the newspapers do not really reveal the whole story.

Mrs Dobson: That is useful to us; that is what we are here to scrutinise. We would not be doing our jobs properly if we did not do so. I think that it would be very useful to get that, Chair.

Dr McBride: Absolutely.

The Chairperson (Ms Maeve McLaughlin): We can seek that information.

Mrs Dobson: I have just another quick point, if I may. For my trust, the Southern Trust, you said in your briefing that the cash-release savings for 2015-16 are £13 million. How does that compare to other trusts, given the relative size and scope of the Southern Trust when compared to others?

Ms P Clarke: I think, Jo-Anne, that you will have heard, as the others outlined in their levels of savings, that, to a degree, it does reflect the size of the different trusts. I think that Michael started off at around £20 million, which reflects the size of the Belfast Trust. So, from that point of view, I think it is in line with what we call our capitation share.

Mrs Dobson: In your presentation, you referred to contingency actions for 2015-16. I note that you referred to a £2·8 million reduction in administration staffing levels.

Ms Clarke: No, it was not £2·8 million; it was 2·8% over the last two years in our admin and clerical staffing bands. There was also a 4·3% increase over the same period in our professional staff, which is nursing, medical, social work and professional and technical staff.

Mrs Dobson: OK. I am sure that you did not hear me, earlier today in the Chamber, asking the Finance Minister about that extra £47·6 million allocation to health and whether it would stem the trusts' seeing domiciliary care as a soft target. Do you think that it will?

Ms P Clarke: Do you mean whether the additional money will go towards that?

Mrs Dobson: Domiciliary care workers feel that they are almost the soft targets for the trust. Do you think that this money will alleviate that problem or do you think that it will help stem that?

Ms P Clarke: The additional funding is in-year funding only. For me, the domiciliary care issue is one of recruitment in trusts' home care delivery, and we know that independent sector providers are having difficulties in some geographical patches in particular. As an organisation, we have moved to identify, over the winter period, a targeted enhanced rate for hard-to-secure-package areas to see whether that makes a difference. I note that the £47 million includes a generic winter pressure element.

Mrs Dobson: It would be useful for you all to hear the Finance Minister's response to me earlier, because she agreed, as a constituency MLA, as well. Paula, you know that I have been in touch with you about a considerable number of cases in which patients cannot leave hospital because they do not have a package available. The Finance Minister seemed to have had experience of that. If you get a chance to read the Hansard report, you will see that she alluded to it in her response. I am interested to find out how trusts are addressing this. I agree with what the Finance Minister said in her reply to me on this. Surely, putting a proper package in place is better for the patient and more cost effective for you as well.

Dr McBride: I agree. I do not think that any of us regard domiciliary care as a soft touch. It is vital for supporting people in the community. It is vital for maintaining flows through our hospital system, as you have clearly indicated, Jo-Anne. All organisations are looking at a reablement model, which is basically about having very proactive, therapy-led options to re-empower patients to remain independent in their own home.

Take the experience of the pilot of reablement in the Belfast Trusts, which we established in September 2012. We invested £1·2 million in it last year and are going to invest another £900,000 in it this year. Reablement is the early intervention. You saw a piece on TV recently from someone in the South Eastern Trust who is receiving reablement care that is supporting them in their own home. With reablement, we can reduce the requirements for subsequent domiciliary care in Belfast by 40%.

It is about changing how we do things. However, you are quite right that it is also about ensuring that, with fewer individuals providing those services, we can be assured of the quality of that care, that we can maintain the market and give security to providers in the marketplace. In Belfast, we have increased the hourly pay rate for domiciliary care from £11·70 to £12·16 per hour, because we do not see it as a soft touch. We see it as being a vital part of the service we provide, and I know we are all working in a similar way.

Mrs Dobson: Finally, a lot of the people who provide that care feel that they are the front line, and morale is very low.

Dr McBride: I accept that perception.

Mrs Dobson: It is important that they feel valued and have the time to carry out what is a crucial role in the community.

Dr McBride: We can all very much reaffirm that. If any of them are listening, we do value them. They do an invaluable job. I hear that about the staff providing that service from the patients I speak to. It is an invaluable service, and they are the unsung heroes in many respects.

The Chairperson (Ms Maeve McLaughlin): I am going to move things on, because I am conscious that there are quite a few members still to speak. I appeal to members to be succinct and for the trusts to be succinct in their responses. I have Kieran next and then Tom.

Mr McCarthy: Thanks very much everybody for —

The Chairperson (Ms Maeve McLaughlin): Sorry, Kieran, just a second. Do you have to leave, Tom?

Mr Buchanan: Yes, I am supposed to have a meeting.

The Chairperson (Ms Maeve McLaughlin): Is it OK if Tom asks his question first, Kieran?

Mr McCarthy: Go ahead, surely.

Mr Buchanan: Thanks for that, Kieran. I welcome you all here today. I commend you all on the work that you do and on continuing to provide an increase in services while having to make savings every year. That is a challenge. I am not sure that it is a challenge that anyone sitting around the table today would want to have, but it is a challenge that somebody has to meet. I commend you on that.

One of the issues that seemed to come through from all of you folk today was staffing: agency staff, locums, reduced overtime and all that type of thing. Are you satisfied that you can do that and still provide the service? Look at administration staff, for example. In the Western Trust area, I hear concerns at times that there are not enough administrative staff to draw up the doctor's notes and do all that type of stuff. Can we continue to look at reducing staff and still deliver the service that we want to deliver?

Dr McBride: I do not know who wants to —

Mrs Way: I thought that your answer was going to be, "I do not know", because I think that that is probably my response — I do not know. I think that you make a very valid point, and it is so encouraging to hear somebody publicly support the invaluable role that administrators play. I had a look at what they are doing to try to ensure that the vast majority of them are delivering front-facing patient care, and they are; they are doing the sort of things that you talk about.

The biggest challenge for us is this: our savings plans. We do our savings plans by saying, "I am going to have a vacancy, so I might hold on to it for a couple of months, because I will make a couple of months' savings on it". So, you get a wee bit of cash out of that. Also, if a post is vital and is for safety, you will say, "Well, I have to replace it straight away, but as I cannot get somebody into the post I will pay an agency and locum", or you will say, "I cannot really increase my workforce, so I will go for a temporary nurse to fill the post". I am sure that my colleagues will agree that nurses no longer want the offer of a temporary post. I am finding that if the period is less than six months, they will not take the post, and each of us is having that experience; likewise with the medical workforce. You know how many challenges the west has had over many years.

We have our savings plan and the savings target that we talked to you about, and we try to drive those plans forward to get the reductions made so that we can concentrate on more flexibility in the workforce so that we keep it safe but have some temporary staff in while we are doing that, because we have not got the money invested to make them recurring. When I get my share of the £40 million for reducing waiting lists, I will be asking staff to work flexibly and do things differently. I want more temporary nurses, more temporary admin, more physiotherapists, more social workers, etc, but they may not want to take it on that basis, and that is a huge challenge for us.

Dr McBride: The other issue is sickness absence, and Hugh mentioned that in his introductory comments. It is tough out there on the front line, delivering health and social care whether it is in an acute sector or in the community. It is sometimes made even tougher by some of the headlines we see and read. That is not me bashing the media at all. However, I think that we have to be better at, and more proactive in, communicating much more effectively the good things we are doing and the changes we are introducing. We should also ensure that those who have a good experience of service do that communication on our behalf.

We do need to make improvements in sickness absence. As Elaine said, it is about improving the working environment for staff, looking at hours and looking at how we make the working environment a pleasant place to be. It is also about us, as organisations, realising that we have a duty of care to our staff. In Belfast, we recently launched a new staff health and well-being strategy, Be Well. We have advice for staff online; a mobile app that staff can use from home; over 50 videos and areas of advice with 90 minutes of clips of advice for staff with everything from smoking cessation to back care to diet and exercise. We have themes around smoking cessation and weight-loss exercise. I want a healthy happy staff. I want the 22,000 employees to be happy and healthy in their work, and I also want them to be champions in their own homes for improving the health of the population.

We have 22,000 employees, some of whom come from the most deprived parts of Belfast, and I want them to be champions in their own community. From April to September last year to April to September this year, we reduced sickness absence by 0·5%. You may say that that is not a great achievement, but I think that it is the beginnings of a start, because it will help us to reduce that expensive backfill and overtime that we all face. It will also communicate, as we all do, that staff are valued, important, and are doing an excellent job.

Mr McCaughey: Just to clarify, Tom, we are not trying to reduce the number of staff. We are trying to reduce the reliance on temporary staff like agency and locum staff. We are moving towards having more permanent staff. In the South Eastern Trust in 2012-13, we increased our staffing by 500, almost exclusively in the professional groupings.

We are keen to have people as permanent staff, because that tends to be better value. When we rely on new temporary staff, whether agency or locums, if they are not used to the trust, then they have to find out the ways of doing things. Permanent staff tend to be more effective, because they know the systems and people, and are part of the team. When bringing agency or locum staff in for a short term, there are issues around their induction and how they fit in. From the financial point of view, having permanent staff is more efficient. It also tends to be more effective: they work better as part of the team.

Where we use temporary staff, we try to use a bank staff rather than agency staff. So, our own, if you like, in-house bank staff are still employed by us but they do bank hours and cover shifts and gaps, rather than us relying on agency staff. That also tends to be more cost-effective. Staff coming from bank typically come on a regular basis, which means that they also know the systems.

Mr Buchanan: Do the trusts feel that the Minister's recent proposals to remove the board and streamline the system will put more pressure on them or allow them to deliver services better?

Mrs Way: I was probably the only trust chief executive back in 2006 who said that trusts should have responsibility for planning as well as delivery. That is about local accountability. I could make a change in Omagh and say to the Omagh community that I am doing it because the commissioner will not give me the money or because of this, that and the other. It is important that local health service leaders have the conversation with communities about what needs to change, why it needs to change, what the overall envelope is, and if this happens, then what happens here or there.

Michael said the right thing, and I feel it strongly about this: some of my best friends work on the Health and Social Care Board, and they are good people and have done great work. However, the system could do with a tweaking; and most trusts see this as an opportunity to improve services for patients and clients.

Dr McBride: The excellent opportunity is that which is afforded through local government reform, in the context of Elaine's comments. With the introduction of community planning, and the trusts, subject to the proposals outlined in detail by the Minister and Department, there is a real opportunity for an uptake in a wider population-based health approach, having greater accountability to the local community, and working in a more integrated way.

Mr McCaughey: The Minister's intention is to simplify decision-making and speed up the transformation. Elaine said, as did the Minister, that there are many talented people on the board. Some of the board's functions will go to trusts and some will go to the Department; so, many of the people at the board fulfilling those functions will be required elsewhere. We will still need assessment of need and some of the functions of the board. That still needs to be done.

The Chairperson (Ms Maeve McLaughlin): Thank you, Tom, and thank you, Kieran, for cooperating.

Mr McCarthy: That is all right. I am delighted to hear what you said in relation to the new system that will come when the board disappears. The people I talk to — GPs, professionals etc. — feel that they are being hindered in some ways. If they had direct access, with new ideas, etc, they could put those into practice without having to go through that tier of bureaucracy and delay. That is good news, and you are all nodding in agreement. We look forward to that.

The good news announced this morning has been a long time coming. There was a request in, I think, the June monitoring round for £98 million. The £47 million is £50 million short of that. Hopefully, that fantastic money will go to reducing the waiting lists, which we are all shouting about, but £50 million is not coming. Mental health and learning disability will still be deprived; £16 million was asked for that, but that is not coming. Twenty-three million pounds was asked for existing pressures and Transforming Your Care, which we all support. For some reason or other, it has been held back; the funding has not shifted to Transforming Your Care. How are you going to overcome that? That £50 million is not coming to you. Are you with me?

Dr McBride: I will make a start and then hand over to Hugh. As we have all said, this is very welcome news. The challenge for us now is to get that money on the ground. We have had discussions. Obviously, we need to plan and anticipate. All of the organisations have been working to maximise elective activity with the resources we have. We, as a system, would be planning and preparing for any announcement in relation to additional funding. Even today, we have had further discussions with the Health and Social Care Board in terms of how we maximise that spend, how we get it on the ground quickly, how we increase additional elective capacity in the Belfast Trust, and all the trusts, and how we use the independent sector across all the areas where we have excessive waiting times. The challenge for us now, in the remainder of this financial year, is to get that money on the ground to make sure that the people waiting longest and the patients at greatest risk of harm and pain —

Mr McCarthy: It is 88 weeks.

Dr McBride: Yes.

Mr McCarthy: That is unbelievable.

Dr McBride: None of us sits here comfortably, Kieran, in relation to the length of the waiting times. It diminishes us all as a system in terms of the length of time that people are on waiting lists. Our challenge now is to move quickly to bringing about improvement.

Mr McCaughey: Like Michael, I welcome it. In the last number of years, all of us have been involved in bringing waiting lists down from the poor levels they were at and getting them down to where we were about a year ago. To see this deteriorating again is not something that we, or our clinical or managerial staff, who worked to improve the situation, enjoy seeing.

You talked about the £98 million. An element of it is that this was back in June. There is a reality, given that we are now in November, about how much we can do between now and 31 March. As I am sure you will appreciate, it is about the ability to spend now and ratchet up the infrastructure and people that will actually deliver it. You will need doctors, nurses, allied health professionals and a whole range of people. You will need additional clinics and lists, and, potentially, even additional equipment. To get all those things in place, there is a certain amount that we can do through additional initiatives.

There is finite capacity in the independent sector. The big challenge for us will be to make sure that we get the infrastructure up quickly and use it maximum effect. Obviously, we want to use the £40 million to maximum effect and reduce waiting lists as much as we can. However, we should not forget that part of this problem is that there is an underlying capacity issue in certain areas. This is non-recurrent money that will improve the situation by 31 March next year. But, on 1 April, we will still have that underlying capacity problem; the money will not have addressed that. Again, going back to the pressure on the system, we will still, next April, have a shortfall in the capacity to meet the demand. This is one of the issues that we will have to look at. I particularly welcome the fact that one of the things we are doing is looking at how we get the regions leading on a piece of work around a three-to-five-year elective strategy that will get us into balance. That is particularly important.

Mrs Way: You made a very good point about mental health and learning disability. The trusts have made bids for investment in that area. We will continue to press for that to be priority funding.

Mr McCarthy: I am glad to hear that and what you said about the ability to spend that money before the end of the year. How do trusts coordinate decisions that are made on changes to service provision to ensure that decisions in one trust area do not simply displace demand to another?

Dr McBride: Elaine tells us how it will be. [Laughter.]

Mrs Way: Thank you, Michael.

Dr Stevens: It would maybe be useful to give one example, which is the work between our trust and the Western Trust at Altnagelvin and Causeway on urology. Very clearly, we have had impending difficulties in delivering the service on both sides, particularly on the Causeway side. Developing the network there and working very closely together has enhanced our ability to recruit and has also very significantly reduced waiting lists. The trusts effectively work as a network and the chief executives keep in very close contact on a day-to-day basis about what is going on. As part of our planning and in collaboration with the Health and Social Care Board, we are continuously thinking through the implications of one action against another and one counterbalance against another. Indeed, going forward, given the Minister's announcement and the demise of the board in due course, the trusts will have to work even more closely together. That requires really good needs evaluation and planning. It also requires the trusts to accept that they do not need to do everything. Talking on behalf of the Northern Trust, we certainly accept that. Can we do everything? The message to our communities is that we will do everything that we can to deliver services as close to your home as possible, then to your nearest hospital, then maybe to a regional hospital, and then even outside of Northern Ireland. We are continually talking and having that conversation about how you escalate on the grounds of complexity. It is just key to the way that we work at the moment.

Mr McCarthy: Finally, in today's announcement, there is no specific funding for Transforming Your Care, and there has been criticism that the funding has not gone to where Transforming Your Care wants us to get to.

Mrs Way: I am very enthusiastic about Transforming Your Care; I believe that it is the right policy.

Mr McCarthy: Of course, but we are behind.

Mrs Way: I do not know that we are behind. One of the things that I had brought along today and which I cannot go into but would love to, particularly with my own MLAs, is changing the respiratory care pathway that has allowed patients the enjoyment of being cared for safely at home or in their community without all of these regular admissions to an acute hospital bed. I have been monitoring those savings that are coming from drugs, oxygen and reduced admissions to hospital etc. Our estimate is that, annually, we could save £900,000 from that shift left. We have lots and lots of those projects and, as I understand it for the system, £45 million has shifted left, and £7 million of it has shifted in the western area. I want it to be more but we have to work with our colleagues, particularly in primary care, because we have to make sure that we are not shifting left at a pace where the GPs in particular feel, "Hang on a second. You are trying to dump work on us". Even this morning, we were having a TYC implementation board meeting to discuss with general practitioners and others how we effect this change. I do think that it is the right policy.

Mr McCaughey: Kieran, I think that it is also about more than Transforming Your Care. As organisations, we have been doing reform in a whole range of ways. For me, one of the critical things is how we deliver on making life better. How do we make sure that our population ages better? That goes back to my opening remarks about the growth in demand and that demand growing by 3% or 4% because of the ageing population. What can we do to do something about that? As Elaine mentioned, Transforming Your Care often talks about a shift left. That almost sends the message that it is about the location of where we treat, but how do we get upstream and prevent some people from needing treatment? How do we ensure that our older people stay well for longer? The World Health Organization's stated goal is two more years of healthy life, not just about us all living two years longer. For me, if you are talking about shifting it out of hospital into community, we also have to get further upstream, which is doing something about the underlying demand and trying to help people to age better so that we lose some of that demand.

Mr McCarthy: My final question is for you, Hugh. You mentioned the provision of a new mental health inpatient unit in Dundonald. Can you tell us when will that happen, at least, on paper?

Mr McCaughey: I cannot. It is in the capital plan at the moment but, as you know, there are significant difficulties with capital. We are working with the Department to make sure that we can secure it as quickly as possible. It is at the top of our priority list because we really do believe that there is a need to consolidate our inpatient units on one site and address some of the infrastructure problems that we have in the existing three inpatient units. We are very keen to see that happen quickly, but it has to fit into the overall capital plan.

The Chairperson (Ms Maeve McLaughlin): Five other members wish to speak, so I ask members to be succinct and to direct your question to one of the trust representatives. I am not trying to limit contributions.

Mr Easton: You will be glad to hear that I will be very quick. Hugh, you knew it was going to be you. [Laughter.]

Mr McCaughey: I anticipated that, yes.

Mr Easton: Do not worry; it is not too bad. Your savings plans mention procurement. What procurement issues have you been able to work through to make savings?

Mr McCaughey: When I was talking about procurement, I was specifically looking at some of our voluntary service contracts. We had a large volume of contracts, so we were looking at whether we could consolidate some of those and deliver them in other ways. We also looked at whether there were performance issues that needed to be addressed in the contracts. We went through a fairly detailed exercise with the voluntary and third-sector bodies to look at those contracts.

Mr Easton: OK, so you all did the same thing.

Dr McBride: I am not across all the detail, but we had a very engaged process with the community and voluntary sector. In previous years, we had not gone there because we realised how vital those sectors are, but we have been able to negotiate, with their agreement, reductions in administrative overhead costs with no diminution in the excellent care and support that they provide. We realise the role that the community and voluntary sector plays not only in service provision but in the local community economy. We have probably all taken a very similar approach in that respect.

Dr Stevens: One important point to make, Alex, is that our external auditors require us to take a more businesslike approach to our dealings with the community and voluntary sector. That does not mean cutting, but it means that they have to be able to demonstrate publicly, just as we do, that they are providing value for money in spending public funds. Part of the Northern Trust's approach to this is an ongoing process of support in that regard. It should, hopefully, deliver true savings without cutting or marginalising smaller organisations.

Mr Easton: OK, that is great. Hugh, do you know much of the £46 million that was announced today the South Eastern Trust might get?

Mr McCaughey: Not at this stage. We have submitted our priority areas and where we think we could spend. As I said earlier, it is very much about how we can step things up in-house in our waiting-list initiatives, with the limited capacity that we have, and also how we can achieve the best impact for our residents and waiting lists through the use of the independent sector. We are all keen to maximise the benefit of that.

Mr Easton: Can the trusts move quite quickly on that when that money becomes available?

Mr McCaughey: We have already submitted the details of what we believe we can deliver. We have provided details to the board and the Department.

Mrs Way: As Michael said in response to an earlier question, our trusts were in conversations this morning, as soon as the announcement was made, about how we can accelerate this and get patients moved very quickly, either, as Hugh says, through appointments in our system or in the independent sector.

Mr Easton: That is you off the hook, Hugh. My last question, which is about agency staff, is for Michael. It is such a huge cost.

Dr McBride: It is, yes.

Mr Easton: Do not get me wrong; agency staff do a really good job, but at such a huge cost to everybody's budget. My perception is that it has almost got to a stage where it is easier for somebody to go to an agency and do a job that suits their hours instead of taking a permanent job in the trust. It has almost got to the stage where agencies are the place to go and they have a monopoly on how many staff we can attract, overtime and all those sorts of things. Those costs are really driving down the system.

Dr McBride: It is a challenge that we all face. Elaine covered it in her earlier answer and Hugh referred to it. Agency costs in the Belfast Trust are significant as well, whether medical locum staffing, nursing, social work or other professionals. A third of our productivity savings target, within our overall target of £20·4 million, is to address that very issue of the expense of agency spend. I suppose that, if we compare and contrast ourselves with the rest of the UK, we do not pay the nursing agency rates that the NHS pays. Even so, it is a big cost pressure for us. I will give you an example. In Belfast, we have taken a very innovative approach to medical locum costs. We have put in place a medical group that looks at gaps in rotas and proactively engages with those we know are out there to rota those gaps in advance and not go through agencies. We have been able to bring down our costs by adopting that approach. But it is an ongoing challenge and I think that it is about a combination of making permanent posts attractive, as we have heard already, and making sure that we continually bear down on that cost. There are no easy answers to it but we are beginning to make some progress.

Mrs Way: Agency jobs are not necessarily attractive. If I were speaking to a young enthusiastic nurse, I would say, "You will not get pension, for example. You will not get the holiday entitlement. You will not get your sickness covered". It may be that when they are 23 or 24, they see the cash in hand and think, "Gosh, that is really good", but the NHS is actually a wonderful employer, even though things such as pension entitlements have changed. They have been reduced because we are all living longer. Nevertheless, our terms and conditions are very good, and I encourage any young, talented and ambitious nurse to come and work in the west. [Laughter.]

Dr McBride: Or work in the health service in Northern Ireland.

Mr Easton: There is a note of discord now. [Laughter.]

Mrs Way: Sorry.

Dr McBride: The most rewarding work in the world is to work in the health service at whatever level or capacity, whether in a management role or in front-line delivery. It is the most rewarding job in the entire world. Come and work for the health service in Northern Ireland.

Mr McCaughey: Alex, in total terms regionally, it sounds like and is a large number. However, my trust's spend on agency staff last year was, I think, £5·6 million out of a total salary bill of more than £300 million. When you add it up, it is a large sum but it is relatively small in percentage terms, although we are still trying to drive it down.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. Thanks very much to you all for coming here today and for your presentations. I will try to keep it brief. Most of my questions will be directed at Michael. I know that you have all had to face a huge challenge. It is hard to find savings with such big challenges to consider. Given that you have all come up with what you are planning to do, how does the coming winter and the challenges that it may bring factor into your thinking?

Dr McBride: Thank you for asking that question, because it is something that concentrates all our minds. All of us are fully aware of the pressures that our systems will face in relation to unscheduled care this winter. Last winter was particularly challenging in the face of an unfortunately very ineffective flu vaccine. We know the impact that had, particularly on our frail, older population, in admissions to hospital and an increase in discharge delays because of complexities.

No hospital in Northern Ireland fell over last winter. Fifteen trusts in England declared major incidents. Yes, the Belfast Trust declared a major incident the previous January. We have worked very closely as a system collectively. We have worked with the Health and Social Care Board, the Public Health Agency and the Department to put in place sustainable improvement. We in Belfast had a very critical report by the Regulation and Quality Improvement Authority. There were 59 recommendations and 12 further recommendations, but I am pleased to say that, with the move into the new emergency department, we have put in place a very robust new way of working within that emergency department. I alluded to the 30-bed clinical assessment unit, which is avoiding up to 12 admissions a day.

Last year, we had 325 people waiting for under 12 hours. I am not using 12 hours as a measure of success, because I do not want anyone waiting for over 12 hours. In the same period, August to October, this year, we had 25. We have also delivered a 10% improvement in the four-hour performance across August, September and October, and that has been sustained. We have shaved 14 minutes off each ambulance attendance time at the Royal Victoria Hospital. That 14-minute figure applies to 2,500 ambulances and 11,500 attendances a month, which means that we have freed up 580 hours of ambulance time back onto the road, where they should be, addressing 999 calls.

None of us is complacent; we in the Belfast Trust are certainly not complacent. We have a single emergency service across two sites, the Mater and the Royal, and we have put in place a strong foundation for improvement. The improvement that I have alluded to is in the face of an 8·6% increase in attendances at our two emergency department services compared with the same period last year. I think that there is cause for optimism from the new working models in Belfast. We have challenges, but if we look at September of this year, we see that, regionally, 67 people were waiting for more than 12 hours. That is the lowest number of people that we saw waiting in our emergency departments for over 12 hours since 2009, despite the highest number of attendances to our emergency departments since 2007.

This is an ongoing challenge, and it will require a different and radical model for how we provide services. I think that we are moving in the right direction in Belfast, and the other trusts are already there. There are challenges, and those are challenges that we face as a system. There will be times when one or more organisations will face pressures and difficulties, and we will work as a system, because we provide one system for Northern Ireland. We will provide support for other organisations, because they provided support for the Belfast Trust when it needed it, and our priority is providing care for the population of Northern Ireland.

Ms McCorley: What opportunities do the proposals that the Minister announced last week give to further improve things?

Dr McBride: It probably goes back to the question that Kieran posed. In his opening statement at the cancer centre, in his first week, the Minister said that his door was open and that he wanted front-line staff to be empowered in innovating and putting in place change and improvement. He reiterated that in all of his subsequent statements. I look at the changes that have been brought about in Belfast. As Paula and Elaine indicated, those have been clinically led, and I mean "clinically" in the broadest sense; all are professionals. They have been clinically led and they have been supported by skilled managers who have vital and essential skills, and they have built on the improvement capabilities within our respective organisations, which are being invested in. Hugh mentioned the work that has been going on in the South Eastern Trust. That work is going on in the other organisations. I think that we have realigned the natural order in the system so that those delivering the care in the acute facilities and the community feel empowered to say, "You know what? We have ideas about how we can do this differently." Management is fulfilling the role, which it always should be doing, in supporting and enabling that change.

Clinicians know what needs to happen, and managers know how to make it happen. When you combine that, and you have the single interest of doing what is in the best interests of the patient, I think that that is an unstoppable force. I do not underestimate or downplay the challenges that we will face this winter, but I think that we, as a system, are better aligned, are in a better place and are working more collectively. I think that there are signs of encouragement. I very much welcome the Minister's statement on the establishment of a new regional group under the leadership of Valerie Watts and Eddie Rooney to ensure that the system works as one in addressing those challenges.

Mr McCaughey: Rosaleen, you talked about this being a challenge for us, but I think that the growth in demand is actually more of a challenge for our staff. As the Minister said in his statement last week, it is a real challenge for our health and social care system. Unless we do something different and find a way to change and reform the model to make it better — I refer particularly to the element of keeping people healthier — that growth in demand will just keep going, year on year, and it will put ever more pressure on the system until it eventually collapses. You asked for reflections on what the Minister said last week. I have had a lot of reflections back from professional staff about the fact that they want public-sector leaders like us, and, I suppose, their elected representatives, to ensure that there is a change to the model so that we actually can develop a better model for the future. They have warmly welcomed a lot of what was said for that reason.

Ms McCorley: Given that it is a holistic system and that the sum of the parts makes up the health system, the Commissioner for Older People has made big criticisms of domiciliary care and said that the care home experience for older people needs to change. She made damning comments about how her report on care homes, which was extremely negative, was met by the Minister, in particular. Having a poor experience in a care home will increase the chances of an older person ending up in hospital. If domiciliary care is good, it will be beneficial to the whole system. If it is poor, again, that will increase the probability of older people ending up in the hospital system, where we do not want them to be. What are your views on that? I would be interested to hear what any of you have to say about that. Have you read the now former commissioner's comments, in particular the one that nobody should be limited to 30-minute care? There is also the idea is that older people should be listened to on design and delivery. I am interested to hear what you think about that.

Dr Stevens: I will make a couple of comments on that, Rosaleen. First, I do not think that any of us argue with the detail that came from the commissioner. All of us are trying very hard to respond to the demands of our growing elderly population. On the demographic detail, in the Northern Trust area, for example, we will see a 20% increase in the number of people over 75 in the next five years. In the last three months, we have seen a 17% increase in the number of over-75s coming to our emergency departments. We had not anticipated that, so we are very clear that this is a priority. I think that all the trusts recognise that it is an absolute priority.

I will pick up on the nursing home issue first. We have very good private-sector or independent-sector nursing homes in Northern Ireland. Like us, they are challenged at present because of the relative shortage of qualified staff. One of the challenges at the moment is that the trust could recruit every available nurse in Northern Ireland, including every one in the independent sector, and, if we did, it would further destabilise them. So, all of us are working on supporting our nursing homes, even those in the independent sector. For example, we have an in-reach service whereby we skill up staff in nursing homes. We give them additional support to help them to keep the elderly in their nursing home even when they become sick and to help them to have conversations with families about what happens when the very elderly get ill. It is not always in their best interest to go back into hospital, but we do not always have those conversations with elderly people or their families about what their wishes are.

We just assume that, when they get ill, they will want to come back into hospital for more antibiotics and more treatment, but that is not always the case. A lot of work is going in to supporting them on some of those soft issues.

We are also working with a lot of the elderly who may be at the end of their life, as well as with Macmillan. All of us are benefiting from some really good collaborative work with Macmillan to look at people who are in the final stage of their life being cared for at home. So, there is a lot of focus on that.

Again, every trust is in a slightly different position, but for us in the Northern Trust, about half our domiciliary care provision is still provided by the trust and not by the independent sector. As I said in my opening piece, we are seeking to increase the number of staff that we employ, because we can reduce our overtime. It is becoming apparent to us, particularly in the very rural areas, that we can provide it more reliably. Our biggest problem is rurality. Daithí will know that, in the glens area, at least one of our independent sector providers struggles to provide care for the most complex cases. What we are doing is looking at increasing our in-house provision, which would mean better jobs in a way because we have national terms and conditions: the Agenda for Change terms, conditions and pensionable service. So, a lot of the things that the Information Commission — sorry, that is an interesting faux pas — Commissioner for Older People was concerned about was the independent sector's terms and conditions compared with in-house use, but we need a balance, because the independent sector can provide a really valuable additional resource and can usually produce it at a lower cost.

Again, one of the things that we have to do, as with the nursing homes, is support them. All of us are working with the independent sector at the moment to try to support them in their business model and to create the market that we need. But the bottom line, I suppose, that is coming is that the independent sector will have to charge more to compete with Lidl, Tesco or whoever for those people. That is going to create a very real increased cost for the same amount of service. That is coming for us. That is the challenge that not only the trust but the Executive will face in working that through. It has to happen, but, in the meantime, there is a lot that we can do.

The other thing is that we can work with the community and voluntary sector. So, for example, in Coleraine, we have the dementia-friendly service. We have the pathfinder service directing people, and we have the Agewell groups, which are providing a whole range of services on the north coast through, for example, COAST. We all have Agewell groups doing a whole range of things. So, pulling all those things together can help to support this.

We are also supporting families, and Michael referred to reablement. One of the ways of managing the capacity is to reduce the number of people who need the service by good reablement, so we will have more to go round. We all agree that the service and individual needs need to be designed for that individual. For some people, 15 minutes is all they need. Some people need only a telephone call or a good morning call. Other people need much more complex packages. So, the question has to be this: are they getting the vital package —

Ms McCorley: Can I just butt in there, Tony? Excuse me for cutting in, but that is the point. I think most domiciliary care workers feel that they are expected to do far too many short calls. It is acknowledged that people need someone to talk to. You cannot just rush in and start pushing a meal down someone's throat. That sounds a bit crude, but you know what I mean. There is a social aspect to it, and the majority of them do not believe that they have enough time to do what is required to leave that person and to be comfortable that they are feeling OK. There is this tension now between the level of care that is required and the burden that is placed on the care workers, where they are nearly doing work that they are not getting paid for.

Dr Stevens: I think we genuinely accept that. We are all working with our care providers to resolve that, but it is about providing a package. So, can you do something with Agewell or the community and voluntary sector? Can we come up with a mixed model with district nurses and care workers? You are absolutely right: it is about the complete package for the individual that meets all their needs. It is not just about looking at what one care worker does. I think we all agree with you that 15 minutes is a limited time to travel and that another 15 minutes is really demanding on them. We are now looking to design the packages around people.

Ms McCorley: Are you all committed to that mixed package? That is probably a good idea, but it is about the person who requires the care getting the care and the human contact that they need in whatever way that is.

Mrs Way: I was going to come in with a wee bit of a qualification on this. If we look at the Western Trust area, we see that, at the moment, we are providing domiciliary care to over 5,000 people. We spend £600,000 a week providing domiciliary care, but even with that level of spend — that is £32 million in a year — we are able to meet only critical and substantial needs. That is the reality. People now have very complex needs. We have people who have care packages that involve two carers coming four times a day and so on. Because there is such demand and such pressure — I want to be absolutely straight with you about this — I do not think that the notion of everybody having half an hour could be delivered in the Western Trust area. For example, as Tony said, and I agree with him, out of all the hours that we provide every week, a very small number of people get 15 minutes, and that is largely about making sure that somebody has taken their medication. I do not think that I could say to you today that I could guarantee that we could build in socialisation, because the demands on my budget are absolutely huge and I am providing responses only to critical and substantial needs at the moment.

Ms P Clarke: Rosaleen, to add briefly to this, I will give you one example of how we are addressing the issue. I know that others are looking at similar models. In one small area, we have been piloting with the families, the individuals and the domiciliary providers the idea that, rather than using what we call the time for task model, which results in a person getting x minutes for this and y minutes for that, we will move towards a caseload model, which is kind of similar to how our other professional teams work. That allows a bit more responsiveness, in that a person might say, "I might not be that great today, so I might need a little bit more input, but, generally, I am OK and a lesser time is sufficient". That allows targeting towards more intensive input at the earlier stages of an illness after the person has come out from hospital, for example, and it reads back into the reablement. Rather than having a reablement service, a domiciliary care service and different types of service, we are trying to bring together some of our teams into just a service that is available for an older person and their family, and we are trying to build up that caseload model. It is too early to say whether that will work at scale in every single approach, but it has certainly been welcomed by families and carers.

Dr McBride: Rosaleen, you touched on a hugely important issue. There is the whole issue of socialisation. Loneliness is often one of the greatest challenges that people face, whether they live in an isolated community or alone. If you look at sickness, admission to hospital and illness, you will see the direct correlation with loneliness. There are some excellent initiatives under way. I think of the Creative Local Action, Responses and Engagement (CLARE) project in Mount Vernon, which is a community-based programme that is about empowering the local community. It is so important to knock on the door to visit an older person.

There is huge potential there, and we have had ongoing discussions in the Belfast strategic partnership with Belfast City Council and, indeed, all the community organisations about how we identify innovative approaches to ensure that we use our collective resources to ensure that that social interaction happens with a knock on the door. It does not matter whether it is the postman delivering a letter and taking a few minutes longer to have a conversation, someone delivering something else or an approach through community policing — whatever it might be. There are a range of public services that interact with communities, and we need to maximise the potential to make every one of those contacts count in that way.

I agree with Hugh on this. As we increasingly look at how we implement Making Life Better — I agree, because that is something that I am fundamentally passionate about — it is about how we make those connections between a range of public-sector areas and how we use local government reform and community planning to really deliver that on the ground. We in the health sector will do our bit, but it is also about working with other public-sector providers to ensure that we collectively deliver for the population.

Mr McKay: How will the so-called living wage affect your budget for next year? Do we have any calculations yet?

Mrs Way: We are beginning to do that work. In fact, in my organisation, we are engaged in a process of looking at 2016-17 financial planning. However, we are at the stage where we do not yet have any indication from DFP, for example, of what the overall resource will be. Within our planning, we have a line that says, "Impact of the living wage". I cannot remember what the figure is, but it is certainly millions of pounds.

Mr McKay: What range of millions are you talking about, out of interest? Is it £1 million to £3 million?

Mrs Way: It is certainly under £10 million. I would prefer to —

Mr McKay: Is that just for your trust?

Mrs Way: Yes. I do not want to say a figure; I would rather drop you a line and give you the figure. If I give you a figure now, it would be wrong. We were looking at a whole lot of pressures yesterday, including the impact of National Insurance contribution changes and pension changes etc, so I am a bit confused about which figure relates to the living wage. Can I send that to you?

Mr McKay: Yes. Will the cost be around the same range for each trust?

Mrs Way: It will be millions.

Dr Stevens: In theory, it will, if affordable, have a very positive impact, because recruitment is the key issue. Effectively, it brings the independent sector much closer to the Agenda for Change terms. So, you would reduce the tendency for us to poach people from the independent sector. Having said that, the cost has to be considered. Elaine gave you the figure for the number of hours we are providing, so you can scale it up.

Mr McKay: What percentage of your workforce would that affect? The other point is this: would that not be a positive thing where better productivity is concerned, because they are getting a better wage at the end of the day?

Dr Stevens: All the trusts are different, but roughly half the domiciliary care provided in the Northern Trust is provided by the independent sector, so it will affect half the workforce. Off the top of my head, I cannot recall exactly how many hours that is, but it is huge and runs into hundreds of thousands.

Dr McBride: In the Belfast Trust, 29,000 hours are provided by the independent sector by up to 3,100 individuals. I think that there are 10,000 hours in addition to that provided through our own services. Again, the mix will vary from trust to trust, but you can do the sums; it is not an insignificant sum of money.

Mr McKay: We will shortly be in December, and budgets obviously begin at the start of April. What is the delay from DFP? Surely you should have had enough time to work out the figures. When will you be in a position to know what your budgets are for next year?

Mrs Way: I do not know the answer to that. I have a letter that requires me to do a draft financial plan and to submit it by the end of next week as an opening conversation. As part of that, we will detail all the things that we describe as inescapable pressures. We will then have a conversation with commissioners and the Department, who will say, "You can take that inescapable pressure off your list, because it will be funded centrally". That is what happens every year.

Mr McKay: I was speaking to a nurse who cited an example of a day when she started work at around 7.15 am. It took her half an hour to get from home to the hospital where she worked, and she worked until 8.30 pm without a tea break. That goes back to the point about valuing staff. I understand the budgetary pressures that the trusts and hospitals are under, but, if staff are overworked, they are more likely to be sick, to be less productive and, most crucially, to make mistakes. To protect staff and ensure that they get adequate breaks and that their health and well-being is looked after, how do you prevent those situations from reoccurring year after year?

Dr Stevens: Daithí, I do not know whether that was a Northern Trust individual, but, given where you are from, I suppose it is likely to have been.

We are working very hard. By and large, our nurses have protected breaks, but there are times when they do not. You describe somebody who sounds as though they were doing a 12-hour shift. We have had an ongoing programme to consolidate rotas and to take out 12-hour shifts. We had to slow that programme down, because a significant number of our staff were so wedded to 12-hour shifts that they did not actually want us to withdraw them, but we, as an organisation, would prefer not to run 12-hour shifts. We believe that we could take them out, but women in particular, who make up the majority of our nursing workforce, quite like working a two 12-hour shift week. The challenge then, of course, is to make sure that they get their breaks.

In a way, you raised two issues. First, should people be working 12-hour shifts? Secondly, if they do, do they get their breaks? Yes, they should get their breaks. If there are circumstances where that does not happen, they have to be exceptional circumstances. But there is a separate argument to be had about whether we should persist with 12-hour shifts and the value of that.

Mr McKay: Tony, now that you raised the issue of nurses in the Northern Trust, could you give us an update on the Antrim Area Hospital situation? I know that talks are ongoing there. Are we any closer to a resolution?

Dr Stevens: In paediatric nursing?

Mr McKay: Yes.

Dr Stevens: That is an interesting question. I met Unison for a lengthy discussion on Monday evening, and we agreed that, during the period of ongoing consultation, we would keep our traps shut, although that may be an inelegant way for Hansard to report it. We suggested that we would not openly discuss that, obviously, in this environment, it is reasonable to say that I think we made real progress. I think that we can and will resolve the issues.

Mr McKay: Good.

The Health Minister has introduced his plans for restructuring, and he intends to work more closely with the Public Health Agency. I am very much on the same sheet as the Minister when it comes to innovation, investing to save and prevention. Are the trusts going to change the way they approach public health if it is going to be more of a priority for the Minister, certainly in the next few months?

Dr McBride: You are preaching to the converted here, and I think I share that view with all our colleagues. You heard Hugh's comment specifically on this, and Paula mentioned the importance of Making Life Better. The health service is key, and one of the key tenets in Making Life Better at a policy level is the realignment of health and social care. It is as much about keeping people well, preventing ill health and doing more upstream to prevent our having to manage the downstream consequences. We can talk about all the different models and the shift left, but as Hugh said, if we genuinely, as a system, really want to bring about improvements in the health of the population, it is about getting in much earlier.

We have a role in that, and I think that is why local government reform is a very exciting opportunity for getting round the table with all the other sectors to consider how we can empower local communities and keep them well. Making Life Better is not just about improving health and well-being; it is about allowing communities, through community engagement and empowerment, to take an asset-based approach to ensuring that they realise their full potential.

We in the health sector have a huge opportunity here. That we can do more work in the area is a win-win situation for us. Exciting work is already under way. I think that there is a great opportunity. Coming back to the earlier point I made, I have 22,000 employees in the Belfast Trust and I want every single one of them to be a champion for health and well-being in their local community. When we follow the good example of the Western Trust and go smoke-free, as the Minister indicated we would be by 9 March, I want to fulfil our responsibilities, with the assistance of the trust, to keep and improve the health of our staff. I want each and every one of those individuals to be champions in their community. I want every one of those individuals in the Belfast Trust to engage on our weight-reduction and healthy exercise schemes. I want them all to be champions in their community.

We have huge reach in health and social care. We have amongst us 60,000 to 70,000 people. That is a huge opportunity for us to really make an impact and to equip everyone in our workforce with the skills to keep themselves well, improve their individual productivity and the value added that they feel from work, as well as to gain upstream in their communities. That is where we want to go.

As I said, this is a population health-based approach. We are getting much, much better at managing long-term conditions with chronic disease management models. As I have said before and in other capacities, public health is too important to be left to public health doctors. It is that end-to-end piece. We cannot see delivery of health and social care as something that we do over here and the public health bit, with keeping people well, as something that is done over there by someone else. It is that end-to-end continuum and taking a whole-population approach. That is the opportunity that we have in Northern Ireland. We are small enough and connected enough, and I think we have put in place the right level of changes with the Public Health Agency, bringing a renewed focus with a new public health framework that has been agreed by the Executive and with impressive and, I think, really empowering local government reform. We could be an exemplar of health and social care systems around the world, not just in the United Kingdom.

Mr McCaughey: Just building on that, because I agree very strongly with what Michael just said, there is a real opportunity for the new councils in their community planning role to play a central part in this. The challenge is very much on how we create a healthier population and how we help our older people to age better. That goes back to the Commissioner for Older People. We would actually be better getting upstream and keeping them well, preventing isolation and keeping them fit and healthy, as opposed to then trying to treat more and more people.

The community planning opportunity, which councils will play a central role in, is absolutely vital. I think that is one that we must harness. There is a challenge in that, because traditionally an awful lot of the discussion has been about protecting the existing model and an awful lot of that has focused on hospitals. How do we actually change the focus to say, "Let us get this right, keep our population healthy and keep them well" and really get upstream to early intervention and prevention?

Mr McKay: Obviously, each of you is a champion of public health in your own leadership roles. How have you been working and who will you be working with? Taking Belfast as an example; you are responsible for Belfast, Michael. How do you work with the council and tell DRD, for example, or the local council, "Look at the figures for obesity in Belfast", and say that, "The way we need to deal with this is through transport. We need different transport and to change people's habits in walking, cycling and all those things"? How do you do that in your leadership role?

Dr McBride: I do not think that you have long enough to hear how excited I am about that. The chief executive of Belfast City Council, Suzanne Wylie, the chief executive of the Public Health Agency, Eddie Rooney, and myself, in my capacity as chief executive of the Belfast Trust, meet regularly. We are developing a plan for Belfast that will address all those issues. We had a meeting just two weeks ago with all the community groups that are involved in this to start to flesh out and develop that. We are working as one because — you are absolutely correct — it is only when we do two things, one of which is to engage.

We are beginning from a fantastic starting point, because we had Investing for Health. We were doing all this when no one else was. We were taking a social-determinants approach to improving the health and well-being of the population back in 2002 when we launched Investing for Health. We have learnt from that. We have Investing for Health partnerships in place. We have all the community engagement. We did community engagement before anybody else was doing it. Two weeks ago, I was asked to speak at an international conference about what Northern Ireland is doing and the impressive work that we have done on community engagement. Part of that grew out of the conflict that we had here. A rich legacy of community engagement has developed from that, and that is something that was channelled into improving community health and well-being. Others are not in that same place. There is a common language that people understand in those community groups.

Now the role for us is to put in place an overarching structure. Eddie Rooney will chair the implementation group and will work with the chief executives of all the councils on implementing Making Life Better. In my role in the Department, I will chair the overarching group that will report through to the Executive and Ministers about how we implement that.

I have no doubt that the detail of what we are doing in Belfast will be replicated in all other council areas. One example in Belfast of our improving health and well-being is the B Well strategy for staff. Over the last six months, we have had detailed discussions about introducing the Belfast Bikes scheme to our sites at the Mater, the Belfast City Hospital and the Royal. We will tear down the smoking shelters as we go smoke-free and replace them with opportunities for the community, those using our services and staff travelling between sites to use the Belfast Bikes scheme. That will be one of our key priorities in increasing exercise and improving fitness among not only staff but people who use our services. That is just one example. In many respects, I use it because it is a very topical example of the huge success of the Belfast Bikes scheme. That is how we are using our combined resources to make a meaningful difference to the population and shift the focus to not only keeping our workforce well and using them as champions but investing in a different way of working with the community and local government.

Mrs Way: May I put on the record, because of the locality of the chairman and Gary, that we have had a One Plan in Derry for some years now? That is very much about our all being signed up to priorities such as early intervention, prevention etc. That needs to shift because we now have the new Derry City and Strabane District Council. Also, councils now have a different responsibility for community planning, so the chief executive of the new council, John Kelpie, is leading work on a strategy board. That involves our local politicians, statutory sector providers, community groups etc. Like Michael, I think that it is very exciting and the only way that we can deliver.

Mrs Cameron: Thank you all for your time today. I know that it has been a long session. The good news is that most of the questions have been asked and answered. It has been a very positive session, given the subject matter, and I take great heart from that.

I have always been one to praise our health service. I think that it is fantastic. Many cases come through our constituency door, and we all have relatives who access the health service — or try to access it — daily. Yes, we have a few complaints, and you always hear about those, but you probably do not hear the majority of the praise. The biggest complaint is about people waiting to be seen. They do not complain about the treatment. There is nothing but praise for how they are treated once they get there. It is very positive and it is good news.

I want to ask Tony a question. You will be surprised to hear from me. Your briefing refers to how you have prioritised initiatives to reduce the pressure on acute hospital beds, and you gave as an example of direct access for GPs to assessment and diagnostics. I presume that you are talking about the acute assessment unit at Antrim Area Hospital. I know from experience that it is a fantastic unit. Has anything more happened with that since we last met or is it continuing at the same pace?

Dr Stevens: It is currently as you saw it. You met the two specialty doctors working there, Kyle and Ryan. We have now expanded to a third doctor and will go to a fourth, and we are extending the hours. Currently, the unit stops taking people at 5.00 pm, but it will take people until 8.00 pm, which will allow us to deal with most of the GP surge in afternoon clinics. We are also moving surgical assessment and elderly assessment into there. A significant proportion of the moneys released to us as part of the Chief Medical Officer's initiative enabled that clear expansion. Other winter planning initiatives are going into that, and we believe that it will definitely have an impact.

We currently see about 15 patients a day, which does not sound like very many when about 200-plus patients attend the emergency department, but they all tend to be elderly and frail. We currently discharge or do not admit 60% of them. We plan to increase that to about 30 patients a day. If we are able to continue with a discharge/non-admission rate of 60%, that will have a significant impact on our admissions. The short answer to your question is that there is very definite continuing investment.

Mrs Cameron: That is fantastic. I did not realise that there was such a big change coming. It is very welcome. You mentioned 15 patients a day. From my experience of going with someone else, I know that is not like an ED. The unit is completely different and people are seen straightaway. If anyone is waiting, it is for diagnostics or whatever. It is a fabulous service — really brilliant. Do any other trusts have this model of care?

Ms P Clarke: Yes.

Mrs Cameron: Do you all have it?

Ms P Clarke: Do you mean a direct GP admission unit or acute assessment? We all have acute admissions, in some form. We call them different things. The acute assessment or direct GP admission is accessed in different ways. We have a direct hotline, for example, for specialist advice, and we can fast-track people. Each trust has a variation.

Mrs Cameron: It must be a great comfort, too, for GPs, who deal with so many people within narrow windows of time. It is vital for them to have that backup.

Ms P Clarke: That matches with Acute Care at Home, which is designed to avoid people having to come to the hospital at all. Our Acute Care at Home scheme still provides access to rapid diagnostics and provision of pharmaceuticals, if you need an intervention or an IV at home.

Dr McBride: We all have that. The South Eastern, Southern, Western and Northern Trusts have variations of it. We have a very similar Acute Hospital at Home model to the Southern Trust. There is a slightly nuanced version in the South Eastern Trust. Belfast has BCH Direct for frail older people, which was one of the recommendations in the Regulation and Quality Improvement Authority (RQIA) report. We also have a clinical assessment unit for those other than the frail elderly. We join all that up to prevent those admissions. We also have a new ambulatory service, through which individuals who do not require admission may come up for two to three days for follow-up treatment or investigation. That is what I am saying about a radically different model. We steal each other's ideas shamelessly.

Ms P Clarke: We share.

Dr McBride: If there is a model that is working, we go along and say: "That is a really good idea; we will steal it." There are really good examples of that. We have learned from a lot of the work in the Southern Trust. The model for four-hour performance in the South Eastern Trust is excellent, and we can certainly learn a lot from that. We share, and the clinical teams keep in close contact. The work that was previously coordinated and led from the Department, now to be led by Valerie Watts and Eddie Rooney, will further enhance such sharing. A system should be designed once and then implemented at scale across the service.

Mrs Cameron: I am very glad to hear that you steal best practice. I would be horrified if you did not. Tony, the next line in your briefing paper is about improvements in seven-day working. What has changed?

Dr Stevens: We already had a fair amount of seven-day working, particularly in delivering imaging. We are investing, subject to being able to recruit the right people, in more radiographers to work at weekends and in enhanced laboratory capability. Allied health professionals (AHPs) are working in our emergency department seven days a week, which is a great way of turning patients around. We also have improved minor injuries streams. We are doing a variety of things.

Everybody will have variations on this, but, on the Antrim site — it is a bit more of a challenge for us on the Causeway site — four physicians from the main specialties are in on Saturdays and Sundays, doing the pick-up rounds. It is an improved way of making sure that the expertise needed at weekends is there. Also, it creates the capacity that allows not just patients admitted at the weekend but people already in hospital, particularly those with the potential to be discharged, to be seen by a relevant specialist.

That pretty well sums up most of what we are doing. What is really important is that seven-day working in the hospital is of no use without seven-day working in the community. We always struggle a little to make sure that access to domiciliary care, nursing home placements and so on is available seven days a week.

Given some of the challenges that we have in domiciliary care, that is a bit of a problem. We are looking at innovative solutions, possibly through using district nurses and multidisciplinary teams.

Mrs Cameron: Good. I know that there are legal issues in pharmacy, but, not that long ago, we had the Ask Your Pharmacist week. I go every year to see different pharmacists and the fabulous work that they do. One of their biggest challenges is making up blister packs of medications. Elaine touched on carers and domiciliary care, which I know is a huge issue when it comes to keeping people, especially the elderly, out of hospital. That is much easier if they are getting their proper medication. People have confidence in a care worker or family member administering medication that has been organised into a blister pack. However, that is a big pressure on pharmacists because it takes them an awfully long time. They have to be very careful when making up those packs, but I know that they are keen to do it.

Mrs Way: I am looking to Michael because that is an issue for community pharmacies rather than hospital pharmacies

Dr McBride: I am certainly happy to pick up on that. Not a single worker in healthcare is other than invaluable, whether they keep the lights on, the wheels turning, provide meals or perform high-end surgery, but pharmacists have a vital role. As Tony mentioned, in addition to the physicians, the whole team that make the system work are crucial in facilitating the discharge of patients — occupational therapy (OT), physiotherapy, pharmacy and so on. Pharmacists check the prescriptions and make sure that the drugs are appropriately arranged to facilitate a patient's discharge. These are challenges. It may seem almost bizarre that after the decision to discharge is made, a patient can wait for many hours to get their drugs.

The point that you made was about why do we not work very differently to make sure that drugs are made available, and, therefore, patients discharged in a more timely manner, and maybe we should have an arrangement with community pharmacies. Work is going on that area, as you said. The wider picture for us is that we can demonstrate, particularly in Belfast, the significant savings that we can make by having ward-based pharmacies. We can also bring about significant improvements in patient safety through the medicines reconciliation work that was launched by the Minister a number of months back. Excellent work is going on there, and I think that the Northern Trust is taking a significant lead role in some aspects of it.

There is significant gain to be made in pharmacy, down to the very practical issues of who checks and packages the pills. There is then a responsibility on the Department, as you say, to deal with the legal aspects of the liability of pharmacists, should there be a genuine error in the preparation of medications for discharge. As you know, the Department is looking at that and is, with other Administrations, very keen to address it.

Mrs Cameron: Thank you.

Dr Stevens: Pam, sorry, I was going to cut across. Mike Scott of the Northern Trust is leading on the medicines optimisation project, and —

Dr McBride: Optimisation, sorry; I beg your pardon. Thank you for correcting that.

Dr Stevens: — there is the regional centre there. A couple of things that we are doing involve working with community pharmacists. Medicine optimisation is about making sure that people are not only on the right drug but taking the right dose at the right time. There are many ways of linking into domiciliary care and multidisciplinary teams. Importantly, pharmacists are taking an increasing role in hospitals and the community. The links between GPs and their local pharmacist, in particular, are becoming increasingly important, and the integrated care partnerships are creating an environment in which that can happen.

One example of that is a project that developed from a recent research project led by Mike Scott, and we are using some of the money available to us this winter to roll it out. It follows up patients discharged from hospital with a weekly call from a pharmacist to make sure that they are taking their medicines correctly. We have demonstrated a 20% to 30% reduction in readmission through that pharmacy-led project. I think that one of the values of pharmacy at the moment is that it is one of the few clinical specialities in which we are not short of staff. There are enough pharmacists around, so we are all looking at ways to use our pharmacy colleagues more effectively at a time when we are short of doctors.

Mrs Cameron: I know that they would welcome that, too. All the pharmacists whom I have spoken to are incredibly passionate about looking after people, and they know their customers.

Dr McBride: I go back to Jo-Anne's point, and Daithí also made a point about technology. There has been some really exciting work on smart devices that will advise patients when they have not taken their medication, whether it is an inhaler or whatever. That is why, increasingly, we need to invest not only in using the excellent skills of the pharmacy teams in the respective organisations and in the community but in innovation and technology. I know that pharmacists across all the trusts are taking a lead on research into some of those smart devices.

Mrs Cameron: I do not agree with the member at all about those devices; I welcome the use of technology. After all, it is 2015, and we are probably behind and need to catch up. Will electronic care records be made available in time through smart devices?

Ms P Clarke: Directly to the patient?

Mrs Cameron: Maybe not to the patient — I do not know what good that would be to the likes of me — but to district nurses and so on.

Ms P Clarke: They are made available currently through the Northern Ireland electronic care record (NIECR). The record of what happens in a hospital is available. The record of what happens in a GP practice is more limited: it is more about medication and allergies etc. Does your question go back to the tablet issue?

Mrs Cameron: Yes.

Ms P Clarke: We all aim to provide them to our community teams, who need to be able to access that information. We have used the community information system (PARIS) along with the electronic care record for our respiratory team in the hospital to link directly with our community respiratory team. That has shown great dividends in improved patient care.

Dr McBride: We are very good at hiding our light under a bushel in Northern Ireland, but the Northern Ireland electronic care record achieved a national award and national recognition. We all have conversations with those who work in healthcare, and you can ask any one of them about the difference that the electronic care record has made. However, I made the point that, if we look at what healthcare systems around the world have done with their electronic care records, we see that we can go much further. There are some completely integrated systems.

The important thing is not to see it just as technology. The technology will enable a transformation in how we provide care. It is not about a high-tech ICT programme; it is a transformational model for how care is provided and how individual patients who use services can access information. There will be no more phoning a GP for your blood results; you will access your results online. There will always be individual patients who need to be part of long-term condition support groups and require specialist nurses to advise and support them, but that will be supplemented by patients accessing that advice and support online. There is a huge potential gain for the health system. Sir Liam pointed that out in his report when he talked about the Centre for Innovation and how we utilise that and make sure that we invest in it for the medium to longer term. The tendency is always to focus on what we do not have and what we cannot do. You have heard from us all today that we are confident about what we can do and what we will do and that we need to begin to deliver on the Minister's vision for innovation and improvement.

I hugely support the Minister's outline of the concept and model of a change fund — a transformation fund for HSC — because we need to do some double running. A good example, which Paula mentioned earlier, was about building up alternative models and then switching. You need to build public and patient confidence in those alternatives. There are some double running costs associated with that, and that is why we need that transformation fund.

Mrs Cameron: I could not agree with you more. It is absolutely needed. With our ageing population, the greater demands and the new medications available, we are all living longer and more complicated lives, so we definitely need to find a different way of working to keep up with the demands. Thank you very much. You have earned every penny of what you earn.

Mrs Way: Thank you.

Mr Middleton: I deliberately left myself to the end to give Elaine the last word. [Laughter.]

Dr McBride: She would take it anyway.

Mr Middleton: As they say, if you snooze, you lose, and I was left to last.

I will not go through everything that others have said. It has been a very good discussion. You deserve a lot of credit for what you do. People talk about low morale among staff. We can attribute a lot of that to the fact that, sometimes, the health service does not praise itself enough. We do not hear enough of the positive stories.

Thank you, Elaine, for the regular briefings that you give us, as MLAs. They are particularly useful in giving us more information on what we are talking about. All trusts face workforce pressures, but we always hear about the unique circumstances faced in Foyle and in our city. How much of the £3·8 million deficit do you attribute to the unique circumstances faced in the Western Trust?

Mrs Way: All of it and more. Last year, we spent £10·6 million on medical locums. This year, I think that I will spend about £12 million on locums. My colleagues spend — forgetting Belfast; I never compare myself with Belfast, Michael — about £6 million or £7 million on locums. I know that because I watch the figures and responses to questions in the Assembly and so on. You can see that that is a particular issue.

The other issue on which we are working with the Department and the Health and Social Care Board is the Northern Ireland Medical and Dental Training Agency's allocation of junior doctors. We get fewer junior doctors than we expect given the busyness of our hospitals. To keep our rotas safe, we recruit and pay for locums. We have been well supported by our colleagues in the Department and the board in relation to this issue. I can say with absolute certainty that £3·8 million is certainly part of our workforce additional costs. Looking at my colleagues elsewhere, all of it is down to that issue rather than other service pressures.

Mr Middleton: Is there anything else that can be done — obviously, we would love to see the likes of the A6 road upgrade — to help to make it more attractive for people living elsewhere to come to the north-west? You mentioned an international recruitment drive, which has to be welcomed. Hopefully, we will see more people opting for that. Is there anything else that the Department could do to try to make a fairer playing field?

Mrs Way: Michael spoke very well today about the current level of collaboration and the sharing of learning between trusts. That is our new reality. It is very important. However, when you get into difficult places, particularly with staff and wanting to recruit, everybody, including me, looks after their own patch first. It goes back to the Sir Liam Donaldson work as well: what will be the shape of our hospital services into the future? I know with absolute certainty that Altnagelvin is a very significant hospital outside the Belfast hospitals. The Government have decided that Altnagelvin will have radiotherapy. The HSE and the Saolta University Health Care Group in the Republic have decided that they will partner, particularly around Letterkenny, on a range of services. The only two primary percutaneous coronary intervention (PCI) sites in Northern Ireland are in Belfast and Altnagelvin. We should all, as system leaders, say that we need to do all that we can to make sure that they can recruit and retain high-quality medical staff and other clinicians in the north-west. As I have often said, if only we could move Altnagelvin closer to Belfast, we would be OK. In reality, however, as my colleague chief executives and I know, anybody can live in Belfast and travel to Craigavon, Antrim or the Ulster Hospital. We have a particular challenge that people have to live and move and have their being. Speaking as somebody who came from the east and went west, I encourage people to do that because the quality of life is superb. I think, Michael, that the regional overview of the shape of our hospitals is desperately important.

Dr McBride: It is, and the Minister made that point when talking about the next steps, as he sees them, of a panel with local and international input, and a discussion. It is about having appropriate engagement with local elected representatives and their electorate on what that model might look like. More unites than separates us on this. As you say, it is too important.

I am regularly invited to Altnagelvin, where Elaine is responsible for the services. Every time I go, I am hugely impressed, and I always come back over the Glenshane Pass having stolen ideas. The last time I was down, I was chatting to a number of medical and nursing staff and asked them, "Why here?" There is no doubt about the quality of life that they feel that they get in the west of the Province, and one doctor said, "Because I like surfing."

There is an excellent quality of life in the north-west. We have done a huge amount of work. The City of Culture and so on did a lot to promote the area, as did the One Plan that Elaine mentioned. There is a real can-do, will-do attitude there. I must say that I always come back feeling better for having been there, but I think that we do need to work —

Mrs Way: However, Chair, I did say that I could have the last word. [Laughter.]

I just wanted to say that I am from the Western Trust, as you know, not just Altnagelvin, and there are unique challenges in recruiting staff for the South West Acute Hospital. I have exceptional pressures, but I am relentlessly positive and have a can-do attitude. I am sure that we will get there, and we are getting increasing support for and understanding of our circumstances.

The Chairperson (Ms Maeve McLaughlin): I am pleased to give the last word to the west, of course. [Laughter.]

Michael, you are welcome any time.

Today has been very informative, and there is a lot of food for thought. There are a few actions that we will want to pursue. Thank you for being so generous with your time, folks, and safe home to the west, Elaine.