Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): I welcome Niall McGonigle, director of the Royal College of Surgeons Northern Ireland, and Mark Haynes, consultant neurologist. Thank you both for coming. We are delighted to have you here. It is timely, given the visit that we made this morning. We are keen to hear what you have to say. We have approximately one hour for the session. We have a lot to get through today, with two important briefings. I want us to cover as much as we can, so I remind members to try to keep their questions succinct. I invite you to make your opening remarks.

Mr Niall McGonigle (Royal College of Surgeons): Good afternoon. Thank you, Chair and members, for inviting us to talk about surgical hubs. I will give a brief summary to set the scene.

We remain in a dire situation with waiting lists in Northern Ireland. The most recent figures, published in November 2024, showed that 109,506 patients are awaiting admission for inpatient or day-case care. The majority of those are in general surgery; trauma and orthopaedics; ear, nose and throat (ENT); and neurology. The median waiting time is between 47 and 51 weeks. The reason that there is two figures is, as you probably know, because of the difference in the reporting mechanisms between trusts, given the ongoing roll-out of the Epic Encompass digital system, which has affected the ability to produce data over a period. Overall, 82,181 people — or 75% of the patients on the waiting list — are waiting more than 13 weeks. Some 52,935 people — or 48·3% of the patients on the waiting list — have been waiting over one year. Members will be aware that the targets are that 55% of patients should wait no more than 13 weeks and that no patient should wait more than one year. Those are admirable targets to have set, but, clearly, we are falling significantly short of what we want to achieve for our population.

I do not need to remind you about the ongoing crisis in our emergency departments and unscheduled care, which is having a knock-on effect on elective care. We continue to see demand in our hospitals exceed capacity.

Many surgical hubs in the UK were developed, or under development, prior to COVID. During the global pandemic, it became increasingly clear that utilisation of surgical hubs, green sites or green pathways allowed for and supported the delivery of elective care. That utilisation increasingly recognises that, in recovery, they can deliver on elective waiting lists, which is what they were primarily designed to do. We understand that approximately two thirds of the patients on our waiting lists are waiting for day-case-type procedures, with the remaining one third requiring inpatient or longer-stay admission. Whilst our waiting lists are long, we must acknowledge that there have been small, incremental reductions over successive quarters, in which surgical hubs have no doubt played a role.

A surgical hub is a dedicated, ring-fenced, elective care facility with resources and staff that are distinct from unscheduled care. They excel in the delivery of high-volume, low-complexity work: for example, hernia repair; cholecystectomy for gall bladder disease; joint replacement; cystoscopy; and ureteroscopy. There is no specific model set for a hub or how a hub should work. Several models have emerged over the years, ranging from a site that is completely and physically separate from all other operating flows to a hub that is in a business-as-usual site. The main principle of a hub is to ring-fence beds and staff so that care can continue to be delivered despite pressures elsewhere in the system. The three main models are a hub within a hospital, a stand-alone hub and a specialist hub providing specialist surgery. All too often, elective and unscheduled flows compete for pooled resources, including theatre space, staff, equipment and pre- and post-operative beds. Hubs aim to prevent that.

At present, there are two dedicated day-procedure centres, at Lagan Valley Hospital and Omagh Hospital, which, between them, treated 27,000 patients from October 2020 to October 2024. There are three elective overnight-stay centres: at Daisy Hill Hospital, which you visited today, the Mater Hospital and the South West Acute Hospital (SWAH). Between them, they delivered care to 15,000 patients between April 2023 and October 2024. In addition, there is a dedicated orthopaedic hub at Musgrave Park Hospital, which treated 2,000 patients between September 2022 and May 2024.

As part of our written submission, we advised the Committee of the Health Foundation analysis of surgical hubs in England, which, we believe, provides supporting evidence to the validity of the model and is extendable to Northern Ireland. As of August 2024, there were 108 surgical hubs in England, with a plan to open a further 26 by the end of 2025. Among the key findings was that trusts that had a hub pre the pandemic undertook 11·25% more elective surgery than they would have without a hub. More importantly, there were shorter hospital stays, adding to the overall efficiency of the system. Furthermore, the 31 trusts with newly developed hubs in the aftermath of COVID showed a 21·9% increase in activity in that high-volume, low-complexity work.

Early evidence is also coming from the University of York with MEASURE (mixed methods evaluation of the high-volume low-complexity surgical hub programme), a four-year study that commenced in 2023. We have provided limited data on that because the study has not been published yet, although it has been provided to us. However, the provisional results show that surgical activity increases by about 20%; that there is a reduction of about 9% in the length of hospital stays; and that there is a significant effect on waiting lists. It is clear that the hub model works and works well, but it requires investment, support and an ability to grow and change. None of that is deliverable without an appropriately trained, reliable and resilient workforce, which Mark will talk about.

We are all here because we care. We want to see a healthcare system that delivers for the well-being of the people of Northern Ireland. However, we must all strive continuously to reduce the effects of the constant lurching from one crisis to another, which causes harm to patients and to our health system's greatest assets: its staff.

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

Mr Mark Haynes (Southern Health and Social Care Trust): Thanks, Niall.

As Niall mentioned, I will touch on the workforce element. In January 2024, the Royal College of Surgeons published the 'Advancing the Surgical Workforce' census report. That report showed that 53% of Northern Ireland's surgeons had considered leaving the workforce during the previous year. Of those aged 55 to 64, 91% said that they planned to retire within the next four years, and 62% of Northern Ireland's surgeons who responded cited a lack of access to theatre as a main challenge facing the surgical profession. Some 66% said that burnout and stress were also main challenges.

That report made a number of recommendations, including on trusts developing policies and guidance that beneficially impact on the well-being of surgeons; tackle bullying, harassment and sexual misconduct; enable flexibility and less than full-time working; improve the working environment, including by providing places to rest, hot meals and dedicated places for study; and increase training numbers across all surgical specialities and prioritise training opportunities.

There are a couple of things to highlight about the hub model. The development of hubs, whereby surgeons do not find their theatre access being closed off because of the impact of unscheduled care, helps to increase theatre access. It is important that we ensure that trainees are facilitated in being able to attend the hubs and that it is not a service that is delivered only by consultants — it has to enable training. We have to make the model of working fit with what is realistic for surgeons. It is OK for a surgeon to travel two hours to and from work for a short period, but is that a deliverable 30-year job plan?

Niall talked about waiting lists. Another thing to mention is the vacancy data. We know that, across Northern Ireland Health and Social Care (HSC), there are a significant number of vacancies — over 5,000. Within that, there are vacancies at consultant level in the surgical workforce and at other grades below consultant level. There are around 300 surgical staff vacancies.

Mr McGonigle: Sorry, that is consultants across the service; it is not just in surgery.

Mr Haynes: That is consultants across the service, not just in surgery.

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

I have a couple of questions. It is really good to get those figures, because recruitment and retention is probably our biggest challenge. You have outlined the percentages of people who have considered leaving and the even bigger percentage who will be leaving, having made the decision to retire. Are we confident that those people will be replaced, or do we see that as a massive challenge, particularly the people at consultant level retiring? We heard about some of the waiting lists this morning — about what those look like and the impact that they have on people's lives. Given that we will see a huge swathe of surgeons retiring, what do you see coming through to potentially help with that?

Mr McGonigle: We talk about the three Rs: recruitment, retention and retirements. Yes, retirements are becoming a major issue. As Mark said, when we did our census two years ago, 91% of consultants or surgical staff in Northern Ireland aged over 55 said that they intended to retire within the next four to five years. That is a massive number of senior, experienced staff. Not all consultants are the same. Senior consultants can deliver a lot more, so we have to be cautious about them leaving. Is there a flow back in? No. Unfortunately, recruitment numbers, not just in Northern Ireland but across the UK, have remained stagnant over a number of years. In fact, a lot of statistics have just been released in the past couple of days. There is a lot of anxiety amongst trainees about there not being enough training places. We are not meeting those. We are not in a position to deal with people potentially coming out of the system by replacing them with people coming into the system.

The Chairperson (Ms Kimmins): That is the concern. This is probably more a question for the Department, but are we planning for that? Are we trying to look at why those challenges exist in the first place and why people do not want to come into the field? Are we trying to deal with that in advance?

Mr McGonigle: I do not think that it is that people do not want to come into the field; it is that training numbers are set. Each year, you get a certain number of trainees coming into each surgical speciality. That is out of the hands of the colleges; that is for the Northern Ireland Medical and Dental Training Agency (NIMDTA). The numbers are, though, generally set across the whole of the UK, and we have national selection. For example, in my speciality, which is cardiothoracic, you are appointed to a training programme in Northern Ireland, but you are not appointed in Northern Ireland; you are appointed across the whole of the UK. Those training numbers have not increased over a number of years. We know that we have a shortfall.

We need to start looking at workforce planning and ensuring that the people who come out of training are fit to fill the gaps. The way that it works at the moment is that a surgeon might go into general surgical training and decide to become a breast surgeon, but six surgeons might choose to do that when you actually need four or five colorectal surgeons. We have not managed the workforce as well as we could have from that perspective.

The Chairperson (Ms Kimmins): OK. It goes back to the broader piece about workforce planning across the health service and, specifically, the fact that we could see really major issues if it is not addressed soon.

We have talked about this before. In the briefing papers, we see that there is a real appetite to move to seven-day sessions. We had conversations this morning when we were in Daisy Hill about how you could increase capacity and put a real dent in the waiting lists, but I understand that that is not as straightforward as it may seem. I want to get an understanding of what the barriers are and what we could do to try to address them, because, if that appetite is there, we should do everything that we can to try to move to seven-day sessions, if it will mean that we can improve outcomes.

Mr McGonigle: The Getting It Right First Time (GIRFT) data for surgical hubs says that the aim is that they should work at least 14 hours a day, 48 weeks a year, six days a week. Most of our hubs are not achieving that, and, therefore, yes, we need to ask why. A lot of it is down to staffing issues. We are dealing with a workforce that is stressed and burnt out and in which morale is low. We have staved off a few industrial actions on the basis of pay parity with the rest of the UK. It has already been addressed in Northern Ireland. We have talked about it before, and it is being seen across the water in England as well: when you have a workforce like that, it is difficult to start increasing. It is difficult to move to six- or seven-day working, because you are asking your staff to work more and more and more. There are limitations in that. Filling those gaps is difficult. With some of the hubs and stuff, we are already reliant on locums. Part of the policy is to try to reduce the number of locums, which is certainly a good and economical thing to do, but it is about trying to fill those gaps in the service.

The Chairperson (Ms Kimmins): Is it fair to say that, if, by moving to seven-day sessions, surgeons and surgical staff got more opportunity to do what they are trained to do and to use their expertise, that may attract staff and stabilise a lot of the staffing issues?

Mr McGonigle: It absolutely would. One of the things that was reported in our census is that 50% to 60% of surgeons, at consultant and training grades, are unhappy in their job because they do not get access to theatre. We have produced data that shows that, in Northern Ireland, depending on which trust and which speciality they work in, consultant surgeons spend about 20% to 30% of their normal working week operating. I do not think that anyone would disagree that it seems a bit peculiar for somebody who is trained to such a high level and has spent so long training to be, I suppose, an expensive commodity that we do not really use.

The Chairperson (Ms Kimmins): That came up in our discussions this morning too: if there are staffing issues and you have to cancel surgeries, that reduces theatre time.

My last question is about specialist surgery. An issue that we are all hearing more and more about is obesity services and bariatric surgery. I have dealt with constituents in this regard. A growing number of people are going abroad to have those surgeries because they cannot access them here. A couple of weeks ago, the Committee met the Northern Ireland Obesity Coalition, including Professor Miras. I learned so much from that group about how transformative it would be if we had a regional obesity management service in place and an ability to carry out bariatric surgery. Has the royal college been looking at that? Do you hope to see that?

Mr McGonigle: We have always supported that. When there were moves to introduce it at the SWAH, we were supportive of that. It was disappointing that that did not happen. It is sad that we are in this position. We hear horror stories about people going to Turkey and other places for surgery, having complications and then coming back and having to deal with those complications. The fundamental question that you have to ask yourself is this: why are people going there to have that surgery? It is because we do not have a service here. We have forced those people into that. They have not chosen to go there; they have been forced to go there, because we have not given them a realistic option here.

The Chairperson (Ms Kimmins): The key thing that I learned from the meeting with the coalition is that the reasons that people require that service in the first place are so nuanced. There are so many different aspects to it. We are always looking at the pressures on the health service and people requiring more primary care. If we were able to provide that service, that would take pressure off elsewhere. If people were living well, all the health conditions that are associated with obesity could be eliminated or managed much better. There is so much to the issue, and we should definitely look at it very closely. The warning that we got that day was that this is coming down the tracks quickly and could cause a real crisis across the board. We should really look at that. I know that a strategy group is in place, and I think that a consultation went out last year. I am keen to see about that. We can follow it up with the Minister as well.

Thank you for that. Linda is next.

Mrs Dillon: Chair, we are not using microphones, but I do not need to press anything; do I?

The Chairperson (Ms Kimmins): No, they are just recording.

Mrs Dillon: I was just checking. My hearing is not good, so I did not want to take that for granted.

The Chairperson (Ms Kimmins): On that point, we have Assembly Broadcasting here, and it is recording the meeting. When we revert to members for questions later in the session, please pause before asking your question to give the team time to move around the room.

Mrs Dillon: And please speak loudly, because I really have a hearing problem. Mark, I think that I caught most of what you said. It is not your fault but mine. Some day, I will get the hearing aids that I clearly need.

I have a couple of questions. Niall, will there be any positive knock-on effect from the hub model? We know the kinds of things that the hubs will deal with: seriously needed but less-complex surgeries. Will that have any knock-on effect for the more complex surgeries that need to happen in the likes of the Royal Hospital and Craigavon Area Hospital? Because it was raised with me again today, I am thinking specifically of paediatric spinal surgery. Is there potential for improvement in that service if we had greater capacity to move other things out, or would that not really have an effect because it is more about taking pressure off the —?

Mr McGonigle: The expectation is that it would have an effect on the basis that a lot of the low-complexity stuff can be moved out of specialist centres and tertiary hospitals — as we call them — in Belfast, for example, thereby creating more capacity there. Because you are not doing that type of surgery there and you have somewhere else to do it, it would have an effect. There is an ongoing project to develop a paediatric hub. In the past week or two, there was a workshop on that, although, unfortunately, I was not available to go to it. There are plans to move towards having a hub for paediatrics, because we know that we have a paediatric waiting list. At the last count, we reckoned that there were in the region of 7,000 children on those lists waiting for inpatient care. If you moved that out of places like the children's hospital, you would free up capacity to do the more complex work.

Another thing is that, as surgical hubs grow, their work increases in complexity. Whilst you might look at the surgical hubs' numbers of cases done and see them go down a little bit every so often, that is not because they are doing less but because, as they grow, they take on more and more complex work.

Mrs Dillon: OK. I will not ask you about specific cases in this meeting.

On the hubs, we have already talked about the workforce challenges. Do you have any idea as to how we might overcome those challenges? We know that surgeons is one element, but it is also about theatre staff and all the staff who would be needed in the hubs. Can those things be addressed? As far as you are aware, do the Department or the trusts have a plan in place to overcome that?

Mr McGonigle: The Department has started to look at that again more recently. The issues exist not just for medical staff and surgeons but for all hospital and healthcare staff. The cross-cutting components are basic. Can you park your car at work? Do you have appropriate rest facilities for when you want to take your break? Can you get a hot meal? If you start a shift at 1.00 pm and do not finish until 10.00 pm or 11.00 pm, can you get a meal? Those are the things that are really important to people. It is about travel time as well. It is about making staff feel valued. We talk an awful lot about pay parity and things like that, but there are a lot of other ways to incentivise staff and to make them feel valued and part of a system that appreciates them.

Mrs Dillon: When we met junior doctors, they said that pay is only one element of the challenge. I do not want to single it out, but, during those conversations, Altnagelvin Hospital came up as having some of the worst facilities for staff. Never mind whether you could get a cup of tea, there is nowhere to have it and nowhere even to put your coat. They talked about the facilities for staff who have to stay overnight, spending time away from their families. You are absolutely right.

I will ask two more questions. Are there examples in other places of best practice on workforce, whether that is in other parts of these islands or beyond? I am concerned about what you have said about more experienced people leaving and the number of trainees. Even if we had more trainees, if we do not have the people to train them, we will have a real problem. Are there examples of best practice in other parts of the world for how to deal with that?

On the positions that are vacant, the Royal College of Nursing (RCN) and others have told us that the vacancy rate for nursing positions, for example, that we are given include only the jobs that are being advertised and actively recruited for but are not the actual vacancy rate — the number of people that we need to make our health service work. Is that the same for surgeons?

Mr McGonigle: There were a couple of questions there. I will start with examples of best practice. We have spoken about Getting It Right First Time — GIRFT, which is an organisation that comes in to look at what you do. It does that as best it can in a non-judgemental way. If it goes into a hub that is carrying out four hernia procedures in one day, it may say, "Another hub is doing eight such procedures in one day. Why are you only doing four?". It looks at the factors that are causing that. It may be that, from that, you get best practice learning from somewhere else. It may ask, "Have you thought about doing it this way instead?". There is a lot of that. We would like to see that learning and sharing throughout Northern Ireland. Where one organisation, department or service is doing well, it should share that with another. It is not that the other group is not doing as well by any construction itself. It may be that there are blockers that it has not recognised, or that it has recognised but has not been able to change, and another organisation can say, "Why not do it this way?".

You are right about training. To encompass two questions that you asked: yes, with junior doctors, it is the time that they get to do the training.

You have to remember that junior doctors — the resident doctors and doctors in training — are there for two reasons. They provide a service, which is our NHS model, and they are there to be trained to be the next generation. You will hear me going on about this all the time at the Royal College of Surgeons: "No training today, no surgeons tomorrow". We have to realise that we have to train people in order to keep them coming through that process. If we do not do so, we will not have a workforce down the line.

We have to ensure that time is set aside for senior doctors — consultants — to train their juniors, work with them and make sure that they are progressing. If we pull them in 10 different directions and they cannot train, we are not training the surgeons of tomorrow. It is about making sure that they have appropriate study facilities, that they get away to do their studies and that they have courses etc paid for rather than paying for a course and maybe getting the money back 12 or 18 months down the line. It goes back to being valued.

Mr Haynes: I will touch on two things. The hubs have a big role to play for the trainees, but they have to be freed up to get to the hub. The nature of the hub is such that they will not be disturbed for emergencies, so they can be trained surgically there.

At least three specialities across Northern Ireland have had GIRFT visits and reports published by GIRFT on how services can be delivered. Reports on trauma and orthopaedics, gynaecology and urology have been done.

Mr McGonigle: And paediatrics.

Mr Haynes: Yes, and paediatrics.

The Chairperson (Ms Kimmins): OK. Thank you.

Mrs Dillon: I thank you for your last point about paying for exams and training. We need to raise that with the Department, because the junior doctors raised it with us, and I cannot get my head around it, to be honest.

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

Mr Donnelly: Thanks for that, both of you. At the start of your presentation, you described a "dire" situation. For the more than 50% of people who wait longer than a year, it is still dire. Those are our constituents, and we hear about them all the time. I have heard of a lot of constituents being forced into a situation in which they have to pay privately or look to go away. That is a terrible and costly thing for them to do. We have a two-tier health system in Northern Ireland.

I have a couple of questions that are based on what you said. We are in the throes of winter pressures again. What has been the impact this year of the hub model's being in place? What impact has that had on working down waiting lists during our winter pressures? Has there been a difference this year? Has work on bringing down the waiting lists been better protected? Have you seen a bigger difference?

Mr McGonigle: I cannot answer that at the minute, Danny, because we do not have access to the statistics until the Department produces them, and it will probably be a few months before we get them. However, anecdotally, our members feel that, with the hubs, they have been able to deliver elective care by alternative means, without hospitals. I work in a speciality that is delivered in a tertiary setting in Belfast Health and Social Care Trust, and I can tell you that the pressures on the hospital from admissions in the past couple of months with flu, COVID and respiratory syncytial virus (RSV) have had a significant effect. They have put immense pressures on trying to get patients in and cases through. We have managed well, but there is no doubt that there has been a knock-on effect.

Mr Haynes: There are incrementally different pressures depending on where you go. At a stand-alone day procedure unit such as Lagan Valley, things have been able to roll on and work as previously. It is the same in Omagh. In on-site hubs — I work in Belfast and in the Southern Health and Social Care Trust, so I have been in the hub here at Daisy Hill — we have been able to carry on working, but there have been more challenges, with pressures from some patients having to be moved around because of the emergency department pressures. In a specialist site such as the Royal Victoria Hospital (RVH), where there is a big emergency take and, as Niall said, his speciality, the pressures are higher again.

Mr McGonigle: To cover another point in your question, there is a lot of data from Merseyside and GIRFT that shows that surgical hubs reduce health inequalities. Patients in the most socially deprived areas tend to deteriorate quicker on waiting lists than other people. If you deliver their care quicker, you prevent them from getting a lot of the associated comorbidities.

Mr Donnelly: Thank you. One of the things that we heard today is that the waiting lists seem to be bizarrely counted. I think that they are counted differently in different regions as well. The waiting lists may still include people who have died, those who have become too frail for their surgery or even those who have gone private. Are we painting a false picture? Are we getting an accurate picture of the waiting lists, or do we need a regional Northern Ireland-based re-evaluation of the waiting lists?

Mr McGonigle: That is a very good question. Do we know whether, as you say, all the patients sitting on waiting lists still need an operation? Is the operation that they are listed for still the correct operation? One of the things that our members have reported is that they may be asked to perform, for example, a cholecystectomy for gallbladder disease in a surgical hub. If a patient with gallbladder disease was added to the list three years ago, they may have been in four or five times with cholecystitis, which is inflammation of the gallbladder. If their gallbladder is now really stuck, it is a really difficult operation to do, and it is not suitable for a surgical hub.

The other issue is that patients deteriorate and get other things when they are on a waiting list. One surgeon said, as an anecdotal example, that somebody on a list had two heart attacks in the intervening period and was no longer suitable for the operation.

It is important to validate the waiting lists and keep them up to date for two reasons. It means that you know who is on the waiting lists and who needs what done. It also gives information to patients so that they do not feel forgotten about. If you say, "We know where you are on a waiting list, and this is where, we think, the surgery is going to be", patients feel empowered. They say, "I know where this is going to be". At the minute, a lot feel that they are just being put on a nebulous waiting list in Northern Ireland. All they ever hear is negativity about it, and they think, "I don't know whether this is ever going to happen".

Mr Donnelly: One of the things that we were told is that patients get a letter saying, "Do you want to stay on the list?". That is the only communication that they get.

Mr Haynes: I will come in on clinical validation or clinical reassessment, which is how I view it. That has been started, but it is not embedded in practice. It is not embedded in practice that, once a patient goes on a waiting list, they get a planned review. It is really important that we know whether those patients who have been on a waiting list for a long time are fit for surgery and still want or need it. Is the procedure that they were originally listed for the right procedure in the right environment?

My speciality is male prostate surgery and is a good example. The options available for treatment while patients have been on the waiting list have changed hugely. Patients who have been on the waiting list for a longer period were never considered for a day-case procedure, but that is now available. By reviewing them now, we are able to channel those patients into day-procedure units where they can be treated.

Mr Donnelly: So a regular review is necessary?

Mr Haynes: Yes, but that is not embedded in practice. We are talking about inpatient day-case surgical waiting lists, but, remember, we have the same waiting lists for new referrals, follow-up appointments and everything else. I often refer to things as a game of whack-a-mole: which one are you going to hit?

Mr Donnelly: Give a smack to.

In your presentation, you referred to the census report. When that came to the Committee early last year, I remember it being quite shocking and hearing that we were facing that crisis. Have any of those numbers changed? Anecdotally, have the numbers got better? Are we going the right way?

Mr McGonigle: We do not know that at the minute. We will do another census. That will potentially start towards the end of 2025 and report in about 2026. Anecdotally, it is difficult to say. There was a bit of a delay in the partial retirement and retirement of senior surgeons. As a result, some may have gone into retirement as opposed to taking partial retirement, where they still work for the NHS but do fewer hours. Given that there has been movement on that, a lot of them will probably take partial retirement as opposed to full retirement, which will provide very senior people in those roles in hospitals.

Mr Donnelly: My final question is about Encompass, which is something that we hear about regularly at the Committee. The roll-out is ongoing, and I believe that it is coming to this trust in May. Have you seen benefits from the roll-out of Encompass in the trusts where it has been rolled out? Do you see the benefits, specifically, of the data that is collected?

Mr McGonigle: It is good to have all the data in one place where it can be looked at together instead of having to go to individual trusts. As Mark works between trusts, he will probably want to talk about the fact that Encompass is very good because it allows him to better follow the patient when they go from his trust to Lagan Valley. Encompass is a great system. It is great to have electronic records. It is a one-size-fits-all system, so it will never work for everyone. Overall, however, it has the benefit of allowing us to follow patients a lot better. You do not lose medical records, which means that you are not sitting in a clinic asking, "Why is this patient here?" because you have a blank sheet of paper and cannot access any notes about them. It has its negatives, but it is primarily positive.

Mr Donnelly: Would it make addressing waiting lists regionally a lot easier?

Mr McGonigle: Yes, it should do that.

Mr Donnelly: Thank you very much.

Miss McAllister: Thank you very much for your presentation. I have a couple of questions about training numbers, robotics, the elective care framework and the protected time.

Following on from the point about training numbers versus vacancies and commissioned posts, in which you outlined that the training allocations were UK-wide, I assume — correct me, if I am wrong — that it is the Department of Health in Northern Ireland that commissions posts for consultant surgeons for each speciality here. Do you know whether that is based on population health or the trajectory of what is needed? Is that up to date and fit for purpose?

Mr McGonigle: It is probably a bit more complicated than that, because various specialities recruit either locally or nationally.

Miss McAllister: OK.

Mr McGonigle: For example, trauma and orthopaedics run a recruitment process in Northern Ireland. They set the number of trainees that they want per year in Northern Ireland and recruit for those within Northern Ireland.

Miss McAllister: Who do you mean when you say "they"?

Mr McGonigle: NIMDTA.

Miss McAllister: OK.

Mr McGonigle: In the case of other specialities, such as mine, which is cardiothoracic surgery, there is no local recruitment. It is recruited nationally. You put in a bid to say whether you will be able to take a trainee or trainees, and the number of trainees you will get is decided nationally.

There is a slight difference and a potential opportunity when it comes to core surgical training, which is where, following their foundation years, surgeons come in and start to do basic surgical training. Core surgical training used to be administered nationally. At times, when it was administered nationally, out of about 40 posts, we may have got six people into post. That was because people did not want to come to Northern Ireland. When that changed to being local recruitment in Northern Ireland, we filled all the posts every year. During COVID, we had to go back to national selection, and we had the same problem again: for 40 jobs in Northern Ireland, nine people said that they would take up a job, and only six, I think, turned up. There is a lot —.

Miss McAllister: Every other year, when you did it locally, you filled 40 posts?

Mr McGonigle: It has been almost completely filled every other year.

Mr Haynes: One of the challenges with national selection is that the appointments are based on points; the job offers go to the top candidates, who then get to select the posts that they want. For people who already have family, property and roots in England, Scotland or Wales, it takes more to look at moving here than in a case such as mine: I moved from Cardiff to Sheffield to do my training.

Miss McAllister: We attract people when we do it locally, though.

Mr Haynes: That is because those people apply knowing that they are looking at a job in Northern Ireland.

Miss McAllister: OK. That helps me to understand it a bit more. It is rather complex, but it is useful to know who allocates and commissions places.

I understand that robot-assisted surgery is used mainly in the field of urology in Northern Ireland. In order to keep up to date with advancements in technology for our surgeons, what areas should we look to prioritise for robotics? We have heard about that a number of times, including earlier today during our visit here, and from a number of other surgeons across the different trusts, so I want to hear your thoughts on it.

Mr Haynes: As you said, currently, in Northern Ireland, the primary user is urology. A limited number of procedures in the Belfast Trust are being done using robotic surgery, such as, I believe, colorectal and some gynae. We are in desperate need of a robotic surgery plan for Northern Ireland that covers most specialities and how it is going to be delivered across all trusts. We cannot have a robot in Belfast that attracts new consultants to Belfast but leaves the other trusts struggling to appoint. We need access to a robot for general surgical procedures and gynaecological procedures in every trust. We need access to a robot for cardiothoracics in the RVH.

Miss McAllister: Is it a different one per speciality?

Mr Haynes: I could talk for a long time about robotics. There are lots of different consoles. The most commonly used console is the one that we currently have in Belfast City Hospital. There is a benefit to using a single console, because people are not then training to use different consoles in different places. Most robot-assisted surgery procedures were developed on that robot first. It would make sense to develop a plan for how robotic surgery is going be delivered across some specialities across all trusts and use it as a recruitment carrot to attract and retain consultants.

Miss McAllister: I assume that it does not look like a robot, but that is what I see in my head. Why do we have one robot in the Belfast Trust that is focused mainly on urology? A question for written answer that I submitted to the Department revealed that, of the 599 patients who had robot-assisted surgery, 513 were male and 86 were female, and the majority were urology patients. Why is there just one?

Mr Haynes: The evidence for and development of robot-assisted surgery commenced largely in urology, and it was developed in prostate cancer surgery. The robot was originally commissioned for prostate cancer surgery. The vast majority of patients who have been treated on the robot in Northern Ireland were treated for prostate cancer, and so are male. That is where the evidence base for the advantages of robot-assisted surgery commenced.

Urology is a high-volume speciality using the robot. Urology then branched into other procedures. The next procedure that was commissioned here was for kidney cancer — partial nephrectomy — which affects both genders. Other procedures have developed robotic training and robotics across other specialities, but robotics started in urology. The reason for the male/female split is that prostate cancer is a very common cancer. I think that we treated around 150 cases surgically in the past year, so you get a lot of men treated on the robot.

Miss McAllister: I understand that; it is just that it is quite stark, given that it can be used in other specialities. It is a massive, stark difference. What are we talking about on costs for it to be rolled out across all trusts? Technology is not just the future: it is the now. You may not be able to answer that question.

Mr McGonigle: The issue is that robotic surgery outside of urology is not a commissioned service in Northern Ireland. That is one of the big holding points at the minute.

Miss McAllister: That is what the Department —.

Mr McGonigle: The issue with costs, if you want me to go into that, is that it is probably cost neutral in terms of individual cases. With other cases at present, there is a significant financial thing. As Mark talked about, there are several different platforms that you can buy, but the upfront cost of the one platform that is used in Northern Ireland, which will, hopefully, be replaced by a very similar system, is around £1 million.

Miss McAllister: That is what I wanted to know. There is then the training of the people and —.

Mr Haynes: The upfront cost for a single console is around £1 million to £1·5 million, depending on your set-up. You can get a training console that sits with that, so you can have a trainee being trained at the same time, and that adds to the cost. That is the ideal set-up, but, again, it is a significant extra outlay to do that. If we want to develop robotic surgery, we need to look at the robots and how we train. Having a single console and surgeons swapping places is, perhaps, not the best way to train.

Mr McGonigle: The other thing is the non-financial cost of not having services such as that. For example, we will train surgeons to a certain level in Northern Ireland. They may go off and do robotic fellowships elsewhere around the world, and we do face that at the minute. They will then look to come back to Northern Ireland and say, "Why would I go back there? I cannot do the job that I am trained to do". We face a brain drain as a result of that. We really have to look at the non-financial component.

Miss McAllister: It is something that we will certainly have to follow up on, and we will.

Mr Haynes: On that point, that was one of the main drivers behind us pushing for and commissioning it in urology. We had a robotics trained surgeon who had not been able to use the robot for a number of years. Having the robot, we have now recruited two consultants from posts in England and Scotland to come to Northern Ireland. We have also been able to train our own trainees and to retain them in Northern Ireland delivering robotic surgery. Recruitment and retention with the robot works.

Miss McAllister: Thank you. I will follow up on that separately.

I do not think that the elective care framework had been published when you were last here. I cannot remember whether the update in May had been published then. I want to ask about the priorities in the 10-year plan. We know that budgets are difficult at the minute, but, from your point of view, what are the priorities in your areas of expertise and specialities?

Mr McGonigle: I am very keen to see priorities included and longer-term plans, because, as we talked about in the opening statement, Northern Ireland is very reactionary. We wait until there is a crisis and then do something about it. We have a winter crisis at the minute and are talking about how we deal with elective care during it. We need to have those things decided on years down the line. Something that I always say is, "You do not know where you are going to be or want to be in five years. That means that you have to have waypoints along the way. You have to have them for six months, a year or two years. It is only by developing those that you will get to where you want to be in five years' time.

Miss McAllister: The last time you were here, you called for that road map to be established. Has the engagement got any better? Has it improved with the Department, the strategic planning and performance group (SPPG) and the royal college? Is it feeding into the reconfiguration, as well as framework implementation?

Mr McGonigle: We have continued to feed into that and to give our views, and I think that those are being received well by the Department.

Miss McAllister: OK. That is positive.

Mr McGonigle: Have we affected major change? I am not sure yet.

Miss McAllister: OK. That is positive to hear, and we will engage further on that.

Last time, we spoke about the specialist services that are contained only in Belfast. I will not name them, because I always forget some, like yours — cardiothoracic. Is the situation getting better on them being protected? Is it improving? On the schedule, emergency takes priority, but with regards to elective care and surgical hubs and protecting the services that can take place only at Belfast, is it getting better?

Mr McGonigle: We have touched on that already today. Yes, I would say that of all services. Hospitals are like a bottle — there is only so much that you can pour into it. If you keep filling it up with unscheduled care, you cannot pour in for elective care and deal with it. We are having the knock-on effect in that we do not have access to the beds, which is a problem. It is accepted that there is a winter crisis every year, but when does the winter stop?

Miss McAllister: Have we moved away from any elective care at the Royal where it is not protected?

Mr McGonigle: No, we still do elective surgery.

Miss McAllister: I am talking about elective outside of specialities. I may not be making myself clear.

Mr Haynes: It just came to me as Niall was speaking that we have forgotten to mention the other surgical hub in reality, which is Belfast City Hospital. It does not have emergency admission pressures, so, for our major cancer specialist surgery that takes place in Belfast City Hospital, we are not impacted on. That is where I do my surgery in Belfast. I am not impacted on in the way that Niall is for his speciality because he is at the Royal Victoria Hospital.

Miss McAllister: I am probably being confusing with my question, but are we doing elective care in the Royal where that is not in the four or five contained specialities that can take place only in the Royal and nowhere else across Northern Ireland? I remember that, at one point, that was a difficulty for waiting lists and pressures.

Mr McGonigle: There are still three surgical specialities in the Royal, and those are cardiothoracic, vascular and neurosurgery. They are regional specialities, and they are delivered only in the Royal. Some surgery in the vascular speciality such as for varicose veins is done at Lagan Valley.

Miss McAllister: Are those continuing to be protected?

Mr McGonigle: Are they ring-fenced? No, they are not.

Miss McAllister: It would have been easier if I had just asked that. We got there in the end.

The Chairperson (Ms Kimmins): Before I bring in Diane, I ask members to keep the volume up. With the air con, it is hard to hear sometimes. It is not like it is in our Committee room, where we have the amplification from the microphones. These are just recording, so please keep that in mind.

Mrs Dodds: I have a couple of questions. Some time ago, I asked a question of the Health Minister about the amount of time that surgeons spent in theatre, and that varied between 20% and 30%, depending on the trust. There was a commitment in a follow-up that the Department and the trusts would work with you to try to see how that could be improved by having access to theatre, by having nurses in theatre and by dealing with cancellations because of emergency cases and so on. How has that worked out?

Mr McGonigle: The simple answer is that I do not think that we have seen much change since we last spoke about that. Our rate-limiting factor always remains capacity. Capacity to get into theatres for all the surgical specialities remains the main problem. All the theatre lists in all the hospitals are kind of maximised out based on the number of staff that they have. The other thing that we talked about was rotas and how they work and the number of staff that you have. You have a numerator and a denominator. It has not necessarily changed since we last spoke.

Mrs Dodds: That is disappointing.

Mr Haynes: The other factor in it is that, even if you wanted to increase the amount of time of a surgeon in theatre, you would need to still provide the outpatient activity that they are doing. We have the same outpatient pressures, so, without expanding the workforce with an expansion in theatre so that job plans can reduce outpatient activity and have greater theatre access, you are again playing that same game of whack-a-mole. You are stopping seeing people in clinic to do extra theatre lists.

Mrs Dodds: That leads us to almost a circular problem in that access to theatre means that we will always continuously have longer waiting lists and that the problem will go round and those will be impacted on by what we call "winter pressures" but which, in effect, are pressures all year round in the health service. It is disappointing because I had thought that the Department was going to start to do some work to try to look at how we could work on that. It is also disappointing given the fact that, in Health and Social Care, we have higher numbers in the workforce than we have ever had before. It is disappointing because we have to try to work out a system that does that. I will follow that up, because I think that that is important.

That leads me on to my second question. In Northern Ireland, over half a million people are waiting for a first consultant-led appointment. You have detailed the number of people who are waiting for surgery. Those are higher numbers than we have ever had before. We will always have the ongoing emergency stuff that has to be done, but we have the huge backlog that we seem to accept is there, and we are not quite sure how to deal with it.

Is there a way — I do not know whether you have thought about this; I am just throwing it out — to look at the ongoing day-to-day work of looking after people in the health and social care system while trying to deal with the backlog separately by expanding elective care hubs? At the moment, those seem to be only nibbling at the edges of the backlog and not really getting to the heart of it. As the people at the coalface, what do you think should be done?

Mr McGonigle: The word to use is "efficiency", and that is what we have been looking at. Is the health service doing things as efficiently as it can? You were quite right when you said that the hubs were "nibbling" away at the backlogs. You can see the waiting lists coming down a little bit. What you have to think about as well, Diane, is that you are not adding to the waiting list. Where the hubs have been very good is in dealing with the new acute admissions and stopping them going on to the waiting list and, at the same time, pulling some people off the waiting list. So, it is working to do things in two ways.

The key to the surgical hubs is to move some of the surgery from one place to another place that is doing the high volumes that it needs to do. We know that, for example, when a theatre in a hub is doing hernias and that is all that it is doing in a day, it can maybe do six or seven, whereas a standard theatre cannot do that, because it has a mixed bag of stuff to do. It may be doing a hernia or a gall bladder or something like that. The idea is to move as much of that work into those really focused streams with staff who can go through as many cases as possible in a day. Probably, one of the big things that we have talked about already — there are potential negatives and detriments to it — is extending the day: having longer operating days in order to get through as much of that work as possible and bring in some of the stuff that has been on the waiting list.

Mrs Dodds: In order to do that, do we need more elective hubs?

Mr McGonigle: The simple answer is yes, because we will have to deliver more and more elective care. You have to realise that surgery and medicine are changing. When we think about hospitals, we think about a model that existed 30 years ago, but medicine and surgery are completely different now. They have moved on, and we need to move with the times. We need to move with how things are changing, and being able to deliver work like that in surgical hubs is part of the answer. It is the ability to say that we now have a centre and that you are not going to a hospital that has a mixed bag of different practice. You are going to a centre that has a theatre that does hernias six days a week or to a theatre that does gall bladders six days a week.

Mrs Dodds: Right. That gives us another interesting scenario. No surgeon will want to stay in one place and do only one thing, so surgeons will have to move around in order to maximise our capacity and the efficiency that you talked about in the health service. Just this morning, when we were here, we talked about the governance difficulties around that. We have picked up on that. Given that we are in a trust building and members of the trust are here, it would be interesting to see what work can be done to ensure that you have the freedom to move around and the legal governance and structures to enable you to do that so that we can get the best out of the theatres that are here but that are sometimes not operational when they could be. Some of those are in the SWAH but have never been commissioned. It will be important to do that, and perhaps the Committee will continue to press the Department to do that piece of work around the structures that will enable you to move around legally, safely and in the correct system.

Mr McGonigle: Mark works between different trusts.

Mr Haynes: I believe that the solutions are already there but are, perhaps, not known about widely enough. As Niall said, I have worked across the trusts since 2017, and many of my urology colleagues across the trusts are able to do elective work in the Lagan Valley Hospital hub.

Our patients move across trusts, we have had lots of conversations about joint waiting lists, and we operate on people from other trusts' waiting lists. The model is there, but how to set it up is perhaps not widely enough recognised. Niall touched on Encompass being an opportunity in that way. Prior to Encompass, you moved patients from one waiting list to another list in a different trust, whereas now, with an Encompass waiting list, you can select sites and trusts and amend or change that within the same case request.

I will touch on robotics in answer to one of your questions. A key element in maximising efficiency is embracing early things that result in shorter stays. By not embracing robotics early across specialities, we have left ourselves in the position of being back at lengths of stay that are historical in many centres in, for example, England, Scotland and Wales, where there is more ready cross-speciality access to the robot, and the procedures are managed as overnight stays.

If we look at the prostate cancer story before robotics, we see that, before robotics in Northern Ireland, we offered only open radical prostatectomy, which involved a stay of a number of nights. That went down to one night only. You create efficiency by embracing technology and advancements in surgery. We need to be early in embracing new technology so that we can develop and breed that efficiency in our surgical services.

Mrs Dodds: Thank you.

Mr McGonigle: As a further response to your question about working between trusts, I was a consultant in England for six years: my week involved working in three trusts, and I moved seamlessly between them, so it is possible.

Ms Flynn: Thanks very much, Niall and Mark. I will go back to the census. I know that you previously briefed the Committee on that, which must have been just after the January 2024 census was published. You gave us a figure of about 91% for the proportion of consultants over the age of 55 who intended to retire in the next four years. I am conscious that we are a year on from that. As you said, Niall, maybe you cannot judge how those figures sit today, but you will be able to do so if you do a census for 2025-26. A year on, the 91% of surgeons in that age bracket may still intend to retire, so we could face a cliff edge in three years. Nuala asked a question about it, and I want to pick up on it again from the perspective of the Department and the focus that has been put on the issue, because it is extremely serious. You mentioned, Niall, that we can be "very reactionary" at times in dealing with and responding to things. For me, it cannot get any more urgent than 91% of surgeons potentially leaving the system in three years' time. Has the Department formally responded? Is it working with you in any sort of coherent or structured way to try to address that issue?

Mr McGonigle: Yes. It is not isolated to surgery; it is all of medicine. A lot of things are outside the Department's control. For example, certain pension changes have affected how long surgeons and doctors in general want to work. There comes a point at which it is almost financially unviable to continue working. That is outside the Department's control. Yes, it has engaged, and we have developed a process to allow partial retirements. Briefly, that means that you retire, but you come back and do almost half, or whatever proportion, of the work that you did before. I have two consultants who would otherwise have left, but they decided, "This system is in place. I can now take a partial retirement, so I will stay".

Those surgeons are important to surgical departments. They do a lot of the teaching. A lot of them are good at doing the rather complex cases. More importantly, it is about progression. You can bring somebody else into the Department with funding that is available because you are no longer paying somebody full time. That partially retired person is able to train, supervise, support and mentor the new person. There are a lot of positives to that.

Will it change from that percentage? I think that there will be change, but a lot of it comes back to the fact that this is about not just retirement, pensions and stuff like that but people getting to a certain age — 60 years of age — at which, as we said, 60% are burnt out and stressed, and 50% feel that system challenges prevent them doing their day's work. When you change that situation, focusing on those challenges, people want to stay in their job. The types of things that Diane just talked about are important. If you increase the amount of time that a surgeon spends operating, you give them a feeling of autonomy. They feel that they are valued and want to stay on in their job.

Ms Flynn: Mark, you mentioned the brain drain in relation to robotics. We could have all the surgical hubs in the world in every part of the North, but, if we do not have the surgeons and consultants to staff those hubs and train the junior doctors coming through, it is pointless. Diane touched on the issue of theatre capacity and utilisation. Earlier, at Daisy Hill Hospital, we discussed with some of the staff there how they can maximise the use of surgeons, consultants and nursing staff. You said that, at the minute, the biggest barrier is not having the staffing resource, but Diane mentioned that there are unused theatres and a significant number of unused beds in the South West Acute Hospital. Given that that space is sitting unused at that location and that that is public knowledge, can you provide any options to make use of that space, using the staff whom we already have, as an interim solution to the staffing crisis, or is there simply too much pressure on people?

Mr McGonigle: Were access to be offered, that offer would probably be taken up, but, yes, there are certain challenges. One thing that our members would bring up, which Mark has touched on, is difficulties with travel. We know that about 80% of people are happy to travel to have their surgery somewhere else. Some of that is based on the fact that there is continuity of care. We know, through GIRFT and stuff, that, in cases where a patient has seen a surgeon, they are increasingly unlikely to go somewhere else to be operated on by somebody whom they have never met. We would have to address those issues.

You talked about the location of hubs. One issue with that is time: is it a good use of a surgeon's time to spend four hours travelling up and down to a surgical hub? It is about moving staff around. Mark touched on people being at different stages of their careers. It may be that senior people are quite happy to travel to spend time in other places, whereas more junior people are not able to do that. Overall, we need an expansion in the number of staff: that may be at consultant level as well as an expansion in the number of trainees and an expansion in the number of staff at the surgical hubs. If those facilities at the South West Acute Hospital were on offer, though, they could certainly be utilised more.

Ms Flynn: Thanks for that. This is my final point. I am a Belfast representative and a service user of the Belfast Trust. Today's visit to Daisy Hill Hospital was my first, and it was fantastic, particularly seeing its elective overnight stay centre. One of the big pitches that you are making today is that we need more of those centres. They are a case in point: the fact that they can take on additional procedures helps to train additional junior doctors and other staff who are coming through. That proves the point that you made earlier, Niall, about the importance of expanding surgical hubs and how helpful and beneficial that will be for training.

Mr Haynes: Sorry, I was just going to come in with an answer about the retirees. There are probably some other things to say on that. I think that Diane described the hubs as nibbling at the edges, but there is another little thing.

Niall described how he has had two colleagues partially retire and come back. That is great, and it worked in his speciality. However, some other specialities can be left with a challenge: someone has retired but wants to come back, but the speciality needs to fill the post that that person held previously, because it needs to fill the on-call rota and cover emergencies. In filling that post, the speciality no longer has any funding to pay the retire-and-come-back person. We could look at some means of providing finance for that short-term, part-time working for the retire-and-come-back consultants. Trusts and specialities are commissioned to have a number of consultants. Once they are full, they struggle to find the money to commit to a salary for that part-time consultant.

Ms Flynn: Thank you for that. That is a helpful solution. Thank you very much, Mark.

Mr Chambers: First, across the overall surgical workforce, is there an imbalance in the number of anaesthetists, surgeons and theatre nursing staff? For instance, a surgeon may be frustrated from carrying out a procedure by not having an anaesthetist or theatre nursing staff available. Equally, could an anaesthetist and a team of nursing staff be frustrated from going ahead with a procedure because a surgeon is not available? Is there that imbalance?

Secondly, this would not be an issue in the hub situation, but, over recent weeks, we have seen how the flow through EDs has been impacted on by the lack of beds. Can your elective surgery work be impacted on by the availability of beds? Can that unavailability of a bed at the other end have a negative impact on the procedures that you want to carry out?

Mr McGonigle: In answer to your first question, I do not think that there is necessarily an imbalance of staff. There are staff shortages everywhere. Put simply, you may have surgeons who work in different specialities and deliver various types of surgery and operations. The anaesthetists with whom they work might work across different specialities as well, so they may not be available all of the time. We have the situation in which there may be a rate-limiting factor in a day of the number of anaesthetists who are available to do lists within the whole of the operating suite. If you have 10 theatres but only eight anaesthetists, you can run only eight theatres. You may have 10 surgeons, but two will not have an anaesthetist.

We are seeing a lot of changes in some of the hubs, with their having to shift over to more and more local anaesthetic to try to reduce the number of general anaesthetic lists as well. That is a very positive thing, but it also means that, at times, some of those lists are not being covered by anaesthetists. One speciality had six lists before COVID. After COVID, it went down to three. It is now down to 1·25. In fact, it has just lost the anaesthetist for that. That is a massive drop. Again, that is back to a shortage of staffing.

Does unscheduled care affect elective care? Yes, it does, because we cancel cases. We try our best not to, and we work hard with patient flow between the surgeons and the ward staff and all of that. We try not to, but there are times when surgeries, including cancer surgeries, get cancelled because there are no beds.

Mr Haynes: It is very dependent on the site. Lagan Valley and Omagh manage without an issue. I mentioned Belfast City Hospital: we are not impacted on. However, move into Niall's world in the Royal Victoria Hospital, and you get a greater impact. If you move to the inpatient care in Craigavon, the Ulster Hospital, Antrim and Altnagelvin, you will find exactly the same: the emergency pressures are felt on those sites.

Mr Chambers: You said earlier that surgeons spend only 30% of their time in theatre. The lack of bed availability for a patient coming out of theatre into recovery could be a contributory factor.

Mr McGonigle: The 20% to 30% calculation is based on what is called a job plan, which looks at the amount of time in your normal working week that you are scheduled to be in a theatre. It goes down even more when you get cancellations. I worked in a stand-alone cardiothoracic hospital in England. That is all that we did. There was no ED or anything attached to it. In those six years, I could probably count on one finger the number of times that I had a cancellation because of a bed issue.

Mr McGrath: Apologies for missing your presentation. It appears that the only thing scarcer than a National Health Service appointment is a parking space in Newry. [Laughter.]

Sometimes, when you come along to these meetings and hear an awful lot — they are long meetings with lots of presentations — you shake yourself and ask, "Did I just hear that correctly?", and you have to write things down. Having surgeons who do surgery only 20% or 30% of the time is scandalous. Michael O'Leary would not employ pilots and have them fly only 20% of the time because they do not have aeroplanes, cabin crew or other stuff. If surgeons spent 80% of their time performing surgery, that would still be a scandal. We have a health service that has let people down for a generation when it comes to workforce planning. At the same time as surgeons are performing only 20% of the time, we are all saying, "I wonder why we've got such long waiting lists". We cannot get people into surgery. What frustrates you most about your job? I think that that is probably the answer. What most frustrates you about our health service when it comes to doing your job?

Mr McGonigle: I am very pleased with your analogy, Colin, because I say exactly the same thing. Let us use the example of Michael O'Leary as well. You do not have pilots sitting twiddling their thumbs; they fly planes for all their hours and do not do any other work. We know through our census that one of the things that upsets 50% of surgeons, from consultants down to trainees, is, "I'm not getting into theatre to do the job that I want to do. This is a job that I have devoted my life to. I have spent, on average, around 14 years learning to become a consultant. There has been a multitude of professional and personal sacrifices along the way to get to that level, and here I am not able to do the job that I want to do". That is causing massive dissatisfaction.

It used to be that, across the UK, surgeons spent two days a week operating a lot of the time. That has come down a bit because they are pulled more into doing different things now as well. If there is one single thing that causes frustration, it is not being able to do your job. That builds into their seeing patients in an outpatient setting and saying, "I've seen this patient. I know that I can improve their quality of life by removing some of that disease, but I'm not being given the opportunity to do that. I'm putting them on to a waiting list", even though they know that that waiting list could be anywhere between months and years and, in some cases, up to almost a decade.

Mr McGrath: Is there a recovery plan in the Department? Does the Department have an active plan to address the specific issue of how a surgeon can perform more surgery? Is there a specific, detailed plan from the Department to address that issue, or are you just subjected to a workforce plan here and a hospital plan there? Is there a dedicated plan for that?

Mr McGonigle: I am not aware of any dedicated plan for that, but you cannot necessarily take that in isolation. It is about infrastructure, such as the number of theatres available in a hospital. It is about ward beds. It is about nurses for the theatres. It is about equipment, robots, attracting people and all of that. It is not as though you can just say, "Right, we're going to increase everyone up to 50%". A multitude of other things cut across it.

Mr Haynes: There is also the impact of — Niall touched on it — vacancies in a rota. If you have a speciality with a heavy emergency surgical requirement, such as general surgery, and you have vacancies in the consultant rota, in covering the gaps that they were to cover, you inevitably reduce the number of theatres that are there. Michael O'Leary may be a good example, but the 80% may not be realistically achievable, because surgeons in some specialities in which there is acute care have to deliver that as well.

Mr McGrath: I would say that he would get it working and achieve a higher percentage.

Mr Haynes: Getting up to that two days a week, which I experienced when I was a consultant in England, is absolutely achievable.

Mr McGrath: I hope that, as a follow-up to this, we will write to the Department — I propose that we do — to find out whether it is aware of the issue and, if so, what measures it is taking to address it. If it is not, we are missing the point.

Mr Donnelly: Niall, you mentioned patients travelling. Most patients whom I have talked to would be very happy to travel anywhere and take any surgeon. Are surgeons happy to travel and to work with other surgeons' patients?

Mr McGonigle: In general, yes. One of the things that people forget about a little in some of this is the practice of medicine itself. When you see a patient and offer them surgery, there is almost an unwritten contract between you and the patient. Some surgeons want to take their patients through the whole journey. Some patients may say, "Well, I saw this surgeon, somebody else is operating on me, and I'm being followed up by somebody else. I'm not keen on that".

The GIRFT programme started to ensure that patients were treated by the same person. It also reduced travel. Patients were told, "Well, you will be seen at your local hospital for your pre-assessment. Your surgery could be 50 miles or 60 miles away at a different hospital, but your review will be back at your local hospital". The buy-in from patients was fine. Taxis were provided for patients who had to travel. I think that that was offered to patients in south-east England or London, but I cannot remember exactly where. Out of 800 patients who travelled to a hub, 16 asked for transport.

Mr Donnelly: So, patients are very happy to travel.

Mr McGonigle: More than happy.

Mr Haynes: On the surgeon travel side, Niall touched on the issue of points in career. When you have, say, a young family, you have childcare needs. I remember living and working in Sheffield and screeching into the nursery car park with the children sitting on the edge of the path. That would not work if you were travelling to a hub that was an hour and a half or two hours away from where you live. You have to consider what is a manageable, deliverable work-life balance for the surgeons as well. You cannot expect a surgeon to be in one hospital on Monday, a different hospital on Tuesday and another one on Wednesday, spending a lot of time in their car travelling.

Mr Donnelly: What about working on another surgeon's patient?

Mr Haynes: It is interesting. Niall touched on an aspect of it. Quality-of-life functional surgery, which a lot of the high-volume, low-complexity work is, is possibly a bit more important than, say, the big cancer surgery, such as taking out a kidney cancer. That is pretty much the same expectation across the team that delivers that. However, when it comes to managing some urinary incontinence with functional expectations and

in there, the surgeon-patient relationship may be a bit more important.

Mr McGonigle: In general, we pool patients, because we know that, where we have service delivery problems and delays, particularly in cancer surgery, a lot of patients will be pooled to say, "Well, this patient has waited for a certain time. They're next on the list". The surgeon who has seen them could be off on leave for two weeks. It is not appropriate to have them wait for two weeks, so they will be operated on by somebody else. In general, I would say that probably less than 10% of patients would ever say, "No, I would prefer to wait". The vast majority are quite happy.

Mr Haynes: We certainly pool in our high speciality, in our cancer surgery, without any issue from patients.

Mr Donnelly: Thank you.

The Chairperson (Ms Kimmins): Thank you, Niall and Mark. That was a really informative session. Given that we had heard so much on the ground this morning, it was really good to get a lot of that feedback. We appreciate your coming back to the Committee. Thank you for your time.

Mr McGonigle: Thank you for having us.