Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): You are both welcome. Thank you for your patience. We have in attendance Peter Jakobsen, director of regional health services transformation, and Michelle Estler, head of the transformation branch. We have slightly under an hour for the session. I ask you to make some brief opening remarks, and then we will go to questions. We have a good briefing paper as well, so thank you for that.

Mr Peter Jakobsen (Department of Health): We issued a short briefing paper in advance of the meeting that focused on the hospital network consultation. I will briefly reflect on the recent Bengoa conference and the wider reform agenda, and I will say a few words about the hospital network consultation.

I will focus on the key takeaways from the Bengoa event. One of the key points was that Professor Bengoa was clear that health and social care systems everywhere are grappling with the same issues as we are. All health systems face increasing demand due to demographics, greater case complexity and advancements in medicine. The clear message was that we need to accelerate the shift left, and that means focusing on prevention, population health and building up capacity in community services, primary care and social care. The stark message was that, if we do not make those changes, Health will eventually swallow up the Executive's entire Budget.

It is important to recognise that reform is not a silver bullet that will solve everything. We cannot get away from the fact that we need additional capacity, for example, to tackle the backlog in the waiting lists. Changing how we do things can certainly help, but that has to be accompanied by investment, more capacity and a real focus on productivity. Moving ahead with that agenda requires strong leadership from all parts of the system. It feels as though everybody is up for that challenge, but the Bengoa event helped to encourage it.

Hopefully, you have all had a chance to read the hospital network consultation document. I will not go over the details, but I will highlight that a key purpose of the paper is to set a strategic context for future reconfiguration decisions. The document, therefore, does not contain any specific reconfigurations, because each addition will be highly complex and will require detailed analysis, engagement and, most likely, its own public consultation.

The document was co-produced with the trust, the Northern Ireland Ambulance Service (NIAS) and the Public Health Agency (PHA). It is important to recognise that there was significant clinical input to the document. As you will also be aware, we undertook a pre-consultation engagement exercise with the royal colleges, the trade unions and a group of service users. Following that feedback, we made some changes to the paper and recognised that much of that feedback would probably be addressed as we take forward actions after the consultation has concluded.

As a result of the feedback, we also worked with a group of service users to co-produce an easy-read summary document that has also been published alongside the main paper. We are now working with each of the trusts to organise consultation events in each trust area. The first event will be in the South Eastern Trust, and details on it will be publicised shortly. The other events will follow as soon as we have dates and venues identified and confirmed. Following the consultation, we will analyse the responses and provide advice to the Minister on the next steps. I am pretty sure that that will incorporate some recommendations on how we progress the proposed actions in the document.

That is all that I want to say. I will be happy to take any comments.

The Chairperson (Ms Kimmins): Thank you, Peter. My comment ties in with a question that was raised with me this morning. In the briefing paper, you outlined how the Minister plans to publish his three-year plan. It says that that will happen in the "coming weeks", but that could mean anything in politics. Do you have any sense of when we are likely to see that?

What sort of detail will it have? We have had the reconfiguration document, which is very high level, and, obviously, more meat will be put on the bone as we go through that process.

A three-year plan was mentioned, and I am conscious that we all have lots of plans. I am not being critical; I just want to get an understanding of it. In the seminar that I attended this morning, a lot of the health leaders who were there were keen to hear more about that plan, when we will see it and what it will look like.

Mr Jakobsen: We hope to get it out before Christmas. It all depends on what the Minister thinks of it, obviously. We are starting to engage with the Minister on it now. He might well want some changes. That might mean that it takes longer, but we certainly hope to have final drafts in soon, have a discussion and take it from there, so, hopefully, it will be out soon. If it is not out before Christmas, I would certainly like to think that that will happen for January.

The contents consist of three parts that are, again, subject to the Minister's views. A narrative sets out a bit of context and summarises some of the key outcomes that we want to achieve by year 3 of the plan. There is an annex that sets out links to all the major reform programmes that are under way. The second annex is the detailed plan, which has actions across all the areas under three domains: delivery, stabilisation and reform. We have graded some actions underneath those headings for each of the years, and I will set out in some detail what we plan to achieve.

It is important to say that the Minister thinks that this is an ambitious plan. As you know, the budget position is really difficult, so it is hard to be ambitious with actions if you do not have the budget for it. Some of those things will be subject to budget. That is the only way that we could do it that would allow us to try to set up what we want to achieve. We try to distinguish between what can be achieved with the budget that we have and what can be achieved if we get additional budget, bearing in mind that we do not know what our budget will be for the next two years.

The Chairperson (Ms Kimmins): As you were talking, I was thinking that I am under the impression that the Finance Minister and the Executive will be looking towards a multi-year Budget for the rest of the mandate. Will that be factored into the plan? I know that it is difficult, because we do not have it at this stage, but I would like to think that some level of planning on that is happening and on what we could do with it, if and when it becomes available.

Mr Jakobsen: We would need to have a fresh plan. If we are going to publish before Christmas or in January, because we will not have the Budget, we will not have that. If we get the Budget, it will set out clearly what we can do with it and what we can achieve. How much of that we can achieve depends on how much we get of that Budget.

The Chairperson (Ms Kimmins): I know that that is probably a bit of a hypothetical question.

Mr Jakobsen: It is difficult, because I suppose you could always wait and keep waiting for the next Budget event.

The Chairperson (Ms Kimmins): Absolutely. I take that point. In the event that the foundations were there and a multi-year Budget were available, I would like us to be ready. That may not be possible at this stage, because I am conscious that not long is left of the mandate and that that has to be factored in. Thank you for that update, Peter.

On communication and consultation on the reconfiguration in particular, the document mentions the personal and public involvement (PPI) framework. That work will impact on people across our communities, and I want to ensure that we do everything that to the best of our ability to ensure that everybody is engaged. That is not always easy, but, where the changes may happen, that will probably affect more people in the more rural ends of our constituencies and things like that. I would like a wee bit of understanding of what that engagement looks like.

You mentioned the consultation events. What else is being done on that engagement and consultation? Are there other things that we could look at? I think particularly of our elderly population, because there may be people who do not have online access, whether that is because of broadband issues or those types of things. I do not ever want to be in the position where we are on the other side of a consultation and a small portion of society has fed into it but those who have probably been impacted most do not have full understanding of what exactly it is or have not had that opportunity. I know that it is not possible to get to everybody, but I am just trying to think outside the box. Is that in that framework?

Mr Jakobsen: Are you talking about consultation on the framework, the document itself or future reconfigurations and decisions [Inaudible.]

The Chairperson (Ms Kimmins): Those elements and the wider reform piece on transformation, because any change can be difficult to manage, if people do not fully understand it. I hope that that makes sense. I was talking specifically about what the engagement and consultation look like from the Department's perspective.

Mr Jakobsen: For this document in particular, we will have an event in each trust. We are working with the trusts on those. The events will be publicised — the trusts have already reached out to their local communities — and we will publicise them through the trusts. We will do it through our productivity challenge as well. We will also work with the Patient and Client Council (PCC) and meet as many groups as we can that way. We will do an online event as well. That might not reach as many people, depending on whether they have broadband, but there will be an online mop-up event for people who miss the physical event.

In future, there will be a commitment to PPI; that is clear. There is a statutory duty on health bodies to do that. This process does not change that; it will have to happen. Each decision that a trust takes forward will have to have full engagement.

Ms Michelle Estler (Department of Health): That is why we did the summary document for service users. We recognised that some of the language might be clinical and not fully understood, so we tried to make sure that the 80-page document had a 10-page summary. We ran that past service users, and they came back with positive feedback that said, "Yes, what you were trying to say in that bigger document now makes sense to me".

The Chairperson (Ms Kimmins): That is key to what I was thinking. It is about looking at the service user groups who may be in hospital, attending clinics or whatever it may be and making sure that there is an opportunity for people, including staff, to get involved. That includes elected representatives.

I will move on to the challenges, because they are the key part in all this. Yes, we know what we have to do and what needs to happen — that message came across strongly in the conference this morning — but it is about how we get there. Workforce is one of the critical elements of that. In the previous briefing, some of which you may have heard, we spoke to part of that with the officials. Diane pointed out the increase of 16·4% in our workforce from 2018 to September this year, but we heard today that over half a million people are still on waiting lists for a first consultant appointment and that more than half of them have been waiting for over a year.

We understand the challenges. There are fundamental challenges in the workforce. We see the vacancies. The problem is well rehearsed at this stage. I am trying to understand what impact the increase is having. Phil Rodgers, who was here earlier, said that more people are working for Health and Social Care (HSC) than ever before, yet we have the worst figures. I am trying to understand that and how it ties in with the bigger transformation piece. The Minister said that transformation has been happening, albeit at a slower pace than any of us wants. That ties in with the introduction of elective care hubs and the mega-clinics, which, for me, should mean that waiting lists are coming down, not going up. Can you give me an understanding of that?

Mr Jakobsen: I am not leading on elective care, but I will tell you what I know. You may have to pick that up, or we may be able to give you more information in writing. The Department was clear that, this year, for example, we needed much more funding just to stand still. Part of the issue is that we do not have the capacity to deal with the demand. I cannot remember the exact number, but I think that we needed £130-odd million to stand still —

Ms Estler: It was £135 million.

Mr Jakobsen: — but we got £70-odd million. That is part of the issue. Obviously, we need further investment to tackle the backlog. That would not be ongoing investment; it would be non-recurrent. If we could have in excess of £100 million for five years, we could probably tackle the backlog, but, until we have the extra capacity, we will not make inroads into the waiting lists, despite the transformation that has happened.

As the Minister has said, we need to get the most from what we have. We have to really focus on productivity and make sure that the centres that we have deliver the most that they can. The productivity challenge is the ongoing focus of the strategic planning and performance group (SPPG) in particular.

The Chairperson (Ms Kimmins): I recognise that, but what are we measuring? We talk about the roll-out of multidisciplinary teams (MDT), but I am not talking about them specifically. Overall, we have seen some roll-out of MDTs, as we have of elective care hubs and mega-clinics, all of which are there to alleviate pressure on the service, to make sure that people are seen more quickly, when they need to be seen, and, essentially, I hope, to promote better outcomes for patients.

Are we measuring what has happened to date with those small elements of transformation and the impact that they are having? If they are having the intended impact, surely we would be making savings. I know that that is easier said than done, but we have to track it closely, because, if we want to make the arguments that ensure that we get the funding that is needed, the evidence base has to be there. It is there. We can see that already, particularly around MDTs, because appointments are being freed up. That will all lead into addressing the workforce challenges that we hear so much about.

Mr Jakobsen: My understanding is that we are tracking the throughput in the various clinics, mega-clinics and day centres etc and the impact that they are having. That information should be there, but I do not have it to hand.

The Chairperson (Ms Kimmins): Maybe that is something that we could pick up, because I would like to get a sense of what that looks like. A quandary that I always find myself in when I have conversations with people is thinking that we know that we have to tackle the symptoms — I mean the waiting lists and the other critical issues that are upstream — but can we do that and transform at the same time? We have a budget of over £8 billion, but we are still saying that we need a hell of a lot more. Surely we are starting to see the benefit where transformation is already happening.

Peter and Michelle, in the current situation, is transformation essentially on hold or going at a very slow pace because of need elsewhere, or is there an ability to walk and chew gum at the same time, to put it nicely?

Mr Jakobsen: It is happening as we speak. For example, over the past couple of years we put in place urgent care streams and urgent emergency care, such as local Phone First services. Those are new services that have been put in place. We also expanded on what is called "same-day emergency care", which is designed to take demand away from emergency departments (EDs), yet we still see huge pressure on EDs.

Part of me thinks that there is something about understanding the increase in demand that we are experiencing. If we have more staff but are not seeing the outcomes that we want, an explanation could be that demand has increased by the same amount or by more than the staff has increased. I do not know whether that is the answer, but it is one logical explanation.

We know that people on waiting lists will probably see their GP more often and that they might end up in EDs more often than they otherwise would. There is something about the connectivity, but tracking that is hugely complex. You probably cannot do it. There is something in there about the pressures that we are under, which is probably partly explained by the long waiting lists. Those things are all connected.

The Chairperson (Ms Kimmins): They absolutely are. You gave the example of someone on a waiting list seeing a GP on numerous occasions and maybe presenting more often to emergency departments. That adds to the pressure, so while we are not doing the transformation that is needed, we are increasing the cost for other elements of the service.

I could probably get into a few more points, but I do not want to, because I want to give other members time.

Mr McGrath: My question is about transformation. What is transformation? Where is the overall plan? Is there an overall plan? I like to think that there is a room in Castle Buildings that has a massive table where exactly where and what the transformation will be is mapped out and that somebody is keeping an eye on it. We hear about changes to children's services, suggested hospital networks, elective surgeries, emergency departments, mega-clinics, Phone First, urgent care and people maybe having to travel to get a better service because the best service is not necessarily close to them.

Alongside that and following on a little from what you said, Chair, is the GP out-of-hours reconfiguration in Belfast a transformation, or is it the result of the collapse of a service that needs to be amalgamated because it cannot get the staff to deliver both sites? The Northern Ireland Ambulance Service is talking about reducing its ambulance cover in the eastern division at night-time from nine ambulances and from 11 at the weekend to six ambulances: is that because of transformation, or is it because the staffing is not available to provide the services as it currently does?

We know about Daisy Hill's maternity hospital and the reconfigurations at the South West Acute Hospital (SWAH), but are those about transformation? People on the ground are not thinking or feeling that they are transformation; they think that those are examples of a collapse of a service. We are constantly told that we have to suck that up because there is an overall transformation process. Is one plan available that has multiple elements to it and about which we can say, "Transformation is going to start here and will this amount of money put into it. These things will be delivered, and the service will look like this at the end in a transformed way"? That would mean that people can see what they are part of and what the process is, or is it just a bit here and a bit there, with people working in different ways on different things?

Mr Jakobsen: OK, there are a few questions there. There is a plan, 'Delivering Together', and an update was published in June this year that pulled everything together in one place. That plan summarises all the bits of transformation that are happening across the Department. You will probably recall that a range of areas is in it. I do not have a control room where we have all that in one place, Colin. However, we have published a lot of reviews and strategies in many areas. It is too complex to pull all that together in one big piece, because it becomes impossible to see all the connections. However, the three-year plan that we mentioned will set out over that period what we will do in three domains, which are stabilisation, delivery — that is about how we get the most from the system — and reform. That plan will set out the actions that we are trying to take forward in the reform or transformation space over the next three years. That is a good place to have everything, and it allows us to say, "Here are the key things that we are going to do". That is probably as good as we have with having everything together in one place. I take your point, but it is so complex with so many interconnections that it becomes difficult to have one kind of —.

Mr McGrath: When we see a collapse of a service, is that registered somewhere as a collapse of a service as opposed to transformation? Often, the argument is, "Oh, you are complaining about something that is a transformation", and everybody is supposed to buy into it. However, there is a fundamental difference between the transformation of a service and a service that collapses because it is not able to survive safely. There is a distinction between the two: is that distinction recognised in the Department?

Mr Jakobsen: Yes. I would certainly not classify a collapse of a service as planned transformation: it clearly is not. It is a reaction to circumstances where you cannot maintain that service any more. I would not class that as transformation; I would class that, as you say, as something that needs to be done for safety reasons. Obviously, if it is a proactive decision, say, where you have a service review that looks at a service and you identify vulnerabilities in that service, you might take action up front to put it on a sustainable footing in order to deliver the best outcomes for patients in the long term. That is transformation, because you are making the service safe. However, I would not classify a reaction to a collapse as transformation. It would be difficult for me to classify it in that way.

Mr McGrath: Finally, Chair, if I may ask this: if that is the case, should trusts be reacting to an inability to provide a service by reconfiguring it and making a plan to look like it is, in some shape, transformation, if that individual service that they are delivering in a trust needs to be part of a Northern Ireland-wide approach where it may be pitched in with others? The Minister has been clear that, while there may be five trusts and he does not want to go down the avenue of removing them and turning them into one, he wants to look at services on a regional basis. Is somebody checking to make sure that, if a trust is tweaking its service in one area, that does not have an impact on the capacity to deliver things on a regional basis?

Mr Jakobsen: A trust needs to engage in a process with the SPPG. As part of that engagement, the SPPG will check with the PHA. In fact, a trust is required to work with other trusts that might be impacted on by its changes to make sure that the regional picture is taken into account. That is baked into the process.

Mr McGrath: OK.

Mr Jakobsen: That should happen.

Mr McGrath: Chair, my apologies. I have to go to a ministerial meeting with South Down representatives at 4.00 pm, so I will have to leave the Committee meeting shortly. Thank you for the answers, Peter.

The Chairperson (Ms Kimmins): No problem. I know that two other members also have to leave. Linda and Nuala, do you both have to leave at 4.00 pm?

Miss McAllister: Yes. We are doing the same Policing Board thing.

The Chairperson (Ms Kimmins): Danny, may I bring in —?

Mr Donnelly: Do you want them to go first?

The Chairperson (Ms Kimmins): Is that OK?

Mr Donnelly: Yes.

Miss McAllister: I have only one question, because I am conscious of time. What data analysis is being undertaken of the services that should be run in each reconfigured hospital to ensure that there are improved outcomes for people? Who is best placed to make the decisions about what should go where? Is data analysis being used in the decision-making process, and, if so, what sort of data analysis is being used?

Mr Jakobsen: It all depends on what the service is and on the nature of the change. As the document sets out, some changes will be trust-initiated and trust-led. Take, for example, the decision in South Eastern Trust to move the urgent care service to the Ulster Hospital site. That change was trust-initiated and trust-led. The trust did a lot of analysis of, for example, travel times and impacts on patients. It discussed and shared that with colleagues in the SPPG, and the PHA also came in on it. All the analysis was there to support that decision.

Miss McAllister: How can it be trust-led, if the Minister says that he has in mind having only one trust and that that is the way in which he wants to look at it? If we are to have a region-wide system, how can we move that power away from being trust-led? Otherwise, if transformation is being led by each trust individually, how will we ensure that it is taking place?

Mr Jakobsen: As I said, it is baked into the process that, when a trust initiates a change, it will need to identify the regional impacts that there might be and discuss them with other trusts as appropriate. The SPPG and PHA will check that the trust has done that and that the analysis is sound. Let us take the maternity service at Causeway Hospital as another example. There will be a probable impact on Altnagelvin Area Hospital, because some of those mothers will probably go to Altnagelvin instead of to Antrim Area Hospital. Again, making that change required engagement among the trusts, and that decision has been quality-assured and checked by the SPPG and PHA. The process is there to facilitate cross-trust working.

Miss McAllister: Should it not be the other way around? Why does it not go from the Department to the SPPG to trusts?

Ms Estler: It depends on the change.

Mr Jakobsen: It depends on the change.

Ms Estler: If it is a local change, you may be able to contain the decision in the trust or across two trusts, but, if it is a Northern Ireland-wide —.

Miss McAllister: I mean all of it. When we have region-wide acute —.

Ms Estler: Yes. If it —.

Mr Jakobsen: There are regional reviews. They are Department-led and take an overarching, regional approach. Examples of that are the neurology review, the ongoing work on stroke service reconfiguration, the elective care framework.

Ms Estler: The elective care framework is Northern Ireland-wide.

Miss McAllister: We are given the assurance that, with trust input, which is essential, it is all led by data analysis.

Mr Jakobsen: Yes.

Ms Estler: Yes. That forms part of the decision-making.

Mrs Dillon: Thanks for the answers so far, Peter and Michelle. I appreciate them. I acknowledge that transformation of some services takes extra money, but we know that there is money to be saved. One issue that trusts raised with us last week was the cost to every trust service of the failure to attend appointments. Deirdre Heenan rightly highlighted Neil Guckian's comment that — this seems to be anecdotal, without any evidence, to be honest — there is an issue with people being able to afford to get to appointments. With transformation, we need to ensure that people can access the service, appointment or whatever it is that they need, whether it be treatment or a diagnosis.

Can we find out whether each trust collects evidence of the reasons for failure to attend? That information would need to come from the trusts, but it needs to come through the Department to us, and that is perhaps something that you can look into, Chair. Have they looked at the examples of best practice? Some were cited in media interviews during the week, so there is no reason that we, the trusts or the Department cannot look at those examples and see whether we can to the bottom of the reasons. That has to be part of the transformation. You cannot reconfigure and transform without having any understanding of whether people will be able to access a service.

It goes back to your point about people in rural areas in particular and how they will access services. In fairness, though, even if people live in Belfast but the service is in Enniskillen, the transport to and from Enniskillen is pathetic. It does not matter in which direction they are going. If people are going from Belfast to Enniskillen, it will not be any easier for them to get there than it is for people to get from Enniskillen to Belfast. If we are going to put services in different places, we have to acknowledge that as a region-wide problem. That is what I want to see happening, but I want to understand how people will access services.

Nuala's point is well made, and my follow-up question is this: how are we going to understand the outcomes for people, by which I mean the outcomes for everybody, not just those who access a service? What are the outcomes for those who, for whatever reason, are unable to access a service? We need to know that, because without that data, all that we hear is that there are better outcomes for everybody who accessed the service. What about everybody who did not or was not able to access services because of transformation? I am not saying that that will happen, but if we do not collect the data, we will not know.

Mr Jakobsen: I noted Neil's comment as well, and it is something that we need to get to the bottom of. Neil would not have said that without there being some anecdotal evidence in his trust that that might be happening, but we have to understand the scale of it. I do not know at the moment. It could be a few isolated cases or a lot more. There is a hospital travel costs scheme that supports people on low incomes with travel costs. There is a threshold, but that scheme is there for people to access, and those on the lowest incomes will get support.

Mrs Dillon: I get what you say, Peter. That is a good scheme for those on low incomes, but not everybody is on a low income. It is about accessibility; it is not about just the financial impact. Yes, Neil made his comment on the basis of potentially anecdotal evidence. I would like to see actual figures for the problems, however. That is not to say that that issue does not play a part. If it does, we need to figure out how to address it. Consideration of the issue has to play a part in a bigger transformation plan. We cannot transform services, put them wherever and then say, "Now we'll worry how we get people there". It all has to be part of the plan. I am not saying that that is all on you — it involves Departments working together as well — but the Department of Health has to tell the other Departments what it needs from them.

Mr Jakobsen: I could not agree more.

Mrs Dillon: It is about getting a sense of that. Can we follow up on that, Chair?

The Chairperson (Ms Kimmins): No problem.

Mr Donnelly: Some of the points that I was going to raise have been addressed by Nuala and Linda. I will just build on that.

My first point is about vagueness. A couple of us have expressed the view that there is little detail in the plan. Yes, it is out to consultation until February. When will we see more detailed plans, and what will they entail? I think that you hinted at that, Peter, when you said that there may be further consultation. Will the decisions that we will see taken each require a further period of consultation?

Mr Jakobsen: For specific decisions, yes. You will see, for example, that the Northern Trust general surgery service is being consulted on at the moment. That is one example of a reconfiguration decision that is being actively considered at the moment. Each individual future decision like that will require its own public consultation.

Mr Donnelly: When will we get a more detailed plan?

Mr Jakobsen: It is an ongoing feast; it will continue. At the moment, trusts will react to changes in population needs and so on that might change how services are configured over time. I do not see the process ever ending; I view it as an ongoing process, with decisions being taken as and when they are required.

Mr Donnelly: The plan for reform at the minute must have a timescale and an end point. What are you —?

Mr Jakobsen: Somebody talked about the core services at three hospitals. SWAH, Causeway Hospital and Daisy Hill Hospital will need their type 1 ED, which is a 24/7 ED, for the foreseeable future. We say at the end of the progress report that 'Delivering Together' is not a for ever and ever document. We will need to review it at some point. I can see it needing to be reviewed in the next 10 years — we may review all of it — but that is kind of the timescale.

Some reviews are coming up in the Department. There is work being done on stroke service reconfiguration. The Committee received a briefing on that. That is probably the next Department-led decision that needs to be taken. There is also a review of neurology services. The Minister has agreed that we will take steps now to prepare for public consultation on that, so there will be another public consultation. There will be things coming out of the Department. At the same time, there will, I suspect, be some reconfiguration decisions coming from the trusts over the next number of years.

Mr Donnelly: Specifically on the hospital network, is there no date for that? We are aiming to see a more detailed plan at the minute.

Mr Jakobsen: I do not think that we can expect to have a more detailed plan on when decisions will be made, but what will be taken forward are the actions in the document. There are 13 actions in there. Depending on the feedback that we get from the consultation, we will need to take them forward. They are not specific decisions; they are actions that aim to help the system to work better. We need to make arrangements to oversee their being taken forward and identify actions that need to be taken. I can therefore see an action plan coming out of the consultation.

Mr Donnelly: At the minute, however, there is no timescale for that.

Mr Jakobsen: The consultation closes in February, so we will need the spring to analyse its responses, get them to the Minister and get the actions signed off next year.

Ms Estler: The timing will depend on the stakeholders and on the action owners. Rather than our saying, "We want you to do it by this time", it will be a case of, "When can they get involved?". Some of them will hopefully be quicker than others, but some of them might take —.

Mr Donnelly: Are the stakeholders the trusts?

Ms Estler: The trusts, clinicians, royal colleges, trade unions and so on: anybody affected by whatever the action covers. Even for the travel issue that we talked about, it will depend on what help we can get from the Department for Infrastructure, volunteer drivers and others on the wider transport side of things.

Mr Donnelly: Implementing each of those actions will require consultation as well.

Mr Jakobsen: No, they will not.

Ms Estler: It depends on what the action is.

Mr Jakobsen: I do not think so. Perhaps —.

Ms Estler: It depends on what they are [Laughter.]

Mr Jakobsen: I suppose —.

Mr Donnelly: Some of them will; some of them will not [Laughter.]

Ms Estler: Some of them might, yes.

Mr Jakobsen: That might be true, yes. Transport policy is one, particularly as significant changes might require there to be a public consultation. I do not think that some of the others will. It depends on the action. For me, probably the most tricky one to address is what we were saying about how we need to make sure that we deliver equal access to services across the system. For example, we know from the neurology services review, that there is not equal access to neurology services in hospitals. For each specialism, we must work out how we can best deliver for the population in the most equitable way. That requires each clinical profession to take the lead. Having gone through it with the neurology services review, I know that it is a long process. There is therefore an action plan to be set out for how we can deliver services.

Mr Donnelly: I appreciate that, and we hear time and again, "We need to reform". As a Committee, we need to see the plan for reform. What we hear is that the current plan is quite vague. It sounds as though we will not get a detailed plan for about a year. Then, some of the actions will have to be consulted on, while some will not. It is a very long process.

Mr Jakobsen: Yes, it is.

Mr Donnelly: We absolutely want to support reform, but we need to see details. We need to know what reform will mean across Northern Ireland, and we are not seeing that.

Ms Estler: I refer you to the 'Delivering Together' progress report, because it follows on from the idea of reform in 'Delivering Together' from 2016. The report provides you with a long list of the things that have been progressed and next steps. I accept that it is not overnight reform.

Mr Donnelly: My next question relates to the points that Nuala and Linda made about the data. Neil Guckian made a hard-hitting point last week about the fact that there are people who do not turn up for operations because of the financial impact on them. I know that it has been said that the evidence is anecdotal. In order that we have data on and understanding of why that happens, do you record the reasons that people come off waiting lists?

Mr Jakobsen: I do not know the detail of that. We may have provided some such information previously.

Ms Estler: The previous time that we were here, I think that we were asked whether people who came off a waiting list did so because they got a private appointment.

Mr Jakobsen: We were, and we did not have that detail.

Ms Estler: We could not get the detail.

Mr Donnelly: I asked that question.

Ms Estler: Yes.

Mr Donnelly: There were a couple of other possibilities aside from the patient going private, such as the patient's moving away, becoming frailer or, sadly, passing away.

Ms Estler: Yes.

Mr Jakobsen: That is not recorded.

Mr Donnelly: Is it not recorded anywhere?

Mr Jakobsen: I think that that is the information that we came back with to the Committee.

Ms Estler: The trusts are trying to manage cancellations, because that can then help with efficiencies and capacity. They want to understand why cancellations happen, so they are looking into that. We do not necessarily capture all the reasons that people come off a waiting list, however.

Mr Donnelly: One of the things that I hear anecdotally from my constituents is that they are forced to use the independent sector, because they fear that, if they do not do so, they will have to wait for years. We do not know how many of them get their operation privately and thus come off the list. That is not a figure that —.

Mr Jakobsen: We can ask again.

Ms Estler: We will go back and enquire about what answer we gave you. I cannot remember, but I do not think that we had the detail behind it.

Mr Jakobsen: My recollection of what we provided by way of a follow-up response was that that information was not available.

Mr Donnelly: Finally, I will ask about the mental health strategy. The written briefing on it that we received made it very clear that the strategy is not being funded to the required level. Some of the figures are shocking. Last year, £24 million was needed, yet only £5·5 million was allocated. This year, £42 million is required, but only £5·9 million has been allocated. I absolutely understand that there are financial constraints on the Department, but those are very concerning figures. We have an agreed mental health strategy and a funding plan, but they are not being rolled out. Can you tell us what impact that is having?

Mr Jakobsen: Sorry, I cannot. I am not involved in the implementation of the mental health strategy or even the funding decisions, which clearly sit with the Minister. That is above my pay grade.

Mr Donnelly: No problem.

The Chairperson (Ms Kimmins): We can maybe write to the Minister about that.

Mr Jakobsen: You can follow that up in writing. I am sure that we can —.

Mr Donnelly: I appreciate that. Thank you.

Mrs Dodds: Thank you for the information so far. Given your conversation with Danny, do you think that reform and transformation will ever happen?

Mr Jakobsen: It is happening, and it has been happening already.

Mrs Dodds: Will we ever see the big changes that we need to see made through reform and transformation? I must say, Peter, that I was surprised and a little depressed when I heard you say, "No, we don't have a big plan, and we're not ready to produce one with more detail". As far as I can see, there is not a lot of difference between the original Bengoa report and the document that came out in October. There is certainly not much more detail provided.

We are now into 16 weeks of consultation. You have told us that the consultation will not be analysed until the spring, after which there will be a further period before we see actions from the consultation. What will we see in this mandate?

Mr Jakobsen: We are probably talking about different things.

Mrs Dodds: Hmm.

Mr Jakobsen: No, let me explain. We are working up the three-year plan, and that is where you will see the deliverables in this mandate, not just for the hospital network piece but for all the pieces of reform that are happening in the Department. The three-year plan is being pulled together at the moment. I will set it out.

Specifically, it is about how we make our hospitals work better together as a network, and the actions are designed to encourage and facilitate that happening. Yes, we will have to take a bit of time to analyse the responses in order to reflect the feedback that we get and then provide advice to the Minister. That will take a few months, because we are only a small team and one that has a lot of other things to do. That is normal practice. An action plan will come out of that work. The action plan is more about making our hospital system work; it is not about the individual reconfiguration decisions that may follow.

Mrs Dodds: I am worried, because, as the Chair said and as I said to the previous witnesses, that is not much good to the half a million people who are on a waiting list: the largest ever waiting list that we have had in Northern Ireland. I am looking to see some urgency. I know that processes are good and that they protect people — I accept and understand that — but I am looking for some urgency when it comes to transformation so that we can start to deal with things better.

I will move on, because I do not want to take up too much more time. You talked about the Northern Trust. As it would happen, Alan and I spent an hour and a half or two hours —

Mr Robinson: Two hours.

Mrs Dodds: — with Northern Trust representatives yesterday discussing the proposal to move emergency surgery to Antrim Area Hospital and have an elective hub on the Causeway Hospital site. I do not want to talk about the overall merits of the plan; rather, I want to talk about the reality of the vision and the planning assumptions that are being made in order to realise the proposal. It emerged in the meeting that there are planning assumptions being made about their preferred option. One concerned ambulance journeys between Causeway Hospital and Antrim Area Hospital, the number of which, we all accept, will increase because of the proposed change.

When I asked what work was being done with NIAS to make sure that there is a fit-for-purpose Ambulance Service, I was told — I paraphrase, so it is not an exact quotation — "We are still working on that, but it will be no worse than it is now". The night before the meeting with the Northern Trust, I had talked to a GP, who told me about a man who had waited for 16 hours to get to Antrim Area Hospital. Change is OK, if it will make things better, but, as Linda said, if we do not underpin changes with proper planning and proper investment in services, things will not be any better.

The second planning assumption was on the need for additional beds in Antrim Area Hospital. I asked how they will get those beds. I then asked the obvious question about how many beds in Antrim Area Hospital were unavailable yesterday because of the lack of social care provision. I was told that, yesterday, 26% of beds in Antrim Area Hospital were unavailable, yet we are trying to create extra beds to meet the trust's preferred option. I asked its representatives how they will get the investment in order to have more beds and was told, "We will talk to people in the community to try to see what is available". I am a bit frustrated by that. That conversation on a preferred option that the trust is planning for took up two hours of my time yesterday, yet there is little planning behind it. If we are planning for transformation in that way, we are in trouble.

What contact have you had with the Northern Trust on the issues that I have raised? The Minister says that he will leave some of the decisions to trusts: how will we hold trusts accountable for the decisions that they make? I understand the objective to create sustainable, safe surgery. That is not the issue: I am talking about the planning assumptions that I heard about. I left the meeting with no understanding of how the trust plans for its preferred option to work. The consultation closes tomorrow. Those responsible for it will do what you are doing, which is to collate the responses, after which they will take them to the board. I, however, left the meeting not knowing anything other than that the trust wants the option that it wants.

Mr Jakobsen: How that process is meant to work is set out in the policy guidance that we issued. It is a bit concerning, if the trust has not discussed it with NIAS. That is meant to be part of the process.

Mrs Dodds: No. It has had numerous meetings, but —

Mr Jakobsen: It has had meetings with NIAS.

Mrs Dodds: — I see no solution to the issue. Nobody provided one to us.

I will hand over to Alan, if that is all right, Chair, because he was with me.

Mr Jakobsen: The trust will take a decision. It will engage with the SPPG, which will then engage with the PHA to ask those questions, a bit like you have done, to satisfy itself that the proposal is sound. I am not personally involved in that process. I do not deal with emergency surgery, so I have not been involved. Policy side will be engaged as well at that point. If the proposal is deemed to be major or controversial, it will go to the Minister for sign-off as part of the process. That is how the process works.

Mrs Dodds: Did the Minister sign off on the moving of emergency surgery from Daisy Hill Hospital to Craigavon Area Hospital?

The Chairperson (Ms Kimmins): That was the permanent secretary.

Mr Jakobsen: We did not have a Minister at the time.

Mrs Dodds: The permanent secretary at the time signed off on that.

Mr Jakobsen: I am pretty sure of that, yes.

Mrs Dodds: OK. Look, I am not interfering in a constituency matter. Alan kindly invited me to the meeting, because I am interested in how, when it makes a proposal for change, a trust arrives at its preferred option. I am also interested in what work has been done in the background to ensure that the preferred option will work. I was not terribly reassured, and I have just prepared a letter to that effect. Alan may want to come in on that.

Mr Robinson: Diane is correct. I will be a bit more direct. Please, forgive me, Peter, but some of the planning assumptions and scenarios that were presented to us of potential patients who would present at Causeway Hospital were based on a world in which we do not live. They were based on a perfect health service without the pressures that, you know and we know, the health service is under. Forgive me for saying this, but the scenarios that were presented to us yesterday were bunkum. They were total bunkum. I was direct with them: I told them that we need to live in the real world.

Mr Jakobsen: I cannot comment on the Northern Trust's consultation. All that I can say is that there is a process to follow. Those questions should be asked through the SPPG and the PHA.

Mrs Dodds: I presume that the Department will then ask those questions. Can you reassure me of that?

Mr Jakobsen: That is what I am saying. There is a process. The Department will engage with the trust following the consultation. If it follows the previous —.

Mrs Dodds: The trust is not in my constituency. I am not commenting on the merits or otherwise of the proposal, but, when I looked at the planning assumptions, they caused me significant concern.

The Chairperson (Ms Kimmins): Thank you both for your time today. Hopefully, we will soon see the three-year plan —

Mr Jakobsen: Hopefully.

The Chairperson (Ms Kimmins): — that will set out the detail on the next steps in the transformation process that we have asked about today. I appreciate your coming to the Committee today. Thank you.