Official Report: Minutes of Evidence

The Chairperson (Mr Gildernew): I welcome Ms Lisa McWilliams, the director of performance management on the Health and Social Care Board (HSCB). Are you hearing us OK, Lisa?

Ms Lisa McWilliams (Health and Social Care Board): Yes, thank you, Chair. Can you hear me?

The Chairperson (Mr Gildernew): Yes, I can hear you. Thank you, and welcome to our Committee. We are also joined by Mr Paul Cavanagh, the interim director of planning and commissioning on the HSCB. Can you hear us OK, Paul?

Mr Paul Cavanagh (Health and Social Care Board): I can, Colm, thank you. Good morning.

The Chairperson (Mr Gildernew): Good morning. I also welcome Mr Alastair Campbell, the director of hospital service reform in the Department of Health. Are you able to hear us, Alastair?

I can see you on the screen, but we are still not hearing you.

We will go back to Lisa. I am sure that Alastair is resourceful enough to get the audio sorted in the meantime.

Lisa, please go ahead and brief the Committee.

Ms McWilliams: Good morning, Chair and members. Thank you for the opportunity to brief the Health Committee on waiting times for elective care. I hope that the short paper that was provided in advance has been helpful. I will outline some of its key points.

It is regrettable that any patient has to wait longer than they should for assessment, diagnosis or treatment. I fully understand the distress and anxiety that long waiting times cause, particularly when patients are suffering pain and discomfort. Long waiting times also have a societal impact much wider than on the individuals themselves.

We last briefed the Committee on elective waiting times in February 2020. Since then, COVID-19 has presented our health and social care system with its biggest challenge since its foundation. That is in the context of the huge strategic challenges that faced the HSC prior to the pandemic, which were well highlighted in the Bengoa report and the Delivering Together agenda.

Waiting times for patients have been unacceptable for some time, and they have deteriorated further as a consequence of the pandemic. At the end of December 2020, some 320,000 people were waiting for a first consultant-led outpatient appointment for assessment. Almost 85% of them had been waiting for longer that the target of nine weeks and more than half for longer than a year. At the end of December 2020 also, some 105,000 patients were waiting to be admitted for treatment. Similar to the assessment position, 82% had been waiting for longer than 13 weeks and more than half for longer than a year. Again at the end of December 2020, 115,000 patients were waiting for a diagnostic test. Of those, 60% had been waiting for longer than nine weeks and 36% for longer that 26 weeks. Although the number of patients waiting for longer than nine weeks at the end of December is broadly similar to the number in the previous year, it is an improvement on the position at the end of May 2020, when we had 93,000 people waiting for longer than nine weeks.

Prior to COVID, the trend in demand for hospital-based elective services had been increasing, influenced by a growing ageing population and a greater prevalence of chronic health problems. That increase in demand had not been met by a corresponding increase in capacity. As a result, people were waiting longer that the target waiting times. That trend is expected to continue and will be addressed only if we take action to increase capacity, promote healthier lifestyles and tackle health inequalities.

The impact of COVID-19 on waiting times has been profound and will undoubtedly be long-lasting. Throughout the pandemic, Health and Social Care (HSC) continues to provide high-priority and urgent services such as emergency care and time-critical treatments. Given the detrimental impact of COVID on elective care, and the reduction in the level of HSC capacity that could be delivered, the need to explore all opportunities, in both the HSC and the independent sector (IS), to see and treat patients was paramount. To that end, the Health and Social Care Board worked closely with three local IS providers to increase theatre capacity during 2021.

In the first stage of the pandemic, HSC had full access to all three local IS hospital facilities to treat cancer and time-critical patients. Although those arrangements ceased at the end of June 2020, HSC has continued to access IS capacity on a theatre-session basis. As a result, many thousands of patients have been treated by HSC consultants in private healthcare facilities: approximately 4600 in the year to date. In addition, HSC has secured capacity from a number of other IS providers in Northern Ireland and the Republic of Ireland to provide assessments, diagnostics and treatments. Furthermore, a number of private healthcare providers are insourcing services, whereby privately recruited teams of consultants and clinicians are using HSC infrastructure to treat HSC patients. HSC will continue to require access to IS capacity to reduce the backlog of patients for assessment and treatment for some time.

During the pandemic, it has been essential that all available capacity be protected for the highest-priority patients, but on an equitable basis. Following the significant challenges over the Christmas and new year period, the Health Minister agreed to a regional approach to the prioritisation and management of elective activity. As a consequence, a regional prioritisation oversight group was established, chaired by me. The group has met weekly since January to ensure that the relative clinical prioritisation of cancer and time-critical cases across specialties and trust boundaries is consistent and transparent in order to ensure that all available theatre capacity, both in-house and in the IS, is fully and appropriately maximised. That regional approach, although remaining agile, helps minimise the risk of a postcode lottery and ensures allocation on a basis of clinical prioritisation. Although that may mean that patients will need to travel further for their surgery, it is better that the highest-priority treatments are delivered rather than not at all.

If the vaccination programme is successful, surge three will hopefully be our final surge of this pandemic. Even then, we are only at the start of an enormous period of rebuilding. The Department's 'Rebuilding Health and Social Care Services: Strategic Framework' requires trusts to prepare three-monthly rebuilding plans that seek out how routine activity will be restarted in the wake of each surge. HSC trusts made enormous efforts to resume elective services and succeeded in rapidly increasing activity over last summer. Regrettably, from the point at which unscheduled admissions began to rise significantly in October 2020, there has been a prolonged detrimental impact on elective services.

An example of the staff's efforts is that, from 1 October to 31 December 2020, trusts committed to delivering 228,000 outpatient consultations. In fact, they delivered 264,000. Similarly, they aimed to deliver 114,000 diagnostics and instead delivered 142,000. Taking account of the de-escalation as we come out of surge three, coupled with the need for staff to have time to recover from the demanding winter, trusts have been asked to develop plans for the period April to June 2021 and thereafter on a three-monthly rolling basis. Those plans will be published. Of course, that will be subject to the future pattern of the pandemic and the number of patients requiring unscheduled admission. As part of the rebuild plans, trusts will have to outline their plans for green pathways and green sites to ensure complete separation of planned routine services and emergency services.

The rescheduling of theatre lists is currently under way, and trusts are slowly increasing the provision of in-house capacity, which will help equalise waiting times across the region. Waiting list additionality in HSC trusts will, however, take some time to be re-established. The bottom line is that our waiting lists are too long and are getting longer. We know that the way in which services are structured is not fit for purpose, and the elective care plan's road map for reform was outlined in our previous briefing. Reform will not be enough without the investment necessary to deliver it, however. Without major sustained investment, it will not be possible to return waiting times to an acceptable standard. The Minister has made it clear that hospital waiting lists across all programmes of care must be a major priority in 2021 and beyond. The level of funding available will be made clear through the Budget Bill, but I can assure the Committee that work is already under way to ensure that any additional investment is fully utilised to the best effect.

In summary, addressing the waiting list backlog and reforming services to ensure future sustainability is complex and will take time. Multi-year funding, both recurrent to close the capacity gap and non-recurrent to address the backlog, will be required over and above what is needed for the delivery of core services. The required investment continues to be estimated to be in the region of £750 million to £1 billion. and it is likely to take up to 10 years to tackle the challenge. I am now happy to take comments from the Committee.

The Chairperson (Mr Gildernew): Thank you, Lisa. We met representatives of the Royal College of Surgeons (RCS) informally, and they outlined some of the difficulties and suggestions, prominent among which was the development of green pathways and sites. We discussed the need for urgency and focus on the matter, similar to that for the redesign of services in the light of COVID. Are you satisfied that the trusts will have the plan in place to press forward significantly with the provision of green pathways very quickly in April? How will you ensure that that happens and that that urgency is maintained so that we do not discover in June that there is a time lag?

Ms McWilliams: We have been operating a number of COVID-light sites in our hospital trusts and facilities throughout the pandemic. When the emergency department at Daisy Hill Hospital was coupled with Craigavon Area Hospital, it acted as a COVID-light site. Lagan Valley Hospital and Mid Ulster Hospital have continued to act as COVID-light sites. Those sites are separated from, in particular, emergencies and unscheduled admissions.

In their plans for April to June, the trusts will be looking at sites, including the like of Musgrave Park Hospital, where we undertake orthopaedic activity in the Belfast Trust, to see how the workforce can be protected and to ensure that fractures are not decanted into that site, thus preventing it from being a COVID-light site. The workforce is key, and the scale and pace of the process, including the designation of Belfast City Hospital for complex surgery, will take time. The trusts' plans for April to June, however, will step through the scale and pace of their green pathways and sites. It is acceptable to have green pathways at sites that have an ED and have unscheduled admissions, but you separate ward admissions and emergency theatre access. The trusts are working through that, and there is a very clear expectation and desire for the trusts, clinical teams and management to resume elective services.

The Chairperson (Mr Gildernew): OK. Thank you for that. That leads me on neatly to what is perhaps the major issue, which is that all those services and procedures depend on people, who are the front-line staff who have been so hard-pressed. It does not matter what the infrastructure is like if you do not have the nurses, the anaesthetists and all the ancillary staff. Given the pressure that staff have been under and the fact that many of them have been redeployed out of the area that they were trained for and to which, I believe, they would be keen, across the board, to return, what are the plans and timelines for returning those key people and making them available for key surgeries?

Ms McWilliams: We have been de-escalating as we have come out of surge three over the past number of weeks, so we have been moving operative staff — theatre nurses and surgical ward staff — back to the jobs that they would normally do. We have been doing that in phased steps as we have been able to close the escalated ICU beds. We have already started the process of, if you like, reverse deployment of staff back to their core jobs. The trust plans are building in a period of downtime for staff. Staff have also indicated that returning to their core jobs is a type of break, although not a full break. People are keen to get back to what they would normally be doing.

Mr Cavanagh: May I add to that? I have been very closely involved in the critical care operational hub that we have had in place since January. The third wave, as we all know, has had a very severe impact on health and social care in Northern Ireland. I am immensely proud of our staff for the work that they have done in recent months and am very humbled by them, because they really have gone more than the extra mile. I am sure that the Committee will share that sentiment.

The challenge has been that we reached a point where we had increased our critical care beds to such an extent that we had drawn staff in from a range of other parts of the system, not just our hospitals but some of our community services. That included staff from the likes of theatres, who have some shared skills with critical care staff and so are very useful, but also from across the board. A whole range of staff have come into our critical care system in recent times.

During the third wave, longer stays in hospital have also been evident. Patients have stayed longer in those beds, and a lot more beds have been put up compared with our normal critical care numbers. There has been a mix of trying to cope with the number of patients with COVID-related issues and those with non-COVID issues and critical care requirements that we see in any other year, such as major trauma and so on. It has been very challenging for us to reduce that.

One of the principles that we are very clear about is that, as we reduce — we have seen a considerable reduction in the last three weeks in the number of critical care beds — we are very conscious that we need to give staff some time to rest. Each trust is thinking about that. As we reduce beds, the staff who have come from all over Northern Ireland to support the Nightingale wards and Belfast City Hospital have been released back to their home trust and are getting some time off. The staff in Belfast are beginning to get the respite that they need as they begin to return to their work in theatres. In that way, we have not just been able to flip the switch and say, "Today, you are doing critical care. Tomorrow, you are back in a theatre and back in a surgical ward supporting patients". We have had to be patient.

The de-escalation has taken longer than we first anticipated, but it is a reflection of the number of patients who are still in our beds. While we are in much better shape today than we were a month ago, at the same time, we are not out of the woods yet, and I think that everyone recognises that. Again, we have to give our staff a chance to recuperate and to get back to the hard but excellent work that they do.

Mrs Cameron: Thank you to the panel for being here today to discuss such an important issue. The Chair referred to an informal briefing that we had with the Royal College of Surgeons yesterday, and one of its key messages to us was that patients are presenting with conditions that have not been seen for years, like perforated colonic cancers and ruptured hearts. Those representatives also referred to the waiting lists as "devastating" and spoke about nursing staff being their most important resource. Fair pay for nurses is vital for recruitment and retention. What plans are in place to dramatically increase the staffing levels, and what has been done to train others to support nursing roles and free up nurses to return to theatre work so that elective care can resume urgently?

Ms McWilliams: Thank you. With regard to the nursing workforce, one of the underpinning tenets of our elective care reform is expanding the skills mix and ensuring that people are treated in the right place, at the right time and by the right individuals. We have been working on enhancing experienced nursing and creating the advanced nurse practitioners, but we have also been looking at, to go back to the operative setting, our operating department practitioners. They are effectively the runners in the theatres, and they release theatre nurses to do purely nursing duties in theatres. We have a small number of operating department practitioners in a number of sites, and we, as an elective care cell, will target that going forward to support theatre nurses.

The Chief Nursing Officer was with you a couple of weeks ago and indicated the number of vacancies, and you are aware of the significant increase in preregistration training and midwifery university places. They have gone up from 710 to some 1,300 since 2016, so we are enhancing the pure numbers of nurses coming through the system. We are also looking at expanding the whole skills mix, including, if we look at our radiology departments, the enhanced skills of radiographers and moving to consultant radiographers. We are looking to make sure that we are not missing a trick anywhere in any of our professions to fully support the workforce and to build capacity and capability in order to address demand.

Mr Alastair Campbell (Department of Health): Chair, can I come in briefly? Hopefully, members can hear me this time.

The Chairperson (Mr Gildernew): We can hear you, Alastair. Go ahead.

Mr Campbell: I will add briefly to what Lisa said. Obviously, the main issue with the workforce is time. It will take time to increase the workforce. We know that we need to do that, but it takes time to train them and can take years for them to come through. That will not be a rapid fix at all.

My other point is that a piece of work is happening, under the Chief Nursing Officer and led by Mary Hinds, on perioperative nursing and the model for that. That work is happening now, and it is looking at different models and roles in the theatre teams.

The Chairperson (Mr Gildernew): OK. Thank you, Alastair.

Mrs Cameron: Thank you for those responses. Obviously, the Department's elective care plan focuses heavily on transformation and reform, including the £1 billion commitment to address waiting times for elective care. Given the clear pressures on public services as we chart our way through the COVID recovery, is there a plan B in the interim to promote better outcomes using available resources? What plans, if any, do you have to utilise the independent sector in the short term?

The Chairperson (Mr Gildernew): We are not hearing you, Lisa.

Ms McWilliams: Apologies, Chair. Is that it?

The Chairperson (Mr Gildernew): Yes. We can hear you now. Thank you.

Ms McWilliams: Pam, I was indicating that I will start, but Alastair may wish to supplement my answer.

On the funding of £750 million to £1 billion that we costed to address the backlog and the capacity gap, there is an acknowledgement that that will require the workforce and hospital infrastructure being able to deliver that. We are aware of the budgetary position, which, for 2021-22, is unlikely to have an investment in elective care of that scale. We had an indication in advance of the Budget of a small amount of elective funding that has enabled us to continue with the IS provision into April, May and June. Otherwise, we would be switched off that small amount of capacity. We intend to fully utilise all the available capacity.

As part of the published 'New Decade, New Approach', there was an indication that we would seek to send our longest waiters, potentially, to UK providers in order to address our longest waits and to enable the system here to focus on our critical and time-critical individuals. Unfortunately, COVID has closed some of that available capacity down, because England now also has long waits and one in 20 patients there is waiting for more than a year for treatment and surgery. That said, Paul's team in commissioning and contracting in the board has an agreement with NHS England's framework to draw from the IS providers in the English system, which allows us to access the IS capacity there. We also have continuing contacts with the IS in Northern Ireland and the Republic of Ireland (ROI). We have provision for surgical, some cardiac and a number of other procedures in the ROI, and that will continue. The funding will determine the scale of that, but there is an anticipation that we will continue to utilise the IS. Alastair may want to supplement that answer.

Mr Campbell: Thanks, Lisa. Three other areas are worth mentioning. The first is that the Lagan Valley Hospital is operating as a regional day-case elective care centre. It had a slightly different function throughout the pandemic than we expected initially, because it has had to take on additional urgent and red-flag procedures rather than being the day-case site that it was intended to be. As we go back into more normal business, it will become a regional day-case site. We hope that it will be more efficient, because it will be a completely dedicated elective site rather than what is the case under the current models. We also hope to expand that model in the future to other sites, which can become regional elective day-case sites.

The second point is about orthopaedics, which has been hit incredibly hard during the pandemic. Waiting times were already very bad before the pandemic. It is obviously an area that impacts a huge number of people across Northern Ireland. Demand increases every year, with the ageing of the population. We have set up an orthopaedic network, which is looking at how we rebuild and how we improve efficiency in the system. That involves looking at different pathways, different ways of working, new models of care, the skills mix and all those kinds of things. We want that to be up and running pretty much in the next two or three months. It is already reporting, but we want to have some more product out of it, so that we can start to change the way in which things are done.

Allied to that is the point that Lisa mentioned about Musgrave Park Hospital, which really needs to become a dedicated, elective orthopaedic site, and it needs to be protected, with the staff and theatres protected for elective. It does about two thirds of the elective activity for orthopaedics in Northern Ireland, and we really need it to do that. In the pandemic, it was reduced to providing one theatre list; I think, it was one day's theatre capacity for the week, as opposed to the normal 10, so we need to get back up to the 10 as quickly as we can.

My final point is probably an answer to Pam's previous question, but I forgot to mention it. It is around the No More Silos work. We are very aware that there will be people presenting as emergencies, or later stage, in this. They may be presenting through urgent or other unscheduled pathways. The No More Silos work is intended to provide a faster way for patients to access that, as opposed to just going through an emergency department. It is supposed to provide better links between primary care and secondary care and smoother ways for people to access the care that they need, as opposed to spending a long time on trolleys.

All three of those, together, are the immediate actions that we want to take to try to improve the way that we are dealing with patients at the moment.

The Chairperson (Mr Gildernew): Thank you. We are fairly tight for time, this morning, so I ask all members to keep questions succinct, please. If we get a principal answer from the panel, and there is additional information to be added, that is fine. However, I ask everyone to keep answers as succinct as possible.

Ms Bradshaw: Thank you, panel. The first question that I put to the representatives from the Royal College of Surgeons yesterday was about the regional prioritisation list. I am glad that they support the approach adopted by the Department. I got the impression that they think that it would probably be easier if we had one trust in Northern Ireland, as opposed to five. Is the Department of Health, through the transformation and implementation process, looking at that?

Ms McWilliams: Alastair, would you take that, please?

Mr Campbell: I am happy to take that. There is a way of thinking that regionalisation is definitely the way that we need to go for a lot of specialist services. There are lots of services where, partly, we may be trying to provide them in too many places, but it is mainly that we are trying to provide them as separate services, when really they should be regional services for a lot of those areas. Whether it is one single trust or multiple trusts is less important than those services being managed on a regional basis.

Bear with me for a moment, Chair. I do not want to go into too much detail on this. From the breast assessment work that we did previously, the main issue is that, when one service, on one site, falls over, it is treated as one separate service, as opposed to all the other services picking up the demand that is out there. In areas like that, when we are recruiting, quite often we are recruiting from other trusts into a trust where there is a vacancy. In effect, we are just pushing the vacancy around Northern Ireland. All those are definitely much better suited to having a regional approach. Rather than me going for the governance issues around one trust versus others, I can definitely say that we are looking at regional services and a regional approach to planning those services.

Ms Bradshaw: Thank you, that is very encouraging. The other issue that was raised yesterday was about how targets and waiting lists are measured. I do not want you to start massaging figures or anything, but is any work ongoing about how better to present the severity of the numbers waiting on the list? It is very difficult for us to get our heads around the 324,000, or whatever the number is, who are waiting. Is there any work on that?

Ms McWilliams: Paula, it is not necessarily connected straight to changing a target per se, but the work that we have had to do, out of necessity, through the regional prioritisation, has required an extensive look at the totality of the waiting lists, in order to understand the cancer and the time-critical. The regional prioritisation oversight group looks, weekly, at those individuals who have just finished chemotherapy or radiotherapy and, therefore, have a very short window, sometimes just seven days, for surgery. It captures those with confirmed cancer, who have a month to have treatment, and those with suspected cancer, who require an urgent diagnostic day-case procedure. It also captures our most complex benign cases. We are not excluding it purely to cancer, because, quite often, cardiovascular individuals have a more time-critical pressing factor. Our system has looked at that cohort of treatment waits. It is not necessarily to drive a target, but it allows us to target resource more appropriately and to be clear on what our waiting lists contain. It is also important because it is the only way that we can equalise capacity across trusts to make sure that we do not rely on a postcode lottery. It is not to change targets per se. It is to understand what is on the waiting lists and what cohort is most likely to come to harm and in what time frames. It is about informing how we match capacity with demand.

Ms Bradshaw: Thank you. Finally, I have a question about the deterioration of people's conditions while they are on a waiting list. As you know, a lot of people have comorbidities. While they are waiting, they are quite down and maybe have mobility issues. That may have an impact on their dementia, for example. How are we treating patients, in their totality, while they are on the waiting list, to make sure that, when they get to the operating table or the consultant, they are not in a far worse position?

Ms McWilliams: Thank you, Paula. There are two sides to that. One is the emotional health and well-being of patients who may be dealing with pain and discomfort. The other is the perioperative and making sure that people are still fit and have support once they get a treatment date. I will start with the emotional and mental health and well-being strand. We have developed a number of online resources, and teams, through necessity, have enhanced their crisis response and mental health liaison in the urgent treatment centres and EDs to make sure that we are supporting as best as possible. Unfortunately, the move that we have taken to virtual outpatients is not suitable for all cohorts. A virtual consultation is not necessarily suitable for dementia patients, for example. The teams sift through very carefully and ensure that those patients receive face-to-face consultations. However, we have had to reduce our face-to-face contact, due to spatial and social distancing. The teams are keeping an eye on those individuals.

With regard to the perioperative work, we are at the start of the journey, particularly with cancer patients. There is a dedicated focus on that going forward as part of the cancer strategy. There is evidence that, if people are fit for surgery, they recover more quickly, their length of stay is shorter and they get the benefit of their treatment more quickly. We are at the start of a journey on that perioperative enhancement.

We have been doing enhanced recovery for orthopaedics for some time, even before COVID. Patients are fully briefed. For example, if someone is having knee or hip surgery, we tell them, "Here are the exercises that we want you to do now. You will have a 23-hour or a one-night stay. We will be getting you up within two hours, and these are the exercises that we need you to undertake to recover quickly". We have models of that, but it will be key, going forward.

Ms Bradshaw: Thank you.

Ms Hunter: Thank you all for being here today. My question is around mental health. Can the panel give a picture of current waiting lists and times for mental health services? As a result of the pandemic, we foresee an increased need. Paula touched on a fantastic point, following our discussion with surgeons yesterday, about people living with chronic pain. Some feel that they are living unfulfilled lives while waiting on things like hip replacements. That has a psychological impact as well. Does the panel have an assessment of what is needed to address staffing and finance for the issue of waiting lists?

Ms McWilliams: Thank you, Cara. There is a mental health action plan that picks up on the workforce issues and, similar to elective care, the requirement to reform the way that services are delivered, in particular, building on previous reviews. Departmental colleagues and trust colleagues are working through that mental health action plan.

I will pick up your point about pain and people living with pain while they wait for treatment. There are a number of pain-management resources. As part of the elective care plan, we had instigated a lot of musculoskeletal pain-management services and supports to ensure that people were enabled to manage their pain without an overdependence on particular drugs. Surgery will not be the answer for everybody who experiences pain. Our pharmacy colleagues in the board have been doing a huge amount of work on pain management and supporting individuals. I am sure that we would be happy to provide further information on that after the meeting, because I just do not have it to hand.

The mental health action plan is the blueprint. Going back to Alastair's point, there is an element of regionalisation; it is not about a single trust but about a regional approach being taken to mental health. That will remove the postcode lottery and variation in practice and also the variation in staffing models, because, where we have the biggest waits, it can be tied back to the number of staff vacancies. We have seen some improvement in adult mental health waits over the past number of months, particularly in the Western Health and Social Care Trust, which had a large cohort, because it was very successful in filling vacancies and also at looking at skills and skills-mix changes in its model. The mental health plan actually underpins all that.

Ms Hunter: Thank you, Lisa. That was a really good answer. I am just looking at new models of care. I think that Alastair touched on that. Can you outline any innovative ways that are currently being used or explored to try to overcome the issue of waiting lists? Is there any pilot programme or anything creative being done?

Ms McWilliams: Sure. Cara, I will pick up on one that we have been using this year, which is the faecal immunochemical test (FIT) that we have been using in all trusts. Following a GP referral to secondary care for suspect colorectal cancer after a bleed or in compliance with the guidance, the clinical team triages that and will then issue a FIT to the individual. That FIT is then returned, and there is a pathological examination of its results. We had always wanted to move FIT testing into primary care as a way of being clear about which patients needed to join the red-flag pathway. However, during COVID, because colonoscopies were considered to be such a high-risk aerosol-generating procedure, we had to switch back all colonoscopies up until the most truly urgent. Therefore, we have been using the FIT testing to prioritise those individuals who must have a colonoscopy.

Despite a 30% reduction in colorectal referrals into the system, and a 50% reduction in endoscopy, the FIT testing has resulted in comparable pathology reports of about 85% compared with those of the previous full year. Therefore, it demonstrates the benefits. We are not going to lose that. We did it out of necessity, but we absolutely intend, with our colleagues in the Public Health Agency, to move that to primary care. We have allowed it to be tried and tested, and we were able to do that, probably, in a much quicker fashion than would have been the case if we had brought it in as new technology. Hopefully, that is a good example of an opportunity that is of huge benefit to patients and also means that we can allocate capacity to those who truly need it as opposed to those who would have got a colonoscopy automatically, but there was no requirement necessarily for them to have it.

Ms Hunter: That is great. Thank you, Lisa. Thank you, Chair.

The Chairperson (Mr Gildernew): Thank you, Cara. I will go, in the following order, to Carál Ní Chuilín, Jonathan, Gerry and Órlaithí. Go ahead, Carál, please.

Ms Ní Chuilín: Thank you, Chair, and thank you, Lisa, Paul and Alastair, for being here this morning. In 2017, the Department produced its elective care plan, needing anything from £750 million to £1 billion to tackle the waiting list crisis, which was likely to take up to 10 years. What are your views on that? Obviously, that was pre-COVID.

As other members have mentioned, we met the consultant surgeons yesterday. They were at pains to point out that staff retention, more so than recruitment — well, as well as recruitment — is critical. You have already mentioned that there are gaps and that waiting lists are more intense where those gaps appear. Can you give us an update on that?

My final point is on the independent sector. It strikes me that, whilst money will be spent to tackle the waiting lists, we are going full circle. Unless we get to the bottom of the retention and recruitment of the staff needed to have these in-house facilities, we will constantly come back to this. Some of the intensivists and ICU staff from different hospitals who went to Nightingale facilities are returning to their hospital. Do you have any idea what that looks like per trust?

Ms McWilliams: I will pick up a couple of those points before turning to colleagues. The board did the financial assessment on the costing backlog and the capacity gap for the elective care plan in 2017. That was updated in the two months before the pandemic started. In doing that, we were clear that the funding backlog had increased by about £100 million.

When we did the pure number assessment of the capacity gap, it had not increased, but that was largely because patients were not getting through the system. That was prior to COVID. The downturn in referrals during the COVID pandemic means that we do not have a true picture of capacity. The £750 million to £1 billion estimate always had an element of additional staffing, infrastructure and space within it, and our best assessment is that we are still in that range.

What has changed is that we previously said that it would take five to 10 years to address the scale of the waits. The assessment of the board and the Department is that it will be towards the latter end of that time frame. It will take longer. The IS approach is always the approach in the short run, with short-term funding to address backlog, but it never addresses capacity. If we do not address capacity in parallel with that, as we clear one patient from the backlog, we will automatically add another patient to it. We will always accept non-recurrent funding — it is always welcome — it addresses the backlog only for a certain period. Investment in the capacity gap is required to keep us moving forward.

On staff retention, the COVID experience for has absolutely had an impact on emotional health and well-being, and people have been displaced. Some post-traumatic instances may need to be supported through our occupational health and trust management teams working closely with staff. Our clinicians tell us that they want to be able to do their job. They want to be able to treat patients and to be proud of their service. Getting elective care switched back on, taking on board the learning of what will make a difference and listening to patients have a huge impact on increasing morale, which helps retention.

Alastair may want to pick up on whether the Department is doing anything specifically on retention from the policy side. Sorry, I do not have that information.

Mr Campbell: This links to before COVID. The main thing that staff want is to do their job and leave when they have done their shift. As part of that, in elective care centres, we are trying to ensure that staff will come into work, see their first patient immediately, work until it is time to leave and then go home. That is the experience that we hear from some who have gone to other countries. They know what hours they have to work and that they finish when their working day finishes. That is where I want to get to. However, because that requires investment over a long period, it will take time to do it properly .

We were in a similar position with investment, although not quite as bad, in 2005. Over a four-year period, we got the waiting lists down until they were at acceptable levels. However, we focused a great deal on additionality and non-recurrent funding. That was the funding that we had available. If we do the same again, we will end up in the same position. We will get waiting lists down to an acceptable level, and then will they continue to grow again. We are looking at a long-term period: we need to start in-house, because that is where the capacity will be, and with funding additionality. However, over time, if we want to make this improvement sustainable, we have to turn that into recurrent funding and increase capacity in-house. That is definitely the direction in which we need to go. Think about recurrent and non-recurrent funding as a scale that starts with additionality, and, over time, that becomes your in-house capacity, but you need sustained investment.

Mr Cavanagh: I will pick up on the final question. At the height of the most recent surge, Nightingale had 40 beds. Eight of those were what we call regional beds, and they were, I suppose, to keep pace, because a lot of beds there were for Belfast patients. Staff came from all over Northern Ireland. Unfortunately, I do not have the numbers to hand, Carál, but I am happy to follow up on that, if you wish. A number of staff came from the other four trusts, and additional staff came from within the Belfast Trust to support the 40 beds in Nightingale, particularly the additional pods. Those staff have been redeployed back to their home trusts, but their efforts have been well recognised in recent months.

The Chairperson (Mr Gildernew): I am going to — [Interruption.]

Ms Ní Chuilín: Sorry, Chair.

those who had to travel a long distance.

Mr Cavanagh: Absolutely.

The Chairperson (Mr Gildernew): No, Carál. I need to move on.

Mr Buckley: Thank you, panel. Waiting times have been a long-term, paramount concern for me both pre-COVID and now that they have been exacerbated by COVID. The statistics released in December are harrowing. They highlight the scale of the challenge facing our health service, as your report outlines. It is important that we note those statistics: they are people. Over half of patients were waiting for more than 52 weeks for their first consultant-led outpatient appointment. A further 57,000 were waiting for more than 26 weeks for a diagnostic test. Those figures are scary. The sad thing is that they are real-life stories: behind each statistic is a person. There needs to be a recognition that a single-track focus on COVID-19, particularly as transmission drops, is a threat to fairness and equality in the health service. As an elected representative, I have listened to first-hand accounts of late presentations and advanced cancers showing up as a result, in part, of not being picked up due to the pandemic. I look at cancer, in particular. About two thirds of those waiting — just over 95,000 — are waiting for tests, such as an endoscopy or imaging test, that could be used to help to diagnose cancer. Waiting for a test that could tell you that you have cancer is stressful; being told that there could be a six-month waiting list is even worse. Can anyone provide figures for how many endoscopic and imaging procedures are planned to take place in the IS? For long has IS capacity been secured?

Ms McWilliams: Thank you, Jonathan.

Mr Campbell: Lisa, you probably have more of the detail around endoscopies and so on. I will start with the wider point. It is important to say that we are not prioritising COVID over any other conditions. We are prioritising unscheduled presentations. Anyone who turns up at hospital requiring urgent or emergency care needs to receive that care. I do not think that there is any way round that. You cannot turn away people who need urgent emergency care. We have been talking about scaling up our hospitals and ICUs to deal with the people who need that urgent and emergency care. Unfortunately, that, inevitably, has an impact on our scheduled services. Our main way to get through that is to keep the COVID levels low, because the COVID numbers translate into increased requirement for hospital and ICU admissions. That is what we need to avoid. We are not talking about prioritising one condition over another.

Mr Buckley: Alastair, I am not saying that you are, but there is no doubt — it was presented to us by trust officials and through first-hand accounts — that there is a genuine fear that late presentations at A & E, because of the COVID pandemic, have led to an increase in cancers that are at an advanced stage and cannot be dealt with. We are also hearing that in relation to GP services. It is a genuine concern for me and other members, and we need to take account of it.

Mr Campbell: It is absolutely genuine, and I absolutely agree that it is very worrying, but I do not want anyone to get the sense that we are prioritising any area over another area. It is purely the case that, if people arrive at hospital in need of treatment, we need to be in a position to provide that to them. I agree that it has a huge impact across the board, and we need to focus on that.

You mentioned the challenge for the health sector, and I agree with you on that as well. Perhaps, however, it is even more than that now; it is a challenge for the public sector in general. It is that serious an issue. As well as the physical and health impact, there are mental, social and economic impacts. I think that, going forward, this is a huge challenge for all of us in the public sector.

Mr Buckley: If you do not have the figures to hand right now, I am happy for you to supply those to me.

Ms McWilliams: Jonathan, we have at least two providers that we have consistently used to enhance our in-house endoscopy capacity over the past two years. Those two IS providers have really stepped up and are insourcing in some of our facilities where the infrastructure is available but the staffing is not. We have been using those two companies extensively through the pandemic response, and we envisage continuing to use them. One of the providers, by way of example, is committing to doing 250 scopes for oesophageal gastric, and other scopes are being provided. We foresee using those two providers going forward. We had used them to enhance and as additionality to the in-house capacity, but they have been able to use our facilities and our equipment when our staffing has not been available over the past nine months.

Mr Buckley: The FIT triage tool that you mentioned is exciting. I want to ensure that the funding is secured for that.

I will make this my final point because time is tight. I welcome the creation of a regional prioritisation oversight group, and I certainly see a need for that joined-up working. For example, the Southern Trust area, part of which I represent, has the largest proportion of waits, at over six months for a diagnostic test. How can we ensure that our approach to restoring elective services is fair and does not indirectly lead to further inequalities across our communities?

Ms McWilliams: Jonathan, our radiology network has taken on responsibility for equalising diagnostic waits. Although it is not possible to have a single waiting list, because we use different systems for diagnostic, particularly imaging, the managing radiology network has treated this as a regional list and has been moving resource around. You will be aware that, under the NHS supply agreement for COVID, we received an additional CT scanner in a box, which we placed in Musgrave, and all trusts utilise that. Therefore, it is not a Belfast resource but a resource for the region. We have received additional X-ray and ultrasound equipment. Our managed radiology network has made great efforts in equalising waits. Similar to regional prioritisation, it looks at the waits and at available capacity and moves the trust access around, including for the Southern Trust. It does that on the basis of chronological and clinical priority. There is extensive work in that area.

Mr Buckley: Thank you. Will you come back to the Committee on the point about securing funding for FIT? It does not have to be now.

Ms McWilliams: Yes, we will.

Mr Carroll: Thanks, panel. My first question is on the issue of using private healthcare providers to help to manage the lists. I believe that this model is not only unsustainable but unregulated, and I will tell you why. The Department of Health said to me that, in a three-month period last year, £10 million was spent on specific care from three private providers. Lisa mentioned that 4,600 people were seen by private consultants, presumably in private hospitals. What is the cost to the public of the reliance on the private healthcare add-on?

Also, I am concerned about the fact that, when I asked a question last year about the number of private hospital beds included in capacity, I was told that I could not get an answer because it would be too costly to find out that information. I am really concerned that we are throwing public money at a model that is unstable, unfair and more expensive in the long run. I am concerned that it reinforces the two-tier healthcare model in which you can get treatment if you can afford to go private; if you cannot afford it, you are on a waiting list for a long time.

Ms McWilliams: Thanks, Gerry. I will start with the payments to the three private independent sector hospitals and the £10 million that you referred to.

At the very start of the pandemic when, effectively, we stopped outpatient and surgical services, we had a head of terms agreement that went through both legal and probity. We had external auditors take over the totality of their infrastructure, such as their theatre nurses and employed anaesthetists, and HSC-employed consultants travelled to treat patients. Therefore, we had outpatient, day case and in-patient capacity from those three providers.

We had that arrangement in place. However, as we came out of surge one and went into surge two, particularly at the end of surge one, those private providers started to see an increase in private demand, and we were moving away from the totality of our need for their facilities. Since then, we have been buying on a theatre session basis, and we pay only when an HSC patient is treated in an IS theatre. That has been the arrangement from June to date. We are buying theatre sessions in accordance with the tariff arrangements that are in place. There is a high level of scrutiny, and, as I indicated, an external auditor has gone through every element of the head of terms agreement and the claims from those three providers. We excluded elements that we felt were not justified. I can give you some assurance that there has been a high level of scrutiny and probity on IS use. For us, the move to paying for theatre sessions is a much better value-for-money approach.

On your point about the commercial information relating to those providers and the number of beds available, we have some of that information through the head of terms agreement, and Paul will advise of that. It is probably still commercially sensitive information. However, the auditor had that information, and we are doing the cost-benefit analysis against that.

Mr Cavanagh: Gerry, we have that information for the initial April to June period, which is when we had, effectively, taken the IS hospitals over for our use. Since then, it has been a much more sessional approach.

Mr Carroll: Thanks. I would appreciate the head of terms agreement and capacity information being shared with the Committee.

Has there been an assessment of the impact of the 1% pay offer? I know that the offer is for NHS England, and we are still waiting for an offer to be made to healthcare workers and nurses here. Will it have an impact on retention?

I have asked my final question before but not received a proper answer. We have asylum seekers and refugees with unsecured immigration status who are doctors or healthcare workers. To me, those people are not being targeted and pulled into the healthcare system. Do we have a sense of the numbers of refugees, asylum seekers and others with unsecured immigration status who are trained healthcare workers but unable to work because of the archaic immigration laws?

Ms McWilliams: Unless Alastair knows, we will have to refer to our workforce policy leads in the Department for an answer on the number of asylum seekers and refugees who could be utilised as healthcare workers. If the Committee is happy, we will link with departmental colleagues and come back with the information.

Since the offer of a 1% pay rise was made in England, there has been a lot of speculation. However, we have not had an offer. I am not sure that there has been or will be any work on how that will be received or the impact that it might have until we actually have a pay offer. If I am wrong on that, Alastair will correct me.

Mr Campbell: That is absolutely right, Lisa We will have to refer to our workforce policy colleagues on both of those issues.

The Chairperson (Mr Gildernew): OK. Thank you. I will pick up on Gerry's point about the number of beds in the independent sector that are being used. I do not understand why that information is commercially sensitive. Money from the public health budget is going to private healthcare providers. I understand that there might be commercial sensitivity around the amounts being spent, but that information should not be concealed from the public either. It may be embarrassing and concerning — it may be many things — but it is not acceptable that we do not know how many beds we are talking about. I do not see commercial sensitivity there, to be honest, Lisa. We want to have that information.

Ms McWilliams: Chair, apologies if I have misled you in any way. We know the number of beds utilised and the number of days that patients utilised those beds. We have that information. We will share that with you, particularly the information for that first period, when we come back to the Committee with the additional information requested, and we will include any information that will provide additional assurance from our auditors. Apologies if I have misled you on that.

The Chairperson (Mr Gildernew): OK. Earlier, I was concerned when you said that you will continue to use two providers in the independent sector "going forward". I hope that there is no reliance on the independent sector in the longer term. I hope that it is only a stopgap and that all the planning efforts are going into how we rewind and bring those services back into the public realm.

Ms Flynn: Thanks to the panel for coming today. Carál touched on the money required to tackle this ongoing, long-term challenge. The figure is in the range of £750 million to £1 billion, and you said that £100 million of that relates to capacity. Do you have a full breakdown, Lisa, of the costs required to deal with this issue? Do you have a detailed breakdown of how much needs to go towards capacity, hospital infrastructure, workforce etc?

Ms McWilliams: Órlaithí, thank you. Following the February 2020 briefing, we provided an indication of the costs, but we will update that because, clearly, our backlog costs have increased. We are happy to come back with a breakdown. When we talk about the backlog and the capacity, we have modelled that at specialty level, so we understand demand, we understand what our commission volumes are, and we understand what the waiting lists are. There will be a process of rebalance as we start getting all the appropriate referrals into the system. The current picture is certainly not a true picture of our outpatient gap. We can certainly provide that information.

Ms Flynn: That is great, Lisa. Thanks very much for that. I am conscious that I need to leave six minutes for Alan to ask questions, so this is my final question. You mentioned the use of the independent sector and said that a number of patients will be able to receive treatment in the South of Ireland, England or through whatever local resources you have in the North in the independent sector. Do you have any figures or forecasts? You mentioned the April to June period. Do you have a forecast of how many patients might be able to receive their treatment via those referral routes?

Ms McWilliams: Órlaithí, at this stage, we have the total number who have been treated to date and the number that we anticipate by 31 March, because that is in line with our current contracts. Going forward into 2021-22, we have an indication of what IS capacity will be utilised in the next four weeks, because it is dependent on the available funding. That said, the arrangement with NHS England for its IS gives a lot of scope, and it will be about the timing and appropriateness of patients travelling either down South or via a ferry or plane to England, given the COVID restrictions. We have an indication of what capacity might be available but not a firm number of patients, because that will depend on the scale of the funds available.

Ms Flynn: I know that the uptake of the workforce appeal was not great. The other week, Charlotte McArdle told us that about 300 or 400 places were filled after 9,000 expressions of interest and 5,000 formal applications. Are the Department and the board looking at any options to try to utilise that workforce appeal to help you in the coming weeks and months?

Ms McWilliams: Yes, Órlaithí. One of the drivers that will help that is the move to the green or COVID-light sites. Recent retirees from surgical operating theatre nursing may be willing to come back in response to the workforce appeal, if they are guaranteed not to be employed at a site where they may be exposed to COVID. That green pathway/green site work is really important, and our understanding from our trade union colleagues is that such messaging associated with any workforce appeal is likely to be welcomed.

The Chairperson (Mr Gildernew): I want to follow up very quickly on Órlaithí's question. One of the comments yesterday, Lisa, was to do with the electronic care record (ECR), which makes it easier to make a referral to England than to the South. Referral to England involves inherent additional difficulties and risks of travel for families. Do you recognise that, and is anything being done to address that difficulty and to allow transfer North/South more readily?

Ms McWilliams: Absolutely, Chairperson. Ultimately, the Encompass initiative, although it has been impacted on by COVID, will fix some of those difficulties, and there will be a more streamlined approach. We have always had an historical arrangement with the ROI providers that we have been using in recent months. The clinical and management teams have a streamlined approach to addressing that. It is not necessarily a touch-of-a-button approach, but the governance and the information transfer are appropriate, because they are tried and tested. Going forward, Encompass and the links to UK and ROI systems will address that.

Mr Chambers: I will be brief. It is easy, I suppose, to blame COVID for the current waiting lists, and I accept that it has not helped. However, the pandemic has focused more attention on the capacity problems in the NHS. Does the panel agree that politically painful transformation is urgently needed, that there will be no overnight solutions to all of the health service's problems and that it is slightly misleading to suggest otherwise?

Ms McWilliams: I could not agree more, Alan. COVID has made the waiting list situation worse. However, prior to COVID, it was already unacceptable, and people were already waiting too long. New Decade, New Approach made that very clear, and that was before COVID. Transformation — changing how we do things, changing settings and changing the workforce — is absolutely key, as is ensuring that we work with Departments and agencies to address the socio-economic impacts on health. We need to work with all of the agencies. That is the only way to address health inequality and promote healthy lifestyles. Prevention, where possible, will always be better than addressing disease presentation. I do not think that anyone would disagree with your statement, Alan.

The Chairperson (Mr Gildernew): Thank you very much, Lisa, Paul and Alastair for your attendance today and for your answers, as far as you were able, to the large majority of our questions. I also thank you for your commitment to provide to the Committee further information that you did not have to hand. The Committee's key concern now is rebuilding, and the focus on waiting lists will mean that we will talk to you again in due course. I wish you all the very best. Please take care over the next while.

Ms McWilliams: Many thanks, Chairperson.