Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): Minister, thank you for agreeing to meet the Committee today at such short notice. We appreciate that it is a very busy time for everybody, but I hope that you recognise why we wanted to meet. At the outset, I will say that the purpose of the meeting is not to attack or be critical of anyone. I know that everyone is trying their very best, but we need to give the public confidence and understand what the key issues are and what can be done and is being done in the here and now and inform future planning. We really appreciate your coming today, Minister, and thank you and your officials for your time.

The Minister is joined by Tracey McCaig, the chief operating officer of the strategic planning and performance group (SPPG); Jennifer Welsh, the chief executive of the Northern Health and Social Care Trust (NHSCT); and Dr Joanne McLean, the director of public health at the Public Health Agency (PHA). You are all welcome.

I remind members and witnesses that we have approximately one hour and 30 minutes for today's session. I know that Committee members will have lots of questions to ask and points that they wish to raise, so I ask that they be respectful of other members so that we can give everyone time. If there is time at the end and we need to come back on anything, I will be flexible, as we work through it. The session will be reported by Hansard.

I invite you, Minister, to make some opening remarks, after which I will open up the meeting to members.

Mr Nesbitt (The Minister of Health): Thank you, Chair. I welcome your invitation to join you and to work collaboratively on the issue. You will be aware that I am keen that the Committee assist and advise as per the Northern Ireland Act 1998.

I begin by paying tribute to all Health and Social Care (HSC) staff for the work that they have carried out over the Christmas period. Many of them have not had the opportunity for a break, when many take such a break for granted at this time of year. I am very grateful to them, but I understand that we cannot run the health and social care service on goodwill for ever. It has to be, by definition, finite.

I have been looking for levers in the short term, but, as you know, I am also offering a blank page for next year. However, we need to be honest and realise that there is already an available slate of immediate actions. If available, they would have been implemented a long time ago. However, what is happening, where resources allow, is the implementation of the short-, medium- and longer-term recommendations following the Getting It Right First Time (GIRFT) review of urgent and emergency care.

Among the measures that we were able to introduce was the introduction of Pharmacy First sore throat services across all pharmacies in Northern Ireland. They started from 1 December 2024 for everybody aged five and over. There was also the roll-out of vaccination programmes for COVID-19 and influenza, along with an additional respiratory syncytial virus (RSV) vaccine. We had the provision of an extra £3·4 million to help GP services to meet additional winter demand, with a further £4·6 million being provided to assist the delivery of proactive support and care to people in nursing and residential homes. There was also the provision of Phone First services across all geographic trusts for urgent and unscheduled care. Over 160,000 people accessed the Phone First and urgent care services last year, 85% of whom completed their care without needing to attend an emergency department (ED). An additional investment of £5 million has been allocated to trusts for 2024-25 to enhance independent sector provision of care packages for the over-65s. To make best use of available home care capacity, trusts have also been provided with £697,000 in recurrent funding to establish early review teams to help to release capacity by identifying whether needs have reduced in the period since returning home.

Chair, I emphasise that this is not just a Northern Ireland-specific problem. Over the weekend past, a Liverpool health trust declared a critical incident. Similarly, two others — Plymouth and Hampshire — have declared critical incidents. I say that not to minimise the importance of what is happening here but to illustrate that the pressures are serious and nationwide. Across Northern Ireland, we have seen 3·6 times as many patients hospitalised with flu this winter compared with last year.

I will not insult members by asking them when they last visited an ED — none of us could compete with Mr Donnelly on that front — but I have made several planned at short notice visits. This morning, I visited Altnagelvin ED, which is the oldest, and, this afternoon, I visited the Ulster ED, which is the newest. There are common themes. Patients arrive with a reasonable expectation that they will not have to surrender their dignity and privacy, but that is often the case in these times of crisis. Staff are suffering moral injury. They did not sign up to deliver a service in this way.

Emergency department pressures are a symptom, not the cause. That is not my assessment but the view of the Royal College of Nursing (RCN), the Royal College of Emergency Medicine (RCEM), trust emergency consultants, ED managers and ED directors. We face a whole-system challenge involving who comes through the front door and then where they go. Is it to an ED? Is it to an ambulatory unit, such as an urgent care, respiratory or cardiac unit? Is it about Hospital at Home? Is it about access to GPs? Is it about Phone First? Of course, it is about all of those things. It is also about getting people out the back door. We know that domiciliary and care home availability and capacity is a huge challenge. We also need to increase the workforce and increase pay.

As I said, I offer a blank page to look ahead to the winter of 2025. The question for you, Chair, is this: what role does the Committee want to play? Does it want to be positive? It appears to me that certain MLAs engage only after the fact, when the opportunity arises to criticise without offering alternatives.

I published the winter plan on 6 November 2024, but it had been planned since springtime — March 2024. The plan was clear that it expected a very difficult winter and that it would not eliminate the pressures but, at best, mitigate them. We know that people get sicker for longer over the winter months and that that adds to the 365-day pressures on the EDs and the whole HSC system.

Winter pressures are real, but they should not take our focus away from the fact that ED pressures are now felt daily. If anybody around the table thinks that there is an easy, quick or cheap solution, I am afraid that they are mistaken.

HSC, of course, needs buildings, equipment and medicine, but it also needs staff. Without the staff, everything else is meaningless. My most important contribution to addressing winter pressures was to avoid immediate industrial action by staff. On that front, Chair, I need all your parties to help with the relatively small gap in delivering pay parity that I need to close. I invite you to encourage your Executive colleagues to support that initiative in January monitoring.

I have heard some members of the Committee say that it is not about money and that Health gets over 50% of the entire Executive Budget. I respectfully suggest that the percentage is a red herring. This should be about assessed need. It is, of course, also about efficiency and productivity, but no amount of efficiency or productivity will close the gap between demand and capacity.

When getting back into Stormont in February, we made an argument about the block grant: that it should be based not on a crude headcount but on assessed need, and, on that basis, it moved from 100% of English spending to 124%. It is not about headcount: it is about need. Without the resources to change, we cannot change. Without change, frustration will continue for patients, service users, staff and, via the media, the population at large. Without resources, we will fail — we will fail collectively — and that, surely, is not an option.

In conclusion, let me say that demands for easy, immediate answers are understandable but misguided. I have set out my three-year plan. In it are the key actions that, I believe, will improve health and social care delivery. I am clear that we need to invest in community and primary care. One aspect is that we need to improve the availability of social care. As you know, my predecessor invested £70 million in social care this year. I plan to go further and ensure that all social care workers receive the real living wage, at an estimated additional cost of £50 million. That will help to stabilise the system. Hopefully, it will also attract new people to work in it. In short, I intend to be the Health Minister who brings to an end minimum wage employment for social care workers. The Committee can help by backing my case for additional funding to meet that cost.

In primary care, I want to invest more in multidisciplinary teams (MDTs). That will help by allowing more people to be treated in the community, and it will reduce future hospital attendance. On winter pressures, it will free up GPs to see more patients with flu symptoms and help to address access issues. The Committee can help in that respect by backing my bid to the transformation fund for MDTs.

Those are practical examples of steps that need to be started now in order for them to take effect in the coming months. I began by saying that I was looking for levers to alleviate the current pressures. Just before I left the Department to come here, I was able to sign off on one such lever. Flu vaccines will now be available to the over-50s: the age group 50 to 64. That is a new development. Having prioritised those most at risk and healthcare workers, I am now in a position to widen the reach of the flu vaccination programme.

The Chairperson (Ms Kimmins): Thank you, Minister. Few of us around the table would disagree with the vast majority of your opening remarks. On the funding issue, we have said on numerous occasions that Health should be prioritised. We all know that there is not enough money in the overall Budget to go round every Department. However, on your ask for the next monitoring round, there has been a clear prioritisation by Executive colleagues to give money where it can be given. I also hope that that gap will be closed in the next couple of weeks.

Minister, you have said that you welcome any suggestions or solutions. Like you, I have spoken to many front-line workers' representative bodies over the last week. In particular, this morning, I met GPs in my constituency. They are keen to support in any way that they can.

My first question relates to the fact that the vast majority of the patients whom we see sitting in ED corridors are vulnerable, elderly, frail people, many with dementia.

As you and your colleagues around the table know, those prolonged waits in undignified and inadequate environments — that is not being critical of staff or anyone else — cause further deterioration in those people's overall health. People who have gone in with a physical health need may have a deterioration in their mental health and cognitive ability in a short space of time, which has further implications for their stay in hospital and their assessed needs for discharge.

Some issues and suggestions that have been brought to my attention look at how we can keep people from having to go to hospital in the first place. You will be aware of the Acute Care at Home service, which is predominantly in the Southern Health and Social Care Trust area. That works extremely well. I spoke to a lady this morning whose mother accessed that service in recent weeks, and she could not speak of it highly enough. My question relates to that. Can we do more to enhance that service and create an extension of it? I know that it does not exist in all areas. Can we look at the potential to provide it seven days a week? From my experience of working with older people, I know that it would really help to alleviate pressure in the here and now and would have really good impacts on patient outcomes. That is my first question.

You mentioned investment in primary care, and I know that that is a long-term goal. The sore throat service is, I think, due to end at the end of the month. Is there scope to extend some community care and primary care elements, such as GP services and community pharmacy? That would definitely help to alleviate what we see in our emergency departments.

Mr Nesbitt: There is a lot to unpack there, Chair. I will start where you started. As I said, today I visited two EDs: Altnagelvin Area Hospital and the Ulster Hospital. The common theme among the staff there is that patients who come in are suffering physical and mental harm because they spend much longer than they should in an ED. Of course, that, by definition, is bad for them, but it also makes the challenge of offering them cures more difficult, because the problem becomes more profound. That impacts on the moral injury to staff that I was talking about, because they see it as they go about their shifts, and it really hurts. I get that.

I saw people at Altnagelvin this morning, among whom was a man who had been sitting for four days in the same chair since Friday — four days. That chair was in the corridor, so where was the dignity and the privacy? There were three small plastic chairs side by side with a set of blankets and a pillow on them. The patient had, obviously, gone off to do something. Another example at Altnagelvin is the washing facilities. I think that there are two toilets in the ED. There are no washing facilities for people who are in there for day after day. I know that I am digressing a bit here, but we need a new ED at Altnagelvin. It will get one, but it is probably five years away.
Services such as Acute Care at Home and Hospital at Home are the future. When it comes to cost-effectiveness, they are a better financial proposition than having people in an acute hospital overnight. More important, they deliver better outcomes. Yes, I am extremely keen this year to talk about how we expand those services, because they are not available everywhere. I see Jennifer nodding: she may wish to add to that comment. We have to look at things like Phone First. About 160,000 people, I think, have used Phone First in the past year, and maybe a quarter of those phone calls resulted in people being told to go to an ED. Things are happening, and reform is under way. Jennifer, you may want to come in on that.

Ms Jennifer Welsh (Northern Health and Social Care Trust): Thank you for the opportunity to be here today to discuss these things with you. Acute Care at Home is absolutely one of the key things that we need to take forward. You mentioned the Southern Trust. It is probably the service that is best developed and advanced. We hear great things about it. I would like to have such a service in my area.

Mine is the one trust that does not currently have an Acute Care at Home service. We have elements of it, but it is an area in which we would be very keen to expand.

Because we do not have that service, we have invested in other ways. We have put a lot of our money into our ambulatory care work stream, so we have a comprehensive ambulatory care service at Antrim Area Hospital and Causeway Hospital. GPs have direct access to that service, as does the Northern Ireland Ambulance Service (NIAS). Having that ambulatory care process in place is another way of keeping people out of emergency departments. We believe, however, that there is still more that we could do with an Acute Care at Home service.

The Chairperson (Ms Kimmins): My question about Acute Care at Home was more about now. Is there anything that we can do to enhance the service now? Minister, you talked about looking to the future, and, ideally, we would like to see that service in place across the board permanently. Are there any levers available, or is there scope in the system at the minute to expand it now to support what we see in our hospitals?

Mr Nesbitt: Not in a particularly significant and meaningful way, because we are now pretty much at full capacity. You have to remember that Health and Social Care staff are not immune from contracting influenza, so there are huge staffing pressures.

I will bring in Tracey, but, first, you asked about the Pharmacy First sore throat service. It will not end at the end of January; it will be extended until the end of March.

The Chairperson (Ms Kimmins): That is positive. Thank you.

Ms Tracey McCaig (Department of Health): Our team on the strategic planning and performance group has been having discussions with trusts to see what can be done. As the Minister said, the ability for us to do something this month is absolutely constrained. I have, however, been talking to chief executives about what we can do in the slightly longer term. We have the ambition to have more Acute Care at Home services and more Hospital at Home services. There are lots of versions of those services. The Southern Trust, which you mentioned, has been running such services for much longer than others. There is a lot to learn from its model, but we would like to extend services, we would like more of them, and we would like them over a seven-day week. All of that will require investment and a reshaping of services, but, absolutely, the ambition is there to take that forward. That is unlikely in the coming weeks, however, so, unfortunately, it will not help us with what we have at the minute.

Mr Nesbitt: I think that you were with me at Daisy Hill Hospital when we met a service user of Acute Care at Home.

The Chairperson (Ms Kimmins): We met afterwards, I think, but I know that you had seen him.

Mr Nesbitt: Right. If you could bottle him, it would be fantastic. He is such a fan of what is achievable.

The Chairperson (Ms Kimmins): Yes. As you said, it is a real solution. The vast majority, particularly frail elderly patients, are much better being kept in their own surroundings. I cannot imagine what it is like for any patient, much less an elderly patient who may have some level of dementia, to sit in a corridor for three or four days with the lights on for 24 hours, staff and patients walking up and down, visitors coming in and out, no privacy, no dignity, all sharing the one bathroom and having all their meals and everything else there. I cannot imagine what that must be like.

In the past day or so, I heard of a patient who went in relatively fit and healthy with no cognitive issues. He is an older man with a physical ailment who has been in a corridor for three or four days, and he is now very confused. That is the level of deterioration and how rapidly it can happen. I just want to highlight that. My approach to that is to say that there are people who could be looked after elsewhere in a much better way. How do we do that? If there is any flexibility to enhance that service, be it through speaking to staff on the ground to see whether there is scope to move staff into Acute Care at Home teams, that needs to be explored.

Mr Nesbitt: When I talk about "levers", I am talking about whether we can nudge something here or there, such as we have done with vaccinations for 50- to 64-year-olds.

You are right, however: people get confused. Falls also happen in emergency departments, so that is another issue that needs to be addressed. Could you imagine being in an ED because you have a severe mental health issue, with the lights on all the time and the level of noise and activity? That is not good for people.

The Chairperson (Ms Kimmins): That leads nicely on to my next point. My understanding is that patient flow through the hospital is from the front door to admission and then to discharge those who have previously been admitted. We have heard clearly that people are in an ED for long periods because they have nowhere else to go. I have spoken to staff, and queries have been raised about potential ward space in some hospitals. There may be ward space or beds in the Belfast Trust: can we utilise that? If not, why not? Is it a staffing issue? What is the scope for doing that?

A suggestion that was put to me for triaging in EDs — if it is not already happening, which is why I want to ask about it — was to have a senior registrar or consultant on duty who could assess patients from, say, 7.00 am until 9.00 pm, because no one, particularly an older person, will be discharged after 9.00 pm. Likewise, is there scope to bring GPs into EDs, where that is possible? That is not to dilute the service on the ground. There was a pilot, I think. Was it in the Northern Trust, Jennifer? Was there a pilot whereby GPs could have access to direct admission?

Ms Welsh: That is our direct assessment unit: the ambulatory pathways that I mentioned. Yes, GPs have direct access. They do not have to send the patient to an ED but can phone in, have a conversation with the consultant in charge and refer the patient directly to the direct assessment unit.

The Chairperson (Ms Kimmins): Is that ongoing across all EDs or just in certain ones?

Ms Welsh: It is probably most developed in Antrim Area Hospital and, secondly, Causeway Hospital. Most people in trust areas have access to elements of ambulatory services. Although we in the Northern Trust do not have an Acute Care at Home service, we have a well-developed direct assessment unit. It is slightly different in other trust areas.

The Chairperson (Ms Kimmins): The question is about having a registrar or consultant on duty. Is that service in place, and, if not, could it be introduced across that key period? There are also the extra bed spaces. Are we looking at whether there is any scope to increase the number in order to move people out of EDs in cases in which they need to be admitted?

Mr Nesbitt: At present, 351 undesignated beds are in use. That is not enough. We then get into questions of space and, in particular, staffing: the workforce to look after the beds. As of yesterday, there were, I think, 288 patients in hospital with flu. As of yesterday, there were 516 patients who had been deemed medically fit and were awaiting discharge. That is a lot more than the number of patients in EDs who are waiting for a bed. That is where the problem with flow is.

It may be worth addressing some of the things that have been said in the media in recent days first, Chair, and I will ask Jennifer about Whiteabbey in a second. The problem is with internal flow in hospitals and the lack of capacity in community provision — care homes and domiciliary care — so I do not see any practical role for the military. When the military was here during COVID, its use was in offering vaccines and in physically moving people around within hospital campuses. That is not what we need in this situation, so I do not see that as an option.

Jennifer can speak about Whiteabbey specifically.

Ms Welsh: Thanks, Minister. Before I move on to Whiteabbey, I will reiterate the point about opening up extra beds. The Minister talked about the large number of additional beds that are already open. I will delve into the detail for a moment. There are 351 additional beds. There are an extra 36 in Antrim Area Hospital and an extra 18 in Causeway Hospital. We are limited by the physical space that is available, so we could not go beyond that number. Some trusts have been able to do more, simply because they have the physical space. As the Minister said, staffing constraints then become a real challenge. It is easier to set up smaller numbers of beds in wards close by, where you can expand the existing staffing resource, than it is to do something completely new, such as opening a new ward in Whiteabbey.

It is important to mention that we have some additional beds open in our community hospitals. Again, I use the Northern Trust as an example, given the different community hospitals that we have. We have significantly increased capacity there over the past number of years. Technically, I am funded for 228 community beds. Last December, 329 community beds were open, and 349 are now open. We are doing as much as we can to be as productive and efficient as we can. Those community beds are closer to local communities and are really helpful when people are discharged from an acute hospital but still require a period of ongoing assessment and rehabilitation.

We are finding that there are now delayed discharges even from those community beds. Those beds work well when you have a really vibrant, robust and sustainable domiciliary care service and can move a person onwards to a permanent placement in a care home or nursing home.

We have looked at Whiteabbey. We had the successful Nightingale rehabilitation ward there, and we have other services running at Whiteabbey. Over the longer term, we are looking at the model around our community hospitals. We would like to bring another ward into use at the Whiteabbey site, but we will not be able to do that quickly. We think that we can extend it by six beds by the end of February. Bringing another ward into use will mean that we will have to decant another service that we have put in and find appropriate space for it. It is also a very important service, so that is not something that we can do quickly, but it is part of the answer to what we need to do in the longer term.

Mr Nesbitt: Tracey, more generally.

Ms McCaig: More generally, as the Minister and Jennifer have said, a lot of beds are not necessarily in the places that we would all want them to be. That creates a lot of the difficulties that we have been discussing. Through the winter planning process, we looked at what else could be done. We are constrained by human resource and by space in some areas. In some other areas, we might have space, but moving the human resource over would impact on other services to such a degree that we would have to assess where the priorities are. At the minute, what can be done and what could have been done safely has been done, but it is a challenge daily.

We looked at all available space. Jennifer and I had conversations about all the sites that are available to, for example, the Northern Trust. Those conversations would have been repeated for each trust. That is the challenge.

I will put into context what is causing the increase this week. We had two different weeks' patterns. Up to 24 December, the winter plans were holding reasonably well in most locations. We had fewer attendances and fewer admissions than we had discharges, so the balance was in the right way. In the next week, from 25 December, we had 773 more attendances than we expected. Clearly, over Christmas week, we do not discharge as many; that is just the pattern. That week really impacted on what we had. Although we had planned and although everyone worked really hard with all the resources that we have, that one week was exceptionally difficult. That is what you are seeing play out, unfortunately, in our hospital stock at the moment.

The Chairperson (Ms Kimmins): My other question is about the potential, if it is not happening already, to have a senior registrar or consultant on-site to support those assessments throughout that period. Is that in place? If not, will it be considered?

Ms Welsh: It is important to say that all EDs have senior staff. Our direct assessment unit is led at consultant level. I am sure that the other trusts are similar.

The Chairperson (Ms Kimmins): Maybe we can explore that and find out whether it can be put in place. I am told that, if we have that level of cover, particularly between the hours of around 7.00 am and 9.00 pm, it could, if it is not already in place, be a real help in getting patients in EDs assessed and discharging those who can go home if they do not need to be admitted. The longer they sit and wait, the more likely it is that, at a later stage, there will be no choice but to keep them there, which adds to the problem.

I will ask my two last questions quickly. You have answered one of them, Tracey. I needed to understand whether what we are seeing was expected, and you answered the question: the number is much, much higher than what was expected.

I know that we did not have a Minister in place for the winter preparedness plan last year. As part of the planning process, was the effectiveness of last year's plan reviewed to inform what happens this year? As part of that, did you take into account potential increases? I do not know what modelling the Department looks at. Does it look at what happens in different parts of the world to see how likely it is that we will see the same trends? Is that part of the planning process?

Ms McCaig: I can certainly talk to the winter preparedness planning. We started early. We were in March before everybody got a little headspace from last winter. We took that plan. There was a series of workshops. We invited extra support from the Getting It Right First Time team to independently challenge us on our plans. We looked at the lessons from last year. We looked at the levers. We then had a budgetary piece come in over the top to see what we could do and what we would be able to do, and Dr McLean might want to talk to that. We look at the modelling from other parts of the world for flu at different periods.

Joanne might want to comment more on this, but, certainly, when the timing of the peak plus the Christmas period collide, it is really challenging for us. From a resilience and capacity perspective, with those two things, we would never have had the available space or human resources to manage that effectively. We would have seen some level of difficulty. The fact that the numbers are as high as they are is a real challenge and is probably not one that we would have had the resources to manage in any case.

Dr Joanne McLean (Public Health Agency): In terms of numbers, this has been a worse flu season than we have seen probably since prior to COVID. It is significantly worse than last year. It is worse than the year before that, which was 2022-23. There was a really bad year — I think that it was 2017-18 — and then flu kind of went away during COVID. We were all social distancing and doing all those things, so flu did not really spread. It came back with a bit of a vengeance in 2022-23. We saw quite high admissions numbers. Last year, we had flu but not to the same levels. This year, we have had much more flu. Flu has reached a higher peak than it did in 2022-23.

It is lucky that we have not had as much COVID around at the same time, so most of the admissions are flu admissions, but, as Tracey said, the other thing is that the peak of the flu hit just before Christmas. The absolute biggest number of flu admissions was during the week commencing 16 December, and then some trusts had their peak in Christmas week. That coincides with a time when, inevitably, you get a change in how people use health services and it is more difficult to discharge people from hospital. That combination of flu with what is already a pressured system has resulted in particular difficulties this year. This has been and continues to be a worse flu season than last year's.

Looking at the figures that we have to date, we can see that it is a wee bit tricky to look at patterns of health service use and infectious diseases over the Christmas period, because how people use services changes and how people mix changes. Schools and workplaces are closed. We think that we have reached the peak of admissions. We expect and hope, that, over the coming weeks, the numbers will come down. That may not be a smooth reduction, because people are back at work and back in school. It may be a bit of a bumpy reduction, but we think that we have reached the peak numbers and that they are on the way down.

The Chairperson (Ms Kimmins): Thank you, Joanne.

It has been helpful to get a better understanding of where we are and why we are where we are. I know that you have said, Minister, that you will plan in February. As a Committee, we probably have some actions that we would like to see as we work with you on that and review and monitor it as we go along so that we will not be in this situation again and will be able to mitigate problems as far as possible. The message that we need to get out today to our staff, who are burnt out and exhausted but very resilient and powering on through, is that we have their backs. The message that we need to get out today to patients and their families is that everything that can be done is being done. That is why I wanted to explore the specifics of what we can and should look at. I know that other members will want to do that. I think that one of my colleagues will probably raise the social care stuff, so I will not go into that.

Thank you for your answers so far. They have been helpful. I will go to Linda.

Mrs Dillon: Thanks to all of you. I have a couple of questions. I have a quick one to follow up on the extension of the vaccine. Joanne, what has been the uptake among those who were already entitled to the vaccine? The extension is great, but what are we doing to increase uptake among those who were already entitled to it? They are the vulnerable people who are most likely to become admissions.

Dr McLean: We prioritise the groups that the Joint Committee on Vaccination and Immunisation (JCVI) recommends we vaccinate. Broadly, those groups are people who are aged 65-plus, people who are under 65 who have underlying health conditions, Health and Social Care workers and children from the age of two up to year 12. They are prioritised. They are the groups who get most benefit from vaccinating.

This year, our uptake of the flu vaccine has been a wee bit disappointing. Our numbers are not as high as they were last year or in 2022-23, when flu kind of came back. Our most successful flu vaccine programme ever was in the 2022-23 year. Uptake came down a bit last year and a bit more this year.

If we look at the most up-to-date numbers, which I pulled out last night — they are not the final programme numbers; the programme is still going and we still have data coming in — we see that, for those aged 65-plus, we had a 71·2% uptake. For those aged 75-plus, the rate is higher, so the older people get, the greater the uptake. That is good, because the people who are most likely to become sick are the older people. For care home residents, uptake is almost at 80%. Again, that is good, because that is a very high-risk group. For care home staff, unfortunately, uptake is really disappointing at 6·4%. For Health and Social Care workers overall, the rate is just under 18%. We are not entirely confident with the denominator for the under-65s who have other conditions, such as heart disease or whatever, but we have vaccinated roughly 99,000 people in that category. I talked about them earlier. Our best estimation is that there is probably about a 40% uptake in that group. As I said, those are provisional figures that have been provided during the campaign. We have vaccinated almost 60,000 children in post-primary schools, over 100,000 children in primary schools and just over 2,360 pregnant women.

Those are the figures for all our groups, and it is disappointing that our numbers are not as high as they were in previous years. We have done a lot to promote the vaccines through social and media appearances; the Minister and I have appeared. Any support that we can get from elected representatives to encourage people to come forward would be great, because, while we think that we have reached just past the peak, we still have a fair bit to run in this flu season.

Mr Nesbitt: I will just add that vaccine hesitancy is a thing and is not specific to Northern Ireland.

Dr McLean: We regularly meet our colleagues in England, Scotland and Wales and down South. Every one of those countries is seeing the same things as we are, such as less enthusiasm about coming forward and difficulty getting the uptake that they had in the past. We are doing a lot of work with them to understand how to improve uptake for future years.

We are still appealing to people who are in an at-risk group to please come forward. We will now extend the programme, because we have some vaccines left over. We will make that offer available to the 50-plus age group. It was really important that we prioritised and had a good offer for the people who are in those at-risk groups first.

Mrs Dillon: Thank you. I do not want to dwell on it, but we need to understand what is behind the vaccine hesitancy. We need to be open to listening to people about why they are hesitant. We cannot just lock down and say that it is an overhang from COVID. We have to be open to listening to people, because it should be a choice. We need to understand and have open and honest conversations about that.

I want to focus on the social care element. We know that the front doors of the hospitals are open, but the back doors are bolted shut. Nobody is leaving, and the figures tell us that. You are right, Minister, to ask when the last time any of us were in an ED. I visited one last year. I certainly would not visit one this year, because they would not want me. It is right for you, Minister, to be there, because you need to show leadership, but the staff would not want us all traipsing through their EDs. That would be of no help to them at this time.

The one thing that they said to me in Craigavon ED was, "Please do not extend our ED. Please do not add beds to the ED. That is not what we need. The money needs to be invested in getting people out through the door". When I was in Craigavon ED, 68 people were in beds and 62 people were ready to be medically discharged, and, of those, three were being discharged. There has been no change from last year to this year, and that is a big concern.

I get where you are coming from about money. We can have all those conversations about the need for additional money, but we all know that money can be saved by not having people stay in hospital. We know how much it costs to have somebody in a hospital bed or at home with a domiciliary care package. You are right, Minister, about the demand, but it is about where we meet that demand. Where are we meeting it? We are meeting it in hospital beds. We are keeping people in hospital beds and making them sicker; we know that.

Then, they need a higher level of care package. You might have somebody coming in who does not have a care package at all but who leaves needing two people four times a day. That is just not a sustainable model. We need to turn this thing on its head.

Jennifer, you are well aware of that. You have been in front of the Committee. All the trusts have been in front of it, as have the Minister and all the officials. We know where the money has to be invested. Let us take the money that is being invested in the additional beds all the time.

I know that this cannot be done overnight, but we have to start addressing domiciliary care. We need to pay people properly. The Minister has said that he will do that, and I really appreciate it, because the people who are doing the work need it badly. We need to pay our domiciliary care workers in rural areas their travel expenses. Asking people to go out on some of those roads on a normal day is horrific, but asking them to go out today, tomorrow or yesterday is absolutely —. It is unimaginable that you ask people to go out for the money that they are paid, but they are doing it, and they are doing it with heart in hand. Their neighbours go out and clear roads for them to do it. All that good stuff is happening. People have goodwill, but we will break their goodwill by not paying them and not looking after them.

Let us reinvest. It is not always about looking for additional money. You need it — I get that, and we support that; we do not need to have that conversation — but we really badly need to reinvest what is being spent.

I have one other question, but I will let you come back on that first.

Mr Nesbitt: One of the points that you made was made to me an hour and a half ago in the ED in the Ulster Hospital, which is that it is big enough. They do not need a bigger emergency department: what they need is flow. This morning, they had 76 decisions to admit (DTAs) and no beds for them. I think that they have 35 cubicles, so the number was more than double their capacity to safely and comfortably hold people who are waiting for an acute bed upstairs.

I think that you know that my ambition, which is longer-term and cannot be done in weeks or months, is that, if you need to access healthcare, you get it at home if at all possible or, if not at home, as close to home as possible. We are talking about primary care and community care. The second worst option is having to visit an acute hospital. The worst option is visiting an acute hospital and having to stay over. Nobody wants to do that. To my mind, the direction of travel is clear, but the question is how you achieve it. We struggle to maintain the service with current resources and budgets. If you are going to transform and reform, you need resource and budget. It is about how we find that and release it from the current system.

Let us not lose sight of the fact that, while we are rightly focused on the winter pressures and the problems in EDs at this moment, I am still well short of delivering pay parity. If industrial action had been voted on when there was the threat of that vote, we could have had nurses and others on strike and taking industrial action at this time. Imagine what that would do to the winter pressures and our ability to handle them.

I am very much in tune with what you say. I want to pay more. I am talking about trying to find £50 million to give workers in social care the real living wage. That will, hopefully, mean that we make it more attractive, attract more people and retain more people. This has to be where we go: getting the emphasis off our acute hospitals and on to care in the community.

Mrs Dillon: Does anybody else want to come back on that?

Ms Welsh: I am happy to add to that, Linda. I echo everything that the Minister has said. I really welcome the opportunity to have this conversation. Everybody here knows that the answers to this are predominantly not in the hospital. That is not to say that there are not more things that we can do — we should always be looking at how we improve our services — but there has been historic and significant underinvestment in the community over many years, not just here but elsewhere. The real living wage is an important part of that.

We also have to look at how our population has changed over the last number of years. I have been in the Northern Trust for seven years, and, in that time, the population has changed dramatically. The growth of the population is 2%, but, within that, the growth in the number of over-75-year-olds is 19%. That is a fantastic thing, and lots of us have grandparents and great-grandparents around for a lot longer. However, think of all the people we know who are over the age of 75: some of them will be in rude health, which is fantastic, but many fall into that frail elderly category. You cannot have that level of growth in the population without appreciating that, yes, we will have difficulties.

We work closely with our colleagues in the independent sector. They do a fantastic job, but they struggle with staffing at times as well. On that flow out, when we think about care homes and nursing homes in particular, it is important to say that we know that there is work to do in that sector. Beds are currently available — some of you will have heard that being said in the media — but we are now struggling with the enhanced needs of individuals and how to place those individuals in the right bed and get them close to their family. That is a really complicated situation. There is certainly work to be done there.

On domiciliary care, you mentioned some of the issues around travel. We are running a pilot in the Northern Trust area, recognising that we cover a large geographical area and that, given its rural nature, it can be difficult to get to some parts of it. We are contracting with a number of providers and looking at an outcome-based contract rather than a time-based contract. It is about asking, "What does this individual need?". Rather than saying, "You are getting 15 minutes or 30 minutes", we ask, "What do you actually need?". It is early days, but we are already seeing good outcomes. That is the direction in which we want to go. We are running the pilot ourselves, and I hope to come to Tracey after that to say, "Here is the proof of concept. We need to do this in a different way".

I really welcome the conversation about the focus that we definitely need to have on our social care and community services.

Ms McCaig: We await the outcome of the pilot, but other things are ongoing at the same time to help us use what we have most efficiently. We cannot turn on an infinite workforce; we have to encourage people to come in and have career pathways in our domiciliary care services. My daughter works in that area, so I have some personal insight.

We have been looking at how we help with digital in those spaces, which are not necessarily part of the Encompass programme with our independent sector providers. Two areas are coming on stream. One is to do with our care homes, so that we have greater and faster visibility of vacancies and types of bed and have a seven-day ability to discharge into those beds, helping our trust and our independent sector providers in that space. The other is for our domiciliary or home care services so that, if care packages are not required, we can reallocate quickly.

When we talk about this, it is not always about "more" and "new" — it often is — but about us demonstrating, before we come in front of anyone, that we are doing the best that we can with the resources that we have. In a constrained budget environment, a lot of effort has been made to look at that. Even when we do not have significant resources, there is still the ambition to use what we have to best effect.

Mrs Dillon: One of the questions that the Chair asked was whether we are getting the best use of resources. I would appreciate the Committee getting updates on that.

Ms McCaig: That would be helpful.

Mrs Dillon: You will not be able to answer all of that today, but we need to know what is happening.

Minister, was a bid made for domiciliary care packages or for social care? I am putting you on the spot.

Ms McCaig: No specific bid was put in for that. We prioritised it in the budget that we had. That is where the £70 million from last year that was announced previously came from. We saw that as being inescapable. The first thing that we said was that we had to meet the financial demands of the minimum wage at that time, and we were obviously looking ahead to the next uplift. That was encapsulated in the overall budget but was not a separate bid.

Mr Nesbitt: The main bids were for waiting lists, and they were not met.

Mrs Dillon: I appreciate that.

My only other question follows on from the Chair's question on Acute Care at Home. It is a general point. The service in the Southern Trust is brilliant, if you know about it. There is not enough linking between primary care and Acute Care at Home to ensure that, if you contact your GP service or some other primary care service and if Acute Care at Home is the right service for you, you get it. If you are lucky enough to know about it, someone tells you about it or you just happen to be lucky enough to fall into that service, that is good, but there is not enough tie-in. That is one of the pitfalls that need to be addressed. Tracey, you could have a conversation with the Southern Trust to make sure that there is a good tie-in.

Mr Nesbitt: Is there solid evidence on that, or is it anecdotal? I am not questioning it.

Mrs Dillon: I can say from my area that GPs do not often refer people into it. It is usually a case of families who have heard about it asking for it or of them contacting me and me saying, "Why have you not asked for it?". That is a wee bit of a concern. We need to ensure that that works well. It is an excellent service. I want to see more of it, and it is something that we can do more of. I agree with everything that the Chair said.

I do not want to take up more time, because there is a lot more.

The Chairperson (Ms Kimmins): Our meeting on 23 January will be at Daisy Hill, and we will meet the acute-care-at-home service as part of that, so maybe we can tease out some of that then.

Mrs Dodds: Thank you, Minister and team, for coming today at short notice.

We in this room are — I do not know how to express it — vexed and worried about the situation in our hospitals and EDs. Everybody understands your plight as to how to manage a very difficult situation, but there are things that we need to explore and understand.

We have talked quite a bit today about the flow of patients through hospital. I tabled questions for written answer on that in March 2024. I was told in the answer that 628 patients in Northern Ireland were medically fit for discharge but could not be discharged. I asked virtually the same question in July so that I could understand the difference between times when we might be experiencing winter pressures and times when we were not experiencing winter pressures. The Department answered that 512 people in Northern Ireland were medically fit to discharge but could not be discharged. That did not include figures from the Western Trust, which could not, for whatever reason, provide them. It is an issue that we know about; it is not new. When I was with Jennifer at the end of November, we noted that, on that day, about a quarter of beds in Antrim Area Hospital were occupied by people who were fit to be discharged. We keep seeing the problem, but I am interested in what we have done about it.

The answer to the question that I tabled in March referred to:

That was meant to make the sector more financially stable and viable. The answer also referred to performance management of trusts by the SPPG. We would like to understand why the situation just continues as it is despite the promises and the £70 million, which was, I presume, a substantial amount of money to give at the time. Are there figures on how many additional care packages, respite beds etc were provided from that? We can talk about flow through the hospital, but this is not a new problem that has arisen in January 2025. We have had it for a considerable time, and we continue to have really high levels of it at all times of the year: the issue needs to be addressed. That is the first area that I would like to explore.

Minister, I am glad to hear you talk about a living wage for social care workers. Domiciliary care workers play an enormous role in communities, but they have been the poor relation when it comes to pay and conditions, such as paying for their transport. There is no one on the Committee who will not support you in trying to get that through. That is really good, but it is a long-term issue, and it does not help us now.

I think that people watching this Committee meeting will be disappointed that we are being told that we have to kind of chug along as we are in the hope that we will get something better. I am just expressing a view as I see it. The issue for me is about hospital flow. It is about improving domiciliary care services. It is about creating extra beds in our communities. I warn — I hear a lot on the news about Belfast, and I hear Jennifer talk about Whiteabbey — that there is life outside greater Belfast. Speaking as an MLA representing an area that is not in greater Belfast, I think that we need to see that investment across Northern Ireland.

There are some really brilliant things happening in healthcare; they are just not consistent and on a large enough scale. The Hospital at Home service in the Southern Trust — my area — is a really good service, but it depends on what care family can provide to help to maintain that. It is important that we get enhanced care for people who are availing themselves of that service. I have personal experience of the direct assessment unit at Daisy Hill Hospital. It was fantastic: from seeing a GP at 3.00 pm to being treated in a direct assessment unit at 4.30 pm. It was amazing. It is a really good service, if we could only expand it. However, its opening hours are not terribly long, so you have to be sick within certain times. If we can expand that, we can surely help to ease more of the pressures in EDs.

Mr Nesbitt: I am glad that you are acknowledging that, every day, the Health and Social Care service delivers thousands and thousands of really positive results —

Mrs Dodds: Yes, it does.

Mr Nesbitt: — and that is great. I will go through in turn some of the issues that you raised.

I am not sure how disappointed people are that we are chugging along. I think that people understand very well that MLAs voted for an entirely inadequate Health budget and that we now see part of the consequence of supporting that budget. You point out that discharges dropped by only 116 between March and July; in fact, had we had accurate figures for the Western Trust, maybe they did not drop at all. That just confirms what I said in my opening remarks: the pressures are not just winter pressures; they are 365 days a year. To change that, you will have to invest. You will have to increase the resource, the budget and the workforce. Otherwise, we will chug along.

I am slightly surprised that there is a misunderstanding about the £70·7 million that my predecessor, Robin Swann, invested. It was not for social care packages. A total of £62·1 million was to cover the national living wage. It went to independent sector nursing and residential homes; supported living settings; jointly commissioned supported accommodation; independent sector children's homes; independent sector domiciliary care; self-directed support and direct payment contracts; and HSC contracts in community and voluntary and hospice settings. The balance, which was £8·6 million, was allocated to domiciliary care providers to increase the provider rate to £20·01 an hour, and that was to stabilise the workforce and capacity with enhanced payments. It was not about buying additional packages.

Mrs Dodds: OK. On the back of that, may I ask about care packages? An elderly person goes into hospital. They have a care package, and that care package may be the most extensive that can be had, which is literally 15 minutes four times a day. However, if they are in hospital for a certain time, that care package may be removed. I think that there may be one trust in Northern Ireland that guarantees the care package beyond that time. It is a great source of worry for families that those care packages could be removed. They then go back to the bottom of the assessment list, and it is really difficult to get things moving again. Is there anything that can be done to look at that?

Ms McCaig: Jennifer might want to come in on the back of my answer. That is in the protected packages space. When you have challenges, there is a fine line between how long you protect a package and stopping someone else receiving it. I know that it is a source of distress to people when they have to go through the process again, but they do not necessarily go back to the bottom of the queue.

Mrs Dodds: Do you have figures, Tracey, for the exact length of time for which you are allowed to protect that package?

Ms McCaig: I cannot give you —.

Mrs Dodds: It is a relatively short period.

Ms McCaig: I cannot give you the figures today, but I will provide the Committee with that information.

Mrs Dodds: That would be helpful.

Ms McCaig: It may be useful in discussing some of the other elements that you want to look at, particularly around domiciliary care. It is a judgement call, and trusts are always trying to make the best use of whatever resources they have. I think that the packages are protected in two trusts, but I will have that confirmed rather than speculating when I do not have the information.

Mrs Dodds: Those care packages are precious, and they are hard fought for. It is a huge issue for families.

On the issues with patient flow, do you regularly publish figures on delayed discharges? Maybe you do. I may have missed them on the website.

Ms McCaig: We do not, but we will. As a result of changing to the Encompass system and all five trusts moving to digital, the information is coming from different places at different times. We want to make it comprehensive, but our trusts work with the regional coordination centre (RCC) and provide that information every day. We will work with trusts to enable them to put that information on, because it is information that we are happy for people to see. We will put it on the same place on the HSC system as where you get all of the waiting times and all of the other information, and we will try to have that up and running over the next week so that it is publicly available.

Mrs Dodds: Has any work been done to assess the amount of money that could be saved if we were able to get people back into their own homes with an appropriate care package as opposed to keeping them in hospital? Has significant work been done on that? That is key to progressing the issue around patient flow.

Ms McCaig: It will have been done in pockets, not as a whole composite. Obviously, we are looking at the demand-capacity piece for urgent care services, but, when we are looking at different pockets of investment, we absolutely look at the differences. It is a constantly moving picture. At the minute, we may have 350 beds, and, next week, that number might be slightly lower. It is a difficult one to absolutely peg as a regional composite, but we look at it.

Mr Nesbitt: I am not sure that there is an actual saving in moving somebody from an acute bed into their home unless they are the last patient who wants that acute bed. If there is another patient waiting in ED for that bed, the costs continue.

Ms McCaig: It is the constant movement and the growth in demand.

Mrs Dodds: It is about the movement of people out of hospital. Hospital beds are constantly being held for people, but care packages would allow a significantly greater flow through hospitals, which is really important.

Mr Nesbitt: It will improve the flow, but it will not save money.

Ms Flynn: Minister, you were speaking about visits to emergency departments, and I bumped into you when I was in an ED with my son. I do not think that you recognised me, because I had not slept and was sick with worry.

A lot of the conversation has rightly focused on the experience of older people, including people with dementia. Elderly people who are very sick are going through long waits in corridors, and the lights, the noise and the activity are traumatising. I will give my perspective of having my two-year-old in the emergency department for two nights in a row. All those wee sick babies and young children with stressed-out and worried parents were in that same cramped, noisy environment. When I had Torin down the first night, there were no seats in the waiting room for me and the baby. When he was admitted the next night, there were no beds. That was all fine, because all I cared about was that he got better. I am sure that the same goes for the patients who are in the emergency departments at present: all they care about is getting better or their loved ones getting better. That is all the staff care about as well. You can see, however, as I did at first hand at the start of December, the conditions that staff work in and the pressure that they are under, as well as the pressure and stress that the patients are under.

All that said and as you pointed out following Diane's remarks, the main message from all of us on the Committee to any Health and Social Care worker who has tuned in to watch this meeting is that we fully support them. They got my baby better. I got him home two weeks later. That is all that matters to anybody who seeks help and care in hospital. All that matters is that their loved ones get the treatment that they need. The doctors and nurses are brilliant, amazing angels. I am just saying that that is the way that we all feel. That is what is most important. That is the reason for the recall of the Committee today. The Committee has been recalled to see how we can help and support those staff members, the Department and you, Minister. We all want the same thing: to ease the pressure.

Tracey, you mentioned that the immediate measures to ease the current pressures have kicked into place and that you have gone around each trust area. I will ask two quick questions. My first question is this: are our Health and Social Care staff — the leaders in each trust and, more important, their staff who work in the emergency departments — content that all immediate measures that can be put in place have been put in place? Is anyone holding a watching brief and contacting staff daily to see whether something could be done differently or whether someone might, tomorrow, come up with an idea that we could put in place? I am conscious that there may be ways and means of changing things in the immediate term that could help.

My second question is on GPs. I know that this might require more finances and may not be as straightforward as simply kicking this into place. Can anything additional be pumped into the out-of-hours GP services whereby additional doctors or nurses could go out into the community when patients ring up to say that they are sick, thus preventing those patients from going to the emergency departments? In the longer term, there is the matter of GPs' hours over weekends and in the evenings. Has any of that been explored? Could it be explored in the here and now or in the longer term to address pressures on EDs?

Ms McCaig: I will take your questions in reverse, starting with the GPs. Jennifer might then want to comment on staff feedback.

Our GP services have been delivering significant additional hours over the winter period. The Minister mentioned the additional investments that we prioritised in order to help in that space, in GP services and community pharmacies. In a week, our GPs normally have 190,000 to 195,000 consultations. Generally speaking, 56% of those consultations are face to face. That fluctuates a little, but those figures give you a sense of what we have had. We think that the preliminary figures will be in the range of 200,000 to 210,000. We have increased weekly face-to-face and virtual consultations with our GPs. Those consultations could be with a GP or with one of the multidisciplinary staff — the nurses, the paramedics or others who work with the GP practices. Significant work was done. I have evidence of significant support from a GP practice: by sending out a member of staff, it prevented the hospital admission of a family member. Those investments are working.

Ms Flynn: Do you mind me cutting in briefly, Tracey?

Ms McCaig: Sure.

Ms Flynn: Was that within the nine-to-five working hours of the GP practice?

Ms McCaig: It was. Our out-of-hours services then continued. Those services were constrained in some areas and at certain points because of staff availability and absence, so we had pockets of challenge related to the sheer volume and to people being ill, just as the rest of us got ill during that time. Our urgent care centres, which are supported by our primary care staff, were working as well. We have a lot of that working. It might not be just your GP practice that works over that period. We also have our primary care support community in different places across that piece. The support will not necessarily be from the GP practice that you would phone from Monday to Friday; it is built in in other ways.

Planning was in place for as much extra as we could reasonably ask our GP community to deliver, and it is doing so. We see messages in the press, but I am pleased to say that we can see that work coming on board, and the investment that we have made has been well received and delivered on by our GPs and our Community Pharmacy colleagues, who support us with problems such as sore throats and urinary tract infections (UTIs), which has been helpful.

Without having significant budgets, we have tried to prioritise what we can where we can in order to have the biggest impact, to avoid admissions and to support independent-sector providers, with which I have significant contact. A lot of the funding last year was about stabilisation and trying to maintain a workforce to be able to continue to deliver. As quickly as we could manage the 500 packages, there would be 500 more behind them. The growth in our elderly population to which Jennifer referred continues, so there is a relentless focus on all those things. There is no one-off resolution, whereby we deliver 500 packages and are then back to where we need to be. It is a continuum.

Ms Welsh: I will talk about staff feedback. As you can imagine, I have been in our ED and on our wards very frequently over the past while. Thank you for recognising that we are dealing with daily pressures and not just winter pressures. There is a particular exacerbation at the moment, but the situation is difficult every day.

Interestingly, there was a meeting held just yesterday. We have mentioned the regional coordination centre, which all trusts take part in, including the Northern Ireland Ambulance Service. We got feedback from all the trusts and the RCC team. That came from our people on the ground. I have heard the following directly from consultants and nurses when I talk to them. They talk about how we can keep people living in their nursing home and how we can support them to stay there when they are unwell. That is partly to do with Acute Care at Home services. Our staff are asking whether there is more that GPs can do. I recognise that our GP colleagues are under huge pressure, but is there something that we can do to support them in order to allow them to look after people in care homes? In addition, there are questions about how we manage palliative care in a better way in the community. People are being brought to hospital EDs, and that is not a dignified thing for them at the end of life. Most often, even in EDs, staff are looking down the line to the discharge and talking about what they need for people with delirium, dementia or enhanced needs.

Everything that they are talking about that is needed is outside of the hospital. It is all about the community. It is about supporting people to be discharged in a safe way if they have enhanced needs such as a risk of a fall or help with feeding. It is about a dementia or delirium placement. That is what my teams are asking for.

Ms Flynn: Thank you very much.

Mr Donnelly: Thank you for your answers so far. Other members have asked a few of the questions that I was going to ask. That means that we are all thinking in the same direction, which is good. First, I welcome your nudges to the levers that you have announced here today. The expansion of the vaccination programme to over-50s is a very good idea, and that will help protect people going forward. We all know that vaccination is the best way in which to protect people from flu and COVID, and I encourage everybody to get vaccinated as often as they can.

The other nudge, which is the extension to the sore throat test-and-treat scheme, is wise. I know that there was some apprehension that the service would end at the end of January, so it is good to hear that it is to be extended. Our community pharmacies do a great job, and extending the scheme will also help reduce pressure. I also welcome your commitment to paying the real living wage to domiciliary care workers, which will be a fantastic step forward.

I will go back to the winter preparedness plan that you announced to us in November. You stated that planning had started in March. I am curious as to why the plan was not published earlier, during the summer. Would that not have given the plan more time to bed in, be established and be a bit better understood? I am also keen to know whether the plan was co-designed with healthcare professionals in Northern Ireland, such as the RCN and other healthcare organisations. You have talked about a blank page for next year. When are you planning to have the plan published for next year? Will you look at having an earlier publication date?

Ms McCaig: Yes, we started the plan in March, and that seems like a reasonable time to do so, because, when you allow people to get through the pressures of winter, you are into February or March before you can start. We worked with trust colleagues from different areas, and we worked with our primary-care colleagues as well to take through the plan. We brought in colleagues from GIRFT to oversee it, to challenge us and to be that critical friend to us to make sure that we had covered all that we should have covered.

Why was it not published at that time? That is a good question. It was under constant review, and we looked at it on different levels. We looked at it regionally. We then had colleagues from GIRFT look at it, after which we looked at it locally. We then went back to our regional coordination centre colleagues, who will work with trusts, and challenged it down to a granular level. That went on constantly, all the way through to, I think, the week before Christmas; Jennifer may remember. The process was continuous. We do not just plan and leave it. We will have public health information coming through on the likelihood of flu cases, so we are constantly looking at the plan. When we publish the plan is one point, and we can provide that information to the Committee, but I reassure members that it is not something that we do and then leave on a shelf. The plan has to be dynamic and has to be reviewed constantly.

We do not have all the levers that we wish to have. We do not have all the resources, financial and human, that we need or the space, capacity-wise, to do everything that we want to do, so everything is done in the context of what is available to us. That is why the plan is not published earlier. We went through a significant programme. The Minister's plan for this year will be even more comprehensive, with other stakeholders involved, but we have had service users and others with us for the programme for this year. We will reach out widely. We are open to reaching out as widely as we can in order to get the widest possible voice.

Mr Nesbitt: I plan to start this year in either late February or early March at the latest. I cannot tell you how long it will take, because I do not know how many people will try to populate that blank page, how difficult it will be and how much research we will have to do in order to test ideas, but, once we have done that, I see no reason not to publish it right away and then perhaps re-emphasise it closer to November or December this year.

There are two ways of doing co-design. One is to write up the plan and then say to stakeholders, "What do you think?". In my view, that is not co-design. The other is to take a blank page and say to stakeholders, "How are we going to fill this in?". That is my idea of co-design. I want to be in a room like this with somebody from the Royal College of Nursing, somebody from the Royal College of Emergency Medicine, a consultant from an ED, a director of unscheduled care from an ED and a chief executive — whomever we need — and say, "How can we design levers that make this significantly better come the winter of 2025?". I do not think that we will crack it, but it is important that we are seen to be making a significant, measurable and noticeable difference, not least for staff morale, because I think that we all acknowledge that they are absolutely burnt out. The problem is that they do not see light at the end of the tunnel. They do not see hope, and we have to inject hope.

Mr Donnelly: You mentioned the royal colleges: were they involved in this year's winter planning?

Ms McCaig: I would need to confirm that for you. I do not want to say yes or no. I was not involved personally, so I do not want to say at this point. I will confirm that for you.

Mr Nesbitt: I am not aware.

Mr Donnelly: No problem. Thank you.

I will build on a question that the Chair asked about making best use of the available resources. Using nursing agencies and the like is something that we generally try to play down. Are you aware of any resources that are available that are not being made best use of or that are not being flexed yet? Is there anything that we can tap into in order to bring in staff?

Ms McCaig: I am not aware of any option that has been proposed that we are not already trying. We have certainly had a number of conversations, and, if a good idea were proposed and there were a financial impact from it, we would absolutely look at it, but that has to be seen in the context of not yet having financial balance to enable pay parity. Again, it is on a scale the whole time, but there is nothing coming to the SPPG and me at this point that says, "If only you could provide funding for such-and-such". My comment to Jennifer and her fellow chief executives was that we will look at any and all options, if they are there, that would make a difference quickly. We would absolutely talk about them in a positive light, but I am not aware of any.

Mr Nesbitt: We have to give credit to Jennifer and her colleagues. They have driven over £200 million of savings in this financial year, which is absolutely unprecedented. I am not aware of any other Department that, on a pro rata basis, has delivered savings on that scale. She and her colleagues will be asked to do more in the next financial year, so, if there is any room in the system, we will flush it out.

Mr Donnelly: Thank you, Minister. I was encouraged to hear that you were talking to workers on the front line to hear what they think. What did you learn from talking to them?

Mr Nesbitt: What was confirmed was what I mentioned in my opening remarks, which is that they feel a moral injury, because, to them, it is not a job but a vocation. They feel hurt when they see people on a chair for four days in a row or when they see people deteriorating and deconditioning while sitting in an ED. They really feel that. They take it home with them. It hurts them mentally and psychologically.

I have also talked to some patients. I spoke to a patient today who is terminal but not in a hospital bed. He was full of praise for the nurses and doctors. He talked about people being worse off than he is. He is dying. All healthcare is personal. I have to take this really personally. Otherwise, I cannot do it.

Mr Donnelly: Thank you. One other thing that I would like to raise is vaccinations. A couple of the figures that you read out were shocking, as, I am sure, you appreciate. The figure for care home staff —.

Mr Nesbitt: It is 6·4%.

Mr Donnelly: Yes. That was a shocking figure. I cannot quite remember the other healthcare figure.

Dr McLean: It is 18%.

Mr Donnelly: Is there a particular drive on at the minute to get care home staff and healthcare staff vaccinated?

Dr McLean: As I said at the outset, those are interim figures. The programme is running on. There are likely to be care home staff and Health and Social Care staff who have been vaccinated in, for example, their GP surgery because they have asthma or something like that. They are not being properly counted as a Health and Social Care worker. That is a real issue. The uptake is likely to be a bit better than it appears, but it is not as good as it needs to be. The care home staff figure is low, and we need to understand a bit better why it is that low. Community Pharmacy vaccinates in care homes. Its staff go into care homes and offer the vaccine to all the staff while they are there. That is where we get that figure. The vaccine is brought to the staff and made accessible to them. We want to work with trusts next year to explore how we can improve Health and Social Care staff uptake. The best uptake that we achieved was when we used a lot of peer vaccinators. We had staff in each ward vaccinating.

The low rates are also symptomatic of the wider pressures in the system. We just do not have as many staff to go out and deliver the vaccine in as many locations as we might have done in the past, but we want to work with trusts next year to get the rates up, because it makes a difference if we get our Health and Social Care workers protected. It will be a priority for us. We are, of course, still encouraging uptake. Trusts are bringing the vaccine to canteens to try to make it accessible. They are also making sure that night staff have access to it. Clearly, we want to improve the rate, but, as the Minister indicated, there is also particularly low uptake among care workers in other jurisdictions. There are differences in uptake between groups of staff. Medical staff, for example, tend to have a higher uptake than some other staff groups. We need to do a lot of work.

We have not been advertising — the paid-for advertising on buses and on TV and radio for the flu vaccine — and I think that this is the second year in which we have not done that. The last year in which we had advertising was 2022-23, which was when we had our record uptake. We have not been able to afford to do it because of general budgetary constraints across Departments, but we, as an agency, will be making a bid for funding and saying, "Look, we think that it's important to advertise in order to raise awareness".

As Linda said, we really need to understand better why people are not coming forward for vaccination.

The agency has an ambition to develop a behavioural science team to understand what we can do to make it easier for people to get their vaccine and how we can explore people's anxieties and fears. We have to accept that it is a choice. I want people to be vaccinated because it makes such a difference to their health and the health of the whole population, but it is an individual choice. We have to work with people so that they make those choices.

Mr Donnelly: Absolutely. I was going to say that I had not seen a public campaign to encourage people to get vaccinated this year and that that has impacted on the vaccination rates. I remember the previous campaigns, and they were very impactful. It was a reminder and encouraged people to go out and do it, and there is value in that. Was that because of budgetary concerns in the PHA?

Dr McLean: The Minister will be better able to speak to that, but my understanding is that, as part of making the best use of the resources across the Executive, there are limitations on paid-for advertising, and that is one of the campaigns that we have not been able to run. We hope that we can make a case to the Department and the Executive to advertise it next year, because, when we evaluate our programmes, we can see that they make a difference.

Mr Donnelly: Was a case made for keeping paid-for advertising for vaccination?

Dr McLean: The organisation asked whether it could be funded, but unfortunately, it was not. We do lots of other things; it is not the case that we are doing nothing. We mentioned that we do a lot of press releases, media interviews and social media, and I would not underestimate the power of social media and the reach that elected representatives can have to make people aware that the vaccine is still available.

Mr Donnelly: Those are not the big, mass-market, TV and radio adverts.

Mr Nesbitt: There is a moratorium on that, but I am not sure that that sort of advertising would impact on the 6·4%.

Dr McLean: I do not think so, no.

Mr Nesbitt: We need a deep dive into that to get a better understanding, because that figure is shockingly low.

Mr Donnelly: You mentioned that vaccine hesitancy is an issue. Are you looking at anything specifically on vaccine hesitancy and encouraging people?

Mr Nesbitt: It is about trying to understand the figures.

Dr McLean: We are working with colleagues in other nations, as I mentioned, and work is being done to understand vaccine hesitancy. The agency wants to develop capability and understanding so that we can develop interventions to encourage people and improve the uptake. We are being very negative here: more than half a million people have had the flu vaccine.

Mr Donnelly: Absolutely.

Dr McLean: Most of the people who are eligible came forward and got the vaccine, and that is a good thing. We have vaccinated more than half a million people. The season is not over, and we want to encourage people to come forward, particularly those who are eligible, and the offer will extend to those aged over 50. Vaccinations work, and they reduce your chance of getting the flu, and, if you get the flu, they reduce your chance of getting really sick. They work.

Mr Donnelly: Absolutely. I completely agree. Thank you very much.

Mr McGrath: Thank you, Minister and team, for coming along, although, I am not sure that, by the end of the meeting, anything will be different from what it was at the start, and that is the reality. We need to accept that. We are where we are. I had hoped that you might have been able to tell us about different things that would take place, such as pulling the levers that you referenced. Again, we have heard that there is very limited scope.

This meeting was called in response to the fact that, over the past two weeks, there has been a growing crisis, which is likely to take two or three weeks to ease down again, as has been referenced. Vaccinations are likely to have little impact on that, because it will take a month or six weeks to get people vaccinated. People have mentioned shutting down beds and moving care into the community, but then there will be no beds for the people who are sitting in the EDs to move along to.

Minister, you are a member of an Executive, and I ask this genuinely, as a member of the Opposition: do you feel that your Executive colleagues are supporting you? Three or four weeks ago, when you could see the projections about the problem that was coming, had more money been made available to you and had it been spent, would things be any different today? Would there have been support for some people, or are we looking at a situation that is out of control, like a runaway train that will crash, and we cannot do anything until it has crashed, and then we pick up the pieces at the other end?

Mr Nesbitt: It is well known that every Executive colleague has pressures — financial and delivery pressures. I make the case that the pressures in Health can have catastrophic impacts in that the impact on patients can be fatal. Yes, there is mutual understanding of the pressures. What I have objected to and have done so publicly, so I am not breaking any Executive confidentiality, is the idea that, suddenly, the assessed need, which was so successfully used in the argument for the block grant going to 124%, is not being recognised. The idea of, "You have more than 50% of the block grant" being some sort of reason for saying, "Just get on with it" is not logical, because the assessed need is the assessed need. If that means that we need 52%, 53% or 54%, then that is where it is.

People think that reform will save money. The best thing that can happen from reform is that it will slow down the pace at which extra money will be required. I am keen to do that. As I said in my opening remarks, I want to drive productivity and efficiency, but no amount of efficiency and productivity will close the gap between capacity and demand.

It is difficult for Executive colleagues because they are looking at an eye-watering budget. It will be over £8 billion. That is an awful lot of money. Do we all understand one another's pressures as well as we should? I am not sure that we do, and I have argued for a more collective approach. If you take any significant subject that we are trying to improve as an Executive, you will see that very rarely will one Department be able to fix it. We now know that all of these things are interrelated. Take educational underachievement, for example. Healthier children do better at school, so it is not just Paul Givan's problem; it is my problem. We are maturing in that collective approach. However, I am not the one who is saying what has been said about short-term levers. I sat with the Royal College of Nursing, the Royal College of Emergency Medicine and representatives of trusts, including Jennifer's, and asked "Are there levers that we are missing in the short term?". Basically, the answer was no.

Mr McGrath: I accept that that is what is being said. If there was a significant problem with the health service in Scotland or Wales, the Scottish or Welsh Cabinets would get together to find some sort of resolution. They would try collectively, across all of the Government, to find levers that they could pull. Has there been or are you aware that there is due to be an Executive meeting of all Ministers to consider the peril that the health of our population is in? Is a meeting being planned to discuss that issue in the coming days?

Mr Nesbitt: Yes. There will be an Executive meeting in the coming days. I will raise the issue at some point during that meeting. The meeting will not be called about this issue, but I will raise it.

Mr McGrath: So, it will be an Executive meeting, as normal, that you will be at, and you will raise the issue. I hope that you do, because I hope that we can find a response from the entire Executive to the crisis. I am not calling it a crisis; other people are calling it a crisis. I hope that you can raise that issue, Minister, and I hope that there will be a full Executive response to it, because it is for the health of our population, and it is a crisis in our hospitals.

Mr Nesbitt: Yes. Another thing that I have said — I think that I have said it publicly, so I can say it again — is this: if we have nine priorities in the draft Programme for Government, one of which is waiting lists, and the narrative in that document is that the waiting-list situation will get worse before it gets better and all bids for ring-fenced money to address waiting lists are rejected, we are not being consistent or particularly honest with people. We are saying, "It is a priority, but we are not spending money on it".

Mr McGrath: I wish you well at that meeting, and I look forward to seeing what the outcome from all Ministers of the parties represented here today will be. Good luck.

Mr Robinson: Thanks, Minister, to you and your team for making yourselves available.

Minister, I do not want to say this to be negative; I just want to understand. It is welcome that you said that the over-50s would now be included in a flu vaccine roll-out. Why is that being done now rather than at the start, as part of the winter preparedness plan? Some might say that that is being a bit reactive rather than proactive. I do not say that as a criticism. Please do not think that. You know me, and I am being honest with you, Minister.

Mr Nesbitt: Yes.

Mr Robinson: That is not my style. I just want to understand why that was not done in advance of this crisis, as Colin calls it.

Mr Nesbitt: The answer is relatively simple, I believe, Alan. We tend to follow JCVI advice, and the under-50s were not part of the JCVI advice. We focused initially on the vulnerable, the elderly and Health and Social Care workers. As you have heard, the uptake in some areas has been a lot lower than we would have liked, therefore we have spare vaccines. I do not want those to go to waste, so we will use them by extending beyond the JCVI advice and offering them to that new group of people, the 50- to 64-year-olds. However, we did not have that capacity while we were targeting the elderly, the vulnerable and the health workers.

Mr Robinson: That is fair enough, and I appreciate that response, Minister.

I do not want to be too negative. I want to talk about some of the positives because it has been a bit of a negative meeting and a negative run-up to the meeting.

I have a couple of family members, close relatives, who picked up the respiratory virus that is doing the rounds at the minute. The two of them were very unwell. Both are in the Western Trust area. One received the Hospital at Home care, and I have to say that it was absolutely wonderful. Two nurses attended, one in the morning and one at night, and those nurses are still tending to that relative. That has kept my relative out of hospital. It has broken one element of the flu chain. I am a little disappointed that you are telling us that there is no capacity to ramp up or expand that service, given that we are consistently being told that so many people are receiving undignified care. There is so much constraint on space in hospitals, yet here is a service that would prevent people from having undignified care. It would create a bit of space and capacity in hospitals.

I cannot get my head around why that service cannot be expanded and enhanced, given the examples that I have given you today. We could see more examples of people who would otherwise, potentially, be in hospital being cared for in their own home and happy for that to be so. I am convinced that, had my relative not received the Hospital at Home care, they would have been in hospital. They already had underlying issues and were fearful of going into hospital, so they were helped not only physically but psychologically. I am very grateful to the Western Trust and the GP service in the Limavady area that provided that service. I am convinced that, potentially, they saved that person's life.

Mr Nesbitt: If you want to expand that workforce — I would love to — you need the money to do it, and the money does not exist. I will continue, during my entire tenure as Minister of Health, to try to find that money from existing budgets and resources. As I said, Jennifer and her colleagues have done amazing work to achieve more than £200 million worth of savings. Those were not £200 million worth of savings so that we could expand services; that was so that we could contract services to live within budget.

I have to say that voting for the Budget, which, as Robin Swann and I warned, was entirely inadequate for healthcare provision, has consequences. You have just defined one of those consequences.

Mr Robinson: OK.

Miss McAllister: I will jump straight into my questions. I have supplementary questions that follow on from other members' questions. Before I ask my first question, I want to go over again the number of patients who are awaiting discharge, those who are medically fit for discharge and those who are awaiting beds. Can we have those numbers again?

Mr Nesbitt: Yesterday, the total number of people waiting for discharge was 516.

Miss McAllister: And those awaiting beds?

Dr McLean: As of 8.00 am this morning, the number of patients for whom there had been a decision to admit was 423.That will have fluctuated throughout the day.

Miss McAllister: I ask that, because, in answer to Diane's question about discharging people and using the beds, you talked about how that would not save money as those beds would be used anyway. The transparency was not exactly there. I know that Diane did not really appreciate that answer, and we are not getting complete transparency in those answers.

I want to delve a bit more into whether the number of those who can be discharged is greater than those who are waiting for beds. Have we been provided with the wrong information? There needs to be a bit of transparency in the way that we deliver health. Can we get that? I do not want to be wrong or unfair when asking questions.

Mr Nesbitt: I said that, if the patient who was being discharged was the final patient to use a bed, you could have a saving. I do not see where there is a lack of transparency.

Miss McAllister: When it comes to beds that need to be occupied, if the number of patients who are awaiting a bed is 423 and the number who are awaiting discharge is 516, there is a way and a means for us to use the money differently. Will that situation provide savings? I am talking about community care in the form of domiciliary care. Yes, that means that there will be money used for those services, but something has to be done differently. If the number of people who are in hospital far outweighs the number of those who need beds, we have to be honest about the difference that could be made. I am not saying that it is a massive difference, but we also have to be fair.

Ms McCaig: It is a challenge. Along with those numbers that we talked about, there is a large number of people in EDs who will still have to sweep through the system. You might see a number at any point and think that it all adds up and works out well, but, if it were as easy as that, we would be doing it.

The difficulty is that the beds that a lot of our hospitals have put up are additional in wards that are already staffed. I do not want to get too technical about the accountancy of it, but that means that there is a marginal cost that is not as great as the cost of putting the bed there in the first place. It is a marginal cost additionality. The cost of some of the complex packages that we need can be as expensive, if not more expensive. The growth in the elderly population means that that cost continues to grow. You might solve one part of the issue, but it continually comes round in a cycle. There might be 500 people today that we need to move, but there will be another 500 tomorrow. That takes a long time to do. There can be pockets of savings, as I said, at the time for some elements, but it is not as binary as saying, "That could be moved to another area". It is much more challenging.

Miss McAllister: I absolutely appreciate that and your point about marginal cost and complex needs when it comes to care at home. We could perhaps change from looking at cost to looking at better patient outcomes. A person who is looked after in their home, a rehabilitation facility or a step-down facility after hospital, such as a nursing home, has better patient outcomes. Last spring, we were developing that plan. Delayed discharge is not breaking news. We knew that it was happening, so what exactly was done to increase the domiciliary care packages or the beds available from those nursing care providers? I do not want to use the term "nursing homes". Some of them are private independent providers, and very few trust step-down facilities are available. What was done between last spring and this winter to increase those things in order to allow patient flow?

Ms McCaig: For that question and others, it might be useful if you got a fuller response after the meeting, because I do not have all the figures in front of me that relate to what I am about to go through.

In that period, there were a number of initiatives. Early review teams were created to ensure that we could use every hour that we have in our domiciliary provision as best we could. There was a stabilisation package from within the £70 million and the increased amount of money for domiciliary workers in the independent sector in order to ensure that we could stabilise the workforce; indeed, our hope was that we could grow that workforce. A lot was going on in that space to ensure that we could all maximise, with the resources that were available, the independent sector's human resources and our financial resources.

It might be good if we gave the Committee a fuller response to a number of those questions with some of that detail.

Miss McAllister: That would be good. The Minister just talked about the £70 million or the £62·1 million. He did not say that it was not for better patient outcomes, but it was not for an increase in patient provision.

Ms McCaig: There are two things. One was the national minimum wage for the vast majority, and £8·6 million was to increase our independent sector domiciliary care to pay significantly above the national minimum wage. That was to stabilise the system, and there was an expectation that, if we were putting more wages in, we would potentially get more capacity.

Miss McAllister: Did we get more capacity?

Ms McCaig: I will need to get the details of the answers for you.

Miss McAllister: It would be helpful if we got those. If we are looking at a blank sheet of paper that represents what we do in the next year, it would be helpful to see whether what we did last year made a difference. To us sitting here today, it sounds as though it did not. I am not saying that the people, whether that is those who are on the front line or the management, are not trying to make a difference, but, if it made no difference, how do we evaluate and change it?

Ms McCaig: It is —.

Miss McAllister: I appreciate that it might take time to get those details.

Ms McCaig: Sorry; I am speaking over you. I did not mean to.

Miss McAllister: No, you are OK.

Ms McCaig: It is about the significance of how much, because, in the same period, we lost provision in our care home stock in a number of our locales. We were losing capacity in our home care sector and our domiciliary provision. If we did not stabilise the situation and make it better, we would be in a worse position now. If all that we had to do was stabilise the system, we took the opportunity to do that and to be more productive in the utilisation of those hours during the year. There is a challenging dynamic with the other market forces.

Miss McAllister: That raises the other issue of those care home providers. We in the Committee hear a lot at informal and external meetings about Regulation and Quality Improvement Authority (RQIA) reports on care homes across Northern Ireland. Lots of families are shocked to read those reports. Is it any wonder that, when people are fit for discharge, families do not want to accept putting them into a care home, whether it is the furthest away or the nearest? We also need to examine what we can do better in that space.

The other issue that I will pick up on is the Northern Trust pilot scheme on the social care element. Your predecessor, Minister, was in the Chamber last year responding in a debate on social care during which we talked a lot about the social care collaborative forum. Those pilot ideas are not new. The social care collaborative forum had been discussing all those initiatives for years. I do not know why it has taken so long. I am glad that it is getting off the ground and that a pilot is starting now. It was not news; it was something that your predecessor mentioned.

We talked about moving away from the 15-minute allocation time, which is based on need. What has happened? What has been improved or changed in that for winter preparedness? Have you fed back to members of the forum to get their assessment? We need to recognise the work that the community and voluntary sector does, particularly on discharge. We also need to recognise those who provide help and care who are seen as being outside healthcare but massively help the healthcare system.

Ms Welsh: Those are all really important points, Nuala. The Minister is right about having a blank page for the winter plan for next year and about how the different elements across the health and social care sector need to be involved in that. You made good points about how and where we spend our money. That does not mean that it is easy to release it quickly.

You talked about the delayed discharges and the number of decisions to admit that we have to make. On the face of it, it looks as though it should be easy and straightforward, but it also has to be considered in the context of the 350 additional beds that we have right across the system that we are not funded for.

We have had to pop up those beds, and we have been able to do that largely by adding an extra bed or two to every ward and by stretching the staffing in some areas — yes, absolutely — but not in Antrim Area Hospital, because we do not have the physical space to do that.

Given that we know that our emergency departments are so busy, we have also had to overstaff for the weeks of winter. We deliberately roster more staff. The Minister mentioned the savings that we made. We deliberately carve out an element of funding every year, to the tune of about £3·5 or £4 million, so that I can put up additional beds and roster additional staff into EDs. That is not recurrent money that I could give to something else. That is one of the biggest challenges in how we start to shift. However, there is something in that that is about bridging funding to allow reform and change to take place, because we know that we could do this in a better way.

Miss McAllister: I agree with that absolutely. I appreciate your position, Minister, in standing up and speaking for your Department, but it is a bit unfair to say that the situation is a consequence of the current Budget when it is actually the consequence of years of running the health service in the way that we have been. It needs to change beyond preparedness for the upcoming winter. We know that.

I will also ask about Phone First. We heard that 160,000 people use that system. As MLAs, we have been lobbied about it, and people have contacted us to say that Phone First may not be the silver bullet or the best lever to take pressure off the ED. The feeling on the ground is that a lot of the people who are assessed do not go to the ED but to a minor injury unit where they are assessed anyway. Will there be evaluation of the way in which the Phone First system is utilised by each of the hospitals in the trusts? Will there also be an evaluation of the benefit of running Phone First versus using the money that is spent on it to provide more resources for people to be assessed at that point? Constituents, doctors and nurses have told us that appointments are given over the phone but that, in reality, that does not matter because, at a lot of the hospitals, people are assessed when they arrive. What is Phone First doing? Can we get that evaluation? I know that we are running over time.

Mr Nesbitt: Before Tracey comes in, I will say that Phone First is not a silver bullet. There is no silver bullet. What I would like to see in 2025 is a more consistent regional Phone First system, because, to some extent, it differs depending on the trust that you are talking about. I like the idea of regional services whereby we find where best practice is and make it common practice across all the trusts. Sorry, Tracey.

Ms McCaig: Supported by that, I have been co-chair of the urgent and emergency care board since I took up my post. That board has representation from emergency departments, medics from primary care and elsewhere and service users. Conversations are being had about looking at Phone First as the kind of 111 service that you see in other jurisdictions. We have made a number of visits to see how that has worked. It is about how we can make the service different in future. How do we make it regional and more effective in the points that you mentioned? All that assessment is ongoing, and a lot of work is going on behind it to consider and develop what might end up at the end of the process being a business case for changing what we have into a fully functioning 111 service. However, we have to weigh that against other priorities. That is one of the choices that we will have to make at the point that we finish the assessment, but it is actively under consideration as one of the key planks. Colleagues from NHS England have said to us, "If you do it in the right way, this will be really helpful to you", but, again, we need to look at the investment, how we bring it in and when we could bring it in. It is absolutely under active consideration.

Miss McAllister: Thank you. I appreciate the answers, and I know that we are running out of time, so I will move to my last quick question. What I would like to ask more about but cannot is the modelling for the predicted numbers of people who are expected to attend A&E and to be admitted. Why did the modelling fail, and, in the case of those who have been admitted, what happened?

I assume that the majority are being admitted with flu. We understand that under-65s are an issue. Whilst the delayed discharges are of over-65s, the admissions that we are looking at are of under-65s. Why did the modelling fail? What has happened that has meant we are seeing this spike?

Dr McLean: The modelling that Tracey referred to is not actually the infectious disease modelling that we were used to during COVID. Projections were made — Tracey can talk to this better than I can — but they are not public health-type modelling. They are projections that were made based on past ED attendances and things like that. It was not modelling in the sense that we think of modelling.

Miss McAllister: Do we not do that?

Dr McLean: We now have the capability to model. Remember that flu is only one of the reasons that people are going to hospital at the minute. We have the capability to model now. That came into the agency during and as a result of COVID. It was, I guess, a positive legacy of COVID. Modelling flu is extremely difficult. We have a model in place, which we use and are testing with colleagues across the UK. The UK Health Security Agency (UKHSA) is the main leader in this space. It is still working on its flu modelling and testing it. It is not the same as the modelling that we used during COVID. The figures that Tracey is referring to are projections based on past attendances rather than infectious disease modelling, which is what, I think, you are referring to. We need to remember, as Tracey said, that there are 288 patients in hospital with flu and that the vast majority of patients in our hospitals are in with other things. It is flu on top of all the other things that is the issue.

Miss McAllister: We need to do both. Will that change? Going forward, will we do both?

Dr McLean: We know that flu comes every winter. We do not know the size of the flu wave. That is very difficult to predict, because flu changes from year to year. It is a different virus. We are not sure just how well the vaccine will match the virus, and that is why it is trickier. However, we know that we will get flu every winter, and the chances are that it will coincide with the Christmas period when the services are a bit different.

There has been a lot of discussion around what we can do on admissions and managing discharges and other things better. I have been sitting here looking at the orange circle on the poster behind the Chair, which says, "Prevention is Better than Cure". When we are thinking about what to do differently next year, we, as a group of people in the health service and society, need to think about prevention. The Minister has that as one of his top priorities. I am thinking about smoking, which is the biggest preventable cause of death and illness in our community. There are other things that we can do as well. As well as all that public health-type prevention, we need to think about how we manage people who are diagnosed with heart failure. How can we manage them optimally so they do not end up having to go into hospital? It is about a whole suite of things. It is really quite complicated, but, because I have been looking at that, I am excited about what we do in the future and seeing how we bring prevention into it and think in a different way so that is not just about our hospitals or managing sick people but is about how we stop people getting sick.

Mr Chambers: Thanks very much, Minister. When I followed the comments yesterday from the Secretary of State for Health and Social Care, Wes Streeting, it struck me that there seems to be much more political point-scoring in the media here than in other areas. Perhaps that is a symptom of having a multi-party coalition. Does the Minister feel that our health workers and, indeed, the public do not want to hear our politicians sniping from the sidelines? Can that have an adverse effect on staff morale?

Turning to the point that my colleague Mrs Dodds made about the questions for written answer that she has tabled since March 2024 on the number of people waiting to be discharged and how the figures are not really coming down, will the Minister explain how far back we need to go to find when the seeds were sown for that situation to develop?

My last question is to Dr McLean. Can she confirm that it is never too late to get the flu vaccination?

Dr McLean: Yes. It is not too late until the programme finishes at the end of March or the vaccine runs out. You can still protect yourself this winter. If you have not had the flu vaccine and you are eligible, you can still get it. It will be available right up until the end of March or whenever we run out of stock. I encourage people to come forward; it could make a difference to you.

Mr Chambers: Thank you.

Mr Nesbitt: In response to your other questions about how far back we have to go, we all know that part of the problem is that the Health and Social Care system has been underfunded for many years. Therefore, the fix will not come in weeks and months; it will also take years. Publicly, I tend to talk about it taking five to 10 years, but the timescale for some of the things that I want to achieve will be generational.

We all accept that Health can tackle about 20% of health inequalities, while 40% of the issue is socio-economic, 10% is related to environment and 30% to behaviour. It is a whole-Executive challenge. I put that point to Executive colleagues — it was a, "By the way" kind of conversation rather than an in-depth "Let's spend an hour talking about this" conversation — and I was encouraged by the response from people such as Conor Murphy and Andrew Muir, who will be involved in that because they are the Economy Minister and the Environment Minister. They were very positive about those things. Yes, we have a multi-party coalition Government, and people will put out party-political comments; that is just part of where we are. I do not think that it will be particularly welcomed by Health and Social Care staff, who would like to see us working together. I mostly get a good vibe from the Executive. I genuinely believe that, since we came back in February, there has been a different atmosphere in the Building and the debating Chamber. That is probably because we all realise that, if it goes again, it is gone — you can forget it. I cannot see it coming back if that were to happen. It would be very difficult to mount a negotiation on the scale of the negotiation in 1998, given the context of social media and the modern environment.

I will finish optimistically. There are challenges, but I will volunteer to try to fix those challenges. I do not think that I can achieve everything between now and May 2027, but we can take a lump out of it, and I would like to do that, collectively, with all of you. Perhaps, by the time we get to the end of the mandate, we will have set a direction of travel that the next Health Minister will feel compelled to follow because the results have begun to show. Some of those results will take a long time, particularly on health inequalities. Healthy life expectancy has not improved since devolution in 1998-99. Can you imagine a situation where, by May 2027, we have shifted the dial — even if it is only beginning to vibrate — in the right direction? That would be a huge achievement and would be very encouraging for the next mandate.

Mr Chambers: Thank you.

The Chairperson (Ms Kimmins): Thank you, Minister. Before I conclude the meeting, Linda and Danny indicated that they have each have a small point to make. We need to go quickly.

Mr Nesbitt: I know that everyone has changed their diary, Chair, but I need to be somewhere else.

The Chairperson (Ms Kimmins): Absolutely. I will bring them in quickly.

Mrs Dillon: Mine is a point, not a question. I am absolutely, 100% for the regionalisation of services, so long as they are accessible. I have said this repeatedly, Minister, so you have it in your head: everybody needs to be able to access services, so do not forget about people in rural communities. The South West Acute Hospital (SWAH) has a lot to offer. I am not saying that everything needs to be there, but this meeting has just proved that we need all the hospital space that we have.

Mr Donnelly: Mine is also just a point. Two of the main parts of your winter preparedness plan involve GPs and community pharmacies. We have heard in the Chamber that those two sectors are under extreme pressure and suffering from closures. Obviously, they are important sectors in preparing for the winter. I would like to hear, quickly, about what you are doing to support those two sectors.

Mr Nesbitt: There has been investment, Danny. The issue of GP indemnity was becoming really toxic. I said that I would do something on that by the end of the last calendar year. We have put out a proposal to fix that, and I hope that that proposal will be acceptable.

When I started saying that I wanted to shift left, meaning that we would have more community care, more GP care and more community pharmacy involvement, people thought, "He just wants us to do more for the same". I do not. If people are going to do more, they have to be rewarded for doing more. I get that.

The Chairperson (Ms Kimmins): Thank you, Minister. As you said, we all shifted our diaries, but this meeting was important. Contrary to some who believed that it was not worthwhile, I believe that it was. As a Committee, we have a good understanding of where things stand, but I hope that the message that goes out to the public today is that everything that can be done is being done.

We now have scope to look at how we work in the here and now. There may be actions from today's meeting that we can work through in the planning period for the next winter pressures and in relation to the ongoing pressures.

I will ask you, Minister, to agree that, on the other side of this winter period, we get a debrief on what happened, how we dealt with it and where the gaps were. Then, we can work with you, your colleagues and the sector staff, who have the solutions, I think, to lots of the issues. We talked about co-design, and that is a critical part of it. If you agree, the Committee could also get an early briefing on next year's plan, particularly around domiciliary care and that ongoing work. That would definitely be useful. As others have rightly said, those are ongoing pressures that we will keep a watching brief on.

Mr Nesbitt: I am more than happy to give you the debrief, once we have analysed how we have done this winter. When it comes to that blank page, I would like the Committee to be involved. The blank page is not a blank page any more, because I have already had one idea, which relates to something that you said at the beginning about whether we should try to involve GPs in a hospital setting.

The Chairperson (Ms Kimmins): I know from the meetings that I have had, even as recently as this morning, that part of that is about looking at the investment in primary care and GPs. They could do more and, I think, in many cases, for a lower cost than is happening in other elements of our health service. That is a saving, but it also represents a better use of really valuable resources that we have there.

Mr Nesbitt: Thank you all for your time and for your support. If you could leave your bank details with the Clerk, that would be greatly appreciated. [Laughter.]

The Chairperson (Ms Kimmins): Thank you, Minister. Safe home, everybody. I really appreciate it.