Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): The Minister of Health is here to give us a briefing. He is accompanied by the permanent secretary, Peter May. You are both welcome, and we appreciate your being here today. It is good to have you both here.

We have approximately an hour and 30 minutes for the session, and it will be covered by Hansard. I remind members that we are time-limited. I will have to be strict about questions and contributions, so I appeal to you to work with me.

I invite the Minister to make his brief opening remarks, after which I will open up the session to members.

Mr Nesbitt (The Minister of Health): Thank you very much, Chair. It is good to be here, and I apologise that it has taken so long. At the risk of delivering a John Hume-type single transferable speech, it might be useful to return to my first remarks as Health Minister in the Chamber. In doing so, I pause to pay tribute to my predecessor as Minister of Health, Robin Swann. I welcome his new role as a Member of Parliament and encourage him to continue to promote our Health and Social Care (HSC) system in the House of Commons. Robin and I will continue to press the UK Government to acknowledge that our shocking rates of poor mental health and well-being are, to a large extent, a legacy of our conflict and therefore deserve investment and support. Were that funding to come, it would have no repercussive consequences for England, Scotland or Wales. It is a population health issue for us alone.

In June, if you recall, I asked members to imagine a blank map of Northern Ireland with no health service. Question 1 was this: do we want one? Question 2 was this: why? There were at least two answers: to keep people healthy and to cure the sick. That takes us immediately to a judgement call. Even if we had unlimited resources, funds and workforce to help to keep the healthy healthy, people would still get sick. We will always need buildings, large acute hospitals, technical equipment, medicines and highly specialist healthcare professionals.

Last week, Professor Bengoa reminded us that the only sustainable future lies in what we call the "shift left": delivering maximum care in the community and not in our hospitals. In my world, if you need access to healthcare, the ideal is that you get it at home or, if not at home, as close to there as possible. The second-worst thing is to have to go to an acute hospital, and the worst outcome is to go to an acute hospital and stay overnight. I have articulated that vision many times in front of people, including trust chairs, chief executives and surgeons, and nobody has disagreed, even privately.

I was comforted by the fact that Professor Bengoa confirmed that we are not an outlier when it comes to our issues. The healthcare challenges that we face are the same as those faced by Governments around Europe and beyond. To tackle the incorrect belief that the Bengoa report has been on the shelf gathering dust for eight years, I would like to give you some examples of progress. There are the multidisciplinary teams (MDTs) in primary care. I suggest that MDTs are the shining light of reform to date. We now have rapid diagnostic centres that provide early detection for many who have only vague symptoms and might otherwise have lived with those symptoms to their disadvantage. We have had the creation of high-volume day procedure centres and elective overnight stay centres. In urgent and emergency care, which, at this time of year, sees further pressures, we have introduced Phone First, urgent care centres and direct access pathways. On an issue that is close to my heart, we now have a mental health champion and a regional mental health service that is driving through joined-up working across key partners. Of course, none of that would have been possible without our willing and exceptional staff.

Progress has been made towards stabilising our workforce. Compared with where we were, say, a decade ago, in recent years, there has been an increase of just over 1,000 — 27% — in medical staff and an extra 3,000 — 21% —in registered nursing and midwifery. The Committee will be aware of the reduction in spending on agency nursing staff, and I have now asked officials to move at pace and be similarly ambitious in tackling the unsustainable expenditure on medical locums.

Members, you do not need me to tell you that our workforce still bears the painful scars of repeated recent industrial disputes. I want to help my ministerial colleague Conor Murphy in seeking to define a "good job". For me, it is a job that you look forward to when you wake up; one that you enjoy; one that offers you appropriate pay scales, good terms and conditions and a good work-life balance; and one in which you feel respected and cherished equally by your employer, your peers and those whom you serve. That is my ambition for our staff. One way is to shift healthcare delivery from hospitals to the community. That is my ambition.

Chair, I feel that I may be going a little too long, given that you asked for brief opening remarks. I will just say that I look forward to working with the Committee. I understand that you have a dual role: you have to hold me to account, and you must "advise and assist" me where possible. I wish you well in both, and I offer sincere willingness to work with you on those fronts.

You are aware of my passion for tackling health inequalities, and I welcome your assistance in an aspect of that: alcohol misuse. I have asked officials to progress work on the introduction of minimum unit pricing for alcohol, which I would like to achieve in this mandate. To my mind, that would complement the Tobacco and Vapes Bill that is about to go through Westminster. Both can be key contributors to tackling health inequalities. Alcohol pricing can progress only with Executive approval, and I will engage ministerial colleagues in due course. If approval is forthcoming, I would like to work with your Committee, and, in particular, I would welcome your advice on where to fix any minimum price. It might be 50p, 55p or somewhere else. Figures indicate that alcohol misuse costs Northern Ireland up to £900 million a year, never mind the devastating impact on individuals, families, communities and, indeed, the stress on our health service. In 2022, 356 people here died from alcohol-specific causes, and that is the highest total on record. In health inequalities terms, deaths are up to five times higher in the most deprived areas. We have significant research from Scotland that shows the empirical benefit of minimum unit pricing. I am happy to share that with you and, of course, for officials to engage with you on the subject.

That is my opening offer of what, I hope, will be collaborative working, Chair, delivered without prejudice to your ability to hold my feet to the fire. Of course, I am more than happy to take questions, particularly if the answers begin, "The permanent secretary is a renowned expert in that field".

The Chairperson (Ms Kimmins): Thank you, Minister, and thank you for keeping your remarks brief, which gives us a good opportunity to keep the discussion open for as long as we can.

You mentioned your priorities on health inequalities, and we have been talking about that quite a lot, particularly since you came into post. It is good to hear that some proposals are coming forward, particularly around alcohol. We did some work on the Tobacco and Vapes Bill, prior to the general election in Britain in July. We are keen to pick up some of that, especially now that we see that the South of Ireland is pressing ahead. For the sake of alignment and ensuring that we are all on the same page, that is good to hear. That feeds into how we tackle some of the causes of ill health. The work that we can do on that was discussed at one of our sessions here yesterday with representatives from parts of the sector. It is definitely good to hear.

Minister, we have a number of written briefings as part of the papers provided by your Department. Following on from the conference last week, I will go to Professor Bengoa's report, 'Systems, Not Structures'. It is safe to say that it was a good conference. Lots is coming out of it, and we are keen to see that acceleration of change.

We have heard clearly that every hospital cannot deliver every service: we know that. However we try to do this — it will tie in with the hospital reconfiguration report and the public consultation that is open at the minute — we have to ensure, as Bengoa said, that this is workforce- and patient-led. In that engagement, how can the Department ensure that those voices are heard throughout the process, so that people are part of it and have a real stake in it? We have seen examples where people do not always feel that.

Something that came out yesterday in one of the discussions that we had was understanding consultation questions. How we work with people is about showing them exactly what they are getting and what that will mean for them when they need healthcare or social care. Will you tell us a bit more about meaningful co-production and co-design and that engagement?

Mr Nesbitt: That is essential. If you want success, you need to bring people with you. You look at the stakeholders: the workforce and the community. I think that I said in the Chamber that we all have to recognise that, potentially, at times, when you are trying to effect change, there will be tensions between certain communities. For example, clinicians may say that the best thing to do is x, which may mean consolidating a service from two hospitals into one. However, if it is moving from one hospital, the people who use that hospital may feel that something is being taken away from them. You have to manage that.

Let us take a live example: the Northern Health and Social Care Trust is consulting on general emergency services moving from Causeway Hospital to Antrim. To be fair to the Northern Trust, it has had the courage to say, "This is our preferred option of the range of options". What you could say there is, "Yes, we're taking something from Coleraine and moving it to Antrim, but what we're going to put into Coleraine is actually better, and that's an elective overnight stay centre". If you separate emergency and elective or planned surgery, you take away the risk of somebody who has been waiting for a long time for his or her elective surgery waking up on the morning of the surgery and getting a phone call to say, "I'm sorry, but we have to postpone because there's an emergency and the theatre is in use".

How do you persuade people who feel that they are losing something that they are not losing out and are getting something better? That is the challenge. It is about constant communication and honesty. You have to be honest with people. You cannot have an acute hospital at the end of every street, and I think that people have now got their heads around that. The document that I have already published, which is the high-end precursor to the more detailed document, makes it clear that I understand that people think of the health service as personal and local, and so they want their local hospital to do everything. I think that people now realise that that is not possible; you have to have a network.

I grew up in the shadow of the Ulster Hospital, and I want it to do everything. It is an acute hospital, but, when I needed a pacemaker and a defibrillator, I had to travel, although not very far; just across town to Belfast City Hospital. That was easy for me because I have a car, and I have friends and family who will drive me and bring me home. How do we look after the transport arrangements? It is about being honest about what we want to do; why we will do it; the issues that that will bring up, such as transport; and having that constant communication and engagement with everybody who will be affected, whether it is residents, patients, service users or the workforce.

The Chairperson (Ms Kimmins): Thank you for that. Are those discussions happening across government? You referenced transport. For a lot of people, that is the biggest issue when it comes to the infrastructure. We have seen the recent issues around emergency general surgery at the South West Acute Hospital (SWAH), which, as you will now, was a service collapse; it was not planned change. That caused concern and anxiety. There are other examples in Newry in my constituency. There has to be a discussion about any planned change. Yes, it is part of the transformation, but it has to be accessible to people, including staff. A lot of staff may have to move sites or whatever. Is that part of the current discussions or engagement that is happening?

Mr Nesbitt: It is. There was much more detailed consultation on the plan that we put out on trying to create a network for better outcomes than was part of the public narrative. I have heard comment in the media that there was not detailed comment, but we did well in trying to engage stakeholders. When we go to the more detailed three-year plan, any specifics will require a public consultation. I go back to the point that, if you can bring the maximum number of people with you, your chances of success are at their highest. I have no desire to do anything but have full consultation with everybody who will be affected.

The Chairperson (Ms Kimmins): We have had numerous discussions about the workforce, and it will be key to hospital reconfiguration and the delivery of services in hospitals. Most importantly, there is the community outside the hospital, and we can see a shift in focus to early intervention and prevention. To date, given the challenges in the workforce, we have seen that it is challenging in the children's social work teams and nursing teams. What work is happening or needs to be done to move the plans forward? If we do not get that part right, everything else will fall by the wayside before we get there. There are huge challenges across that sector.

Mr Nesbitt: I see two things, Chair. Part of it is about the shift left to get care out of hospitals into the community, and we are talking about primary and social care. You know that I am keen on social care. Ministers, to send a signal out on their first day, are normally encouraged to be seen out and about, and the Ulster Hospital is just around the corner from the Department. I said that I did not want to go to a hospital; I wanted to go to social care settings. There is a huge challenge for the workforce delivering social care. I have heard from many Members of the Legislative Assembly and other groups about burnout in social care. We have to focus on that and make sure that we move at pace to fill vacancies.

I also think a lot about the idea that the workforce has increased across Health and Social Care, but is that reflected in productivity and efficiency? It draws me to the conclusion that we are asking an awful lot, particularly of the geographic trusts. On the one hand, we are asking the trusts to make unprecedented savings — we are talking about £200 million in one financial year, which is absolutely unprecedented and a massive challenge — on the other hand, at the same time, I am asking them to focus on productivity and efficiency, which is an entirely different area of work. However, we need to do that because, if you are expanding your workforce, the logic has to be that you are being more productive and efficient.

The Chairperson (Ms Kimmins): Before opening up to the other members, my final question is on the back of that. Trusts are in a difficult position and have to make unheard-of savings. Your recent announcement about the breast cancer service shows what can be done. Will there be further consideration of the regional approach, particularly for waiting lists and red-flag cancer referrals that are time-critical? Can we look at cross-trust and cross-border working, given that we have seen good examples of how that already happens? When we focus on the best possible outcomes for patients, we have to look at every option that is available to us. Is the Department doing that?

Mr Nesbitt: The permanent secretary is a renowned expert in that field. When I took up my role, I asked myself this: "Why does quite a small geographic location have five geographic trusts? We are 1·9 million people, so would we be better off with one geographic trust?". I quickly realised that moving to that position would soak up so much resource and energy that it would become a distraction. I then thought about some of the big restructuring that has taken place. For example, we moved from 26 councils to 11, but did we see the savings that were to follow from that? The answer is no, absolutely not. The Assembly moved from 108 MLAs to 90, and are we better off because of that? I am not sure that we are. I have told the chief executives and the chairs of the geographic trusts, "In my mind, you are one. I do not want you to compete; I want you to collaborate and cooperate. Let us find the best practice, and, where there is best practice, let us roll it out to become common practice.

Let us learn from each other". It seems to me that it would do no harm for different trusts to be recognised leads on different procedures and policies.

Peter, do you want to come in?

Mr Peter May (Department of Health): Yes, certainly. I will give a few examples of things that are being looked at on a regional level. Work is going on to review neurology services. Depending on the Minister's views, we might be able to put that out to consultation later this year. Work is in progress, though not as advanced, on a review of stroke services. Each review needs to engage all the clinical leaders in those spaces before it is mature enough to bring to public consultation.

Similarly, to dive into even more detail, as it were, the Department commissioned a report on urology services from the Getting It Right First Time team. Its report suggested that there should be more sub-specialisation between trusts as to the nature of the procedures conducted in the urology speciality. That begins to show something of the complexity of the field. It is right to say that we should look at regional solutions, where those make sense, but each of those needs significant work for us to be able to bring forward proposals that will work and will withstand scrutiny from the Committee and the public.

The Chairperson (Ms Kimmins): Thank you both for that. I will open the meeting up to members' questions. I advise anyone who came in late that we are very time-limited today. Each member probably has eight minutes for questions, and I will stick to that so that we can get to our next briefing. I appeal to members to restrict themselves to that.

Mr McGrath: Minister, thank you. I will give you this: you are an excellent communicator. You were involved for many years in an industry where you had to communicate.

I want to take a realistic look at our health service and at some of the issues. The other day, you announced that £200 million had been stripped out of our trusts. Primary care budgets have been reduced. Dentists tell us that they cannot afford to do treatments. Vacancy levels in social services settings in some areas are as high as they have ever been. Community pharmacies regularly tell us that they have to close, that they cannot afford to do what they do or that they have to pay for the drugs themselves. Consultations on things like public health tell us that it is an absolute disaster: people do not want to be involved in it or find difficulties with it. Industrial action is on the horizon again. Waiting times are longer. A&E and ambulance wait times are up.

I was at the Bengoa conference last week and heard a lot of words, but I do not see the plans. I am not suggesting that, in a couple of months, you will get all of that right, but there is, at times, a disconnect between the inputs that we get from Department officials at Committee or during debates in the Chamber and what we hear from the sector. Sometimes, I tend to put a bit more weight on what we hear from the sector. Registered groups and headquarter bodies tell us that things are not rosy; they are really difficult. Yet, from the inputs we hear at Committee, you would not think that there was a problem at all.

Looking at the overall issues that we have, is there any work on trying to put a timetable, even if it is over 10 years or whatever length of time, on fixing the problems? I do not know whether we are getting a handle on any of the problems. You are not Superman. I do not expect you to have done that in a short time, but there might need to be a dose of realism.

Mr Nesbitt: I try to balance realism — acknowledging and talking about the real issues and challenges facing Health and Social Care — with optimism — trying to put a little more hope into healthcare. I do not buy into the fatalistic narrative that the National Health Service is plummeting irreversibly towards collapse. Yes, you can list the issues at length, as you have done, but 70,000-odd people deliver healthcare. I will not disrespect the effort that they put in daily or the tremendous results that they produce, which go largely unnoticed. Of course, their efforts will not make the headlines in the 'Belfast Telegraph' or on Radio Ulster.

There are some plans. I published the plan, 'Hospitals - Creating A Better Network for Better Outcomes'. Work is progressing on breast cancer, starting with a regional booking system together with a broader review of how we deliver the assessments. Things are happening. I expect — I hope — to be Minister for another couple of years, until May 2027. I have no expectation that, even if I were to stand for election again and be lucky enough to be re-elected, I would become Health Minister again. At the end of that period of a couple of years, however, I hope that we can all look at the health service and say, "It is, at least, a bit better. It is not totally fixed, but it is a bit better". It is important to me that the next Health Minister look at the direction of travel and say, "That's the right route. We need to continue on that route," rather than saying, "Stop everything; we are going to start again".

Mr May: We have set out plans in a range of areas. There is a 10-year mental health strategy and a 10-year cancer strategy, both of which have clear funding streams set against them. At the moment, the challenge for us is that we do not have clarity on what finances will be available for the future. We, with the Minister, are developing a three-year plan that will set out what, we think, is achievable in a range of areas within that window of the rest of the mandate. We will have to prioritise, however: if we try to solve every problem, we will end up solving none. There are always other things that we could look at. We regularly respond to motions in the Assembly and beyond that set out lots of things that we ought to do. We may well agree with many of those things in principle, but it is about what can be achieved in practice. A partnership with the Committee would include trying to understand and agree the key priorities.

Mr Nesbitt: Money is also an issue We have a 10-year mental health strategy. If you speak to the mental health champion, however, who is an independent assessor, she will tell you that the budget for this year's action plans is about an eighth of what is needed. I am being realistic about that.

Money is an issue, but it is not the only issue. One of my favourite quotes, which I have up in my office in the Department, is from a writer called Ivan Turgenev:

It is an imperfect world, and you do what you can.

Mr McGrath: You highlight the issues, detailing that there is a cancer strategy and a mental health strategy but we cannot get funding for them: are your Executive colleagues supportive? In the Chamber, we always end up in the position where lots of people ask for things to be done, but your Executive colleagues do not give you the money to do them. It seems that we invariably go round in circles, with you asking, "Can we please have more money to do this?", and the answer being, "No, but we want you to deliver more services". How can you deliver that change, if you do not get the funding? You are being asked to do lots of other things by the very people who are not giving you the money.

Mr Nesbitt: Yes, colleagues on the Executive are supportive. I have met the First Minister and deputy First Minister privately, and I have no doubt that they are bona fide in saying that they are keen to help.

Mr McGrath: Is there a chequebook? Otherwise, those are just words.

Mr Nesbitt: You were in the Chamber this week when Diane Dodds raised the matter of breast cancer in her constituency. You know that the Minister for Infrastructure spoke from the Back Bench in his capacity as a private Member. Yes, the Minister for Infrastructure has huge problems, particularly with water. Every constituent is probably in his ear about there being a pothole in their street, but you heard his words in that Adjournment debate. He made the point that this is about saving lives; it is about people dying because we do not have services. Yes, I think that I have the support of the Executive.

Mr McGrath: I hope that the money comes with it.

Miss McAllister: I have a lot of questions, so I will jump straight in. Following on from the transformation agenda, I want to ask a bit more about engagement. There is a major difference between engagement and co-production. We already have the blueprint, and I am aware of the media narrative that you referred to, but will the action plans that, you say, are being developed be developed in conjunction with stakeholders, rather than being consulted on afterwards? I do not mean consulting just individuals sitting on boards or those in work streams. Do you consult stakeholders such as the royal colleges and the allied health professionals (AHPs) before an action plan goes out to wider consultation?

Mr Nesbitt: That is absolutely my intention. One of my big takeaways from the meeting in this building last week, having listened to Professor Bengoa, was his encouragement to me and others, saying, "You need to be tight on outcomes but loose on how you achieve them". I might say, "I want X outcome", but how to deliver that is not down to me, because I am not an expert. It might be the clinicians; it might be the nurses; it might be the royal colleges; it might be the BMA; it might be the stakeholders; it might be residents in the community where you are trying to make the difference. Absolutely, that is my intention.

Miss McAllister: OK. Thank you. That is helpful.

I welcome the plans for neurology and stroke: it is really important that the region-wide approach is being taken in different areas, but you also talked about the "shift left" into the community. In the 'Creating a Network for Better Outcomes' document, there is discussion about the triangle approach to community care that leads to hospital care as the last resort. That was also highlighted by Bamford and, again, Bengoa. One of the key pillars of that approach is community pharmacy, but there are also GP services. We had Health questions in the Assembly last week, but I will speak a little about last year's GP indemnity costs, on the basis of what we, as individual MLAs and parties, have heard. Was funding for indemnity costs last year ring-fenced, or did GPs have to use it to plug gaps elsewhere? The feedback that the Committee received was that GPs had to use money that should have been ring-fenced to plug holes elsewhere and that that did nothing to help. You said in the Chamber that that was not the case. Can we have a bit more clarity on that today?

Mr Nesbitt: We, as a Department, are clear that that money was ring-fenced, with £5 million being made available to GPs for indemnity in this financial year, but, it is fair to say, the BMA Northern Ireland general practitioners committee takes a different view. I met its members a few days ago. We were not able to resolve the difference of opinion in that meeting. What I have offered — they took it away rather than decide on it because they want to consult their members, which is perfectly reasonable — is independent arbitration. Somebody can come in and look at the contract and say whether we are correct or they are correct. Their view is that we have resiled in some way from the agreement: we believe that we have not.

All that said, we want a solution. I want to make them happy or happier, and, in the meantime, we are working on it. At that meeting, we made a commitment to them that, certainly by the end of this calendar year — hopefully, significantly earlier than that — we will come to them with a proposal for the long-term solution with regard to indemnity. I get the impression that it started as one of a basket of issues that were part of the negotiation and that it has almost detached itself and become a single issue.

Do you want to add to that, Peter?

Mr May: No, that is fine.

Mr Nesbitt: It needs to be sorted and to be sorted quickly. It is important for me to say that my departmental officials are absolutely sure that they have not resiled from any agreement.

Miss McAllister: I hope that that is the case. Financial records will show it up. What is more important is how we move forward from here —

Mr Nesbitt: Yes.

Miss McAllister: — and not only with a long-term solution. I am not saying that a deal was reneged on, but, if anything was incorrect, it is about how we make up for that shortfall. That is important.

I will stay with the issue of doctors and add dentists to that. Will you give us an update on the payment of doctors and dentists in line with the recommendations of the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) for 2024-25?

Mr Nesbitt: At this stage, I am afraid, I am not in a position to do that, because we need to hear what is happening at the end of the month with the autumn Budget statement.

Miss McAllister: Have you bid for that in October monitoring?

Mr May: Yes. The Department of Finance is fully aware of the quantum of money that we would need to meet the shortfall in services at the moment, to fund those services and to meet in full the DDRB and Agenda for Change pay recommendations.

Miss McAllister: Thank you for that. I realise that I am asking a lot of questions; I am trying to get them all in.

Minister, you invited us earlier this week to ask about an update on respite services. We have had the 'Spotlight' programme in the past two weeks. That is not the only time that the matter has been raised. Families and various organisations have taken multiple judicial reviews (JRs) to seek that service from trusts. This does not start at a young age. I think of Muckamore, where they are having an inquiry, I believe, almost daily now. We see that, when we do not help families at the start, some are unable to continue the care themselves. They then place their loved one into a facility that becomes a long-term facility, and that just perpetuates the cycle. There are simply not enough places. You said that you may have an update: will you clarify for the Committee whether there is an update?

Mr Nesbitt: I want to say — I think that Peter agrees with me — that the relevant officials have worked at real pace to develop options. I have that, but I have started to study it only today. I have only just been put in receipt of a number of options.

I will try to manage expectations and to be realistic. To solve the issue there are probably three areas on which you need to put a focus. There is the issue of where the respite occurs, so it is about properties. It may be at home, but you need facilities. You need funds — it costs money to do that — and then you need a workforce that is properly qualified. Those three areas need to come together, and none of them is easy to resolve, particularly in the short term. I am confident that we will have movement — not a solution, but we will have movement — in a short time and that things will be better by the end of the financial year.

Miss McAllister: Hopefully, that will be good news for many families. I just want to highlight again the issue of the for-profit independent sector with regard to that care. Rainbow Lodge, for example, was not able to attract staff, but, when you look into it further, you see that that was because of the wage offerings. That really needs to be taken into consideration. You did not give an outright view earlier this week, but that should be factored in as well.

Mr Nesbitt: The three things go together. For example, Professor Bengoa and I, before we came here last week, visited a social care setting in north Belfast and were told that they had five beds but only two were funded by the Belfast Health and Social Care Trust. Even if the trust started tomorrow to fund the five, the workforce is not there to man the additional three beds, so it is not an easy problem to fix.

Miss McAllister: It is a different skill set, too. It is not just social workers in that field; you can have youth providers as well. That is part of the issue, too. Thank you.

Ms Flynn: Thanks, Minister, for coming along today. I have three questions, and I will ask them all at once.

The Committee has identified children's services and children's health as key priorities. We have been following Ray Jones's recommendations and getting regular updates from your Department and the sector on how those are being delivered. The Chair spoke about our visit last week to the children's hospital in Dublin, which was due to open this summer, and the joint Health Committee meeting that we held with the team in the South. A couple of weeks ago, we held a North/South Inter-Parliamentary Association meeting, when elected representatives from across the country met. One issue that we spoke specifically about was perinatal mental health services and how we can, hopefully, establish better working relationships and more services across the island.

On children's health, I have three areas for questions. First, have conversations taken place up to this point with Dublin about the new children's hospital? I think that that new hospital will be leading on 42 new paediatric specialities. Are there ongoing conversations around opportunities, if and when sick children might need specialised help?

In the Chamber the other day, you said that conversations had taken place about, hopefully, finding a solution to paediatric pathology. I am aware, Minister, that you might have nothing to add. Is that heading towards a positive outcome so that wee babies and their families will be able to get that service in the South as opposed to travelling on a plane?

The mother-and-baby unit came up at the meeting between the Health Committees and at the North/South Inter-Parliamentary Association. Previously, when we were briefed by officials, there was talk about whether we would get the mother-and-baby unit first and foremost in Belfast. There are also plans to get one up and running in the South. Do differences in legislation between North and South cut out any options of cooperation? Is any work taking place, or are there ongoing conversations about that?

In your opening remarks, you mentioned our particular need around mental health and your conversations with the British Government on funding. You referenced that in your response to one of our debates in the Assembly Chamber two weeks ago. Is there any update on that? You said that you are pressing the British Government on the need for additional funding for mental health. Of course, you are making that case with the whole Executive. I know that that is happening. Is that conversation going anywhere with the British Government? Is there any back and forth and follow-up? Do you believe that anything might come out of that for mental health? Peter mentioned that the 10-year mental health strategy is sitting there, so it would be great, if there were a possibility of getting additional funding, if you could set it aside for that one issue.

My final question is on health inequalities. You have openly and proudly stated that it is one of your priorities as Health Minister, and that is fantastic. Has any work been carried out or any further detail looked at on targeted screening programmes for the areas of highest deprivation? I know that you referenced that. I am not sure whether that was in your speech — apologies — or was privately, in conversation, but I know that one of the issues was around looking at targeted screening for areas that are more deprived than others.

Mr Nesbitt: I will take those in reverse order, if I may. On health inequalities, the two demonstration areas for what I call the "Live Better" initiative have not been chosen by me. I did not want to risk being accused of any sort of bias, so officials looked at areas of deprivation. The only thing that I wanted was to make sure that they were tight geographically, because you have to be able to show the maximum empirical evidence on how you have made a difference.

On what goes into those packages, we are talking about taking services that already exist, putting them into a package and kind of flooding or bombarding those two areas with them. Again, it was not a question of officials saying that we will do a, b, c, d, e and f and putting those together; it was a matter of going into the two areas that would be chosen and speaking to the GPs and the community to find out what services they would most like to have. That is what has been done, and I think that we are close to announcing where those two demonstration areas will be. The hope is that we get enough empirical evidence for me to go back to the Executive table and say to colleagues, "We made this initiative. It has delivered. You all know that health inequalities are about 20% health, 40% socio-economic, 10% environment and 30% behaviours, so are you going to join me and are we going to have an holistic, all-Executive approach for the next areas of deprivation that we go into?".

Mr May: I can pick up on mental health, if that is OK. You will understand that any bid for additional funding for Health needs to go through the Department of Finance to the UK Government, and we will work in that way. We will not be making any separate case to the UK Government. It may be that, when the Minister meets other Ministers, he will raise that as an issue, but we will put any case for funding formally. It is, therefore, the Finance Minister who will be able to provide updates on where things are with relations with the UK Government rather than us, because we will not be directly sighted on it.

Mr Nesbitt: My approach is more political than the one that Peter is involved in. If you take a map of the Troubles and put in the hotspots for murders, shootings and bombings and then take a contemporaneous map of mental health issues measured by attempted and completed suicides and drug abuse etc, you will see a match in, for example, north Belfast.

I have been making that argument. I have made it to the Prime Minister, to Wes Streeting, the Secretary of State for Health, and to the Secretary of State for Northern Ireland. The reaction that I received was that they were surprised. They had not thought about it before, but they got the logic of it. To my mind, to get success here, the first thing is awareness. It is about making the right people aware that it is an issue. The second thing is to get them to act. Within that awareness, I am also saying, "Look at what the previous Government did with the Northern Ireland Troubles (Legacy and Reconciliation) Act 2023. They did an almost unique thing in Northern Ireland; they united everybody against it. You have a problem around legacy, and here is something where you can unite everybody in favour, by addressing the mental health legacy.". Those messages have landed, but that is no guarantee that they will convert into action, but that is where I am. As Peter said, to a certain extent, it is outside the Department of Health. It is an opportunity for the Government to say, "Here is what we are doing with the Legacy Act, but, in tandem with that, we recognise that you have a specific mental health need and we are bringing in an initiative for you", which may be backing the regional trauma network.

With regard to the mother-and-baby unit, we have identified the Belfast City Hospital as the preferred site. We know what it will cost, and I am now of the opinion that we will have to fund it ourselves. There will be no Shared Island funding for it.

With regard to paediatric pathology, I want to be careful because I have had conversations, but, if there is going to be a positive announcement on this, it will not be mine. It will be Stephen Donnelly's, and I do not want to step on the toes of the Health Minister or the Government of Ireland. All I can say is that we have had two discussions, and they have been positive and encouraging. I am sure that the service that is offered at Alder Hey Children’s hospital in Liverpool is first class, but it is the fact that parents have to travel. How can you ask parents to travel too far? The shorter and more private the journey, the better. It has nothing to do with the clinicians at Alder Hey. The difficulty is attracting a paediatric pathologist these days, and everybody is concentrating their services. I am very open, should it come to pass, that an all-island solution would be fine and very acceptable.

Ms Flynn: Just on the specialities with the new children's hospital, is there any communication North and South on the services that will be offered?

Mr Nesbitt: I am not aware of that.

Mr May: There is certainly a willingness to look at any service that would not be sustainable in one of the jurisdictions alone and whether it would make more sense to do that on a shared basis. It could be in Dublin or our new children's hospital in Belfast. There is a willingness to look at those, but it is fair to say that any consideration is at a very early stage at the moment.

Ms Flynn: Thank you.

Mr Donnelly: I have four areas of questions. I will copy Órlaithí and knock them out to you.

First, it will be no surprise to you that staffing and the workforce are big issues for me. I was glad to hear you mention the workforce a couple of times this morning. We all know that, without healthcare staff, there would be no health service. There are significant issues that we have heard again and again at the Committee from various corners of the health service. Many of our staff are overworked, burnt out and staring into a winter where, again, pressures look as though they will be a lot heavier.

The Programme for Government (PFG) has one line about staff, which says "investing in our workforce". Those are the only words about healthcare staff in the Programme for Government. I would like to hear what you are doing for healthcare staff and what you plan to do around fair pay and safe staffing. I know there is a consultation going on at the minute about safe staffing, but there is no mention of pay and conditions in that. What do you plan to do about workforce planning and how we focus that on need and assessed future need? How do you plan to maximise the use of allied health professionals to strengthen the service? That is, basically, my first, broad question on staffing.

My second question is about the main bottleneck in the health service. We talk about patient flow all the time. At the minute, we have a bottleneck where patients cannot get out of hospital and, on the other side, patients cannot get in. Two weeks ago, we visited the Ambulance Service. Ambulances are backed up outside hospitals, regularly for up to 12 hours, and patients cannot get into hospital. Obviously, that is a horrendous situation. How do you plan to widen that bottleneck?

On waiting lists, one question that constituents ask me again and again is about the cross-border initiative. Many of my constituents are waiting for routine operations, and, if they do not get them, their quality of life will be badly affected. Have you considered reopening the cross-border healthcare directive? It was very successful when Minister Swann reinstated it a few years ago.

My last question is about the cost of not doing transformation. We talk about the savings, but what is the cost likely to be if we do not transform the health service and where do we go from there?

Mr Nesbitt: Again, I will go in reverse order. Please, jump in, Peter. According to Professor Bengoa, who spoke in this Building last week, the cost of not doing reform is that, by 2040, Health will absorb the entire — the entire — Northern Ireland Executive Budget. There will be nothing for schools or infrastructure — nothing for anything except Health. We have to do it. He made the point that we are not an outlier in that; the situation will be the same for Governments across Europe if they do not do the reform piece.

With regard to waiting lists and the cross-border initiative, I am afraid that an irony klaxon is going off in departmental headquarters. It will be ringing loud and clear at the moment, because we made a bid for money for waiting lists, including for the cross-border initiative, and it was not accepted in the Budget. You know how you voted on the Budget.

As regards patient flow, on one of the first days that I was in post, I was given a list of potential areas where we could try to achieve those eye-watering cuts of £200 million in trusts. One proposal was to cut over one million hours of domiciliary care. I immediately thought, "That is madness", because, if you do that, more people will be stuck in hospital beds because they cannot get home with a care package, and, if they are there, the people in the ED who are waiting to get into those beds will be stuck in ED, and, if they are in ED, the people who are in the ambulances, waiting to get into ED, will be stuck in the ambulances. The flow is everything, to my mind. If we can get the flow right, we will see huge improvements.

On the workforce —

Mr Donnelly: Sorry: just on that, what are you doing to improve the flow?

Mr Nesbitt: We are trying to release as many resources as possible so that we do not have blockages. The big blockage is that people are not getting the packages that would allow them to go home, but resources and funding are constrained, not least because of the Budget, so there is only so much that we can do. I ask people to be as productive and efficient as possible and to recognise that there is a flow and that we need to address every area where that flow can be blocked.

On workforce, I will invite Peter to say a few words. As I have said often, we need buildings, equipment and medicines, but all that is nothing if we do not have the workforce. It is really important to define what a "good job" is. It is not about saying that good jobs in the health service are those of surgeons and clinicians, because, if you do not have hospital porters, the system breaks down. It is about the idea of whether, when you wake up, you look forward to doing your job and it is a job in which you feel that you are respected through your terms and conditions and in which your peers, your employers and the people whom you serve look at you and say, "You are fantastic. Thank you so much". A lot of it is about respect. Increasing the workforce, again, depends on the funds.

Mr May: We all recognise the real pressures on our workforce and the sense of moral injury among many who work in our system at all levels. While the service that is delivered is excellent in many cases, too many people are waiting too long and there is too much unmet need in our system.

The approach has to be taken at a number of levels. At a departmental level, we have a workforce strategy. Minister, you launched a document on workforce well-being a couple of weeks ago, and we are looking to implement that. We are developing our proposals on training numbers for next year. In our provider community and our trusts, the way in which the culture of the organisation operates — how people in the organisation feel — is equally important. From my visits to and engagement with trusts, I see how hard they try to create as positive and good a working environment as possible, but there is no doubt that, if you work in areas that are under huge pressure every day, it is difficult to achieve that, however hard you try. Part of the answer to the workforce problem is about how we turn the curve on some of the wider problems that we have talked about today. We would be naive to think that we can resolve the workforce challenges while the really big problems that face our health system remain.

You mentioned AHPs specifically. That is a diverse area: 14 specialities come together to form our AHP workforce. There are certainly more opportunities, and anybody who was in the auditorium yesterday will have heard me mention one example. We know that there are ways in which we can use the skills mix in our workforce better, and that is part of our ongoing effort to improve efficiency and productivity. No one pretends that we have got to the end of that equation. That was one of the specific points that you raised.

Mr Donnelly: The other two points that I raised were on fair pay and safe staffing.

Mr May: Proposals for legislation on safe staffing are under development on a co-production basis with trade union colleagues. They will come forward when they are complete.

The Minister addressed the pay issue, if you are talking about the 2024-25 pay in particular. We are waiting to see the outcome of the Executive's deliberations on the Barnett consequentials that are being held at the centre.

Mr Donnelly: OK, no problem. Thank you.

Mrs Dodds: Thank you for coming, Minister. I want to ask a series of questions. The longer I have listened, the more questions I have added to my list. We will try to get through some of them.

The presentation at the Bengoa conference last week was interesting, but I was a little underwhelmed. I asked a question to which I got what, in your former, journalistic career, you might have said was "a politician's answer". I asked, "Do we have enough capacity in the system to undertake reform and clear the backlog?". We have patients waiting years upon years for hospital procedures. Do we have enough capacity to undertake reform — that would be significant, and I hope that the Committee can support your proposals for reform — and clear the backlog?

Mr Nesbitt: It is an absolutely massive challenge. Our current budget would push me towards giving a negative response to your question, but we are trying to be imaginative. For example, we have put in a bid to the Northern Ireland transformation fund for the roll-out of multidisciplinary teams. We are still in the game — we certainly have not been knocked out — but I do not know whether we will be successful with that bid. If we get it, that will release new funds, which will mean that we can start the process of transformation. With limited budgets over the past number of years, we have managed to initiate some degree of reform. I listed some of the reforms —

Mrs Dodds: I would like to proceed because I want to ask you questions about those. Do you have figures that tell us at what capacity rapid diagnostic centres, elective centres and overnight stay centres are operating?

Mr Nesbitt: Yes.

Mrs Dodds: In Mairead's response to me, she said that our elective centres must become like factories, churning out operations over and over again. Is that what we are doing? Are we operating those on a seven-day basis? How and at what capacity are they operating? Are we anywhere near optimum capacity?

Mr Nesbitt: No, absolutely not. I do not think that we have peaked out. I have had conversations with officials, and we have looked at the efficiency of some services in the new regimes. We were not happy with them, and we took action. In some cases, we have had rapid, positive responses.

Mrs Dodds: That is serious and concerning to me. If those are the stars of reform and they are not operating at an optimum, I am not sure how we can reform and clear the backlogs. We have years of backlogs to clear.

Mr Nesbitt: Well —

Mrs Dodds: I am conscious that the Chair will start shouting at me soon.

The Chairperson (Ms Kimmins): I am not that bad.

Mrs Dodds: You also talk about health inequalities, and I agree with you. You know that, in my lifetime, I have represented some of the most deprived communities in Northern Ireland. I do not take away from your work on that, and I will be really interested to see the outcome of it. However, there are huge structural inequalities in our health service.

The debate that we had on breast cancer services was a well-conducted, good debate. For the sake of the room, I will demonstrate the inequalities between trusts, because they really concern me. In the Southern Trust, about 10% of women who discover a lump in their breast are seen within the required time. In the Western Trust, it is over 80% of women. In the South Eastern Trust, where we are now, it is just over 4% of women. In the Northern Trust, it is just over 7% of women. Those are utterly appalling statistics. That is the differential of service that women get.

I know that you have launched the review, but the breast cancer service is but one of many services where there are those differentials between trusts. How do we sort that out, and how do we make trusts accountable to sort it out? If we are going to give trusts the say on what services are delivered in which areas, how on earth can we do that when we already have those existing inequalities?

Mr Nesbitt: I have already said that I want to identify best practice — that might be best practice that is discovered elsewhere, outside our five geographic trusts — and make that common practice.

I have to go back to say that you cannot expect 100% efficiency, particularly in delivering lists. There will always be occasions when somebody is unavailable because of perfectly understandable, last-minute reasons, and, if one key person — the surgeon, the anaesthetist or the theatre nurse — is missing, that list falls and your 100% becomes 90-something per cent. We are trying to make sure that, when lists are cancelled because somebody has dropped out, that person is replaced where there is a reasonable opportunity to replace them. We are making good progress with that.

I return to the point. What is best practice, and how do we make it common practice across the piece? You know that I accept that there are some really unacceptable levels of performance, not just in respect of breast cancer.

Mrs Dodds: How do we get accountability for that? It seems that we wring our hands and say, "This is terrible", but we need accountability for it. This is about women's lives.

Mr Nesbitt: The buck stops with me.

Mr May: The Department takes a performance management approach through our strategic planning and performance group. It has set a five-stage escalation process. If a trust is not delivering and that group believes that the reason for that is not reasonable, there can be an escalation process. That is the accountability mechanism. It is based closely on what exists in Scotland. Under that mechanism, you draw out into the public domain only those that get to levels 4 and 5. You look to work in the system to address the problems at levels 1, 2 and 3. That is the performance management process that we go through, be that for breast assessment or any other service that is not delivering. As the Minister said, there may be occasions when, although the numbers are not right, a trust has no obvious way to rectify the situation.

We need to be sensible about the approach that we take. You can hold people to account only for things that they can reasonably be expected to resolve and address. That is the kind of mechanism that we can use.

Mrs Dodds: Is it possible for you to write to the Committee and tell us how that accountability mechanism works and which trusts and services you are working with, particularly those that are in danger of going to levels 4 and 5?

Mr May: There are no services currently at levels 4 and 5. The system was introduced relatively recently — in the last few months — so we are still growing and developing it. It is a different way to approach the performance equation.

Mrs Dodds: I am interested in getting further information on that. We have to make people accountable for that really poor performance in an area that is time-critical.

I have two more questions. The first is about the children who are still waiting for percutaneous endoscopic gastrostomy (PEG) surgery. There was an initiative in October. Will that continue? How do we resolve the issue? I have an email from parents who say that, even though the initiative took place, eight more children were added to the list in October.

My last question is about the capital budget. What capital builds will not go ahead because of the huge overspend on the maternity hospital? Does the Department have any sense of what the remediation costs will be?

Mr Nesbitt: I think — keep me right, Peter — that there are just over 80 children on the list for PEG surgery. It only happens at the Royal Belfast Hospital for Sick Children. A review of that list is under way. Negotiations are ongoing to see whether it would be possible to also offer the service at the Ulster Hospital. Staff training would be required before that could be undertaken. Is that about right?

Mr May: There has already been a reduction in the number of children awaiting the surgery, as, I think, you highlighted. There are plans to continue that.

It is always important not to look at any one procedure in isolation. Some children have complex needs, so it is not purely the case that one procedure will meet their needs. There may be other procedures that the same group of surgeons and nurses is responsible for. By focusing entirely on one service, you can lose sight of that and create a different problem elsewhere. You have to look at an overview of the position as well as the specific issue that you raised previously.

Mr Nesbitt: I am not aware of any capital projects that —

Mr May: The way it works is that you get a capital budget for each year. The changes in spend on the maternity hospital over a number of years have been accounted for in the spending for those previous years. The total remediation cost will depend on the outcome of two reviews that are being conducted by independent experts: one firm is from Portadown, and the other is called Hydrop. The Belfast Trust expects to receive the final reports from both independent experts in the next couple of weeks. That will enable a proper judgement to be reached about the right remediation steps.

Mr Robinson: Thanks, Minister, for your input today. We really appreciate it. There may be times when you feel that we are being in some way negative towards you or are attacking you on the Floor, but we are not. We recognise the difficult challenge that you and your Department have.

I am pleased, Minister, that, in your earlier communication, you touched on the importance of public messaging, especially around reform. The 'Delivering Together' report states:

It was you who raised that with regard to Causeway Hospital. Do you recognise that, over a period of years and not just in recent weeks and months — forgive me for bringing it down to that level — there has been poor messaging around that hospital? Over a significant period, the mantra has been that there is a vision for Causeway Hospital. In recent weeks and months, we have heard about the elective hub, yet we have no meat on the bones. The people whom I represent — not just ordinary members of the public but former staff, including senior clinicians — are concerned that, with the proposal to remove emergency surgery and push it towards Antrim, you are kicking away a key pillar. We have a series of services being removed from Causeway Hospital. All the while, we are told that services will come to Causeway Hospital, but we have not seen them. When will we see that detail? There was an announcement about an MRI scanner. That is 10 years too late, albeit it is a good news story. We want to see meat on the bones.

There is a lot of chat about showing leadership, but it is difficult for me when I go into a public meeting. Forgive me for using this language, but it is not people with pitchforks at those meetings; it is respected people who serviced that hospital for 25 years and members of the public who were prepared to trust them with their lives. Those members of the public hear former staff members saying that that is a key pillar being kicked away. What would you say to the senior clinicians who worked in Causeway Hospital for all those years who attended the listening session last week or the week before and made their feelings known? I asked you about Causeway Hospital in the Assembly, and you told me to speak to clinicians. I have spoken to former clinicians, and they are concerned.

May I also ask about MDTs? I know that you touched on those. That is a good news story. We talk every time about the bad news stories in the health service, but MDTs are a positive story. The evidence is there: no GP surgery that has had a full complement of MDTs has handed back its contract. Will it be possible to see a full roll-out of MDTs, or am I asking for the moon and the sky?

Mr Nesbitt: At the moment, I cannot say to you that the roll-out of MDTs will go to the full 17 federations by x date. Hopefully, the next three federations will get their roll-out of MDTs if and when we are successful in the bid to the transformation fund. If so, that would happen relatively quickly.

I said in my first remarks in the Chamber as Minister that I would never criticise a former Health Minister. I do not see the point of that. If criticising a former Minister was going to improve the prospects of a single patient, I would certainly think about that, but it will not, so I will not do it. You are giving me a perception that there has been bad communication about Causeway Hospital: I have to accept that as a valid perception among the people whom you represent, and that is fine. I have spoken to a former surgeon who is very much against moving general emergency surgery to Antrim. I have listened to him. He is passionate about the hospital where he worked vocationally for all his career, and I respect his opinion. However, I have also spoken to clinicians who work for the Northern Trust today. The trust is saying, "This is our preferred option", but those clinicians are saying, "It is not: it is the essential option to prevent the collapse of the service".

We always need to be better at saying, "If and when we move a service, you are going to get something better in its place". That is difficult, because it prejudges the outcome of a consultation. I understand why we got into difficulty there, but I want people to understand that my motivation will be a number of steps, all of which are part of creating a new jigsaw that will ultimately be about delivering better outcomes overall. That will include a degree of pain for people, because nobody likes to lose a service. I understand that, if you look at it in isolation, you will think, "I'm losing a service. That's bad". However, you then have to think, "Is this part of a continuum? Is this hospital being run down to the point that it is unsustainable?". That is absolutely not my motivation. The Causeway Hospital has a future. If it becomes an elective centre, it will have more certainty. I go back to the point that, then, your operation would not get cancelled because an emergency case has gone into the theatre. Change will always be difficult and challenging.

I understand that there is an ageing population on the north coast. People with relatively high levels of wealth want to move to somewhere like Portstewart or Coleraine on the triangle when they retire. I am conscious of all those things. Ultimately, there will be an element of judgement call in every decision we make. You cannot keep all the people happy all the time. I will be guided primarily by the clinical advice, and then I will be determined to go out and try to persuade the community affected by the decision that it is a good thing for them.

Mr Robinson: MDTs?

Mr May: The Minister said that we could not make a guarantee, but MDTs are a high priority for us in transformation and reform. How quickly we can take the steps that we would like to take and how quickly we can make progress will depend on funding.

Mr Chambers: Minister, we can all acknowledge that setting the Executive Budget has been an extremely difficult exercise. It has been fraught and even divisive. What approach would you like to see adopted in setting the Budget for 2025-26? Hopefully, Departments will soon engage in genuine discussion and deliberation on next year's allocations, rather than leaving it until a last-minute rush, as has, unfortunately, been the case in most recent years. Are you optimistic that the Executive will ever get round to setting multi-year Budgets that could offer everyone more certainty and assurance, particularly in your area of responsibility?

Mr Nesbitt: Thank you. There are two points there, and I will respond to them in reverse order.

I am optimistic that we are moving towards multi-year Budgets. At one point, I thought we might even get there as soon as the next financial year. It will probably be financial year 2026-27 by the time we have a properly embedded three-year Budget. That is because we have a new Government in London, and I do not think that they are quite ready to go to multi-year Budgets next April. However, I am optimistic. In its own way, that will be transformational to how we deliver healthcare in Northern Ireland.

Your other point is, effectively, about collaboration. When I introduced the First Minister and deputy First Minister in the conference hall this morning, I said that I had been an MLA for 13 years, which is about half the time that the institutions have or have not been up and running, and that, in February, when we went back in, I sensed a different atmosphere — a better and more positive atmosphere. There is a determination like never before to deliver. In June, when I sat down around the Executive table for the first time, I sensed the same determination to deliver and work collaboratively.

As we have discussed the Budget over recent months, we are coming to the conclusion more and more that, rather than each Minister inputting to the Finance Minister, "These are my concerns. These are my issues. These are my demands. These are my inescapable pressures", we should sit down together and listen to each other's inescapable pressures. You then come to a point at which you say, "We have a problem: we cannot build houses because the water system does not work. How important is that against the fact that cancer or breast cancer services are not up to scratch?". We have to come to a decision about what the real priorities are, given the Budget and the resources that we have. I am really encouraged by the fact that, increasingly, we recognise that that is what we have to do, and that is what we are starting to do. I imagine that, by the time we get to sorting out the next Budget, you will notice a different, collaborative attitude to it.

Mr Chambers: Thanks, Minister.

The Chairperson (Ms Kimmins): Minister, just before we finish — we are just on time, nearly to the minute, so thanks to everybody —

Mr Nesbitt: The last one is always the tricky one.

The Chairperson (Ms Kimmins): It is on an important issue that you will be aware of. We have had a lot of conversation about post-19 provision for SEN children and young people. We are all well aware of the Caleb's Cause campaign, which is led, ferociously, by Caleb's mum, Alma. At a recent meeting of the all-party group on learning disability, we received an update from Nigel Chambers from your Department and Claire Thompson from the Department for the Economy. What collaboration is happening with other Departments? Are you considering potential legislation on post-19 SEN provision?

Mr Nesbitt: The permanent secretary is a renowned world expert on the issue.

Mr May: We are not looking at bringing legislation forward on this subject, certainly not in this Assembly term. There are a number of legislative vehicles that we are looking to advance. Resources will need to be prioritised to try to deliver against those, rather than bringing new things forward. We can certainly write to you with more detail, if you would like us to.

Mr Nesbitt: I met Alma the other day, and I am entirely in tune with what she is trying to achieve. It is just about the practicalities of doing it. Again, it cannot be just me or just the Department of Health. There are so many issues that need to be addressed, but that should not put us off getting on with it.

The Chairperson (Ms Kimmins): Thank you, both. There are so many pressing issues that we could probably do another hour, but we will not put you through that. If there is anything else, we will follow up in writing. We really appreciate your time. As we said at the start to both you and your predecessor, the Committee is keen to work collaboratively as much as possible. We will hold you to account, but, where we can work together, that is always better.

Mr Nesbitt: Thank you, all.