Official Report: Minutes of Evidence

The Chairperson (Ms P Bradley): I welcome Dr Michael McBride from the Belfast Trust, Hugh McCaughey from the South Eastern Trust, Francis Rice from the Southern Trust, Dr Tony Stevens from the Northern Trust, and Elaine Way from the Western Trust. You are all very welcome. I will allow you a little bit of time to give us a briefing. We will then open it up for questions from members. Who wants to take the lead and kick off?

Mrs Elaine Way (Western Health and Social Care Trust): We have all tried to look at what the priorities are and what issues we face in health and social care. We have had the opportunity to meet the Minister. We are absolutely clear about her priorities. The agenda is transformation and reform, and I hope that our presentations will describe that in each of our geographies. We also very much welcome the decision of the Assembly and the Finance Minister this week to award another £72 million to the health service. That is very welcome news, and it will go some way to helping us to address our priorities.

I am conscious that many of the members are new members, so I will start by saying a little bit about the Western Trust. We were established back in April 2007, and we have a large geographical area. I describe it as being from Bellarena to Belleek. Although we have the second city of Derry/Londonderry, our services are largely delivered in rural settings to a population of just under 300,000 people by 12,500 staff. We have high levels of deprivation and unemployment in the west, and those create health and social care challenges for us. We work from around 130 sites, and the most well known are Altnagelvin Hospital and the South West Acute hospital in Enniskillen. However, the majority of our work is done in communities, particularly in people's homes. We also provide some specialties on a wider basis, including oral surgery, orthopaedics, ophthalmology and urology.

During 2015-16, over 113,000 people attended the emergency departments in Altnagelvin and the South West Acute Hospital and the urgent care and treatment centre in Omagh. Over 190,000 patients were seen or reviewed as outpatients and almost 75,000 were treated as inpatients or day cases. Interestingly, almost a quarter of a million people received diagnostic tests and over 21,000 were treated for fractures. Every year, we deliver over two million hours of domiciliary care, and 4,100 babies were born under our care.

We work very closely with our local politicians. We work closely with our MPs, MLAs and our local councils, and the new community planning process has given us a tremendous focus to work with the councils. I work with three: Derry City and Strabane District Council; Fermanagh and Omagh District Council; and Causeway Coast and Glens Borough Council. We also share a border with the Republic of Ireland and, over many years, have built a strong, mutually beneficial relationship. The most tangible evidence of this good cross-border working will be the opening of the radiotherapy unit towards the end of this calendar year.

This is my tenth year as chief executive of the Western Trust, and I must say that I am enormously proud of the very many achievements that have been made by our staff. I wish to emphasise that a lot of the positive initiatives are driven by clinical staff, doctors, nurses and other professional staff such as those from the social work profession. We have, as all trusts do, an overarching reform plan that very much chimes with the Minister's focus on transformation and reform, and each of us has many examples of excellent progress. In my case, I am very proud of the redesign of respiratory services and a focus on supporting people with that chronic disease in their homes rather than having to have a number of admissions to acute hospitals. We have first-class cardiology services, from cardiac assessment in Omagh through to what is called primary PCI — percutaneous coronary intervention — in Altnagelvin Hospital, which was first introduced in September 2014 for patients from the west and from the northern half of the Northern Trust are and, from May 2016, for patients in Donegal. We have redesigned cancer and diagnostic pathways and are consistently delivering a very high performance there. We have many awards, and I am particularly proud of the dementia and memory services, which are award-winning. Indeed, mental health is a particular concern for us all in Northern Ireland and for the Assembly, and we are working hard on what we call the suicide think tank to try to make suicide in the western geography a never event. As well as the work that we are doing in acute hospitals, we have established an excellence in community care programme to try to see how we can support citizens in the community, and we have a particular focus on self-directed support as we promote a personalisation agenda. Finally, we have also redesigned our looked-after services for children to try to meet the increasing demand for care and to provide best outcomes for children and their families.

We have a lot of building going on in the Western Trust and have had over the past number of years. When the trust was first established, we had an £850 million capital project, and our priorities include the radiotherapy unit; the Omagh hospital and primary care complex, which should open at the start of next year; the redevelopment of Altnagelvin's north wing; and mental health facilities, a recovery and rehab accommodation and acute inpatient beds in Omagh. We are also managing a very complex PFI contract for the £270 million South West Acute Hospital. That is the capital work.

While there is much that is positive in what I have described for our patients and clients, we continue to experience a significant increased demand, particularly for emergency services in both our acute hospitals. Last year there was a 9% increase in demand for services in Altnagelvin for unscheduled care over and above the previous year, and in the Southwest Acute Hospital it was 5%. When more people are turning up at the emergency departments, and there are more admissions, that does impact on our ability to consistently provide our planned interventions, particularly surgery.

Like other trusts, we are concerned about improving our elective care performance. In the Western Trust, and this will be no surprise to the MLAs locally because they have heard me brief them on this regularly, we have particular challenges with regard to the recruitment and retention of medical staff — largely because of our peripheral geography. We have developed a strategic plan to try and address this, and it includes an ambitious programme of overseas recruitment. I am delighted to say that we have successfully appointed 31 additional doctors to the trust, 20 of whom are already in post as I speak.

We are engaged in very positive discussions with the Department of Health, the Health and Social Care Board and the Northern Ireland Medical and Dental Training Agency to try and secure an improved allocation trainee posts for junior doctor and we are getting some results from that.

While medical is our biggest workforce challenge in the west, we are also experiencing difficulties with other groups. Nursing shortage is an emerging issue in the west, and the trust is involved in a regional and international recruitment exercise to try to overcome those problems.

Ms P Bradley: Thank you, not that I am in any way biased, but it is wonderful to hear you speak so highly of the social work profession at the beginning of your presentation. Thank you; we will get on very well. [Laughter.]

Dr Michael McBride (Belfast Health and Social Care Trust): Thanks Chair, continuing on in that direction, I am not going to rehearse any points that Elaine has raised, because there are many common themes. Belfast delivers health and excellent social care to around 340,000 people in Belfast and the greater Castlereagh area, as well as the majority of the specialist regional centres for the population of Northern Ireland. There is an annual budget of some £1·2 billion, some 22,000 staff, and it is perhaps one of the largest trusts in the UK. That is to give you a sense of the scale and complexity.

You will be familiar with the inner-city hospitals, which I will not list, in the interests of time, but we also have seven health and well-being centres in Belfast. We work with clients and in-patients with learning disability and mental health in Muckamore Abbey Hospital and Knockbracken Healthcare Park. We provide some 7,000 care packages, and we are corporate parent to some 950 children. My own children often ask me how can I be a parent to 950 children, but we have that full corporate parental responsibility for those individual children and also responsibility for 382 children on the child-protection register.

Elaine mentioned the achievement of staff, and I think it is important that we recognise the achievements of staff. They have continued in Belfast, as in the other trusts, to demonstrate their commitment to improving the lives of patient and clients in a number of ways. Just some of the highlights: we have a very ambitious programme of quality improvement in the trust over the next three years; we have specific work around seven-day fracture lists, which is achieving very significant benefits in terms of patients operated on within 48 hours; and we have a significant programme of work around reducing bed sores, falls and thromboembolism.

In common with other trusts very actively working in this area, the trust was awarded its Investors in People bronze accreditation this year which was a recognition externally of a mark of excellence. Staff have won many awards. I am minded particularly of our four winners at the Nurse of the Year ceremony this year in Hillsborough. Members will have been present. Our most recent care quality award for cancer treatment in recognition by the Institute of Healthcare Management. Indeed, many trust staff were honoured and recognised in the Queen's Birthday Honours and New Year Honours. Perhaps one of the most notable achievements this year is to be credited with being the European leader in the live donor transplant programme. No other trust or hospital in Europe carries out more live transplants than the team in the Belfast Trust — none. It is a regional service, provided on behalf of the population that we all serve. The outworkings were recently demonstrated when the team performed five successful kidney transplants in 24 hours, transforming the lives of five individuals. Only once in the world, in a large US centre, was this achievement ever bettered: it completed six.

We invest in our staff through a highly active health and well-being programme of events throughout the year. We developed the much-applauded B Well website and mobile app. As Elaine said, we are working with local government. We supported Belfast Bikes in installing bike parks at the Royal, Mater and City hospitals. We participated in the most recent Active Belfast challenge. Again, learning from the example of colleagues in the west, the regional smoke-free initiative has made great progress in our sites; but it is a journey. We are working very closely in partnership with the arts in health.

Finally, I would like to note our successful partnership work with the community and voluntary sector, which is something I am immensely proud of. We have some 432 volunteers in the trust who continue to improve client experience and make it as good as possible.

I will give you some of the headline performance figures. It is helpful for new members to get a sense of the volume of our work. Some 132,000 patients attended our two adult emergency departments in 2015-16, 7,000 more than in the previous year and 6,000 more to the Royal alone. We managed a 3% growth in ambulances; they bring some of the sickest patients to emergency departments. Our children's hospital experienced a 13% growth in attendance. That is just shy of 2,500 more sick children attending, with none waiting longer than 12 hours. Despite the increase in demand on our adult Emergency Department (ED) services, we achieved an 8% improvement in our four-hour performance, and we have reduced the number of patients waiting over 12 hours by nearly 75%. Those are remarkable achievements by teams across the trust.

Key to that has been the development of different pathways and new ways of working, led by the team and supported by management and the organisation, including the new ambulatory care pathway. We are admitting 2% fewer patients now, despite the increase in times last year as a result of those different ways of working. Just to give you a sense of scale, there were 165,000 new outpatient appointments, 415,000 review outpatient appointments and 27,000 elective inpatient episodes, all more than the previous year.

As Elaine said, we face challenges in waiting times, and we are currently reviewing our theatre infrastructure and looking at capital investment. There are capacity constraints on facilitating the increasing demand. We have delivered a range of in-house and independent sector waiting list initiatives, and it is important that we are able to access funding to maintain that momentum over the next number of months.

It is important to recognise that we work in collaboration. Belfast provides much of the activity for most of the region. We delivered nearly 6,000 babies during 2015-16, many of them high-risk deliveries, and carried out 116 renal transplants, substantially more than the ministerial target of 60. There is an excellent cardiac intervention catheterisation lab in Belfast and, like Altnagelvin, it carried out 2,376 stenting procedures and nearly 1,000 complex cardiac surgical operations. Returning to the seven-day fracture list, 98% of our patients with a fractured neck or femur are treated within the ministerial standard of 48 hours.

I turn now to work in the community, which is a really important part of what did in 2015-16. No child or young person waited longer than nine weeks for assessment at the child and adolescent mental health services (CAMHS). No person waited longer than nine weeks to access our dementia services. We exceed our ministerial target of carers assessments undertaken. We face the same workforce challenges, and I will not go over them again. We can pick them up in the discussion.

Looking ahead to 2016-17, the early indications are that we are likely to see continued increasing demand. We are concentrating on six core themes within the organisation: continue to improve the quality of the care that we provide; improve services in the community, because we need to improve the capacity and capability of the service to deal with the demands we are seeing; manage patients differently; provide care differently; improve the delivery of elective care, and we do not need to rehearse here the details of that, because we know the challenges that we face in elective care in terms of the demand/capacity mismatch; and, finally, further improving the delivery of unscheduled care.

There a number of big capital projects, for which we are very grateful for the investment. The new regional children's hospital, an Executive flagship project, is fully on track. The new maternity hospital remains on track. Construction there will be completed in 2020, ready for occupation in 2021. A new mental health in-patient unit will replace the current facility, which is not fit for purpose. That work will begin in the summer and will be completed in 2018 for moving into in 2019. I mentioned major capital works in how we might increase our operating capacity at the City Hospital, the Royal Victoria Hospital (RVH) and Musgrave Park to help to bring down waiting times, which I think we would all accept are unacceptable at this point.

We have committed to a process that we refer to as "new directions". This is our blueprint for how we will deliver health and social care services in Belfast, looking at distinctive pathways, unscheduled care, elective care and at patients with long-term conditions, and how we use our existing infrastructure in a more effective way. Rather than trying to provide a little bit of everything across all the sites, how do we ensure that we are making best use of the sites that we have across Belfast?

Colleagues are engaged in similar work, with active collaboration and discussions amongst us at present.

Dr Tony Stevens (Northern Health and Social Care Trust): Thank you for this opportunity to tell you about the Northern Trust. For those not familiar with it, it is a large, geographically spread organisation. We cover and provide services to people from Pomeroy to Ballycastle and from Castlerock to Newtownabbey — a very diverse range of people, who do not always necessarily have the same perspective on where and how their health and social care should be provided.

Our catchment population is 460,000 and we employ just short of 12,000 staff. We span four council areas and have good working relationships with all those councils, and we are working hard on our community plans. That reflects the reality of the Northern Trust: it is a large community trust and should be seen for the richness of the community services it provides. We also provide secondary and acute services in two hospitals, Antrim and Causeway, and I will talk a bit more about those in a minute.

We have a significant proportion of the elderly population on our patch. That is a privilege to serve but also a challenge. Between 2012 and 2021, that is predicted to grow by 35%. We recognise it as a challenge but also a compelling reason for transformational change, which I will describe to you briefly.

I am conscious that we could overwhelm you with numbers, and I could list all the things that we do. I am more than happy to provide those separately, but I will give you a couple of highlights. The first is that 125,000 people went through our two emergency departments last year. Interestingly, in the first five months of this year, we have seen an 8% growth in that. We have been used to something in the region of 3% or 4% year-on-year growth. We have seen a step change this year. That has been accompanied by a 4% increase in ambulance attendances at our emergency departments.

In playing to my theme of our elderly population, a significant proportion of that is a step change in the age of people coming to our emergency department. That hints at some of the challenges we face, particularly working with our general practice colleagues in developing new ways of working and providing new alternatives to hospital care.

Like Belfast, we have, however, been successful in reducing the number of people being admitted. Despite the 8% increase in attendances at ED, we had a 9% decrease in admissions. That is largely due, in my view, to initiatives. For example, one that we call our GP hub, or direct assessment unit, is a one-stop shop alternative to the emergency department, where GPs can arrange for frail, elderly people in particular to be seen, assessed and a decision made in a calm environment as to whether or not they need to be admitted or can go somewhere else.

We have also had a very successful nursing home in-reach project, which we developed with the integrated care partnership in collaboration with our general practitioner colleagues and community organisations. This is a project where we support our colleagues working in the independent sector and nursing homes, to skill them up to be able to keep, in particular, older people in nursing homes for longer and reduce the likelihood that they cycle in and out of our hospitals.

As I said, we see ourselves in large measure as a community-based organisation. It is useful to point out that we had 1 million contacts within the community in the last year. We provided 2·5 million hours of domiciliary care. Our district nurses had 330,000 different contacts with people in the community. That has to be an ongoing focus for us, if we are to be successful.

As Elaine and Michael described, we also provide a busy range of secondary care services. Unlike them, we tend not to provide specialist hospital services, but we have very good network arrangements with both Altnagelvin and Belfast to provide seamless care, particularly, for example, on trauma and orthopaedics and cardiology. Cardiology is a really good example of that with Belfast, where our excellent team of cardiologists all do sessions in the Belfast Trust. They all have catheter lab lists and can do their own investigations and interventions. That has to be a model for us. Michael, Elaine and I are talking about how we can continue to enhance that, to ensure that the 460,000 people whom I serve get the very best services, without necessarily duplicating those services.

In thinking about the trust and where it is at the moment, last year, we launched our reform and modernisation programme. We call it RAMP; we are keen on acronyms in the north. It was backed by the then Minister as a way forward for the Northern Trust. It is a way of looking forward, rather than looking back at some of the difficulties that have been experienced previously. It is a five-year plan that outlines an ambitious reform agenda, focusing on keeping people safely at home or in the community, and delivering effective services from our two acute hospitals. As I have said, there is a strong focus on developing networks with our two neighbouring trusts.

To deliver RAMP, we have mapped out three key areas. We want to focus on service reform and transformational change; developing our people, that is, the people who work for the trust; and ensuring the best use of resources. I will give you a couple of examples of each of those strands. On service reform, our absolute priority is to deliver a locality model, bringing our teams together in four localities. We have split the Northern Trust area into four community areas: Causeway coast and glens; east Antrim; Antrim and Ballymena; and mid-Ulster. Unfortunately, those areas do not correspond completely to the council areas, but that would be an impossible task for us. The important thing is that we have totally integrated teams working within their locality, knowing their population, encouraging community and voluntary sector involvement and building on social capital. The best example of that which we have to date is our Dalriada pathfinder in Ballycastle, which is a truly diverse group of people coming together from the council, the Health and Social Care service, voluntary groups and local GP practices to provide alternatives for people. Based on the Living Well model in Cornwall, it is about finding alternatives to hospital. It is an example of something really positive coming out of a challenging period for us, which was discussion of the future of Dalriada Hospital. It is an absolutely fantastic example. I have already mentioned our nursing home in-reach, which again is a collaboration with GPs and the independent sector. Our focus is on a completely different approach to delivering community services.

The second element of transformation is in our acute hospitals. We have a clear vision for the Causeway Hospital, which has been supported by our local medical staff. We see it as a busy elective centre, providing a range of elective services and services for people with long-term conditions.

We believe that we will be able to deliver a dialysis unit there very shortly, but, more importantly, we believe that, by having that range of services, we will also be able to maintain the acute and emergency services that are still needed in that area. We are conscious, however, that that will play out and be influenced by Professor Bengoa's report. We await that with interest.

Antrim is in a slightly different position. We believe that it is a strategically important area hospital. The hospital serves a fair part of mid-Ulster, Ballymena and east Antrim, right into north Belfast. It works collaboratively with the Belfast Trust in delivering elective and emergency care. We need to work smarter there. We have a plan to right-size Antrim, which means making Antrim more efficient in the flow of patients and ensuring the best possible outcomes, and also recognising the need for a capital development of the site. Unlike Elaine and Michael, I probably cannot turn to a huge number of significant capital developments in our patch, at the moment, but we have put clear plans forward to the Department for getting Antrim to the right size to deliver the services that, I believe, the region will need.

The other things that I want to touch on, very quickly, relate to the best use of our resources. We have 330 buildings and pay a lot of money on rates. We would like to see some reduction in the amount of rates that we pay and to invest that into staff. We have an active programme to do that. We would also like to retire some of our older institutions. Holywell, for example, comes to mind. We have put our plan forward for an acute mental health inpatient unit.

The only thing that I want to mention about our people is that we had a very active plan to bring social workers — I will mention them first — nurses and doctors into management and leadership roles. We have been very successful in doing that. We now have a senior leadership group and development programme for 60 people, including all specialties and practitioners. We are moving to a situation where we want to be practitioner-led — have decisions made by the front line — and management-supported. We have funded that shift by a reduction of our professional managers and other management costs.

Others have mentioned awards that they have won. We have been successful in winning awards too, but I will mention just one, because I think that it is important in terms of the confidence that people have in our acute hospitals. Our acute hospital services, for a second year running, have won a top national patient safety award. It reflects our priority on that.

I am conscious that I have probably used my time. I will mention one other thing: mental health services and our absolute focus on them, particularly our new rapid assessment, interface and discharge (RAID) model. If I had time, I would explain it to you. Like Michael's, our CAMHS turned round in the last year, and we no longer have young people waiting for more than nine weeks to be seen. On that, I will stop. Thank you for listening. I hope that it was helpful.

Mr Hugh McCaughey (South Eastern Health and Social Care Trust): I will say a little about the South Eastern Trust. I will give some background, details of some of the reform and change that we will be making, some of the highlights and maybe some of the challenges.

Our population is similar in size to the other three trusts outside Belfast. We have about 350,000 residents. We spend over £0·5 billion and employ roughly 12,500 staff. I have a sheet with a large number of statistics on activity. I will share that with the Committee Clerk who can circulate it. That will save you having to listen to more facts and figures on activity. Needless to say, we provide the full range of services across all the programmes of care: mental health, disability services, older people in primary care, children's and acute or hospital services. In addition, we provide all the healthcare for the three prisons in Northern Ireland. We also provide the regional secure care unit for children in Lakewood, and plastic surgery in the Ulster Hospital.

Our hospital services comprise one large acute hospital at the Ulster Hospital, two smaller hospitals at the Downe and Lagan Valley, and two community hospitals at Ards and Bangor. Those are the five main what we term hospital sites.

I move now to some of the transformation and reform. There has been a gradual and evolutionary process of change across our services over the last five years.

Some of the highlights are that we had the first two stand-alone midwife-led units in the Downe and Lagan Valley. Indeed, those were the first two on this island. We have been trying to evolve and change, in particular, our smaller hospitals, to strengthen them, address some of the vulnerability that lies around them and make sure that they have a strong and vibrant future. We have developed an urgent care model in the Downe and Lagan Valley. We have a large growth in ambulatory services, so we have more day cases and a broader range of outpatients and more diagnostics going. We have been able to extend the range of ambulatory services to both those hospitals.

On mental health, we, like others, have been on the journey of moving from institutional-type care to one that is much more based around recovery, therapeutic intervention and rehabilitation. One of the highlights is the establishment of the recovery college, where we do a lot of work, co-produced and co-designed with users of the service, that provides training to people and enables them to help with recovery and rehabilitation and gives them the skills to deal with mental health issues.

There is much publicity about and attention on unscheduled care. At the Ulster Hospital, we have seen a 40% increase in admissions over the last four years. That is very significant growth. We have been doing a lot of work to try to help with how we ensure that patients move through each of the hospitals smoothly. We have done a lot to enhance seven-day working and ambulatory pathways, where we offer alternatives to ED and admission, so that people can come back the next day or access one-stop shops and services on an ambulatory basis, where they do not need to be admitted. In the last number of months, we have established a frail elderly rapid assessment unit in the Downe, which has been very successful. We plan to extend that into the Ulster in the coming weeks. We have also increased our senior medical presence and decision-making at night and weekends, which enables us to ensure that patients are actively treated and processed through the hospital much more quickly and efficiently. We also, last winter, established a community hub in the hospital, which was very much a bridge between the hospital and community services. It has worked really effectively; we have significantly shortened the length of time that people wait in the hospital for discharge, particularly for patients who wait for over 48 hours for our own residents. We are pleased with a lot of the developments that have been happening there.

In the community, similar to many of the other trusts, we have been extending and developing the range and level of our services. We have an enhanced care-at-home model, which we have piloted in the last year in north Down and Ards, and that extends the range of things that we provide in people's homes. We have a falls service, which is trying to intervene and prevent some of the falls with older people. We have an early supported discharge for stroke patients, so again we are facilitating and improving services in people's homes. We have a home oxygen service, where we can do things that we could not in the past. Also, the range of things that we can offer in our social care response is extending.

Critical to our transformation is the question of how we get upstream and how we help people to age better and stay well. I notice that one of the statements on the Health Committee's banner is about a focus on prevention and well-being. That focus is critical to the transformation and some of the major changes that we need to make.

We have had a focus in the trust on early intervention and how we can help people to age better. How do we address the challenge of rising demand? We have done a range of things to try to improve health development. We have quite a number of early intervention and self-management schemes across chronic disease, particularly heart attack and diabetes. We are working with councils, particularly on their community plans and how we can reach into communities to offer services that will help people to live independently. We have befriending and care-in-community schemes. We also have programmes for people with hazardous drinking. We are doing quite a bit; it is an important focus.

One of the highlights over the last five years that I would like to mention is the development of our quality improvement programme — the safety, quality and experience (SQE) programme. We have trained approximately 500 staff, and we have had over 150 quality improvement projects, where people at the front line have the skills and are choosing to make improvements to their service and things that we, at board level, cannot see. We are giving staff the skills to make improvements in every service right across the organisation.

Earlier this week, we held our end of SQE programme for this year. It is a nine-month programme, and we had 40 projects this year right across acute care, disability, mental health, dementia and children's services — all were things that improve the quality and efficiency of service that was being offered by our teams.

I will now turn to capital schemes. In the last six or seven years, we opened the new Downe Hospital, and there was significant investment there. We will finish our major capital scheme for the Ulster Hospital — the first phase of phase B — which will open in the spring of 2017.

As the others have said, the challenges are to do with addressing rising demand. As I said the last time at the Health Committee, we face the issue of 3% to 4% growth, largely around ageing, maybe 1% to 2% inflation and 1% new things, which gives us a drive of about 5% to 6%. How do we address that? It is very difficult to invest at that level, so it is critical that we transform our services and, particularly, do that piece about getting upstream and helping people to age better and not need health and social care services. In that respect, we will be working very closely with councils and their community plans. The capacity, elective waiting times and workforce issues that people have talked about are very similar in our trust.

Mr Francis Rice (Southern Health and Social Care Trust): Thank you for the invitation to come here today. I will briefly give you a little background about the Southern Trust, and I will talk about some of the strategic change, modernisation and notable achievements and then the challenges, which are very similar in nature to those in the other trusts.

The Southern Trust delivers the full range of health and social care services to a population of 390,000 people. The trust experienced a 19% population growth between 2000 and 2013, and this is significant in a number of areas, including younger and older populations. There has been a 17% increase in births from 2001 and an 11% increase in the growth in the zero to 17-year age group. The trust has a high level of children with statements of educational need and a central and eastern European migration, which accounts for 4·2% of our population.

The trust has a daily expenditure of £1·7 million, which is £595 million a year, and 14,500 staff delivering local services to local people. In 2015-16, over 160,000 patients attended our emergency departments and minor injuries unit. The trust delivered just under 6,000 babies and received over 12,000 childcare referrals. Approximately 58,000 patients were admitted to our hospitals and 392,000 patients attended outpatients' appointments and consultants. The trust supports 5,000 people in their own homes, delivering over five million domiciliary care visits each year to older people and those with mental health and learning disabilities. The trust also supports carers and undertook just over 1,000 carers' assessments last year, recognising the critical role of carers.

The trust works very closely with the three councils within its geographical boundaries: Armagh City, Banbridge and Craigavon Borough Council; Newry, Mourne and Down District Council; and Mid Ulster District Council. The trust is very active in ongoing community planning activities. The trust shares a border with the Republic of Ireland and is a member of the Cooperation and Working Together organisation, which has supported the delivery of the first telepresence robot in the UK, giving intensive care specialists in Craigavon Area Hospital the ability to remotely access and support patients in Daisy Hill Hospital. The trust has strong links with its local statutory, independent and community and voluntary sector partners.

I am proud to be the interim chief executive of the Southern Trust, supported by an established senior management team, and able today to share a range of clinically and professionally driven initiatives and improvements that reflect the trust's commitment to safe, personal and effective care, many of which have been nationally recognised, as they have been in the other trusts. That recognition includes the achievement of the CHKS Top Hospitals award for the fifth consecutive year and a range of national awards across our entire staff base, recognising practice leadership, excellence and innovation.

In 2015-16, the trust has continued to embed its quality improvement framework, which aims to keep patients at the centre of everything that we do and build capacity and capability in quality improvement to embed a culture of continuous improvement. At the same time, it continues to deliver consistently on productivity and efficiency, which is evidenced through external benchmarking, whilst delivering a balanced financial position.

The trust is progressing a number of infrastructural changes to meet best practice guidelines and improve service user experience and is currently developing the outline business case for the redevelopment of Craigavon Area Hospital, which, I am sure, most people may know is over 40 years old now. Other schemes awaiting capital investment include an enhanced pharmacy aseptic suite. In addition, key strategic developments ongoing include new paediatric developments at Craigavon Area Hospital and Daisy Hill Hospital, due to complete in 2017, as a result of our Changing for Children strategy in the trust. Community care and treatment centres have been delivered in Portadown and Banbridge, and a further development is planned in Newry.

The trust continues to support the delivery of Transforming Your Care and successfully delivered a shift left of £7·4 million at March 2015. It continues to maximise independence via a range of models, including the reablement service — supporting older people to live as independently as possible at home — and acute care at home — a consultant-led service that provides acute care to older patients in their home setting to avoid admission to hospital. This service currently supports the equivalent of approximately one virtual acute ward at home.

Supported living options, a range of floating support and sheltered supported living units for older people and adults with mental health and learning disabilities are being progressed in partnership with Supporting People and the Northern Ireland Housing Executive in a number of trust localities, primarily around Kilkeel, Armagh, Dungannon, Banbridge and Dromore. We have also had enhancements in specialist community teams and technology to help manage long-term conditions in the community, with the development of one-stop clinics for rapid access and treatment, for example, in geriatrics and respiratory services. The trust is piloting a new domiciliary care service model delivering an outcome-focused approach.

The trust has completed the resettlement process from the Longstone and St Luke's Hospital sites and has developed a range of community-based services to support people to live in their local communities, including home treatment crisis response, behaviour support services and the development of day opportunities. Also, over the past number of years, we have put an extension on the Bluestone unit in Craigavon, which currently provides all inpatient acute hospital services for people with mental health and learning disability problems. A crisis response service for learning disability is the first of its kind in Northern Ireland that has been nationally recognised. It has been established to help adults with learning disabilities to avoid hospital admission in times of difficulty.

In services for children and young people in the Southern Trust, we have established the intellectual disability service in CAMHS and the infant mental health service for CAMHS in the region.

The trust continues to work on the further development of the autistic spectrum services model. We welcome the additional investment that we received recently, which supports the assessment, diagnostic and intervention services that we are able to develop for patients and clients with autism.

The trust has also worked to reduce reliance on residential placements for young people, developing a range of community alternatives, including the expansion of a front-line fostering scheme and recruitment of additional carers to the intensive support scheme, which is professional fostering for children with complex needs.

In our acute paediatric facility in Daisy Hill Hospital, the trust has successfully trialled the first baby heart screening test for the region and can detect up to 76% of heart defects. Both hospital sites have extended their provision of ambulatory care services as alternatives to hospital admission for children.

I will move on briefly. We have the same sort of workforce challenges. We have particular challenges around our medical workforce in the Southern Trust — indeed, we now know that nursing, in particular, is on the Government's UK shortage occupation list — but we are taking forward with NIMDTA, the commissioners and the Department initiatives to address those areas of difficulty, and, with our overseas recruitment, we have just recently secured 16 doctors to come and work in the Southern Trust, which is very positive.

On the nursing workforce, some colleagues mentioned the ongoing international recruitment. We have also welcomed the additional pre-registration nursing placements that the Department has commissioned because they will help us to address a significant problem. In the trust, we have 98 nursing vacancies across all branches of nursing.

We also have challenges in the trust with psychologists and domiciliary care workers. We need to recruit 120 staff each year to manage and maintain our services and manage turnover. Those are two others that are quite an issue for us.

Another issue is GP out-of-hours services; we are very challenged with that at the moment. I think that it is recognised that there are a number of challenges in in-hours and out-of-hours GP services across Northern Ireland. Again, we are working with the commission and the Department to see how that may be addressed through additional placements and overseas recruitment on all those issues. That is an issue, and some members around the table today will appreciate that there are other significant issues in the Southern Trust at this time. The issues with elective care access and unscheduled care access are the same as those that have been mentioned.

On usage, the trust has experienced an increase of over 10% in ED attendances in the past five years. May 2016 saw the highest ever number of ED attendances in the trust in the 10 years or so that we have been in place. In the last 14 months, both Craigavon and Daisy Hill emergency departments have seen a significant increase and, indeed, significant pressure. I think that it is also important to say that 80% of our attendances are triaged as being from category 1 to category 3, which means that they need to be seen immediately because they are either very urgent or urgent. We are working to understand the type and the nature of admissions, and I think that some of my colleagues also referred to the acuity and the age of patients coming through emergency departments.

Chair, I will leave it there, because all the other issues have, I think, been covered by my colleagues. Thank you.

The Chairperson (Ms P Bradley): Thank you all. It does us good at the beginning of a mandate to have an overview of just exactly what is happening in each trust. I know that a lot of the issues will spread across trusts. As a North Belfast representative, speaking personally, I fall into the Northern Trust and the Belfast Trust, and having a good relationship with the chief executive and their office bodes well for us in helping our constituents. I think that I probably speak for all MLAs when I say that. I am really encouraged to hear about council community planning and about how that is broadening out provision as well. That is also extremely helpful.

You spoke about your many achievements, which is great because that is what we need to hear. That is a message that needs to go out, and we need to make sure that the public hears that. There was a little about the challenges. I will not ask you to expand too much on some of those challenges, but I know that workforce planning is an issue. Some of the figures on the increase in people arriving at EDs are quite unbelievable. There has been a sharp increase, so we need to drill down a wee bit into why that is happening and how it can be averted. That was interesting.

I have to leave shortly, as I have a meeting in Holywell Hospital with, funnily enough, the Northern Trust this afternoon, so the Deputy Chair, Gary, will take over,. There are a few members down for questions: first, Jo-Anne; then Paula; Gerry; and Catherine.

Mrs Dobson: Thank you all for a comprehensive overview. Like Paula, I have a great working relationship with Francis, and I wish him and his successor well in their new roles. I think that it is important for us as elected representatives to have that access. It seems as if it is nearly 24/7, Francis, so I commend you for always being available.

I know that there is major concern in the whole system about the changes to the Health and Social Care Board. Will you outline for us, from your perspective, the concerns that you have about the potential impact on your trusts and on the finances coming from monitoring rounds? I think, Elaine, that you were the first to welcome the £72 million, which is very welcome. I am referring to the £40 million, the £30 million and Tuesday's £72 million announcement. Can you assure us that every penny will be spent?

Mrs Way: You mentioned the major concern about the changes to commissioning and the ending of the Health and Social Care Board. Michael said — it is a fact — that there is great collaboration now not just between the trusts as provider organisations but between all organisations in the system. Michael, Tony and I were at a meeting earlier this week at which we talked about the Health and Social Care Board being removed and what the system would look like. I think that it would be fair to say, Michael — you might want to expand on this — that the entire system, including colleagues who work in the Health and Social Board and in the Public Health Agency, is working towards the same aim, as Tony described, namely that the patient and client is at the centre of all our work. We should not let organisational structures get in the way of trying to deal with the many challenges that we all share and face together. The entire system is working very positively. Our staff were very engaged in responding to consultations on structural change and so on, and we are all committed to making sure that no ball drops as we go forward. As I said earlier, we met the Minister and she made it clear that she would like to spell out her vision for the future. It will take into account issues like Bengoa but also the Health and Social Care Board.

I can only speak for my organisation, but I do not think that there is anxiety among front-line staff about potential changes. They see a huge opportunity to work more closely with councils, GPs and other primary-care providers, and the community and voluntary sector, to address local needs.

Mrs Dobson: Is that view shared by all?

Dr McBride: I will build on what Elaine said. Sir Liam Donaldson's report talked about commissioning and said that we have the worst of both worlds at the moment in that we have never fully gone down that pathway and we have a sort of halfway house and all the transactional implications without having a true commissioning vehicle and mechanism. There was a very thoughtful consultation. We all participated in that, and, as Elaine said, the permanent secretary in the Department has had in place for a significant period a strategic leadership group that we all input into. We have a restructuring programme board, which, again, has representation from all the parties, and we have a very engaged and participative process in how we redesign a more effective model.

Let us be clear: as the then Minister said, this is not a reflection of the skill, talent and commitment of the individuals working in the Health and Social Care Board. The functions will still be required in assessing population need and looking at the best evidence on how we meet that need. As Tony said earlier, it is about how we ensure that we get the system of care right for the population that we serve. We have a really exciting opportunity with, as you mentioned, Professor Bengoa's report and in how we then reverse that report and its recommendations and, subject to the Minister's consideration of that and due process, how we then fit that into the restructured health and social care model that we have. The progress that has been made is tremendously exciting, as are the developments in local government and the introduction of community planning. Hugh mentioned the importance of health being better aligned to improving health and well-being and to making sure that people are less dependent on health and social care services. As organisations, we are trying to improve that. It is a very exciting agenda and one that colleagues in the Health and Social Care Board will be partners in, because their skill, knowledge and experience will be required.

Mrs Dobson: What about my second point about the monitoring round? Can you assure us that the money will be spent?

Mr McCaughey: That will be very easy to answer. I think that the answer will be yes.

Mrs Dobson: Every penny will be spent.

Mr McCaughey: I do not think that we will have any bother spending every penny at the delivery end. In fact, if you can give us any more pennies, I am sure that we can spend them as well.

I will add to the point about the Health and Social Care Board's change. One of the concerns that has been touched on is the uncertainty during the transition period in any restructuring. Michael has already covered it, but we have arrangements in place.

We all have a role to play to ensure that in the next two to three years, which is a period in which we can — and need — to make lots of change, we do not have major distraction, but I think that the arrangements that we have put in place can manage that. We all have a role to play to make sure that we continue to support that transition but transform and reform the service as we do.

My only other concern is that there are clearly 500 to 600 people for whom this is very traumatic, and we all have a role to play to make sure that that personal trauma is minimised. As Michael says, many of the functions will continue, and we need to make sure that, for the individuals involved, many of whom have spent a long time in health and social care roles, that trauma is minimised.

Dr Stevens: There will be some challenges with the reform, but there are fantastic opportunities, particularly if you see each of the trust areas as a health economy, or even as a sub-economy below that. We have all referred to the demands on our emergency departments, the solution to which has to be in the community and in working collaboratively with primary care: GPs. I think that that may unlock some of the potential for us to work more collaboratively to find local solutions. At one level, we have to work across the system. For me, it is working with two other trusts — well, all the trusts, but two in particular — in delivering services. Equally, looking inwardly, there is an opportunity to find the solutions that will care for people outside hospitals. I see real opportunity in this.

Mrs Dobson: Francis knows that I keep a keen eye on this in my own trust, the Southern Trust. My second question is about waiting times. There is considerable variance between trusts in waiting times for breast cancer treatment. I want to take a little time to outline that. Seventy-six per cent of urgent referrals were seen within the 14-day target. However, there were wide variances. Elaine in the Western Trust was at 99%; in the Southern, Francis was at 93%; in the Northern, Tony was at 78%; in the South Eastern, Hugh was at just 66%; and in the Belfast Trust Michael was at just 43%. We know that there were issues that led to the figure being as low as 24% in Belfast in December. Let me put it very bluntly to you all that none of you can guarantee that no patient came to harm as a result of not being seen in time.

Dr McBride: I want to pick up on that. I know that the figure for the Belfast Trust in May was 70%. I do not have the figure that you refer to before me. We have to recognise that, across all the services, these are very small teams. It is a consultant-provided service, led by skilled individuals at consultant level. It is a multidisciplinary process, a one-stop shop where individuals are not coming back for three or four visits. They come and have their assessment and all their diagnostic work-up; they have their diagnosis there and then; and only seven out of every 100 women with red-flag referrals actually have a breast cancer that requires onward treatment. That is important to bear in mind: seven women out of 100. I do not intend, in any shape or form, to minimise the distress that individuals have in waiting. The last Health Committee spent an extensive period discussing this.

Mrs Dobson: We did, yes.

Dr McBride: The Committee met the clinical team from Belfast. There are significant workforce issues that we all experience in these small teams, such as sick leave, sometimes significant periods of sick leave, and maternity leave. That is the reality of small specialist teams. However, we should look at the totality of the pathway. That is the important bit: seven out of 100 women who are referred up as urgent, red-flag referrals, and who have a cancer diagnosis. I have the figure for Belfast; I am sure that colleagues have the figures for elsewhere. In Belfast, 94·5% of those patients have their definitive treatment, their surgery, within 62 days. That is the important aspect, and we should not lose sight of it.

There are challenges with the initial 14-day period of the pathway, but those women who have diagnosed with a breast cancer are having timely, effective surgery across sites in Northern Ireland. We also need to put it in the context of having the best breast cancer survival rates in the UK.

Mrs Dobson: If they get to the treatment in time —

Dr McBride: I am saying that we are getting to the treatment. At a population level where we are better than the other parts of the United Kingdom in terms of results for breast cancer and definitive treatment for those with a diagnosis of breast cancer — yes 94·5% are getting it within the important time frame of 62 days. I absolutely accept there are challenges; certainly there are challenges in Belfast with capacity. The capacity in our service in Belfast is 60 to 70, and we were seeing in the region of 20 to 30 more per week over and above that. We have worked collaboratively to support one another when there are pressures on one service to ensure that we minimise the impact on other services. However, it is a challenge, and every year around October we see with the breast awareness campaign a significant —

Mrs Dobson: That concerned me because you referred to it. We discussed this extensively during the last mandate in the Health Committee. One thing that did concern me was that officials on the board attempted to suggest that breast cancer awareness month in October was somehow to blame for a deterioration because it was so successful.

Dr McBride: No, raising awareness is important. What we want to do is encourage women who have symptoms that they have been worried about, but who have not sought advice, to seek advice. The service gears up for that. We plan for that, and in Belfast we had geared up for a 25% increase in demand; we actually saw closer to a 35% to 40% increase.

Mrs Dobson: You know that it happens every October.

Dr McBride: And we plan for it, but the demand exceeded what we had planned for. It is important that we do not put a message into the public domain — or that we at least put a considered message into the public domain — that women are coming to harm as a consequence. It would be unwise for that to be the message being communicated publicly because we are providing excellent treatment and care for women diagnosed with breast cancer, and we need to improve our performance.

Mrs Dobson: When they get it.

The Deputy Chairperson (Mr Middleton): I am conscious of time and the need to ensure that all members get their fair share. We are going to go to Tony first and then to Hugh.

Dr Stevens: I will very quickly give you a little bit of reassurance. The first is that all the trusts take part in an annual breast-screening programme, and we get a report based on national data. I cannot speak for the other trusts, but I know that they are pretty much the same. The Northern Trust has achieved 80% breast screening of eligible women — the best in the UK. Critically, we are hugely successful at identifying and getting to the women who need to be screened. The problem that we have all faced, and these are highly technical and very skilled teams, is that if you get a 20% to 30% increase over a short period, with the best will in the world, you will not cope.

Jo-Anne, you are quoting average figures, and I can only say for the Northern Trust is that we are back up in the high 90s.

Mrs Dobson: Good.

Dr Stevens: We had a couple of bad months. I do not want to blame the screening programme, but it brought a significant wave, and we dipped. The point that I make to you about providing reassurances is that, although you might miss the 14-day target, ask how we do by 16 days or 18 days, and you find that nearly everybody has been seen. Two or three days will not make a material difference.

Mrs Dobson: Those are Government-set targets for 14 days.

Dr Stevens: I realise that, but you asked whether people come to harm, and I am saying that, no, they will not come to harm because we are talking about a few days. The issue is whether you are putting a woman through an extra few days of anxiety, and we do not want to do that. However, it is not changing the outcome.

Mr McCaughey: I am conscious of your time and I have a few quick points, as Jo-Anne did mention our figures, which have dropped. We are sometimes accused of not always co-operating and helping one another, but part of the reason that our figures dropped in autumn last year was because Belfast had a particular problem. We worked together to provide assistance. Our figures took a drop during that period, but it was an agreed position so that it minimised the impact across the two trusts. It is a very good example of how we helped each other out.

The second point, building on what Michael said, aligns with what is proposed in the new Programme for Government, and that is the outcomes — they are the best in the UK. Whereas, when we were looking at just the 14-day target you could think that this service was in particular bother. There is a message in there about us moving from speed- or access-based targets, as is the intention of the Programme for Government. What we have to do is increasingly look at the outcomes of our interventions. What is the impact of our services on the overall health status of the population? That is a good example of how, in many ways, outcomes are more important than the process measure, albeit it was a target. That is where we are trying to move from clock-based targets to things that embody outcomes much more.

Mrs Dobson: People waiting, concerned and anguished.

The Deputy Chairperson (Mr Middleton): We want to get round as many members as possible. We can go back round if we have time, although I doubt it.

Ms Bradshaw: Thank you to the panel. It was very interesting. We have this first session over two weeks. You have just answered my question about outcomes in the new Programme for Government. What plans are you putting in place to start measuring them, and how do you define having reached somewhere? I was thinking of the talking therapies, which is a small programme. I think that they measure very much in terms of how many people availed themselves of the six services. I thought an outcome would have been the number of people who came off anti-depressants. How are you gearing up to putting in place your outcomes-based accountability framework to measure, using IT or whatever? I just wondered, because it is a significant shift.

Mrs Way: We are at a very early stage. There was a cross-departmental workshop recently looking at the Programme for Government and how outcomes-based planning would be approached. We recognise that in a lot of areas, we cannot do it on our own. That takes us back to what we have been saying about needing to work with our colleagues in primary care, the councils and so on.

When talking about street drinkers, homelessness, etc, you can tell that we are going to have to be joined-up. Likewise with suicide prevention. We cannot do that on our own; there has to be a whole-systems approach. We are just beginning to re-look at this. Next week, we are beginning to look internally at our planning and how we need to shift towards an outcomes-based approach.

Because we are professionally and clinically driven, we tend already to use an evidence base that if you make that intervention, you can expect this outcome. We measure ourselves against that, and against best practice, but we have to change our thinking towards it being not about just us but about others who make contributions and how we can bring them in and plan together towards better outcomes.

We are at a very early stage of the process and are learning as we go along. We will look to other areas that have good examples. We heard about great working in Scotland, and that is the sort of thing that we would be looking across to try to accelerate our learning so we get better at this.

Dr McBride: Jo-Anne made a very valid point: that is the target. It begs the question: do we have the right targets? Hugh mentioned the importance of outcomes. The Scottish Government are looking at entirely reviewing their programme of work on the outcome measures that they have in place for health.

Process measures have their limitations, as Hugh said. We discussed the 14-day target for red-flag referrals for breast cancer. However, some process measures are hugely important. Getting your fractured hip operated on within 48 hours if you are medically fit can make a difference between your surviving or not surviving, so some process measures really matter, and some things are time-critical.

We mentioned some of the quality improvement work that is going on across the service. Organisations record that. We do not necessarily measure that at a system level in terms of the clots on the lungs that we have prevented because we are doing the right thing for patient care. There is the problem that we have with sepsis and how emergency departments ensure that we get people who are septic the appropriate diagnostic tests and antibiotics. Some of the measures that we are taking for falls among frail elderly people, which Tony and Hugh mentioned, are important in improving health and well-being in all the population.

You touched on the Programme for Government.

Breastfeeding rates in our hospitals are something that we measure but will not necessarily report on. Another is the differential in smoking in our maternity units. Smoking in pregnancy sits at something like 14·7% regionally. In the Belfast Trust, it is, off the top of my head, 19·1%. That does not mean to say that Belfast is doing a really bad job. What it means is that, if you go into different geographical areas, there are particular challenges. As Hugh and Tony said earlier, it is about us linking what we are doing as a health economy or as sub-economies working with local government and seeing how we can align what we do with realising elements of the Programme for Government through what we deliver in health and social care.

Patient-reported outcome measures — their experience of their care — are important. Often, we will measure hip fractures or orthopaedic procedures on the basis of the numbers of procedures that we provide, but what does that mean for the individual patient's mobility or return of functionality? We need to get cleverer and smarter about measuring those things. Elaine is absolutely right: some of them are difficult to measure because they are very difficult to quantify, but we increasingly need to move towards having a more outcome-based approach to health and social care.

Mr McCaughey: It is not only that they are difficult to measure; it is that it may take some time to change the outcomes. There is a very positive feeling in the service that, with the Programme for Government, community plans and a move to much more outcomes-based accountability, there is an alignment right through from government to local level for what we are trying to achieve. As I said, your banner talks about prevention being better than cure, well-being being everyone's business and being healthy in body and mind. That is a very clear statement that health status is the big goal.

The Deputy Chairperson (Mr Middleton): That is useful. Tony, do you want to say a few words?

Dr Stevens: I have just a very quick point to make. Paula, you mentioned the talking therapies —

Ms Bradshaw: I was not criticising. I was just saying —

Dr Stevens: I wanted to give you an example. It has already been referenced that we ran a quality symposium in the Northern Trust. Our head of psychological therapies, or talking therapies, presented on the work that clinicians are doing with young people who present with acute mental illness. They completely turned the service around and front-ended it to do early intervention. Their very clear outcome measure is the number of young people who go on to develop a psychotic illness. You can define psychosis: it is a very severe illness. It is a negative outcome if they develop a psychosis. Since they front-ended it and turned it around, nobody out of about 150 or 200 who have gone through it so far has gone on to develop a psychosis. Clinicians are the people whom we trust to develop and quality-assure the services. They are developing outcome measures. I raise that because you very specifically mentioned talking therapies.

Mr Carroll: Thanks for the presentations. I have a few questions for Michael — he might have got wind of them earlier — about the annual report. It stated that there are savings of £20 million to be made by the trust. I have a few questions, so I will just go through them. Where do you intend those to come from? Our packs mention the closure of the Whiterock and Everton mental health day centres. That is something that I am extremely concerned about. How can that be proposed when there is a mental health epidemic in our society? We said earlier that areas of deprivation experience health inequalities and the highest levels of self-harm and suicide. One of the users in Whiterock mentioned to me that, if Whiterock were to shut, he would go nowhere else. It is a big concern, and a big loss of service. The annual report states that the decision will go ahead and that, subject to consultation, the changes will be made.

Next week, there will be an announcement of the consultation process, but there have been thousands of responses to say that mental health and learning disability centres should remain open. As I am sure that you are well aware, the initial decision was to have been made on 14 January. The period in between has caused a lot of fear and anxiety to service users and their families, because they do not know what will happen in the future. Are you aware of that? Moreover, will the concerns of the service users, their families and the people who have objected to the moves be taken on board in the decision to be announced?

Dr McBride: OK, I will deal with the first question very quickly . I do not have the detail of the paper with me, because that was the last presentation on savings in the previous mandate. The trust has worked assiduously to realise savings, and, like all organisations, we seek to do so while avoiding any impact on front-line services. Again, the major areas would have been reducing overhead costs and management costs in all trusts. In the Belfast Trust in particular, the management costs compare very favourably with anywhere else in the UK. By that I mean costs associated with procurement and from reducing sickness absence. Indeed, we have achieved the ministerial target in reducing sickness absence, saving some £800,000. It is not just about training management and providing a new toolkit but about ensuring that we promote staff health and well-being through the roll out of the new "b well" app. We have also made savings in pharmacy services. The approach that we took was to minimise, as far as possible, the impact on front-line services, and I am pleased to say that the trust broke even last year. Obviously, next year is next year, and we are not in a position at this point to discuss the details of that.

You made a very important point on the mental health and learning disability consultation. It is entirely consistent with the Bamford recommendations and review. Mental health services and learning disability services have transformed significantly over recent years. In mental health, we have moved away from institutional-based care to community-based care, with home support teams and rapid-response teams. In learning disability services, significant capital investment was made across all the organisations, as you heard, in the Southern Trust and, as I outlined, in the Belfast Trust.

Will those changes happen? Obviously, there was a consultation. There was significant engagement with carers, users of service and elected representatives. There were a number of public meetings held, and significant representations were made. We probably had more responses to that consultation than to any other that we have ever had. As a result, it has taken us longer to work through all the responses, and we then ran into purdah and the election. Those were factors. We have a statutory responsibility for there to be public and patient involvement in consultations under the 2009 order. We publish our consultation schemes to engage, and I think that we have engaged. I hope that the recommendation that the trust makes to the public trust board on 21 June will reflect the fact that we have listened, that we have heard, and that we have taken on the views and concerns of carers and users of service. The recommendation remains subject to consideration and approval by the trust board. It will then be considered by the Health and Social Care Board, and, finally, any decision will be ratified, or not, by the Health Minister.

Mr Carroll: If the overwhelming number of responses are against the day centres closing, will you give me a commitment that that will be the decision reflected in the meeting next week?

Dr McBride: I can give you an absolute commitment that this has been a genuine consultation process, and, as an organisation, we are mindful of our statutory responsibilities for there to be patient and public involvement. We have listened and we have heard, and we have gone through the responses that we received. Those views and everything that we have heard through every meeting will be reflected and captured in our recommendation to the trust board.

As the chief executive of the trust, I am not at liberty to outline what that recommendation is at this time, and it is right and proper that we go through due process. We will make the recommendation to the trust board at the public trust board meeting, at which carers and users of service will have speaking rights. Moreover, we are endeavouring to facilitate that public trust board meeting by laying on transport for carers and users who wish to come to the venue. We had to identify a venue that is sizeable enough to accommodate the range of views that you say has been expressed, and we have worked very hard to accommodate that, including changing the time of the meeting to meet the needs of service users and carers. It will be consultation in action, I hope.

Ms Seeley: I apologise, but I need to leave in five or six minutes. I have a meeting to attend now, and I have to meet Francis and my colleague John O'Dowd later this afternoon. I will keep my points brief, and we can go into Upper Bann issues in the meeting this afternoon.

I have points to make rather than questions to ask, because I appreciate that the time is nearly up. First, I want to say that I am encouraged to hear that front-line staff are going to be considered for management and leadership roles. I hope that some of those roles go to women, because I note that our chief executives are predominantly male. I hope that we are prioritising the recruitment of women into leadership and decision-making roles in the different trusts, and I am sure that that is ongoing.

I have some concerns, but most have been addressed in today's responses. They include how where you live dictates the level of service and the priorities of the trusts. However, I am heartened to hear that there are strong relationships with the Armagh, Banbridge and Craigavon Borough Council. It seems to be a trend, and it is vital in community planning that the social issues and how we need to work together to respond is understood.

I have a brief question. I promise that it is brief, and it is also relevant because it was not touched on, but I am sure that it is happening. It concerns your relationship with the Education Authority. It is undergoing huge change at the moment. Yesterday, its representatives presented to the Education Committee. It is going to appoint people to roles in particular areas. What relationship do you have, or hope to have, with the Education Authority, particularly given the fact that we have 2,000 children awaiting an autism statement. We can tackle such issues better and more quickly only if we work together.

Mrs Way: Many years ago, one of my directors of social services said to me that it was a really good thing that social services are integrated with health. Where it is not a good thing is that we are not integrated with education. The relationship with children is a critical one. We have very good relations with the local offices that still exist. I personally know some of the senior staff in the Education Authority. Together, we agree that there are priorities. Hugh made a very good point about early intervention and prevention, and we all acknowledge that, in infant mental health strategies and so on, we need to work more closely with education and support each other. That is particularly so around the whole area of autism assessment, where we are very dependent on teachers, for example, inputting what behaviour a child demonstrates at school.

Catherine, it is a very good point. It is a critical relationship for us, and one that we are putting effort into building, although the Education Authority is going through so much change at the moment. Sometimes, there is a risk that the relationship could be fractured, but there is a great strength in having local bases still in place.

Mr Rice: Catherine, it is similar for us. We have very good relationships with our education partners in the Southern Trust. There is a piece of work that the commissioners are taking forward at the moment with the Department of Education on younger people to try to see how we can better integrate and share resources as we progress with the Programme for Government. It was very clear, at that workshop that Elaine mentioned, that the outcomes-based approach that we are hoping to develop is important. The outcomes cannot be siloed. Education cannot have its outcomes and health have its. We need to cross-reference those. As we get better at doing that and as we develop the whole process, there should be many more benefits.

Dr McBride: Health and education are inextricably linked, as Elaine said. Educational outcomes contribute to life opportunities, which impact on health outcomes. You are absolutely correct. We need that joined-up approach. We need to be working with colleagues in education and local government to address it. Certainly, in Belfast, the Belfast Strategic Partnership, the Public Health Agency and local government are working together, so we have a mechanism for doing that.

You touched on an important point, and it would be remiss of me not to comment on it: the waiting time for individuals' assessment for autism. I can comment specifically on the number of young people waiting for that in Belfast. The time people are waiting not for treatment but for their first assessment is not acceptable. It is now in excess of 20 weeks.

That is not good enough. To reassure Committee members, I can say that we actively engage with the Health and Social Care Board. We secured confirmation of investment of some £420,000 in a letter at the end of May. We are working with the board — indeed, we had a meeting with it yesterday — on how we might address the issue in the short term while we recruit those specialist staff required in psychology and elsewhere, as Francis said.

It is another example of a mismatch of demand and capacity, which is one that the then Minister recognised and put in investment. We now need to get on with addressing it.

Mr McCaughey: I will mention one other thing. We are all members of the Children and Young People's Strategic Partnership, which has a multi-agency approach to getting children a better start in life and achieving to the maximum. One strand of that is about a better start in life and educational attainment so that children should fulfil their maximum potential. We are all involved in that, and I am conscious that that had not been mentioned.

I cannot resist saying that I have eight directors, and there are four men and four women.

Ms Seeley: That is great news. That is a gold star.

Dr McBride: I have four women as well. I am outnumbered all the time.

Mr McCaughey: There being more men is maybe a sign that we do not have enough sense and take on these posts.

Ms Seeley: That is maybe it.

Dr Stevens: Catherine, as several people said, we are all corporate parents. We all have an active road-to-success programme to encourage educational attainment for young people. I am proud at the moment that one or two of my young looked-after children are going to university this year. One, a young woman as well, is going to medical school. She is hoping to go, as she got the offer, so we are taking that part of our educational responsibilities very seriously.

Mr Durkan: Is the £420,000 that you mentioned, Michael, your trust's share of the £30 million?

Dr McBride: It is, yes.

Mrs Way: We have got £340,000, Mark.

Mr Durkan: I will write that one down.

It is clear that there are common themes and challenges emerging across all the trusts. The amount of collaboration between the trusts and, importantly, with others is also clear. There is going to be the need for even more of that collaboration and working with others through the community planning process and because of the need for improved relations. You say there are good relationships between yourselves and the Education Authority's local offices, but we have to have more than good relationships. We need to have good results. That is the most important thing.

It is clear as well that you can learn from each other's successes and, indeed, from each other's mistakes, because we are all human, and mistakes are made. That is a point that you made in your earlier presentation. You do not always cover yourselves in glory as a Department or, indeed, as trusts, but I find that it is often a lack of communication that makes bigger difficulties for trusts further down the road. In our trust area, we have a good model of communication with elected representatives. I do not think that it is foolproof by any means, but the communication with us is good. It is even more important that you have good communication with your staff, patients and, indeed, the wider public.

Elaine, you mentioned the work that has been done on North/South collaboration, and I know that there are other trust areas that straddle the border. I have forgotten the name of it —

Mrs Way: CAWT?

Mr Durkan: The radiotherapy unit.

Mrs Way: The radiotherapy unit.

Mr Durkan: It seems to be a totem of that kind of collaboration. Obviously, to sustain the ability of that centre, we will have to have patients, and will have patients, coming from the South. Given the week that is in it, and I know the sort of work between jurisdictions that goes on, it is not always that simple. Do you see any potential consequences or it becoming any more difficult in the event of —

Mrs Way: Oh gosh, Mark. I am going to have to be political here.

Mr Durkan: No, it is about practicalities.

Mrs Way: No, I do not believe there will be, because, from my perspective, the biggest hurdle that we had to get over initially was the fact that they were seen as two jurisdictions. Some of our clinical staff had different rules about their registration and how they worked. Once we began to knock those blocks down, we created a different culture.

I have shared with you that, of the five trusts, I have the smallest core population size — just under 300,000 — yet, it is known that, in order to sustain a full range of acute hospitals, you need about 600,000 people coming through the door. Tony is a great partner, with the northern half of the Northern Trust, but, in Donegal, there are 110,000 patients who largely would have gone to Galway or Dublin, particularly for very specialist treatment.

When I was speaking at an event in Ballyshannon recently, I described it clearly as a win-win situation for both of us, because it allows Altnagelvin to have the full range of acute services and that population base and it allows people in Donegal to access high-quality services on very easily. The relationships now are so strong between us and the Health Service Executive and between us and the Saolta healthcare group, which is based in Galway but runs all the services that we have done a couple of major projects together and brought them home — radiotherapy and primary PCI — and we are now sitting down as a group and saying, "What other services would we like to share and benefit?" I have said, Mark, that it cannot just be one-way traffic. It cannot be that everybody comes to Derry. It also has to be that some of our clinical staff are working in Letterkenny, and we need to look at Sligo and the South West Acute Hospital. Personally, I do not believe that either jurisdiction should allow any result from a referendum to get in the way of that important work. I have said to previous Health Ministers in both Northern Ireland and the Republic of Ireland that this opportunity saves lives. Therefore, for as long as I am chief executive, no matter what the decision is, I will be pushing hard to continue this vital work.

Mr Durkan: They should not allow it to stop. I mean that they will not allow it.

The Deputy Chairperson (Mr Middleton): Are you happy enough?

Mr Durkan: Yes. I will have plenty of opportunity.

The Deputy Chairperson (Mr Middleton): There will be plenty of opportunity. The members here appreciate the work that you do with us and with local council representatives. Thank you on behalf of the Committee for attending today.

Mr Durkan: May I ask just one more question? Francis, you said that May 2016 had been the busiest month ever. Is that the busiest May ever or the busiest month ever?

Mr Rice: It was the busiest month every, strangely.

Mrs Way: Altnagelvin was the same.

Dr McBride: In Belfast, it was the busiest May ever on record. There was a 10% increase in activity compared with May last year at the front door.

Mr Rice: The thing is that we have winter pressures all year round now. They never go away, unfortunately. It is surprising, I know.

Dr Stevens: It is a very bold example for Antrim. Antrim Area Hospital tends to have between 6,000 and 6,500 people attending its emergency department each month. In March and May — May of all months — we topped 7,000 people in a month. We have never seen anything like that. All the trusts have experienced the same thing. It is stark.

Mr McCaughey: It is not that long ago that our record number of attendances in the Ulster Hospital in a day broke 300 for the first time. One day last week, we had 350.

Mr Durkan: I know that we are only halfway through June. Are there any indications that the figure is going back down?

Mr Rice: It is not winter pressures.

Mr McCaughey: No, I do not expect it to go back down.

Mr Rice: That is the unfortunate thing. It just keeps going.

Dr McBride: That brings us almost full circle to the reform and remodelling, the range of ways of working more in the community and having a completely different approach. The model that we have needs radically reformed.

The Deputy Chairperson (Mr Middleton): Absolutely. Thank you very much for attending.