Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): We are joined by Phil Rodgers, director of workforce policy; Peter Barbour, head of the workforce development unit; Stephen Galway, head of the workforce policy development business support unit; Rodney Redmond, head of workforce strategy; and Chris Wilkinson, head of the pay and employment unit. You are all welcome, and I thank you for your attendance today. We have about an hour for the session, which will be reported by Hansard. I invite you to make your opening remarks, and I will then open the meeting to questions.

Mr Phil Rodgers (Department of Health): Thank you, Chair. Good afternoon, everyone. I do not propose to make a detailed opening statement.

The Chairperson (Ms Kimmins): That is fair enough.

Mr Rodgers: We provided a paper, so I will just highlight a few developments and successes from the past six months since we were last with you in May.

We continue to make good progress with delivering the actions in our workforce strategy action plan. We have also begun the process of refreshing that plan and developing a new action plan for the 2025-26 to 2027-28 period. We see continued growth in the Health and Social Care (HSC) workforce. There was 16·4% growth between March 2018 and September 2024, according to the latest figures, which were published a week or two ago. That is across all the key professional groups: in that period, we saw a 24% increase in the medical dental workforce; a 16%, nearly 17%, increase in the nursing and midwifery workforce; and approximately a 22% increase in the professional technical workforce, which includes our allied health professionals (AHPs).

Despite the financial challenges that we face with the DH budget, we managed to grow the number of commissioned places in our undergraduate programmes starting in August/September just past. We have ambitions and an identified need to grow that number further in the coming years. We also managed to grow our general internal medicine medical speciality training programme through the Northern Ireland Medical and Dental Training Agency (NIMDTA).

We are making reasonable progress with agency spending. When we look at the baseline year of 2022-23, which was probably the high point of agency spend, we see a £17 million reduction in spending over the year to 2023-24, which includes a reduction of £90 million in the off-contract spending. For this financial year, 2024-25, we estimate that we will see a £39 million reduction compared with the 2022-23 baseline in nursing and midwifery spend, with another £5 million reduction in healthcare assistant spend and a £13 million reduction in social worker spend. In those three professions, that is the guts of a £60 million projected reduction in spend for this year. Obviously, a lot can happen between now and the end of the financial year.

The other thing to highlight is where we are with pay. We are making reasonable progress with some of the outstanding 2023-24 pay awards relating to the ongoing dispute with the resident doctors and the speciality and associate specialist (SAS) doctors. I met the resident doctors yesterday. I cannot say too much about the detail, because we agreed that we would not say too much publicly, but we are making good progress in that space. On the 2024-25 pay award, you are aware of the financial challenges that we face. We have identified a gap between what we need to maintain pay parity and what we need to implement the full 2024-25 recommendations of the various pay review bodies. We are engaging with the unions and, again, making progress there. If it is OK, we want to keep those discussions pretty tight at the minute. We are working away with them in the background.

The Chairperson (Ms Kimmins): Thank you for that, Phil, and thank you for the papers. There is a lot of detail in them, so it is good to have the opportunity for you to speak to that.

I will not ask you for specific detail on the pay negotiations. I saw that the SAS doctors had recommended the pay award that has been proposed, so, hopefully, that is good progress.

This might be a stupid question: given that we have a figure for the amount required to achieve pay parity for 2024-25 but we are negotiating for 2023-24, if agreement is reached on the proposal that is on the table, will that impact on what is required for 2024-25?

Mr Rodgers: No, it should not. We have the money for the agreement that has been made with the SAS doctors and which they are putting to their membership. Technically, if they accept it, there will be a very small impact, because you are applying whatever the recommendation is for 2024-25 to a higher base figure.

The Chairperson (Ms Kimmins): That is kind of what my question was.

Mr Rodgers: It will be a marginal amount.

The Chairperson (Ms Kimmins): Likewise with the resident doctors?

Mr Rodgers: Yes, likewise with the resident doctors. There will be an implication, but it is marginal in the grand scheme of the gap that we have.

The Chairperson (Ms Kimmins): I ask that only because that shortfall is still there. There is a whole-Executive approach to addressing that — to achieve pay parity. I am thinking that, hopefully, that will not be another —.

Mr Rodgers: It is fair to say that we have included an assumption that the implications of the SAS and resident doctors are included in our estimate of what the gap is currently.

The Chairperson (Ms Kimmins): That brings me to my next question, which is on agency spend. I note in the briefing that there has been a marginal reduction in year from 2022-23 to 2023-24, but one of my biggest concerns relates to the off-framework spend. In 2022-23, it was £196 million, and, for 2023-24, it went down to £106 million. That was a reduction of £90 million. From 2018, we have seen a 2·3% decrease in the nursing and midwifery workforce. I imagine that some of the reasons for that will include disparities in pay and issues around pay and such things. That could be a reason for people leaving the workforce; there are significant pressures.

We have met the Royal College of Nursing (RCN), the Royal College of Midwives (RCM) and others, and those issues come across clearly, particularly around safe staffing. We are now trying to achieve pay parity as well. I can only imagine the impact that it has on morale if someone is working for a particular amount, but someone who has maybe been flown in from England is working beside them, doing the same job and being paid at a higher rate. I will not quote figures, because I do not have the exact figures in front of me, but there is a significant difference in the rates that are being paid for doing the same job. I understand that, in emergency situations, there is probably no choice — if we cannot get staff to deliver a safe service, we have to look at all options available — but I would like to think that a concerted effort is being made in that regard. The previous Minister brought in a policy to try to tackle that. Have we any sense of what that further reduction might look like in the off-framework spend for 2024-25?

Mr Rodgers: I do not think that there will be any off-contract spend for nursing and midwifery in 2024-25. There may be a couple of small areas in which there will be some spend: prisons, because it is particularly difficult to recruit to prisons, and, I think, Muckamore. Is that right, Stephen?

Mr Stephen Galway (Department of Health): Yes.

Mr Rodgers: Before the last suspension of the Assembly and Executive, the previous Minister's challenge to HSC was to completely remove off-contract agency spending, and we have done that. The new contracts are in place. Trusts report to us that organisations that previously provided staff through off-contract are contacting them to see how they can get on to the contracted framework. The answer is, "Sorry, at the minute, you can't; there's no room. We have identified our 20 people". There will be a very, very small amount of off-contract spending in nursing and midwifery. It will be used in just those difficult areas.

The Chairperson (Ms Kimmins): Hopefully, by the time you guys are next in, we will have a better sense of what that looks like for this financial year. It beggars belief that the rates of pay for those off-contract services are agreed as they are. There might be a good reason for it, but it seems to me that, if we want to drive people out of our workforce, we are doing the right thing.

Mr Rodgers: Stephen and I will be at a meeting tomorrow that the trusts are leading on medical locum spend. That is the next big area. We have the new contracts in place for agency nursing and midwifery. We are taking further actions to support and drive down spending in that area. That is all working reasonably well. The next focus is to look at medical locum spend. You talked about the eye-watering amounts of money being paid to individual medics. There are some big numbers there, and it is quite —

The Chairperson (Ms Kimmins): What jumps out at me is that you are talking about £169 million for off-framework — I know that that was in the 2022-23 financial year — and we are sitting here saying that we need £100 million to achieve pay parity to stabilise our workforce and look after our permanent staff, who do it for a far lower rate. That is where our focus needs to be. We must get that right. Even though it is non-recurrent, it is essentially recurrent funding, because it is needed year-on-year, albeit it is reducing gradually.

From speaking to staff who work in various elements of our health and social care system, I know that staff who do bank shifts get the same rate of pay for that as they do for their ordinary shifts. To me, that is a disincentive to come in and do overtime or help out where needed. We need to look at that, if possible. I would rather see in-house staff fill the gaps in a team. People will be more willing to do that, if they are valued properly.

Mr Rodgers: That reflects the new protocols that are now in place. The same protocols are in place across all of HSC. It is a stepped approach. The first thing we do, before we take a decision to employ agency staff, is look at our team, the overtime and our bank staff. Eventually, you will get to on-contract agency staff, and, because they are contracted, the margins are much tighter. There is still a bit of additional spend associated with the agency framework, but it is not at the same level as off-contract spending in the past, which we are really happy about.

The Chairperson (Ms Kimmins): I know that there is a stepped approach. As I said, it is probably a last resort. My point is that in-house staff are more likely to do it if they feel that there is even a slight incentive, and that could help to offset the costs. It is only a suggestion. Maybe, in practice, it would not work, but we should consider it. In my area, enhanced shift pay was introduced recently to try to stabilise cover for maternity services, and it helped.

This is my last one, because I know that others will have plenty of questions. This morning, I attended the Policy Forum's online seminar on the health service. One of the things that came across strongly was the need for workforce stabilisation, if we want to protect and secure our health service. One of the cornerstones is our GPs. Given that over 20% of the GP workforce are over 55 and that the most recent report by the Royal College of General Practitioners (RCGP) noted that many of them are considering early retirement because of the huge pressures that they are under, are you looking at specific measures to retain GPs? If those services collapse further, we will be in dire straits, because people either will have to go into secondary care way before they need to or will not be seen and will end up with far worse outcomes. I want to get an understanding of that. I know that there have been various elements of negotiation around GP indemnity and all of that, but retention is crucial.

Mr Rodgers: I will slightly pass the buck on that one. GPs are not part of HSC per se; they are, obviously, independent contractors. On workforce policy, our remit there is not quite as direct as it is in other areas.

We have made some moves. Peter may have some figures on the increasing number of training places on the GP programme to try to build that workforce for the future. Through the workforce strategy, we have plans to work with the chief professional officers. Looking ahead, the next action plan will have a range of retention plans, because there are retention challenges in all the professions. Certainly, a retention plan for the GP workforce would be something —.

It is not just about GPs per se; it is about the GP workforce and the primary care workforce and looking at multidisciplinary teams and the professional groupings that work across primary care. There is an intention in our workforce strategy to put retention plans in place for a range of professional groupings, and that will include GPs.

The Chairperson (Ms Kimmins): Is that in engagement with GPs to understand the issues that are driving GPs out of the service?

Mr Rodgers: It will be very much driven by our chief professional officers. We will look to our medical officers to drive that forward, but we will work across key stakeholders. There is ongoing work in relation to nursing that is looking across the professions. There is engagement with the royal colleges and all the appropriate stakeholders in order to develop a retention plan for a particular professional group. We will be looking at that going forward as part of the next iteration of our workforce strategy.

Mr Peter Barbour (Department of Health): As Phil said, our focus is on encouraging workforce supply. We recognise the importance of general practice now and for the future delivery of services and how they will be constructed. We are looking at growing the numbers coming through from medical school into our GP training programme. There have been two initiatives over the last couple of years: one has been working with Queen's University, which has reoriented its medical programme so that 25% of clinical experience will be in general practice. It has been great to see how the GPs have embraced that, notwithstanding all the other pressures that they are under, in stepping up and supporting that. It is a massive change, because Queen's University was at about 6% or 7% before that, and it is now up to 25%. Secondly, the new programme at Magee has a similarly high level of exposure. The evidence is that, when people find a good experience in their training and education, it is more likely that they will choose that profession as a long-term career. There is clear evidence behind that.

The other side that we are involved in is the commissioning of the general practice training programme, which is provided through the deanery in Northern Ireland. In 2015-16, 65 people went through that programme, and, in this accounting year, we have recruited 121 people. That is at the commissioning level. We are trying at a number of levels to work through generating the supply. Clearly, though, Chair, as you pointed out, it is a complex issue, and you were also talking about retention.

The Chairperson (Ms Kimmins): Absolutely.

Mr Barbour: We are trying to ensure the vision and to raise the opportunities and to facilitate that.

The Chairperson (Ms Kimmins): Thank you for that. It is great to see the increase in numbers, but my fear is always about whether, once we get them, we will keep them. A newly qualified GP in particular, for example, may be going into a very pressurised situation. We have heard explicitly the real stories of what it is like in GP surgeries at present. It is the same in social work: there are newly qualified social workers going into children's social work teams that are on their knees, with really complex cases, and they are not able to do the work that they want to do. That drives people out before they even get an opportunity to —.

Mr Barbour: I do not want to underplay that at all, although there are issues for GPs.

The Chairperson (Ms Kimmins): I know that, but I just wanted to make the point.

Mr Barbour: If I may, I will share one aspect of that. We have discovered that there are many GPs who want to encourage other people to become GPs. There are young people coming through, and people like that engagement with medical students: indeed, that happens in the GP programme. Notwithstanding all the other pressures, we have been able to get a system that has facilitated this massive expansion in clinical placements across general practice. That has also helped some of the GPs. As you have probably heard, they like to have portfolio careers, and this is a way of enriching their experience and encouraging them to stay in the primary care scenario.

I like to think that they can enthuse the new folks who are coming through. Hopefully, that will be part of it. There are, obviously, many other aspects to it, but that is one of the things that we are working to develop on the training and development side with the universities and with GPs.

The Chairperson (Ms Kimmins): OK, thank you, Peter and Phil.

Mr Donnelly: I declare an interest: I work for the South Eastern Health and Social Care Trust's nursing bank as a band 5 registered nurse. I place that on the record.

I have a couple of questions that relate to what you said about bank and agency spend. First, I acknowledge what you said about the negotiations on pay parity. I appreciate that you are not able to go into it and that, as you said, there are reasons for that. I urge that the Minister prioritise the negotiations, because, without our staff, we do not have a service, and we certainly want to avoid any industrial action as we come into the winter. I appreciate your answer on that. It was going to be one of my questions, but I appreciate that you cannot go into it.

Agency and locum spend is at £400 million, which is, if my maths is correct, 5% of the entire Health budget.

Mr Rodgers: I will take your word for it. I am trying to do the calculation in my head, but I will have to take your word for it.

Mr Donnelly: No problem. What is driving that spend? Why are we spending so much on bank and agency staff? Is it because of sickness, staff vacancies or staff leaving the service? What are the main gaps that require agency shifts and locums? What are we doing to reduce those gaps?

Mr Rodgers: It is driven by a combination of some of the factors that you have outlined. Certainly, there are vacancies. If you have a vacancy, that is a gap in a service, and you need someone to do the job. If a post is not filled, you have to try to fill it or cover the shift in some way. Some of those might be covered through agency staff. It will also be sickness levels and things like that. We see some progress on sickness levels.

When we look at it in the round, we see that the reasons for people needing to engage with agencies to bring in temporary staff are multifaceted. In the process of driving down the agency bill, we have seen some positives in that we see more people working in HSC than ever before and the vacancy rate and sickness levels coming down. That all plays into it. For me, it explains why we are starting to put a brake on to limit agency spend.

In some areas and medical specialities, it is a seller's market. We saw that from our analysis of the medical locum piece. We would rather that people were employed by and working in HSC, but, in some circumstances, that is obviously not the case, and, as we have seen, people can effectively ask for whatever price, they think, they are worth. If we need to maintain a service, that price sometimes has to be paid. That is probably our focus moving forward.

We have made good progress on agency spend on the nursing and midwifery side and the social work side. We continue to drive those spends down. The focus now is turning to medical locum spend, and we will put in place a new contractual framework for supplying medical and dental locums into the system. That should be in place by next year. As with what we did on agency nursing, we need to take lots of complementary measures to drive the spend down. Those will be about encouraging more people into HSC employment and perhaps increasing the number of resident doctors by increasing our number of training programmes. It will be about increasing supply, where we can, by increasing undergraduate places or looking to international recruitment. All those measures will complement the new procured framework.

Mr Donnelly: We have seen figures that show agency and locum spend ballooning over the past couple of years. Only a couple of years ago, it was about £200 million, I think. What is a reasonable level of agency spend, and when do you plan to get to it?

Mr Rodgers: It is difficult to say what a reasonable level is. We have to recognise that 2022-23 was probably the high point. It was then, in response to the challenge laid down by the previous Minister, that we and the system collectively started to work to drive that down. We saw that progress in the past financial year and are seeing further progress in 2024-25. I expect the number to be well down again this year.

It is difficult to answer the question of what a reasonable number is. I do not think that, collectively, we would have an answer for that.

Mr Donnelly: Is there no target?

Mr Rodgers: There are no targets for reducing agency spend, other than —.

Mr Donnelly: Is there a target expressed as a percentage of the budget, for example?

Mr Rodgers: No. We have targets for some of the things that influence the agency spend. For example, we have targets for vacancy rates and sickness levels. We do not, however, have any targets for agency spend, other than to say that we want to see it driven down.

There were some targets. We want to eliminate off-contract agency spend, and we have done that. We want to eliminate social work spending, and we have done that. That is something to reflect on, but we have not identified specific targets for a reduction in agency spend.

Mr Donnelly: I find that shocking. From what you have described, particularly about it being a seller's market, it seems that there is a perverse incentive not to work for a trust. You get paid a lot more to do locum shifts.

Mr Rodgers: Our aim is to start to tackle that and try to shift the balance so that it is more attractive. We have seen that we can do that: we did it in nursing, where, as the Chair described, off-contract nurses were flown in from England, costing significantly more than an HSC-employed nurse such as you. We have eliminated that practice. That shows that it can be done, but holding that line takes a lot of will, determination and — dare I say it? — backbone from individual trusts and bits of trusts.

Mr Donnelly: I totally appreciate that the off-contract stuff is hyper-expensive compared with a normal, contracted staff member. Is eliminating off-contract staff what would be referred to as the "low-hanging fruit"? The savings that you plan to make are, obviously, on top of that saving. If you have already eliminated the low-hanging fruit of the off-contract staff, where will the rest of the savings be made?

Mr Rodgers: The rest of the savings will come from reducing demand for agency staff, which will mean getting more people to work for HSC. We are starting to see the fruits of that when we look at our workforce stats. All professions are growing. Employment of whole-time equivalents is growing in all trusts. We are growing our HSC workforce. More people are working for us than ever.

The other bit to eliminating demand for agency staff is reducing sickness levels. We see good progress being made by trusts there as well. That will continue to be a focus for trusts.

More people will go into training, as we recognise that they will be the workforce of the future. Employees who are undertaking medical speciality training deliver services as well as being trained. Hopefully, all those things that we are doing collectively will serve to drive up employment in HSC and drive down demand for agency staff.

Driving down the demand for agency staff is one element of making those savings. Another element is that the way in which the contracts are structured allows us to squeeze the margin annually. Stephen might say something on that. I talked a bit about the price that we pay to an agency for someone working a shift being more than the cost of employing someone directly. The contract allows us to squeeze that margin every year, and that is revisited every year. The collective ambition of the trusts, as the decision makers, is to squeeze that every year.

We should also squeeze the excess, and, again, that should reduce it.

Mr Donnelly: I have a last question, if you do not mind. The alternative to agency is bank. What are you doing to incentivise people not to go to agencies but to register with their bank?

Mr Rodgers: We have a project specifically on addressing and reforming the bank, looking at a regional system. You said that you were with South Eastern bank, but we are looking more at a regional system of bank. The project is part of the agency reduction working group that will drive the reforms. The project will be taken forward in the coming months.

Mr Galway: It is to try to enhance the process of using the bank by looking at how IT infrastructure could work regionally, across all trusts, and how payments could be made much faster than they are at the minute, ensuring that staff are incentivised by that as well as by our looking at rates of pay, if that is an option. It is looking at the potential to pay staff more quickly by ensuring that, if someone identifies a shift that they want to work, they can be paid for that the following week. That is the sort of option that we are looking at for bank reform.

Miss McAllister: Thank you for the information so far. You said some interesting things, and I want to expand on them. You mentioned that you did not have a target for reducing spend. Has consideration been given to undertaking a needs-based assessment of the staffing infrastructure of HSC, rather than looking at just vacancies? The vacancies are for the posts that you cannot fill, but we know that, even if they were all filled, that would probably not be enough to meet the need of each discipline. Take social work, for example. Vacancies may be filled, but we hear from social workers that they need more staff. Has there been a needs-based analysis to establish what we need to have a functioning, stable health service that does not have people languishing on its waiting lists? That, in itself, would create a target of meeting the identified need and would inevitably also reduce agency spend. Has that been done for any discipline?

Mr Rodgers: There are probably two parts to an answer to that question. One part is that we undertake a programme of regular workforce reviews. That is a rolling programme across a range of specialties and services. In the papers, there is an annex —

Mr Barbour: There is a list of the reviews in the programme.

Mr Rodgers: — of all the workforce reviews that we are undertaking. Those workforce reviews will be based on an agreed model pathway of care that tells us how many people we need. We gross that up to population level, which tells us how many people should be working in a particular area and how many people we need to think about training for that organisation. At an operational level, trusts do similar things. For example, in nursing, we have Delivering Care or, rather, our nursing colleagues have Delivering Care, which is a tool to identify need for a particular service in a particular location.

Miss McAllister: What is it called?

Mr Rodgers: Delivering Care.

Mr Barbour: As we speak, they are looking at a refresh of that programme. That draws in all the trusts, including at a more operational level — Phil and I are talking about the strategic review of supply and training numbers — which goes down to clinical settings.

Miss McAllister: It is important. We have heard about it from a number of bodies. It is about looking geographically at need. I used social work as an example of an area in which certain districts have larger caseloads than others and where filling all the vacancies would not meet the need for staff. It sounds as though you are telling me that that needs-based assessment happens, but that is not what we hear.

Mr Rodgers: Our expectation is that the trusts do workforce planning at an operational level. They should know broadly what their caseload is.

Miss McAllister: Are they doing that according to what they can afford?

Mr Rodgers: That is a question for the trusts. I assume that what they will have done —.

Miss McAllister: Does the Department work on the basis of need or what it can afford?

Mr Rodgers: Our responsibility, at a strategic level, is to ensure that there is a supply for the system.

Mr Barbour: Yes. That is also related to transformation: what is the optimal way of delivering services across the region for all our population and, as you say, addressing issues such as inequalities, which the Minister is particularly into addressing. We deal with it at that level. We look at the optimal skills mix, because that is changing as well, and things like that. It is a complex issue. It is about the interface between the strategic bits and the operational day-to-day reality.

Miss McAllister: That is interesting, though. It is an area worth exploring further with the trusts. I know that it is not as simple as this — it is complex — but what is the point of doing the strategic thinking if —?

Mr Barbour: Yes, we then have to align it with the service delivery model and what it needs. That should be absolutely driven by meeting population needs, which are assessed across the region. In a sense, the Department does not allocate people; it provides the workforce supply. The emphasis under the workforce strategy is to provide those tools.

Miss McAllister: It just comes back to what we hear, which is that the service model is not meeting the needs. At some point, there is a disjoint. Maybe we can pick that up again with the trusts.

This is my last question. You mentioned, Phil, the new contract for medical and dental locums. Could you expand a bit on how it differs from the current one?

Mr Rodgers: It is still in development at the Business Services Organisation (BSO). Much as we did with the nursing and midwifery framework, BSO will take the lead on behalf of the region. Actually, the nursing and midwifery one —.

Miss McAllister: You are at the early stages.

Mr Rodgers: Yes, it is reasonably early. Are we looking towards summer for the new medical/dental locum contract to be in place?

Mr Galway: Yes. The contact will be extended. Hopefully, as Phil mentioned, we will have a workshop tomorrow — a steering group meeting — to look at an action plan for the delivery of that new framework for medical and dental contracts in about June of next year.

Miss McAllister: Maybe we should leave that until the process is further on.

Mr Rodgers: Let me say, just when we are talking about procured contractual frameworks for agency staff, that BSO won an award for the agency nursing framework. It was a procurement award for how that was dealt with on a multi-agency, cross-regional basis.

The Chairperson (Ms Kimmins): Any more questions, Nuala?

Miss McAllister: That is me.

Mrs Dodds: Thank you for the presentation. I want to pick up on some of the points that Danny and Nuala raised. I find it difficult to understand why the Department does not have a target for reducing agency spend, since it is such a considerable spend in the overall budget. Maybe I will come and talk to you about it, because I just do not understand why that is the case. You have said that you want to drive down the conditions that create agency spend. I understand that, but I am pretty sure that, if we do not start to set some targets around it, we will continue to muddle on as we are. That is not acceptable.

I will get on to my question. The increase in staff is really good news, particularly on a day when we have had terrible news about health waiting lists. I think that we all knew that, but it is really stark to hear it again. We have more people than ever on waiting lists in Northern Ireland, yet we have had a 16·4% increase in HSC staff over the last six years. That increase, when we break it down, shows a 24% increase in doctors and a 17% increase in midwives. We are investing more and more in staff. That is not a criticism; I am really glad to see it. Why, then, is the public's access to services so poor?

Mr Rodgers: That is a difficult question for us to answer. We deal with workforce policy.

Mrs Dodds: You must think about that. As you set a target to increase the number of midwives or whatever part you are working on at that time, you must think about how that will improve access to services. Today's figures indicate that we have the highest number of people on waiting lists ever in Northern Ireland. That is shocking stuff.

Mr Rodgers: We do not disagree about those difficulties. A question that — not necessarily we — the Department would ask is this: if more people are working, why are we not seeing progress on reducing waiting lists? There will be reasons. Things like the roll-out of Encompass had a significant impact on output at that time.

Mrs Dodds: Phil, with respect, you have been using that reason for a year now, since I came on to the Health Committee. I understand. I was with the Northern Trust yesterday. I asked it to write to me specifically on the downturn in services and how it hopes to make up that downturn in services for the period when Encompass is being installed. I accept that, while there will be disruption, there will be benefit from Encompass. I accept all that. However, I do not think that people out there can understand that, even though we are increasing the number of doctors by 24%, nurses by 17% and staff by 16·4%, which is all good, we are not seeing a corresponding response in access to services.

Mr Rodgers: We share that view. Our position is on workforce policy.

Mr Barbour: We see that as a success for workforce policy and workforce strategy, in that the two main pillars of the increase in staff were recruitment and retention. We know all the pressures that there have been on the service and professions. The stats that we outlined, which are the empirical evidence of the growth of the workforce, at least show that we have made good progress in achieving that element. I absolutely get that you are referring to the fact that there is a big —.

Mrs Dodds: Does that mean, Peter, that you work in such silos in the Department that you do not talk to other parts of the Department so that they understand the strategies that you are putting in place and how they will impact on other parts of the Department?

Mr Barbour: For example, we are aligning strategic workforce planning with transformation. We are engaging with policy leads and the rest of the Department on the skills that are needed. New professions are coming in. There are advanced practice opportunities to bring into play. We are trying to work with them. Our job is to give the system the tools to deliver. That is the way to look at it.

Mrs Dodds: You have just segued into my next question really brilliantly.

Mr Barbour: Great. Thank you. It is for Phil, I hope. [Laughter.]

Mrs Dodds: Yes. That is prophetical.

I was with the RCN. I was up where the Minister was this week. I was there last week in my local GP surgery in Banbridge. One point that GPs and the RCN were making was about the skills mix, issues of professional development and how we make people more skilled and reduce pressures at different points in the system. One issue was around advanced nurse practitioners. Have you thought about how we can enhance that role and create more such roles? It is an exciting way to move problems on and see people more quickly. Some of those people are very skilled and experienced.

Mr Rodgers: Peter might come back in. Certainly, we focus on new roles in our workforce strategy. That will be reflected in our new action plan from next year. Certainly, for us, it is about working with the relevant professional lead in the Department. In the case of advanced nurse practitioners, that is the Chief Nursing Officer's (CNO) office. Equally, there are advanced practice AHPs.

Mr Barbour: First-contact physios, for example.

Mr Rodgers: Yes. There has been growth in some of those areas. Our ambition is for that to continue. It is very much about working with key stakeholders, whether that be the professional leads or, indeed, the trusts.

Mrs Dodds: Is that an ad hoc arrangement, or is there a strategy to do that? Forgive me for not knowing that. I would like to think that it was more of a plan.

Mr Barbour: A key element of our workforce strategy is to identify that because — you are absolutely right — it is about having a clear idea of not only what the service delivery model should be but the skills that are required to deliver that.

That feeds through to the training, and it can often be the advanced practice roles that we are talking about: for example, nurse practitioners. All those things then fit in with what we want to do about retaining staff and providing career pathways for staff in HSC.

In answer to your question, it is all weaved into all of that as part of our workforce strategy. We are developing a new iteration of the implementation plan to deliver that over the next three years.

Mr Rodgers: That is very much developed with input from the chief professional officers, because they will drive forward the development of advanced practice roles etc. They are an integral part of our workforce strategy, and we work closely with them to ensure that that strategic approach is taken for the different professions.

Mrs Dodds: I have two more quick questions. The first set of students on the four-year medical course at Magee should, I think, finish soon. Is it this year?

Mr Rodgers: This summer coming.

Mr Barbour: Yes. Graduation is on 30 June, I think.

Mrs Dodds: Do we have any indication of how many of those students will stay in the north-west or in Northern Ireland, or is it just too early? Am I being a bit too impatient to know about the outworking?

Mr Rodgers: It is possibly a bit too early. February is the time for us to find that out.

Mr Barbour: February is when students will sign up for the UK Foundation Programme, which is a UK-wide medical programme that runs across all 18 deaneries, including Northern Ireland. We will know then what the outworking has been.

Mr Rodgers: We will know then how many intend to apply to the Northern Ireland NIMDTA programme.

Mr Barbour: We will also know what their preferences are, because they will apply by preference for deanery.

Mr Rodgers: It will probably be August, which is when that programme begins, before we can be sure, because people can enrol but not start.

Mrs Dodds: We will have an indication, though.

Mr Rodgers: We will have an indication.

Mrs Dodds: That is fine.

The honest truth is that I do not know whether this is a statement or a question. I talk to quite a number of GPs on and off in my role, and one thing that strikes me is the issue of moral injury. I talked recently to a GP who was concerned that she was having to repeat red-flag referrals. I left the conversation concerned about her as well, because she was so worried for her patients who were not being seen. Is there a part of what you do that reaches out and looks after, or is that just left to the British Medical Association (BMA) or professional organisations?

Mr Rodgers: No. We have things that we can talk about. This year, the Minister launched a new health and well-being framework for HSC, which is about supporting HSC employers to benchmark their health and well-being interventions against best practice. That is rolling forward. We are also working on the occupational health services provided by trusts to staff. Those occupational health services are also available to general practice staff under service-level agreements (SLAs). Depending on where you are, you have an SLA with an individual trust to deliver those occupational health services. Those are provided and available to staff in GP practices as much as to staff in Health and Social Care.

Mrs Dillon: A number of the questions that I had in my head have been answered, but I would like to get an understanding of one issue. There has been an increase in the number of training places for GPs, and I understand that a significant percentage of those are being taken up by international students, which is welcome. We always want to see people coming here to work, learn and live. However, have we any sense of how many of the GPs who took up those training places remain here to work? The short version of the question is this: is it a bit of a false economy, in that increasing training places does not mean increased GP numbers? That does not work for us. We are not getting a true sense of the situation.

Mr Rodgers: There are probably a couple of issues to reflect on when looking at GP training places. You are absolutely right that some of those increased places will be taken up by international recruits.

Mrs Dillon: Do you have a sense of —?

Mr Rodgers: There is always a risk, I suppose, that people will want to return to their home country after they complete their training.

The other issue with the GP training programme, which we are being made aware of by NIMDTA, is that people are working less than full-time. That is an increasing trend in the GP programme and means that fewer people are available for shifts and delivering services.

Mr Barbour: As Phil said, that is a pattern that we have recognised in the last couple of years across the National Health Service. Anyone who wants to come into our system is welcome, but we recognise that there are particular challenges and opportunities. It starts with their induction and welcome to Northern Ireland. NIMDTA has been actively working on a programme to induct and welcome those whom we call "new to Northern Ireland" trainees. That is really about helping them to find their way around our system, to be able to live here and to understand the health service and the role that they will undertake in the training programme. That is specific pastoral and practical support from the start. There is also an opportunity, with the work that we are doing with the GP programme, to expand the time that trainees spend in general practice as opposed to trusts over the three years. That helps to establish links between training in a GP environment and the trainees themselves.

Ultimately, we need to recognise that a lot of things influence whether people stay: whether they have strong contacts; whether they have a really good experience; and whether they strongly identify with the people whom they have encountered in the teams that they work with in general practice and in the communities that they serve. You are right to say that it is an opportunity and a challenge, but it is firmly recognised by NIMDTA. It is probably fairly early days to assess the outcome, but we will keep track of it.

Mrs Dillon: I accept that it is probably early days, and I fully understand that. As I said, I have absolutely no objection to international students. Our young people go to other places to learn, and it is a brilliant experience for them, so I would not want to prevent anybody from doing that. However, I want to make sure that we get a sense of how this is benefiting us and, if it is not, what we do to address that. It is not necessarily about not welcoming international students; it is just that you might have to look at expanding the numbers or delivering differently. I accept that it might be early days, but, when you have more information, I would like something to come back to us about plans or ideas around that. I am not asking for that now, but I would like it at some stage, because we need to have an understanding. I do not want us to be saying three or four years down the line, "We still have a good number of places. We should have enough GPs, but we don't": that is too late. We will end up in the same position as now: we have an ever-decreasing number of GPs, and it is not working for us. I would like to get a sense of that.

Chair, that is my only question. My other questions have been answered. You have all been asked enough questions today that are not within your remit, to be honest.

Mr Robinson: I will ask a broad question. When you speak to social workers, they, like many in the health sector, will tell you about the pressures that they are under and that, on occasion, they deal with 50 cases at a time. They wish to see a model that allows a maximum of 15 cases at any one time. Will the draft safe staffing legislation go into that detail, or will it be much broader than that? They also say that, when they left studying for social work, they wanted to be social workers. They did not want to be, effectively, admin workers, but, given the volume of paperwork that they now have to deal with, they find that they are. Will the legislation get down into that level of detail, or will it be much broader?

Mr Rodgers: By necessity, as basic legislation, it will be broader than that. On that kind of issue, it will be about requiring particular professions or particular settings to effectively workforce-plan and effectively plan the workload of their staff. The requirement will be for trusts, for example, to effectively plan the workload of their staff, but it will not get down into saying, "You must have x number of cases per worker". That number might change over time, and it would be too prescriptive.

Mr Robinson: You can absolutely understand how social workers feel. I keep using them as an example. They wish to leave the profession because of the volume of work that they have to cope with. Social workers deal with complex cases.

Mr Rodgers: The Chief Social Worker is doing a lot of work on improving the working lives of social workers.

The Chairperson (Ms Kimmins): I declare an interest as a former social worker. There are meant to be protected caseloads, particularly for newly qualified social workers in their assessed year in employment (AYE). From what I hear on the ground, because of the level of demand, that is not always happening, particularly in children's services, which is where a lot of new social workers have no real choice but to go. They then leave within that year because of the huge pressure. On paper, it looks great that we are increasing our numbers, but it goes back to my original point around retention: we can stream in all those new social workers, GPs or whatever the role may be, but, if we are not doing enough to retain them, they will leave. I am not saying that it is just for you guys to deal with, but, although recruitment is an important aspect of workforce planning and workforce strategy, retention is even more important.

I use social workers as probably the most critical example because they deal with child protection, essentially. The most recent figure that I heard this week was that well over 1,000 cases are sitting unallocated. That is really concerning because those are really serious situations. Diane talked about moral injury. That moral injury to social workers is huge. Just last week, I spoke to a girl who works in older people's services, which is the field that I worked in, and I think that she said that her caseload is sitting at around 160. When I was in the job, we had a maximum of 80, and that was a mix of lower-risk cases and other cases involving people whom you needed to be with. One hundred and sixty is a phenomenal number, and, if you add significant complexity into that, we are in a really precarious situation. We know that we are, specifically with children's services. We really need to focus on that. Obviously, the Committee is focusing on it through Professor Ray Jones's recommendations in the social care review, and the conference on that took place this week. If that is not is being looked at, it really needs to be. We cannot continue to recruit and recruit and recruit. Sorry, I am not suggesting that that is the case, but I am not hearing a real emphasis on the need to look at that.

Mr Rodgers: We can lift it up a level and think about our workforce strategy, which has three key pillars, and we will work with individual professions to develop actions around those pillars.

One is recruitment — we have talked about that — one is retention and the other is health and well-being. They are the three broad pillars of our workforce strategy, and, within each, there will be individual actions. For example, the retention pillar will be considered very much on a profession-by-profession basis, as I said. Aine Morrison, who is the Chief Social Worker, is doing a lot of work in the space of some of the professional issues with caseloads and things in order to address some of those challenges. We work with her when she needs it.

Undoubtedly, despite all the positives in terms of increasing numbers, there are still challenges. Even with vacancies, there are areas where there are challenges with retention, and, as a system, we have to work collectively to develop the actions and solutions that will address that.

The Chairperson (Ms Kimmins): Danny, you wanted to come back in before we finish.

Mr Donnelly: I have one quick thing. Thanks for bringing me back in, Chair.

We were talking about recruitment and knowing whether people will stay following recruitment. One thing that I picked up from the slides is that we have quite a few spaces that are funded by the Republic of Ireland. Is there a requirement on students who come from the Republic of Ireland to go back down and work in the Southern health service?

Mr Rodgers: I do not know if there is a requirement. There is an expectation that students funded by the Irish Government will return to the Health Service Executive (HSE).

Mr Barbour: An amalgam of things developed over the past two years. Last year, with the 2023-24 intake, there was an issue because the Minister clearly was not able to fund the number of places that he would have liked to fund. The Republic of Ireland approached us for training for its staff. The compensation for that and part of the arrangement was that it would fund 50 places on nursing programmes for Northern Ireland domiciles plus another five for allied health professions. That was the net positive to us that came from that arrangement. It was really about using the spare capacity in the system, particularly in Ulster University, and it was important to preserve that for our wider good in Northern Ireland.

The most recent arrangement, agreed this year, for some nurses and allied health professionals is for Republic of Ireland domiciles, but, in a sense, they might have been attracted to come to our system through a range of our programmes anyway. We have been able to expand the arrangement to enable that cohort to be trained in our system, but, essentially, it will be for the Southern system. Ultimately, it is a win-win for both our systems, and I think that our Minister is keen to look for opportunities for collaboration on the island in the space of the education of healthcare professionals. Collaboration is better than ignoring each other or competing across the systems.

The Chairperson (Ms Kimmins): I will ask Linda to make a final, final point. If you take one back in, you start a trend and we will go round again.

Mrs Dillon: I am sorry. It is a quick point.

The Chairperson (Ms Kimmins): Go on ahead.

Mrs Dillon: It is on the last point. On the basis of discussions that I had at the time that that arrangement was made, which was when the Assembly was down, I do not think that there is a requirement on those staff. It is a good thing that we retained those places. That allowed us to retain those training places. If we needed to rebalance that and were able to train more people from here and had the funding to do that, it could be rebalanced.

The last point that was discussed is really important. It is about that collaboration, because that is exactly what we need. We need the flow to not all be heading South. We need there to be real, genuine collaboration whereby we have people who see their role being expanded in hospitals and in healthcare facilities in any part of this island, if that is where they want to go, because that is where they will reach the peak of their professional life. We need to have that broader picture of people all working together and making sure that every person on the island gets the best healthcare service possible.

The Chairperson (Ms Kimmins): Thank you for that, Linda.

Thank you all. That has definitely been useful for us, and it will feed in nicely to our next briefing on transformation. We appreciate all your time.