Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Dr Tomas Adell from the Department of Health, and Dr Brendan Lavery and Mark Gillespie from the Western Health and Social Care Trust. I note that neither of you is chief executive or chair of the Western Health and Social Care Trust. That is disappointing from the Committee's point of view. Although we did not specify who was to attend, I would have thought that it is normal practice on such an occasion that we would have the chief executive here. Having made that comment, I hand over to you to give an outline of your report. Then we will take questions from members.

Dr Tomas Adell (Department of Health): Thank you for inviting us here today. I know that the Committee is over time, so I will cut down my opening remarks as far as possible. I apologise if I miss anything, but, of course, we will be happy to clear it up at the end. I will try to address proactively some of the things that the Regulation and Quality Improvement Authority (RQIA) has said. Hopefully, that will focus our discussion.

I want to mention a few things first. The RQIA carried out the review for a specific purpose: to look at the pathways developed in response to the temporary withdrawal of emergency general surgery from South West Acute Hospital (SWAH). The review is not about the decision on temporary withdrawal itself. That is important to note, as you know already. I also want to recognise that every statistic that we talk about is a person — a patient — who is sick and needs care. Emergency general surgery patients are often sick patients who require serious surgery. Even an appendix operation is serious. It is not just a bruise; it is much more. We and our trust colleagues recognise that.

What happened at South West Acute in 2022 was the collapse of a service due to staffing pressures. It is not the way to do a service change. We all recognise that. It is not in line with departmental guidance or the Bengoa principles on changing a service. The pathways were put in place quickly in response to a temporary change that had to be made because of staffing pressures. If we had planned to change the system, we would, of course, have planned things better. We would have done reviews beforehand. Diane, I absolutely recognise the point that you made about the way that it should be done. One way is to make a temporary change, but that is not always possible. However, a post-change review, whether the change was temporary or planned, is always helpful, because we can always learn to do things better. It is good to identify whether what we expected to happen did happen. You mentioned the Northern Trust. If it goes ahead with a change, it will be really helpful to know, six months in, whether its assumptions were right or whether there have been unexpected consequences. One of the big system learnings from the RQIA report is that it is really helpful to have an independent review after a temporary or permanent change of any significant size. RQIA has done that well for us here.

The review was commissioned by the Department. We wanted an independent assessment of the pathways in order to provide assurances about patient safety. We did not commission the review in response to particular safety concerns — we were not aware of patients' negative outcomes; we wanted independent assurance 12 or14 months after a temporary change. That is why we have the report that we have.

I am happy that the RQIA addressed the terms of reference. There has been no change to the terms of reference. Indeed, it would be inappropriate to change the terms of reference of this kind of review. The RQIA is independent. I also want to assure the Committee that the Department has not sought to change the view of the RQIA or, indeed, the contents of the RQIA's recommendations. We would not do that. The RQIA is an independent body, and we want to hear that independent voice so that we can respond. The inaccurate narrative is not helpful, and we stress that that is not how we operate. We accept all the recommendations in full. Some of the recommendations are easier to implement than others — that is the reality — but we accept that they need to be implemented.

I will not address the emergency general surgery situation in any detail. We could spend hours on that topic, and I will be happy to do so at another time. However, it is important to note that the key aim that we are trying to achieve at all times is the best patient outcomes. None of us here would want to do anything that impacts patients negatively. That is really clear. We want to see the best patient outcomes. In emergency general surgery, that means that we must have the best surgeons available for patients. That is the key thing. Patients sometimes have to travel to see a surgeon to get the best patient outcomes. The delay in ambulance handovers can have an impact. Academic research shows that the travel time to see the right surgeon is less impactful on patient outcomes than seeing the wrong surgeon. It is more important to see the right surgeon the first time. That is better for patient outcomes, and my trust colleagues can talk about the evidence for that in the Western Trust specifically.

That is a quick summary of what I intended to say. Hopefully, you will take it in good spirit that I am trying to make sure that there is as long a time as possible for questions.

The Chairperson (Mr McGuigan): Thank you. We agree that, whatever we do, it should be about the best patient outcomes. Obviously, you are going to say that, and that is accepted. I am also glad to hear that you have accepted the RQIA recommendations in full. How are you getting on with implementing those recommendations? You will have heard our conversation with the RQIA. How are you getting on with implementing the recommendation on the double emergency department (ED) waits? It is of major concern that people are waiting in EDs twice, before travel and after travel. How are you getting on with the recommendation on increasing the number of ambulances? My questions have a particular focus on those two recommendations, but how are you getting on with all of them?

Dr Adell: RQIA has, as always with these kinds of reviews, kept the Department updated on progress, so we were aware of what was going to happen. Work started well before the final publication of the report. We would not sit back and wait on the publication of the report when we know that work has to happen. I will hand over to my trust colleagues, who can talk about the double waits much more confidently than I can.

Mr Mark Gillespie (Western Health and Social Care Trust): I am happy to pick up on where we are with the recommendations. As Briege Donaghy said in the previous session, she will be meeting the trust board and receive an update, particularly on those recommendations. From a trust perspective, we have made good inroads on some of the recommendations. We are right to recognise and acknowledge the double ED waits. Pre May last year, 24% to 25% of patients went directly to a bed in Altnagelvin. From a patient-experience perspective, that was not what we had wished for. In May last year, we reset our systems. Since then, as a result of the temporary change that has been in place, 79% of patients go directly to a bed.

More fundamentally, it is important to acknowledge some of the other improvements that we have made around clinical audits, which Briege also talked about. Ambulatory care is a new system and process that is directly linked to good diagnostic services. Patients like it, because they do not want to be admitted to hospital. At the juncture of the temporary change, we put in place ambulatory surgical assessment at South West Acute Hospital and Altnagelvin Area Hospital, because that would help us to be more efficient with the resource that we had.

Through that clinical audit work, we have developed pathways for patients, who now do not necessarily need to come to Altnagelvin for their surgical care. We can book them into the overnight elective-stay centre at South West Acute, which, again, is more efficient and alleviates some of the pressure at Altnagelvin. We have worked through that. On patients presenting with other complaints — for example, patients with a head injury who require not surgical intervention but a period of observation — we are working with the South West Acute team to have them managed there. We have developed a repatriation pathway, because we recognise that it is better for a patient who is undergoing surgery to be rehabilitated closer to their family. That repatriation means that their family will not have to make a prolonged journey. At the end of the acute onset of surgery, we can repatriate those patients back to the South West Acute to have physio, OT and the remainder of their care in an environment that is closer to their home. As I said, we have replicated the ambulatory care at South West Acute Hospital.

Briege talked about communication — the relationship and handover. There is regular communication between the doctors in South West Acute and those in Altnagelvin. There is also an opportunity, at the end of a day, for a safety huddle, which is a virtual meeting between the consultant in Altnagelvin and the team in South West Acute Hospital to discuss any outstanding concerns that they have had on that particular day. It is important to note that, as part of the surgeons' monthly review meeting, the emergency department consultants can come along and look at the progress on the individual pathways. It is also important to note that, in the review, there are recommendations on middle-grade doctors, which are the junior-grade doctors working in surgery at South West Acute Hospital. I am pleased to say that all those positions have now been filled on a permanent basis. Those doctors will rotate to Altnagelvin, and Altnagelvin doctors will rotate to South West Acute. That will give us more resilience in the system.

I come back to the direct-to-beds piece. From December 2022 until 31 January 2025, 1,958 patients were admitted to Altnagelvin as a result of the change in service. In ambulatory care, over the same period, 1,898 patients had their care at South West Acute Hospital, so it is really important that we build that service, along with the consultants who will work as part of the elective overnight stay service.

We have an excellent working relationship with the Northern Ireland Ambulance Service (NIAS). Indeed, often daily, we have conversations with NIAS about how we and they can best use the resource from a private provider. When a patient has to stop in the emergency department, we have a process whereby that patient is prioritised for offload to allow that Northern Ireland Ambulance Service vehicle to go back to the southern sector to serve the needs of the population there.

We have taken on a number of pieces of work as a result of the RQIA review and recommendations. We report on that work regularly to the trust board. We also report to our programme board, which is overseen by our chief executive and has service users on it.

I want to pick up on patient experience, because the insights that patients can give us on the services that we deliver are key. Pre the change, we engaged Care Opinion, but we pretty much left it to patients to approach us with areas of concern. Since the review, we are now more purposeful in seeking those patient experiences. Each patient who has come through that pathway will be written to and asked to provide us with information on their experiences. That, again, will be formulated in reports to the programme board and the trust board. A number of the actions are well advanced, and we will report on those to the RQIA when it meets the trust board.

The Chairperson (Mr McGuigan): That was comprehensive. For clarity: on the double ED waits, I think that you said that, in May, it was in and around 24% or 28% —

Mr Gillespie: Yes, 25%.

The Chairperson (Mr McGuigan): — but it is now 79%.

Mr Gillespie: Yes, 79%.

The Chairperson (Mr McGuigan): Will it become 100%?

Mr Gillespie: That is a good question, because —

The Chairperson (Mr McGuigan): I like to ask good questions. [Laughter.]

Mr Gillespie: — we are dealing with the clinical priority of patients. Patients at Altnagelvin may well have a more significant clinical priority to require access to a bed ahead of somebody in South West Acute Hospital. That is a clinical decision that is made by the consultant or the senior doctor on the day. We have made huge strides on that and continue to have daily oversight of it. To break it down into numbers: as a result of the change, we are now talking about 2·5 patients per day not going directly to a bed; across the week, about 3·5 patients do not go straight to a bed. We will continue to focus and work on that.

The Chairperson (Mr McGuigan): I go back to the point that Tomas made, and that I elaborated on, about patient outcomes. I cannot remember whether it was Belleek or Derrygonnelly that Briege mentioned, but she said that the people of Fermanagh want to know if, with having to travel, their outcome will be the same as that of someone from Derry. You will have heard me asking questions on clinical outcomes. When the report came out, both trusts, in a joint response, said that you had looked at outcomes. Briege said that there was a bit of a gap in the information that was provided to the RQIA. Two years after the collapse, are the clinical outcomes for the people of Fermanagh the same as they were prior to it?

Dr Brendan Lavery (Western Health and Social Care Trust): I will give you quite a long answer. The good news is that the outcomes are actually better. We use a company called CHKS, which analyses the admissions across every trust in England, Wales and Northern Ireland. CHKS looks at every admission — thousands of admissions — and does a statistical analysis of age, sex, comorbidities and the diagnosis that the patient was admitted with, using 260 categories of diagnoses. CHKS uses all that data to generate a risk-adjusted mortality index (RAMI), which is the number of deaths divided by the number of expected deaths. Effectively, the baseline is 100, so, if the figure is more than 100, that means that more patients are dying than would be expected. If the figure is less than 100, you are doing well. At the time of the temporary suspension, the figure for the South West Acute was 110, and the figure for Altnagelvin was 85. We got the figures in July or August last year. Effectively, the RAMI scores for Altnagelvin have continued to fall — to the extent that, if you extrapolate the data to look at mortality rates, you find that, due to the change that we have made, every 40 days, one patient survives who would not have survived.

The Chairperson (Mr McGuigan): OK.

Dr Adell: To clarify, Briege was talking not about knowledge of outcomes of the service but about knowledge of the differential outcomes of patients in the service. There is a big difference between those two things. That is the mortality index. The outcomes for patients who need their appendix taken out, for example, are good in Altnagelvin. We know that, because the trust has readily available information. Briege's comment was not about the quality of the service in Altnagelvin. It is a subtle but important distinction.

Dr Lavery: We have looked at every metric that we can. We have looked at postcode and GP registration. The Public Health Agency (PHA) has independently reviewed the information. There is no adverse outcome for patients who live in that area. In fact, the early information shows that, if anything, the outcomes are better. It all fits with the fact that, if you are operated on in a centre that has a higher turnover and more experienced surgeons who see these things daily, you get better outcomes. It also fits with the review of emergency general surgery, which was effectively about safety standards. The review looked at all the things that are needed on a hospital site to provide the best care.

The Chairperson (Mr McGuigan): I am a wee bit confused. That is an answer that everyone would want to hear, but you heard Briege's answer to my question. I am concerned about why she said that she did not get data that you have said is extremely positive. Can you elaborate on that?

Dr Adell: Some of it is to do with timings.

The Chairperson (Mr McGuigan): OK.

Dr Adell: When the review was carried out — most aspects were carried out before or during the summer — the data was not as easily available as it is now.

Dr Lavery: It takes a while for the company to generate the data and the outcomes, because it is a lot of work.

The Chairperson (Mr McGuigan): That answers my question.

Mrs Dillon: I will follow on from what the Chair asked. I accept what you say, which is that a patient who makes it to Altnagelvin and has surgery in a timely manner will have better outcomes. That is good. That is where we want to be. I want to be clear about that. For absolute clarity, however, is the data that Briege mentioned available on the overall picture? Will it be made available to RQIA at the meeting in April? Can it be made available to the Committee?

Dr Lavery: That data has been made available to RQIA, and we can certainly share it with you.

Dr Adell: There is a bigger piece around communication of the data. We have talked about communication many times. One of the challenges about communicating very detailed data is that the numbers of patients are quite small. If we break down the data too far, it is difficult for us to share the information, because the number of patients is too small. If you talk about 2·5 patients being transferred a day, and if you break that down by procedure, the patient becomes identifiable. That is a challenge for us: how do we tell that story without giving away too much? I hope that you understand what I am trying to say.

Mrs Dillon: I do. I am probably still confusing things. Briege seemed to think that RQIA did not have the data. It would be helpful if the Committee could get that data, because, as the Chair said, better outcomes are what we are all about.

Can we get some data on increased ambulatory capacity and what you would like to reach to make it a really positive picture in which people in Fermanagh get an ambulance absolutely when they need one in order to make it to Altnagelvin? I would like to get that data. You may not have that sitting in front of you today, but it is important for us to get it for our information.

Chair, other members want to ask questions, so I am happy to leave it there.

Mr McGrath: Thank you for that information. It is fairly obvious, though, is it not? If you have a team in Altnagelvin and a struggling team in the SWAH, and if you move all the staff onto the one site, they should provide a better service. That is good, but it is the collapse of a service. There is nothing that you can do about that. It is not good news that the outcomes are better: it should be expected. If we closed down all the hospitals in Northern Ireland and built one on stilts in Lough Neagh, as it was always put to me, with six roads, one into each county, you would expect the best of everything from that hospital, because everybody would be working in it.

That good outcome is to be expected, and it is welcome, but the challenge, fundamentally, is to get the two sets of staff teams, one in the SWAH and one in Altnagelvin, to provide that outcome. That is the challenge. That is not about the management of the trust at the minute; it is down to our long-term management and the fact that we may not have gone through transformation and do not have the number of staff that we need.

The Department issued a statement from the Minister that stated:

However, the actual line in the report is:

Will the review need to go to a second stage to get more data in order to find out what is happening? It feels like a wee bit of spin, does it not, to give half a sentence — the good bit at the start — but leave out the second half, which says that all the data was not available to give the determinations.

Dr Adell: As Briege identified, some data was not readily available to RQIA during the data-gathering phase. That data is more readily available now. That is one thing that we recognise in the departmental response. As Briege also noted, however, a lot of other things were available. In all that other work, RQIA did not, in any conversation with us, say that it had identified any patient safety concerns. It is not spin. We have not identified patients having worse outcomes in any part of the review: that is what RQIA told us. Yes, there are gaps in the data. We recognise that — that recognition is in our response — and that is why we accepted the recommendations. At no point, however, have we been aware of things that have resulted in patients coming to harm. The fact that there were gaps was one of the core reasons why we asked RQIA to do the report for us in the first place. It identified things that we could monitor better, it identified NIAS pressures and it identified the fact that we could engage better with patients, but it did not identify negative patient outcomes: that is a fact.

Mr McGrath: I would not expect it to find major issues, but I do not accept the principle of what you are saying. If there were three living people and three dead people in front of me, and I saw only the three people who were alive, I could say that, clearly, from the evidence in front of me, nobody is dead. If I were to turn to the other side and see the three dead people, however, I would have a different perspective. You may say that you can make a determination, from the data available, that there were no negative outcomes, but you cannot say with confidence that there might not be some negative outcomes, because that is not all the data: we have not seen all the data. The data is increasing, as it becomes available, but my point is about your putting the emphasis on everything being grand and rosy.

Dr Adell: I do not accept that we said that everything is grand and rosy. We accepted the 10 recommendations of the report. It is clear, from our acceptance of those recommendations, that we accept that improvements are required.

RQIA also looked at Datix incidents, serious adverse incidents (SAIs) and complaints. It did not look at only one thing; it looked at many things. It conducted site visits, spoke to staff and looked at the pathways that were in place. It did not identify immediate patient safety concerns through any of that work. That is what RQIA told us. RQIA did not tell us that it thought that patients were coming to harm. We have not heard that. Not once did RQIA tell us that. That is —.

Mr McGrath: That would not necessarily be the case. RQIA may not have found something immediate — we can have another conversation about that — but the fact is that it used the language of "limited data available". It refers not to the data that was available but to the "limited" data that was available. It produced its report based on limited data. Now, based on its report, which is based on limited data, you are saying, "There is nothing to see here". From purely factual extrapolation, given that only limited data was available, other data could exist that may indicate problems.

Dr Lavery: I will interject there, Colin. To be fair, we were unable to give the RQIA all the data that it wanted, but we gave it the vast majority. There is some that we could not provide, because there are two separate computer systems. A Symphony system is set up in Altnagelvin ED and one in SWAH ED, but those systems do not talk to each other; everything has to be done manually. That is how it is. It is the same in every other hospital in Northern Ireland, and the Western Trust is no different. Once Encompass and Epic are in place, that process will be seamless. We are 50 days away from that happening. We will have better data at that stage.

I can reassure you, however, that we have a weekly meeting of what we call the rapid review group. Basically, any staff member — porter, consultant, nurse, junior doctor, nursing staff, allied health professional (AHP) and everyone in between — can raise an issue of patient safety. It is a very simple thing to do: it takes literally two to three minutes to enter that information. That is then reviewed weekly. I chair the meeting of that group. There are staff from all disciplines and all of our hospital sites at the meeting. We look at those issues weekly, and then, if we see something that we are worried about, we escalate it to SAI status. We are yet to find a single patient, even following SAI investigations, for whom the outcome has been different due to the temporary withdrawal. That is very reassuring.

Mr McGrath: Can I —?

Dr Lavery: Looking at that from the micro point of view, we also have mortality data. Looking at the population data, we see no evidence that the temporary withdrawal has adversely affected the population in the south-west.

Mr McGrath: I welcome your saying "vast majority", because there is a world of difference between your referring to the vast majority of the data and the report from the RQIA saying that there was "limited data". Those are not close words.

Dr Lavery: It was not complete. [Inaudible.]

Mr McGrath: It is a massive difference. There is an opportunity, when the next raft of information comes through, for the information to improve.

Finally, you mentioned the fact that no serious adverse incidents were found as part of that. There were, however, 29 adverse incidents and four SEAs — those are significant event audits; that was a new one on me. Is a significant event audit the same as level 1 of a serious adverse incident?

Dr Lavery: It is an SAI. It is simply a lower level SAI. What we want to do with a lot of those is to get answers quickly. What we frequently do is that, if we get limited information, we want to know more information and want to do it properly, especially given the oversight from the public and various groups. We want to investigate it properly. If anything is found, that will then be upgraded to an SAI.

Dr Adell: It is important to note that those patients are really sick. There will be patients who do not have the outcomes that we want them to have, not because the services are wrong or because anything goes wrong but because they are really sick patients.

That is why it is right to investigate, it is right to examine and it is right to explore. That does not mean that there was something wrong that caused the outcome in the first place. We have to recognise that.

Mr McGrath: It does not mean the other way either.

Dr Adell: No, it does not mean the other way either, but we cannot assume that, just because there is a negative outcome for the patient, that is because something was wrong in the patient's care or in the system that looked after the patient. It is two separate things. We cannot assume that it is right either. Absolutely.

Dr Lavery: Again, to extrapolate on that, unfortunately, by the time some patients arrive in an emergency department, they are destined to die. It does not matter what services you have on-site; it is simply down to the illness process that they have. It does not mean that we do not investigate though. We have to have an open mind for all the patients to see whether there was something that we could have done better.

Mr McGrath: Chair, I will leave it at that. Perhaps we could get a written update, because I know that I am taking up too much time. I submitted a freedom of information request to the Ambulance Service, which showed that there were 97,000 upgrades of people's conditions getting worse while they waited for an ambulance, and, in some Fermanagh postcodes, it was about 5,000. Can we check to see whether there are connections between the Department and the Ambulance Service, given that some of those 5,000 could be waiting because the ambulance is up at Altnagelvin delivering people? We could do that separately with the Ambulance Service but on that same issue.

Thank you for your answers.

Mr Donnelly: I appreciate the fact that this is coming from a service collapse point of view, and we are doing all this because of a service collapse. However, it is very heartening to see that the clinical outcomes have improved. Re-forming and reorganising a service can lead to better clinical outcomes for patients.

You mentioned that the RAMI for SWAH was 110 before.

Dr Lavery: That was at the time of the temporary suspension in December 2022.

Mr Donnelly: The figure for Altnagelvin was 85.

Dr Lavery: Yes.

Mr Donnelly: After amalgamation?

Dr Lavery: At the same time, but we continue to monitor it. We have figures for up to one year afterwards. I am looking for further one year figures, and they are continuing to fall.

Mr Donnelly: What is it now?

Dr Lavery: We do not have those figures.

Mr Donnelly: Is it less than 85?

Dr Lavery: It is less than 85.

Mr Donnelly: So, it is continuing to improve.

Dr Lavery: Yes. Again, that is probably because we have a much bigger surgical cohort, things are centralised, our rotas are better and, basically, things are happening a lot more quickly because of the number of staff that we have.

Dr Adell: The review of general surgery identified those things in the "burning platform" element at the start of the review. General surgery has changed massively. There are workforce challenges, sub-specialisation, different patients needs and realistic patient [Inaudible.]

The result of that means that we have many small services, and it is difficult to maintain the good outcomes that we want. The burning platform of the review of general surgery recognised in the standards that there would have to be service change.

It was unfortunate that the SWAH temporary suspension happened six or seven months after the publication of the report, before we had thought about how it could be done proactively, whether through change or reconfiguration, and what that would look like. It is much better to have it planned, but it was clear from the review of general surgery that maintaining the status quo of eight sites at that point was not possible with how general surgery has developed as a speciality. That was very clear in the review of general surgery. There had to be a service change, which would lead to improved patient outcomes.

Mr Donnelly: The one that you mentioned is that, every 40 days, one patient survives who would not have done.

Dr Lavery: That is extrapolating from that data.

Mr Donnelly: It is phenomenal to think that patients' lives are being saved because of it.

Colin asked a question that I wanted to ask about adverse incidents. One thing that struck me was when you said that there would be better data after the introduction of Encompass. That is not quite our experience. It generally takes months to get data after Encompass. It tends to slow down completely.

Dr Lavery: Perhaps to go back to what you brought up when Briege was here, medication is seamless. There will be no photocopied notes and nothing handed over. We fully expect that the number of patients who get an unexpected allergy will vanish, because we will have electronic notes. I have to be honest: Encompass should improve patient care. I am hopeful, although it has not come to the Western Trust yet.

Mr Donnelly: You cannot give a patient the wrong drug, because you are scanning the drugs, which is quite a good system.

Dr Adell: I think that it is the system-level data that we are all struggling with. Individual patient data should be seamless between hospitals. At that level, it would certainly improve fairly quickly. System-level data will be challenging. We have talked about that before.

Mr Donnelly: I have one last thing before you go. You mentioned something that I did not quite appreciate. When somebody finishes the acute stage of their surgery in Altnagelvin, they are going to be —.

Mr Gillespie: There is an opportunity. If their surgical journey is completed in Altnagelvin, but they need more rehab, there is no need for those people to stay in Altnagelvin Area Hospital. They can go back to the South West Acute Hospital and have their care —.

Mr Donnelly: They have their surgery —

Mr Gillespie: They have their surgery. They get over their surgery, and then they go back.

Mr Donnelly: — and they will be taken back to SWAH for rehab. They will still be doing that at SWAH, will they? Those patients will still be there.

Mr Gillespie: Yes.

Mr Donnelly: That is great.

Mr Gillespie: An important point, to pick up from what Brendan said about the outcomes piece, is that we have a very stable consultant workforce now in Altnagelvin, which we probably have not had for a number of years, both at consultant and middle grade. We have no agency locum doctors in that workforce, which, from our perspective, is really positive. We have specialities in colorectal, general surgery and upper gastrointestinal (GI). From our perspective and that of the population whom we serve, that is crucial in delivering outcomes for patients. It is a really positive piece for the service.

Mr Donnelly: Thank you very much.

Mrs Dodds: That is a really great segue into the question that I will ask. There seems to be a bit of a delay between the publication of the RQIA report and some of the measures that you have implemented that are part of the recommendations of the report. Is it possible to get the information that you gave to the Committee? It would be really useful.

Mr Gillespie: A comprehensive action plan was developed in-trust as a result of the RQIA review and its recommendations. As a trust and as a team, we had been working on those well in advance of the publication of the report. Excellent progress has been made in the vast majority of areas in the recommendations.

Mrs Dodds: It would be really good to get that update so that we can monitor the situation. There is no doubt that we will come back to it. Tomas, for you, I could not stop.

One of the things that Briege said, clearly, is that some of the issues that are the recommendations of the RQIA report and in the post-six-month evaluation of change could be done and that the evaluation of change could be done before the change is made, if it is planned change. Can you give us a guarantee that that will be a principle of the Department going forward?

Dr Adell: You know that it is very dangerous for me to give absolute promises.

Mrs Dodds: But I would love that, Tomas.

Mr Robinson: So would I.

Dr Adell: I will give you as close to an absolute promise as I can give. Yesterday, I wrote to the director of planning and performance to propose some updates to the guidance entitled, 'Guidance on roles and responsibilities — Change or withdrawal of services'. That would include exactly what you ask for: planning beforehand, having clear metrics and a post-change review six months later, with a number of principles setting that out. That is what the Minister has agreed to in the published departmental response. We are currently working on the exact details to make sure that we word it correctly.

That is as close to a promise as I can make. I am happy to come back to the Committee in, say, two to three months' time, because, by then, we should have concluded that process and be able to tell you exactly what we are doing. In some shape or form, yes, we will do that, but we are working on the exact form to make sure that we get it right and cover all areas. That guidance on change or withdrawal of services covers all HSC bodies in healthcare and social care. We want to make sure that we word it correctly and that we can use it across all services, regardless of what they are, for changes covered by that guidance. As a principle, yes: but, in practice, give me a few months to work out the practical details and come back to you on it.

Mrs Dodds: I hope that that is not a politician's answer, Tomas.

Dr Adell: You know that I tell you the truth. I am telling you how it is.

Mrs Dodds: I know that. I have known you for a while.

Dr Adell: I cannot promise you something that I have not completed. In principle, absolutely. The Minister has set that out in his response. Therefore, in principle, yes: in practice, we need to work out the details of exactly what it will look like.

Mrs Dodds: I will tell you the reason for my asking those questions. Alan and I had a meeting with the Northern Trust about the proposal to move emergency surgery from the Causeway Hospital to Antrim. During that meeting, it transpired that, although extra beds would be needed in Antrim, nobody knew how they would be created. On that day in November, 25% or 26% of the beds in Antrim were being used by people who were fit to go home. Nobody had any idea of how we would get them home because of the lack of care packages. We all know about the issues with flow and how one particular issue has ramifications for another. There was also the issue of ambulance waits to take people from, potentially, Causeway Hospital to Antrim. No one could answer our questions about how those ambulance waits would be avoided. If you are planning for change and telling people that things are going to be better, it is really important that you are able to tell them that all the services are in place to make things better.

Dr Adell: I could not agree more. There are regular meetings between officials in the Department and the Northern Trust to work out exactly what it will look like, before any proposals are made to the Northern Trust board.

Mrs Dodds: Can I assume that the delay in the Northern Trust's publishing of its evaluation of the consultation is due to that process?

Dr Adell: Is it delay, or is it a process to make sure that we get it right? I would not necessarily use the word "delay"; it is a process to make sure that we have the right things in place so that change can happen safely. We would never support a change if we do not think that it is safe or if we do not think that it will provide better outcomes for patients. That is the core of what we do.

Mrs Dodds: I do not think that any of us is arguing about better outcomes for patients. We all want the best for patients. My argument is that the proper services must be in place to make that possible.

Dr Adell: We could not agree more.

Mrs Dodds: So far, I have not seen that. The honest truth is that we are playing catch-up with the SWAH, are we not?

Dr Adell: We agree. If the Northern Trust came forward with a proposal to make a service change, that would go to the trust board. The Minister would then have to approve the trust board's decision. The recommendation is that the Minister would not approve such a proposal unless those questions have been answered and it can be shown how it would work. It is as simple as that.

Mrs Dodds: Thank you. We will revert to the issue in a couple of months.

Dr Adell: I heard clearly that you want updates on implementation. How frequently do you want those? We can then plan in advance and make it easier for all of us.

The Chairperson (Mr McGuigan): Every three months?

Dr Adell: We will plan to write to the Committee every three months with implementation updates until we are satisfied that it has been fully implemented.

The Chairperson (Mr McGuigan): OK. Thank you very much, Tomas, Brendan and Mark. I appreciate that. It was very useful.