Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome the Minister and the permanent secretary to the Committee. I remind the Minister that we have 90 minutes and that the session will be recorded by Hansard. I will hand over to you, Minister, for a few brief opening remarks.

Mr Nesbitt (The Minister of Health): Chair, thank you very much. First of all, I welcome you to the chair and wish you luck for the rest of the mandate.

I know that you will want to discuss the 2025-26 Budget, but, before we do that, I just want to emphasise, on a positive note, that we have some great opportunities here to make things happen. For example, a couple of days ago, we made sure that Northern Ireland will be included in the UK-wide Tobacco and Vapes Bill. That will change forever society's attitude to smoking, with a new generation growing up smoke-free. I am also very keen, as I think you know, on minimum unit pricing for alcohol, and that relates to areas of deprivation and increased harmful use of alcohol. However, I need Executive support for that, and that is not over the line yet. I have plans to bring forward a new obesity strategic framework, which should be very welcome, I would have thought. There are plans to put in place a new lung screening programme and to expand the bowel screening programme.

I am very pleased that my Live Better initiative on health inequalities is now under way, and that is bringing services and support to deprived areas that need it most, getting it as close to the front door as possible. All the evidence that I see suggests that that means that intake will go up. Properly tackling those health inequalities and improving population health will require a whole-Executive approach. Having a good job, good housing, good education and good environment all go together to improve those outcomes, so I make no apology for again stating that the Executive will need to collectively prioritise health.

I will move to the draft 2025-26 Budget. I set out my position in a written ministerial statement to the Assembly last month. In summary, my Department's proposed allocation represents a 2·6% increase in funding compared with 2024-25, when all the in-year allocations are included. Significant increases in costs will be faced, and that is due to a number of factors, including pay and price inflation; increased National Insurance contributions for GPs, pharmacists and social care providers; and, of course, rising demand, which widens the gap between demand and our capacity to meet it. As a result, my Department is projecting a funding gap of some £400 million for 2025-26.

The health and social care system will be asked to deliver in the region of £200 million in new savings for the second year running. That is a very ambitious and challenging target. Savings of that scale will inevitably impact on services. It is not without risk. You will know that I said previously that I will not stand over catastrophic cuts. Even with those savings factored in, I anticipate that significant in-year monitoring round allocations will be required to achieve break-even.

The draft Budget provides no additional funding for waiting list reductions — there is not a single penny — yet money has been found and allocated over and above departmental baselines for other priorities such as childcare, which I accept is very important. This will be the second consecutive year in which the Executive have provided no such money for waiting lists, despite waiting lists being identified as one of the nine Programme for Government (PFG) priorities.

The elective care framework, which was published in 2021 and updated last year, sets out what we are doing, what we plan to do and what else we could do if resource permitted. Significantly, the level of additional spending on health above that in England is now projected to be at a 10-year low in 2025-26 based on this draft Budget. That projection is that the additional spending will be only 1·5% higher and significantly out of sync with the greater levels of need for healthcare here.

In 2022, a Northern Ireland Fiscal Council report suggested that a 4% to 7% health spending increase was required compared with England. The earlier Appleby report cited 7%. Social care adds to that level of additional need, with the Appleby review indicating that health and social care together needed a 9% level of additional need. To be clear, that means that we cannot match the standard of service that is delivered in England unless the Department of Health here receives up to £109 for every £100 that is provided in England. That is the summary position.

We could now fall into the traditional tit-for-tat exchanges about the Health budget that break out all too often in the Assembly. Those invariably involve calls for health reform and transformation without ever defining what that actually means. They also involve calls to make savings through health reform and transformation, despite key reform measures requiring upfront investment, including investing in care outside of hospitals and in digital solutions. We also regularly see vague calls for efficiencies, conveniently ignoring the unprecedented £200 million that was delivered in this financial year.

The stark reality is that we need to be honest about the current and projected demand pressures on health and social care. There needs to be a reality check. The notion that the Department of Health's budget should not grow any further is delusional. Demand is always growing, and the pressure for increased spending across many different services is immense. Members from all parties know that, because, when they are not telling me to suck it up and live within my budget, they are calling on me to spend more on a vast range of areas. That is part of the pressure. If we therefore want waiting lists to go down, that will require investment. If we want there to be more care outside of hospital, that will require investment. If we want to invest more in staffing, that also comes with a price.

I am sure that members are aware of the recently published official population projections from the Northern Ireland Statistics and Research Agency (NISRA). The population aged 65 and over is projected to increase by 49·6% between mid-2022 and mid-2047, while the population aged 85 and over is projected to increase by 122·2% over the same period. Increased life expectancy is a massive achievement for society and modern science, but the inescapable reality is that we are going to have to meet those health needs. Older people need more healthcare and more social care. Demand is therefore going to grow very sharply, and that has massive budgetary implications. Yes, we can do things differently. In some areas, we can slow the increase in costs, but let us not pretend that we can reduce or virtually freeze health spending while providing the level of services that we want and that the public demand.

The Chairperson (Mr McGuigan): Thank you, Minister. We have 90 minutes, and there is a lot to cover. I have allocated a fair amount of time to each member. We will try to ask as many questions as possible, so we want succinct answers, if possible, in order to allow us to get through as much as we can.

In your brief introduction, you talked about spending in the next year and about where resources are to go to. Is it the Department's intention to assist GPs, pharmacists, dentists and social care providers with the rise in employers' National Insurance contributions that the Labour Government imposed?

Mr Nesbitt: I have written to Wes Streeting, the Secretary of State for Health and Social Care in London, to point out the implications of the employers' National Insurance increase. I also wrote to the former Finance Minister, Caoimhe Archibald.

From our analysis of the draft Budget, we have identified a £400 million gap for dealing with all the pressures, not just the pressure from employers' National Insurance. We are just going to have to work through the pressures. Without significant allocations in-year from monitoring rounds, doing so will be well nigh impossible. As we come to the year end, I reflect on how close we have come to making savings through making catastrophic cuts. We have not gone there, but, when we consider that we have already found £200 million of savings and that we have to deliver another £200 million in the next financial year, we are going to be sailing very close to the wind.

The Chairperson (Mr McGuigan): I am not sure whether that was a yes or no to my question.

Mr Nesbitt: If you are asking whether we are going to dip into funds to pay for the increases, I cannot say that we are going to do that.

The Chairperson (Mr McGuigan): OK. We are not going to get into a debate about how our public services have been decimated over the past 15 years by successive Governments. All that is true, and it is particularly true that cuts have had a severe impact on the Department of Health and that that impact is felt by our population. That should be taken as a given by us all. You have a budget of £8·4 billion, and I am sure that some services will underspend. If so, can you identify where those underspends are likely to be and to where the money will be diverted?

Mr Nesbitt: Some of the budget allocations are predictions. Take the block of money for expensive drugs. We got lucky in this financial year, in that some of the trusts did not spend their full amount and were therefore able to return some of it. We were then able to re-profile that money for it to be used for pay awards. The Committee will know that independent bodies in GB recommend the pay awards, which are made in June or July. The recommendation was a 5·5% increase for nurses, and we are paying that only next month, which is the last month of the financial year. That is not right. We are asking health workers, whom we applauded and banged our saucepan lids for during the COVID crisis, to work on goodwill, in the hope that we can pull the money together. We were able to do that through intense focus and very hard work, but there was also a bit of luck involved as a result of some moneys being returned to the Department. We cannot do the same again next year. As soon as the pay awards are recommended, I want to meet them in full, but that may require a ministerial direction to the incoming interim permanent secretary. Peter, do you want to add anything about how we move money around?

Mr Peter May (Department of Health): Yes. If any budget line shows a reduction in need, the money is put against the deficit. In each of the past three years, the Department has run deficits of many hundreds of millions of pounds, so that money has been used to reduce the deficit to the greatest possible extent. The Minister has rehearsed the point that we will start next year with a £400 million hole, so any moneys that are freed up will go into filling that hole. The challenge is that we are not investing in some of the service improvements that are most needed.

The Chairperson (Mr McGuigan): You mentioned the pay award for nurses, which is crucial. Our healthcare workers deserve fair pay, and it is important that they get it.

Before we move on from staffing issues, I will ask about violence and aggression against health and social care staff. The Department indicated that 50,000 incidents were recorded between 2018 and 2023. From my conversations with the Royal College of Nursing, I am aware that there are increasing levels of fear among nursing staff and students, who may be scared to attend work, having witnessed threatening behaviour to staff and, in some cases, violence. That is very concerning. In 2023, the Department launched the new regional framework to address the issue. It appears, however, that that has not been implemented. What is your assessment of the issue? Does the Department have updated figures that it can provide to the Committee? What is your assessment of the implementation of the regional framework?

Mr Nesbitt: That is a societal issue, so it is sadly not a surprise that it has happened within the curtilage of some of our hospitals. I believe that the move to body-worn video cameras will be significant and successful. I have not had an update on the framework's implementation, Peter.

Mr May: No. We came prepared to talk about budgetary issues specifically. I do not have an update to provide on that issue, but we can write to the Committee, if that will be helpful.

The Chairperson (Mr McGuigan): It is important that you do, given the concerns.

Minister, you mentioned the budget and the need for investment, and nobody can argue with that. You are the Minister, however, and our population want to see strategies and improvements, not all of which require investment. Granted, some do, but not all of them. You touched on some of the strategies, including for screening, and we welcome the fact that the legislative consent motion (LCM) on the Tobacco and Vapes Bill was passed in the House. If we are correct, that legislation will transform the health of our population.

The cancer strategy is also important. What progress has been made on it? What are your priorities for improving cancer services for our population?

Mr Nesbitt: In the current financial year, £10·6 million will be put into the cancer strategy against a projected need of £34·2 million for its year 3. The mental health strategy is similar. Some £42 million should have been allocated this year, and we have put in £5·9 million. We have the strategies, which are really good — they are best in class — and raise hope among cancer sufferers, people with mental health issues, the charities involved and, indeed, the whole health and social care sector, but, because we do not have the money to invest, we are failing to deliver.

It could be argued that that is quite cruel. To my mind, we are better looking at funded action plans and saying, "This is the money that we've got. There is £10·6 million for cancer, so how can we best use that money? It is not going to achieve everything, because we can't afford to achieve everything, but how can we use it to best effect?".

The Chairperson (Mr McGuigan): Can you give us some details of how you are going to use that money in the next year?

Mr Nesbitt: What we are trying to do is to establish centres of excellence. We have red-flag and time-critical assessments and treatments to do, so that is to where the money has to go, because people have potentially life-threatening conditions. We therefore cannot do everything that we want to do. The rapid diagnosis centres, of which there are two, have turned out to be very successful. Those are for people with vague symptoms. I have been to one of them. People are seen within a couple of hours of arriving. They are assessed, get their scan and then get their result. Hopefully, they are OK and can go home, but, if not, they are on a pathway.

The Chairperson (Mr McGuigan): I am jumping from one important issue to another because of time constraints. I am hoping that colleagues will interrogate in greater detail some of the issues that I have raised. Access to GP services is another crucial matter for our population. It would be interesting to hear today what specific steps will be taken to address the underfunding of GP services in the North and whether those steps will ensure a better service for our population and greater access to GPs.

Mr Nesbitt: I am happy to answer that, Chair. As the permanent secretary said, however, we came here on the understanding that the Committee wanted to talk about budgets and legislation.

The Chairperson (Mr McGuigan): This is part of it. I am asking what steps you are taking within your budget to address the very important issue —.

Mr Nesbitt: The biggest issue for GPs is indemnity. It has become almost toxic. We gave GPs an interim solution for this financial year. We have now put a permanent solution to them. We have not had a definitive response from the general practitioners committee (GPC), but I am hopeful that the proposed solution will be acceptable to it. It is my view that if we get that over the line, it gives us permission to say to GPs, "You have to do more about GP access". That is the biggest single issue on which the Department gets feedback. I am sure that you all hear that as constituency MLAs as well.

The Chairperson (Mr McGuigan): OK. I have a lot of other questions to ask, but I am conscious that other members wish to come in.

Peter is with us today. Minister, you announced this week that there is to be a new permanent secretary. We wish Peter well for the future. Is there to be a different job description for his replacement? Are you able to outline any structural changes that the Department may be planning to do with his successor's responsibilities or interaction with the trusts? That is not a budgetary question, but it is a vital one.

Mr Nesbitt: First, I put on record my thanks to Peter, who has been incredibly supportive during my nine months in post. He deserves a much broader thanks for a career of first-class service as a public servant across, I think, four Departments. It is important to say that it was Peter who said that we should not follow the standard procedure for finding a new permanent secretary. As you will know, Chair, we would normally advertise a vacancy within the pool of perm secs. Somebody would be appointed as a perm sec, after which the head of the Civil Service (HOCS) would do a reshuffle. Peter was very clear in his view that the next person in post should have a background in health. He won that argument: Mike Farrar has that background. My expectation is that he will be in post as interim permanent secretary for at least a year. Peter deserves credit, because we were at an event today at which everybody who knows Mike Farrar was saying what a great guy he is. Peter is prepared to listen to that for his remaining weeks, because he knows that appointing Mike Farrar is the right thing to do.

The perm sec is also the chief executive of Health and Social Care. There will be no change to that title: Mike Farrar will be the chief executive. Underneath that role, we currently have an acting chief operating officer. It is our view that that should become a permanent post, which will require advertising. Tracey McCaig is the acting chief operating officer. Those are the two positions. Somewhere along the line, the idea of having a health tsar entered the public domain. I was doing a live radio show when the idea was thrown at me. I have no idea from where it came. There is no tsar as such, but there is a chief exec of HSC, and that person will have a chief operating officer.

The Chairperson (Mr McGuigan): I thought that the tsar idea came from you, but you say that it did not.

Mr Nesbitt: No, it did not.

The Chairperson (Mr McGuigan): I have some sympathy for Peter, because, in the week and a half since I took over as Chair of the Health Committee, all that I have heard is how good Liz Kimmins was. She certainly was. I echo your comments about Peter. I have had lengthy engagements with him in three of his Departments.

Mrs Dodds: I will return to the Health budget, which is important. You talk about a 2·6% increase on the end-of-year position, but surely you should be comparing like with like and talking about the start-of-year position, which shows an increase of almost 8% from where we were at at the beginning of 2024. I understand that in-year monitoring is very important — it will be very important this year as well — but it is important to compare like with like.

Yesterday, we paid a very good visit to the new maternity hospital. It is a fabulous facility. It will represent an enormous change for mothers and babies, as well as for parents who have to stay with very ill children from right across Northern Ireland. That is brilliant. I look forward to its being up and running. Do you have any update on the additional costs that will be required for it? It would be good to know them.

It was indicated to me that the new construction cost-only contract for the work that is about to happen on-site at the new regional children's hospital in Belfast — I think that I am accurate in quoting the figure from yesterday — is £670 million. I have been reading the investing activity report, which states that the construction cost of the new children's hospital will be more than £1 billion. Will you clarify for us where the additional and very considerable amount of money is to come from, and what it covers? The investing activity report states that the cost is going to be more than £1 billion. Is the children's hospital therefore going to cost £1 billion-plus, with the £670 million, according to the figures that I heard yesterday, being the cost only of the construction contract that we have in place?

I will come back in with a couple more questions.

Mr Nesbitt: Before Peter talks about the children's hospital, we could go around the houses and talk about what we compare the budget with, and whether it should be like with like or with the starting position or the finishing position. I am concerned about whether we have enough budget to deliver healthcare without having to make catastrophic cuts, while avoiding industrial action. Those two criteria lead me to the conclusion that we are £400 million short. I do not really see the point of our getting into a discussion about whether we should be comparing start-of-year budgets or end-of-year budgets. We are in danger of having to make catastrophic cuts and of seeing industrial action: two things that I want to avoid in the next financial year.

Mr May: I will add to that response slightly. You have to remember that, last year, a significant amount of the money paid for last year's pay awards. If you ignore the impact of last year's pay awards on the Health budget, you end up with a distorted picture, which is neither sensible nor reasonable.

The number that I recognise for the cost of the children's hospital is in the high six hundreds of millions of pounds: £670 million. I am happy to look at the source of the over-£1 billion figure and write to the Committee to explain, if I can, from where that has come.

Mrs Dodds: I do not understand this. It comes from an investing activity report for the Department of Health, and it states here that the cost is "Greater than £1bn".

Mr May: I am not saying that you are making it up. I am just saying —.

Mrs Dodds: I am not sure why no one knows from where the figure comes. That paper is in our tabled papers every two months. When I looked at the figure, I thought, "Hmm, I've seen a different figure somewhere".

Mr May: I am happy to look at it. I do not recognise it, but —.

Mrs Dodds: We need to understand whether the cost of the children's hospital is to be £1 billion-plus or £670 million.

Mr Nesbitt: Is that a Department of Health document? I thought that it was an investment strategy for Northern Ireland (ISNI) document.

Mrs Dodds: It is an investment strategy report. It is the delivery tracking system document for the Department of Health.

Mr Nesbitt: That is not a Department of Health document.

Mr May: I will need to look at it.

Mrs Dodds: I presume that you provided the figures for it.

Mr May: Let me explore from where those numbers came and reconcile the issue for you.

Mrs Dodds: Excellent. It is important to be accurate so that we can fully understand what the total cost of the children's hospital will be. It is imperative that it be built — I am not suggesting otherwise — but it is also important that we track public money appropriately.

I referred to the budget's start-of-year and end-of-year positions just for accuracy. It is important to be fair. The Health budget has significantly increased. My understanding is that the starting position last year was £7·8 billion, and this year it is £8·4 billion. That is a huge amount of money, and it is really important that we are correct about that.

I have another question that you may have to come back to me on. I was given this information by a constituent who is a teacher. The Belfast Trust is offering to pay for substitute teachers so that teachers can be released to attend sexual health training in order to teach relationships and sexuality education (RSE). Is that the role of the trust? I realise that you may not know about what I am asking, but that is —.

Mr May: If you can provide the information, I —

Mrs Dodds: I will certainly provide the information.

Mr May: — will be happy to respond.

Mrs Dodds: The Belfast Trust is offering schools £130 a day to pay for substitute teachers so that teachers who may be teaching RSE can go on a day-long course. The trust then offers to come into the school for half a day for a whole-school development session. Is that the role of the trust or of the Department of Education?

Mr May: It does not sound as though it is a core part of the trust's activity, but, if you can provide us with the information, we will get more detail for you.

Mrs Dodds: I will absolutely provide it, because it is important. You have indicated that savings need to be made, so I do not understand why we are doing something like that.

Mr Nesbitt: Without commenting on the exact detail, our Department overlaps hugely with other Departments, particularly the Department of Justice and the Department of Education. In delivering joined-up government, it is right that that cooperation exist. The longer that I am an MLA, the more that I think that there are very few issues that can be addressed and solved by a single Department working in a silo. That is a general point and not specifically about the issue that you have raised.

Mrs Dodds: I accept that entirely. I will bring up an issue that I raise frequently with childcare services in your Department, and it is that of bail fostering. In the Southern Trust, we have a well-developed programme for fostering young people who would otherwise be in prison awaiting trial. Amazing people take in those young people and foster them for a period, but the programme is always funded only by the Southern Trust rather than in conjunction with the Department of Justice, which, to follow on from your point, it should be. That is really important.

I will ask a further question, which is about GP out-of-hours services. I will say, before you tell me, that I know that you are not here to talk about that issue. At the weekend, I received an email from a constituent who was very distressed that they were not able to get through to a GP when they phoned the Craigavon out-of-hours service. I have since established that no GP was on duty at the time. Can we get a briefing from the Department on GP out-of-hours services and the issues that there are with staffing those services? I am told that that was not a one-off and that the situation has been ongoing for some time.

I would appreciate a follow-up answer on whether the investment strategy investing activity report's figure for the cost of the children's hospital is accurate.

The Chairperson (Mr McGuigan): The document is in the tabled pack. We will provide you with the information.

Mrs Dillon: Thank you, both, for your presentation and your answers so far. Peter, I wish you all the best for the future. I have worked with you in my role on the Health Committee and previously in my role on the Justice Committee. I get all the nice jobs. We have genuinely always had a good working relationship, and I wish you all the best for the future. I hope that the new person who is coming into post will fix everything. That is my wish for this year.

Minister, you made an announcement — I do not have the date of it in front of me — about the £13 million additional budget for respite care and therapeutic services for young people with learning difficulties. There is an additional £2 million this year. Do all the trusts have specific plans for how that money will be spent? Will it all be spent this year? If not — if everything cannot be put in place in time — is there flexibility to allow the trusts to spend it in the next financial year?

I will let you answer that first, and then I will come back in.

Mr Nesbitt: This financial year was part-year, so we said that we would aim to spend up to £2 million. Currently, we are looking at that being £1·377 million. You might consider that to be disappointing, and I might not disagree with you on that, but, as a matter of principle, there are four things that tend to be needed in order to deliver healthcare: buildings, equipment, medicine and workforce. If we do not have the workforce, it does not matter what buildings, equipment or medicines you have. We need a properly trained and motivated workforce. It is one thing to put the funds in place, but, if we do not have the buildings or the workforce, it becomes extremely challenging to spend the money. That is why we are at £1·377 million. That is a good effort, but, unfortunately, it suggests that we will not get to spend the £2 million.

For next year, we have business cases of up to £13 million to be considered. At this stage, however, my guess is that it will be challenging for us to get the full £13 million spent on the ground.

Mrs Dillon: Can the Committee, at the appropriate time, get sight of those business cases? I would like to know what will be delivered by way of additional respite care and therapeutic services, in what trust areas that care and those services will be delivered and what that will mean for families. Will it mean so many additional respite beds?

Mr Nesbitt: Yes, we can let you have sight of them.

Mrs Dillon: Can we also get some reassurance that the business cases address what has brought us to a tipping point? Respite or short-break beds were being used for residential care. One person in need of residential care could be using the whole facility, thus taking up anything up to 13 beds when they needed only one bed. Can we therefore get some reassurance that the money will address that specific point? I understand and appreciate the point that you are making, but the issue must be addressed. If we do not provide respite care, we will end up needing more residential spaces. That is stuff that we know.

Mr Nesbitt: I acknowledge that the issue came to the fore because of a BBC 'Spotlight' programme. It was a brilliant bit of journalism by Tara Mills. To assure the Committee, it was not that we then started to look at the issue, but it certainly accelerated the focus. Be assured that we are doing the best that we can. It is not a question of Peter or me asking officials what they are doing. I will bring back the mothers from the 'Spotlight' programme, whom I have already met, for an update. I will ask them what they think about how we are doing.

Mrs Dillon: I appreciate that. Those mothers were very brave in doing what they did. Unfortunately, we have been dealing with mothers, fathers, families and carers like that for many years. Thankfully, the mothers' voices represented those families, but we need to make sure it has an impact on all families because we know that there are so many out there in the same position.

Mr Nesbitt: I look at them almost as a focus group. I am not saying that if we satisfy those four families, we have cracked it.

Mrs Dillon: I understand that.

Mr Nesbitt: However, if those four families say that we have not cracked it, that is good evidence.

Mrs Dillon: They need the support. Can we get the specific details going forward? Can that be brought back to the Committee?

Mr Nesbitt: Just looking for an update on where we are.

Mrs Dillon: My ask is for the specific details on how you plan to spend that money and the difference that it is going to make. That is really important.

In relation to domiciliary care, do you have any detail, or will you be able to provide us with any detail, on any ongoing work on what the savings would be if we —. I understand that money will have to be spent to make savings — had the appropriate amount of domiciliary care packages and could move enough people out of our hospital beds? We know that the cost of keeping people in hospital is exponentially higher than caring for them in their own homes. There are savings to be made. I understand that when a bed becomes available, somebody else moves into it, but that does not take into account the uncommissioned additional beds that are required because we are not moving people through the hospital. There were 43 uncommissioned additional beds in one hospital, and that is an additional cost. If we do not have that already, can we get that at some point, if there is work ongoing on that, to understand what the savings could be?

Mr Nesbitt: We are working on that, but, as you have suggested, it is about the flow. Over the winter, the problem was the lack of community capacity, and that will remain a problem until we solve it. It is partially about buildings and beds, but it is also about the domiciliary and home care packages. I have committed to the real living wage, which is our best assessment of how to make it a more attractive profession and get the workforce numbers up to where they need to be. It will take a little bit of time to see whether it delivers the results that we hope for and anticipate.

Mrs Dillon: I appreciate that it will take time. Can we get an idea of the savings that will be made by providing that? There are other things that could perhaps be done. The real living wage is a very positive step, and the staff more than deserve it. In rural areas such as mine, there are other challenges around the cost of travel between one house and another. Some pilot work has been done. I really hope that we are going to move towards the specific needs of the person, rather than it being about what we can do. For example, 15 minutes in the morning, 15 minutes in the afternoon, 15 minutes in the evening, rather than saying, "What do you actually need?". I know that there has been a significant amount of work around that. I want to see it not being a pilot. I cannot believe that I am going to agree with a former special adviser for the DUP who was on 'Talkback' this afternoon. He said that we could be piloted to death. That is the other thing that we need to address. If we invest in pilots, we need to ensure that we have the money to roll out the scheme after. If the pilots work, we need to be able to do that. What is the point of investing in pilots to find out whether they work to then say, "That was wonderful. It was brilliant for the year that it lasted. We did amazing work in that one area", and sometimes it is not in the area where it is most needed. Those are the two things, Minister.

Mr May: We can certainly give you the cost of the average escalated bed in a hospital. You would need to compare that against the different places that someone who was ready to leave hospital might need to go. They might need nursing, residential or domiciliary care. We need to unpack the average cost for each of those elements. It is a bit more difficult because, as you will understand, not everybody needs the same level of care. Some people need one-to-one care and attention in whatever setting that they are in. That makes their care a lot more expensive than care for someone who, for example, needs domiciliary care twice a day. It can be quite difficult. I am conditioning your expectations about how clear the evidence trail is going to be.

Mrs Dillon: I understand and accept that. If we see an increase in the number of domiciliary care packages and an increase in the flow through hospital, can we get a definition of what was saved through that at some point? I am not asking for it today.

Mr May: I think that we can offer you some numbers. Defining the savings, as the Minister said, is more difficult, because, often, the beds that are vacated are being used to meet the unmet need that is there at the moment.

Mrs Dillon: But not always. That is my point. In one hospital, we had 43 uncommissioned additional beds because of the inability to have that flow through. I accept what you are saying, but —.

Mr May: I understand the point that you are making.

Mr Nesbitt: You only get the savings if the person leaves the bed and the bed is then not used.

Mrs Dillon: I understand that. We cannot say, if we create more additional —. I am sorry to dwell on this, Chair, but we cannot say that if we create the space to allow people to go home, there are always going to be —. We can still have that over-reliance on hospitals if we are able to get more people out into the community, but I accept that there will be an overlap for a time. I understand that.

Mr Nesbitt: I want to increase community capacity. When I say "beds", they are specific beds. Someone might need a dementia bed, and there may be a spare bed somewhere, but it might not be a dementia bed. There is a match to be had.

On pilots, I get it. I sometimes liken it to a game of snakes and ladders. Your pilot takes you up a nice ladder to a better place, and then it stops because there is no funding. You go down a snake to a worse place, because you now know that there is better, but you cannot access it. In the Live Better campaign, which we now have in Derry/Londonderry and west Belfast, we are calling it a "demonstration" rather than a "pilot", because the point of a pilot is to demonstrate that a need can be met by a set of actions. That is what I am trying to do with the Live Better campaign: demonstrate that the need to address health inequalities can be met by taking a bunch of services, bundling them together and delivering them as close as possible to people's front door. At the first session in Derry, over 170 people got MOT health checks. That is a tremendous number. It was a lot more than we anticipated. It is — touch wood — a decent start.

The Chairperson (Mr McGuigan): Thank you. I have to move on to the next member.

Mrs Dillon: Sorry, Chair, I just want to ask —.

The Chairperson (Mr McGuigan): No, Linda, I have to move on to Danny. You can come back in at the end. I have to be fair to everybody.

Mr Donnelly: Thank you, Chair. I reiterate the comments about Peter, and I wish him all the best in his retirement. We have always had good engagement, and I appreciate that, so thank you.

Diane made a point about the start and end points. A fair comparison is last year's start point. By my maths, that is an 8·5% increase. I do not need any comment on that, but it is only fair to compare a start point with a start point.

Two key elements of the winter preparedness plan were GP practices and community pharmacies. Both of those sectors will be impacted on very heavily by the changes to National Insurance contributions, as mentioned by the Chair. Community pharmacies have said that there is a £10 million pressure on them because of that alone. GP practices are absolutely concerned about the pressure on them as well. Your report says that £36·5 million is needed to meet all those pressures for GPs, pharmacies and community and voluntary groups. It is not clear whether you are going to fund that, and you said that you do not know yet. That is what I took from what you said earlier. Those two sectors are key parts of your winter preparedness plan, and they probably will be next year as well. I was told that the amount that is paid to GPs and community pharmacies for vaccinations was reduced by 25% this year. I would like you to confirm that. Obviously, I know that you have your blank page to do this year. If these pressures are not alleviated to those two key sectors, how can you be sure that they will be involved in this year's winter preparedness plan?

Mr Nesbitt: First of all — keep me right, Peter — on the vaccinations, we brought ourselves into line with the rest of GB. That was the only reduction, was it not?

Mr Donnelly: A 25% reduction?

Mr May: Again, you are on a point of detail that I am not over. I am unable to give you the specifics around it. Last year, a wider group of people were eligible for vaccines, and that may be the reason why there was a reduction. As you know, in January, the Minister widened the eligibility again, and we would have made extra payments as a result. I do not know whether your figures have taken account of those extra payments.

Mr Donnelly: I was told was that, in September or early autumn last year, the amount of funding that had been paid to GPs and community pharmacies per vaccine had been reduced by 25%.

Mr May: I would need to look into the detail of that. I do not have that —.

Mr Nesbitt: It is not my understanding, Deputy Chair.

Mr Donnelly: OK. Given the pressures with the National Insurance contributions on those two key sectors, what can you do to make sure that they are able to participate in the oncoming winter pressures for this year?

Mr Nesbitt: I have made the decision, which we discussed, to introduce the real living wage for social work. Our current estimates for that are maybe £50 million.

Mr May: For the full year, but it may not be for the full year.

Mr Nesbitt: Yes, for the full year. I have already said that, all things being equal —.

Mr Donnelly: Does that start this year?

Mr Nesbitt: This calendar year? Once we get into the next financial year, we will start it.

Mr Donnelly: On 1 April?

Mr Nesbitt: Not necessarily on 1 April —.

Mr May: More likely September.

Mr Donnelly: Oh, right. Not the financial year?

Mr Nesbitt: It will be in the next financial year, but not necessarily on 1 April.

Mr Donnelly: Starting from September, more likely?

Mr May: That is the current thinking.

Mr Nesbitt: We are still looking at those figures. One of the things that we do not know — to be Donald Rumsfeld, a "known unknown" — is what the pay bodies will come up with. They normally come through around June, though I think that the Government would like it a bit earlier.

Mr Donnelly: An estimated 3%, I think?

Mr Nesbitt: We have been working on 2·8%. I met the NHS pay body during the week. I got the impression that it might go higher. We do not know what that figure is. I want to do it at risk, because I think that the staff deserve it. I cannot continue to make commitments of a large scale until we have everything, so I have gone as far as I can. I have made two big commitments without having a finalised budget and gone through all the pressures that I am going to have to meet.

Mr Donnelly: I am hearing from GPs and community pharmacies that they cannot make commitments either. A lot of them are closing, and we are seeing GPs hand back contracts and pharmacies closing as they are financially unsustainable and unable to deliver medicines to people. They are saying that these pressures are compounding and negating their ability to deliver services. As you said, they are key services in the winter preparedness plan.

Mr May: There have been a very small number of pharmacies that have closed, and the GP contract hand-back has been substantially less in recent months than it was in the two years before that.

Mr Donnelly: They have closed, GPs and pharmacies.

Mr May: The number of GP surgeries remains static. It is just that some of them are being run in different ways now. They are not necessarily being run by the same people who ran them before. The Western Trust is responsible for a number of GP contracts, as is the Southern Trust, but they still use GPs to deliver those services. Just to clarify, the £36·5 million is for National Insurance contributions for all third parties, so it is not just for GPs and pharmacists. It covers the likes of social care and more widely, so it has a bigger reach, as it were.

Mr Donnelly: How many GP practices are in financial rescue programmes?

Mr May: We have that information. I do not have it with me today.

Mr Donnelly: Quite a few, though?

Mr May: A number of GP services are engaging through our strategic performance and planning group because they are facing challenges of various sorts. They do not necessarily specify that they are all financial in nature. Sometimes they can be about service provision or the identification of replacement GPs, rather than money.

Mr Donnelly: When we talk to GPs, they tell us again and again that the amount of funding — 5·4% of the budget — that they get is not enough and that they need to progress to getting 10% of the budget, as in the rest of the UK. Will there be additional funding for GP services?

Mr Nesbitt: I cannot make that commitment until I know what the final Health budget is and look at priorities, but you will be aware that I am extremely keen to press on with the shift left in order to get care as close as possible to the front door. Pharmacies and primary care are absolutely critical to that. Very early in my tenure, I learnt that the way that I was talking about it left some GPs thinking that what I was actually saying was, "I want you to do more for the same money". That is not the case; that would not be reasonable and is not where I want to go.

The challenge is with how to release the money. Throughout the winter, we looked at the pressures on our acute hospitals in particular, which is where all the expensive stuff happens. How can you relieve some of that pressure? That is probably a very long-term ambition. If you shift left, you go for prevention and early intervention. If you can achieve those things, you may be able to slow down the rate at which people present with very acute issues to the big hospitals. However, the demographic trends that I mentioned in my opening remarks militate against the ability to do that. Nearly 50% of the population will be over 65 by the year 2047.

Mr Donnelly: Shifting left, as you rightly said at the Bengoa conference, is what Bengoa was talking about, but that requires investment in primary care: GP services and community pharmacies. What out of this budget is for investing in GP services and what is for community pharmacies?

Mr Nesbitt: You tell me. You have a statutory duty to advise and assist. With a £400 million hole, how do I release money without making catastrophic cuts?

Mr Donnelly: There seems to be more pressure on them, so there will actually be more pressure on those two key sectors.

Mr Nesbitt: But where do I find the money? How do I do it? I am open to advice.

Mr Donnelly: It is your responsibility as Minister to give us the answers. Those sectors tell us that they are financially unsustainable and need extra funds. We need those services to be sustainable and to deliver.

Mr May: There is a contract negotiation ongoing with GPs. The Minister has mentioned that indemnity is one issue, and we are still looking at the question around National Insurance contributions. In addition, a bid has been made to the transformation fund to expand multidisciplinary teams so that they span a greater proportion of Northern Ireland. If that bid is successful, that will be a further investment in primary care. We are looking to meet the pressures faced by primary care in a range of ways, as we do across the piece. Part of the challenge with the budgetary situation that we have had, not just this year and looking into next year, but in previous years, is that all parts of our service are under huge financial strain. Often, it is a question of intervening enough to support and sustain each part of the system, but that does not necessarily mean that they will all get the amount of money that they ask for.

I am not sure whether the 5·4% figure that you quoted is the proportion of our total budget that they receive. To compare that figure with England is not to compare like with like. The social care budget is treated separately in England, so our number is rather greater. I accept that it is still not 10%, but the comparison is slightly misleading.

The Chairperson (Mr McGuigan): I am going to have to cut you off there and move on, Danny.

Mr Donnelly: Thank you.

Ms Flynn: I will ask my questions together, if that is OK with Mike and Peter. In the section of your briefing paper, under capital, you mentioned that there are a significant number of new projects that the Department would like to commence in 2025-26 for which, unfortunately, you will not have the budget allocation. I am, however, delighted to see in there, Minister, that you propose to commence the mother-and-baby unit in Belfast. The paper also mentions the new emergency department at Altnagelvin Area Hospital. I would like you to provide a wee bit more detail on that, but I am delighted to see it in the briefing paper. The mother-and-baby unit, if it is progressing, is right up there with the obesity programme, lung screening and the Live Better health inequality campaign, all of which you mentioned in your opening remarks. It is a testament to you that you are investing in mental health facilities. That was something that came up yesterday in the maternity hospital. Everyone sees the importance of it. It came up with Professor Mary Renfrew. Diane also raised the issue. If you had any more detail on that, that would be fantastic.

It is extremely disappointing that the overall spend on the mental health strategy is just £5·9 million out of the £42 million. You mentioned that in the Chamber the other day. That is not a good place to be, given what you could be doing with that strategy. Can you provide any more detail on what that £5·9 million will include? I do not know whether it includes the mother-and-baby unit stuff. Do you have any more detail on that figure?

Finally, you mentioned in your opening remarks that you are asking the trusts for £200 million in savings. You said that there was considerable risk with those savings, as they will essentially impact on services. We had a similar conversation around this during a previous budget session and it came down to savings that trusts might have to make. Some really serious implications and options were discussed. We never get to that breaking point, thankfully, but I want to know, having you here today, what it is that will be required from the trusts. You mentioned the impact on services. What does that mean, or what could it mean, for the trusts providing those services and the patients who require them?

Mr Nesbitt: I will start at the beginning. The ED at Altnagelvin, which, as I think you know, is the oldest of our EDs, is not great. I visited it. We had an Adjournment debate about it. Sometimes we talk these things down to the point at which we might be putting people off attending who need to go. The toileting arrangements in Altnagelvin ED are not great, but some of the language that we use to describe them is questionable. To be honest, a new ED at Altnagelvin is, even with a fair wind, probably five years away. Part of the problem was that the trust put in an all-encompassing plan. We liaised with it and said, "Look, to be realistic, you'd be better breaking that into parts. You're more likely to get

than the whole big thing". That is where we are, and we are progressing with a new business case on that.

I am extremely keen to see the mother-and-baby unit. We have identified the site, which is at Belfast City Hospital. Part of the delay was because we thought that it was fit for funding from the Shared Island Fund. I had some discussions — I am sure that Robin did ahead of me — with Minister Donnelly when he was Minister for Health in the Government of Ireland, and it turned out that it was not going to find favour with the Shared Island Fund. However, we believe that, thankfully, we can fund it ourselves. We think that Belfast is the right place for it to be, because it needs to be proximate to other services. That will be a good news story, as will the children's hospital. I am delighted that you visited the maternity hospital. It is a magnificent facility.

Over £500,000 of the £5·9 million funding for mental health has gone to the regional mental health service. I am very keen on having a standardised regional service, wherever possible, rather than wasting time trying to create one in a single trust, which will not necessarily deliver better than the five trusts learning to cooperate and collaborate, which, to be fair to them, they are doing. Child and adolescent mental health services (CAMHS) received £2 million. Perinatal services received well over £1·5 million. There was £86,000 for eating disorders, and the same for personality disorders. We spent over £350,000 on a crisis service and £1 million on early intervention and prevention.

Ms Flynn: My final question was on the issue of the trust savings.

Mr May: The impact?

Ms Flynn: Yes.

Mr May: We are still working through trust returns. The trusts will have set out the level of saving that they believe that they can make and what the high and catastrophic cuts would mean. We need to go through the detail of the returns. There is always a process where we invite the trusts to respond to us, and there is then a challenge process before we get to a final view as to what the position looks like. I hope that that answered your question.

Ms Flynn: The briefing paper refers to £200 million. Are you saying that, when the trusts come back with their papers and suggestions, they might not have to make those cuts? How do you determine whether that has to be —.

Mr Nesbitt: If I may, last year, it was tabulated to show low impact, medium impact, high impact and catastrophic impact. Robin Swann said, "Don't go anywhere near catastrophic". When I came in, I said, "I won't sign off on catastrophic". They have done what are, effectively, the easier ones: low and medium. I am still waiting on the final word on how close we sailed to the line of catastrophic with regard to that £200 million. Logically, however, you can assume that we will potentially cross that line if we go to another £200 million. There is a negotiation still to be had in order to try to avoid that.

Mr May: Not all the savings that were made this year are year-on-year savings; some of them are one-off savings that cannot be repeated. I estimate that around £120 million were recurrent savings and that about £70 million, for the trusts alone, were not recurrent. When you add another £200 million on to that, it essentially means that they are looking to make around £270 million in new savings on top of the recurrent savings. That is where the problem is likely to be. Since the Minister said that he did not wish to sanction any catastrophic cuts this year, there will not have been any catastrophic cuts this year. It is next year that we have to look at now.

Ms Flynn: It would be great if the Committee could get an update on that when you have done the deliberations on those savings.

Mr May: I think that our finance director is coming to the Committee at the end of March. She will be able to give you more detail on that information.

Mr Nesbitt: We need a bit of time to liaise with the trusts.

Mr May: If I may come back to Diane Dodds's question about the two documents relating to the children's hospital, I think that I have worked out what the difference might be. I think that the investment strategy for Northern Ireland document will have included what some of the running costs for the children's hospital will be when it is up and running. It is the total business case cost that is included in the ISNI rather than the capital development costs, which was the £670 million that you quoted. I think that that is the difference. I will, of course, check that, but, having reflected on it, I am pretty confident that that is what the difference is.

Miss McAllister: Thank you for coming today, and best wishes to you, Peter. I assume that you are moving onwards or semi-retiring. Whatever you do, good luck. I hope that it is enjoyable.

I have a lot of questions, some of which are quite short, so I will get stuck in. How much was available to allocate to resource in the January monitoring round? How much was there to allocate overall?

Mr Nesbitt: I believe that it was £7 million for resource.

Mr May: We received £7 million. I cannot remember what the total was for the Executive as a whole.

Mr Nesbitt: Sorry, did you mean for the Executive?

Miss McAllister: Yes. My understanding is that it was £10 million. I do not know whether that is completely correct, but I am 90% sure that it is correct.

Mr May: Before they got to £10 million, I think that some money was allocated to other inescapable needs, but I do not remember the precise numbers.

Mr Nesbitt: We were given first dibs — first call.

Miss McAllister: There were the inescapable needs, but the additional resource was £10 million, of which Health got £7 million. Do you agree that having over 70% of what was available —.

Mr May: Surely you are not suggesting that £7 million in a budget of £8 billion is a meaningful —

Miss McAllister: No. I am not suggesting that it is meaningful.

Mr May: — number by which to judge the total commitment.

Miss McAllister: I am suggesting that £7 million out of £10 million went far in a collective Executive view on Health spend being increased. I wanted to come back on that, because you threw out the fire at the start of this session, criticising the other Executive parties for not working collectively. With respect, however, there is a bit of collective working.

Mr Nesbitt: I am not criticising them for not working collectively. I said that other things were prioritised. You will recall that, in the negotiations to bring back Stormont, which came back last February, every party said that Health would be the priority. You may have heard Jayne McCormack of the BBC saying at the time of the anniversary that the first time she spoke to the First Minister and deputy First Minister, they said, "If we can get anything right, it should be childcare". That is not the Department of Health, albeit a very worthy ambition.

Miss McAllister: Given that each Department has responsibilities and priorities and has to put those forward in its bids, yet Health still gets over 50% of the Budget every time, do you not recognise that the Executive are a collective?

Mr Nesbitt: No. The percentages are red herrings. I would rather talk about assessed and objective need.

Miss McAllister: OK. Perhaps I should ask whether the Executive got enough money for what they need to do.

Mr Nesbitt: No. Every Department is under pressure.

Miss McAllister: OK. There you go: that has answered my question about the Executive being a collective. In criticising the collective nature of an Executive, we have to be honest and say that the Executive did not get enough money.

Mr Nesbitt: I am not criticising the lack of joined-up working by the Executive.

Miss McAllister: You did in your opening statement. I think that it was very unfair. I know that Alliance is just one of the Executive parties, but fair is fair when it comes to working collectively.

Mr Nesbitt: Fair is fair in your opinion; fair is fair in my opinion.

Miss McAllister: Is it important for value for money to be a priority in your Department?

Mr Nesbitt: Value for money is a necessity.

Miss McAllister: That goes alongside good patient outcomes, of course.

Mr Nesbitt: If you think that any amount of value-for-money or efficiency and productivity work will close the gap between demand and capacity, you are wrong.

Miss McAllister: That is not where I was going with that. I am just asking whether value for money is, alongside patient outcomes, a priority in your Department.

Mr Nesbitt: I do not even know why you ask me that: of course it is.

Miss McAllister: We have heard — it has been reported in the media — about health spending without proper procurement practice, in social care in particular, on residential placements for our older population, whether short-term, for rehabilitation so that people can move back into their home, or long-term. According to the figures that we have received and as has been reported in the media, expenditure on such placements, of £486 million by the South Eastern trust, £650 million by the Belfast Trust, £473 million by the Southern Trust and £420 million by the Western Trust, has been made without proper procurement practices or, in my view, at times, looking at patient outcomes.

I bring that to your attention and set it alongside the findings of the Regulation and Quality Improvement Authority (RQIA) so that it can become a priority for you. In a number of the care homes in which there was such spending by the trusts on placements, the RQIA found a lack of progress from previous inspections; beds being made up with soiled linen; patient care plans not being followed; nutrition plans not being followed; ineffective maintenance of water systems, which can lead to legionella; and governance and oversight issues. Those are just a few of the issues.

Many of the care homes that have been named received that money without proper procurement process being followed. From today, will you, as Minister, make it a priority to find out why that happens? We understand that, when people need placements, those need to be found quickly and that patient outcomes should be a priority, but I hope that you will examine that.

Mr Nesbitt: It is my understanding that, where we set a price and somebody meets that price and can also deliver the quality, it was not felt to be necessary to have procurement. However, I can assure the member that that policy is under review.

Miss McAllister: That is good to hear, because soiled linen, patient care plans and nutrition plans not being followed —.

Mr May: It is important to recognise that there are two separate issues. The first relates to the price point for the care to be provided in a care home. The complexity there is that lots of individuals need different levels of care. That makes it difficult to enter into procurement in advance, because you cannot preordain exactly what care the individual coming out of hospital will require. There is an entirely separate question about whether care homes provide the level of service that they should for the cost that has been decided using the contracted arrangements. There are RQIA inspections, and there are duties on trusts to ensure that the appropriate level of care is provided. Where there are incidents such as you described, of course action should be taken against the care homes, but they are two separate issues, just to be clear.

Miss McAllister: That is why I asked whether the issues should be taken together. I completely understand and accept what you said about the price point having to be followed and why you could not procure. I respect that, but, in healthcare, we talk about value for money as well as patient outcomes. We are talking about huge sums of money — over £2 billion. We are also talking about a system that, at times, has failed the most vulnerable in care homes, so we can no longer look at that in isolation.

I do not expect you to have all the answers today, to be fair, because we have only just received the figures. Can you commit to examine that issue so that we can approve that it is value for money and improve the outcomes?

Mr Nesbitt: The answer is that it is under active review and consideration.

Miss McAllister: I appreciate that. Like the Chair, I am moving across issues. The previous member to put questions to you asked about respite. The Committee gets a lot of correspondence. We had over 40 pieces of information and lots of papers last week, and it was one of the issues that was up for discussion last week. Some of the detail in that correspondence was around how that £13 million is being spent across each individual trust, but I want to draw particular attention to the point around getting the detail. There is detail in here, but it would be helpful to know about the extra, specific individuals and families that it can help.

I asked about one specific area, which is the South Eastern Trust and Belfast geographic area. Redwood is a residential care home that is not currently open because it does not meet fire regulation standards, and it would cost £50,000 to fix the problem.

Mr Nesbitt: The problem was the staircase, I think.

Miss McAllister: It is not included in the correspondence that we were given the week before last. The cost is £50,000, and I appreciate that there is staffing involved, but can you commit to seeing whether that is included in that £13 million to ensure that it is brought up to regulation standards? Does the money have to come from capital, meaning that it cannot be taken from the £13 million? To me, it seems such a small sum, but it could have an impact and help. It might be only three beds, but it is still three beds.

Mr Nesbitt: If I am thinking about the right facility, the problem is around fire safety regulations. I think that it applies to a staircase. The £13 million is resource, and the staircase is capital.

Miss McAllister: Is there anything that we can do?

Mr Nesbitt: I became aware of the issue only in the past week, so I am not in a position to say that there is nothing that we can do, but I am not in a position to say, "Here is what we are going to do".

Mr May: We will have a look at it.

Miss McAllister: The other issue is around the GP indemnity. We understand that contracts and overall funding for GPs will fall into the budget, and I appreciate that you are here to talk about the budget, so I will try to keep it linked to that. The BMA and the Royal College of General Practitioners were at the Committee a number of weeks ago, and they made clear to us that they were not given any options; they were told, "This is what it is".

My feeling and the feeling of the rest of the Committee was that we were not content with what had just been provided as the permanent solution to the GP indemnity issue. I think that it would be worthwhile for whoever is leading those negotiations to watch that Committee session back. I am sure that they will, but we got a clear message from GPs. They told us that they do 200,000 consultations a week. We talk about pay parity for England, Wales and Northern Ireland, but we need to look at pay parity internally. When we have pay awards for staff in our hospitals or secondary care, we do not expect to then say to them, "We are giving you this, but you will have an additional duty".

Everyone is under pressure, so the same parity should be applied to our GPs and community care. If we are going to fix their funding model, it should not be to do only that. Let us give them more. That needs to be taken on board. I recognise that that is not strictly a question.

Mr Nesbitt: I have been involved in a number of discussions with GP representatives about indemnity. It is not as though we suddenly decided, out of the blue and without discussion, to say, "There is your solution".

Mr May: As I understand it, the amount on the table for indemnity is a number that the GPs themselves would recognise as one of the things that they were looking for. I recognise that they will always ask for more, but we are in the process of dealing with lots of people who are looking for additional funding. On asking for extra, when pay rises come through for staff in the Agenda for Change unions and for those in our direct employment, we replicate that in GP salaries, which will go up by the amount that the Review Body on Doctors' and Dentists' Remuneration sets out. An amount is then made available for inflationary payments more widely.

When we talk about widening access, we are essentially talking about introducing systems that will allow people to book appointments online, and that will then reduce the queues of people trying to get through early in the morning. A number of people do not need to see a GP that day. They want to see a GP in the next two weeks and are quite happy to go online and book an appointment at a time of their choosing. That is good practice and suits everybody. It helps to reduce the pressure, and that is how you reduce the access requirement. It is not reasonable to say that that is placing an extra burden on GPs. That is inviting them to use some of the best IT, and many GPs are already using that and spreading that practice across the whole the sector.

Miss McAllister: I think that it is fair —.

The Chairperson (Mr McGuigan): Apologies, Nuala, for cutting across you. These are important issues, and I know that members would love more time, but, as Chair, I have to be fair to everybody, so we have to move on.

Mr Robinson: Thank you, Minister and permanent secretary. On the issue of tracking public money, I was looking at the paper that we were provided with, and I want you to clarify something. I have five different questions, but I will start with this one. The original projected funding requirement for period products was £5·7 million. During our sessions in the Committee, we were told that trusts were predicting a cost of £200,000 to £300,000 per trust, which equates to about £1·5 million or £2 million. Can you clarify the difference between the original projected funding requirement, which is detailed as £5·7 million, and the £2 million maximum that we were told?

Mr May: Is that a document that we provided to you?

Mr Robinson: Yes. I have the document here.

Mr Donnelly: It is in the briefing pack.

Miss McAllister: It is from the strategic planning and performance group, I think.

Mr May: I am happy to explore where the numbers come from or what period they cover. The question can often be whether they cover a longer period than, for example, a single year. I do not know. I would need to explore that.

Mr Robinson: The paper seems to indicate 2025-26, so, if you could come back to the Committee, we would appreciate it, Peter.

Mr May: Sure.

Mr Robinson: The issues involving GPs have been well rehearsed. They presented to us, and I know that you have met them, Minister. They gave a very powerful presentation, and their three key asks are on core funding, GP indemnity and National Insurance contributions. That has been already touched on by a number of contributors today and you. On GP indemnity, can you clarify whether will that be new, additional money?

Mr Nesbitt: It will be ring-fenced money, and it is my impression that it is new.

Mr May: We have already made some payments for indemnity this year. I think that it is a total payment for indemnity; it is not additional. We paid some money out this year on a one-off basis. I think that the new sum is the total sum for indemnity. That is my understanding.

Mr Robinson: So that I can understand this, can you tell me whether the money for the new contract will be new, additional money?

Mr Nesbitt: That contract is not completed, is it?

Mr May: It is still being negotiated.

Mr Robinson: It is still being negotiated. OK. I know that the hope is that it will be additional money.

Mr Nesbitt: Everybody wants additional money.

Mr Robinson: I know that. There are a lot of outstretched arms.

Mr Nesbitt: Yes, and everybody, by and large, has a reasonable case. National Insurance increases came out of the blue and will hurt everybody.

Mr Robinson: I want to ask about the multidisciplinary team proposals in the paper. The paper says that they "continue to move forward". Can you clarify whether that will be new money, recurrent money or money from the transformation fund? Will it be one-off money?

Mr Nesbitt: It will be transformation fund money. We have a bid in and are through to round 2. That will take us from seven of the 17 federations to 12 of the 17 federations. That is profiled over the full five years, is it not?

Mr May: It is profiled over the years of the transformation funding. At that point, it is assumed that the Department will take on any residual costs after that.

Mr Robinson: The Department will pick it up after that. OK. I note that prescription charges are referred to in the paper. How much would they raise? Would it require an Executive decision to approve that prescription charges be reintroduced?

Mr Nesbitt: If we reintroduced prescription charges, factoring in the cost of administering the scheme, it would raise a low number of millions.

Mr Robinson: Is that in the grand scheme of the overall Health budget?

Mr May: Yes. About £20 million is the estimate that I recall. There would need to be a public consultation and legislation, so it would require Executive agreement.

Mr Robinson: Can you indicate where the greatest need would be for the money that would be raised?

Mr May: We are some way off having the legislation through, so we would want to take that decision at the point when it arises, rather than deciding years before what would be the case.

Mr Nesbitt: Sorry, are you asking where would we spend the money?

Mr Robinson: Yes. The paper refers to redirecting any money raised from:

Define the "greatest need". There will be many, I am sure. As I say, there are many outstretched arms.

Mr May: Assessment would be made at the time on the basis of what the current situation was, rather than being made so far in advance. You are right to say that there is a range of choices that could be made.

Mr Nesbitt: You could make an argument that, if we are not spending enough and if the waiting lists are too severe in cases of red-flagged cancer or threats to life, limb or sight, that is the greatest need.

Mr Robinson: The trusts are to be applauded for the efficiencies that they are making. Some might call it "fat in the system". Do you recognise that there may well be fat in the system? If you do, why were those efficiencies not made sooner, rather than continuing on the trajectory that we are currently on? Could we have flattened the curve sooner?

Mr Nesbitt: When you talk about a health and social care system that employs 70,000-odd people, you are talking about a vast organisation with so many moving parts and buildings and so much equipment and bureaucracy, so do you ever get to the point at which there are no efficiencies to be made? I very much doubt it. Why did we not do it previously? Ask the previous regime.

Mr May: The other thing to reflect is that, during COVID, the focus shifted very significantly to meeting the pressures of the pandemic, and we have been reasserting the financial and management disciplines needed. That is one of the reasons why we have been able to make these efficiencies. We have to recognise that there was a point when everybody's focus was on dealing with the pandemic, and that has had some implications.

Mr McGrath: Thank you, Minister and Peter. I also want to go on record as thanking you, Peter, for the work that you have done in the Department of Health and wishing you well for the future. I also want to go on record to thank you for recognising the democratic mandate that MLAs have when other political parties did not. Giving us an opportunity to meet regularly to update us on what was happening in the health service and give us a heads-up on the problems and issues that we were facing was certainly appreciated by the MLAs who turned up and had that opportunity to participate when this place was, once again, not functioning.

Minister, following on from what Alan has said and picking up from our debate last week, when is a cut a cut, and when is an efficiency an efficiency? We seem to have had a difference of opinion on that. It would be good to give us the chance to flesh that out.

Mr Nesbitt: If you have a cut and an efficiency to make, surely nobody in their right mind will go for the cut first. They will go for the efficiencies. I am sure that you had sight of our tabulation of the impacts, from low to catastrophic, and that is where we are. To categorise everything as a cut implies that everything has done severe damage to the service delivery, and some efficiencies will not necessarily have done that. I look at the five trusts and ask whether we have too much management. Against that, I am absolutely of the opinion that, if I were to suggest having one geographic trust, it would become an obsession and a distraction. Would we get what we thought that we would get as a result of that? I point to the 26 councils that moved to 11 and the Education Authority that replaced the education and library boards. Neither has necessarily delivered the service that we thought that it would. There are efficiencies to be made, but, if we are to get the extra £200 million out of the trusts, there will have to be measures that you, rightly, will call cuts.

Mr McGrath: I will set the context as your being a Minister in an Executive and my being in the Opposition. We have a health service that is struggling, and we are delivering a significant number of efficiencies first. The opposite of inefficient is efficient, so if we are cutting out the inefficiencies, we should have a more efficient system, but our waiting lists, waiting times and red-flag referral times are getting longer. Everything in the system is getting worse. If we are making better efficiencies, those things should be getting better, and they are not. If the next stage has to be cuts, that means that the issues and problems will get worse. How will the Executive prioritise the health needs, given that, despite the efficiencies that we have clawed out, there are still long lists, and our cuts will reduce the service capacity that we have? What is the future?

Mr Nesbitt: You make very valid points about the unacceptable waiting lists and the fact that things are not getting better. Empirical evidence shows that they are getting worse. In the future months, we will not concentrate just on supply, which is what we do. We do not have the capacity to meet demand. We may have to go to the demand side and start looking at managing it in a different way. Our population is growing: we are nearly two million people. I have rehearsed the demographic changes, which are magnificent for someone of my age. The over-85 population is to go up by over 100%. How cheery is that for somebody like me? What, however, are my expectations of how health and social care services will meet my needs? What if I am terminally ill? Do I need to have a conversation before I get to the point when I need a lot of HSC services? We need to look at demand, and that will be a sensitive, challenging and difficult conversation. However, that is where we need to go, rather than focusing on just the supply side.

Mr McGrath: I hope that that forms part of the transformation that we have talked about. The transformation is that we have to stop people getting sick. If we can move our community towards that ambition and tackle the bigger levelling-up piece, which may be where the health inequalities sit, to stop greater numbers of people in certain areas getting sick, that may reduce the demands on the service.

My next question could be called a plant or a lead. It is a yes/no question, and I will leave it there. Is the best service that we can offer in Northern Ireland reflected in the fact that, time and time again, a significant number of ambulances sit outside hospitals because they are unable to hand over their patients, thereby reducing the provision across the North?

Mr Nesbitt: I will go beyond a single syllable answer, if I may. Anybody who thinks that the health and social care service is as good as it can be is delusional. Is any public service as good as it can be in Northern Ireland, the UK, the Republic of Ireland or anywhere else? No, of course not.

Mr McGrath: That was a good long no, but I will take it. Thank you.

The Chairperson (Mr McGuigan): Thank you very much.

Mr Nesbitt: Chair, if I may, I have a point about GP indemnity. The money is additional. It is not being repurposed from existing budgets. The indemnity is new.

The Chairperson (Mr McGuigan): Thank you. Minister, I recognise that we are just about on time or a bit behind.

Mr Nesbitt: Very good.

The Chairperson (Mr McGuigan): You will not mind waiting to take questions from your colleague —.

Mr Chambers: I am all for balance.

Mr Nesbitt: You know what they say: the Opposition are over there, but the enemy is behind you.

Mr Chambers: Minister, from listening to the cross-party narrative that comes out of the Chamber and, indeed, this Committee, it seems that the two big priorities are the roll-out of multidisciplinary teams and tackling waiting lists. If I read your briefing paper correctly, you seem to have made a bid for £300 million to tackle both of those issues. My understanding is that that bid was rejected. Will you confirm that was the case? I would be extremely disappointed if that were the case, and I hope that that disappointment would be shared by everyone in the room.

Once again, you set out in quite stark terms the financial shortfall that our health and social care system faces next year. In light of the draft Budget for next year that was published before Christmas, is it your experience that all Ministers and Departments have approached the allocations with a more open mind to determining the true level of need, or do you think that, as it seems, despite the benefit of time, we are destined to repeat some of the same mistakes once again?

I struggle to understand the motivation of some members who today made some mathematical arguments about what the starting and finishing figures were for this year's budget. They bandied about various percentages. Surely, you agree with me that the most important figure is the one that is in front of you in your budget for next year. That budget affects what you can and cannot deliver. Really, all the other arguments about percentages are academic distractions.

Mr Nesbitt: I will go in reverse order. I go back to my point: is the budget enough to avoid industrial action and catastrophic cuts? My assessment is that it is not. Therefore, once again, we will rely on in-year monitoring round moneys to try to make that right.

We have not had a penny for our bids to get money for waiting lists. I now take the view that, if this were day zero or year zero and there were no lists, over the next £12 months, we would need up to £80 million to deal with the waiting lists that would develop in that time. The long tails of waiting lists mean that, on top of that £80 million, we need £135 million a year for five years to deal with them. That is the scale of the problem that we face. The solution is a multi-year solution, even with that scale of investment in the problem.

You talked about collaborative working. I will try to finish positively, Chair. It is the first time that I have been in the Executive, so I am not comparing with any previous experience, but I get the sense of collaborative working and a growing sense of realisation that very little can be fixed by one Department. I look at the Education Minister, and we always ask, "What about educational underachievement?". We cannot point the finger solely at the Education Minister any more, because healthier children will do better at school, so it is my problem. Children who live in better-quality housing will tend to do better at school, so it is the Minister for Communities' problem as well. It is a collective problem.

We reckon that the health inequalities that I want to tackle come from 20% health factors, 40% socio-economic factors, 10% environmental factors and 30% behavioural factors, so it is an all-Executive challenge. I made that point, albeit in a superficial opening gambit, but the kind of response that I got from Executive colleagues was, "Yes, we are up for this". If my demonstration areas show that Health is achieving part of the 20%, I can go back and say, "OK, let us look at the socio-economic and environmental factors and the behavioural things, like tobacco and vapes", so that we do that. I want to be optimistic. We all know about the collapses and problems that devolution has had. After all of those, if it were to go again, my assessment would be that it had gone for good. Could we renegotiate on the scale of the 1998 negotiations to get a devolved settlement again? I find that highly questionable. Therefore, let us be realistic about the problems that we face, and let us have honest and robust conversations about what those problems are and how we might go about fixing them, but let us also give a bit of hope to patients, service users and the glorious staff who deliver health and social care.

The Chairperson (Mr McGuigan): Thank you, Minister and Peter. We really appreciate your coming before us. There are a number of things that we have asked for further correspondence on, so we look forward to seeing that. The document that Alan referred to in his first question is an equality impact assessment document. That is where the figures were taken from.

For your information, Minister, on 11 March, the Committee will meet the families involved in the 'Spotlight' programme on children's respite services.

Mr Nesbitt: Oh, right. Good.

The Chairperson (Mr McGuigan): It will be very good to hear from them.

There will be positivity in my summing-up. There was a bit of conversation about the Executive and funding. As an MLA and now as Chair of the Health Committee, I have found it positive that the Executive have taken a united stance with the British Government on the budgetary underfunding of our public services here in the North, which has a knock-on effect across all Departments. Minister, the Executive have clearly demonstrated that health is a priority, given that they have allocated 53% of that inadequate Budget to it. On a couple of occasions, including in your summation, you talked about how there is more to health than just health, whether it is education, infrastructure, housing or poverty and how all that has an impact on health. You talked about 70,000 staff, and I contend that childcare is very important in that. If you are looking to recruit more doctors, nurses, domiciliary care staff etc, childcare is vital in supporting the health service.

Thank you, both, for coming. We look forward to engaging with you, Minister, in the Assembly over the next number of months and seeing you back here again in the future. As everybody has said individually, we collectively, as a Committee, wish you well in whatever you do in the future, Peter. Thank you for your public service.

Mr May: Thank you.

Mr Nesbitt: Thank you, Chair.