Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): You are all welcome back. In attendance we have Lisa McWilliams, director of performance, strategic planning and performance group; Dr Tomas Adell, director of elective care and cancer policy; and Joanne Elliott and Catriona O'Connor, both of whom are heads of elective care policy. Thank you all for being here.

Tomas, I know that you need to leave at around 3.00 pm.

Dr Tomas Adell (Department of Health): Yes. We all need to leave at 3.00 pm.

The Chairperson (Ms Kimmins): Everybody needs to go at 3.00 pm. OK. Let us keep the opening remarks as brief as possible, and we can then open the session up for questions, if that is OK.

Dr Adell: Yes. I believe that my opening remarks were shared with you by accident.

Mr McGrath: We have already read them. [Laughter.]

Dr Adell: I will keep my remarks very short. First, thank you very much for having us here today and putting us first on your agenda. You know who we are, and it is great to be here again. We have shared a briefing paper with you and my opening remarks, and I hope that you found that helpful.

Quickly, there are four things that I want to address. The first is the concept of a big bang in elective care. You want us to say that we will do just one thing that will solve waiting lists: I want to make it really clear that there is no such one big thing that we can do. The big transformation in waiting lists and elective care is elective care centres. It is creating various levels of day procedures, elective overnight stay centres and complex elective care centres. The fundamental structural change required has, essentially, been done. We have day procedure centres, elective overnight stay centres and a complex care centre in Belfast City Hospital. That is really good work, and it presents good news stories around what is happening. In the interest of saving time, I will not go through where exactly those are or what has happened, but you know roughly what is happening. This is the big reform: it works in other jurisdictions, and we know that it works here when it is working well. That does not mean that there is not more to be done in those areas, but the big changes have been done.

On top of that, we need to do everyday reform. We need to make sure that the day centres work well, that each speciality operates as effectively as possible across the spectrum and that pathways are as perfect as they can be. All of that is really important work, and it is hard, grinding work that takes significant time. None of those things alone will create massive change, but many small things added together create a big difference.

We have created reviews of general surgeries and set standards for surgeries that are applicable across certain specialities. We do "Get it right first time" reviews of a number of specialities. We are looking at outpatient modernisation so that we can have a better outpatient service. That is happening across many areas. That work is hugely important and is at the core of what we are focusing on in order to make sure that things work well and are optimal. It is important to highlight the fact that difficult decisions will have to be made as part of that work.

Some procedures that traditionally result in patients staying overnight will need to be done as day cases in treatment rooms. That will mean a cultural shift for our patient population. Many patients assume that, when they have elective surgery, they need to stay in hospital overnight for the best outcome. The reality is that it is best for the patient to go home as soon as possible. That is not just for efficiency; it will be better for patients, and it will make the system much more efficient.

Another move is to patient-initiated follow-up. The change will mean that patients may not be asked to come back to see a consultant after surgery; instead, they may be given information on how to contact the system, if they need to do so. That is better for patients. It works. It avoids patients travelling to hospitals unnecessarily. It works really well across cancer services. Most cancer patients are not asked to come back for regular check-ups; instead, they are asked to contact the system if something is wrong. That is a big cultural shift that we need to go through.

We also want to reconfigure how services are delivered. That is not about closing things; rather, it is about moving a speciality from one hospital to another to make sure that the service is more efficient and provides better patient outcomes. Obviously, we will do that with you and the wider public, but it is important that we look at how we get that right. We do not expect every hospital to do everything; instead, hospitals can specialise in certain areas so that one hospital becomes really good at something and another hospital becomes really good at something else. That will be better for patients, because the staff will be doing that work all the time. It will also be better for efficiency, because the system works better that way.

We cannot do that alone. We need your help and that of the public. I am not saying that you should not challenge us — please do — but we have to accept that the answer cannot just be no. There has to be a want to change. Those are difficult things to do, and there are other things as well. We certainly hope that, when we come with proposals, we will get your support, after robust challenge, of course. I am not asking that you do not challenge us.

I want to address the huge patient backlog. We have two problems: demand versus capacity and a backlog. The backlog is huge. The numbers are completely unacceptable. That is not a new problem. If you look at our statistics, you will see that it has been going on since 2010, bar a short exception in 2013. Fixing something that has been happening for many years takes time. We cannot fix the huge backlog quickly; it is simply impossible. We estimate that it can be done in five years, if we have huge investment. However, we want to make it clear that it will be not an easy fix.

When it comes to investment, we have a significant gap between demand and capacity. For elective care services, which are those outside cancer and time-critical cases, we estimate that there is a gap of about £80 million a year. To deal with the demand, we need to increase our capacity. That is after the efficiency work that we are doing currently. Ever after making efficiencies, we still have a significant gap. If we fix the backlog but do not fix the gap between demand and capacity, patients will keep being added to the lists.

As I said, we need to fix the backlog. We estimate that it will cost up to £135 million a year for up to five years. Obviously, the numbers are big. There will be variations if we get funding to go through that, and, hopefully, with everything that we are doing, we can reduce that cost. That is our estimation on the basis of who is on the waiting lists. It is a very significant investment requirement in a challenging context, but that is the reality. We cannot do it by just making efficiencies or just doing things better. To fix those things, we need to invest or to reduce demand by changing whom we treat. Those are the options available to us.

That was a quick tour of my opening remarks. Thank you very much. We are happy to take questions.

The Chairperson (Ms Kimmins): Thank you, Tomas. We had an informal session in which we teased out some of that. Certainly, the figures in the briefing paper on the waiting times for breast cancer services are absolutely shocking. You will not be surprised that I raise that. I want to speak to that first, if that is OK. I had this conversation today with a GP. I know that the Minister announced the regional service, so I am keen to hear where that is.

The table shows that the figures for the 14-day target are getting worse for every trust. At present, the average number of people seen by that target is just under 31%, and those are urgent referrals. The figures that really confused me — "confused" is not the right word; they shocked me — were those showing the difference in the Belfast Trust. In September 2023, 95·6% of people who received an urgent referral after being seen by a breast cancer specialist were seen within that target. Three months later, only 25·1% were being seen. That has got continuously worse. In March, it was 20·4%. We do not have the figures for June because of the roll-out of Encompass. Is there any explanation of why there was a fall from 95·6% to 25·1% in those three months?

Dr Adell: There are a number of reasons. The first thing to remember is that the 14-day target is a black-and-white target, so, if somebody is seen on day 14 or 13, they are within the target; if they are seen on day 15, they are outside it. Therefore, even a small shift will show. If patients are often seen at 10, 11 or 12 days, a small shift in capacity or other small change will push everyone above the target. In that period, the South Eastern Trust went live with Encompass, so its capacity was reduced and the Belfast Trust was taking on its patients. That is one big reason.

All the services in the region are small and have a small number of staff. There are a small number of consultants in each trust, so, if one consultant is not available for whatever reason — sick leave, maternity leave, annual leave — the service struggles straight away. Small changes can have a big impact on the numbers, whereas the total difference is not necessarily that big.

Looking at how long people wait in Belfast, let us take it from the beginning of November for people who do not have an appointment yet. Most patients wait for less than 14 days; some for between 15 and 21 days; and some between 22 and 28 days. No one waits beyond 35 days. That is better than it was a year ago. It is improving, but it is not as good as it should be.

The Chairperson (Ms Kimmins): I appreciate that; it is just to get an understanding. When you look at all the figures, you see that that was a huge fall in a short time. I know that Encompass will have had an impact, but the percentage continues to decrease. That really shocked me.

Then we looked at the Western Trust, whose performance is gradually worsening, but, in June this year, it was still able to achieve 82·6% within target. Have we an idea of why it is doing so well in comparison with other trust areas?

Dr Adell: The Western Trust is doing remarkably well. The latest stats show that no one waits more than seven days for the service. One reason for that is that it has a stable workforce, and that workforce is willing to do extra hours to accommodate all its patients. The core stability of the workforce means that it can see the patient who should be seen.

In the whole region, there are about 16,000 referrals in breast cancer over a year. The system deals with about 16,000 patients. Therefore, over 12 months, we do not have an overall increase, but the number goes up and down in different places. The Western Trust is really stable, so it is always really stable. All the other trusts fluctuate. That is why we want to regionalise the service: to make sure that we have the same lengths of wait everywhere, so that, wherever you are from, you have the same access to service.

In the beginning of that work, we expect the percentage meeting the 14-day target to decrease. It will get worse because everyone will have to wait a little longer. Therefore, because the waits will be equalised, the Western Trust will get worse. However, instead of some people waiting seven, eight, nine or 10 weeks, everyone will be waiting three or four weeks, if that makes sense. That is because we are equalising those waits.

The Chairperson (Ms Kimmins): The Minister has announced a regional service. Where are we with that? We see such a difference across trusts. I know that, generally, the performance of the other four trusts is pretty low. Do you feel that a regional service will help to introduce more equal access and that greater equity in capacity versus demand will mean that people can access the service more easily?

Dr Adell: The initial phase is the single waiting list, which will go live for the Belfast, Northern and South Eastern Trusts first, because they have one data system. That means that patients will be allocated a space where the next available slot is. Obviously, it is common sense to place people as close to home as possible, if that is possible. However, the waits should be equal across those trusts. The Southern Trust will go live soon after the Western Trust. It will probably wait until after the Western Trust, which does not have a backlog, goes live in May next year.

The Chairperson (Ms Kimmins): When will the Belfast, Northern and South Eastern Trusts go live?

Dr Adell: In the next few months. I do not want to give an exact date

The Chairperson (Ms Kimmins): OK. Did you say that the Southern Trust will go live in May?

Dr Adell: No. The Southern Trust will be soon after that.

The Chairperson (Ms Kimmins): The Western Trust will go live in May.

Dr Adell: The Western Trust will go live in May. It does not have a backlog, so it is not an immediate concern in the same way as others. For the other trusts, we want to make sure that we equalise waits very quickly.

It is not the fortnight target that worries me most but the really long-term waiters. In reality, if somebody waits for two or three weeks, that will not have a great impact on their clinical outcome. If somebody waits for eight, nine, 10 or 11 weeks, however, that can have a great impact on their clinical outcome. There are people in the Southern Trust who are waiting for over 42 days for an appointment. There are people in the Northern Trust who are waiting for more than 36 days for an appointment. That is what we need to fix. It is a priority to fix those things. Do not get me wrong: we do not want people to wait for 13 or 16 days — we want the wait to be as short as possible — but we first have to address those who are waiting a really long time.

The Chairperson (Ms Kimmins): If you tie together all the funding that, your briefing paper states, is needed, it comes to approximately £291 million, which includes £76 million for this year. How confident are you that that can be achieved? I ask that because, if we were able to tackle waiting lists, pressure would be relieved elsewhere. I know that you know that, but is that being emphasised in the broader conversation in the Department? Is part of that conversation, "If, for subsequent bids, we can allocate that within our budget, it might impact on other areas in the short term, but it will actually have a benefit"?

I meet GPs, and they tell me — we know this; we have had these conversations — that people are coming into their surgeries who are on a waiting list for treatment for a hip, a knee or whatever it might be. Those people are in chronic pain and are in their GP surgeries constantly. That is a huge pressure. There may also be people who are in A&E, depending on what the issue is. It is about trying to balance that out. Is part of the conversation, "If we don't do this, we will need more money in the budget over here, but we could take a risk and allocate more to the waiting list initiatives outlined here, which will have a timely benefit"? Do you understand what I am asking?

Dr Adell: Absolutely, and that is very much part of the discussion. We know from research in other jurisdictions that somebody who is on a waiting list goes to their GP surgery somewhere between once every month and once every two months. When you are talking about quite a few hundred thousand people, that is a lot of GP visits. It is the same for emergency department (ED) attendance and so on. We highlight that to show that the financial pressures across the system are huge. There are difficulties. It is hard to take money off unscheduled care when there are people standing in EDs.

The Chairperson (Ms Kimmins): Absolutely. I am not suggesting that you do that.

Dr Adell: It is a difficult scenario. One of the problems that we have is that that kind of care — secondary care — is expensive. Theatre work is one of the most expensive things that we do. To get to the levels that we need, a lot of other stuff would have to stop. The other way round would be easier in terms of financial equalisation

The Chairperson (Ms Kimmins): I get that. I was just trying to understand how it has worked out like that. If we got a really good grip on waiting lists, we would see benefits across the system.

I will ask one more question that ties into that. It is about waiting well. What work is being done to help patients who have been waiting a long time to wait well? It is a huge issue, given that it puts pressure on other aspects of the health service. I recently met organisations that are vocal on that issue, including Versus Arthritis. It is right that they are vocal on it. It is about the broader impact, going back to the example of orthopaedics, on people who are waiting for surgery and are out of the workforce for the period that they wait, as they are not always retired. There is an impact on their quality of life and all of those things, and that has a broader impact not just on our health service but on the economy and our communities. It would be good to get a bit of understanding of what work is being done on that.

Ms Catriona O'Connor (Department of Health): A team in the Department is working on the development of a waiting well policy. You mentioned Versus Arthritis. We are very engaged with that organisation and with the Long Term Conditions Alliance. We have met and engaged with officials in Wales. Our Welsh counterparts have a policy called the "3Ps", which is about promoting healthy behaviours, preventing deconditioning whilst waiting and preparing for treatment and recovery. We are very much in that space, where we recognise that the biggest problem is trying to reduce the waiting lists, but the reality is that people will wait, and, while they wait, they have the potential to deteriorate. We need to support them and signpost them to where they can get support when they need it, even for the likes of rehabilitation or just knowing what charities are out there to help them. We recently funded a local pilot in the Western Trust to test the concept. It is about looking at patients on orthopaedic waiting lists and directing them to things like walking groups and other things that can help them to stay active. It is a huge issue but one that we recognise the need to act on. We are working on that and hope to have a policy drafted within the next six months that we will then take to public consultation.

The Chairperson (Ms Kimmins): OK. Thank you, Catriona. You have just reminded me of something that came up when we met the trusts to talk about the number of people who did not attend appointments. It has sparked a real conversation about what we are doing to tackle that. I learned, even from that meeting, that there are methods in place across the water and in other areas to tackle that using AI and other technologies. That leads me to ask this question: is there a focus on looking at why people do not attend? I know that people get calls the day before and all of those things, but there is still a reason why people do not attend. It is about trying to make sure that we do not lose sight of that and looking at whether there are issues with people getting to appointments. Is there a particular emphasis on that?

Ms Lisa McWilliams (Department of Health): I will respond to that. At the moment, if an individual does not attend an assessment or a treatment appointment, there is no mechanism to catch that individual's feedback on why they did not attend. Therefore, trusts have done small-scale audits. Some of the questions were about whether travelling to one of our new elective centres was an issue, and the Western Trust's audit found that travel was not an issue. There is no systemic way of capturing that information, so we have asked the waiting list management unit to audit a cohort of the June "Did not attends" (DNAs) for Lagan Valley. We are working with the South Eastern Trust to get the data access, and then we will reach out to those individuals. We need them to engage with us when we reach out, so that we can understand why they did not attend. The reason for doing that is that it may be that we had not given the right information to them or that they had no way to contact us when an issue arose. We will use that audit to change some of the communication.

We need to understand whether it is about value: is the appointment valued? If someone has waited a long time, you might assume that it does not have the same importance and that they can wait longer. Is that an issue? If that is the case, we need to be clear that it is not a free good; it is stopping someone else having access to that slot. We need to speak to the individuals to capture that information, and we will target the issues that emerge.

There is something about indicating how many of the slots are lost and how much that costs the public. We need to target communications. We know that the cancellation level for pre-op assessment is one of the challenges, so we are working on pre-op assessment across the region to see whether we can make that better. If someone has been on a waiting list for a long time, we need to make sure that the pre-op assessment is correct so that they are still being signposted to the right location. We need to ensure that their condition has not changed so dramatically that they are no longer suitable for the procedure or that they need to move from a day case procedure to an inpatient procedure. We are already doing work in that area, but we will commence that audit in January.

The Chairperson (Ms Kimmins): Yes, it is critical, given that we are trying to increase capacity and get through the waiting lists. The slots are there, and, if someone got a phone call the day before, they could easily take one of them. I understand how that is possible.

I will not go on any more. I could, but, given that our time is limited, I will not.

Mr McGrath: Thank you very much for your opening remarks, not least for getting them four days in advance, which was useful.

In your remarks or your submission, there was reference to a 20% reduction in waits. The Minister also mentioned a 20% reduction in waits in his speech on Monday. However, he went on to say that, taking into account the data available for the Belfast and South Eastern Trusts, it represented a decrease of 5·5% in the numbers waiting. Is it 20% or 5·5%, or is it 20% for some and 5·5% for others?

Dr Adell: You may not have seen the document, which refers to a 14% reduction. It depends on how you count. Treatment waits seem to peak in 2022 compared with the latest stats that we have for all trusts, although that is in the knowledge that the Encompass data is not necessarily as safe as we want it to be. There was a 14% reduction in that period, and, obviously, one reason why the document was not meant to be shared with you was that the numbers had not been fact-checked. Please accept our apology.

Mr McGrath: That leads into the next point, which is the importance of data to the Committee in carrying out its scrutiny role. I am beginning to worry that we are hiding behind Encompass a bit when it comes to not being able to give accurate or up-to-date figures. That is the case for the South Eastern Trust and the Belfast Trust at the minute, but we will quickly have the rest of Northern Ireland online with Encompass. I feel that, next year, we will stray quickly into a phase where the figures that are being presented will not be accurate and will not tell us anything. From your perspective, why is it that Encompass cannot provide the information that we need? It is supposed to be all-singing, all-dancing, and I suspect that the words "all-singing, all-dancing" were probably used when the business case was being put together to spend tens if not hundreds of millions of pounds on it. Why can it not tell us what the waiting times are and how long people wait?

Dr Adell: There are many answers, and Lisa can provide some of them. One thing is that we need to make sure that we measure exactly the same things. When do we start to count something? When do we not count something? What do we count and not count? Different systems have different starting points because things are coded differently. That is one reason why it is difficult to compare data straight across. Data for the South Eastern Trust and Belfast Trust are published but with the caveat that there might be inaccuracies — or, sorry, that we are not as confident. That said, our waiting list numbers are so big in the first place that, if we — I do not mean to sound flippant — are a little bit off, it does not change the scale of the problem that much. The scale of the problem is still completely unacceptable. Does that make sense?

Mr McGrath: Yes, sure. Fair enough.

Ms McWilliams: There is a difference between data — the official statistics that need to meet the industry guidelines — and management information, which is what the trusts and the strategic planning and performance group (SPPG) management use. We have information that allows us to see the trends, and we still use that. We are looking at that area.

Scopes are a good example. You mentioned the reduction in waiting times. Scopes waits are now back to their pre-March 2020 level, which is a 35% reduction. We had a big peak after COVID because scopes were one of the areas of concern during COVID. That list had a massive rise, but we can see that it has reduced by nearly 14,000. We can see that through management information, which might not meet the industry standards for official statistics. There is still information available.

With Encompass, as with any new system, as Tomas indicated, when we are first pulling reports, it is about checking whether something has changed. Have we changed the way that we set up a service? Are we counting the same inpatients as we were counting before? That has been a real challenge because that is not necessarily a direct read-across.

There is an embedding period. The Northern Trust is the most recent trust to have gone live, and it is working through that process of understanding whether there are workforce challenges and whether the system is being used correctly. We will have that period for every trust that goes live. The next two trusts go live at the same time in March, so there is an acknowledgement that they will go through a similar verification process whereby the official statistics will take a bit of time to have the conditions and caveats removed, but that does not stop management information, which trusts will use at service level. We certainly have access to that from a performance and planning perspective.

Mr McGrath: Absolutely. For the purposes of performance and accountability, we need those figures. We cannot just continually go, "Oh, sorry, Encompass is there. It is skewing it". I hope that that gets settled soon.

I have a final question on waiting times. We rely on our health service staff. They are worked to the bone. Many of them are stressed. Many of them are approaching burnout. They are covering extra shifts and extra hours, and we still are not even at a stage where we can confirm that we can pay them the same amount as is paid to other professionals across the UK.

Yet, on Monday, we were told by the Department and the Minister that you are going to get them to do another 57,000 health service initiatives by just working harder. How can we ask our staff to work harder than they are working at the minute and not guarantee them the right level of pay? Already, through all of the agencies, they are telling us that they just can do no more. How is it possible to come up with 57,000 extra initiatives?

Dr Adell: There are a couple of things. First, we all want to acknowledge that our health service staff work really hard. There are no questions about that. I must declare an interest that my wife is a nurse.

Mr McGrath: If you get up in the morning and tell her to work harder for the day, you will be in trouble.

Dr Adell: The key thing is that it is not about asking individual staff to work harder; it is about getting the systems to work better so that the staff can do what they are best at. It is not the staff but the system that needs to work better, if that makes sense. We need to enable staff to do what they are good at. That is, essentially, management's and our issue, not the staff's issue.

Ms McWilliams: We have alluded to the efficiency and productivity drive. The calculations that we have done have been looking at where we could be, if we were at our optimum theatre utilisation — we are not quite there in some areas — and if we were to use all our tools to address the DNAs and if we were to tighten up the hospital controllable cancellations. Those are all the calculations that lead to that. It is not about longer days without that being paid for, and it is not about doing weekend or evening lists without that being paid for. As Tomas said, it would help if the system complied with the protocols that we have for people who have not attended for a number of appointments. Instead of being discharged, those individuals are being kept on, and that is not good for the system and uses slots that others could use.

The additional factor is that efficiency and productivity being put in and modelled against benchmarks where we know that we have areas to move so that we have a full calculation behind it. It assumes that we will not have any significant loss in workforce over the next three years but are just driving that efficiency and productivity. It is about the system helping the teams and having the right focus and clinical teams being supported throughout their organisation. It is about having the focus on ensuring that we have best value for money with the resource that we have. Can we be sure that we are using it? It is not about doing more through doing extra hours without pay; it is about being really strong with our processes.

Mr McGrath: I still contend that the 57,000 extra interventions will have to be carried out by doctors, nurses and healthcare professionals, so they will be doing stuff that they previously will not have been done.

Ms McWilliams: Some of that is about getting back to our pre-COVID levels, which we are not at. They were previously doing that, so it is going back to some of those levels.

Dr Adell: Theatre staff want to operate. That is what they are there for, and that is what they enjoy doing. If one in 10 patients do not turn up, the staff are standing in theatres ready to operate but do not have a patient. If we as a system can reduce DNAs, they will have a patient. That is what they want to do. They do not want to stand around doing nothing. It is not about asking more of staff but about making sure that staff get the opportunity to do what they want to do.

Mr McGrath: Some of the next questions might be from a practising healthcare professional who may tell you that not many people are standing around doing very little, but we will pass on that.

The Chairperson (Ms Kimmins): I am conscious that we have less than 10 minutes before the officials need to leave. The members with questions are Alan Robinson, Diane Dodds and Danny Donnelly. Please keep that in mind. If there are any questions that we do not get through, we can follow those up in writing.

Mr Robinson: Thank you, team, for giving us the overview. I am not sure that any of us will leave today with a spring in our step, given the detail in the first few paragraphs. On top of the £76 million, you require £80 million in recurrent funding and £135 million in non-recurrent funding. We are grasping onto any good news that we can get from the report.

I notice that reference is made to Shared Island funding. Can you give us some information on that? It refers specifically to a number of high-profile cancer projects. Can you give us a bit of detail on that?

On the back of what Liz referred to about those who did not arrive for appointments, I assume that the increase in traffic congestion in Belfast is adding to the number of people who are not getting to the main hospitals in Belfast. Is that data being captured?

Dr Adell: On the Shared Island funding, I will have to come back to you in writing with the details. There is cross-border work among officials on cancer that has been going on for a long time, and there have been discussions on the Shared Island funding about what we can do to enhance the cross-border work. The North West Cancer Centre, for example, takes patients from the South and the North. We have had meetings with officials from the South on those issues, but I will have to come back to you in writing with the details.

Ms McWilliams: On the specific point about traffic congestion and the impact on "Did not attends", we will have to pick that up with Belfast. I do not think that they have done an audit to capture that, but, I think, traffic conditions are more likely to show individuals turning up late for appointments as opposed to not attending. Where possible, clinics and even theatres will move around to accommodate that. Some of the Lagan Valley Hospital's audit might be for patients who had to travel through Belfast to get to Lagan Valley, so that might be picked up in that audit. However, I have no evidence at this stage that traffic congestion has played a part.

Mrs Dodds: The figures that you quote for cancer waiting lists are up to June 2024. I quoted those statistics in a debate in October on cancer waiting times in the Southern Trust. I received a letter from the Minister on 29 October that went through some of the issues that I had raised about those very statistics. He said that there were plans to reduce immediate pressures by transferring people to other trusts with additional clinics and mega-clinics. I understand that the South Eastern Trust, at least, has convened mega-clinics. Why did you wait so long to convene the mega-clinics, and why did we have to have that level of scrutiny for those mega-clinics to happen, when you knew that cancer waiting lists were that bad in June 2024?

Dr Adell: The cancer mega-clinics and moving patients around is not a new thing. That has been going on for a long time.

Mrs Dodds: I sense that some of those mega-clinics have happened since the letter of 29 October.

Dr Adell: Absolutely. The Southern Trust took breast patients in April. On a rough calculation, 200 patients were waiting for more than four weeks for an assessment. At the beginning of November, that figure was about 30.

Mrs Dodds: Yes, because it had the clinics in between time.

Dr Adell: Because it had clinics.

Mrs Dodds: My question really, Tomas — I do not want to focus on this issue, because I have a couple of other questions that I want to ask you — is this: why does it take that level of scrutiny before we get to the mega-clinics and so on? You knew that that was happening. Those are figures from June. They are old figures; they are almost six months out of date now. I hope that, when we see the figures in a short time, they will have improved dramatically. However, it seems to me that it always takes a bit of a push and a hue and cry to make the thing move, and that is really bad.

I will just talk about women's health. Why do we do that? We have the example this week of the Southern Trust and the issue of women's health. We have the example of breast cancer policy. I would really like to know the answer to that, but I do not want to focus on that today. I have a couple of other questions that I want to ask.

Dr Adell: I will answer quickly. I will take breast cancer as an example. Those clinics are not happening just after correspondence or just after stats; they are happening where the need is greatest. Earlier this year, in January and February, they were in the South Eastern Trust, because that is where the longest waits were. Patients moved from the Southern Trust —

Mrs Dodds: To shorten this, because I do not want to keep you beyond 3.00 pm, maybe somebody will write to us and tell us what mega-clinics happened, why they happened and what the stats were that triggered those mega-clinics etc. That would be useful.

Dr Adell: Do you want to focus on breast cancer as an example, or do you want to focus more widely?

Mrs Dodds: Even if we focus on breast cancer at this point, because those are the stats that you gave in the presentation, that would be useful. That is to let us know where we start.

You said that elective care centres are the way forward. That is fine; you, along with the clinicians, make those judgements. I am content that that is the way forward. I have asked questions about the elective care centres that we have. At what capacity are they operating? Could they operate at a greater capacity? I note that the Northern Trust wants to make Coleraine an elective care centre. If we had more, how many more operations would we do and how many more surgeons, theatre staff etc would we need to do that? That is one question. I am happy for you to write to me in response; I know that you are running out of time.

The other issue is no-shows; patients who do not turn up for an appointment. We had the chief executives of the trusts in here. I was interested in something that you said, Lisa. The chief executive of the Western Trust said that people do not show up for appointments because they cannot afford to take time off work. Are you telling me that there is no particular data on why patients do not show up or that trusts have not done that kind of data audit? I wonder whether the evidence that we were presented with was anecdotal or data-driven.

Ms McWilliams: The trusts all confirmed — we spoke to them after the evidence that was given — that they have only small-scale audit information. The Western Trust identified that travel was not an issue and said that communication and pre-op assessment was an area that it was focusing on. That is the information that the trusts have provided.

Mrs Dodds: I wonder why we were given that kind of information in the Committee.

Ms McWilliams: There is some evidence nationally that —

Mrs Dodds: No, no; that was specific to the Western Trust.

Ms McWilliams: — it was socio-economic.

Dr Adell: We cannot comment on what was said.

Mrs Dodds: When people come to Committee, they should have evidence that they can stand over.

Dr Adell: On elective care centres, we are happy to write, because we have modelling —.

Mrs Dodds: That is fine. I accept that.

Two Mondays ago, a number of members and I met parents of children who are waiting for percutaneous endoscopic gastrostomy (PEG) surgery. They are probably some of the most vulnerable children in our society. They are likely to have complex medical needs. PEG surgery would really help them to start to thrive in a way in which they cannot currently. I would like the Committee to have information on exactly how many children are waiting for that surgery. For how long have those children been waiting? Do you make a distinction between children who are waiting for the initial insertion surgery and those who perhaps need a resiting of the PEG tube that they already have?

I had a constituent with a young person, and the area around the child's PEG tube has broken down badly. They probably need it resited — I am probably not even using the proper clinical terminology — but they cannot get that done. That child is in constant pain, and they live in fear of infection etc. This week, I met a mum whose little boy has a bleeding condition and had pulled out his nasal tube. They went to the children's hospital at the Royal, but they were told that it could not be put back in because the hospital did not have the correct staff to monitor his other conditions.

The situation that we have is intolerable. We had a waiting list initiative in October. I want to see what we are doing to resolve the issue. We should not be keeping those children in pain and on waiting lists for a long time.

The Chairperson (Ms Kimmins): Danny, I am so sorry. We are very tight for time. If your question cannot be responded to now, it can be responded to in writing.

Mr Donnelly: I have a couple of questions. I will write to you, Tomas. As you probably know, they are about the gap in the decrease of patients and whether we have a breakdown of the patients who have left our waiting list system entirely for reasons other than having had their operation. Do we know how many patients have left the system to go privately? We know that there has been a huge expansion of private healthcare in Northern Ireland.

Dr Adell: The simple answer is that we do not know that.

Mr Donnelly: We know that there is a two-tier system in Northern Ireland and that people are driven to the independent sector (IS), but we do not know how many of them have been on our waiting lists and for how long.

Dr Adell: We do not have information on what is happening in the private sector.

Mr Donnelly: We are celebrating a decrease, but we do not know what is driving it.

Ms McWilliams: We have information where waiting lists have been validated on the reason for patients coming off, but it does not give us a quantification. It will probably say, "Treated already", and it may be because the patient has come through an emergency department or been treated in another trust. It would not specify whether they were treated in the IS. We have information, but, if the IS treatment is not funded through our waiting list initiatives, it is commercially sensitive, and we do not have that.

We certainly have a breakdown of where our validation has removed individuals from a waiting list. The pre-op assessment mega-clinics will remove some patients because they have competing conditions that are much more serious or they might be an inpatient and not be suited. We have a level of information, but we do not have statistics on whether the patients were treated in the IS, unless we have paid for it through the waiting list initiatives.

Mr Donnelly: We do not know how many people on the waiting lists are effectively being driven into the independent sector.

Do we know how many people are passing away while on the waiting lists? Will that count as part of the decline?

Ms McWilliams: I need to check that, because we have an automatic system to capture deceased patients. I will double-check the information and whether we can give it to you.

Mr Donnelly: Will you write to us with the results?

Ms McWilliams: Yes.

Mr Donnelly: I will follow on from Diane's question about children with PEG tubes. From what I understand, there are fewer than 100 children on a five-year waiting list for a procedure that takes about 15 minutes. Surely there is —.

Ms McWilliams: We have asked the Belfast Trust for an action plan. Diane alluded to the waiting list initiative, and there has been work with other hospitals, such as Alder Hey Children's Hospital. We have asked the Belfast Trust for an action plan in that space, because of the concerns that we have about the individuals who are waiting.

Mr Donnelly: I appreciate that there are probably other groups in similar situations, but this is children in pain.

Mrs Dodds: It is terrible.

The Chairperson (Ms Kimmins): Thank you. We are slightly over time; apologies. We appreciate your time, and there will probably be some follow-up questions that we did not get to.

Dr Adell: We are always happy to write or come back to the Committee.

Mrs Dodds: If somebody writes to us about the issues that I raised, that would be great. Thank you.

The Chairperson (Ms Kimmins): Thank you all very much.

Mrs Dodds: Have a nice Christmas.