Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome from the Regulation and Quality Improvement Authority (RQIA), Briege Donaghy, chief executive, and Professor Stuart Elborn. The witnesses have indicated that they want to make a brief opening statement before moving to members' questions in order to make the best use of the Committee's time, so fire away.

Professor Stuart Elborn (Regulation and Quality Improvement Authority): I will do a quick contextual introduction. Thank you for inviting us to provide additional information on the independent review carried out by RQIA of the effectiveness of the clinical pathways in the South West Acute Hospital (SWAH) for general surgery, following the temporary suspension. It is important to note that, while RQIA was requested to undertake the review by the Department of Health, we did so independently and engaged experienced clinical staff to contribute to the review, which adds further independence and expertise to the process.

While the focus today is on the review of the South West Acute Hospital and the pathways relating to general surgery, the review's recommendations relate to the Western Health and Social Care Trust, the SWAH and the local population. We point to the Minister's response that all the recommendations have been accepted by the Department and the trust. As a result, the Department has committed to updating the guidance document on the change or withdrawal of services. That will apply across the system and to all trusts, whether the withdrawal of services is temporary or permanent. The updated guidance will include the need for trusts to undertake clinical audits and/or evaluations of how pathways are working and how those clinical outcomes are being achieved for patients. That includes the need to report the findings of such audits; drive improvement; and determine the consequences for other co-located services. It also includes the need for the trust to be proactive in seeking out the experience of patients.

In summary, the recommendations are about the need to identify relevant data, act on evidence to support change and ensure good governance in this area. I hand over to Briege, who will briefly summarise the three key recommendations of the review.

Ms Briege Donaghy (Regulation and Quality Improvement Authority): I am happy to do that, Chair, but equally I am happy to go to questions, if that is your preference.

The Chairperson (Mr McGuigan): Do you want to briefly go through the key recommendations?

Ms Donaghy: I will go through them briefly. Ten recommendations were made. Everyone whom we met while carrying out the review — patients and their families; staff in the Ambulance Service, the South West Acute Hospital and Altnagelvin Hospital; clinicians; and senior managers — wanted the best possible outcomes for patients. No one whom we met did not endorse that point. I thank everybody for their candour and for contributing to the review.

I know that there are some questions about the timescales for the recommendations. We have not set out recommendations to be implemented within one month, two months or three months. We have used different words such as "immediacy", "urgent" and "promptness". We are trying to indicate the need for pace, and we recognise that some of the recommendations are not easy to achieve. They focus on a couple of urgent actions regarding ambulance capacity and emergency department (ED) waits in Enniskillen and Londonderry and, as Stuart said, on undertaking audits and gathering evidence to demonstrate the effectiveness of the service, so as to assure the public, the patients, the staff, the board and so on about the service and how it operates.

I appreciate that there are time pressures, so we are happy to take questions immediately.

The Chairperson (Mr McGuigan): I have a couple of other questions, but I will go to what you said about the recommendations. You talked about urgent recommendations, fixing ambulances and double waits in ED: has there been any progress in any of those areas?

Ms Donaghy: I know that you have colleagues coming behind me, Chair, who will be able to give you updated information. Really good efforts have been made, but you will still be able to demonstrate that challenges exist, and colleagues will confirm that. The trust continues to publish its infographic on its website. That is available to me and to all of you and demonstrates some of the challenges that are still being faced. I know from the commitment that was made in the recommendations that a huge endeavour is being made to address that. However, I would prefer it if the trust spoke to the progress on that.

The Chairperson (Mr McGuigan): We will ask them about that, fair enough.

The Minister made a statement that he would not make any change without evidence. We are all clear that we want outcomes for patients to be the way that they should be, so it is good that he will make no changes without evidence. I want to ask about the evidence and data that you had available to you when you were making your recommendations. Were there deficits? What data did you have? Was it good, and did it allow you to do the work that you were aiming to do?

Ms Donaghy: Yes. I am happy to answer that, Chair. We had lots of information available to us, which we have endeavoured to demonstrate in the report. The experiences of patients and their families are particularly well evidenced in the report. Listening to those who had first-hand experience of the changes was a big part of that as well as the experiences of staff working in the EDs and some of the other services, such as the Ambulance Service and so on. A lot of other data was available, such as the protocols that had been developed to guide clinicians and the Ambulance Service during the changes. We had information from the trust board's minutes and papers available to them. We had the infographic that I mentioned, some of the calculations and waiting times in EDs. There was quite a lot of information; so much so that we felt in a position to make 10 significant recommendations.

There was, however, an area that needs work: the clinical outcomes for patients on the pathways. The trust fully accepted that, and I understand that it is working hard to address it. Put simply, people were asking, "If I need to have my appendix removed and I live in Derrygonnelly, Rosslea, Enniskillen, Belleek or anywhere else on that pathway, am I every bit as likely to have as good an outcome as someone who lives in Londonderry or Strabane and is accessing the emergency surgical service in Altnagelvin Hospital?". That information is available, but it is tied up in the computer systems and the patient records. The trusts were able to explain to us that its current computer systems do not readily make that information available. It is there and will be available, but it will have to be manually drawn out.

When we talk about clinical outcomes, they are not complicated outcomes. People want to know, "Will I stay roughly the same length of time in hospital? Am I any more likely to have an infection or some complication as a result of having my procedure? If I come through those pathways and transfer from the South West Acute Hospital to hospital in Londonderry, for example, am I more likely to spend time in intensive care or in a high-dependency unit? After I have been discharged, am I any more likely to be readmitted with some post-discharge complication ? Is my outcome — my time in hospital — or anything that I will experience likely to be the same as it would be for someone of the same profile and age and with similar health conditions and so on?". We heard that that information being made available would provide a lot of assurance to people in spite of the difficult journeys, the ambulance transfers and the many issues that we heard about. There were distressing and anxious aspects that we heard about — of course there were — but, overwhelmingly, people wanted to know this: "Will my outcome be the same?".

The Chairperson (Mr McGuigan): Just so that I am clear, are you saying that you were not provided with that information?

Ms Donaghy: That is correct, Chair. We did not have that level of information. We spoke with the trust about it. It recognises that it is possible to get that information, but getting it requires a significant manual effort.

The Chairperson (Mr McGuigan): How much of a hindrance was that lack of information to you in doing your work, producing your report and making recommendations?

Ms Donaghy: It would be preferable to have it available immediately, but the important thing is that we still made the recommendations with all the other information that was available to us. Let us not underestimate that. Statistical data such as on the clinical outcomes that I have modestly described would be vital for reassurance, but the information from patients and front-line staff and the information available to the trust board was sufficient for us to make 10 significant recommendations. That has shaped — at least, I like to think it has — the clinical audit programme that the trust will carry out, because it informs the trust of the information that the patients, public and staff want to see and hear about. We did not put timelines around them, but we said that several of the issues — if we get an opportunity, I would like to address the issue of immediate patient safety, because people have asked us about that — must be undertaken at pace.

We will meet the Western Trust board in early April, and I am assured that we will discuss not only the report and its findings but progress on some of that work. There is a full commitment to undertake that work. I have no doubt that the work is under way, and, as soon as it is available, that will add a huge element to the layers of assurance that are necessary to indicate to people that the outcomes are acceptable and, perhaps, improvements. That all has to be made available to the board and to the public.

Mr McGrath: Thank you for your presentation. One of the most important things that will guide an investigation like the one that you have done is the terms of reference. That is pretty important and tells you exactly what you need to do. However, there were significant differences between the original terms of reference and the ones in the final document. Words were missing that would somewhat direct you in a different way. Were those changes that you made, or were they changes that the Department asked you to make?

Ms Donaghy: There were no changes, and I apologise to the Committee, to the public and to anyone else who was confused. The fault for that lies entirely with me. There was a transcription error.

I will challenge something, if you do not mind: I do not believe that they were materially different. There were a couple of words about population health that were missed. That was entirely a transcription error from the original terms of reference to the final document. The terms of reference never changed, and we never changed in our endeavours when we were out there. We always intended to look at population health issues and patient safety. I apologise that that caused confusion.

Mr McGrath: Thank you for the apology. It has created a lot of mistrust in a situation where there is already mistrust. Among the words removed were "system learning", which relate to a pretty big piece of information when it comes to a review of a situation like this. For those words to be removed from the final version suggested that there was no system learning or that that was not a focus. With the patient population outcomes, if you are talking about moving emergency surgery, there could be nothing of more importance to patient outcomes. Anyway, I will maybe —.

Ms Donaghy: May I just quickly say this, though? Whilst I accept entirely the point that you are making — it caused confusion, and I apologise for that — the outcome of this has been system learning. You may well have looked at the Department of Health's response, and I want to emphasise that the learning out of the Western Trust and South West Acute Hospital has led the Department to determine that all service change in future, temporary or permanent, will be subject to independent evaluation at six months and will have already had, in the lead up to it, a clinical audit programme. That is really important, because we know that, as a community, we face service transformation: hospitals will be different. This is a commitment. Learning from SWAH that, in future, that will be the norm is the most obvious example of the system learning, despite the terms of reference causing that confusion.

Professor Elborn: Additionally, the system's learning depends on connected data and information so that we can develop that into evidence. Encompass will help with that, but we also need to access data from other parts of the Health and Social Care (HSC) system. For example, the Northern Ireland Ambulance Service (NIAS) needs to talk to the trusts etc in terms of real data, so there is still a lot to do on that digital transformation.

Mr McGrath: Eighty patients were part of the patience experience work that you did. Is that a good number of people, or is that a regular or low number of people for that type of work?

Ms Donaghy: I would say that the review was not typical, but, as regards engaging with the number of people, that would be exceptional. That would be a high number of people, and, as you would have noticed too, we engaged with a significant number of front-line staff. I am not saying that we have received everybody's views, but that is a significant number of people, yes.

Mr McGrath: If there was an "exceptional" number of people, in your words, and you made 10 recommendations, why does none of them relate to sections 7, 8 and 9, which deal with patients, families, staff and stakeholders? If they all engaged in the process and told you their views but you did not provide any outcomes that address the issues of the exceptional number of people who engaged in that process, they might feel a bit left out as a result.

Ms Donaghy: I hope not, because I wrote a paragraph leading into that section to say that they underpin all of the recommendations. We do not attribute recommendations to the public. The public are not accountable for making the recommendations. We listened to their experience, and it has led to all of the recommendations. I wrote a little paragraph leading into that section or at the end of it to say that you will note that none of the recommendations is directly related to patient experience, because they are not accountable for it. It should not be that that is a direct consequence of somebody telling us something. We triangulate — whatever word you want to use — information that we receive from patients and their families with clinical information, information from front-line staff. The recommendations are ours. We are accountable. We are responsible, and the public and patients have informed that.

Mr McGrath: I am not so sure that people engage in a process to be triangulated, but I think that they want to see their recommendations in the report. That was some of it.

My final question is this. If, as a result of that process, people have to move from the SWAH to Altnagelvin, that is a considerable distance and will have a considerable impact on individuals who have to be moved at some of the most difficult times in their lives. This is a small point, but I would have thought that there might be some impact on the medication that they have to take or the medication that is administered to them or the handling of their medication. Is that something that was —

Ms Donaghy: Mentioned to us?

Mr McGrath: — mentioned or discussed?

Ms Donaghy: Oh, yes. Many patients mentioned medication to us. I am reflecting the review: the important thing about patient experiences is that we wanted to hear from patients and families how they were treated, how they felt, what they observed and all of that.

In the report, we identified things that, lots of people told us, they find distressing, particularly the second wait in ED, the journey and all of that. Medication management — the prescribing and administration of medication — is unique to each individual. I understand that, sometimes, patients may have their concerns about it, but it is a part of clinical practice. It is not a patient experience issue; it is a clinical practice issue, and we would expect that to be examined thoroughly in the clinical audit programme. The management of medication, clinical decisions and the journey from Enniskillen to Londonderry are all things that may have an impact on the clinical outcome for a patient, and I know that everyone will understand that medication that is prescribed for someone will take account of their condition, comorbidities and a range of issues. That is not an experience issue but a clinical practice issue, and we would expect that to be covered in the clinical audit.

Mr McGrath: Yet the report does not mention medication.

Ms Donaghy: No, it does not mention the patient aspect of it because those medication issues are personal. Throughout the report, we mentioned the need for clinical audit. Clinical audit would cover medical decision-making and medication management. I am sorry that the report does not mention every aspect of clinical audit, but I would expect medication to be a key part of that. I am sure that Stuart, as a medic, would expect the same.

Professor Elborn: Management of medication means that there is adequate transfer of information from SWAH to the Ambulance Service to admission to Altnagelvin. That should be a routine area of audit that is undertaken in the trusts.

Mr McGrath: I will leave it at that. I worry that you say "should" when you have completed a report. The idea behind a report is to find out what happens and make recommendations, so if, at the end of it all, we leave that "should" in there, it creates the doubt that concerns people. Thank you for your presentation.

Mrs Dillon: Thank you for your presentation and for your answers.

Chair, you have covered most of it, but I want to go back to the data issue. My concern is that, if you do not have the data, how did you decide that people's outcomes would be worse? You say that people had the data, but they did not pull it out, so I have a wee bit of concern. Nobody speaks more clearly about it than I do, and nobody is on the record more than I am as saying that it is about the best outcomes for patients — if a person whom I love is sick, I want them to get what is best, not what is closest — but it is about access, particularly for people in Fermanagh. It is about outcomes. Do you expect the work to have been done by the time you meet the trust in April? Its representatives are coming in after you, so we can ask them that.

Ms Donaghy: It might be better, Linda, to double-check that with trust colleagues, but we indicated that there was a need to work at pace, and, although the report was published by the Department in late January, it was submitted to the trust in October; indeed, we gave feedback to trust colleagues and others at the end of last summer. I expect that, when we meet the trust, we will hear that there has been really good progress. There was a full commitment by the medical director and the senior team to undertake clinical audit.

Although that particular element was not available, the trust provided, for example — I know that the medical director will be here today — mortality information that it had studied, in which it had found no particular outliers. We obviously consider mortality — if people pass away — to be a very important outcome, but it is not the only one. Patient experience and staff experience formed a massive part of the work. On the basis of those two things, supplemented by the information that the trust was able to provide, which it did openly — it had no qualms about that — we made two recommendations for urgency. We do not use that term lightly. We said that, urgently, additional ambulance capacity needs to be put in place and that, urgently, the idea of people waiting twice in an ED needs redress. We have said that people are making efforts on that.

It is important to make a point on ambulance capacity. Sadly, we all hear of the pressures on ambulance services; indeed, earlier this week, I saw the Northern Ireland Audit Office (NIAO) report on them. It is important to say that, in this case, the issue of ambulance capacity serving that geography is not a pressure. It presents as a pressure, but it is a known, quantifiable, understood change in the service. People will now be seen in Altnagelvin. That generates a quantifiable, predictable increase in demand. It is not about the winter, it is not seasonal and it is not unpredictable. That is why we point out that, in the west, there is an opportunity to demonstrate that service change is followed by a change in the ability to access the new service model.

You said, Chair, that people have to be able to access the service. This is about emergency general surgery. The Minister has spoken about people's willingness to travel for specialisms. That is probably understood by some and not agreed by everyone, but this is about emergency surgery, so people will need to be facilitated and assisted to access it. The Ambulance Service has indicated that, whilst it has put additional capacity in place, that has been done very much on a goodwill basis at the moment, with crews working overtime and that sort of thing. We made that an urgent recommendation, but we did not say that it should be done in two months, three months or four months. You cannot create ambulance crews and vehicles overnight or in a week or two, but there is an urgency to the need to put in additional capacity, and that was expressed by the Ambulance Service. In its report, the Ambulance Service explains the amount of money that it spends. It also makes public its response times and so on.

None of those things is isolated from the others. The changes in the South West Acute Hospital and their transfer of the service up to Londonderry is not isolated from the winter pressures. All those things get mixed together. This matter is specific and predictable, however: it is a service change. That is why we are, to be honest, absolutely delighted that the Department has used the review from the South West Acute Hospital and the west to say that, in future, every service change must be accompanied by a post-six-month independent evaluation, rather than waiting for the outcomes at that time. As we described and discussed, the clinical outcomes would be available because, as with engagement with patients, that is already a requirement.

This is an opportunity for that work to be done. Although it was born out of crises, we are now two years on, and, although I know that it is still temporary, people rely on that service. There needs, therefore, to be a demonstration that the service model can change to adapt to a new delivery model. We are told that not every hospital will have the same service. This is an opportunity to demonstrate that. That is why people should not wait twice in ED. That is a dreadful patient experience that the Committee has seen in spades and is definitely not good for ED services. ED already operates well outside its scope and capacity, and the last thing that it needs is people coming in who have already been assessed and require hospital admission. That does not mean that it is easy for the trust to create additional bed capacity. This is a changed service model, and that is the challenge. The model will change, so we have to demonstrate that the changes effect the new model and allow people to access it.

Despite not having the clinical outcomes that need to come from audit, those two pieces, in themselves, are significant principles that must be applied to service reconfiguration. That is why we did not want to wait for the outcome of the clinical audit. We recommended that a clinical audit be carried out, and that has been accepted. We even guided on areas that might be useful to look at, such as the effectiveness of the ambulatory care unit and all those other things. Those things are important.

I know that time is short, but, if I may, I will add this. We raised an issue about immediate patient safety issues not being identified. Many people have spoken to me about that since then, saying, "I can't understand how you didn't identify immediate patient safety issues". I will tell you as quickly as I can what we mean by "immediate patient safety". When RQIA staff or anyone who engages with them go out to review, inspect or investigate a hospital, care home or anywhere else and the team there identifies an issue that puts patients in immediate harm's way, that team will not leave the site that day until it has spoken to the person in charge and pointed the issue out to them. The team expects a response that day or the next day, but it is immediate. That is what we mean by "immediate": it must be acted on immediately and with no delay. It must be done hastily.

I will give you some modest examples. If a team was to go out to a ward and find vulnerable adults who are at risk of choking and have a lack of supervision and support at mealtimes, that issue must be acted on immediately. That could not wait for a report to be written and sent 28 days later; no, that must be acted on that day, and we would want to receive assurance on that day. Other examples include environmental issues such as fire hazards, medicine trolleys that are not properly managed or medicine being mismanaged. Those issues are to be dealt with immediately. For those actions to be immediate, it must be reasonable for the trust to be able to act.

You and I know that people come to harm when they are queued up in ambulances at our hospitals or when they are in our crowded EDs, despite the best efforts of staff. It would be unreasonable for the RQIA to say, "Resolve the ambulance queue immediately". It is not within the ability of the staff to do that that day, but they must deal with related issues. For example, actions may be required in ED if there is a spill-out area, which is definitely not desirable. Are people coming to harm? Yes, but are we clear about who is in charge? Are there medicine kardexes available? Is there good infection prevention and control going on? Those are immediate issues.

We said that we found no "immediate" patient safety issues, which means that there was nothing that teams saw on the day during their observations, or in the information that they had or in the environment, that caused them to say, "That's to be resolved today". However, two issues required an urgent response, and all of the other issues required a prompt response. We have demonstrated that those need to be completed at pace. We cannot say that they must be resolved within three months or four months; they must be completed at pace. It is really important that they be addressed.

I hope that that clarifies a little bit what we meant by "immediate". Colleagues, Committee members and others have said to me, "I don't understand how you didn't find immediate issues". Those have to be addressable by the trust and must be acted on that day or the next day. There is no debate about that.

The Chairperson (Mr McGuigan): That was very clear.

Mrs Dillon: Thank you, Briege, for being so clear. We now know exactly how reconfiguration should not happen and why rural people are so terrified of it. It is not because you may not have better outcomes; it is because things that are supposed to be put in place to make sure that you have better outcomes are not being put in place. We are talking about planned service change, not collapsed services.

Mrs Dodds: Thank you, Briege. That was helpful. You said that one of the key things to come from the RQIA report was that every service change must be accompanied by a six-month post-clinical evaluation. Would it not be helpful to do some of that beforehand, in order to understand how things are going to work?

Professor Elborn: It is critical that we baseline before we introduce change and we then measure what the change affects in terms of outcomes and processes. We need a health and social care system in which data is joined up, which would mean that you could do that very efficiently. We do not have the staff or the capacity to do data management bespoke to every question. We need to find a systematic way to do it, so that we assess change in an appropriate and understandable way for staff, patients and the population.

Mrs Dodds: I think that patients and our community in general feel that the health service is so dire that there is nothing that we can do but change it. They want to know that everything is in place to make that change, as you said, workable, so that it delivers better outcomes. Doing some of the evaluation post change is a bit like closing the stable door after the horse has bolted. That is definitely a question that I will ask the departmental officials.

Professor Elborn: In that situation, the change was made, and we were then asked to do the review. We recommend that, in future, we be part of the journey, so that we get the right inputs to make the right decisions.

Mrs Dodds: Take the proposal for the Northern Trust. Those evaluations should be done before the change is made, not after. That would mean that people would know exactly what to expect or not, or whether it is possible in that context. That is helpful.

I noted Colin's questions about the terms of reference. The Northern Ireland Audit Office report this week indicated that private ambulances are not regulated in Northern Ireland. Is there is concern about that?

Professor Elborn: Yes. We recommend that they be regulated, and we now need to engage in a conversation about that. It is noted in our report but also clearly in the NIAS audit. It is important that they are regulated. They are managed by the trust in a contract, but there are no regulatory requirements, and that might need a change in legislation. We will be strongly recommending that a regulatory process is undertaken, that they are registered and that they have some quality assurance standards to live up to.

Mrs Dodds: And that it should be part of planned change.

Professor Elborn: Yes.

Ms Donaghy: Yes. Under the current legislation, as Stuart said, the only ability that the RQIA has with the private ambulances is to review, inspect or investigate, through the contract with the trusts, but we could not look at their role more broadly. Private ambulances provide services to hospitality, festivals —

Professor Elborn: Sporting events.

Ms Donaghy: — sporting events, no doubt, and a whole range of things. We could look at private ambulances — indeed, we may do if we have the capacity — and how they are contributing. There is a role for private ambulances, it seems, and we can see that it is increasing, but at the moment, they are not subject to any regulation.

Professor Elborn: The private or independent sector is growing in Northern Ireland and we are exercised by that. Right across the independent sector, we need to ensure that we have the right proportionate and appropriate regulation to ensure safety.

Mrs Dodds: Did you look at ambulance waiting times and the potential for harm? It is a long, long way from Rosslea to Altnagelvin. I know Fermanagh very well; I have family from Fermanagh, and it is a long way. It is a long way if you are waiting on an ambulance, even to get to Enniskillen from Rosslea and then knowing you have to go the other bit of the journey. Has any work been done on that and the potential for harm that it might cause to patients and how the Department looked at the rural needs assessment for that?

Ms Donaghy: We did look at the ambulance response times because they are in the public domain. The Ambulance Service also provided us with a lot of information. I did not go, but the review team visited the ambulance headquarters. It was not possible to isolate the impact of the service change in the south-west as a discrete piece on the ambulance response times. As I said earlier, it adds additional pressure, and we can see that, overall, the service pressure on the Ambulance Service is not abating. However, it was not possible to extract the direct implication of it, so we did not go into that level of detail. I suspect that the Ambulance Service would be well able to give an indication of what impact it is seeing on the ground.

Mrs Dodds: Thank you. A bit of clarity for that would be helpful as we progress to talk about potential change. I hope that the Department takes that up as a principle for change.

The Chairperson (Mr McGuigan): I should declare an interest as someone who fell off my bike in the middle of a race and broke three ribs and a collar bone, I made good use of the private ambulance service that day.

Before I go to the next member, I want to ask, because there has been a bit of conversation about ambulances, has the RQIA, itself, considered any contingency measures should the Ambulance Service at Altnagelvin become overwhelmed?

Ms Donaghy: Contingency in what respect, Chair? The RQIA's role with regard to the HSC system is relatively modest — and I know that I use that word too much. Much of its endeavour is around registered services. The trusts, including the Ambulance Service, are subject to a statutory duty of quality. They are accountable for the quality, the commissioning and all of those services to the Department of Health. The RQIA's role is to go in and shine a light on issues to help inform the Department. Maybe I am not understanding the question properly. I would be happy to get more clarity on that.

The Chairperson (Mr McGuigan): As regards shining a light on a problem that may well be encountered as a result of the change, as a layperson, I can envisage an already under-pressure Ambulance Service becoming increasingly under pressure. Given your role and your recommendations, have you considered what should happen in those circumstances?

Ms Donaghy: We would have a concern about the implications for patient outcomes if the recommendations were not acted upon. Despite the fact that the responsibility for taking the actions lies between the trust and the Department, RQIA has an independent role, and should we be concerned that those issues had not been addressed, we could use our role to investigate, inspect and shine a light on them.

The Chairperson (Mr McGuigan): OK, fair enough. Thank you.

Mr Donnelly: The evidence so far has been really useful. It was great to read the report, the detail, the considerations — everything that is being put into this. We are in a time of change. Our health service is going to change. We know that we are going to have to manage change over the next couple of years. It is useful to have that baseline provided beforehand and the independent evaluation six months afterwards. We now have a change structure.

Having been a nurse — that is my background — I am very familiar with the RQIA. I know the levels of risk that you look into and the things that you do to keep patients safe. That is absolutely the right thing to do. I was surprised to hear that private ambulances are not regulated. I was not aware of that. We should look at that, because private ambulances transfer sick patients from hospital to hospital on the road network .

How is somebody assessed at SWAH before they are transported up the road to Altnagelvin, and how is that information passed between SWAH and Altnagelvin?

Ms Donaghy: You are taking us out of our comfort zone a wee bit, although I have knowledge from colleagues who have attended and visited South West Acute. My understanding is that, when patients are assessed at South West Acute and accepted for admission to Altnagelvin, from the point of transfer, they are under the care of the surgical team at Altnagelvin. To be perfectly honest — unless, Stuart, you feel differently — the trust would be much better at giving you the detail of that. I, personally, was not out looking at that. It was clinical staff who went out and assessed it, and they were satisfied, I have to say, with the assessment methodology. You will see in the report that compliments are paid to the work done in the ambulatory care unit in Enniskillen, so much so that the review team recommended that it should be further assessed and that the success of its retaining people in the south-west area should be looked at. However, I would prefer if you would be kind enough to ask the trust for the detail of how people are assessed and triaged and how decisions are made.

Professor Elborn: We are moving from paper-based handovers —

Mr Donnelly: That is where I was going.

Professor Elborn: — to digital handovers with Encompass. Encompass will follow the patient or the patient will follow Encompass — whichever. A digital record will be accessible, and, as soon as a patient leaves SWAH to go to Altnagelvin, the staff at Altnagelvin will be able to see all that data.

Mr Donnelly: The report highlights the communication between emergency departments, wards and hospitals. Encompass certainly should improve that, but the Committee has heard time and time again, "Encompass should improve that".

Professor Elborn: Encompass is not the whole solution, but it is a big part of it. Encompass will track with the patient, but we still need to join up other data inputs such as NIAS data. Does that data align? Does it help us to understand why there are delays? There is a lot of work to be done, but we are moving into an era when we will have a strong base to do it, because we will have patient information across the whole system.

Mr Donnelly: I totally agree: the more information we have, the more we understand what is happening in the system.

Recommendation 6 mentions palliative care and end-of-life patients. At what point would end-of-life patients be transferred between hospitals?

Ms Donaghy: Again, you will have to ask colleagues, but end of life does not mean end of care. Someone who is facing into end of life may still require some type of intervention for comfort, pain relief or a range of other things. I know, from speaking to trust staff — I think that we reflected this — that the trust had been looking at alternatives to the transfer of, for example, patients who came from a care home after a fall or from palliative care. There may be circumstances when patients do not need to transfer, or when those who do need an intervention have it, return as early as possible to South West Acute. However, again, I am not clinically qualified, so I would prefer the medical director to answer those types of questions.

Mr Donnelly: Given the sensitivity of the situation, I absolutely agree. That is great. I am happy with that. Thank you very much.

Mr Robinson: Briege and Stuart, I do not claim to be an expert on the issues around SWAH, but I am aware of the Save Our Acute Services (SOAS) lobby group. It appears to me, as an outsider, that that group has fought admirably for the services, a bit like the lobby group in the Causeway area that is fighting for the retention of emergency general surgery. I had sight this morning of the SOAS response to the RQIA report. It would do the group a disservice if I were to say that it savaged the report. That would be wrong. SOAS has used language such as "flawed". Have you sat down or do you intend to sit down with representatives of that group to address their concerns? I have the SOAS conclusion here. I do not want to publicly embarrass you both, but some of the comments are savage. It might be beneficial if you were to meet the group in order to bring clarity and smooth out any issues that it has.

Ms Donaghy: Absolutely. I have met members of the SOAS group many times. I met them a few weeks ago. After the report was published, they kindly came up to the RQIA headquarters, as they have done several times. We spent a couple of hours together. Dr Miriam McCarthy and I met Jimmy, Helen and Father D'Arcy. They were, as always, really respectful, and provided us with lots of information and evidence. They have done a huge amount of work. We have huge respect for SOAS and other lobby groups. Those people put a huge amount of time into all of it.

I know that SOAS does not agree with our report. I received the group's formal response to our report yesterday. I absolutely will meet its representatives. I email Helen and Jimmy two or three times every week. We are not covert in any way. We accept that others do not necessarily agree with our findings. I have tried to say to the SOAS group, "I can understand your concerns. We absolutely understand all the things that you have said, but we want to make sure that evidence is made available to you to let you make a decision about this". We have no difficulty with people making claims about wanting to keep a local service. People hold those views. It is important that we now put the evidence in place so that people can be assured. It is about assuring not only the campaign group but, as I always say, the "quietly concerned", who do not campaign and just sit at home and worry about it. It is important that we put the evidence into the public domain, be that through boards, infographics or whatever, and make it available in understandable language. People will ask, "Is my outcome going to be every bit as good as that of somebody from Strabane or Londonderry, despite the difficult journeys? What are you doing to make those difficult journeys in ambulances from Rosslea or wherever better, more sustainable and more comfortable?".

We say this back to SOAS: let us look at the evidence. We know and respect your point of view, but let us look at the evidence and what it says.

Mr Robinson: I am glad, Briege, that, earlier, you brought some clarity on the terms of reference. That was one of my questions, so I am glad that you clarified that to Colin. Thank you. I welcome the fact that you intend to meet SOAS.

Ms Donaghy: Absolutely. I have no difficulty with that.

The Chairperson (Mr McGuigan): Briege and Stuart, thank you very much for attending and taking our questions. It has been helpful.