Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): We welcome Julie Thompson, deputy secretary, resources and performance management; and Deborah McNeilly, deputy secretary, healthcare policy. Thank you for attending. I hand over to you, Julie, to make the opening remarks.

Ms Julie Thompson (Department of Health, Social Services and Public Safety): Thank you for the opportunity to update the Committee today on the latest financial position facing the Department in 2015-16, which includes the outcome of the November monitoring round and our position on the findings of the Committee's 2014 budget report.

On current expenditure, our latest assessment is that the Department will live within its budget allocation for 2015-16. That position assumes that savings opportunities and cost reductions of some £160 million will be delivered across the trusts, prescribing, the Department and its arm's-length bodies. However, in the context of the challenging financial position, the Department welcomes the current expenditure allocation of an additional £47·6 million received through the November monitoring round, which was announced last Wednesday. The majority of that allocation — £40 million — will be directed at elective care and diagnostics across specialties such as orthopaedics, gastroenterology, neurology and ear, nose and throat (ENT). It is estimated that that funding will allow up to 40,000 additional assessments and between 10,000 and 15,000 additional treatments to be progressed by the end of March 2016. A further £7·6 million will be invested to meet priority pressures across essential front-line services, including unscheduled care, patient flow, Transforming Your Care (TYC), the family fund, insulin pumps, psychological therapies and children's services.

On capital expenditure, we are on target to fully spend our capital budget in 2015-16. Unfortunately, no additional capital resources were allocated to the Department through November monitoring.

Finally, the Committee's 2014 budget report identified a list of findings about the Department's approach to the 2015-16 budget process. Those included findings on the relationship between strategic priorities and spending decisions, including TYC, the approach to efficiency savings and income generation, the total funding envelope for the Department and the quality of the information and timetable for the Committee input to the consultation.

The briefing paper provided to members for today's session outlines how the Department has responded to the Committee's findings and the steps that we are taking in relation to each of those factors in the 2015-16 departmental financial planning processes. We have engaged with the Committee on financial issues at regular intervals and have been able to update you on our budget position as we have moved through the year. We are, of course, happy to continue doing that at key stages in the budget process as we move forward. I trust that that has been helpful. We are happy to take questions.

The Chairperson (Ms Maeve McLaughlin): Thank you, Julie. I suppose the initial commentary is that the Department will live within its available budget, but your briefing paper refers to how that is possible only because a range of planned investments and service developments have had to be put on hold in 2015-16. Will you give us an indication of what those are?

Ms Thompson: The main development that was put on hold was in the space of elective care. That is the position that I referred to when we were at the Committee in October. We also made bids in June monitoring, as you will recall, for a range of services to look at service developments, whether with children, mental health or learning disability. We have had to look at all of that and establish what we could and could not afford. Obviously, the additional money in November monitoring has now allowed us to move forward, particularly in the space of elective care, and put the £40 million into that. Some of the investments that were on hold prior to November monitoring will now be able to go ahead. That is the investment of the £47·6 million coming through as we look to the November monitoring outcome.

The Chairperson (Ms Maeve McLaughlin): What was the total cost of the services that were put on hold?

Ms Thompson: In June monitoring, we bid for £89 million, and we did not receive any of that. We then looked to see what was spendable between now and the end of the year from the November monitoring round. That drove the £47·6 million investment that was allocated to us. We looked at the whole of the £89 million to see what we could and could not do between now and the end of the year, and obviously, with time passing, there have been changes. In the meantime, some investments had been made from within the existing departmental budget. For example, the Minister made an investment of £1·5 million in the National Institute for Health and Care Excellence (NICE) drugs. We were looking at the whole of the budget, taking the bid for £89 million and establishing how much of that was spendable between now and the end of the year. That led to the £47·6 million.

The Chairperson (Ms Maeve McLaughlin): How do you measure or mitigate the negative impact from something being put on hold?

Ms Thompson: There is a range of issues. Through the Health and Social Care Board (HSCB), we manage the performance of the trusts against a number of targets. We are certainly looking at those; we are seeking to understand what is spendable at such a late point in the year and what we can do. We will look at that again as we move into the 2016-17 processes, but we measure the performance of the trusts against all the commissioning plan direction (CPD) targets on an ongoing basis.

The Chairperson (Ms Maeve McLaughlin): The £40 million for elective care that was awarded in the recent monitoring round will pay for a certain number operations and assessments. I think that it is 15,000.

Ms Thompson: It will cover 40,000 assessments and 10,000 to 15,000 treatments.

The Chairperson (Ms Maeve McLaughlin): How many people do you expect to be on the waiting list at the end of March 2016?

Mrs Deborah McNeilly (Department of Health, Social Services and Public Safety): The last time we were at the Committee, we indicated that there were around 150,000 people waiting longer than nine weeks. The money covers 40,000 assessments, but, given that the number will have crept up since then, the total will probably come in at somewhere around 160,000 to 170,000. This investment will only slow the issue, because of the backlog.

There were 150,000 people waiting more than nine weeks when we spoke to the Committee the last time. That number is increasing because more of the activity in recent months has been focused on those in greatest clinical need. The number of those waiting longer is increasing. It is hard to make a prediction at this stage because we are coming into the winter and demand is continuing to increase. Even if the figure stays at 150,000, because we are tackling longer waiters the investment will not have a huge impact. It will be hard to figure out exactly because of all the different levers, including increasing demand and the focus on clinical urgency and trying to address clinically urgent cases with the £40 million as well as some of the longer waiters.

The Chairperson (Ms Maeve McLaughlin): There was a calculation done somewhere. We were all told that it would cover 40,000 assessments and 10,000 to 15,000 operations.

Mrs McNeilly: That is what the £40 million would buy and what could be spent. If 150,000 were waiting more than nine weeks, that figure stood still and we spent all the £40 million on 40,000 assessments for those waiting over nine weeks, the figure would come down to 110,000. However, it will not stand still; it will creep up due to the ongoing demand trends. It is a mitigation measure to slow things and, hopefully, address some of the longer waiters.

The Chairperson (Ms Maeve McLaughlin): I very much welcome the intervention, which is critical, but, by March, we will not have seen much of a difference to the 150,000 figure for people waiting over nine weeks.

Mrs McNeilly: If the 150,000 figure did not get any worse due to increased demand — say another 20,000 were added and we took 40,000 off it — you would still have around 130,000 still waiting over nine weeks. It is very hard to tell —

The Chairperson (Ms Maeve McLaughlin): I know that one issue that cannot be foreseen is the seasonal element and everything that comes into the system at that time of the year. However, what would it take to remove that waiting list? There must be a calculation.

Mrs McNeilly: In totality?

The Chairperson (Ms Maeve McLaughlin): Yes.

Mrs McNeilly: When we were spending on waiting list initiatives, for example, we spent £80 million to £90 million in some years, but we have not spent that this year. Patients were effectively paused in August 2014, so we have had over a year — almost a year and a half — of that now. If we were spending roughly £90 million in a year, another £45 million would be added for that half a year, so that takes it up to £135 million. That is just a very rough guide based on what we used to spend in the sector.

The Chairperson (Ms Maeve McLaughlin): So roughly £135 million would be required to eradicate the list of 150,000 people waiting for over nine weeks.

Mrs McNeilly: That £90 million is what we would normally have spent over an annual period. We have stopped spending, effectively, and, if we have stopped spending for over a year and a half, the same level would be £135 million.

Mr Easton: Chair, if I could come in on that point, that would not clear it because, between now and whenever you got through that 150,000, thousands more would have been added. It is never going to clear it.

Mrs McNeilly: No, it is not going to clear it; it is maybe just going to —

The Chairperson (Ms Maeve McLaughlin): No, I absolutely accept that. There are things that we will not be able to see in the immediacy of this, but it is useful to get a sense of it. A sizeable amount of funding is required to deal with the 150,000 people who are waiting for over nine weeks. I am not being negative about the spend that is there, but those 40,000 assessments will not make a great deal of impact.

Mrs McNeilly: The rate of increase in those waiting in the earlier part of the year was around 8,000 a month. There are four months to go. There could be up to 35,000 more going on and we are only taking 40,000 off if the pace of demand continues at the rate of 8,000 or thereabouts a month. It varies, and it is hard to predict the trend, but it is about trying to slow the progression that we have seen earlier this year.

The figure of £135 million is based roughly on what we used to spend, in non-recurrent funding, on waiting list initiatives. We got up to £90 million, and that was for 12 months, so if we have not been spending for maybe the last year and a half, that very quickly takes you up to £135 million just on the spend on our previous activity.

The Chairperson (Ms Maeve McLaughlin): Where do you envisage that funding package coming from?

Ms Thompson: We expect that, after today's comprehensive spending review (CSR) announcement in England, DFP will commence its 2016-17 processes fairly shortly, now that it is hopefully clear about the numbers coming across to Northern Ireland from Barnett consequentials. We would expect to feed into a budget process in the not too distant future. Timelines and guidance are yet to be provided by DFP, but we would factor elective care into that process for 2016-17. Work has been ongoing with the board in trying to get that elective care plan for the future in order to understand what it would take financially and to come up with suggestions on what we can do to pull it back.

The Chairperson (Ms Maeve McLaughlin): What stage is the plan at now?

Mrs McNeilly: We have received a draft plan at this point. I have met board colleagues who will do some more refinement to the plan. After that, I expect it to be formally submitted to the Department for consideration.

The Chairperson (Ms Maeve McLaughlin): In what time frame?

Mrs McNeilly: I expect that to happen within the next couple of weeks.

The Chairperson (Ms Maeve McLaughlin): Will that form the basis of your analysis of what is needed to deal with waiting times for elective care in future?

Mrs McNeilly: Yes.

The Chairperson (Ms Maeve McLaughlin): I assume that that will give you the overall cost of the current shortfall. Will it start to explore funding models? Will it start to explore how bids are made?

Mrs McNeilly: It will not necessarily include funding models; it will be more about what improvement activity and reforms we might need to implement in elective care and what revised models we need to put in place. There will be a high-level element of that going through to the plan, with some costings. If the high-level direction of travel is accepted, we will have to work up implementation plans and the detail underneath that.

The financing will probably be picked up as part of the outworkings of the commissioning review of how we move away from the commissioning finance model to a new model.

The Chairperson (Ms Maeve McLaughlin): How much is the crisis in waiting times down to underperformance?

Mrs McNeilly: The latest information that we have from the board is that, in the core activity levels, there has been an improvement in recent months, but there is still an under-delivery in core activity of 8%, which is a significant amount, given where we are. That said, trusts — I have been speaking to colleagues in the trusts — are delivering more general surgery than they have in the past, but more of it is being directed into unscheduled care. The general surgeons are doing more work, but less of it is going into core activity because the unscheduled-care patients are displacing the productivity gains of general surgery. That is just one example of where the —

The Chairperson (Ms Maeve McLaughlin): The recent figures that I have looked at show that all the trusts failed in their performance targets.

Mrs McNeilly: In core capacity?

The Chairperson (Ms Maeve McLaughlin): Yes.

Mrs McNeilly: At regional level, the figure is 8%. In different trusts, there will be elements of different performance for different specialities, but the overall regional position is 8%. The out-turn for core capacity last year was 7%. The year before that, it was 4%, so there are, obviously, ongoing difficulties in that area. The board is monitoring that very closely and is having regular meetings with the trusts. I have met the directors of planning and performance in the trusts and have pushed on them the importance of delivering core activity. I recognise that it is particularly challenging for them to do that because the demands on the unscheduled care side impact on their ability to deliver elective activity. Nonetheless, a very high level of monitoring and challenge is being applied to the delivery of that. Normally, at this time of year, you would see another improvement, if we look to past years, in the delivery of core activity. I suspect that it is not going to go from 8% to 4%; it will possibly go from 8% to 7% or 6%.

The Chairperson (Ms Maeve McLaughlin): Is 8% high compared with previous years?

Mrs McNeilly: In 2014-15, the out-turn position at regional level was 7%. The year before that, it was 4%. There has been a deterioration, but the trusts are facing challenges with the increased demand on unscheduled care. It is cold comfort but, if it comes in at 7%, at least it is holding as opposed to getting any worse. They face significant challenges.

The Chairperson (Ms Maeve McLaughlin): How would that 8% translate? What would that mean for waiting lists?

Mrs McNeilly: Looking at it in the context of it being 7% last year and 7% again this year, if it has not got any worse, it would not have had any significant impact in terms of any significant deterioration this year. If the performance was 7% under last year and it is 7% this year, it has not had a hugely detrimental impact overall.

The Chairperson (Ms Maeve McLaughlin): In what year was it 4%?

Mrs McNeilly: That was in 2013-14.

The Chairperson (Ms Maeve McLaughlin): It is underperformance that we are talking about.

Mrs McNeilly: Yes.

The Chairperson (Ms Maeve McLaughlin): In your analysis, what causes that?

Mrs McNeilly: The board has been working with each of the trusts, and each of the specialties work with the very trusts very closely. Some of the issues may be down to significant difficulties in recruiting staff. As I said, some of the issues may be down to pressures on unscheduled care, which sometimes have a knock-on effect on elective care. At other times, the issues are less clear-cut. Those are the issues that the board will particularly work with the trusts on. In the past, some money has come off trusts where the board does not think that the trust has been doing enough to deliver its core capacity. From recollection, I think that some money came off them in 2013-14 in relation to that issue. As I said, the board works very closely with the trusts on all the specialties. If a trust has run several recruitment exercises and has done everything it can to get people into some of the specialties but has not been successful, the board may not take money off it, but if the board feels that a trust is not doing enough, those are the occasions when, in the past, the board has acted to take money off a trust.

The Chairperson (Ms Maeve McLaughlin): I suppose that the issue is one of giving additional money to an underperforming system.

Mrs McNeilly: Yes. The additional money will go to some of the key clinical priorities. The board works closely with a trust because it wants to see something delivered for that. It will want to see additional patients going through. This is not a case of getting additional money to prop up something. The board will look at exactly what money goes where so that it is seeing an outcome in the key clinical priority areas where the focus has very much been on red flags and urgent cases. The board will look to the trusts to do more in those areas but I do not see it giving money to prop up somewhere where it does not feel that the trust is doing enough.

The Chairperson (Ms Maeve McLaughlin): Is it fair to say that, at times, trusts will focus on the need to get additional resources for the eradication of waiting times when, in effect, there is an underperformance issue?

Mrs McNeilly: They may, but colleagues on the board will have the data and they will have benchmarks of how others are performing. The board will scrutinise those types of issues and challenge the trusts on them. It is not a case of underperforming and wanting and getting some more money; there has to be an evidence base for it. A productivity analysis must be done. For example, there is an ongoing review into demand and capacity in relation to allied health professionals because the lists had been difficult in those areas. The board will recognise the need for some additional staff, but that is not the entire story. Those decisions are based on evidence, analytics and information, so the board keeps a close eye on that.

The Chairperson (Ms Maeve McLaughlin): Finally, what stage is the commissioning plan at?

Mrs McNeilly: The 2015-16 commissioning plan is published. It has been on the board's website for the past week and a half, I think.

The Chairperson (Ms Maeve McLaughlin): OK. One of the challenges in the budgetary processes that has been flagged up by the Committee through evidence that it sought was that there was a disconnect or disjointedness between, for example, the Programme for Government commitments, the Transforming Your Care policy direction and the allocation of funding. How will that be rectified in the proposed reform of the system?

Mrs McNeilly: As I said earlier, we are about to kick off the 2016-17 budget processes. We will need to understand what the cost of existing services looks like. We will need to understand the Minister's various priorities for investment, elective care obviously being one of those, as we have just discussed. The Minister will also have priorities around the creation and working through of a transformation fund into 2016-17. We will be working with the trusts and across the system on what savings we can leverage to supplement any resources that come to us from the centre. We are working to deliver that whole process, which will result in a commissioning plan direction and a commissioning plan from the board.

The Chairperson (Ms Maeve McLaughlin): What is the time span of the commissioning plan that you published two weeks ago?

Mrs McNeilly: That was the 2015-16 commissioning plan. Work has already started on preparing the direction of the 2016-17 commissioning plan —

The Chairperson (Ms Maeve McLaughlin): When does the one that was published two weeks ago end?

Mrs McNeilly: March 2016. It is the plan for 2015-16.

The Chairperson (Ms Maeve McLaughlin): It is extremely late in the process to set your commissioning priorities.

Mrs McNeilly: We shared the plan and have been working on it with the board, which received the commissioning plan direction for 2015-16 at the beginning of April or May. It then pulled together the commissioning plan in response to departmental direction. During our work with the board, we saw some drafts of that. The board submitted the plan to us before the start of the summer. We had a number of concerns and sought reassurance from the board on a couple of points.

That piece has taken us to now. That said, the board has had the plan, and there have been no substantive changes to it since the start of the summer. We were seeking clarification and assurance from the board on a couple of points. It has had a plan to work to since June, and, as I say, there has been no substantive surprise or change.

We have started work on the commissioning plan direction for 2016-17. In light of some of the recommendations from the commissioning review, we have had a couple of workshops involving trusts, nurses and GP representatives, for example, to help to inform that direction. That is part of our process to see whether we can use that as the basis for further engagement and for the development of the commissioning plan that we will still need for 2016-17. We are trying to dovetail that with the —

Ms Thompson: That will be married with the financial process, because you need the financial and commissioning sides to work together as we move into 2016-17. Until we get a firm financial envelope, we cannot be firm on the commissioning plan direction. We need to do the two in tandem.

The Chairperson (Ms Maeve McLaughlin): I still find it irregular that the commissioning plan, which was published only two weeks ago, will be in effect only until March. So we have a commissioning plan, which is, effectively, the plan that should set your direction for how we commission services, for four months. That is highly irregular, and the plan was very late. I make the further point that, when we reflected on the first draft, there were, undoubtedly, gaps. There was a very apparent gap in that addiction services were not even referenced, at a time when we are dealing with huge mental health issues and all that that brings for our society. That was not even an objective in the plan.

Mrs McNeilly: We provided an update shortly after that.

The Chairperson (Ms Maeve McLaughlin): You did, but the point is that that was not in the plan. The question is this: how does the system agree priorities, set the commissioning directive and allocate funding accordingly? This is another example of having a commissioning plan in November that will be out of date in March. We have already allocated funding through a budgetary process, yet we are only now agreeing it. I find that irregular.

Mrs McNeilly: I appreciate and note your concerns. The draft plan that was submitted to the Department in June did not change substantively between June and the publication of the final plan. As I say, the only thing that happened was that we wrote to the board and asked for assurance on a couple of points, which did not require an amendment to the plan.

The Chairperson (Ms Maeve McLaughlin): How much of this was down to a gap in the Department or a gap because there was no Minister in place?

Mrs McNeilly: We were liaising with the board at that point. There was correspondence back and forward with the board to get reassurance. Some of the reassurance was on financial issues that we were facing this year.

The Chairperson (Ms Maeve McLaughlin): A number of members have indicated that they wish to ask a question. Rosie is first.

Ms McCorley: I will hold off.

The Chairperson (Ms Maeve McLaughlin): OK. Fearghal.

Mr McKinney: Thank you very much. I will kick off on the point on which the Chair finished. You talked about the £89 million that would have been beneficial to move things on. I do not want to drag you into politics, but how frustrated were you that the Executive were not meeting to make decisions on the June monitoring round?

Ms Thompson: All I would say is that, obviously, resources are helpful to us, and we are very appreciative of getting them now. That is probably all that we would want to say on that point.

Mr McKinney: You could, however, have spent more had you got more through earlier decision-making.

Ms Thompson: Certainly, earlier decisions allow you to take a slightly longer perspective. I agree with that.

Mr McKinney: I will translate that into patients: patients have suffered as a result.

Ms Thompson: We will spend the £40 million, and the 40,000 assessments and 10,000 to 15,000 treatments will be very welcome to those patients.

Mr McKinney: Where will the money be spent — as in, who will the money be spent on?

Mrs McNeilly: Do you mean the key areas and specialties?

Mr McKinney: No, not the specialties — well, it might end up being the specialties. Will this all go into a private sector effort to reduce waiting lists, or will it be spent internally?

Mrs McNeilly: There will be an element of both. For internal capacity, we will look, in the first instance, to the trusts to maximise as much as they can do internally.

Mr McKinney: Can they do that?

Mrs McNeilly: The expectation is that they will maximise as much as they can. We will, inevitably, have to use the independent sector at this late time of the year, particularly as we approach the winter period. We will also look to primary care to assist in what we can get done. In primary care, meetings are going on with GP colleagues and GP leads about their contribution to providing additional assessments — for example, if there is a specialist GP in a certain area and additional activity. It is a three-part approach.

Mr McKinney: What sort of breakdown do you envisage?

Mrs McNeilly: I expect that the majority of the money will be spent in the independent sector, given the late stage of the year.

Mr McKinney: Given your earlier reference to 8% underdelivery, are we paying for operations and assessments twice?

Mrs McNeilly: No. We will not be paying for them twice. If a doctor is not doing an operation, he is doing a ward round or looking at unscheduled care patients. It is not as if —

Mr McKinney: What I am saying is, if there is underdelivery to the extent of 8% that is contributing to waiting lists — there was an expectation that, if that 8% had been completed, it would have shortened waiting lists — and if we are now getting new money to buy in extra treatment, we are paying for it twice.

Ms Thompson: No. Deborah is right: the doctor is doing something else. Rather than doing that elective care treatment, he is potentially doing an unscheduled care emergency operation instead. The money is being spent in that way; it is not being spent on the same elective care operation twice.

Mr McKinney: No, it is not, but, with underdelivery, we got an 8% failure figure for the money that we spent to achieve a certain result. That contributed to our waiting lists, and we are now going to spend more money to shorten those waiting lists. That, to me, sounds like spending it twice.

Ms Thompson: The money is being spent on another purpose in the system, which is about demand coming through in a different way. Unscheduled care and unplanned admissions need to be treated in that way.

Mr McKinney: I do not quite get that, but I think that you understand my point.

I want to touch on the Four Seasons care home closures. What impact will that have on the budget, given that those closures will happen by February?

Ms Thompson: What all that will mean is being worked through. The priority, obviously, is the residents and ensuring that the transition is as smooth as possible for them. We will also need to flow money from one home to another, which would be expected to follow the residents. That all needs to be worked through to get the finances in the right place and to ensure that, wherever those residents go, the money will flow with them.

Mr McKinney: When did you know about this?

Ms Thompson: We have been aware for a while that there are difficulties in the independent sector. Deborah and I are not over that brief; it is not our area. Issues in the independent sector, even in domiciliary care, and vulnerabilities in the market apply equally in the health sector. It is about ensuring that people get the right nurses and the right provision. I am aware of the generality but not the specifics of the situation.

Mr McKinney: When did the alarm bell ring in your office?

Ms Thompson: I am aware only of general issues not specifics. I am afraid that we are not the right people with whom to have that conversation.

Mr McKinney: It will, however, have an impact on your budget.

Ms Thompson: It will, but, from my point of view, the money will flow. Those residents will still require care, and they will get it. It will be in a different place, but, from a financial point of view, the money will flow with those residents. At that level, the financials are not the overriding concern; the overriding concern is about ensuring that the transition is managed as smoothly as possible for the residents. It will not have a significant financial impact on our overall finances.

Mr McKinney: In numerous conversations prior to this in Committee, we talked about TYC and the investment in assessing older people's need. Do you now regret that that major work has not been done to evaluate older people's needs?

Mrs McNeilly: As I understand it, a review has been completed of domiciliary care and what that service should look like. Various work streams were in place for residential care reviews and so on. Those will help to inform us about where we go next. Through TYC, we have been focusing on the frail elderly, which is one of the key work streams. Reablement and acute care at home have been put in place. A lot has been going on in that space. The markets are vulnerable, particularly the independent sector, and those issues are also referenced in the independent sector in GB.

Mr McKinney: This is what I do not get. We have all known for a substantial period about the extent to which the private sector is under pressure. It is now flagging up further pressure because of the minimum wage. The minimum wage is a whole other story, because valued staff are paid at those rates and the system is pressured as a result. Why are we carrying out a further consultation on residential care if everybody has known about the pressures that the system has been under?

Ms Thompson: I guess that the consultation is looking at our sector and its needs and facilities. As the Minister advised yesterday, that work has been paused.

Mr McKinney: Does that not speak volumes?

Ms Thompson: I think that, given where we are and yesterday's announcements, it is the right and appropriate thing to do. We need to understand what that means and where our capacity and that of the independent sector will sit as we move forward, and that is what is happening.

Mrs McNeilly: The ongoing review is about residential care homes; the Four Seasons homes are nursing care homes, which have a higher level of provision and a different client base. The two services do not necessarily match. Pausing is a precautionary measure for the residential care element.

Mr McKinney: Figures show that TYC is only half implemented. Do you think that this failure, particularly the failure to plan for older people, has led to the very budgetary challenges that we are talking about?

Ms Thompson: There are budgetary pressures for a host of reasons. Certainly, the fact that our population is getting older and has more complex needs is part of the explanation. What we can do for people is also a part. Obviously, for 2016-17, we will look further at what those needs are, what can be done by way of transformation and what more needs to be put in place. It is all part of looking ahead and ensuring that we continue to build on the models that we have in place across Northern Ireland and that we pick up on what is working well and continue it into 2016-17 and beyond. We want to take the acute care at home and other models that are helping to keep people out of hospital and spread them further through the system.

Mr McKinney: That was the original ambition. However, the document states — apologies for harping on about this, but there was significant consensus on that plan — that failure to plan would lead to haphazard change. Are we not seeing that in A&E, elective care, domiciliary care, residential care and now the independent sector?

Ms Thompson: You need to understand the reasons for all those things. Issues with elective care are predominantly to do with not having the funding to support the numbers of assessments and treatments that we had in the past. As Deborah said, there has been progress on reablement as part of the domiciliary care agenda. Progress is being made, although we have not had the scale of funding available for TYC that was proposed. A range of issues have resulted in our being where we are, but, equally, an awful lot of good things have happened. It is a bit of both at the same time.

Mr McKinney: Does the Minister's new plan not simply amount to changing the nameplate in Linenhall Street?

Mrs McNeilly: No. He said that it was about removing layers of bureaucracy in order to streamline processes. We expect information to be available more rapidly for decision-making, more influence to get things happening on the ground and better understanding and sharing of information. That should mean that people go through fewer processes to get decisions made. That will release staff on the ground to allow them to do those good projects and get them up and running more quickly. The review will look at how we streamline the complicated commissioning process and focus more on outcomes. This provides us with a huge opportunity to do that. I do not see it as being a change of nameplate.

Mr McKinney: What figure do you expect to put on the transformation fund?

Ms Thompson: It will be for the Minister to decide that. He has advised that he would like a sizeable proportion to go into that fund, but we need to see it in the context of a proposed settlement from DFP and the Executive and the pressures that we have. Ultimately, it will be for the Minister to decide what that looks like and its scale as we go into next year.

Mr McKinney: My final question is about the definition of front-line services and the support services that are consistent with front-line services. In that context, should the Northern Ireland Fire and Rescue Service not be a front-line service?

Ms Thompson: Yes, you could have that discussion about the Fire Service, the Police Service and so on. The Executive's definition and their approach was that there is front line in the currency of health and social care, and we looked at that. In common parlance, that does not mean that front line does not apply to a lot of other areas. In the way that the budget process was run, it applied only to front-line health and social care.

Mr McKinney: In other words, the definition did not come into play, albeit that a definition was attached to the decision.

Ms Thompson: I guess that a different approach was taken to the Fire Service and front-line services in other Departments.

Mr McKinney: Was that arbitrary?

Ms Thompson: As in any budget process, there is a choice at Executive level about what happens.

Mr McKinney: I have one final, final question. Are prescription charges now off the table?

Ms Thompson: That is our understanding.

The Chairperson (Ms Maeve McLaughlin): With Transforming Your Care, how much of the £83 million has been shifted?

Mrs McNeilly: It will be £45 million at the end of 2015-16.

The Chairperson (Ms Maeve McLaughlin): Thank you.

Mr McCarthy: Thanks very much for your presentation. The first page of your briefing paper gives the impression that everything in the garden is rosy, but I very much doubt that, given the horrendous number of patients waiting for treatment. You are hopeful that you will break even by the end of the year, which is good. Let us hope that we reach that position. In fact, the Committee had the trust chief executives in last week, and they were also hopeful that they would break even. Let us hope that they do, despite having to save £160 million, I think, between now and then.

In the June monitoring round, you put in a request for £89 million. It was said at the time that, if you did not get £89 million or nearabouts, there would be dire consequences, with waiting lists extended and patients put in danger. You did not get £89 million; you got £47 million, so there is a balance of £42 million that you did not get. How can you be so confident that you will break even by the end of this financial year, so that the waiting lists and everything else in the garden will be rosy?

Ms Thompson: There are several issues there. Deborah explained the elective care position and where waiting times might go towards the end of the year. On the financial side, we closely monitor the overarching financial position. We have made sure that, in the trusts and across the system, we can break even. That means that not everything that you would want to do can be done. We are putting an extra £40 million into elective care, whereas, in the past, the numbers might have been running a lot higher than that. That certainly has an impact on waiting times, but, from my perspective and from a financial position, we expect to break even. With winter demands, anything can happen, but, as we look at it today, we expect to break even. We are ensuring that we spend not the £89 million that we asked for but the £47·6 million that we got. We will set out to do that.

Mr McCarthy: Hopefully, that will happen, but do you not agree that, come April 2016, we will be back to exactly the same position, and waiting lists will start to creep up again?

Ms Thompson: I guess that needs to be seen in the Budget outcome for 2016-17, which we do not yet know.

Mr McCarthy: It must be a fear and a worry.

Ms Thompson: It is a concern, and we expect to need a significant amount of money going into 2016-17. That is what we are working through.

Mr McCarthy: In the briefing paper, there is nothing at all about the capital investment position. That is disappointing because, in my area — the South Eastern Trust — we had a business plan. Last week, I asked Hugh McCaughey about the new inpatient mental health unit for Dundonald and the new adult resource centre for Ards, which the plans are in for. There is no money whatsoever for that, and those are only two items.

Ms Thompson: In the currency of 2015-16, there is no further money. It can be very difficult to spend capital money towards the end of a financial year, because big projects of the nature that you are talking about need planning and working through before you spend money on the ground. Equally, we will come back on 2016-17, but, that said, a lot of the capital moneys for 2016-17 will be capital commitments for existing capital projects, of which quite a few are already in train. You will appreciate that we have to ensure that those projects finish before we can start any further projects, whether in the South Eastern Trust or any trust.

Mr McCarthy: How is the Department planning to avoid a situation in which waiting lists seem to be determined by when and how much money the Department gets through the monitoring rounds? There is a lot of dependence on monitoring rounds to prevent waiting lists growing and so on. That is not an ideal situation. What can you do about it?

Ms Thompson: As part of the 2016-17 Budget process, we expect to ensure that there is an understanding of the amount of money that we require for elective care in 2016-17. I do not know what happens in an Executive process and what budget allocation we will get, but I know that we will be looking for a substantial amount of money. You are absolutely right: if we can get it into our base budget at the start of the year, it makes it a whole lot easier. You can plan for it and it is all there from the start, but we can do only what we can do and live within the resources that we have. We will put those bids on the table, and, if they are not sufficient, we will aim to supplement them through the monitoring rounds. We do not yet know the answer to those questions, because we do not have a 2016-17 settlement.

Mr McCarthy: It is not an ideal situation.

Ms Thompson: We would prefer to be able to plan for it and ensure that we have the money up front. If we had that, we would be in an excellent position.

Mr McCarthy: Assuming that there are no changes in the model of service delivery, what level of growth in health and social services expenditure would be required each year to meet the rising demands and changing demographics?

Ms Thompson: We estimate that, normally, about 6% is required, but the level of growth that we tend to get is in the order of 2% or 3%, and we have to supplement the gap with efficiency savings or monitoring round money. We are working through those processes for 2016-17 to ensure that we quantify all the pressures and understand that against any settlement that we might be given. It is complex work.

Mrs Cameron: Thank you for your presentation. Most of the questions have been asked and answered. I have one query about the £40 million allocated to elective care. What conversations has the Department had with the private sector to calculate how many procedures it can process? Obviously, timewise, there is a very small window of opportunity. Does the Department converse with the private sector beforehand to calculate how many people it can shift through the process relatively quickly to reduce waiting times?

Mrs McNeilly: The Health and Social Care Board has been working with its providers regarding the framework contracts it has in order to get more detail on contracts and capacity to match against demand and see that we can get though as much as we can. Very close liaison has been going on. Existing contracts still have headroom in them, around orthopaedics, and patients have already been referred to the independent sector. Indeed, some appointments have already been issued in relation to that. We are working very closely with the board to make sure that it knows what is required, and it is liaising with the providers. The trusts are also working very hard to review the waiting lists and identify the most appropriate patients to refer to the independent sector. This will make sure that we refer appropriate patients out. Two pieces of work are ongoing, but, in the meantime, as soon as the names of appropriate patients are available, we are not expecting any lag in them being referred out. An awful lot of work is going on in relation to managing the process.

Mrs Cameron: That is very welcome, especially for those receiving those referrals and getting appointments now. That is very welcome news. I am just concerned that bureaucracy will not stand in the way of achieving more, if that is possible. I hope that the board is liaising with the private sector as best it can to ensure that we are not getting caught up in red tape and that time and money is not being wasted, so that we can see as many procedures put through as possible in as short a space of time.

Mrs McNeilly: That is the case, absolutely. That is the very clear message that we have provided to the board. I have regular updates from it on where it is going with that, and I am pushing it because I do not want to hear that it has a list of names but cannot send them out to somebody. That has been made very clear, and the board very much appreciates that that is where we are and is working to make sure that that is what happens.

Mrs Cameron: As a last comment, well done on balancing, once again, what is a difficult Department to manage. That is appreciated.

Mr Easton: I have a quick question. Do you know how much will be allocated to each trust from the £40 million to get waiting lists down?

Ms Thompson: No, not yet. That is the process that Deborah is describing. They are organising lists and getting clarification on patients and on who needs what and where. All of that is being worked through, and then it will be decided where they will go. The money will follow, so there is no issue about getting the money to the right place. The trusts will get the right money for the patients who are being treated. We have allocated the moneys to the board, but they have not got to the trusts yet. That is not holding up appointments being issued or working through the patients in what you have just described as well. The money flow is not creating a blockage.

Ms McCorley: I will follow up on the issue around homes. How do you see things panning out? On the one hand, the Department was closing down homes, and you could see a reduction in the statutory sector. Obviously, the intention was that the reliance would be on the independent sector. Now, with what has happened, there is going to be a huge gap in that provision, and others might follow, given what we heard from the Older People’s Commissioner. What contingency plans do you have for that possibly becoming the norm? Will the Department have to start thinking about reinstating the statutory sector?

Ms Thompson: I guess that we can only talk about that generally as it is not our direct area of responsibility. That having been said, the Minister has put the decisions on residential care homes on pause so that we can reflect on the implications and what this may mean. As Deborah said, the homes in yesterday's announcement were nursing homes, whereas our facilities were in the residential care home sector, so it is slightly different. Nonetheless, it is important to understand what is going on. From my perspective, the broader issues are the impact of the living wage, for example, which you mentioned earlier, and the quantification of those pressures for our staff and those in the independent sector. We are very much alert to that, and we will expect to come through that as part of our 2016-17 processes. So, it is about working through the financials, if you like, and understanding the capacity. All of this has to be worked through, but, most important, at the moment, is ensuring that the current situation is managed appropriately and that residents can be moved and transitioned smoothly. The whole picture will need to be looked at, and that is what is being asked to be done.

Ms McCorley: Do you foresee further negative impacts coming out of this, given the impacts on the old people who are affected by it? I am sure that everybody heard people commenting on this and saying that a lot of people in homes need routine and familiarity, and that conditions often deteriorate once change happens. Given the enormity of what has happened, do you have contingency plans for what the outcome of this could be?

Ms Thompson: The trusts will be working through that with the homeowners to see what needs to be done to make the transitions as smooth as possible for the residents. A lot of focus and attention will be given to that to try to ensure that people can be moved to suitable accommodation near to where they are used to living. You are right; it is going to be unsettling for those individuals and their families, but it is an ongoing piece of work.

Ms McCorley: What impact will this have on the intention of TYC?

Ms Thompson: A lot of the focus on the older care piece in TYC has been around domiciliary care, reablement and trying to keep people at home, more so than in the nursing home side. Part of what was driving the reduction in our need for the residential homes sector was the fact that a priority was placed on keeping people at home and supporting them to live in their own homes. So, the work around reablement is still very important and needs to continue, as does the focus, as Deborah said, on the frail elderly as part of TYC. That population is growing, and that demand will increase. We need to keep working at this to try to keep as many people supported and ensure that their needs are met as we look forward. It is complicated, because the numbers will continue to grow, as we see when we look at the sheer numbers in the elderly population.

Ms McCorley: Do you feel confident that it will be manageable?

Ms Thompson: That is what we have to do. We have to marry need with the resources we have and ensure that we are doing as much as we can with those resources. That includes ensuring that people get access to the care they need, and the appropriate levels of care, whatever those might be. We must also ensure that best practice when doing things is accessible for people; that is the planning that needs to happen. But, you have to marry that with the resources you have. That is where the two can, sometimes, be very challenging, because one is going up higher and stronger than the resources against that.

Ms McCorley: So you do not foresee a crisis in a month or two in which a lot of elderly people will not be able to access suitable places. They might get places, but those places may not be suitable. You do not foresee that sort of a crisis happening.

Ms Thompson: I know that that is something that the board and the trust will focus on in dealing with the existing issues and trying to look ahead to see where we are with capacity. The pause on the current processes internally will allow a little bit of space to allow that to happen.

Ms McCorley: Some time back, we had a presentation from health professionals. I remember one person saying that a lot could be saved in the health service if attention was given to elderly people falling. Do you have any plans on how you might look at that? Maybe you are already doing so. If you are, what are the plans?

Mrs McNeilly: One of the integrated care partnership pathways being developed in the South Eastern Trust is a fall service. It means that where a person is seen as being at risk of a fall — from a GP perspective, a social care perspective, or, maybe, as a result of a nursing home or emergency department attendance — someone will risk assess them within 48 hours and work with them to minimise the risk. It might relate to simple things around the home or it might be that people need additional support with reablement, for example. So, a falls service is having a positive impact in the South Eastern Trust. We are monitoring how that is working. If it is successful, we will look at the possibility of scaling it up.

Ms McCorley: Is it a pilot scheme?

Mrs McNeilly: It is certainly a new scheme in the South Eastern Trust. As I said, they have not got to the stage of having a formal assessment yet. They will assess it and, hopefully, if it is OK, it will continue. So far, the feedback has been very —

Ms McCorley: Would you expect it to be rolled out?

Mrs McNeilly: If it is successful, we would look to see whether it is right to scale it up. That is just one example from the South Eastern Trust that I am aware of at the minute.

Ms McCorley: How would you measure success in a project like that given that it is preventative? You would not know whether people would have a fall and all that.

Mrs McNeilly: It would depend on who refers them to the falls service. It may be that they have had a fall in a nursing home and the home has notified the falls service to provide assistance; or they may have had a fall in their own home and the ambulance has gone out, checked them and referred them to the falls service, which would go out very quickly. They will monitor the extent to which that person has had a number of falls and look at whether it is a trend that is continuing for that individual. There will be a bit of monitoring of individuals to see how they have responded to the interventions they have received. They will do it in that way.

Ms McCorley: I also want to address the issue of the closure of day centres, which is an issue for some people who have isolation and mental health issues. A meeting took place somewhere — I heard about it through the media — and what came from the floor and the people who use services was different from what the organisations were saying. How much do you feel that people who access services need to be listened to? What I heard was that the views of people who use the services, who were saying how it affects them, did not seem to be taken into account.

Ms Thompson: Anything of that nature — a closure — would be subject to a consultation process. That would allow people an opportunity to give their views. All the trusts have PPI schemes to engage with their stakeholders, which includes their service users. That is part of a process.

In day-care centres, it can be about different models of care and different day opportunities rather than just going to a day centre and that being worked through. You are right: we would expect service users to be engaged with. Any significant change is subject to that consultation process that would include those users.

Ms McCorley: What came across was that the ability to access a day centre could be one of the most, if not the most, important factor in some people's lives to keep their mental health in a safe place. It is worrying when you hear about closures. That might cut off the one lifeline that some people have.

Ms Thompson: Quite often, day centre models are about different ways of providing day opportunities. They can still be about getting people out of their houses, engaging with them and the interactive side that you are talking about, but in a different way without the day centre necessarily being in play.

That work would be part of considering whether something was the most appropriate way of caring for somebody's needs and what that looks like as we move forward. That would be the subject of ongoing review across the trusts and a trend in the same way as children being cared for in children's home rather than in foster care or through adoption. It is that trend of trying to keep people in the community and their homes as much as possible.

Ms McCorley: So, people are not going to be cut off and without a service.

Ms Thompson: I cannot guarantee that for everybody, but certainly part of those decisions tend to be about different models of care.

Mr McKinney: Thanks for letting me back in again. I have two points. I finished on the bit about the prescription charges. The Minister is now indicating that that will not happen, but, of course, that was part of a consultation on cancer drugs and individual funding requests. Where is that?

Mrs McNeilly: We put a paper to the Minister for his consideration. Subject to his consideration of that paper, hopefully there will be an announcement shortly — in a week or two.

Mr McKinney: Have you any indication when?

Mrs McNeilly: I had better not say. [Laughter.]

It would not be fair.

Mr McKinney: The other issue is financial transactions capital (FTC). There was a reasonably good uptake by primary care in accessing that loan provision. There has been some consideration in the wider community about increasing that, for example, in relation to the Cancer Centre. Have any further discussions taken place in the Department about how that might happen, given the potential positive impact it could have on jobs and capacity there?

Ms Thompson: Certainly, FTC is something we would like to access. Primary care facilities tend to be the place where that conversation is most active. What we have at the moment is what you might call enhancement to GP premises and that sort of thing. We are looking to see whether we can access it for some of the bigger scale schemes. We will do what we can to access it. It is a complex funding source, so it does not fit everything. We will be trying to do what we can, particularly in primary care, to see whether we can use FTC as a means of levering in additional capital moneys.

Mr McKinney: That type of project is not outwith the potential.

Ms Thompson: The bigger primary care schemes are not outwith what we are looking at. If we can get schemes to work, that would be highly helpful.

Mr McKinney: That type of thing around a university hospital and —

Ms Thompson: You have to have a private sector bit here —

Mr McKinney: I understand that.

Ms Thompson: — so it is finding models that work with a private sector bit. If we can get models and a scheme that work, then that is something we are very open to. However, you have to watch all sorts of things, such as restrictions on state aid. There are a lot of complexities within it. However, we will do what we can to access that funding source, particularly if that gives us an extra means of taking a scheme forward; it is absolutely sensible to do so.

Mr McKinney: In terms of that project, is that under active consideration?

Ms Thompson: Which one?

Mr McKinney: Say, for example, expansion around the Cancer Centre.

Ms Thompson: I have not seen it mentioned specifically for the Cancer Centre. Discussions that I have been involved in have been more around the primary care side, more so than anything in the Cancer Centre space. However, we are actively looking at it. We will look at anything that can fit the scheme's intentions and rules.

Mr McGimpsey: I apologise for having missed most of the presentation. Stop me if this has already been covered. I want to talk about the seven Four Seasons homes that have gone down last night. I take it that you have talked a wee bit about that. What interests me is that I hear about the pause on the statutory homes closures, but we are aware that the frail elderly do poorly when they are moved permanently. It is a life-limiting exercise, and you start losing them when you start to move them permanently. What consideration are you giving to stepping in to maintain the homes as they are, keeping them open to ensure the best chance for residents?

Ms Thompson: We have already had a reasonable discussion of that. All I can say is that the board will be working very closely with that provider to understand what can be done, particularly with those residents' needs in mind. I understand your point and why you are making it, but it will depend on what the private provider wants to do with the facilities and how open, or otherwise, they are to anything else. Residents' priorities are of absolute importance at the moment in trying to find a working model that allows them to be transitioned, but I am not sure whether that will necessarily involve stepping in, because that requires buying out.

Mr McGimpsey: Or it could be a subsidy, supplementing their income and giving them a tariff they can live on. On another issue, the board that you keep referring to is due to be abolished; large numbers of people are being moved into the Department, and others are being scattered elsewhere. What will that exercise cost?

Ms Thompson: At the moment, we are working through a process; so, it needs to go through consultation, legislation and whatever. We will be looking to understand, as you rightly point out, where people will go, who will go where, what are the functions; all that, and how the bits of the new system can work together better in the future. That is all part of the ongoing work. You are aware of the voluntary exit scheme that is currently available, and we will be looking into that space to see whether anything can assist, as we look forward.

Mr McGimpsey: So, how much was that again?

Ms Thompson: We do not have a quantification on that at this stage.

Mr McGimpsey: All right.

Mr McCarthy: Just to follow up on that, you will be disappointed that you are only going to get your hands on £3 million as a result of the abolition of the board. The Minister advised the Committee here last week or the week before, that, as a result of the board, there would be savings of £3 million. Are you disappointed that you did not get that? Simon Hamilton told us that when I asked him what the savings from the abolition of the board would be. He said it would be about £3 million.

Ms Thompson: I do not think we have a quantification of that at this stage, because it depends where people will go in the system. I guess that what was previously asked was around the cost of levering the change. What you are asking is for the savings from it. All of that still needs to be factored through. I do not think the Minister has advised what those savings will look like at this point in time.

Mr McCarthy: But he certainly told the Committee Chair a couple of weeks ago.

Ms Thompson: The one thing I know for £3 million is the cost of the voluntary exit scheme for people from the board in 2015-16. That is definitely £3 million.

The Chairperson (Ms Maeve McLaughlin): Finally, Julie, before you go, in terms of the £83 million, £45 million is shifted. When do you envisage we will get to the £83 million target? Is there a timeline for that?

Mrs McNeilly: That will depend. There will be some rolling forward of the existing schemes. We keep that actively under review. It will also depend on what else we do going forward, how much the transformation fund is and where it is directed. At this stage, I could not put a date on when we would shift that, but, as part of the transformation fund, I expect to see some of the things that need done on the system in terms of working to the proposals and the vision set out in TYC. That is something that we would presumably try to fund through a transformation fund, subject to the Minister's consideration.

The Chairperson (Ms Maeve McLaughlin): OK. Thank you both for your attendance and detail today.