Official Report: Minutes of Evidence
Committee for Health, meeting on Thursday, 16 December 2021
Members present for all or part of the proceedings:
Mr Colm Gildernew (Chairperson)
Mrs Pam Cameron (Deputy Chairperson)
Ms Paula Bradshaw
Mr Gerry Carroll
Mr Alan Chambers
Mrs Deborah Erskine
Miss Órlaithí Flynn
Mr Colin McGrath
Witnesses:
Dr Tomas Adell, Department of Health
Mr David Keenan, Department of Health
Ms Preeta Miller, Department of Health
Ms Annette Palmer, Department of Health
Ms Brigitte Worth, Department of Health
Budget and January Monitoring Round 2022: Department of Health
Ms Brigitte Worth (Department of Health): Yes. Good morning, Chair.
Ms Annette Palmer (Department of Health): Yes, Chair.
Mr David Keenan (Department of Health): Yes. Good morning, Chair.
Ms Preeta Miller (Department of Health): I can. Good morning, Chair.
Dr Tomas Adell (Department of Health): I can, yes. Good morning.
The Chairperson (Mr Gildernew): Thank you. I welcome the panel. Thank you for coming to the Committee this morning. Everyone, when you are not speaking, please remain on mute. If you have access to a headset, you will find that one normally helps with the sound. Brigitte, will you and someone else from the panel make some opening remarks? Just let us know how you would like to start, please.
Ms Worth: Thank you very much, Chair. I will start my remarks by covering the future budget position, and I will then pick up on January monitoring. Preeta will then do the same with capital. David, Annette and Tomas have joined us to provide support on more detailed questioning, but they will not be making any opening remarks today. Hopefully, that gives you a sense of how we are going to approach it.
I will start off with the future budget. The Committee will have received copies of the submissions that we made to the Department of Finance as part of the Budget-setting process, so you will be aware from that of the magnitude of the pressures that we are facing and the amount of funding needed if we are to be able to deliver the full extent of our ambition. Clearly, to expect to have received everything that we asked for in those submissions was unrealistic, and I do recognise that Health has been given the lion's share of the funding identified as available for allocation as part of the Budget process. It would also be remiss of me not to recognise that this is a sizeable increase on our existing baseline of just under £6·1 billion. Nevertheless, due to the level of non-recurrent funding that we have received in the current year in particular, it does represent a much more modest increase on our opening budget for this year of £6·5 billion, and, in 2022-23, it actually represents a reduction of some £200 million on our post-October monitoring position, which is nearly £7 billion. That means that, with health inflation running at a recognised 6%, the funding gap to deliver our existing services next year is likely to be well in excess of £500 million.
As I said before, this position has arisen due to a lack of recurrent funding in previous years, particularly in the current year, where, as you will recall, just £50 million of our additional funding was provided recurrently. This has forced us into a position over the years of funding increased levels of ongoing commitments from non-recurrent sources. I will give you a few examples of that. Some £175 million of Agenda for Change pay and safe staffing commitments are funded non-recurrently in 2021-22, and these must now be the first priority from our allocation. Also, it is a positive development that the £49 million of transformation funding that we have previously received non-recurrently has now been allocated across the three-year period, but this will simply enable us to fund the activity that is already on the ground, and it does not allow us to expand that programme. Also, unfortunately, as you have spoken about today, Chair, there are COVID response costs, which we had very much hoped would be non-recurrent and would disappear after the current financial year. It is increasingly looking like these are likely to remain with us for some time. As just one example of that, the cost of providing additional PPE this year is estimated at around £130 million, with our overall COVID response totalling somewhere in the region of £480 million.
All of that adds up to the fact that the additional allocation of £713 million next year, whilst undeniably a very significant sum of money, will be insufficient for us to continue all our existing activity, and that is before we even look at pay and price inflation. To live within the allocated budget will, therefore, require reductions in spending from current levels in some areas, and that will mean that we will be faced with some difficult decisions to determine what can be funded from the allocation available. It also inevitably means that it will be impossible for us to fund all our proposed rebuilding activities.
You will appreciate that this has been a relatively recent development and that more time will be needed to carefully consider the impact of this, and what we can do in the short term will be constrained by what is possible in the time frame available. On the next steps, we are aiming to publish a summary of the likely impact of the budget as soon as possible, with an equality impact assessment (EQIA) to follow early in the new year. I am happy to take questions on that during the session, but you will appreciate that the level of detail that is available to me at the moment is limited.
I turn now to January monitoring. First, I apologise to the Committee for the late submission of the paper. I know that you received it yesterday. I am sure that you will appreciate that there is a lot going on in the Department at the moment, but, with that in mind, I will take a bit more time than usual to talk you through the information in the paper. It starts with a summary of where the budget was after October monitoring. As I mentioned, the additional allocations have brought us to a total of nearly £7 billion. That is shown in table 1 in the papers. The narrative goes on to provide further detail on the bids submitted at October monitoring and highlights the fact that most of them were met. The one notable exception was in relation to trust deficits, where funding of £15 million was provided, which left us with a remaining deficit of £60 million at that time. A depreciation bid was also only partially met, leaving a ring-fenced pressure of around £11 million.
As I am sure that you will appreciate, things are currently changing very quickly. In that context, as the paper says, significant slippage has materialised, and additional funding has also become available over and above the levels that we anticipated in October. Against that, however, we have also identified significant pressures that continue to materialise. Table 2 shows the additional funding that has become available since October monitoring, although I stress that we await final confirmation of the test-and-trace amount shown in that table. Table 3 lists some of the pressures that we funded from the additional funding, including the additional requirements for COVID vaccinations and the package to support increased provision of domiciliary care. Against the trust deficit of £60 million, we are now allocating £30 million. As you can see from the paper, trusts are now reporting that their deficit position has decreased to £50 million, and we expect further slippage in the order of £20 million to emerge over the coming months to bridge the remaining gap, although, of course, we will have to keep that position continually under review.
The paper then provides the Committee with further detail on the other pressures being funded at this time. Overall, that leaves us with a surplus of some £30 million, subject to funding being received in relation to our proposed bid for depreciation pressures and also to the receipt of funding expected from Treasury in relation to the change in the discount rate for personal injury cases. If those two things are not funded, most of that £30 million will be required to cover those pressures, and we hope to hear about the Treasury amounts in the near future. However, the paper highlights the fact that, if that is not the case and we do get the funding, the Minister is considering how that money can best be allocated to support the health service through the winter, including the potential to supplement the pay settlement. You will appreciate that I am unable to elaborate further on those issues while the Minister is still considering the position.
As you will see from the paper, any remaining surplus following consideration of those issues may be returned for reallocation to other Executive priorities, but for now, as I said, the picture remains uncertain. Should requirements exceed the funding available, a bid will obviously be submitted. In summary, however, at this time, I can confirm that we will be submitting a bid of £12·5 million for depreciation.
With that, I will pass you over to Preeta. She will cover the capital position.
Ms Miller: Thank you, Brigitte. I will start with the Health budget as well and then move on to January monitoring. With the budget, the proposed net capital budget settlement for the three-year period is £349·9 million, £369·8 million and, in the last year, £368·3 million. Whilst the allocation in the first year, 2022-23, is sufficient to meet our minimum requirements, the funding in the last two years falls short by £80 million and £61 million respectively. Although the overall quantum shows an uplift on previous years' capital allocations, the issue that we are facing is that the funding that we need for our flagship projects has also increased over that three-year period. When you factor that in, the residual non-ring-fenced funding that we have in the latter two years is a reduction compared with 2021 and 2022.
The Budget settlement will enable us to fund our flagship projects and contractual commitments and will contribute some funding towards the maintenance of the health and social care (HSC) estate and new strategies such as elective care and the cancer recovery plan, all of which we deem to be inescapable. To fund those inescapable pressures, we will need to reduce our planned allocations to backlog maintenance in the latter years. The fear is that that will exacerbate the backlog maintenance position, which now stands at £1·2 billion. Despite that, the Budget settlement for everything that we must do will still fall short and will inhibit our ability to commence significant new investment. I note that our assessment of what is affordable is based on profiles known at December 2021. That position is likely to change, given the inherent unpredictability of construction projects. It is also exacerbated by the current volatility in the supply chain and the price of materials.
I turn to the current year's January monitoring round. Following the October monitoring round, we have a capital budget of £352·9 million. In this monitoring round, health organisations have reported £28·9 million of slippage, which is primarily as a result of delays in supply chains and difficulty in gaining access to hospital sites to complete estate works. Against that, we received £16 million of bids, which included vehicle replacement, medical equipment replacement, imaging equipment and licences required for cybersecurity. In addition, we plan to hold £500,000 of slippage for any bids that may emerge between now and the year end, which will leave us declaring a reduced requirement in this monitoring round of £12·4 million.
Brigitte, Tomas, David, Annette and I are happy to take any questions that you have.
The Chairperson (Mr Gildernew): Thank you, Preeta. Brigitte, you mentioned possible access funding of £30·5 million and that there are additional pressures. Can you provide some further information about the additional pressures that you referred to?
Ms Worth: As I said, the Minister is considering a number of options with policy colleagues as to what that funding could be spent on if we do not need it for the discount rate or depreciation. One of those is the potential to enhance the pay offer. Obviously, we are also keeping the situation with omicron under consideration in case any additional funding requirements emerge. You will see that we have already highlighted the need for additional funding for the vaccine programmes to enable the boosters to be fully rolled out. That also provides for a second vaccination for the 12-15 age group.
Ms Worth: As I said, the Minister is considering the options. If we conclude that we do not need the funding for our immediate needs, given that we know that there are pressures being faced across other Departments, we will want to proactively return that money so that it can be spent wisely elsewhere. I am not giving you a guarantee that it will be spent, but it will be spent if it is needed. If our assessment is that it is not needed immediately or cannot be spent immediately in the health system, our recommendation will be that it be returned to aid with pressures in other areas.
The Chairperson (Mr Gildernew): You mentioned that the transformation moneys have been secured for the three-year rolling budget, which is welcome. However, there is no additional bid for any additional transformation moneys in this monitoring round. Why is that?
Ms Worth: It is simply because of the timing of January monitoring. We do not have the time at this late stage in the year to put things on the ground. There is also the issue of recurrent tails into the following year. It is a timing issue. We absolutely could spend more money on transformation if we were given notice and recurrent assurances around that funding being available.
The Chairperson (Mr Gildernew): That is certainly a concern. The Committee has already addressed the issue around workforce and the huge number of people who are leaving; we have agreed to write to the Department about that. I will run through a couple of areas quickly just to check yes or no, in case I have missed out on something. Is there any bid in relation to workforce, staffing, retention or recruitment?
Ms Worth: Not in January monitoring. There were substantial bids as part of our future Budget submission around measures that we could take to strengthen and improve the workforce situation. Again, because training programmes are long commitments, there are no bids in January monitoring for that. You will see, though, that £23 million is allocated to help alleviate some of the workforce issues in domiciliary care, and that is where the Minister felt that he needed —
The Chairperson (Mr Gildernew): Yes, I am aware of that. We have welcomed that. However, I will make the more general point that, given the crisis with the workforce and the staffing cohort, we should be looking at short-term supports and measures. I think that that is appropriate in January monitoring, and I am very disappointed that it is not reflected there. Similarly, I am also disappointed that multidisciplinary teams have been stalled. There is no allocation of money towards that. There has been nothing done, Brigitte, for carers throughout the entire pandemic. Carers are already on their knees, and, yet again, we are going into a period when the Department is not even bidding for money. Finally, daycare centres and respite centres are not providing the service that they were providing or the service that is needed, and there is no funding for that.
I am disappointed at the lack of ambition in relation to those issues and the lack of concern and awareness around them. I think it could be done in a short space of time. We have seen additional moneys provided for staff and uplifts, so there are schemes and frameworks in place. That could be extended to carers, and it could also be extended to staff in order to retain them.
I will leave that as a comment for now because I do not have time to drill into it, but, related to that, it is clear that agency staff spending continues to run away and that agency staff are on hugely enhanced pay and, in some ways, conditions compared with core staff. Is it not possible that we can look at short-term uplifts, even within the premia in Agenda for Change, for our core staff to pay them in a way that provides an uplift at Christmastime, given the pressures that COVID continues to place on our staff? Can we not look at pay enhancements for core staff?
Ms Worth: Certainly and absolutely. As the paper says, one of the things that the Minister is considering with the £30 million that we have available is what we can do in terms of pay for our existing staff. That is actively under consideration. As I say, he is considering a range of other measures. I am not at liberty to comment on those until he has gone through those deliberations, but there a number of things that that £30 million could be used for that the Minister is considering, and certainly I am sure that, if there are short-term measures, he will be looking at everything that can be done with that funding. Indeed, if it is not sufficient, a bid will be put forward at January monitoring for any extra amounts that are needed.
Ms Worth: I am aware that discussions are ongoing. I know that there are difficulties around legislative competence to make those payments. I know that those deliberations are continuing, but I do not know exactly where we are with that.
The Chairperson (Mr Gildernew): OK. Thank you. I will move on. I will come to Preeta in a second. Before I move away from you, Brigitte, I want to say something. I recognise that there is plenty going on in the Department. However, the scrutiny of the budget is not a consequential or secondary matter, and it is hugely problematic that, despite us mentioning to you, over the duration of this Committee, the need to get papers in earlier, we are still getting them the day before. Those are detailed papers setting out spending. I absolutely do not think that that is good enough. I have to say that to you, Brigitte. It is just not good enough.
Ms Worth: All I can do, Chair, is apologise and try to do better next time, and I will.
The Chairperson (Mr Gildernew): OK. Preeta, I have a couple of wee quick ones for you. You mentioned the slippage of approximately £28 million capital, and you have outlined broadly where that slippage lies. Can you outline any of the projects or programmes that will be impacted by that?
Ms Miller: Let me just pull that up. We had quite a bit of slippage in our IT programmes, the main reason, again, being the issues in the supply chains. Where they slip, they slip into the next year, and it is basically to do with kinks in the supply chain, which is a global problem at the minute. I do not think that any programme is necessarily going to be impacted; it is just that the profile has slipped into the following year.
The Chairperson (Mr Gildernew): OK. Finally, then, on the capital side of things, can you provide any further information on the £8·1 million bid for cybersecurity licences? Where is that coming from?
Ms Miller: That is from Digital Health and Care Northern Ireland (DHCNI). It is to do with cybersecurity, which is becoming an increased threat. There is a need to keep on top of that. DHCNI has put in a bid in order to obtain those licences and make sure that we are safe from attacks.
Mrs Cameron: Thank you, Brigitte and the panel, for your attendance this morning, which is much appreciated. At the outset, I concur with the Chair's comments; I am also disappointed by the late availability of the information. We do not have proper time to digest the information and drill down into it in the way that we want to in order to give proper scrutiny to what is an incredibly important topic. That is disappointing, but I accept that you have apologised for that, Brigitte, and that you are seeking to do better.
I also have similar concerns about where we are on the way that staff are paid and the use of agency staff. My colleague Deborah will want to ask you more about that, so I will leave that to her.
It would be deeply regrettable if considerable sums of the Health budget were to be returned to Finance in the remaining months of the financial year. We need to see a contingency plan for money that may become available as a result of further slippage to be spent in a timely and effective way. Have the trusts been asked to submit spending plans for additional unallocated slippage, and what types of projects can be delivered in that narrow window between now and the end of the financial year? At this stage, is there any indication of the amount that might have to be returned?
Ms Worth: We have asked trusts whether they can increase their spending. As always, with the short time span left towards the end of the year, that is incredibly challenging. At the moment, they have indicated that, whilst there are some small things that could be done, additional spending across the piece would be unlikely to exceed £5 million. In terms of direct, general spending, in order to manage the deficit position coming out of October monitoring, we had a moratorium on discretionary spending that did not have an immediate impact on services. Were we to lift that moratorium, there could be some additional spending there.
Ms Miller: Equally, on the capital side, we have reached out a number of times to ask whether there is anything that can be spent. In a way, it is even more problematic on the capital side because of the lead times for procurement. I mentioned that we are also having trouble gaining access to hospital sites in order to carry out estate works because they are already so overwhelmed. We have tried to explore every avenue, and we continue to do that. Our final deadline for submitting our surrenders to DOF is around the first week of January. We are continuing to work with the trusts to see whether there is anything at all on which they can usefully deploy funding before we hand it back. It is in the region of £12 million, Pam; you had asked about that as well.
Mrs Cameron: Thank you for that. Is there any update on the request for additional moneys for the extra 48 beds that are required at Antrim Area Hospital in order to cope with winter pressures? Also, I am deeply disappointed that more is not happening on transformation. We know how vital that is, particularly, as the Chair mentioned, in relation to the roll-out of multidisciplinary teams in primary care. They are absolutely vital. We know how difficult it is for the sector and how difficult it is for people to get in contact with a GP.
We need to see more being done to improve that service to ensure that people can get the help that they need.
I wanted to ask about the military funding arrangements, and I see there is £0·9 million for military support. Can you explain how the funding arrangements for military support works in more detail?
Ms Miller: I will start with the 48 beds. We are working very closely with the trust at the minute to look at that. It had submitted a draft case but it is reviewing that to see whether it can achieve better space standards for the unit that is being built. It is looking at an interim scheme that would be up and running sooner than a permanent build. It is reviewing the space standards and looking at the configuration of the 48-bed unit, or two 24-bed units. We hope to receive a case from it soon. The Department will seek to prioritise that from within the budget allocation that it has received.
Ms Worth: The military support is charged to us at full cost. The MOD will charge us the full cost of deploying those staff for the time that they are with us. That is £900,000, which is a rounding of £850,000, for the 80 combat medical technicians who were with us in October. There is ongoing consideration of whether we wish to ask for additional military support and if that could be provided over the coming months. That is not specifically factored into the figures in the paper, but it is another thing that we may need to deploy the £30 million towards.
The Chairperson (Mr Gildernew): Thank you. Can you send us a breakdown of that almost £1 million spend, Brigitte, for the military? Information has been shared by the Department recently around the workforce appeal. There were 51,234 expressions of interest for the workforce appeal from people who would come back to help out with COVID-19 and other pressures. There were 30,499 new formal applications received by the Department, out of which 16% — 4,936 — new appointments have been made. That means that the Department has 25,563 applications from people in our community who are willing and offering to help out to provide healthcare. Nurses are telling us that they are often doing portering, cleaning and administrative tasks, taking them away from their core nursing role. Clearly, a wide range of skills and jobs are needed there. How many of those 25,000 people is the Department actively progressing by way of assistance into the health service, given the staffing crisis?
Ms Worth: I do not have exact figures, but a number of people from that pool have withdrawn or have declined an appointment. There have also been some issues with matching candidates to suitable roles. For example, some candidates were only able to do specific hours on specific days. I imagine that not all of the 20,000 are still actively in the pipeline as potential employees. Whilst I do not have an answer to your specific question, for any additional workforce that is available and can be deployed, we will seek to allocate funding for that.
The Chairperson (Mr Gildernew): First of all, the figure is over 25,000, not 20,000. Any hours, in a healthcare system that operates 24 hours a day, seven days a week, have to be welcomed. That should not be dismissed lightly. Nurses would appreciate someone able to give them two hours. Every minute will help in the current situation, given the pressures. You do not have the exact figures but can you tell me approximately how many have dropped off or how many are still sitting on the Department's desk?
Ms Worth: I am sorry, Colm. I probably misled you. I do not have any figures in front of me on how many are left from those 25,000 who are still being actively processed. That is something that I would have to follow up on and provide to you.
The Chairperson (Mr Gildernew): OK. Could I ask that that is provided urgently? Regardless of slippage, there are clearly significant thousands of people who have applied to the Department to say, "Listen, I'm prepared to come back into service or provide a service". Those need to be prioritised urgently, Brigitte. We are losing staff. We have already said that 575 staff have gone from a system that is creaking, and with nurses and healthcare workers who are unable to cope. Quite frankly, we have asked too much of them. It is not too much to ask that the Department urgently gets as many as possible of those 25,563 people into our healthcare system and gets their feet on the ground. They have applied; they need to be recruited.
Ms Worth: I can certainly take that message back to my colleagues.
Ms Bradshaw: Thank you, panel, for your briefing. I welcome the £100,000 for research into the minimum unit price of alcohol. Who is going to be delivering that and how will that money will be spent?
I note that there is £5·5 million for the managed quarantine service. Again, I would like more detail on that, and on the £5 million for the mental health fund. If that is to be delivered within three months, I wonder whether the money is going to be spent effectively. Of course, I welcome money for mental health, but I am concerned about whether that can be delivered in a way that really improves the situation.
I will come back with a final question on the longer-term budget.
Ms Worth: The Department commissioned the University of Sheffield to carry out research on minimum unit pricing. That was done in 2014. The money is to enable us to have that research updated so that the modelling that it provides can be utilised in setting an appropriate rate for the minimum unit price in Northern Ireland in the event, obviously, that the outcome of the public consultation shows that that is the preferred option.
With regard to the £5 million for mental health, the Minister established a mental health fund last year. The number of applications to that fund was higher than expected. This money was intended to enable us to fund more of those applications. In that context, we are fairly confident that it can be delivered, and in a meaningful way.
Your other question was about managed quarantine. Although people have to pay to go into managed quarantine if they come back from a red list country, because we have to hire out the whole of an hotel for quarantine purposes, the money that we bring in from the people who are quarantining is not sufficient to cover the overall cost of the quarantine and the security around that. The funding is to bridge the difference between what people pay and what we have to pay to secure the availability of that facility on an ongoing basis even if there may be only one or two people in the facility at any one time.
Ms Bradshaw: I welcome the University of Sheffield doing that research. It is a world leader in that field, so that is positive news.
My final question is about the £15 million provided for trust deficits, with a remaining deficit of £60. I have raised this concern with you before: going into the new three-year budget, there are commissioned services for the trust to deliver 700 hip operations, and they may not deliver 100, but they do not have to give money back for any shortfall in delivery. Is there going to be tighter rein on what is commissioned and funded and what is actually delivered by the trust because you will have that three-year period?
Ms Worth: That is something that we will have to look at as we move forward. In the context of COVID, the sorts of controls that we would have put around that have not been able to be operated in the same way. It is not clear at what point during the three-year period we will emerge from the current COVID situation. In order to live within the funding that we have, we are going to have to look at what services are commissioned and how they are delivered. The challenge, particularly in the short term, in the context of COVID, will be that it is difficult for us to apply what we would regard as a normal level of control.
Ms Bradshaw: I appreciate that, but, if we are moving to £6·5 billion or £7 billion per year, we should have much tighter control of that money.
Mr McGrath: Thanks to the panel for the presentation. As an add-on to Paula's question about the managed quarantine service, can we get some feedback on whether checks are being done on the scale of its usage? Obviously, you can take over an entire hotel that has 100 bedrooms, but if you are only ever using a maximum of five or six of them, maybe a smaller hotel or even a bed-and-breakfast facility could be taken over instead. That might be more appropriate and cost less money. A figure of £5·5 million is a lot of money when that is not being utilised fully.
I also want to ask about test-and-trace funding. I see figures of £20 million and £40 million. It mentions the national testing programme. Can we be assured that the money that we are spending is for the test-and-trace delivery programme that is actually happening here in Northern Ireland, or are we contributing to the national programme, and it is costing us? How will we get that back? Can I get some information on those issues, please?
Ms Worth: OK. Starting off with the issue of managed quarantine, absolutely that is kept under continual review. Certainly, if it is no longer needed, or needs to be scaled up or down, that will be looked at and reviewed, absolutely.
With regard to funding for test and trace, the £46 million that we are expecting to receive from across the water around the time of January monitoring is our share of the funding. Effectively, we are getting our share of the funding that has been deployed to the national programme. It has been difficult for us to plan due to the lack of clarity about exactly how much that funding would be. As I say, back at October monitoring, we were being told that it would be only £20 million, and we were having to plan on that basis. We are now being told that it is £46 million, but we still do not have a final figure. Therefore, that is all playing into our uncertainty. Obviously, had we known, back in October, that we were getting £46 million, we would have been able to plan a lot more effectively to use that funding in other ways. That is not to say that we are not spending the money that needs to be spent on the test-and-trace programme; we are absolutely doing that, but we have had to plan to manage that within the allocation that we already had. Had we known that we would get that additional funding from across the water to pay for it, it might have enabled us to do other things earlier in the year, if that makes sense.
Mr McGrath: Yes. Can you give us a little detail on how that money is being spent? There might be an impression, which I, too, could be accused of having, that the test-and-trace programme is basically a call centre, with which people are interacting. Does it also include the testing element, getting all the samples and putting up all the tents? Is that for the whole programme all together?
Ms Worth: It is for the whole thing, so it includes things like the use of the labs to do the testing, as well as the tracing facility that you have outlined. Effectively, it is funding that we are getting as a consequence of England's spending money. We are not forced to spend it on exactly what they have spent it on, but it is a contribution in recognition of the fact that we have costs for test and trace that need to be funded, because they have the national programme, if that makes sense.
Mr McGrath: Yes, but we are not spending it because we were expecting the allocation to be much smaller. In other words, when it comes in, there will be a differential that has not been spent on our programme, because we were not expecting to get it, and we will be able to spend it on something else.
Ms Worth: That is not exactly the position, because we have spent whatever we needed to spend to make our programme run at the level that we thought was needed. However, because we did not know that we were getting that money, we were having to use some of our other COVID money, I suppose, to supplement it, and, potentially, we could have used that other COVID money on other things if we had known that that was coming.
Ms Worth: The £26 million that we did not factor into our October monitoring position is part of the reason that we are looking at a £30 million surplus in the January monitoring round. Does that make sense?
Mr McGrath: It makes that sort of financial sense. I think that I know where you are going with that, but I got a wee bit lost in the middle.
Ms Worth: Basically, we received more money than we expected to. In the same way that, when we spend less than we expect to on something, we have more money to spend on something else. Because we received more money than we expected to for this, we now have more money that we can deploy to something else. I suppose that I am expressing a degree of disappointment that we did not know sooner that we were getting it, because the sooner we know that we are getting funding, the more effectively it can be deployed.
Mr McGrath: How much will the test and trace cost? You thought that you were getting £20 million for the test and trace. If you get £46 million, how much of the £46 million will you have actually spent on test and trace?
Ms Worth: I expect that we will have spent at least that much. We do not have the figures for exactly how much we have spent, because we were not actually asked to prove that we spent at least £46 million on test and trace in order to receive that funding. As I said, we have a right to receive that funding, even if we have not spent it all on test and trace, because England spent that amount on test and trace. I am trying to say that the fact that we did not know that we were getting that money has not impeded our ability to spend on test and trace, because we prioritised that spend from the other COVID funding that we received. I am sorry, that is a bit —
Mr McGrath: Will you have spent £46 million on test and trace?
Ms Worth: I expect that we will have, but I do not have the figures to give you a breakdown. I know enough about what is being spent to be pretty confident that we will have spent it all.
Mr McGrath: I will ask one supplementary question about the capital programme. When I was on the Committee last year, I asked about the possibility of getting an MRI scanner for the Downe Hospital. The trust, the board and everybody approved that, and I think that it was sitting with the Department for approval. Is the process still that there is a departmental list of priorities? Is it still a ministerial decision as to what goes on that list? Is it still the case that the MRI scanner for Downe Hospital is not on that list?
Ms Miller: We have a group that looks at equipment like that, where it is required and what is procured. In our January monitoring round, we reached out to see whether anything can be purchased. We are also looking at that as part of our budget process. We have just got the figures, however, so we are working through what can and cannot be funded. It will all go to the Minister for agreement, yes. How we spend the budget will be subject to ministerial approval, Colin.
Mr McGrath: Can we get an update in writing about what stage the capital programme is at and what projects are and are not on the programme at this stage?
Ms Miller: Yes. We are going to publish a high-level budget paper on the website. I do not know whether that has been published yet, Brigitte.
Ms Worth: It has not been published yet. It is going through the approval process. It will either be published this side of Christmas or in the new year, depending on the Minister's availability.
Ms Miller: Yes. We are going to publish a paper on that. Is that OK?
Mrs Erskine: I thank the panel members for their answers and for coming to the Committee today. I totally agree with the Chair: I am really concerned about workforce costs. I believe that there is real dependency on bank nursing. I would like to see a breakdown of staff costs, including agency costs, so that we can see clearly how much is being paid out and in what fashion that is being paid out. I asked for figures for three days in October. Over £115,000 had been paid out by the five trusts over that three-day period. That is not the fault of the nursing staff; it is poor management. This week saw one particular agency announce a pay uplift, so this will only get worse. Urgency is needed on that. What is the Department doing to rectify it, so that money can be freed up in our health service? Are discussions going on with all five trusts? Are we finding out why nurses are going to agencies? Are we confident that that will be rectified by this budget?
Ms Worth: I will try to pick through that. A working group has been set up to consider agency costs. There are a number of strands to that. In general, when we use bank nurses or on-contract agency staff, we do not pay a premium in salary. Obviously, we pay a fee to the agency, but a significant proportion of the agency cost is not additional to what we would pay if we had permanent staff, although having permanent staff would be the preference in a lot of cases.
There will always be a need for agency nurses to cover things such as sickness and maternity leave and other short-term situations, although I absolutely accept that we are going above and beyond that sort of use of agency staff at the moment. There is a working group to consider that, although, again, as with many things, it is maybe not making as speedy progress as we would like, due to COVID.
The long-term solution is, obviously, to train more staff. We have, over the past number of years, honoured the New Decade, New Approach (NDNA) commitment to 300 extra nursing places per year. We are up to 600 additional nurses in the current year, so nursing training places are at an all-time high at the moment. Given all the issues, we will seek to protect that as we move forward into the budget, but the Budget settlement does not, on the face of it, provide funding for additional training places, so, if we want to increase training places, we will have to reduce spending elsewhere in order to achieve that. That decision is not mine to make.
Mrs Erskine: Thank you for that. Training is one thing; retention is another. It is about ensuring that we retain the workforce that is already in place and that anybody who is coming through the system who has been trained is also retained as full-time staff in the trust. Maybe you can touch on that.
It is worrying to hear phrases such as, "This will only fund activity on the ground as it is". In April 2021, officials said that Northern Ireland required an additional £400 million just to stand still. We cannot stand still any longer; that is the point. Since I joined the Health Committee, I have heard, "Workforce, workforce, workforce". I have heard about all the pressures. We cannot stand still; we need reform. I agree with the Chair on that. Where does reform fit into the next three years? Is the budget still for a standstill scenario? That is, in some cases, what it looks like to me.
Ms Worth: I think that it was me who said that about the £400 million to stand still. To be honest, because we have had the lack of recurrent funding in the current financial year, we need that £400 million a year to keep things ticking over, because of the rate of health inflation and if we are going to continue to give our staff pay rises. For example, a 3% pay rise plus trying to address the underlying level of inflation costs us an extra £200 million. We will be in a difficult position. Maybe Tomas can say a few words about the potential for reform.
Dr Adell: We have an active transformation programme in response to Delivering Together, which set out how we should ultimately reform the health service to meet our very significant challenges, but, with the current Budget settlement, we do not have any room to expand that reform. We do not have any room to expand transformation and do more than we are already doing. That is a significant limiting factor for us.
Mr Carroll: Thanks, panel. There were a few connection issues at my end, so apologies if my first two questions have been addressed.
The report refers to an allocation of £200 million for the purpose of the COVID-19 response in 2024-25. Is that due to an expectation that new variants will emerge? Is it for long COVID? What is that for?
My second question is about domiciliary care workers and the £23 million extra that has been allocated to them. As the Chair said, we obviously welcome unpaid workers getting assistance and what they are owed, but I submitted a question for written answer to the Minister on that, and I want to tease the point out slightly. I am concerned that that money will go to private organisations and that the full £23 million will not be passed on to the workers. Some of those organisations are profitable, even though the workers are not being paid adequately. The Minister gave some assurances in his answer to my question for written answer, but what assurances can the Department provide that that money will go to workers and will not be pocketed or used for other costs by those organisations?
Ms Worth: OK. First, I will touch on your question on COVID. That figure comes from the Budget papers that we submitted. I will be very honest with you: our COVID figures for the three-year period are very high-level guesses. The 2022-23 number was largely based on what we were spending at the time that we submitted the figures in 2021-22. At that time, we estimated that we would spend £400 million on the COVID response in 2022-23. We then simply subtracted £100 million a year from that number for the other two years, because there is absolutely no way for us to reliably predict what we might need to respond to COVID over that time frame. We hope that we will need less than what we are spending now, so we have put it on a downward trend.
On the reasonableness of the £200 million in 2024-25, at the moment we are spending £130 million on extra PPE. It is very much guesswork, but we looked at that and asked whether we would still see nurses on wards wearing masks in three years. If that is the case, at a very rough guess, £130 million of the £200 million will be spent on additional PPE. Obviously, the less that we spend on the COVID response, the more money that we will have available for other health services. So, it would be excellent if we could make that number smaller by the time that we get to 2024-25.
Your second point was about domiciliary care. You are right that the Department cannot mandate that that money be passed on to workers, but my colleagues have said that they have already seen evidence of that additional funding leading to some providers offering rates of pay in excess of £11 per hour. So, we are seeing evidence of the measure being effective. We cannot guarantee that that will happen because we cannot force domiciliary care providers to use the money in that way, but we are seeing evidence that it is being successful. Ultimately, if they are going to run successful businesses, they need to attract and retain staff, so you would like to think that they would use the extra funding to do that.
Mr Carroll: OK. It should be seen as a service rather than a business, but I will not get into a big discussion about that with you.
If that £200 million requirement for COVID is reduced, can the money be reallocated? Will that money be there in 2024-25 anyway, or will it only come in to cover costs due to COVID?
Ms Worth: We expect that we will have to fund the response to COVID from our 2024-25 allocation. So, the less money that we have to spend on the cost of COVID, the more that we will have left for other things.
Mr Carroll: OK. This is my final question. I read the papers last night and was really concerned — I was dismayed, to be frank — by the section on the response to the DOF Budget. There is a table that details areas that are being looked at, considered or whatever language you want to use. It mentions the possibility of "Prescription Charges", "Domiciliary Care Charges", an "Early Years Registration Charge" and other charges. The document states that that does:
"not represent a definite direction of travel".
To me, it definitely does, and it is a direction of travel that will lead to the dismantling and destruction of the NHS. People who have paid in to the NHS for decades will be forced to pay, even though they cannot afford to. I am really concerned about that, and I want to know where it came from. I presume that it did not come from the Minister. What level of discussion was had in the Department about that? It is a deeply concerning document.
Ms Worth: We were asked, as part of the Budget process, to put forward a range of measures that are super parity to England. We were asked to cost those by the Department of Finance as part of our response to the Budget. That is where that came from. My understanding is that the Executive had discussions on whether any of those things would be implemented, and that, if they were to be, they would be set out in the Minister's statement on the Budget. Obviously, it is still a draft Budget, so I cannot comment on the likelihood of those measures being introduced in the future, but that is the context in which they were put forward. The proposals were definitely not put forward by the Minister.
Mr Carroll: It suggests a very worrying direction of travel that, if implemented, will be fought against.
Ms Flynn: Thanks to Brigitte, Preeta and Tomas for coming along today. My first question is about the January monitoring round, and I then have two questions on the document on the multi-year Budget that Gerry referred to.
On the issue that Paula raised about the £5 million mental health fund, I assume, Brigitte, that that is the fund that the Minister released for a support scheme for the community and voluntary sector and charity organisations to bid for small amounts of funding. If that is the case, does that mean that there have not been any bids in the Budget for any statutory services, including child and adolescent mental health services (CAMHS), or addiction services?
Ms Worth: We had some bids for mental health services met earlier in the year. Again, in the context of the issues that we have with putting more services on the ground when we do not have future funding for them, we made bids in June monitoring for mental health services that could be delivered in-year on a non-recurrent basis. Those were all met at that time, so it is in that context that we have not made any additional bids for statutory services.
Ms Flynn: OK. I do not fully understand that. We all know that statutory and community mental health services are under unprecedented challenge. I am a wee bit concerned that no bids were put in for statutory services.
That brings me to my next question, which is about the multi-year Budget and the preparations that are under way for that. You referenced in your document the mental health strategy and the funding that will be required for the first three years of it. That was good to see, although it is only a drop in the ocean when it comes to what is required over the 10 years. There was no reference to the substance use strategy in the document. Why was that? The Public Accounts Committee is meeting today to discuss a report on addiction services. That is a massive issue that will require a lot of funding. Why was that not referenced alongside the mental health strategy?
My final question is about the section in which you listed some drugs and therapies that need to be funded. The list includes cancer, MS, bowel disease and HIV, but there was no reference to the medication that is required for pulmonary fibrosis. Pam is the chair of that all-party group (APG), and a recent review on the medication was done by the National Institute for Health and Care Excellence (NICE). Why were those drugs not factored into that list?
Ms Worth: First, in relation to your query on the substance abuse strategy, we had to pull together those initial figures on the strategies very quickly, and so we included the three strategies that have been published. At that stage, we flagged to the Department of Finance that it was not a complete list of everything that we required. Indeed, I think that you received a letter from the Minister around October time, outlining the fact that we had fully costed all our rebuild actions. At that time, the substance use strategy was factored in and submitted to the Department of Finance. So, it was in the figures that we eventually submitted, but we just did not have the figures available. We were asked to produce an assessment of how much we needed for Health very quickly, and we were only able to factor in the figures that we had to hand at that time. It was not a reflection of any lack of importance or anything like that; it was simply that those three strategies were published and those numbers were available to us.
Your second question was on the drugs and therapies. That is not a comprehensive list. It was a list of the kinds of things that we would need to fund from that funding. The idea of asking for additional money for drugs and therapies is that it will cover things that we know will be needed and that are in the pipeline. However, it is also a general amount, in recognition that drugs and therapies are continually developing and that new ones come online all the time. It is not a comprehensive list, so it does not preclude other therapies from being funded.
Ms Flynn: That is fair enough, Brigitte.
Chair, I have another quick question. Colin made a point earlier about the officials following up in writing on one of the issues that he raised . If we get written feedback from the officials after today, it would be great if that could include information on the stress test that officials were working on, which we spoke about last time, concerning the percentage share of the Health budget that goes to mental health services. I hope that that work is ongoing in order to keep a check on that area. It would be fantastic if you could provide the information on where you are with that wee piece of work in writing as well.
The Chairperson (Mr Gildernew): Thank you, Órlaíthí. Those are all the questions from members.
On another point, Brigitte, the Minister promised that the proposals on the reform of adult social care would be out this year. Are you aware of, or can you send us information on, the amount of funding that has been set aside for consultations in relation to that or for any future proposals?
Ms Worth: I certainly can provide that information to you in writing. On future proposals, figures are factored into the Budget figures that we submitted to the Department of Finance. Some quite significant sums were factored into the proposals. I do not have the numbers available on the consultations in particular, so it would probably be useful to follow up in writing on both of those points.
The Chairperson (Mr Gildernew): OK, thank you for that and for your commitment to sending information on to the Committee on a number of issues. I thank you for coming to the Committee this morning. We will see you again in due course, given that budgeting and the scrutiny of budgets is a key priority, and the Committee is very determined to improve how it scrutinises budgets. I appreciate your commitment on that engagement, Brigitte, and look forward to it.
Ms Worth: If there is any information in particular that would be helpful for you to have in our papers, we would be happy to engage with the Committee Clerk on that so that we can ensure that the information that we provide to you is as usable as possible.
The Chairperson (Mr Gildernew): Thanks for that. We can go ahead with the rest of our meeting and let you go. Thank you for that. I wish you all a happy Christmas; keep safe over Christmastime.
Ms Worth: Thank you very much, Chair.