Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): You are all welcome on this particularly cold day. Thank you for being here. In attendance we have Roisin Coulter, chief executive of the South Eastern Trust; Maureen Edwards, interim chief executive of the Belfast Trust; Owen Harkin, deputy chief executive and director of finance of the Northern Trust; Michael Bloomfield, chief executive of the Northern Ireland Ambulance Service Trust; Neil Guckian, chief executive of the Western Health and Social Care Trust; and Colm McCafferty, executive director of social work and director of children and young people's services in the Southern Health and Social Care Trust. You are all very welcome, and I hope I got everybody's name right.

We have a heavy agenda, and I remind members that we have one hour and 30 minutes maximum for the session. I ask for introductory remarks to be kept as brief as possible and for members and those responding to keep questions and answers as concise as possible so that we can get through as much as possible, particularly given the weather. I want our staff and everyone to get home safely. Please bear that in mind. With that, I invite you to make opening remarks, and then I will open the meeting to questions.

Ms Roisin Coulter (South Eastern Health and Social Care Trust): Thank you very much, Chair, and "Hello" to everybody on the Committee. Thank you for the opportunity to attend today's meeting to update the Committee for Health on key challenges and priorities across Health and Social Care (HSC). I am joined today by my colleagues from all the trusts in Northern Ireland. In advance of the meeting, we have provided you with a detailed briefing paper containing information on key areas. I will provide you with a 10- to 15-minute overview, as requested, of these prior to taking any follow-up questions with all my colleagues.

Two of the key underlying issues continue to remain across Health and Social Care: finance and resource availability. We pay tribute, first and foremost, to our staff in Health and Social Care, who have been incredible and have kept the service running in the most challenging of circumstances. Our staff find themselves in an environment where, in nearly all areas, demand outstrips capacity. That is what is driving the increase in waiting lists in secondary care, the increase in the number of unmet packages in social care and the pressures experienced by our GP colleagues in primary care. We must support our staff to deliver services, and we must resolve the pay issues and ensure that Health and Social Care in Northern Ireland is an attractive place where people want to come and work.

I do not propose to go through the full briefing: rather, I will provide an overview on behalf of trusts of some of the key areas, including winter pressures, elective care, financial position and short-break provision.

Significant pressures remain in unscheduled care, and, in February 2024, when we were last here, the Committee was updated on the ongoing pressures facing our urgent and emergency care services, resulting in overcrowding in our emergency departments (EDs) and strain on the Northern Ireland Ambulance Service (NIAS). Those pressures led to increased waiting times, longer hospital stays and challenges in patient discharge. Since then, there has been a slight increase in emergency department attendance. Trends have seen a slight increase in new and unplanned attendances to emergency departments of about 1·2%, which is in the region of 9,000 attendances, and the number of patients waiting for more than 12 hours in emergency departments increased by 13% in 2023-24. Fewer patients were also admitted or discharged within four hours, which is down by 5%. The average length of stay in hospital remains high. At eight days, it is unchanged from our previous update, and weekend discharges remain low at around 18%. Those are key areas where improvement is essential.

In December 2023, chief executives established the regional coordination centre. That has started to coordinate positive actions and initiatives across the region in four key areas, including pre-hospital demand management, same-day emergency care, improving patient flow through hospitals and improving complex discharge processes. All trusts are working together to agree and implement our winter locality plans that are aligned to those areas. The regional coordination centre is also supporting the trusts by coordinating our resilience and response in respect of winter preparedness across the region.

As part of our ongoing efforts to improve patient flow and increase community capacity, each trust has developed a locality plan. The main goal is to alleviate hospital pressures and improve outcomes for patients by addressing key bottlenecks across our system. While additional resources have not been made available to put in place specific actions for 2024-25 as in previous years, we have taken forward a range of measures, including NIAS's "Hear and treat" and "See and treat" services, enhancing hospital flow through the SAFER programme, increasing use of discharge lounges and improving discharge coordination and improving support for care homes to prevent unnecessary emergency visits. Other initiatives include expanding our same-day emergency care, increasing capacity for same-day medical and surgical assessment through our ambulatory care hubs and enhancing mental health crisis support.

Despite progress, significant challenges remain in workforce capacity and retention, and staff shortages continue in many areas, including mental health, social work and allied health professionals (AHPs). That limits the implementation of improvements. In summary, whilst we have made progress in some areas, many challenges remain, particularly around workforce capacity, patient flow and discharge processes. Regional collaboration and coordinated efforts will continue to be essential to support those initiatives and identify areas for further improvements.

As we are all aware, one of our biggest challenges is the very long waiting lists for elective care in Northern Ireland. As we know, waiting times for many elective procedures are far too long. In his ministerial statement in June 2024, the Health Minister identified tackling waiting lists as a key priority. We are dealing with more than just backlogs. The real issue lies in the significant demand and capacity gaps that exist across many of our services, the addressing of which requires additional recurrent funding. Simply put, the demand for care continues to outstrip our capacity to deliver it. To tackle that, we are focusing on the principle of "Right procedure, right place". That means ensuring that procedures are delivered in the most appropriate setting by skilled staff, with the right clinical support services.

There has been significant progress in recent years through the development of the dedicated elective care centres to enable certain services to be delivered across trust boundaries, with the aim of protecting and enhancing our elective capacity. We have a range of services in place, including the two dedicated day procedure centres at Lagan Valley and Omagh hospitals, where approximately 20,000 patients have been treated between October 2020 and March 2024; three dedicated centres for cataract treatments at the Downe Hospital, South Tyrone Hospital and Mid Ulster Hospital, where approximately 18,000 patients have been treated; and an orthopaedic hub at Musgrave Park Hospital, which includes the Duke of Connaught unit — a dedicated day procedure unit. We are also making use of elective overnight stay centres in the Mater, Daisy Hill and South West Acute Hospital (SWAH) to perform less complex inpatient work.

The most complex procedures and patients remain in our acute hospitals, but, even there, we have moved to introduce new post-anaesthetic care units that are ring-fenced for elective care to reduce our reliance on intensive care units and high-dependency units. Those initiatives have been key to protecting and enhancing elective care capacity and helping to increase the number of patients treated while maintaining quality. For the public, that will mean that some elective work may not be delivered close to home, but it will be delivered safely by highly experienced staff in a hospital that has become a centre of expertise for the delivery of certain specialties.

We still face some significant barriers and obstacles. Patient cancellations remain an issue due to such challenges as bed availability and patient unsuitability on the day of their procedure. Other issues include the need to provide on-call cover with no backfill availability. Furthermore, it is recognised that the day procedure units are not yet operating as efficiently as we would like. We are working to improve the rates of "Did not attend" (DNA) appointments, but there is still progress to be made. It is essential that we get the full support of the public to maximise attendances and reduce that inefficiency.

In addition to those operational challenges, we face increasing demand in several areas. We see significant growth in cancer red-flag referrals; a 21% increase between 2019-20 and 2023-24 across multiple specialties such as dermatology, gynaecology and urology, among others. The impact of COVID on mental health services in Northern Ireland has, as you will all know, been significant, with various estimates highlighting increases in demand. The Department of Health predicted that the pandemic would lead to a 30% rise in mental health service demand over three years, translating to approximately 19,000 additional referrals to adult mental health services and over 5,000 referrals for psychological therapies. The Public Accounts Committee (PAC) report confirmed that rise, and, although data is not consistent, the waiting times and lists are as predicted.

The number of cared-for and looked-after children is also rising, increasing by 17·2% since September 2019. Workforce shortages and funding gaps in those areas exacerbate the challenges. In 2020, the availability of overnight short breaks for children and adults with a disability was severely impacted by the pandemic. Those services experienced significant pressures and challenges predating COVID, however, and growing demand has been outstripping short breaks capacity for a number of years. Over the same period, the need for longer-term residential care for people with severe learning disabilities increased for a number of trusts. For example, the number of children with a disability in Northern Ireland with long-term residential care provision rose from 21 in 2020 to 42 in 2024: the demand has doubled in four years.

Many of the challenges facing children's services are echoed in adult services in relation to the provision of short breaks for vulnerable adults with learning disabilities or mental health issues across Northern Ireland. A significant factor contributing to the lack of availability in adult services has been the emergency placement of adults in trusts' short break accommodation following family breakdown. The pressure on short break accommodation has been further exacerbated by the planned closure of Muckamore Abbey Hospital and the knock-on impact on longer-term residential placements. However, additional recurrent funding to increase provision of short breaks for adults has not been secured. It is critical that support is offered in various forms, including short breaks, outreach support and access to the Shared Lives programme to enable service users to live in their family home as long as possible. Due to the increase in demand for longer-term residential care, many overnight short break residential homes had to be repurposed to meet that need. Trusts provided for between 27 and 49 nights per week in 2020. That has gone down to between five and 39 nights per week in 2024. That demand for residential care has doubled in the past four years, and, as a consequence, the ability to provide children's short breaks has halved. In 2020, the South Eastern Trust provided short breaks for 365 adults. That capacity shrank to 181 short breaks in 2024. Similarly, the Southern Trust reduced short breaks provision from 223 in 2020 to 181 breaks for vulnerable adults in 2024.

I will turn to the current position on demand for overnight residential short breaks. Regionally, in excess of 321 children are waiting for a service. Where short breaks for vulnerable adults cannot be provided by trusts, alternatives offered include direct payments, spot purchase from the independent sector and day opportunities. There is therefore no defined waiting list for vulnerable adults, but some of those alternatives come at a significant cost. The trusts greatly welcome the additional investment in children's services announced by the Minister, and we are working on short- and medium-to-long-term proposals with the strategic planning and performance group (SPPG) that will ensure that our children and families are fully supported by a range of services. Without equivalent support for adults, however, there is a risk that a further gap in resources becomes an inevitability for those children as they transition into adulthood.

That brings me to the critical point: funding. The financial situation has been well rehearsed in recent months. Similar to the NHS, as outlined in Lord Darzi's recent report, the HSC has suffered from years of funding increases that have failed to keep pace with the increasing demands of an older population with more comorbidities and chronic illness and with cost-of-living increases. Despite plans that direct more funding into community care and disease prevention, there has been little new investment, and much of that has continued to be invested in hospitals and social care. As a result, underinvestment is particularly marked in community services, affecting the most vulnerable: those with a learning, mental health and physical disability and looked-after children in care.

The considerable cumulative annual funding gap that has arisen means that trusts need to make year-on-year efficiencies and cost-containment savings just to stand still. Those are becoming more difficult to make after years of savings in the context of the rising demand. That means that all trusts have accumulated significant underlying recurrent deficits. Moreover, the failure to invest in additional capacity to meet demand means that waiting times have grown and continue to grow. Addressing current waiting lists will require many hundreds of millions of pounds for additional staffing and infrastructure over several years. Even then, we will rely on considerable support from the independent sector. Even if we address the backlog, however, if we do not build extra recurrent capacity alongside service reform and efficiency, waiting times will continue to be an issue. The elective care framework published in June 2021 evidenced the need for a multi-year plan of actions, supported by £700 million of investment. In the three years since, however, there has been less than £20 million recurrently invested to build capacity in services, the vast majority of which is focused on the regional elective and diagnostic centres, but there is much more needed to address the underlying capacity gaps in all trusts. For example, between 2011-12 and 2016-17, the health service in Northern Ireland spent hundreds of millions of pounds addressing waiting lists, and that brought waiting lists down to targeted levels.

My colleagues and I are clear that the challenges can be addressed over time providing that a number of elements come together to work on a strategic and long-term basis. Our message has not changed since our last presentation to the Health Committee. The key aspects required are the resolution of workforce pay issues to ensure that Health and Social Care in Northern Ireland is an attractive and competitive place where people want to work; the maximising of the potential of the whole workforce to ensure sustainable services that meet changing demands; a sustained investment approach, providing multi-year budgets to enable us to plan and deliver sustainable long-term services; a shared commitment to work in partnership; and consistent political decision-making to deliver Health and Social Care's strategic direction and reconfiguration plans. In addition, an understanding is required of the need for prioritisation. It is not possible to deliver everything at once, which means agreeing that some things will not get attention immediately.

The new planning approach — the integrated care system — will provide a platform for greater collaboration, and we need to shift the dial away from a service that is still focused on illness towards one that is focused on wellness, prevention and early intervention. Those are key, alongside the public narrative that citizens need to take greater responsibility for their own health and well-being.

That concludes the formal presentation on behalf of the main providers of health and social care services. We are happy to take questions from the Committee.

The Chairperson (Ms Kimmins): Thank you, Roisin, for that comprehensive briefing and for the briefing papers. We had a further statement from the Minister this morning that outlines in more detail where some of the savings have been made across trusts.

I have a couple of questions. The pay issue is ongoing. Hopefully, we are in a more positive position given the recent allocation to the Department and that issue will be resolved soon. Negotiations continue, and the Minister is putting forward some suggestions, so I hope that that will help to stabilise things, particularly for staff. Without staff, we will not have any services, so that is a key factor in all of the discussions. The information that the Committee has received from the Department states that an additional £5 million has been allocated for care packages for the over-65s. Will you give us more information on that? As we move into the winter period, that group is probably most affected with sickness, in particular those living with dementia. What have the trusts factored into their plans in relation to that? How will that money be used, or is that work that is ongoing?

Mr Neil Guckian (Western Health and Social Care Trust): We cannot overstate the importance of the pay award. We are working in an incredibly competitive working place. We have an opportunity for this to be the first year since 2018 to have a winter without industrial action or a pandemic. We are on the cusp of that, so I ask everyone to use all their efforts. I also ask whether it is just Health that is affected. I am an advocate for Health, and I work in Health. Is it just health workers who are not getting a pay rise this year, or is that situation public sector-wide? I do not know the answer to that, but I ask the question, Chair.

We also emphasise the fact that we are competing against other marketplaces. The Republic of Ireland pays significantly more than Northern Ireland for health and social care workers. I provide services on the border, which means that I have doctors who can live in Derry and provide a rota in Letterkenny. It is the same with Enniskillen and Sligo. We are haemorrhaging pharmacy staff, AHPs and social workers across the border without regular pay awards, and the pay awards are not really keeping pace with inflation. We really cannot overstate the importance of the pay award. Likewise, industrial action will pull our services down during the winter. We cannot allow ourselves to get into that position.

It is my understanding that the funding for care packages was from the start of the year rather than being specific to winter. We have built that into our financial plans during the year, so we will not be increasing our capacity for packages during the winter specifically from that income. Each trust will do its own things as part of a winter plan, and I am sure that we will have an opportunity to outline our winter plans to you during this presentation. We will use other methods. By and large, there is no additional money for this winter, so we are trying to improve the effectiveness and the amount of services in very constrained situations.

The Chairperson (Ms Kimmins): Thank you, Neil. I will jump to a couple of different things. Other members have questions, so I do not want to dwell on one area, but I totally agree with everything you said on the pay issue. I represent a border constituency, so I know just how critical that issue is. We need to resolve it as soon as possible.

My next question is on elective care. The work that has been done to date on the elective care centres and the overnight stay centres has been really positive, but there is always room for more. I am concerned that the Northern Trust said that some of its activity had had to be reduced because of Encompass. Is there a time frame for when that activity will be back on track? More broadly, are we looking at plans to expand the provision of elective care? There are lots of opportunities there as well.

Ms Coulter: I will ask Owen to respond on the Encompass piece.

Mr Owen Harkin (Northern Health and Social Care Trust): As you know, Encompass went live in the Northern Trust on 7 November. In the run up to that, we worked with other trusts and the SPPG to agree how we would manage a downturn in activity for a period of time. That included other trusts assisting us with red-flag and urgent referrals for a time, to allow us to absorb some of that, as well as downscaling some activity. We have plans to recover that activity over the next four to six weeks. We hope to be back to full capacity early in the new year.

Mr Guckian: In terms of generic elective care, Chair, we can confirm that the Department of Health and all trusts are closely on top of that. We have an elective care board that, I think, met yesterday. We are focusing first on making sure that we deliver the sessions that were commissioned. I assure the Committee that the sessions being delivered in the Western Trust have increased significantly since last year and since COVID. Once the sessions are arranged, it is about making sure that they operate as effectively as possible. We are focusing on real-time information to make sure that the sessions start on time and do not finish early or start late. We are really focusing on that.

The next thing is to make sure that the right patients come to the right sessions. That sounds like a really simple thing, but, because people are on waiting lists for a long time, it is really important that they are fit for the operation that they will receive. We are now organising what are called mega clinics on Saturdays, so that we have a wide pool of patients for every session being delivered. That means that we do not have any fallow time in our sessions and every patient is allocated to the right session. They might arrive for a day case but need an inpatient clinic because they have deteriorated while they have been on the waiting list.

The Chairperson (Ms Kimmins): Are the mega clinics specific to the Western Trust, or are they in other areas as well?

Mr Guckian: They are across the patch.

Ms Coulter: Many of us provide mega clinics for certain specialities. For example, the South Eastern Trust recently had one in relation to breast. They are a really good way to do things, if you can. They are difficult to step up, but they enable you to see a large number of patients on one day.

Mr Guckian: Roisin talked about the real initiatives that we have to improve elective care. We need to expand those. Other countries really separate elective care from all other services. There is a real challenge for us in Northern Ireland to go further than we currently have, because of our emergency needs and the needs of our population. DNAs continue to be an issue, and we have done audits and phoned patients to find out the underlying causes. We are asking patients to travel further now, so we want to check whether that is the reason. People have told us that that is not why they do not turn up. We phone them three days before their operation to ask them whether they are definitely coming, yet still people do not come. I believe that it is linked to social deprivation: in other words, people not wanting to admit that they cannot take days off work and therefore forgoing their operation in order to maintain their livelihoods. I think it is a sad indictment of our society. We have to try to have wrap-around support.

I assure the Committee that theatre utilisation, as well as other things, is up. We have to acknowledge that, at times, our elective care suffers due to other pressures. Red-flag referrals are up by an average of 21% across Northern Ireland. I keep slipping into Western Trust figures, for which I do not apologise. In the Western Trust, the figure is over 42%. Clearly, because of the pathway that people are on, clinicians have to concentrate on red-flag referrals, and it is right that they do so, but that is often at the expense of elective sessions.

Trauma, which is the emergency side of orthopaedics, has also significantly increased from pre-pandemic levels. In the Western Trust, there are 28% more hip fractures, and other fractures are up by over 30%. That means that we have to stand down elective sessions in order to treat trauma. The patient does not realise that that is the implication of their operation. Clinicians, however, get frustrated because they recognise the need on their waiting list, and they have to be reminded that they are doing the right thing by treating the patients' needs. We have to acknowledge that emergency requirements have an impact on elective work.

The Chairperson (Ms Kimmins): Thank you for that. You mentioned theatre utilisation, which, I think, is currently 90%. Going back to my earlier point about care packages, is discharge still significantly hampered by the lack of domiciliary care? Does the resultant lack of bed capacity impact on the ability to further utilise theatre capacity?

Mr Guckian: It is not so much about domiciliary care as it is dementia places. That is certainly the case in the southern sector of the Western Trust. There is a reduction in the number of places available for people who need dementia care; there is a demand/capacity gap. That is overwhelmingly the reason for people in the South West Acute Hospital and Altnagelvin being delayed. There is a fundamental gap across Northern Ireland. There are underlying reasons, one being that the tariff for nursing homes is the same in the case of dementia as it is for general nursing. Clearly, we will not entice new entrants into the marketplace while that is the case. We pay more than tariff across the board, and we need to look at that. We recognise that as a regional piece of work to expand that marketplace. That is really important.

The Chairperson (Ms Kimmins): Thank you for that, Neil. That is an interesting point that we can maybe pick up with the Department, particularly the part about dementia care. I chair the all-party group on dementia, which will meet on Tuesday. That issue has the potential to hinder placements.

Of my final two questions, the last one may be for Michael, because I am thinking about theatre and things like that. An issue that was recently brought to my attention was of a person who was waiting to be transferred from one hospital to another. As we know, ambulances and things are extremely busy, so they were held back nearly two days while they waited to go to the other hospital to have their procedure and then to come back. Such cases, in turn, impact on bed capacity. Michael, can you give us a sense of why there are those backlogs in the Ambulance Service? We know that it is very busy, but I want to tease that out a bit.

Mr Michael Bloomfield (Northern Ireland Ambulance Service Trust): We would look to see whether planned transfers such as the example you raised are suitable for our non-emergency service. The vast of them majority are. We have reduced the capacity of our non-emergency transport to some extent, because of transferring some of those staff to support the emergency side, but that has an impact on timeliness.

By and large, however, we are able to meet, to a reasonably high standard, the requests that we receive from trusts for non-emergency transfers. With a delay of that nature — obviously, I would need to know the circumstances — where somebody waits for a couple of days, it sounds as though that was a transfer that required an emergency ambulance crew because of the level of care needed during the journey, as opposed to just transport. A delay of that nature is a bit of an outlier.

The delay in responding to those is all linked to our overall response to 999 emergency calls. Our total emergency response capacity is absolutely based on clinical need. We have to respond in order of clinical urgency to the calls that are waiting at any time in our control room on the stack or the screens, which you and others saw recently. That will mean that, unfortunately, some other calls wait for much too long. It is not unheard of, very regrettably, for calls in category 3 triage to wait for 24 hours. Those are not necessarily inter-facility transfers, but they could be. They include some GP calls that come in. It is not unheard of for a category-3 call to have a 24-hour wait because of the number of catregory-1 and category-2 calls, but the overall pressures on our system have those sorts of impacts, on either people phoning 999 or some planned transfers. We certainly work with our colleagues in trusts to avoid it meaning that someone cannot get the treatment that they need. Hopefully, in the majority of cases, we will be able to do something to address that.

On any given day, we lose around 20% of our capacity, which is waiting outside emergency departments to hand over. All of us have a renewed focus on that. We are trying to introduce additional measures in advance of this winter, particularly around the end-of-shift time, to see whether we can improve that, but losing that amount of capacity — 20% daily — absolutely impacts on our response times.

The Chairperson (Ms Kimmins): I was not criticising the Ambulance Service by any means, and nor was the constituent who mentioned it to me. I asked that to get an understanding of how it works. I know that there are planned transfers and emergency or unscheduled transfers. It sounds as though the planned transfer staff are having to be redeployed because of the demand on the emergency side. We met the staff. Visiting your dispatch headquarters was a real eye-opener. Some of the staff said that there could be three shift changes while one patient sits in an ambulance outside a hospital waiting to go in. I just wanted to get a wee bit of an understanding, so that was really useful, Michael. Thank you.

Mr Bloomfield: It impacts on non-emergency as we redirect some non-emergency staff to support the emergency side.

The Chairperson (Ms Kimmins): We will need to see how we can help to support that. It has a knock-on impact on the wider hospital system.

We talked earlier about regional approaches. Neil, you talked about people travelling to different areas for elective care and other procedures. Maternity services, particularly in my trust area, have been fragile in recent times, but I am aware that that is true not just across the North but further afield. It is my understanding that the Department is working really hard to find solutions. Will you give me an update on that? I know that there is a significant recruitment issue in midwifery but also at consultant level in obs and gynae.

Mr Colm McCafferty (Southern Health and Social Care Trust): There have been significant challenges in the Southern Trust, particularly on the Daisy Hill site, in maternity. Those initially came to the fore in early September around the immediacy of adequate midwifery cover and resulted in regular diverts to Craigavon. We have been able to bring a degree of stability to midwifery as a consequence of a significant number of staff who were on sickness absence having returned to work and initiatives in the trust to stabilise the service. We are confident about midwifery, in the sense that we have recruited. Unlike in a lot of other professions, I am confident that there is not the same challenge in midwifery supply. In the Southern Trust, we expect to appoint approximately 15 new midwives from January onwards, which will definitely stabilise that aspect of the challenge.

In the short term, we have successfully managed to bring a degree of stability to our obs and gynae, but I qualify that in the sense that there is still a reliance on locum for that stability. We are satisfied that, over the next 10 to 12 weeks, we will definitely have sufficient cover in midwifery, and I am satisfied that it will be resolved in the long term. Recruitment in obs and gyyne is more challenging. We are in the midst of a recruitment campaign. I am not hugely optimistic that it will deliver all the cover that is required, so we will continue to work on stabilising what we already have, through locum cover and so forth.

The Chairperson (Ms Kimmins): OK. Thank you, Colm. I know the issues at Daisy Hill, but, for me, it was not a Daisy Hill issue; it was an issue with maternity services in the Southern Trust more broadly. If it is not already being explored — I have been in regular contact with the Minister and the permanent secretary — there is scope for a regional approach and looking at all the trusts working together, because, where an issue like that happens, the knock-on effect is felt in other areas. It is in all of our interests that that is part of the work going forward. We continue to work on that with the trusts and the Department, because it is an area where we simply cannot afford to see any reduction in service. We will continue to monitor that.

Members, I am conscious that I have asked quite a number of questions. Apologies.

Mrs Dodds: Thank you for the presentation. It is sometimes difficult, in health, to come up with exciting new proposals. What you have given us today is a reality check, and that is important for us. I want to focus my questions on a number of areas.

Roisin mentioned the mega clinics. I recently had an Adjournment debate in the House on breast cancer referral times and the initial assessment period, which is 14 days. No trust in Northern Ireland meets that target time, but the Western Trust came out as, by far, the best-performing trust. There are worrying statistics from the Southern Trust, the Northern Trust and the South Eastern Trust. In all those trusts, less than 10% of women are seen within the departmental target time. The figures were just over 4% for the South Eastern Trust, just over 6% for the Northern Trust and 10% for the Southern Trust. Those are really astounding statistics. Has anything happened to improve those statistics? Roisin, you reminded us of the mega clinics for breast referrals, but, really, we are failing women if we continue with those departmental figures and targets being missed in that way.

Ms Coulter: There is a lot of focus on that, and I recognise that it is extremely important. At a regional level, the Minister has requested that we have one breast service for Northern Ireland and one waiting list. There were meetings just yesterday between the Department of Health and SPPG colleagues to look at how we can come together to provide equal access for women to breast cancer assessment, and all the trusts are participating in that. That is the direction of travel and the way forward. NHS England has dropped the 14-day breast target, and, rather than access to assessment, it is focusing more on the outcome when a diagnosis is made of a confirmed cancer.

We monitor closely. In my organisation, the performance does not look good at all. However, no women are waiting longer than 20 days now. That has come down from 78 days many months ago to a maximum of 20 days now. The mega clinics are difficult, logistically, to organise, but it is worth the effort if we can get all the professionals to come together to provide those clinics. We really need interventional radiography staff, medical staff and nursing staff to come together to provide that clinic on the one day. The breast assessment clinic is a triple-assessment one-stop clinic. Women need to come and be medically assessed, have an ultrasound, have a mammogram and get the outcome on the one day. All those parts of the pathway need to be available.

I assure the Health Committee that the South Eastern Trust will be back to 100% by the end of December as a result of the work that we have been doing. That is positive. There is genuine collaboration across trusts to support one another. That is the way forward.

Mr Harkin: Similarly, we have that level of focus in the Northern Trust. We welcome the move to a single waiting list. It helps to take away some of the variation when you are dealing with small teams, particularly when the demand is so much higher than the funded capacity. As Roisin said, it is complex to deliver that mixed, multidisciplinary team approach. If one member of the team is not available, all of a sudden, you have a major problem. Working together as a system across the region will, hopefully, help us to smooth that over a period. It remains very much a focus for us to drive that improvement over the next number of months.

Ms Maureen Edwards (Belfast Health and Social Care Trust): The Belfast Trust consistently met that 100% target for a while, but we are currently part of the collaborative working because we all agree that there needs to be equality. Therefore, our figures have dipped, necessarily so. To go back to what the Chair said, we need more collaboration so that we get equity of approach.

Mrs Dodds: In case I forget, which is a likely possibility, I will say this: we are all worried. Departmental targets are agreed and set for a reason, and whether some other part of the United Kingdom wants to give them up is probably irrelevant. It is worrying from the time when you discover a lump in your breast until you are assessed, with waiting lists being as they are. Roisin, even 20 days — three weeks — is a long time to carry that burden. I am glad of the publication of statistics — that is important to hold everybody to account — but I would really like to see an upturn when we get the next set of statistics for that issue. That is really important.

Mr Guckian: I want to make two points. I will repeat what Maureen said about the Belfast Trust: the Western Trust would meet that target only for the fact that we accept patients from elsewhere in Northern Ireland to ensure that we minimise the total wait for Northern Ireland patients. I pay tribute to my clinical team in that regard.

We also have to look at the context. Red-flag referrals for breast cancer have gone up by 11·4% in my trust. You cannot just look at the wait; you have to look at the totality of the demand. If resources and the ability to address it have not been tackled, there will be a slip in the future. If that 11% increase continues, clearly, you can deliver only a limited service without increasing the size of that clinical team.

Likewise, imaging is under intense pressure. There is a 10% increase in referrals for MRIs per annum and a 10% increase in referrals for CT scanning every year. That has not been resourced at all, so what happens? Something has to give. Our clinical teams are daily trying to prioritise their patients. You are absolutely right: breast patients and patients with suspected breast cancer need to be a priority, but which patient gives? That is the question that our clinical teams have to ask themselves every day. I take my hat off to them: they make that call really well, certainly in the Western Trust. We have always met that target.

Mrs Dodds: I would accept that, Neil, as a reason and an argument, if I did not know that, in the South Eastern Trust, that target is met for just over 4% of women; that, in the Southern Trust, the figure is 10%; and that, in the Northern Trust, it is just over 6%. It is not just that we are not meeting the target; we are not meeting it by a long, long way. I would accept your argument, but there is something wrong systemically if we cannot meet those targets and do not meet them by a country mile. It is not just that we are not meeting them; we are not meeting them by a country mile.

I have two or three other questions. Unless we tackle the issue of late discharge and beds, we will be back into a winter — I was going to say "a winter of discontent", but you know what I mean. We will just be back to where we have always been in winter. I have read the Minister's proposals to ease winter pressures. They are pretty much what he throws out every year: "We will hive off sore throats to pharmacies" and whatever else. There is nothing hugely inspiring in it. Unless we can ensure that social care offers some kind of release valve to get people out of hospital more quickly, we will be in the same position.

You are telling me — I had not picked it up from the Minister's statement — that the £5 million is not new funding. Am I right?

Mr Guckian: It is new funding for 2024-25.

Mrs Dodds: It is new for 2024-25, but it is from the start of the year, so it is not new, additional funding for winter pressures.

Mr Harkin: Not specifically, as far as I know. We planned for the growth at the start of the year. We put that bid into the Department at the start of the year, and it gave us each an allocation.

Mrs Dodds: Of £5 million?

Mr Harkin: That was part of it, yes. To deal with the overall growth of unscheduled discharges, it was for domiciliary care need, care home need etc. That was allocated at the start of the year, and then it was up to us to plan that for the rest of the year.

Mrs Dodds: I could have read it wrongly. It is not new money; it is money that has already been allocated. It is a plan for growth but not specifically for winter pressures. OK.

Ms Edwards: You are absolutely right though: we need improvements in social care. Each of the trusts has initiatives in place. Do they go far enough? We do not often have the tools to make them go as far as they could. There is a capacity issue. There has been huge growth. In those increased numbers, with the older population, there is more comorbidity and chronic illness. As Neil described, there are not the right packages available, or there are not enough packages per se.

We in the Belfast Trust are very focused on social care. One of our initiatives — others have similar — is to revisit care packages soon after somebody has been discharged to be able to release those hours back. Initiatives like that will make the number available go further, but there will be a capacity issue quite apart from any funding issue. The focus is very much on social care. We will have to continue the focus, obviously, on our front door, but the key to real change is in the community, where we have had huge growth.

Ms Coulter: It is helpful to put out some of the key messages. The shift needs to be in three areas: from hospital to the community; from acute treatment to prevention and early intervention; and from analogue to digital, and taking the benefits of that move. An example is the increase in demand for domiciliary care packages. In the South Eastern Trust alone, in the past couple of weeks, we had a request for 108 new packages in one week. There was a request for 1,800 new packages of care in quarter 2 of this year. I just wanted to share the scale of that.

There are challenges, as we know, in the domiciliary care capacity that is available in Northern Ireland. However, we think that it is positive to support people to stay in their own home. They will not, then, end up having to move into the care sector. We really want to support having a more resilient domiciliary care model. We have been doing a lot of work on the reform and improvement of domiciliary care. For example, the South Eastern Trust has been able to reduce the number of unmet packages from nearly 900 to 230, so it is not causing the same blockage or delay in discharges from hospital. There is a careful balance between domiciliary care and supporting the care-home sector.

The point that Maureen makes is extremely important. We all share the learning from the work on early review that we have led in the South Eastern Trust. We have put a little bit more investment into that, because we have seen real outcomes. We have been able to dramatically reduce, by a very high percentage, the amount of care package that someone needs, maybe some three or four weeks post discharge. That whole review to assess the wrapping around of families in their own homes post discharge is definitely a benefit.

Many other increases affect the funding. For example, the cost of the community equipment that is needed to support people living in their own home has risen from £90,000 to over £200,000 in my trust alone. However, for winter planning, the key thing is discharge from hospitals, and making sure that we do not have as many people staying for as long as they do. Just yesterday evening, 36% of beds in Northern Ireland were occupied by people who were medically fit for discharge.

Ms Edwards: At the same time, it is about keeping people out of hospital and in the community: expansion of our hospital-at-home models etc.

Mrs Dodds: It is still, though, a remarkably high number if you think of the number of beds. I do not know how many there are, but you are telling me that 36% of the beds that are available across all hospital sites are blocked, and then we expect the system to run efficiently. It cannot run efficiently if that is what is happening.

I want to ask just two more questions, and then I will be finished.

The Chairperson (Ms Kimmins): Short answers. [Laughter.]

Mrs Dodds: I have here an answer, which I thought was interesting, to this question: how efficiently, from when patients go in in the morning until patients are finished at night, is theatre time used? The figures remained relatively the same from 2021 to 2024, but one stat stuck out to me. We have heard a lot of talk about children and people with special needs not being able to access dental care. In the School of Dentistry, the efficiency of run time was 54% in 2021-22, 49% in 2022-23 and 59% in 2023-24. It might be too specific a question to answer here, Maureen, but, if someone could write to me to explain why that is the case, it would be interesting to know.

I want to bring up another thing, Maureen. You issued a statement yesterday that the anti-Semitic graffiti on hospital walls would be sorted out. My understanding is that it has been there for almost six months. In the interests of having a health service that is available and open and to which everyone is welcome, it is appalling that we have waited for six months to get rid of anti-Semitic graffiti.

Ms Edwards: I completely agree with you. As one of the first trusts of sanctuary, we take it very seriously. We had extreme difficulty getting anyone to take the graffiti down. It will be in the evenings and at night when the graffiti —. We went out to lots of contractors who would not do it. It is being dealt with now. We went to local community groups, which, I have to say, supported us in taking it down, but we had real difficulty in getting anyone to do it.

Mrs Dodds: Thank you.

Mrs Dillon: Thanks for your answers so far. I am glad to hear about the regional breast service, because that is an issue that I raised the last time I was here. People were being referred on, and it was like starting from scratch again, so that is a good and positive thing.

My first question is probably for you, Colm. We hear every day about the big-ticket items, but I am wee a bit concerned that, when we talk about children and families in extreme distress and children who end up in care, we talk about the numbers increasing year-on-year instead of about what we are doing to halt that and reverse it. We know that it is early interventions that we need. I have dealt with you in the Southern Trust, so I know that you know the issue better than most and that you are passionate about it. I want to ensure that we stop those numbers going up. I want to put those numbers into reverse and keep families together. What are we doing to ensure that the numbers do not continue to go in that direction and that we put them into reverse?

Mr McCafferty: It is particularly challenging. For approximately 15 years, we have been in a cycle of the number of looked-after children increasing year-on-year. Some contributory factors relating to new arrivals into the system who are unaccompanied minors explain an element of that, but the majority of the growth in our looked-after population, unfortunately, comes from our indigenous population. I have no doubt that that is linked to significant poverty and significant deprivation across the system. There are real challenges associated with domestic abuse and with isolation and vulnerability across the piece. Our situation means that we are, by and large, reacting and responding to those problems. Professor Ray Jones eloquently identified a lot of that in his review of children's social care services, including the fact that the increasing number of looked-after children is a probably one of the most significant challenges that children's social care has at the moment. It is a huge problem because it means that, when we bring children into the care system, which we do for legitimate and real reasons, we struggle to identify sound, stable placements that will meet those children's needs and address their many emotional, traumatic experiences.

In brief, there is an absolute need for a cross-departmental, long-term preventative strategy. Again, the Ray Jones report identified what we need to do and what we have known in Northern Ireland for many years. We have good community and voluntary sector infrastructure, particularly through the likes of family support hubs under the auspices of the Children and Young People's Strategic Partnership (CYPSP), but they have been starved of investment and simply do not have the capacity to get in and offer early intervention and prevention services not at the point of crisis but much sooner. There has to be a cross-departmental approach to a much more coherent strategic prevention strategy.

Mrs Dillon: From conversations that I have had with a number of organisations over the past couple of weeks, there are probably some things that could be done that do not involve a great deal of cost, if any. They would involve working directly with organisations such as Women's Aid. Many women are afraid to reach out for help when they should because they think that social services will take their children. There is a communication problem. We need to ensure that families understand that social services are here to help them, but we also need to ensure that, when social workers go in, they do not do so with the judgemental approach of, "If you loved your children, you would not stay in this home". There are so many barriers to a woman leaving a home that you just would not know where to start.

Those are simple things that we could look at. I am not even looking for answers — I know that you are aware of that stuff — but those things could definitely be done. This is a focus for the Committee, and we want to support not only the families but social services in helping the families. Going forward, I am really concerned, because that issue leads into all the others: the poor health outcomes and the addiction and mental health issues. That is where it starts: with our children.

Michael, on ambulance response times and how they are assessed when the calls come in, I will ask about a specific issue. I apologise for that, but it raised a concern for me. I know that, when someone has a fall, that will often not be categorised as high-priority, because it is not life-threatening in the immediate term. I am aware, however, that, in an incident yesterday, somebody fell on the ice, broke their hip and lay on the street for three and a half hours. A broken hip may not be life-threatening, but lying in the cold — I do not think that the person was very young but do not want to say that they were older or middle-aged, as I do not know how they see it — is a real concern. Your health could deteriorate through lying at the side of the road, unable to move and with the only people there being those who stopped their cars to help you. Is that the normal process?

Mr Bloomfield: Cases like that are appalling, Linda. I write to people like that or their families every week, unfortunately. Our calls are categorised consistent with an international standard. Category 1 is immediately life-threatening. We aim to respond within eight minutes. Our current mean response time for the year to date is 11 minutes and 39 seconds. By prioritising those calls, we manage not to be too far off that, albeit, given that the target is eight minutes, we are nearly 50% behind. The next most serious cases fall into category 2, for which our target response time is 18 minutes. The targets are set for clinical reasons, which is why they are so precise. Category 2 is for things like heart attacks, queried heart attacks and strokes. In the year to date, our mean response time for category 2 calls is 49 minutes against what should be 18 minutes as standard.

Without knowing the individual circumstances of any call, the majority of falls, including elderly people who have fallen and who have a hip that, although we cannot know for sure on the basis of a phone call, is likely to be fractured fall into category 3 calls, which have a standard response time of 120 minutes: two hours. Our average response time for category 3 calls is around five hours. We still have to respond to calls in line with clinical urgency, but our control room operators do their best. We now have clinicians, paramedics and senior paramedics in the control room. They make welfare calls and are mindful of things such as whether the incident has taken place outside and whether it is raining or freezing. We will do our best to prioritise on that basis. They can upgrade calls to take account of circumstances. They can upgrade a category 3 call to a category 2 call or a category 1 call, but that will come down to availability of resources. We have to send the next available ambulance to the most clinically urgent call. Regrettably, that means that many wait far too long, such as in the case that you highlighted.

There are two things. That is one of the reasons why we need to make sure that available ambulances respond to calls rather than waiting at emergency departments. We all recognise that it is unacceptable that somebody could be in such a state and that, two of three miles away, five or six ambulances could be queuing outside an emergency department and unable to do anything about it. We also need to make sure that we have sufficient resources to meet demand. Like every other area of Health and Social Care, however, we do not have sufficient resources to meet demand, albeit the very welcome investment from the Department has allowed us to recruit 48 newly qualified paramedics. They started in October and will be out on the road operationally before Christmas. We expect to recruit another 48 next year, once they complete their degree at Ulster University's Magee campus.

Mrs Dillon: Thank you. The situation is concerning.

Mr Bloomfield: It is.

Mrs Dillon: I accept that, but at least those things are being taken into account.

I have one final question. I do not want an answer, because I am conscious that other people have questions; I want to know that you will come back to me on it. Neil talked about the significant percentage increase in red-flag referrals. Can we get some understanding of the outcome of that increase at the other end? Is that preventative? Does the fact that those red flags are preventative in nature mean that there is less need for medical intervention? If so, that would be good, because it saves something somewhere: it may increase demand on one end but decrease it on the other, and that is good. If that is not the case, that is worrying. Can we get a sense of that?

Ms Coulter: I am happy to do that, Linda. I will pull that together and send it to you.

Mrs Dillon: I would like to get that in writing. I am conscious that that demands a detailed answer and that it would not be appropriate to ask for it now.

Mr Donnelly: Thank you for your briefing and for your informative answers so far. I could ask you questions all day. People come to us with a million questions about concerns and issues.

I will start with children's respite services. I have been contacted by families in my area, which is covered by the Northern Trust, and from different areas in Northern Ireland. There are two areas that I will talk about in the Northern Trust. The first is Whitehaven in Whitehead, which is a children's respite service that had been used by a lot of families in the area. I understand that it has been closed since September and is therefore unavailable to those families. I understand that there is an issue with there being children on long-term placements there, which might be the issue, but I also understand that there are six beds in Whitehaven, and I would like to get an idea of the trust's plan for children's respite services. I would like to relate that to Rainbow Lodge in Ballymena as well, which, I understand, has been taken over by the trust. Is there capacity to start offering respite services there? I think that that has been unavailable to families in the area as well. That causes a lot of stress for families.

We saw the 'I Am Not Okay' documentary recently, so we know about the pressures that those families are under. Will you, first, give me the trust's plan for how that will be resolved in the Northern Trust? I then have a similar question for the South Eastern Trust.

Mr Harkin: I am happy to do that. I will cover the two facilities that you mentioned. You are absolutely right about Whitehaven: it has not been able to deliver respite services for a couple of months. That is mainly down to a shortage of staff. It was also impacted on earlier in the year by the example that you gave of needing to admit children on a permanent placement for a period, which was due to the demand for permanent placements across our facilities at the moment. The aim is to reopen short-break provision — at a reduced capacity, but open — within the next few weeks.

We took over the facility at Rainbow Lodge, which is now called "Edenview", in April. We have staffing shortages there, but we are working very hard to try to recruit and put in place staff. Staffing continues to be a challenge, but there is ongoing recruitment. The short-break service will open there as soon as we can get the safe staffing in place. That is very much still a focus for us.

Mr Donnelly: Is there a rough timeline for that?

Mr Harkin: I do not have a timeline to hand, Danny, but I can certainly come back to you on that, if that is helpful.

Mr Donnelly: Do you think that Whitehaven will be open again in a couple of weeks?

Mr Harkin: It will be open very shortly. My understanding is that it is imminent.

Mr Donnelly: But at reduced capacity?

Mr Harkin: Yes.

Mr Donnelly: How many?

Mr Harkin: I think that it is around 50% capacity, which is three beds, but I can come back to you after double-checking that.

Mr Donnelly: No problem.

Similarly, I have been contacted by families in the South Eastern Trust. Are you able to speak to Greenhill at all, Roisin?

Ms Coulter: Certainly, Danny. All of this is in the context of there being a tremendous increase in the number of children who have been brought into the care system in Northern Ireland. It is about not only children with disabilities needing respite but the whole picture. In my trust, for example, before the COVID pandemic, we had an average of 450 young people being looked after in care. In September 2024, that number was 741. It has almost doubled, but it has not been possible to obtain recurrent investment in order to recruit people permanently to support young people and families. However, it is extremely important — I totally agree — that so much of our focus be on children. That was referenced in the draft Programme for Government. The number of children requiring residential long-term stay has doubled, which means that our ability to provide respite breaks has, naturally, halved. We have only the same facilities with the same number of beds. We have had to repurpose a number of the short-breaks facilities as residential care facilities to make sure that those children have a home and a place of safety.

Greenhill in Newcastle has been undergoing some changes due to workforce challenges. We have been looking at a number of alternative sites or options, because we lease Greenhill. We are also looking at the potential of repurposing one of our children's homes as a respite unit. That is something within our control that we can do to try to provide that service. We recognise the pressures, and we are very concerned. I meet families constantly, and I recognise that they need support. We, and all trusts, have put forward proposals for the next quarter for what we can do in the short term with the investment that the Minister released to try to get something right across Northern Ireland as quickly as possible. Colm can talk about what we are doing on that.

We absolutely recognise that it is about not just overnight breaks but outreach services and more innovative ways of supporting families, whether that be after school, evenings or weekends. We know that it cannot be just from nine to five; the families need flexible, wrap-around support. Over the next few months, we hope to have a new proposal on the table for an alternative.

It is important to recognise that, for some young people and children with complex disabilities, the complexity is increasing, so much so that, in my organisation, I had to close one children's home completely to enable us to care for one child and make sure that he was safe. That means that the home is not available to provide residential care for any other family or to provide respite. However, we had to prioritise and make sure that that child was safe. Those things can happen.

It would be particularly useful, Colm, to reference what we are doing across Northern Ireland with the funding released by the Minister.

Mr Donnelly: May I just come in there? Is the funding that you are talking about the £2 million for the rest of this year and £13 million a year for the subsequent years?

Ms Coulter: Absolutely, yes, Danny.

Mr Harkin: Sorry, Colm. Before you begin, I will add that, as Roisin said, there are other supports that we try to deliver, such as, in the Northern Trust, the Sharing the Care short break service. We also promote the direct payments route for people to secure short breaks through their own arrangements, as well as after-school work with the likes of the Cedar Foundation. So, there are other processes, but the demand for that residential care is significant, and sometimes it gets redeployed.

Mr Donnelly: I appreciate that. I know that there are children with complex medical needs and challenging behaviours who will not be able to access anything else. Short-break provision will be the only thing that they get.

Mr McCafferty: We touched on some of this earlier. First and foremost, I want to acknowledge to the Committee that, regionally, the provision of short breaks for not only children but adults is nowhere near where we want it to be. I also want to apologise to families who are not receiving the type of support that they absolutely require in very difficult circumstances. We have mentioned some of the challenges. Certainly, they were exacerbated by the pandemic, but there is no question that they predated it. The stats showing the increase in children in care ware pointed out earlier. Unfortunately, children with disability are not immune from that, so the increase was always going to be reflected in that cohort of the population as well.

There are significant issues. There is a real focus on the residential facilities that were repurposed, and I totally understand that, but we need to be much more imaginative. We will not crack this problem by relying solely on residential short breaks. They will certainly meet needs in some of the most complex cases, but we need to position them in such a way that they are designed to meet the needs of children who cannot have overnight short breaks provided through other means. So, the focus is on stabilising residential care, but we can do that only if we sort out the provision for children with very complex intellectual and learning disabilities requiring full-time care. An element of that needs to progress.

We need to have a much more expansive approach to short breaks per se. Certainly, the experience of the Southern Trust is that significant capacity can be generated through short-breaks fostering. We are quite fortunate in the Southern Trust in the sense that approximately half of our short breaks — in fact, more than half of our overnight short-break provision — is provided through foster care, which enables us to target our residential short-break provision much better.

It is important to be optimistic about this. We really welcome the ministerial announcement on funding, in-year and multi-year, which will absolutely enable us to progress some of those developments. We will look to stabilise residential short breaks. In my trust, we will seek to upscale elements of that where we can, but there has then to be a focus on alternative short breaks, namely foster care. There is significant untapped potential there. However, it ain't easy. There is no quick fix. You do not simply advertise and get a queue of carers coming along. That needs be built up over years. For example, in the Southern Trust, we have been on that journey for probably 10 years now and have approximately 15 short-break carers. However, the capacity that that provides us with is significant, so we need to grow that regionally.

I want to ensure that the new investment will also be focused on early intervention, prevention, therapeutic services, day opportunities and so forth for children with disabilities and their families.

Mr Donnelly: Some £13 million a year is planned. What will that go towards in your trust?

Mr McCafferty: I am certainly not getting £13 million a year for my trust. That is regionally.

Mr Donnelly: It is regionally.

Mr McCafferty: What we do in the Southern Trust will be reflected across the five trusts, albeit they are in slightly different circumstances. We will seek to upscale capacity in the two existing residential short breaks facilities. One operates five days a week, and we will move that to seven days a week. Likewise, another one operates six days a week, and we will open it seven days a week. That will increase capacity there. We have a number of very good voluntary and community providers, and we will seek to augment the existing service level agreements to enable them to increase capacity. That will be primarily around day opportunities, with some providers providing overnight stays and weekends away for children, families and so forth. We will look at introducing more of a skills mix to our social work teams to ensure that we have a more responsive and quicker turnaround of referrals coming into the system. Similarly, to mainstream children's services, we have to be more responsive from an early intervention point of view. A recurrent challenge that we have to take the opportunity to reference is around the workforce. I go back to Linda's point about what we need to do: it is critical that we stabilise social work services, and, to date, that remains elusive.

Mr Donnelly: I have one further question, Chair, if that is OK.

The Chairperson (Ms Kimmins): Yes.

Mr Donnelly: Over the past couple of weeks, we we have heard a lot about the potential for industrial action across the board. Hopefully, negotiations are ongoing and that will not happen. Neil alluded to it earlier, but what would be the impact on your services if we had industrial action over the winter?

Ms Coulter: We have already seen the impact. A number of times over the past years, we have had industrial action from a wide range of professionals during peak periods, whether in winter or when we were going live with Encompass — some action was targeted then. It is really important to note, as we reflected this week, that, even today, a number of professions are taking action short of strike. That is having an impact, particularly, for my organisation, on social care and social work. Michael might want to mention the impact on the Northern Ireland Ambulance Service.

We want to support our staff in trying to remove that action short of strike, never mind moving to industrial action. It is absolutely imperative that we avoid staff having to take industrial action. I believe that for right across the public sector, not just in health. In our sector, the impact, as you know, particularly in winter, is about availability to respond to emergency pressures: pressures across emergency departments, including increased overcrowding; the inability to put up more beds in acute hospitals; and pressures on our community response services in supporting families at home. Honestly, the impact is right across and end to end. Aside from that, the other piece is about morale. The largest employer in Northern Ireland is the public sector. It employs people who have given their career to training and becoming a professional, working as part of a team and supporting one another. You cannot overestimate the impact of being involved in industrial action. Staff do not want to go on strike in the health service; absolutely not. They want to come to work every day and provide the highest possible care, as we all do, for our patients, clients and families. It is imperative that we all work together and ask the wider Executive to look at how we can avoid industrial action and ensure that staff receive pay parity. Low morale is already affecting staff. They have been working so hard. Many of you have experienced and seen that when visiting teams and departments. That is the impact. Michael might want to mention something in particular.

Mr Bloomfield: Yes, just briefly, because I support everything that Roisin has said. As employers, we absolutely support our staff's right to take industrial action. We absolutely support them in getting the full pay award. After all the work to get pay parity established, it is unthinkable that it would not continue. Therefore, we are hopeful that the current discussions will lead to a successful outcome. We know that our staff do not want to be involved in industrial action. They do not want to be on strike. They know that the community needs their service and want to provide it, but they are in a difficult position. The point about action short of strike is important, and I am not sure that there is necessarily much awareness of or focus on it.

Action short of strike has a range of impacts on my organisation, such as staff starting only from their base station as opposed to going to somewhere else to start to be crewed up with somebody else, if they need to be. A particular impact is that, in the last hour of their shift, they will respond only to confirmed category 1 calls. That goes back to the question that Linda asked about somebody who waited longer. During that last hour of shift, a category 3 call will not have an ambulance sent to them; somebody coming on to the start of the next shift will go in that case.

Those are some of the impacts of action short of strike. As Roisin said, if there were to be full strike action, as we have seen before, we work cooperatively with trade unions to agree derogations, but, undoubtedly, there is a huge impact on service users, which must be prevented.

Mrs Dillon: Chair, I have a suggestion that comes from Danny's questions about the £13 million. Could we get from the trusts details of what they plan to do with their share of it? We can then look back from a point in the future to see what the impact has been of the additional services that trusts were able to offer.

Ms Coulter: Absolutely. Colm, I will ask you to coordinate that with your colleagues.

Mr McCafferty: Yes. Extensive detail on that has been submitted to SPPG, which is in the process of checking costings and so on.

Mrs Dillon: That is already there.

Mr McCafferty: It is with SPPG.

Mrs Dillon: That is great. Thank you.

The Chairperson (Ms Kimmins): Four members have indicated that they have questions, and we are running very tight on time.

Miss McAllister: Thank you for your answers so far. My questions follow on from what has been asked. On pay parity, it is important that we appreciate our staff in the public sector across the board. Without staff, we do not have a health service. Should staff therefore be the priority? In a lot of this, the decisions are taken above the level of the trusts, but my sense is that staff are the priority. Without them, if they are out on industrial action, it does not matter whether we still have a shortfall of £100 million, because we cannot do anything with that additional money if we do not have the staff. Should staff be the priority, notwithstanding the decisions that need to be made? It is not you who should make those decisions. The options should be weighed up and passed along, because the decisions are essentially political. As directors and chief execs of the trusts, you are the ones who must weigh up and provide the options to make savings — cuts, in other words, because that is what we are looking at now. Do you share the view that staff should be the priority? Without them, whether you get additional funds for services is immaterial.

Mr Guckian: Absolutely. I totally agree. Staff are the priority. It is my understanding — you would have to ask the Department about the regional financial strategy for 2024-25 — that the gap that required the monitoring rounds related to services that were committed and already on the ground. The Department has a choice. Do we dismantle services or do we — I certainly applaud the Minister's innovative approach to the pay award that has got us to where we are now, but it is really important that we get the last bit of the pay award across the line.

Miss McAllister: Can you give examples of the "catastrophic" service impact of savings measures, as the briefing described them? Have those options ever been provided in case decisions need to be taken?

Ms Edwards: It is important to note that, as far as we could, we have made cash savings without impacting in any material way on patients and the services that we provide. The money that the Department made available above the £180 million-odd of savings that trusts committed to this year was to reduce deficits to avoid any further savings that we had already categorised as high-impact and, in most cases, catastrophic. It is about understanding what will generate cash. We can make efficiencies that contain or curb the growth in spend, for example, but they will not yield any money or reduce the annual cost base. To release cash, it is about the quick things: pay; money to suppliers; and agency spend on temporary staff, for example.

We will not end pay contracts, so it will not involve our permanent staff. That means reducing temporary staff costs — agency and bank — but those staff are associated with activity, which means that there is an impact on spend. If you reduce your agency spend in an area, something has to give. So, to reduce temporary staff costs — it would be a logistical and service nightmare — we would have to look at elective services, because you cannot have a downturn in unscheduled services. We would pick an elective service — I will pick orthopaedics as an example — and say, "We won't be able to do any elective activity in orthopaedics for three months", so that we can take the savings from the temporary staff. Of course, not all the temporary staff are in orthopaedics, so we would have to move staff around the organisation in order to be able to provide unscheduled services. That would immediately impact on elective services at a time when the waiting lists are the worst in the UK and, probably, western Europe. That is unfathomable.

Other ways of generating cash include looking at payments to suppliers, such as domiciliary care providers. You would look at having fewer care packages. For every two packages that became free, you would fill only one. We are releasing cash, but, again, what happens to patients and clients? People in the community who required care would not be able to get it and, more often than not, would end up in hospital. They would have to be maintained in hospital, making beds unavailable for elective care. Ultimately, you are back to cutting services.

There are many more ways to generate cash, but they are so catastrophic that I do not want even to discuss them. Even the idea of them is not really for discussion.

Miss McAllister: Does that happen currently?

Ms Edwards: No, the trusts were provided with deficit funding to prevent their having to make savings of above £182 million, which, for most trusts, is about 3% to 4%, after years of efficiency savings. That is a big ask. If we went beyond that, we would be into measures that are catastrophic.

Miss McAllister: We are getting representations from various organisations in which there has been a reduction and what they call an impact on service users. I do not want to name particular organisations, but I can name the service.

Within the £70 million that was announced in March to meet pay costs was a contribution to domiciliary care, and there is an additional £5 million — whether or not that is new does not really matter. We are hearing that different trusts are doing different things. In one, possibly the Southern Trust, the assisted discharge service was being removed from the Red Cross. I am not sure whether that has since been rectified. The service involved elements to help people who are medically fit to leave hospital to do so in a more timely manner.

There are examples in other trusts. A couple of weeks ago, when I was at the Ulster Hospital for Occupational Therapy Week, I learned about what it was doing re discharging people. It was going out to see patients in their home, for example, which seems like a good model and seems to be operating well.

There are contrasting issues across the trusts, and we are being told that they are affecting patient outcomes and service delivery. Regardless of whether that was done in a mindful way, that is happening. There seems to be a lack of a joined-up approach to how, from the prevention end to the treatment end, we address the issues. It is the understanding of all of us that, if you invest in preventative measures, you will have fewer surgeries, fewer patients and fewer delayed discharges. What are we to do about getting a joined-up, collaborative approach to ensure that more services are not cut in one area? That is what we hear is happening. Just because services are not statutory does not mean that they are not focused on patient outcomes. Some services seem to be being removed from one trust area but not from others. What collaborative cross-trust work has been done?

Ms Coulter: First, trusts very much take quite a collaborative approach to their savings plans, and we know the areas that we will look at first. Obviously, patient safety is the absolute priority, so we want to look at making cuts or reductions in spend in the areas where doing so will have the least impact on patient safety and will not increase harm and risk. We also look at where services are commissioned or funded and where they are not. That is a key point. One service may be funded in one area but not funded in another. That is important as well. When it comes to accountability for the use of public money, we need to make sure that that is tied back to assessed need and prioritisation.

The third piece is that the service directors from across Health and Social Care meet and work together every week. There is a regional approach to elective care, mental health services and older people in primary care, including complex discharges and the services that you mentioned, Nuala. For example, I know that from our teams and the early review of discharge to assess, with our OTs going out to the homes. Other trusts have come to work with us to look at the outcomes that that has and at how we can do it.

A lot of it genuinely comes back to the workforce and financial resource that is available to continue to innovate and to have new ways of working whenever demand simply outstrips capacity. That does not mean that we do not continue to look for different and better ways of doing things: that goes to your point about shared learning across all areas. There is much greater collaboration now than there was five years ago.

Mr Guckian: I assure you, Nuala, that, in the Western Trust, there has been no reduction in the domiciliary care hours that are purchased from the independent sector.

Ms Coulter: None with us either.

Ms Edwards: Nor us.

That context is important. You talked about our needing to invest in preventative measures. We absolutely do need to do that, but we also need there to be investment. We are in a system that is acknowledged, worldwide, as a progressive health and social care system. We should be investing about 6% every year, and that is just to pay a reasonable pay award and meet increases in the cost of living. It takes an investment of at least 2% every year to stand still. There is increasing demographic demand. As outlined in the Committee's paper, we have high costs for drugs: we reckon, an additional £50 million for just this year. Most of those people will stay on drugs, and then there are new users.

We also need money for growth and development: technological and clinical advances and preventative medicine in order to move towards having the right, world-class health services. We have not been getting that. We are working on a flat-cash basis. In our paper, we show that the differential between England and us, which used to be a reasonable differential gap that reflected deprivation and socio-economic factors here, has shrunk. England is not getting the year-on-year investment that it needs, as was shown in Lord Darzi's report.

We would like to be able to invest. We would like to have a whole-system approach to preventative medicine and to better housing and employment. It is just not affordable. At the minute, we are struggling just to maintain services — and we have not been doing that. Some of the savings do not currently impact on services but will have long-term effects. For example, we would reduce discretionary spend and maybe not invest as much in our maintenance backlog in estates as we had planned to this year, and that will have long-term effects. We cannot keep struggling, year on year, with those non-recurrent income streams and non-repeatable savings; that will have a long-term impact.

Miss McAllister: I agree with investing to save and investing for transformation, but we must also recognise that we have been spending more per head in Northern Ireland than has been spent in any other region. We need to be realistic about the fact that that cannot go on, producing poorer outcomes. We simply cannot do that. That is why a lot of it is about preventative measures.

I will move to a new issue, which, I think, I brought up when you were last here, although I am not sure whether Maureen was here: Muckamore and the resettlement. That ties into what you said about going out to recruit for Rainbow Lodge. I understand that Praxis was not able to get staff. This is about Muckamore resettlement, trying to find the right place in the community and getting staff to support that community support service. Are those staff's terms and conditions benchmarked? Are they decent terms and conditions that would attract staff? Is there a skills problem? Is there a problem with recruiting the right people? How are we tackling that side of it? Then there is also the overall resettlement of patients at Muckamore. You will have heard that the families of patients at Muckamore have spoken publicly in the last few weeks about their unhappiness with the current inquiry, but, at the top and forefront of many of their minds, they are worrying about the resettlement and how that process is flowing.

Ms Edwards: The issues are multifaceted. Staffing is an issue. Facilities themselves are an issue: getting suitable accommodation and someone to provide it. We do not have the accommodation, so we are looking to others. If providers have identified a facility, they have to staff it. The patients are individuals with very complex needs. We pay higher rates for individuals with complex needs, but it requires very skilled people and a lot of them. Quite often, they are not there.

Miss McAllister: So what is going on there to tackle that issue? What work have you done? Have you had engagement with other Departments, such as Economy, to see what assistance they can give?

Ms Edwards: We have ongoing conversations with the Department for Communities but also with independent providers. Most of them now are with independent providers. Trusts have residents still in Muckamore. The Northern Trust now has plans for the resettlement of all their residents of Muckamore.

Miss McAllister: In the Northern Trust?

Ms Edwards: In the Northern Trust. The Belfast Trust has 16 individuals in Muckamore. We have an ongoing issue with one of the facilities that we had identified. Things were progressing, but then they slowed down. There have been issues with staffing and facilities. Resettlement plans are progressing for all of the residents from the Belfast Trust.

Ms Coulter: We have three patients in Muckamore, and we have placements organised for two of them, with imminent completion. We have then one more patient, who is very complex, to support.

Ms Edwards: The position is similar to that of the children and the adults with physical learning and mental health disabilities. There is a dearth of staffing and facilities, right across Northern Ireland. We need to plan it and to invest in it. We need to be able to commit to people to build, because it takes a long time for them to plan and build facilities and get staff. It all requires a number of years.

Mr Harkin: As Maureen said, we have plans to have all our patients in Muckamore resettled within the next year, I believe, or the next few months. Obviously, there might be challenges between now and then. Events may overtake us in some of those cases. However, we have, certainly, real plans in place for that. We are very optimistic about all that.

I wish to comment on the previous question about population, health and investment and preventative measures. I absolutely agree with that. There are things that we need to work towards. With the SPPG, the Department and the trusts, we are working towards a recovery planning process and financial stability planning. That is a longer-term process. We plan to get through this year. We need to convert that into a transparent, open plan, where we take on board all of those things and choices, such as investment in preventative measures. It will pay back but in a number of years' time. Are we all willing to make that choice? It is fine as long as everybody is clear and categoric about it.

There are processes by which we can drive forward improvements. We can make sure that we are clear about meeting the needs of our ageing population and looking at the workforce, obviously, to meet that. Nearly every question today has been about how we get the skill sets to meet the increasing demands and the increasing complexity of our patients. If we agree on a plan that we all share, that will be really helpful.

Miss McAllister: We hear from representative bodies that the plans should include, "This is what we need"; not, "This is what we have vacancies for", but, "This is what we need for long-term planning". If we think about that —.

Mr Harkin: Absolutely.

Ms Edwards: Some of that will be about more staff for particular areas, for example, in social work, but it is also a combination of more of what we have now but a different workforce. We are looking at the skills mix and different ways of engaging with the voluntary sector, for example, in the children's services there. It is all of those things, but we need a very robust needs assessment. We can see the trends in need, so we can have a good idea of that. Then we can decide what workforce strategy needs to go alongside that and what investment, alongside efficiencies in productivity that the trusts are working on.

Miss McAllister: With regard to the assessment of future need, has there been any assessment of why there has been such a significant increase in red-flag referrals? It cannot just be due to the pandemic. There must be a reason for our having such a large increase in red-flag referrals. At some point, it would be good to get the number of red-flag referrals that do not result in a cancer diagnosis and, therefore, what measures could be put in place to bridge that. Of course, you do not want to take the risk. You do not have to answer that one now. I am conscious of time.

Perhaps, I could have an answer on this now. During Question Time this week, the Minister said on the Floor that four new consultants were appointed to the SWAH to improve elective procedures, but I am not sure whether they were surgical or medical consultants. I assume that they are surgical consultants because elective procedures were mentioned.

Mr Guckian: I can answer that one, obviously. The consultants who have been appointed to the Western Trust, rather than to the South West Acute Hospital, are general surgeons on a trust-wide rota. For the first time, they have South West Acute Hospital interventions in their job plan, so they are obliged now to work in, as part of their job will be to provide, operations in the South West Acute Hospital, thereby stabilising our ability to achieve our commissioned sessions. For the first time in 10 years, I believe, we now have 11/12 general surgeons in the Western Trust.

Miss McAllister: That makes it quite clear.

Ms Coulter: We will send the information that you requested on red-flag referrals and outcomes.

The Chairperson (Ms Kimmins): Thank you. I have four members indicating. We are well over time here, folks. I have Órlaithí, Alan Robinson, Alan Chambers and Colin. Could we keep answers brief as well? We have another briefing. We actually have to get through a number of things.

Ms Coulter: If it is all right, we will ask just one person to respond.

The Chairperson (Ms Kimmins): That would be great. Thank you. Órlaithí, thank you for your patience.

Ms Flynn: I have a question for the trusts and one for Michael, but I will ask them together, if that speeds things up. First, Michael, how successful has the pilot of the Hear and Treat mental health helpline service, which is being run by the Ambulance Service and the South Eastern Health and Social Care Trust, been in reaching people and de-escalating situations? Might it be extended to all trust areas, perhaps, as part of the regional mental health crisis service?

My second question is directed to the trusts. Are the mental health teams and addiction teams in each of your trust areas starting to work more closely together? Are they having conversations about working more closely together? Are any of them already actively working more closely together? I have raised that repeatedly with regard to dual diagnosis and the co-occurring service in the mental health strategy. I know that it will take time and that it is a change for staff, a change in structure and all the rest. Are you actively working with those teams to try to get them working together?

My next question is about theatre utilisation. It is great to hear that you are really trying to maximise that at present. A regional group now meets regularly with the Department of Health and your co-directors of the trusts. In those regional meetings and in trying to do things better regionally and more efficiently, have conversations been had about or consideration given to Sunday daytime procedures? I know that that goes back to the staffing issue; you are still working with the same number of staff.

Ms Coulter: And funding.

Ms Flynn: It is OK to talk about additional hours or days, but you have not got the staff or surgeons.

Finally, we had a conversation about specialist nurses with the Department. It comes up time and time again; if you had more specialist nurses in gynae, ENT and all the departments, it would take the pressure off and free up consultants and surgeons to do more surgeries and stuff like that. Are there any plans or an action plan in place to recruit or train more specialist nurses to ease some of the burden — I do not mean that patients are a burden — and pressures on staff?

Ms Coulter: OK, there are four questions there.

Ms Flynn: Sorry. Three were wrapped into one for the trusts, and one was for Michael, and I think that I spoke for the shortest time of anybody so far. [Laughter.]

The Chairperson (Ms Kimmins): Probably.

Ms Flynn: I tried to get it out in one breath.

Mr Bloomfield: I hope to be brief. Our clinical strategy as the Ambulance Service is to increasingly move away from just going out, providing care at the scene and taking patients to hospital. It is about asking how much more, by increasing our skills in the control room and with staff out operationally, we can do. That is the aim.

One of the key challenges is how we can deal with mental health patients. Our staff are not particularly trained in dealing with people who are in acute mental health distress. We were keen to get that pilot up and running and are grateful to our colleagues in the South Eastern Trust for facilitating it. In short, it has so far been a huge success.

Having advanced paramedics in our control room means that, when general calls come in of the sort that they can resolve without sending an ambulance, the typical hear-and-treat rate, as we call it, is about 7%, and we are aiming to get to 10%. Of that cohort of mental health patients, with mental health practitioners from the South Eastern Trust, of the calls that they have dealt with, the rate of cases not needing an ambulance dispatched has been 40%, because they have been able to resolve or signpost to the appropriate mental health services. That is a huge success. We had a presentation on that at a recent regional meeting that we were all at, and there was strong interest and support from all trusts as to how, with the evidence from that pilot, we can now look to extending it.

I have to say that there are not the resources to do it. That has been done in partnership between us and the South Eastern Trust, with some short-term funding from the Public Health Agency, which has enabled us to do that. The dual benefits are that it eases demand on the Ambulance Service, so that it can send ambulances to other patients where they can provide more need, and it avoids taking patients to emergency departments. However, the top benefit is providing a much better response for those patients. They do not need an ambulance arriving outside their house with lights and sirens or to be sitting in a busy ED for hours or days. It is a huge success, and we will all have to see what we can do to extend it.

Ms Coulter: Neil is going to answer the question about using theatres.

Mr Guckian: We would be keen to use theatres on Sundays, but it would take substantial extra resources. We would need more doctors, nurses, probably more beds, unless it was day-case work, and there would be other costs as well. I highlight the fact that not all of our theatres are commissioned for 52 weeks of the year. There are other opportunities before you need to go to that stage. I would encourage the commissioning of 52-week theatres rather than the 42 weeks in some cases at the moment. There are 10 weeks of the year that are not commissioned, but we do not know which 10 weeks, as it is an average.

Ms Coulter: On mental health and addiction services, our teams are working much more closely. You will be aware that we are also looking at new models of providing support for people with addictions, more so in the community and then also having residential support if available. A lot of good work is happening in that space.

Finally, the issue of specialist nurses is linked to the work that the Chief Nursing Officer is leading in looking at workforce planning and the different types of roles that nurses can undertake. Nurses are innovative and are keen to take on new ways of working in different roles and specialist roles whether that be advanced nurse practitioner or consultant nursing. We have had some good successes. Generally, this comes down, yet again, to the amount of money that Northern Ireland wishes to put into training people to come and be qualified to work in the health service in Northern Ireland, whether it is social work, nursing, medicine or AHPs, and that is one of those examples. There has been tremendous success. Just recently, we had one advanced nurse practitioner in frailty, but we would all like to have a number of advanced nurse practitioners in frailty to provide better services for what is an absolute priority: providing better services for older people. For me, that is a key priority.

Ms Flynn: Thank you, Roisin.

The Chairperson (Ms Kimmins): Thank you, Órlaithí, and thank you all. Those were probably the most concise answers that we have had. [Laughter.]

Mr Robinson: My question was specifically on children's respite services, but Danny posed some questions on that, and Colm kindly put some meat on the bones by providing some detail on it, so I will broaden it out slightly. In October, when the Minister made the announcement, which Danny referred to, of the £13 million and the £2 million in-year, he also said that he expected to see improvements within several months. That raised a few eyebrows in the Committee, in the House and, more so, amongst families. Do you expect to see improvements within months, and when we will get to see that detail? More importantly, when will those families get to see that detail?

Mr McCafferty: I believe that there will be some early wins, particularly with in-year funding. Those wins will not be dependent on recruiting new staff, because, obviously, there is the question about the availability of staff and recruitment processes. Certainly in the Southern Trust, as soon as we get confirmation — I have been in dialogue with SPPG as recently as yesterday to ask for at least an estimate and a letter of intent for the release of funding — the first thing that I will do is immediately increase capacity in the voluntary and community sector. That is because I know of a number of significant and key players in my trust who can immediately increase their capacity, provided that they get the funding to do it. The early wins in our trust, similar to all the trusts, will be in the voluntary and community sector.

The rest, as I outlined, is a lot more complicated with facilities that have been repurposed. Obviously, in order to revert premises that provide short breaks, arrangements have to be made to move the children who are in those places. That will take time. The places that the other young people are moving on to have to be very child-centred. I have outlined in my own trust that there may be options whereby, as soon as I can get confirmation, I will be able to flex up capacity in the two existing short-breaks facilities that are available to me.

Mr Robinson: Michael, you referred to 48 additional paramedics.

Mr Bloomfield: Forty-eight newly qualified paramedics.

Mr Robinson: Will the same number be recruited next year?

Mr Bloomfield: Yes, there is an intake of 48 people every year to Ulster University to its paramedic degree. The first people from that graduated in the summer and started with us in October. On the basis of current planning, that is the number that will graduate each year. Obviously, I do not know how far that will go into the future. Not all staff come from UU, but anyone from UU who qualified and wanted to work in the Northern Ireland Ambulance Service got a job. Our expectation is that we will be able to do the same next year, on the basis of our current turnover of workforce and our current financial position. Beyond that is less clear.

Mr Robinson: It is good that you are adding personnel to the firefight, if I can call it that. Do you see the same problems that others referred to? I think that Neil referred to this, but are you losing staff across the border or to other regions so that they can be better paid?

Mr Bloomfield: That is not a particularly significant issue, partly because the registration is different North and South. In fact, the registration is an issue for us, because we cross the border every day of the week and vice versa for the National Ambulance Service in the South to respond to calls, but our registration does not apply when we cross the border. When we need to do that for an emergency situation, we believe that it is covered, but when we do it for any planned work, such as when we transfer children to Dublin, we need a resolution, and I have written to the Department about that. Unless our staff get themselves dual-registered, they cannot easily apply for jobs in the National Ambulance Service in the South and vice versa. Therefore, we are not seeing an awful lot of movement.

Mr Chambers: I have two questions, one for Roisin and one for Michael, and I will ask them both in the one go. Roisin, you referenced the difficulty that there is in attracting new staff, particularly clinicians. Colm mentioned the difficulty in gynae, and Neil will be well aware of the difficulties that there were in the past with recruiting general surgeons for the SWAH. Recurrently, there is a political debate about a duty of candour, with two choices. There is the organisational duty of candour, which is in place in the rest of the United Kingdom, but there is a debate in Northern Ireland about having an additional duty, which is an individual duty of candour. Some people call for criminal sanctions to be tagged to that. My question is this: even in the short term, will that make it more difficult to attract professionals to work in Northern Ireland?

I have a question for Michael. You talked about category 2 and said that the response time is 49 minutes but the target is 18 minutes. Obviously, the 49 minutes is an average, so some people will get a quicker response, and, equally, there are others who will have to wait longer than 49 minutes. You put heart attacks and strokes into that category. We have been trying to educate the public about how it is preferable to identify a stroke patient early and how early intervention will lead to better outcomes for that patient. Whilst it is not a life-threatening condition, the longer a stroke patient goes without intervention, I imagine, the more potentially life-changing it becomes, and that becomes a bigger burden for the person, the family and the health service. Is that taken into consideration when categorising stroke as a category 2 condition?

You said that 20% of your capacity is lost daily to the fact that ambulances are stacked up outside accident and emergency departments. Will you detail what other difficulties your service experiences that contribute to missing those targets by such a distance?

Ms Coulter: Thank you, Alan. I will cover the duty of candour. It is important that you raised it. In attracting clinicians to work in Health and Social Care in Northern Ireland, the two biggest factors and limitations are work-life balance and pay. Those are primary, front and centre. The pressure that we ask people to work under, including the environment and the demand, is one of the most significant reasons why people leave Northern Ireland to take posts elsewhere, and, alongside that, there is the pay issue. However, it is clear that all the medical directors across all the trusts have been strongly influencing the matter and believe that it is imperative that, similar to the rest of the UK, we stick to the organisational duty of candour. They feel that it would be a real concern and would have an impact on every individual senior clinician if an individual duty of candour or anything referencing criminal sanctions were brought in. We have been trying to support our medical directors in that position and to support and listen to the voices of our medical workforce in Northern Ireland. That is clearly its position.

Mr Chambers: Thank you.

Mr Bloomfield: Thanks, Alan. I will address your two questions. The figure that I gave for category 2 is an average for the year to date. In September, the mean was 65 minutes. That is up from 46 minutes in September 2023. The model that we have for categorising calls is consistent with that used across the rest of the UK, and it is right that only that small percentage, which is about 6% or 7%, is genuinely immediately life-threatening.

Category 2 is probably our largest category of calls. There is a spread of potentially significant issues there. You are right to highlight stroke. It is key. Eighteen minutes is a very precise time, so why was it not 20? The targets have been set on the basis of a clinical indication of when it is important to get people to hospital. Obviously, one of the issues with stroke is getting people to the right hospital in the right time for them to have the right clot-busting drugs in order to prevent the worst effects of a stroke. Some of the response times that we have for patients with stroke mean that, for some, that is not possible. Also there is sometimes uncertainty about the onset of symptoms, which can make it difficult anyway. However, that is why delays are a problem. It is not about not meeting targets; it is the additional impact on and risk of harm to patients. It is an issue, and stroke is a good example.

You talked about the 20% of capacity that is lost at emergency departments and asked what else impacts on our response times. Obviously, we seek to put out 100% of operational cover for every shift, morning and night, seven days a week.

Even when we manage to do that, as I said, 100% of funded capacity is not sufficient to meet the number of calls. There are always more calls waiting. There is an issue, and, as with everything else, there is a mismatch between demand and capacity. However, the challenge that we have in putting out 100% cover is that, for any number of reasons, people may not be at work. We have some vacancies, although we are in a fairly good workforce position. There is a supply, and our turnover is relatively low, but there is always a certain level of vacancies. People are on sick leave. Our level of sickness absence has improved considerably. Last year, it was 14% cumulative across the whole year. In the year to date, it has been 11%, and we believe that it is improving, so we are reducing our sickness absence. However, if people are not at work due to annual leave, sick leave or for other reasons, we are reliant on overtime.

The delayed ambulance handovers and staff experiencing last finishes at the end of their shift, which we are all specifically working on, reduces staff willingness to work overtime. There are people who are less willing to do overtime now than they might have been, because they know the difficulties of the shift. All those things contribute to delayed response times, but the biggest factor is the amount of time that is lost sitting outside emergency departments.

Mr Chambers: Thank you for that.

The Chairperson (Ms Kimmins): Last but not least, we have Colin.

Mr McGrath: Thank you very much, Chair, and I thank the panel. I am not a cynical person, but it is a bit surprising that a ministerial statement that was given to us was embargoed until just one hour before your presentation. It gives details from the Minister and the Department on all the cuts that you have had to make over the last period of time. There is probably an onus on us to ask questions about the details in that paper, one of which is that reforming services to produce better outcomes remains an overriding priority. From your perspectives, going from the Department and through to SPPGs, trusts and services on the ground, is there a coordinated, wholesale and meaningful engagement on transformation? If so, in which year will we achieve it, with the result that services will be stabilised and back to normal?

Ms Coulter: I will give a general overview on that. As you know, for many years, we have all been involved the in reform, modernisation and transformation of Health and Social Care, going right back as far as 'Transforming Your Care'. At that point, which was almost 10 years ago, a dedicated ring-fenced pot of funding was allocated for transformation. We then made proposals that we felt would have the greatest impact. That was successful to a certain level, and we were able to implement new ways of working and new models. However, it has not been possible to lift those at scale and at pace and to deliver them across Northern Ireland, which is what we want to do.

As chief executives, we have been saying that our absolute priority is stabilisation. We want to use whatever funding is available to stabilise the services that we have and then to scale and spread the ones that we know provide better outcomes for patients across Northern Ireland. Two of those key areas are hospital-at-home services for frail older people and multidisciplinary teams (MDTs) in primary care. Those areas support primary care and prevent people having to access secondary care unless it is absolutely necessary.

You asked whether work is ongoing. The reform is being taken forward at regional level across a number of oversight groups. There are dedicated oversight groups for cancer, mental health, elective, social care etc, and there are a number of collaboratives with associated work streams in which everybody takes part. Around the table, there is DH, SPPGs and trusts. The benefits of some of those will be more medium- to longer-term, but early wins are coming through from different ways of working. Those can be seen clearly where we have been able to move forward; for example, the MDTs are really delivering, and they are preventing unnecessary hospital visits.

I want to draw attention to the fact that we are about to go out to public consultation, which DH will lead, on the hospital network reconfiguration. That is a key building block in the overall master plan or model for our hospital network across Northern Ireland. I know that you say that, sometimes, you might be seen as a cynic, but my organisation has already been able to deliver hospital reconfiguration. The model will be similar, to different extents, across other organisations. Everybody has been on that journey already. Whilst the document sets out the status quo, as in, "This is how the hospital network looks today", it also gives us a framework for how, and an umbrella under which, we might continue to evolve hospitals. If you look at Northern Ireland, you will see that our regional services are provided primarily through the Belfast Trust, but they are also provided in the Western Trust and the South Eastern Trust. There is a clear approach to regional services. Five big area acute hospitals have already been established and are supported by our local hospital network. That is the model through which we feel that we can provide safe, clinically appropriate and sustainable services. It is about recognising that every hospital has a part to play in Northern Ireland but that they might have a different part to play. It is really important that, right across Northern Ireland, there is one consistent narrative and message, including from elected representatives, to the public informing them that they will receive their care in the right place and at the right time with the best clinical input.

Where transformation is concerned, we are already aware of all the challenges, including demand outstripping capacity and the availability of workforce and money. The priority needs to be stabilisation, which will involve addressing waiting lists and mental health and, of course, tackling inequalities. Part of that will involve transformation. The absolute driver for transformation for all of us is trying to deliver the shift from hospital to community care.

Mr Guckian: Health and Social Care in Northern Ireland will never complete its transformation journey. As our population needs change, we will have to continually change. I will not repeat what Roisin said, but she is absolutely right about the transformation journey that we have already been on.

We have also been transforming our workforce. The work that we have done in Northern Ireland on nursing is the envy of every jurisdiction in the UK and the Republic of Ireland. Eighteen months ago, Health and Social Care in Northern Ireland was wholly reliant on off-contract agency nurses, to the extent that it cost £136 million. The forecast for this year is that we will have reduced that by £121 million. We have replaced that reliance with substantive nursing staff and on-contract nursing. That means that we are able to buy more nurses for the same money and take resources out of our nursing costs. We have also been able to stabilise and sustain our nursing workforce in the long term. In the past 12 months, occupancy levels in most acute hospitals in Northern Ireland have increased by approximately 5%. We have been able to absorb the nursing costs of that without an increase in our deficits. In times gone by, we would have increased our deficits through the year and would have to go back to the Executive for more money. The Department and the leadership in all the trusts stood shoulder to shoulder. The Minister announced that we were going to end that practice, and we delivered that really well.

The medical workforce will be a bit trickier and will take a bit longer; we believe that it will take a number of years. However, consolidating our workforce and making it sustainable will really link into our transformation.

Mr McGrath: I appreciate that. I absolutely do not envy the job that you have to do. It is key that, while you are talking about stabilisation, the Executive are talking about transformation. The transformation that is coming from the Executive is resulting in smaller budgets for you, which is forcing your hand and making it more difficult to stabilise. We will not be able to square that circle, but it was key to hear from you that stabilising is your key priority. I do not know whether it is reasonable for politicians to ask you to transform and to do so with less resource while you are stabilising. That will lead to some interesting conversations and debates. Thank you very much for the presentations.

The Chairperson (Ms Kimmins): Thank you, all. We are well over time. I appreciate that this has been a heavy session for all of you, but we really appreciate your time. As you can see, everyone had lots of questions. I hope that the session has been as useful for you as it has been for us. Safe home.