Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): You are welcome. In attendance we have Dr Tomas Adell, director of elective care and cancer policy; and Eilís McDaniel, director of family and children's policy. I remind everyone that we have an hour for the session; we have a lot to get through. The meeting will be covered by Hansard. I invite you to make your opening remarks.

Dr Tomas Adell (Department of Health): Thank you for the introduction and for asking us to come up here today. It is good to be here again to talk about these important things.

The draft Programme for Government (PFG) notes nine priorities, and health is relevant to many of them. There is one priority that is specifically about health, which is "Cut Health Waiting Times". I will make some short opening comments on that and then hand over to Eilís, who will continue on other parts that are relevant to the Department. We will then, of course, take questions and discuss whatever you wish.

It is accepted that our waiting times are unacceptably long and much worse than those in neighbouring jurisdictions. There are three areas with waiting times: new outpatient appointments; diagnostics; and treatment for inpatients and day cases. Some patients wait many years for final outcomes. That is never OK. As noted in the draft Programme for Government, following approval of the Budget, the Department of Health has already committed to invest £76 million this year for waiting lists. That is a non-recurrent investment that matches the additional investment of last year, but we need to make clear and recognise that it is significantly less than in the year before that. The £76 million will be used for those with red-flag or time-critical waits, which is people with cancer or those with life-, limb- or sight-threatening issues. That £76 million is not sufficient to do any additional work on those waiting a long time. In a sense, it is what is required just to stand still and does not represent more money than in previous years.

Fixing waiting lists demands a long-term, collective effort and requires sustained and substantial investment through multi-year budgets, workforce development and system-wide transformation. I have been here before, and we talked about investment need. We estimate that £76 million per year — this year and in future years — is needed to address the red-flag and time-critical demand/capacity gap alone. In addition, we require £80 million per year recurrent to address the wider elective care or planned care demand/capacity gap and £135 million per year for up to five years to clear the backlog. In addition, corresponding investments are needed across diagnostics, imaging and pathology in other areas to support the treatment of patients. The plan for fixing our waiting lists was published in an updated elective care framework in May. Those 10 actions, if fully implemented and funded, would address the issues and match the investment need that I just outlined.

I must note that it is not all bad news, though. Much work is happening with what we have. Over the past couple of years, much work has been ongoing. Service reviews have been completed across a number of areas, leading to significant improvements in how we do things. Many decisions to improve access and outcomes have been taken: for example, moving vasectomy services from secondary to primary care, which is more efficient funding-wise and time management-wise and provides good outcomes for patients. That has reduced treatment waiting lists for inpatient day cases for the last eight quarters in a row, bearing in mind that the last figure does not include all trusts because of Encompass and data changes. The sustained, long-term reduction in waiting lists is a clear sign of progress.

The good news includes two dedicated day-procedure centres at Lagan Valley and Omagh, which have treated approximately 20,000 patients. Cataract day-procedure centres have significantly reduced the cataract waiting list. Although it is still long, it is significantly shorter than it used to be. The introduction of mega-clinics to maximise patient throughput has seen almost 25,000 patients treated between January 2021 and July 2024. In the 12 months from March 2023 to March 2024, endoscopy waits have decreased significantly, with a 20% reduction. That is partially because of new endoscopy centres in Lagan Valley and Omagh that are now fully operational.

There have been significant reductions in orthopaedic and general surgery waiting lists — the two longest waiting lists. That is not one-off work, and the reductions are despite having less waiting-list funding than in previous years. They have been achieved through transformation and working better. However, without the recurrent investment that I noted, it will be difficult to maintain momentum to reduce the treatment list, and it is unlikely that other waiting lists will reduce. That is recognised in the draft Programme for Government as well.

I thank you for the opportunity to speak. I will hand over to Eilís, who will continue.

Ms Eilís McDaniel (Department of Health): I want to say something about the application of the draft Programme for Government to social care and public health. While a specific focus on issues such as mental health, child poverty and reducing health inequalities would have been welcome, it is accepted that a reduced time frame in the current mandate made it impossible to include everything that we are doing. As has been the case for all other Departments, it has been necessary to prioritise in the draft Programme for Government, which the Health Minister signed off as a member of the Executive.

Much of what we are trying to do in social care and public health falls under the umbrella of "Reform and Transformation of Public Services". The Committee is aware of ongoing reform in children's social care, adult social care and mental health through implementation of the mental health strategy. Other identified immediate priorities in the draft Programme for Government are relevant to our social care and public health strategic and policy aims, including "Deliver More Affordable Childcare", "Provide More Social, Affordable and Sustainable Housing" and "Safer Communities". The priority of "Better Support for Children and Young People with Special Educational Needs" is also relevant.

Research shows that 40% of health outcomes are driven by the socio-economic environment in which people live. Steps to address poverty and inequality, including enabling affordable childcare, growing the economy and increasing access to affordable housing, are critical in addressing health inequality and will impact positively on mental health.

There are references in the draft PFG to the challenges in children's social care and to the ongoing reform programme in children's services. By way of an update, a paper on the reform programme and the children's services review is being prepared for the Committee's meeting on 26 September. That will set out what we have been able to do on reform to date and provide the latest position on the children's services review.

There is a commitment in the draft PFG to build on the Executive's strategic framework for public health, Making Life Better, to tackle the wider determinants of health. There is also a commitment to redouble efforts to improve the physical and mental health outcomes of the Northern Ireland population and to reduce inequalities through continued implementation of, for example, the mental health strategy.

Specific reference is made to the Live Better initiative recently announced by the Health Minister, which intends to deliver and test a new place-based approach to addressing health inequalities by promoting existing initiatives and programmes and delivering them intensively in communities, in order to make a real and lasting difference.

The draft programme also includes commitments to launch the Northern Ireland food strategy framework and to prioritise sports and physical activity to tackle obesity. The Committee is aware that the Department has worked closely with DAERA and DFC to develop the food strategy and the sport and physical activity strategy, Active Living. Work is under way to develop a new obesity strategic framework that, for the first time, brings together obesity prevention and obesity treatment. The intention is to publish that new strategy early in 2025.

The domestic and sexual abuse strategy is referenced in the draft PFG under the "Safer Communities" priority. The strategy was developed jointly by the Department of Health and the Department of Justice; considered by the Committee at the start of the summer; and approved by the Executive last week. Launch plans are being finalised. The Health Minister and the Justice Minister intend to launch the new strategy in coming weeks.

On childcare, health and social care trusts regulate day-care and childminding provision in Northern Ireland. Proportionate regulation will help to make childcare more affordable. The Health Minister has committed to a review of childcare standards, starting with consultation on a number of more pressing issues: child-to-staff ratios in childcare and health assessments on childcare staff.

On the priority to provide "Better Support for Children and Young People with Special Educational Needs", the Department of Health works jointly with DE on a range of SEN issues, including future planning, reform of services, transitions and development of guidance. Allied health professionals (AHPs) work with children with special needs in our schools — special and mainstream schools — to provide therapies in response to assessed need and to enable access to the curriculum. Our nurses play a pivotal role in working with classroom assistants to provide support for children with medical needs in the school environment. The number of children requiring support and the complexity of need has increased in recent years, and the Department continues to work with Education to ensure that those are being met.

Members will note that, under the priority to "Provide More Social, Affordable and Sustainable Housing", there is reference to a joint initiative between the Department for Communities, through the Housing Executive, the Department of Health and the Department of Justice to:

That is a reference to the intention to:

Finally, the draft PFG acknowledges the work of the social care collaborative forum. That is a reference to the ongoing programme of work in adult social care that is also being led by the Department. The work of the collaborative forum sits in the Department's wider transformation programme. The forum has set the future strategic vision for adult social care in Northern Ireland; is providing strategic direction; and will oversee implementation of agreed actions to support improvement and transformation. The work of the collaborative forum is, of course, long-term. While some measures can be put in place to alleviate immediate pressures, adult social care requires longer-term sustainable solutions and investment, which the collaborative forum will seek to address and influence.

In summary, members, the draft PFG addresses many of the priority issues for the Department in relation to social care, mental health and public health either tangentially through the nine priorities identified or through reference in the body of the programme, mainly under the "People" mission.

The Chairperson (Ms Kimmins): Thank you, both, for that. There may be questions that you are not able to answer, because, as I appreciate, you have specific areas of work. If there is anything on which we need to get feedback from others in the Department, let us know as that would be useful.

I will kick off with waiting lists, which is the biggest issue for a lot of people given the length of them. It is good to hear of the progress that has been made to date. Hopefully, that will continue, given what is planned. Tomas, you said that the £76 million would be used for red-flag and time-critical waiting lists. Is that just for cancer waiting lists?

Dr Adell: Red-flag waiting lists are for cancer, and time-critical waiting lists are for life-, limb- and sight-threatening conditions. It is where something very serious will happen if it is not —

The Chairperson (Ms Kimmins): How much of the £76 million is allocated to cancer waiting lists? Have you targets and indicators for waiting list reduction in the budgetary context?

Dr Adell: The £76 million will be used to fund the gap in service when demand outstrips capacity. We can tell you in writing the breakdown of last year's spend. We hope to find other ways to reduce the spend by working more effectively. Most of the spend is on imaging diagnostics: endoscopy and pathology. It is not all cancer, but it is mostly cancer. We have a fundamental demand/capacity gap in endoscopy, pathology, MRI and CT scans. I would have to reply in writing with a breakdown of the exact spend on those.

The Chairperson (Ms Kimmins): OK. That is fair enough. I am glad that you mentioned diagnostics. We recently had the Minister in Daisy Hill Hospital in Newry. One of the issues that we raised was the MRI scanner, which, as you may be aware, is being rented at very high cost. This is not unique to Daisy Hill Hospital, but the rent is somewhere in the region of £75,000 per month, which is a huge amount of money. On stabilising the system, being cost-effective and getting better value for money, we talked to the Minister about having an MRI suite, which would make more sense in the long term. Will that be looked at as part of the aim to reduce waiting lists and use our money better?

Dr Adell: It is a recognised need, given the demand-capacity situation in MRI. We need long-term investment in imaging; there is no discussion about that. The problem with the £76 million is that it is non-recurrent funding for this year. It is not committing money for the future, which makes it difficult to make long-term investments. Fundamentally, in a lot of areas, workforce is the key problem. The staff simply do not exist, so we need to train staff and invest for quite a few years. As you have heard before, work is being done on the imaging academy, which will strengthen local training in that area. The academy will help with the shortfall in workforce. A lot of the waiting list initiative (WLI) money is spent on imaging for additional capacity, such as evening and weekend work for staff or outsourcing. We simply do not have the workforce to use the resource, although there is a machine shortage as well.

The Chairperson (Ms Kimmins): That is good. I raised the matter at a Committee meeting, because I had spoken to staff who said that they would be willing to work evenings and weekends or whatever, if that could help to get people through. There are concerns that urgent referrals for imaging are not seen as quickly as they should be. The workforce challenges are mentioned in the PFG, and you have mentioned imaging. Are there any updates on planning for the elective care workforce?

Dr Adell: Fundamentally, we need to do things differently. We have a skilled workforce, as we all agree, but we need to think about how we do things differently. For example, surgeons do not spend as much time doing surgery as they could. We do not maximise our resources. That is not because doctors are doing anything wrong; it is because the systems do not enable them to do more. There is work to address that issue. We are looking at the nursing workforce and at having more advanced nurse practitioners and other allied health professionals who can provide services to reduce the pressures and allow doctors to spend more time in theatre, for example. That is ongoing in all the transformation work that we are doing, and it is one of the reasons why we have been able to reduce treatment waiting times.

The provision of extra endoscopy sessions is scope-specific stuff, so that surgeons do not have to do endoscopy in theatres. That is sometimes required because of the clinical need. However, when it might be possible to do it with one endoscopy nurse and one specialist, it can be inefficient to involve two doctors — a surgeon and an anaesthetist — and nursing support. That is one way in which we managed to reduce that waiting list significantly. That transformation work is ongoing continuously. The absence of long-term, recurrent funding makes it difficult to plan long term, but work is ongoing to maximise that as far as we can within existing budgets.

The Chairperson (Ms Kimmins): Is the money allocated through the normal monitoring round process, or is there another process for allocating funding?

Dr Adell: The £76 million?

The Chairperson (Ms Kimmins): Yes.

Dr Adell: The £76 million is allocated to trusts when they require it, through the Department's normal channels. What is procured externally is procured through the normal procurement processes.

The Chairperson (Ms Kimmins): OK, that is fair enough.

On elective care, you mentioned orthopaedic waiting lists, which are probably some of the longest waiting lists. We have raised that issue with the Minister. We asked if there was any potential to start having orthopaedic procedures carried out at the elective overnight hub at Daisy Hill in Newry. I am not being parochial; that is just the one that I am aware of. Across the board, are you looking at expanding the ability to provide orthopaedic procedures through some of the elective hubs that do not currently provide them?

Dr Adell: We need to make sure that we maximise resource to get the best out of the sites and staff that we have. It is a consideration, absolutely; I am not saying no. However, our challenge is that, if we spread the workforce too thin, it is difficult to get effective throughput of services. I am not saying that that is a reason why we cannot do orthopaedics at Daisy Hill, but it is one of the things that we need to consider. The most effective way is to get the staff to be happy to work where they are in an effective way.

In the Southern Health and Social Care Trust, particularly in Craigavon, the fracture pressures make orthopaedics very difficult. Additional theatre sessions in Daisy Hill would not remove the fracture pressures in Craigavon; that is, the unscheduled demand from people breaking bones. The same clinical staff deal with both. That increase in fractures makes it very difficult to deliver an effective orthopaedic service in the Southern Trust. Therefore, the problem is not the site or the theatre room; it is the number of doctors doing that kind of work.

The Chairperson (Ms Kimmins): Will that inform part of the workforce planning around elective care? Could that be looked at? Orthopaedics is probably one of the biggest issues. As you well know, I am sure, as people are on that waiting list longer, by the time they are actually seen, they may need another knee or hip done because of the pressure that has been placed on their joints.

Dr Adell: Absolutely. It is also about thinking differently. At Musgrave Park, in the Duke of Connaught day-procedure unit, we now have nurse-led procedures for, say, carpal tunnel, which is reducing pressures and, therefore, helping to reduce the waiting list regionally. It is about thinking differently. Can we pool the resources to focus on some body parts in some areas to make sure that people get treated more quickly? We are not talking about patients travelling for everyday stuff; we are talking about patients travelling for one-off surgery. If that gets a better throughput of patients, it means they have to wait a shorter time. That is ongoing work. That is the bread and butter of what we do to try and make that kind of transformation happen.

The Chairperson (Ms Kimmins): You will not be surprised to hear me raise this last point. If workforce is the problem in some cases, particularly in orthopaedics, is there any scope to reinstate the cross-border directive?

Dr Adell: It is a funding issue —

The Chairperson (Ms Kimmins): But it has not been funded. There is nothing in this existing budget.

Dr Adell: No, there is nothing in the existing budget. Our waiting list initiative funding for this year is only for red-flag and time-critical cases. The cross-border scheme is for urgent or routine waiters, mostly in orthopaedics; they are not cancer or time-critical patients.

The Chairperson (Ms Kimmins): Yes. That is probably the biggest query that comes through, I imagine, all our offices. If people could go and get it done quickly and be reimbursed, they would be willing to do so. That is not for everybody, but it would certainly help with some of those orthopaedic waiting lists. We have seen how it has helped in the past. If any money becomes available, I urge that it is used to try to offset that temporarily. I do not want that to be a long-term solution — we would rather have our own capacity — but, given the waiting lists, we would hope that that could be kept as an option.

I have two other points to make very quickly. Transformation and reconfiguration is mentioned in the PFG. It was my understanding that we would see the blueprint in early July, but the Committee still has not seen that. I know that it has been out for consultation with the trusts, but it would be useful if we were able to see that or if you could provide a timeline for when we are likely to get an update on it, because it is very important. We have all been asking for that for some time, and the Minister said that he would have it for us.

Dr Adell: A lot of work is ongoing in that area, as you know. I do not have a timeline for that, but we will get back to you. I am sorry: I just do not —

The Chairperson (Ms Kimmins): No, that is OK. I appreciate that that is probably not your area of work, Tomas, but, if we could get an update on that as soon as possible, that would be good. We have been asking for it for some time.

Finally, we have had a series of meetings with various sectors in the health service and worked with some of the palliative care providers. They raised with us their disappointment that dignity in dying and bereavement was not part of a PFG priority. Are you aware of any discussions on whether that should be a priority for the PFG, or about it being included in any other priorities that the Minister has suggested should be taken forward outside what is in the Programme for Government?

Dr Adell: A lot of work in the Department is not covered by the PFG. A lot of work that is a priority for the Department, including on palliative care, is ongoing. Just because it is not in the PFG does not mean that it is not important work that needs done. There are people in the Department who are dedicated to take forward the work on palliative care. I got an assurance on that yesterday, when I spoke to those people. They are happy to come and provide a specific briefing to you, if that would be helpful. A key aim of the Department's overall work is to make sure that we have good palliative care services to deal with people who are bereaved.

The Chairperson (Ms Kimmins): We will follow up on that, because it is a priority for the Committee as well. It would be good to get an understanding on that. Thank you, Tomas and Eilís.

Mrs Dodds: Thank you for the presentation. I want to follow up on a couple of things, and then I will ask a couple of more substantial questions.

In April, I asked the previous Health Minister about transformation and reform, and he said that he would have that blueprint in two weeks' time. The current Health Minister promised us that he would have it in July. If a message goes forward from the Committee, it is that we need to see it. I understand why trusts etc would have a view on it, but, at the end of the day, there will have to be a general discussion on this issue. It is important that transformation and reform is done as soon as possible. I understand that there are reasons why you would want to have as many background conversations on it as possible, but I still think that that is really important.

I welcome the focus on health waiting lists. If my research is right, we have not met a target on those since about 2014, maybe even earlier. It is a huge issue. Everybody around this table will have had constituents present to them in pain and difficulty because of it. So, I welcome that. I know that that the Department is doing a lot of other things that are also really important, but the Executive have rightly made waiting lists a significant priority.

I want to ask you, first, about the reform and transformation unit. How do you understand that that might work? How will Health interact with that unit? Will you have bids for it? If so, will you enlighten us as to what you will actually do on that? It seems that, while it is an important part of the discussion, it is up in the air and not tied down.

Dr Adell: Thank you very much. Reform and transformation is a huge part of everything we do, and it has been for a long time. We welcome having a reform and transformation unit for the whole Civil Service; that is a good thing. There is a transformation programme of funding. The Department has a number of bids in that process. We have a large programme for primary care multidisciplinary teams (MDTs), and we have made a bid for significant funding for that.

Mrs Dodds: Is it for primary care?

Dr Adell: Yes. I am sure that you are fully aware of the primary care MDTs. They provide a service that is close to where people live, thereby providing more effective services and better patient outcomes. That service will help to improve health services in general, but, fundamentally, it provides better patient outcomes with care that is closer to patients. That is a fundamental reorientation of the delivery of services so that they focus on the community. It matches other ongoing transformation work. For example, bringing vasectomies to primary care is better for patients and is a more effective way of doing things. Primary care MDTs are the future for primary care.

There are also three digital landscape review bids. They focus on using artificial intelligence to increase productivity, alongside new data systems and the Encompass EpicCare system, which is being rolled out across the health service. It is about making sure that the publicly funded and independent sector systems can speak to each other to ensure patient safety and that patients who are being treated in the private sector can have their health records transferred across to that sector. It could lead to less favourable outcomes if people do not know what is happening with patients across both sectors. It is also about having a cybersecurity strategy. Those projects are helping us to deliver that to fix funding in order to improve the way that the sector protects information for our population and ensure privacy across Health and Social Care (HSC). Those are the three digital bids. Funding is significant across each year for new ways of doing things. It is in the region of £40 million a year, as you know.

Mrs Dodds: Can you tell us what the bids are?

Dr Adell: I do not have that information. I will have to come back to you on the numbers. The overall funding pot across the whole of society is significant, but, for Health, we know what investment is required for our waiting list needs, and the overall funding that is available is in and around £40 million per year. That is important, but it is not sufficient for significant health transformation.

Ms McDaniel: Every Department was able to submit two large bids and four small bids, if I recall correctly. A large bid was defined as an amount over £10 million.

Mrs Dodds: What was the rationale for submitting bids for primary care but not for capital and imaging and diagnostic services? You constantly tell the Committee, Tomas, that that is where there is a shortfall.

Dr Adell: They serve different purposes. Primary care transformation is the transformational way of changing how we do the health service. It is truly shifting the focus from hospitals to closer care in the community so that, in the longer term, it prevents patients needing hospital care at all. That is the right thing to do long term. It does not fix the short-term problems, but it fixes the long-term problems. That is a good, sound transformation investment.

A lot of work on imaging and diagnostics is on increased capacity. It is transformation as well, but it is not majorly transformational. The shortfall in investment over a number of years has caused the capacity gap. That does not match the requirements of a transformation fund. It is a different kind of investment. Both are equally important, but, for our population's health in the long term, primary care MDTs will undoubtedly have a huge impact.

Mrs Dodds: You referred to the amount of time that consultant surgeons, for example, spend in theatre. I have asked questions about that. It varies across trusts, but, in some instances, as little as 20% of surgeons' time is spent in theatre. What do you think needs to happen to decrease that productivity gap? By the way, I do not know the reasons for that 20%, and I do not know the reasons for the variations across trusts, because I think that they are part of the structural inequalities that we have in the health service, which are really difficult to explain to our constituents. That is particularly the case for those of us who have constituents who border a number of trusts. What is happening? There are fundamental things that we need to look at in productivity and so on. By the way, when I asked that question, I got a note from the Royal College that said, "Thank you for asking that question", because we need to get to the bottom of the issues, whether they are about the lack of theatre time, lack of staff-to-staff theatres, lack of imaging to proceed or too much time spent on consultations. Everybody is frustrated.

Dr Adell: I recognise that. Everyone is frustrated, and that means "everyone". We want to do more with the resource that we have.

There are a number of issues, which makes it difficult. I will point out a few things. The first is the increase in unscheduled pressures. Unscheduled pressures that are on the same sites as planned or scheduled care make it difficult to deliver and plan elective care effectively. If someone turns up in an ED requiring surgery, they will have priority. That is a difficulty. There has been a significant yearly increase, as you know, in those pressures, and there has not been a matching funding increase, which leads to an investment gap in that space.

The creation of elective care centres, separating elective planned care and unscheduled care, is a huge step in the right direction. We are protecting time. Last winter, for example, there was a much lower downturn in elective surgery than in previous years because of that separation. It is a separation of service. It does not necessarily have to be a separation of physical sites. There is a clear distinction in which service is being delivered in which room, essentially. It can be in the same physical building. That is a significant aspect.

Another is the lack of theatre nurses. That is a real difficulty. If you do not have sufficient theatre nursing, you cannot deliver theatres. Theatre nursing is a difficult specialty. It is difficult and heavy work. It is challenging. We have a lot of good staff who are willing to do it, but it is not something that you can just walk into. It requires training and settling in. Therefore, it can take quite a long time. Even after a decision is made to increase the number of theatre nurses, it can take six to12 months before those people are able to start, even though there is no difference in grading, banding or formal qualification.

In addition, we have surgeons doing too much other stuff and not enough surgery. We need other staff to support surgeons so that they do not have to do things such as some routine assessments and patient follow-up, which the patient can initiate. There is a big programme of work in patient-initiated follow-up. Not everyone has to see a consultant after surgery. It can be that, if you have a problem, you phone the consultant. It is a case of trusting our population where it is appropriate to do so. We should always trust the population, but, where it is appropriate, we can say to the patient, "You don't need to come back unless you need to".

So that work is ongoing, but it is not a quick fix. It takes time to build it through, because as soon as you release one surgeon, you need a whole new theatre team, nurses and everything, and those need to be built up as well. A lot of things need to fit into place at the same time in order for that to work. However, we are seeing a reduction in treatment waits because that work is ongoing. There are improvements, but they are slow. However, we are in a better place now than we were two years ago.

The Chairperson (Ms Kimmins): Thank you, Tomas.

Mrs Dillon: Thank you, Tomas and Eilís. I could ask questions on this all day, but I have a couple that I just want to highlight.

Tomas, you talked about putting more into primary care. I absolutely support that all day, every day. Prevention and keeping people well is much better than fixing people when they are already sick, so I am 100% behind that. However, when we talk about vasectomy services being moved out to GPs, we know that they were taken off GPs and then sent back out to them. I welcome that, but the reality is that those services were cut. They were one of the first things to be cut when funding cuts had to be made.

If we are serious about this, we need to genuinely put our money where our mouth is and invest in primary care and look at that, as you said, as our long-term plan. There are many other services that GPs were providing, such as gynae care and specialist diabetic services.

Liz met a group in the Southern Trust to talk about the services that are provided to support people who have cardiac issues. All those services have had their funding withdrawn or are not being funded, and they are either being brought back into hospital services or people end up needing hospital care because they are not getting the service. The starting point is that we need to be totally honest about what we are doing. We do not fund our GP services to anywhere near the level that they need to be. If we want to give services and invest in primary care and if that is where we want people to be dealt with, will we fund them to do that? Will we give them the funding to allow them to do the work?

This question is kind of an aside, but it is also about funding. Tackling violence against women and girls is a priority in the PFG. The funding for Women's Aid has been severely reduced, and much of it comes from the Department of Health. We need to look at that if we are going to address violence against women and girls. Nexus is another organisation that has had its funding removed and its ability to help people severely reduced. We need to fund the community and voluntary sector and the primary care sector, because that is where we do the preventative and early intervention work. I understand the position that you are in with having to deal with the waiting lists that you have now, but, in the long term, if people do not see their GP, they will become very sick, end up in hospital and often get diagnosed too late. We know the statistics for people who are being diagnosed in A&Es, and I am sure that many of us here will know people or have had family members in that circumstance.

I will stick to those two questions for now. I have a lot of questions about children's services, but, to be honest, those would be for a specific session rather than taking up time today. Finally, in case I have to drop out before the item on the Committee motion — I know that there is a closed process for that, so I will not go into any detail — I have a slight change of wording that I will send to you, if you do not mind.

The Chairperson (Ms Kimmins): No problem, Linda. Thank you.

Dr Adell: On vasectomies and the funding of primary care, the primary care elective was funded non-recurrently through the waiting list initiatives. There was year-on-year funding for the primary care elective. In 2021-22, we spent £91·5 million on the double-line total, including the primary care element; in 2022-23, it was £96 million; and £70 million was spent in 2023-24. There was a significant drop in the funding that was available for waiting list initiatives, and that forced us to stop everything that was not red-flag and time-critical, including the primary care elective.

While, in practice, it was a cut, it was not a cut as such; it was a stop on new funding. We did not have the non-recurrent funding to allocate to primary care elective for that purpose. We then moved the vasectomy service from secondary care to primary care. We defunded the service in secondary care and moved the funding to primary care, so the money followed the decision to move the service to primary care. That is a substantive recurrent investment in primary care that is funded by not providing it in secondary care. That is how we can make it sustainable in the long term, and it is one way that we can provide proper investment in primary care in order to make sure that we deliver.

It is important to note that, specifically for vasectomies, patients are satisfied with the outcome. We had no patient safety or outcome concerns, and the service in primary care is about a third cheaper per patient than it is in secondary care. Therefore, we get more for our money, better outcomes and better patient satisfaction, which is a win-win for everyone.

The vasectomy service is quite a small, contained provision and is easy to move. Others are much more complex because of interdependencies and the effect that moving them will have on the ability to deliver other services in healthcare. However, the concept of wanting to do that across other areas is there, and that is what we want in the long term. It is just not easy to avoid unintended consequences. For example, if we reduced the number of doctors who were delivering a service in secondary care, that might have an impact on the ability to deliver emergency care, and, obviously, we do not want that impact. It is about finding the right things and making sure that they are sustainable. They have to be sustainable, otherwise they are not meaningful. I fully agree with that.

Ms McDaniel: We submitted a transformation bid for ending violence against women and girls jointly with the Department of Justice that specifically related to the implementation of the domestic and sexual abuse strategy. The Minister is on record as being disappointed at having to cut core grant funding. That was cut by half this year and last year. The Women's Aid Federation received something like £73,000 this year. That was in addition to the three quarters of a million pounds that health and social care trusts invest in Women's Aid projects. We are starting a process of designing a new core grant scheme, Linda. We are working with the Northern Ireland Council for Voluntary Action (NICVA) on that. A couple of workshops are being organised; I think that they start on 20 September. That is joint work with the voluntary and community sector on the design of a new scheme. We are also looking at putting in place what we are calling a small grant scheme under the domestic and sexual abuse strategy. That would be targeted at the voluntary and community sector. It would be a relatively small amount of money, but we will seek bids from the sector to support the implementation of the domestic and sexual abuse strategy.

The Chairperson (Ms Kimmins): Are you happy enough, Linda?

Mrs Dillon: Yes. Thank you.

Mr Donnelly: Thank you for that presentation. I have a couple of questions, but first, the vasectomy service decision was fantastic and welcome. Certainly, I know that a lot of families in my constituency welcomed the decision to move it back into GP surgeries. They would have had to go to the private sector, effectively, rather than sit on a long hospital waiting list. It is important to them that they are able to use that. It has been able to help them with the size of their family and things like that. It was a good decision that, as you say, saves money as well. It is a good example of how we can make those changes.

I emphasise the need for transformation and reconfiguration in the Programme for Government. Obviously, that is all over it. In Health, that is good to see, but we need to ensure that political will and leadership are there when those proposals are made. It is recognised — I think that both of you referred to this — that we have a truncated mandate, so we have only three years in which to do that. Obviously, we are limited by that.

One issue that you raised, Tomas, was the multi-year budgets. What is the scale of the savings that could be made with multi-year budgets? Do we have any possibility of doing that within the truncated mandate?

Dr Adell: The challenge for us in healthcare services is that almost all cost is for people. To have effective investment and effective delivery of service, we need to know how much money we have to spend, otherwise, we cannot invest recurrently in people. For example, the £76 million that we are spending on waiting list initiatives is non-recurrent. We cannot recruit more staff to deliver services with that funding. That is not an efficient way to do things. We cannot plan future services well. Multi-year budgets, whatever those budgets are, will allow us to plan. We will know what can happen next year, so we know how we can plan services. We know who we can recruit, and, where we need to use other independent-sector companies and providers, we can make longer-term contracts. That is more effective for planning and value for money. It goes without saying that, if you make a three-month contract with a provider, it costs more per unit than if you make a three-year contract with a provider. Multi-year budgets are essential for us to plan and transform effectively.

Mr Donnelly: Do we have the ability for that over the next two years of the shortened mandate? Is there room, and what would be the scale of the savings?

Dr Adell: It is not possible for me to determine savings. We do not have enough funding to deliver what we want to deliver. To fix waiting lists, we cannot save money; we need to invest more money. The question for me is this: if we can invest in waiting lists, how much improvement can we make on waiting lists? If we want to save money with multi-year budgets, we can reduce what we put towards waiting lists and accept longer waiting lists. It is not possible to spend less and reduce waiting lists. Those are incompatible.

Mr Donnelly: Given that the £76 million that is being spent on the red flags — it is mostly for cancer, diagnostics and other things — is non-recurrent, will a lot of those services be bought in from the independent sector? Is a lot of that money for agency spend?

Dr Adell: There is a mixture. There is spending in the HSC on additional evening and weekend work, which is overtime, essentially, and similar work. There is also independent sector spend. Some of that is simply on more capacity where we do not have enough. If we do not have enough endoscopy provision for our cancer patients, we can purchase it from the independent sector. A small amount of spend is on areas for which we simply do not have the provision, because we have never invested in a service but we need to deliver that service. There are some things, to do with time-critical heart surgery, for example, that we just do not do in the health service but that we need to deliver, so we purchase that service from somewhere else. There are a few things like that. That is the kind of thing that we spend the money on.

Mr Donnelly: What is the rough split of that £76 million?

Dr Adell: I can give you the split for last year, but I would have to come back to you in writing on it. We endeavour to do as much as we can in-house, so a planned split for this year would be difficult to provide, because we continue to try to do things better and more effectively. I can come back to you on the split for last year.

Mr Donnelly: Does the lack of multi-year budgeting mean that you are basically forced into spending more on short-term agency contracts?

Dr Adell: Yes.

Mr Donnelly: One thing that came up was the development of elective care centres, rapid diagnostic centres, service reviews and mega-clinics. That is great news, obviously, and it is good news that we are bringing the waiting lists down. I am curious about your ongoing engagement with officials and medical professionals, such as those from the Royal College of Surgeons. What feedback have you had from the Royal College of Surgeons and other organisations, and how has that helped to improve efficiency?

Dr Adell: I sometimes wonder whether I am right to say this, but I am a civil servant and do not know how to deliver effective healthcare services. As a civil servant, I need to seek advice from others, such as the royal colleges and other professional bodies and clinicians. That is how we get the right answers. Quite simply, surgeons know how to do surgery. Speaking to surgeons, nurses, other healthcare professionals and the service leaders — managers — about how we deliver the best service is how we get the best service. It is why we have elective care centres. The current transformation in elective care, which is quite far on, is purely because of our engagement with professionals. I meet the royal colleges — there are four of them — and other professional bodies and professionals all the time. I was at the Royal College of Surgeons of England earlier this week, and I had engagement with clinicians this morning. That is the bread and butter of what we do, because it is what we need to do to ensure that we do the right things.

The feedback about elective care centres is positive. We see that in a number of ways. Surgeons like working in them because they get to operate. That is what they want to do; it is what they are good at. Nursing staff like working in those places. Theatre nurses want to be theatre nurses, and they get to be theatre nurses in elective care centres. Some nurses like unplanned things, so they want to be in an environment like that of the ED. Some people want to work in medical wards, and some want to work in surgical wards. If you work in surgical wards or surgery in an elective care centre, you know what you get, and you get what you want. We therefore see that the vacancy rates are relatively low at those sites — they are good places to work — and that, quite apart from the facts that patient outcomes are really good and that throughput is higher, is really good feedback that it is working.

Mr Donnelly: Absolutely. That is to be welcomed. We have still not seen the blueprint for acute services, although we have requested it a couple of times from two Ministers now. Have you had feedback on that from the Royal College of Surgeons and other organisations?

Dr Adell: Absolutely. When it comes to our elective care or planned services, the whole concept for the reconfiguration framework is based on the work that is already going on. It is based on the elective care centres having different levels of elective care, such as day procedure centres, children's day centres and complex elective care centres. That is developed with the royal colleges and others. Their involvement is the bread and butter of what we do in those areas, so, yes, absolutely, we involve all those bodies.

Mr Donnelly: You are saying that there has been a lot of consultation.

Dr Adell: Absolutely. We should remember that some of those things are pulled together from other work streams. The elective care work that features in the reconfiguration framework is not necessarily new; it is reform work that is already going on. The royal colleges have been key in that work.

Frankly, we would not have been able to do it without them. They are the experts, and we need to use experts.

Mr Donnelly: Thank you.

Miss McAllister: Thank you for the presentation. Like Linda, I will reserve my comments on children's services until our Committee meeting on 26 September. There is no point in rehashing that issue. Political and policy decisions still need to be made, but, by way of an update at that meeting, the Committee would be keen to hear about what has been implemented up until now following the review and about what can be implemented.

I will touch on a few of the issues that we have already discussed, particularly the £76 million. It is good to hear that the Department works with clinicians and so on, and rightly so. That is important, because they know the best ways in which to treat people. Where people are on a waiting list, and theirs are either red-flag or time-critical cases, as you said, Tomas, what does the decision-making process look like that determines who gets money spent on them for time-critical treatment? Who makes the decisions on where the money is spent, not on the red-flag treatments but on the time-critical treatments? Is it the Department, the strategic planning and performance group (SPPG) or the trusts? I am sure that there are people who will think that time is critical to them, because they have been waiting so long. Where is the decision made, at what point is it made and what mechanism is used to determine what is time-critical? There are so many areas and so many waiting lists.

Dr Adell: The time-critical aspect is limited. It is about life, limb and sight, so it is quite specific. That is a clinical decision, and people are prioritised for treatment or for diagnostic assessment as part of a process of clinical prioritisation.

Miss McAllister: Are those decisions made across trusts? Are they made in each trust's silo? I know that the surgical hubs aim to protect sites in order to carry out x treatment. There are still some hubs that operate across the trusts. Do the trusts make the clinical decisions, or are they made higher up?

Dr Adell: The clinical decision as to whether someone's treatment is time-critical is made by clinicians. If the trust cannot deliver the time-critical treatment, it can seek funding to deliver additional work, but as a corporate body, and the Department then provides the funding through the SPPG. It is important to note that not all sites are suitable for all types of surgery, so a day-procedure site will probably not do much time-critical work. In general, time-critical patients are not suitable for day procedures. Some of the regional sites are therefore not suitable for that kind of work at all.

Miss McAllister: Clinicians will therefore make those decisions. That money will run out at some point, but will decisions keep being made? We recognise that there is not an endless pot of money at the moment to tackle the situation, so it has to be very specifically targeted. At what point are decisions made? Is it whenever treatments become time-critical, or do clinical decisions keep being made?

Dr Adell: Time-critical patients will be treated. If we cannot treat them out of that £76 million, eventually something else will be stopped in order to provide treatment for patients who will die, lose a limb or lose their sight if they are not treated. They will always be treated. It is the same for our cancer patients. We know that cancer waiting lists are too long, so I am not trying to justify anything. Treatments for cancers start fairly promptly: there is a 31-day target, based on the decision to begin treatment, and that is sitting at around 90%. Although that is not as high as we want it to be, in general, people who have a cancer diagnosis get treatment fairly quickly. They wait a long time before they get a diagnosis, and it is unacceptable that the target is not higher than 90%, but treatments tend to happen fairly rapidly, because those patients will always be at the top of the pile when it comes to clinical prioritisation. It is other patients who will suffer. If the £76 million runs out, the effect will not be on the time-critical patients immediately but rather on everyone else. We would become much less efficient, because it would not be stopping

on the pile, because those treatment areas are not suitable for those patients. It is about moving resources around.

Miss McAllister: It is almost as if the time-critical patients will always get seen — hopefully, that is reassuring for anyone who is concerned about that — so they are not a waiting list per se. They will always be seen.

Dr Adell: There will always be some waiting lists. We need some waiting lists for the management of patients and the management of procedures to make sure that we have efficient procedures. The question is this: how long is appropriate for time-critical patients to wait, and what is appropriate is treatment within a very short time. I am talking about patients who are at risk of dying, of losing their sight or of losing a limb. That is when we need to treat them quickly. Exactly how quickly depends on each case, of course. Some time-critical procedures do not need done tomorrow. They can be done within a long enough period but before a certain cut-off point. If it is the day before the cut-off point, the procedure is time-critical the next day.

Miss McAllister: It seems to me that, if applies to red-flag cancer patients, and rightly so, and time-critical patients, those people are not on actual waiting lists. What I am trying to get at here is that priorities absolutely have to be decided on. You are right, of course, about red-flag cancer patients, for example, and time-critical patients. You cannot really sell that as tackling waiting lists, however, if that is not the waiting list. The waiting lists are for everything. Although we should reflect on, acknowledge and welcome the progress that has been made, especially with the surgical hubs, that money is not actually for tackling waiting lists. I know that the people who are waiting for time-critical treatments will always get seen. What is the plan for everyone else? Notwithstanding the argument about budgeting, which I completely understand, the reality is that the £76 million is not really tackling what everyone views as being a waiting list. I do not expect you to have all the answers.

Dr Adell: I understand what you are saying, and I can fully accept that that is part of the truth. As I said in my opening remarks, the £76 million does not allow us to treat more patients who have been waiting a long time. If we did not spend money on the time-critical patients, apart from the outcome for those patients, it would mean that they would then push out others who are currently being treated. If the £76 million were not spent, waiting lists would therefore increase significantly. Fundamentally, when someone is on the operating table, it is a patient, whomever the person is, and the space being used in theatre is the same physical space whether it is time-critical patients or patients who have been waiting for five years who are being treated. If you did not have the additional money, overall waiting lists would increase. They would get worse than they are now. The money is for tackling waiting lists, but it is not tackling the issue of the long waiters, if that makes sense.

Miss McAllister: On the importance in the Programme for Government of tackling waiting lists, I have a query on children's health and how that fits in. Is there the same level of problem with children's waiting lists? Will a specific element be included to tackle children's waiting lists? The most notable example that I can think of is the waiting list for percutaneous endoscopic gastrostomy (PEG) tube surgeries for children. A group of a very small number of parents across Northern Ireland has been lobbying quite heavily on the issue. That is just one example, but it brings to light the issue that there are waiting lists for adults and waiting lists for children, so what differentiation is made between the two in the Department and the SPPG when allocating funds?

Dr Adell: I will answer that slightly differently, but bear with me, and I will say in my answer what, I think, we want to hear. Fundamentally, we do not segregate adults and children when it comes to surgery. We want to see surgery for everyone. The normal age bracket into which we put children does not always apply, so what is a child is not necessarily a child in the theatre. Daisy Hill Hospital provides elective overnight stay centres for adults and elective overnight stay centres for children. In our work to transform services, we look at both. We do not distinguish in that sense. There are slightly different answers involved, but, fundamentally, the problem is the same, which is that we do not have enough capacity to meet demand. The transformation will be the same.

While a different surgeon might be involved, the notion that a surgeon does not spend enough time in theatre remains the same.

Theatre nursing is similar. Granted, it is different from anaesthetics, but the same fundamental problem exists. When we tackle waiting lists, we tackle waiting lists across adults and children. We see it as being one problem, because, fundamentally, the underlying issue is the same across both groups.

We deal with individual issues separately. For example, we are finalising a paediatric orthopaedic review, looking at how we can we can improve paediatric orthopaedic surgery waiting lists. There has been significant work done on paediatric ENT waiting lists. That is a particularly difficult list for us, especially for treating tonsillitis. Excellent work was done to consider whether children need surgery, and it was determined that a significant number of children do not to need surgery. It was felt that better outcomes resulted from not operating. That is not because we want to disregard such treatment but because we are thinking about what is best for the child.

A lot of work is ongoing on paediatric surgery as well. It is not a clear separation, however, because it is fundamentally the same transformation work that is required to improve surgery across the board, for adults and children. Does that answer your question?

Miss McAllister: It does, yes. It is just that, in our engagement with the sector, in particular with those in the children's health sector, there is a concern that the commissioning work is not viewed as being a separate piece, and there could be efficiencies made there. That is worth exploring further at a later date. You did answer the question, to be fair.

I do not have anything to add other than to make an observation about working collaboratively across Departments. We have heard from many Departments in all Committees about working together, so one of the key elements of the PFG is collaborative working. Perhaps on 26 September, we could hear your reflections on strengthening the Children's Services Co-operation Act 2015 or on lessons that have been learned from it, because the PFG talks about working collaboratively.

Ms Flynn: I will ask all my questions at once, because I am aware that we are about half an hour over time.

Tomas, on the primary-care issue, you said that it is hard to condense the Programme for Government into priorities, because there is so much that you are working on and dealing with. In the document that we have, however, there is a heavy emphasis placed on the importance of primary care. It is mentioned a few times how we need to invest in primary care and how we need to continue on the long-term journey of achieving long-term reform, which includes how primary care can help tackle health inequalities and, as you said, prevent people from having to go to emergency departments or into hospitals.

A total of £76 million has been set aside for tackling urgent and time-critical waiting lists. Given the emphasis placed on the importance of the service that primary care provides, which you recognise, is any additional targeted investment planned?

You spoke to Diane about the transformation bids for multidisciplinary teams. I assume that that may make up one of your bids for primary care funding. Does that transformation bid include extending MDTs out to all GP federation areas? At the minute, they are operational in only three of the 12 areas.

You gave the example of vasectomy services being transferred from secondary to primary care. There is a lot of work involved in transferring some of those services to primary care, but are any scoping exercises under way to see whether any other secondary-care services might be moved to primary care?

My final question is to Eilís. You mentioned earlier the design of the new core grant scheme. Is that the overall core grant scheme for the Department of Health? You said that there will be an event held on 20 September with the community and voluntary sector, and something instantly came to mind, because that area is within my remit and portfolio as my party's spokesperson on mental health and suicide prevention. The Committee has raised with the Minister on multiple occasions the point that so many groups do not qualify for that core grant funding at present.

We wrote to the previous Minister of Health, Robin Swann, about the Well, a community wellness hub in County Down. There is also the Niamh Louise Foundation in Dungannon and West Wellbeing in west Belfast. A lot of amazing community groups are not getting any core grant funding from the Department, yet they are literally saving lives day and daily through their work on suicide prevention in local communities. They are doing powerful work, so did the likes of those groups receive communication about the event to discuss the new core grant funding scheme on 20 September? It is really important that, if the Department is to take a fresh look at how funding from that scheme is distributed, everyone who has been part of the lobby to get more funds, which I know are really tight at the minute right across the sector, needs to be in the room for that event. How was the process for that worked out?

Ms McDaniel: I will answer that first, and then Tomas can come in.

You are right to say that the current scheme is closed. Some 62 organisations had been receiving core grant funding from the Department for a considerable time. We attempted to reopen the scheme a number of years ago, but that did not go quite according to plan. The plan now, by way of the redesign process, is to create another open scheme that will, hopefully, accept applications from April next year. The work that we are doing is being done through NICVA. It is facilitating the sessions for us. I attended a session perhaps a month ago at which there was great representation from the voluntary and community sector. That session was about designing the process of redesign, if that makes sense.

Ms Flynn: Yes.

Ms McDaniel: My expectation is that we will have good representation at those workshops, because of the involvement of NICVA, which has been communicating with its members. If there are specific organisations that you think would benefit from an invitation to those sessions, I am very happy to get the details from you, and we can ensure that they are at least invited.

Ms Flynn: Brilliant. Thanks very much, Eilís.

Dr Adell: For the waiting list initiative, the £76 million of funding is for red-flag, cancer and time-critical patients. In general, their clinical demands or needs mean that it is not clinically appropriate to treat those kinds of patients in primary care. As a concept, if we could move things to primary care, I would do so in a heartbeat. That is the right way in which to treat patients. Moving things towards the community is undoubtedly better for patients in general, provides better value for money and is something that clinicians like, both in primary and secondary care. The public like it as well. The work on transferring vasectomy services was a start, but it is not the end. It was one of the simple things to move from secondary care to primary care. For other things, the situation become far more complex, and the process behind that — deciding how we do it, in what volumes and what can be delivered in primary care without having unintended consequences for other things — is not an easy process. It takes time to work out what can happen and how it can happen, but I certainly hope to be in a position to announce other things in the future. I do not want to put a timeline on doing that, however, because the process is not simple. The simple answer is, yes, we are working on that in the background.

When it comes to MDTs, the transformation funding will roll out further. I do not know whether it will be rolled out completely, but there will be further roll-out, and we will provide basic training places to increase the level of training across physiotherapy, occupational therapy, nursing and social work to make sure that we have the right staff trained to do that work.

Ms Flynn: Thank you, Tomas.

Mr Chambers: Thank you very much for your presentation and answers.

In the statement to the Assembly on the draft Programme for Government, I heard very little mention of either costings or delivery timelines, despite the document seeming to be full of hope. In healthcare, however, it should go without saying that hope does not provide great pain relief, whereas action does. Have the waiting list initiatives that are referenced in the Programme for Government been costed? How much additional funding would be required immediately to kick-start tackling waiting lists in year 1? If we were to get any immediate funding in this financial year for tackling waiting lists, is there any guarantee that it would be available in future years of the mandate?

Dr Adell: The PFG recognises the demand/capacity gap for red-flag and time-critical patients as being at about £76 million. That is therefore what we are spending now. To meet the additional demand/capacity gap for other planned services, we need about £80 million a year. The backlog is costed at up to £135 million a year for up to five years. If we were to get non-recurrent funding, we could start to deal with the patient backlog. We reckon that it is possible to spend up to £135 million a year. It is simply not possible to spend more, as there is not enough healthcare to buy. That includes all the available options: using the Republic of Ireland's reimbursement scheme; using the independent sector; and using additional resources in-house. Having that money would provide a huge number of additional treatments: for about 20,000 patients requiring primary-care elective treatment and for 4,000 patients through the reimbursement scheme. In total, there are something like 27,000 patients a year needing extra treatment alone for up to five years.

We can spend that money very quickly in some areas, such as on the reimbursement scheme and in the independent sector. That money can be spent at very short notice. It will take time to address the long-term demand/capacity gap. We need to invest in staff. If, by magic, we were to get £155 million recurrent funding, which is the figure required to meet the current demand/capacity gap for time-critical patients and the rest, who are elective patients, we could not spend it tomorrow, because it takes time to train up staff. The certainty of having that future spending, however, would allow us to invest in the future and to plan for doing so.

I hope that that answers your question. Some £135 million a year is needed to meet the backlog. That money could be spent very quickly.

Mr Chambers: Are you saying that, were you to get an immediate windfall, you could not spend it, and that, although it would produce results, there would be a cap on it? Are you looking for additional money to tackle only this year's elective surgery and reduce the waiting lists, or are you trying to get an amount of money that you can spread over the next two or three years?

Dr Adell: I would want both. We could spend up to £135 million a year for the next five years just dealing with the backlog. If we were to do that, we would clear the entire backlog, but, because of the demand/capacity gap and new people requiring treatment, waiting lists would increase again. We need to do that, but we also need to invest recurrently. At the same time, however, if we were to invest recurrently to address all of the backlog, we would have overcapacity for a number of years. It is therefore about having a combination of non-recurrent investment to fix the backlog situation and recurrent investment to make sure that we can transform the workforce and services to make them sustainable. A combination of both is needed. What is clear is that the £76 million is enough to meet time-critical and red-flag treatments but not the rest.

Mr Chambers: Can you carry money forward into future years? If you were to get a big windfall in the current financial year, could you carry that money forward?

Dr Adell: Not in general, no. We can, however, spend significant money on waiting lists in-year.

Mr Chambers: To continue with the Programme for Government initiatives and its wish list for tackling waiting lists, you will have to reapply for funding next year. You will be back in the mix, looking for that funding. In other words, it is not guaranteed that you will get funding in year 2 or year 3, as you will have to bid for it.

Dr Adell: The £76 million is non-recurrent funding. It is for this year. We do not currently have that money for next year.

Mr Chambers: If any additional funding, such as a windfall, were to come along in the meantime to kick-start the waiting list initiatives, you would therefore have to bid again in the next year and in the following year. That funding is not guaranteed. It will not be sitting there waiting for you.

Dr Adell: Non-recurrent funding is never guaranteed. If we get recurrent funding, we can do things recurrently. At the moment, however, we do not have that.

The Chairperson (Ms Kimmins): Diane has a quick question. I will let her come in.

Mrs Dodds: It is a tiny question. You have been allocated £76 million, which, you say is going to go on tackling red-flag and time-critical waiting lists. Will that ensure that you meet your cancer waiting time targets?

Dr Adell: Simply put, no. We hope that waiting times for cancer services will improve. As you are aware, our performance against the three cancer targets is very poor, especially the 62-day target between referral and treatment. It is at around 30%, and that is unacceptable. I am not trying to defend the performance. It is not an easy fix. It will take time to fix, because, even if we were to get significant funding, the backlog will have to be cleared, and doing that is not an easy task. A lot of those patients are waiting for diagnostic and pathology imaging. The 31-day target for diagnosis is at close to 90%, which, although not perfect, is much better than it was. When we decide to treat someone, we can therefore treat them fairly quickly. Getting the person their treatment session is what takes a long time, however. The delay occurs in the first half: getting diagnostic and pathology imaging and seeing the doctor for the first time. That is taking too long. The £76 million will allow us to maintain what we are doing currently but not to do more. I know that that is not satisfactory, but that is the honest answer.

Mrs Dodds: I will write to you with some follow-up questions.

The Chairperson (Ms Kimmins): Tomas and Eilís, thank you very much. That was a longer session than we had planned for, but it was useful. We will want to ask a lot more questions, which we can bring up with the Minister when he comes in on 26 September.