Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Tracey McCaig, chief operating officer of the strategic planning and performance group (SPPG), and Lisa McWilliams, director of strategic performance in the SPPG. I will hand over to you for some introductory remarks, and then we will ask you questions.

Ms Tracey McCaig (Department of Health): Thank you very much, Chair. I appreciate that.

Good afternoon. I know that you have had a busy day, but thank you for the invitation —.

The Chairperson (Mr McGuigan): I apologise for the length of time that —.

Ms McCaig: That is fine. We know how these things work.

Thank you for the invitation to update the Committee on the Department's response and plans to ensure that the Belfast Trust implements with pace and urgency its action plan to address the recommendations set out in the independent review of cardiac surgery by the expert panel. At the outset, I convey to the staff and those who have used or will use that critical regional service that we have heard you and that we will continue to listen.

We are appalled that staff have had such an unpleasant experience. I do not recognise that as the Health and Social Care (HSC) service that I have dedicated my time to. The findings are absolutely unacceptable, and the Minister and the Department clearly articulated that previously. I acknowledge that, in recent years, there have been recorded issues in the cardiac surgery service relating to good relations and culture. In response, the trust invited an external review by the Royal College of Surgeons in 2019, which reported during 2020. In addition, in 2021, the service was placed in the General Medical Council's (GMC) enhanced monitoring for the training of resident doctors. The Royal College of Surgeons review confirmed that the service was safe but made recommendations on operational restructuring, including separation of the cardiac and thoracic surgery consultant teams, as well as changes to management, clinical cultures and relationships. The trust had undertaken significant work to implement the Royal College of Surgeons' recommendations, and progress on that resulted in the General Medical Council removing the unit from its enhanced monitoring process.

Disappointingly, in December 2023, the Public Health Agency (PHA) received allegations about the service. Those related to patient safety and culture in the team. The allegations were shared with the trust's chief executive, and immediate assurances about patient safety were sought. It received from the trust its position on that, but, as part of our role in the Department and the Public Health Agency, our teams have been continuously reviewing the information. That is part of our normal oversight arrangements. The trust's clinical governance arrangements were also reviewed. No evidence of immediate patient concerns came from that review. However, we understand that patient confidence has been shaken, and I reiterate the Minister's statements, the independent review report findings, the Public Health Agency and my performance team's views that the clinical outcome reports indicate that patient outcomes are largely equivalent to those in other UK services. The independent review report further highlights the clinical competence of the individual anaesthetists and the surgeons and how they are a strength to the unit. The outcomes are supported by the National Institute for Cardiovascular Outcomes Research (NICOR), which is a national audit of similar services. However, we must not rely on that alone. The Patient and Client Council (PCC) is working with the trust to ensure that the patient voice is heard in the improvements, and it will work to ensure that individuals get the information, advice and support that they may need if they require services from the unit.

There is much to do, and the Minister is clear in his expectations. The matter has been escalated to the highest level in our performance accountability framework: level 5. In assessing an increase to level 5, there is judgement on whether the current trust team can, with support, make the necessary improvements or whether alternative actions are required.

Under the Minister's leadership, as previously advised, Peter McBride will be one of two experts who will support the trust in implementation. Both those individuals come with significant experience. Peter has knowledge of the trust and elements of the service, and the other person, whose name I cannot say at the moment, as this is being finalised, is someone with very senior NHS clinical and medical governance experience. With their advice and insight, that will support Belfast Trust in its consideration of the implications of culture and of being open, as well as the specific recommendations of cardiac surgery. Our independent regulator, the Regulation and Quality Improvement Authority (RQIA), will also be vital in providing overall assurance in due course.

Given the level 5 status, our normal accountability arrangements have been enhanced. We have now included the Chief Nursing Officer (CNO) and the Chief Medical Officer (CMO) or their deputies. The two independents that I mentioned will also have an assurance function, and we are still trying to have one of the report authors sit with us in that accountability framework in order to give overall assurance. That is yet to be confirmed. That will provide a regular and informed assessment of progress, with the ability to consider further actions as set out in the framework. The framework can go up and can go down, and that will be a continuous fluid judgement that we will take.

The trust draft action plan was received yesterday evening, and our teams from the Department and the Public Health Agency are already working through it. We are considering it against the review recommendations and the wider requirements as requested by the Minister.

In short, we are looking to have improvements in clinical governance, the culture and openness not just in the cardiac unit but on a widespread scale in the trust. It is critical that we restore public confidence in the regional service. This is our only cardiac surgery service in Northern Ireland, and it is absolutely vital to us that public confidence be raised.

The Chairperson (Mr McGuigan): Thank you. That was useful. You ended where I was going to begin, which is with the impact across the trusts. I am still a bit unclear, as are, I presume, the public. In his statement, the Minister said that the Belfast Trust had been raised to level 5, but a lot of the detail of his statement was specific to the cardiac service. A lot of what you were saying was specific to the cardiac service, until your last paragraph, as it were. Are you able to give us some clarity? Will the two independent people, the Chief Nursing Officer and the Chief Medical Officer or somebody to do with the report's authors look at the governance management systems in the whole trust, beyond the cardiac unit?

Ms McCaig: That would be our expectation. The two independents who will be working with the trust, and, obviously, with the Patient and Client Council will have a focus on the cardiac unit. We need to ensure that recommendations are implemented. At this point, we do not want to presume that there is not a wider job of work to do. The concern for us and for the Minister — I made this clear in my statement — is that the culture and relationships in the team have been brought up before. Either what the trust implemented before did not hold or did not work, or this is a situational, time-based matter where something different has happened.

We have to make sure that it is not more widespread. That is what we will do as part of the process. That is the reason for raising the level 5 wider. It is about public confidence. If you rock confidence in one service, you could rock confidence in other services in the trust. We will want to work with that in the actions. It is absolutely the case, however, that clinical governance is not confined to cardiac surgery. We want to ensure that the best system of oversight is in the trust. The second person to be appointed — I cannot, unfortunately, name them today — is someone with significant experience who will be able to provide that mirror to the trust.

There is, then, the staff piece. We have all heard different pieces of information, even since this came out. It is important that we provide confidence to the staff across the trust and outwardly from the work that we are doing. There are two sides to that, which are the cardiac service and services more broadly.

The Chairperson (Mr McGuigan): In his response — it might have been to me, so I should know if it was; it was me — the Minister said that he was going to make the action plans public. You got those yesterday.

Ms McCaig: What we got yesterday is a draft. Lisa and I were away last night with colleagues from NHS Wales and NHS England, so I have not had time to look at that in detail. My colleagues are looking at it today.

The Chairperson (Mr McGuigan): You have a draft plan. Who decides whether it is finalised?

Ms McCaig: There are two levels of accountability. The first is in the trust, which has an oversight team with the two independents working with it on the practical application of what they need to do. Sitting above that at departmental level is our normal support and intervention, which comes from me, as chair, and from Lisa from a performance perspective, along with the chair and the chief executive of the trust and its director of operation planning. We are enhancing that and lifting it up to have the CNO, CMO and others in it. That broad church of people will have to see whether we think that it is addressing all that we want it to address. That is why we would also like the input of the report author, who has an insight into the cardiac element, but it will still be there. Peter McBride and the other person will provide assurances up and in. We are trying to make sure that it is comprehensive and that we have the right people round the table to augment the process so that it is not narrow but broad. We will look at that to see that it fits.

There may be other elements that we need to look at in the time ahead, but I do not want to pre-empt what those might be. Certainly, at this stage, that is our starting position, and we want to make sure that the action plan is comprehensive. To be clear, I do not a want a tick-box exercise. I do not want us to tick a box and say, "I now have public confidence, because I have done a range of activity". It has to be for the slightly longer term. We have tried it before. We have to look at it over a period of time to ensure that those things are embedded and work.

The Chairperson (Mr McGuigan): I totally accept that. Everybody wants that outcome. However, there is a public confidence issue. I presume that the team that is looking at that will provide the Minister with regular updates.

Ms McCaig: Yes. As I set out, those updates will be fortnightly in the first instance. Weekly updates would not allow for enough time to get lots of activity done. There will be work on the ground at pace from operational teams. The oversight will be fortnightly in the first instance. The date of the first meeting is in the diary; I think that it is on the twentieth day of the month, if I can remember my dates. Between now and then, there will be operational conversations about the action plan. We hope that, at that meeting, we will agree an action plan that is reasonable and sensible. I hope that, by that stage, our experts will be available to us at the same time. It will then be about moving that forward. The Minister has committed to providing regular, transparent updates on progress and action. We will take that forward as part of what we do.

The Chairperson (Mr McGuigan): Will the Committee receive regular updates?

Ms McCaig: I expect that that is the Minister's intention. We have discussed being open and transparent as we move forward. That has to be part of what we do.

Mr McGrath: There are quite a lot of references in the report — thank you for that — to culture. I wonder how far that reaches. To me, a culture is set at the top of an organisation, and it permeates right the way down. There will, undoubtedly, be a complaint about a turn of phrase that was used in a letter that was sent to us anonymously, and the references from our panel include the statement that the issue might be just a personal gripe. If the culture is that people could be complaining because of a personal gripe, that may set the tone. I am not saying that that is the culture, but will we look from the top to the bottom of the trust, or is it about just that individual team? I know that we talked about going round other parts of the trust, so will that include an examination of the trust board, how it sets the culture, how the senior management sets the culture and how that permeates through to that unit and beyond?

Ms McCaig: Thank you for that question, because it is really important. That is part of the reason why it is at level 5: it has been escalated to a wider corporate conversation. It is absolutely the case that culture is set at the top. We all try to model what is good in our place of employment. It is also for each individual. If we are going to look at it, we have to do so from both spaces. Peter McBride will look at that in its broadest sense and at whether we have the right conditions for speaking up. When you speak up, how is that received in the trust? Both things can happen at the same time. It will be hard, because the recommendations need to deal with a very specific problem and we then have to do the wider piece. If we do one, we will miss the next opportunity. We want the opportunity to be once and for all and to really set it into the next phase.

The other thing to bear in mind is that we are recruiting for a permanent, substantive chief executive of the trust. It would be inappropriate for me to mention a date, but that appointment is imminent. If successful, that will provide another opportunity for the reset piece. A lot of senior individuals have moved, and constant movement means that it is been really hard to set a tone. We want it to be a supportive intervention for the trust. We have reviewed previous performance accountability frameworks. This is a mature relationship approach. It is about a system working together. We still have to be able to call out when we do not think that things are as they need to be, but it is about saying, "We believe that these are the supports. What other supports do you need? Here are our very clear expectations of improvement". That is why we have gone with that framework. We have seen it work already. Lisa can talk to you about that, although your time might be tight. We have seen significant improvement. It was implemented formally at the end of November last year. I do not think that we have ever seen such significant improvement before, given the speed with which trusts have responded.

It is helpful, but that does not mean that it is easy.

Mr McGrath: Will messaging be examined? In many workplaces and many public spheres, there is zero tolerance of things such as racism, and racism is mentioned in the report. In this whole issue, it feels as though patient safety is OK. We have to be careful, however. It is about building into a culture things that are acceptable and things that are not. No matter what people's role, how much they are paid or their seniority, there is a line, and, if they cross it, they will be moved out. That message needs to be instilled in people, because there are still blurred lines with that messaging, which is typified by the fact that we are, as was suggested, in the ninth or tenth year of this happening. It is obvious that the message not getting through. Can you make sure that that message gets through?

Ms McCaig: That is very much in line with what we want to do with the actions and what we want to see for the trust. Changing a culture, if indeed the issue is more widespread — I cannot speak to that at this point, because we have not done the assessment yet — is not something that happens easily. It takes a lot of effort, and the culture will not change overnight. It is a long, hard slog for anyone who is trying to change a culture. We will stick with it, however. It is not something for which we can tick boxes and make recommendations and then move away. It is something on which we have to support the trust and hold it to account at the same time. We will bring in the right people to assist, and the Minister's expectation is that he needs to see improvement, and, where possible, he needs to see it happen fast.

Mrs Dodds: Thank you for coming. As Colin said, this has been going on for a long time. Given the number of people who have contacted me, it is not just happening in the cardiac unit; it is also about management and leadership in the trust dealing with issues as they arise.

We have had the Royal College of Surgeons' report and RQIA reports. The GMC has had certain folk in. There has been enhanced monitoring. We have had the PHA and the SPPG undertaking reports, and we have had the Peter McBride report. Why are you taking action only now? Were people shamed into taking action because the issue was made public?

Tracey, I have looked at the report in I do not know how many ways, and I find it difficult to comprehend how the issue was allowed to slide for such a long time. It has caused turmoil for people. It has caused good people who turn up every day for work to have the good work that they do almost undermined. Why has action not been taken before now? I welcome the fact that we are taking action now, but why have we not done so up until now, given the issue's long history, the numerous reports etc?

Ms McCaig: The Royal College of Surgeons' report and the General Medical Council intervention produced actions, and both bodies decided that those actions were appropriate at the time. Do we now understand whether the issue slid backwards into something that we were not happy with or is an issue at this point in time? That is difficult to answer at present. The report that the chief executive of the Public Health Agency and I commissioned came about as a result of knowing that other things had happened. Those issues were stopped, and we all went, "Great. That's it sorted", and then something else happened.

This has to be a line from which we move forward and never return. It is really hard to go back over different points in time — when recommendations were made, action was taken, and everyone was content — only then to come back to this. That is not acceptable, and it is not fair on the staff. I do not defend what has happened in any shape or form.

It was challenging to find a group of individuals with the experience and expertise and who had reviewed similar services before to do the report. It was important that, this time, we found a group of people who were independent and experienced and had been through something like this before. For me, it was about drawing a line in the sand. It was one of the first things to land on my desk when I took up my role at the end of last September. I know the energy that has been put in behind the scenes. We have had daily situation reports and weekly escalations, with which I am involved. The work has been significant. I share the concerns about why we continue to go back. I am not entirely sure at this point whether we have absolute clarity on why the interventions that were made at that time, which were accepted by those bodies, seem not to be holding.

The Chairperson (Mr McGuigan): Before you come back in, Diane, I inform the Committee that Assembly Broadcasting is looking for all members to turn down the volume on their laptop, as there is some interference.

Mrs Dodds: The report makes recommendations about the trust's governance arrangements. Those recommendations are massively important. The very first recommendation is:

The report's conclusions tell us that there is no effective reporting mechanism for that at trust board level. Is that acceptable? Will that be —?

Ms McCaig: No.

Mrs Dodds: You are bound to have known about that. Why did nobody know about it? If the trust is not monitoring those things, what is it doing?

Ms McCaig: The reason that we have brought in a second expert is to review the clinical oversight of the safety pieces. That is not to say that the team is not looking at anything. It is about whether they are being most effective in the areas at which they are looking. Although I said at the beginning that the data indicates that the cardiac unit has good patient outcomes compared with other units, we do not want to rely on that. We have to be curious about those things and make sure that we have people with the expertise to understand the data that comes forward.

I have not looked at the data. I am not an expert in looking at clinical data. If it were to come to me, I would ask my experts about it. I would look for the medics to translate for me, because I would not want to presume something only to get it wrong. It is about stepping back and looking at the data. Again, that is why we really searched for the right person — an individual who has significant experience in clinical governance — to come in as a second expert, to make sure that we look at that area and to support the trust. If the situation is not right now, is a small adjustment needed or a more major one? That is what we need to determine.

Mrs Dodds: The report is clear that the trust does not have the process in place to look at the situation. It is not the case that an adjustment is needed: the report is clear that there is not a process in place. That is a huge failure. A huge amount of intervention is therefore needed.

I want to raise another issue, because it is really important that we understand it. The report's recommendations conclude that we should analyse the mortality data on the very extended waiting lists, because we have the longest waiting lists in the whole of the United Kingdom. Will there be a process by which we can do that? The report also talks about the number of people who are admitted as emergency patients because they have waited so long on the list that their situation has become unstable. Looking at those things is massively important. I am gobsmacked, to be honest, that has not been done and at the idea that it is not a normal process. The report states that the trust and the Department should prioritise cardiac surgery. In a strange way, that is a positive for patients, in that the report is telling the trust to prioritise it. Aside from all the headlines about bad behaviour, those are the fundamental issues that the report addresses, and they are of major significance.

Ms McCaig: I agree. It may be helpful for Lisa to give the Committee a bit of an update on the situation with waiting lists. We have been working on waiting lists and on building capacity in the service. In Northern Ireland, it is a service that is quite small. It is a specialist unit. Lisa can update you on what we are doing, after which I will return to the governance piece.

Ms Lisa McWilliams (Department of Health): Colleagues, I have given a couple of briefings in the past on the approach taken to waiting lists. Until this year, we were focusing on the red-flag list and the time-critical list. Cardiac surgical cases were one of the components of the time-critical list. We have an arrangement with a provider south of the border to provide additional capacity, but, now that we have recurrent funding through the Executive's commitment in the Programme for Government, we are looking to enhance that capacity with other providers, because we have a backlog. The backlog of time-critical cases is not as long as that for some of our other, routine patients, but we want to enhance our capacity. We also want to look at how we shore up our team and make it resilient, so we are working through a process to see what that looks like for Belfast in the context of working through all of this. Will we be securing additional training posts? Will we be putting in place additional consultants at some point? That is all being worked through, because cardiac surgery is one of our time-critical services, and the Belfast Trust is the only trust in Northern Ireland that provides the service. That is why we are focusing on it.

I will make a couple of other points about emergency presentations and mortalities. The long waits mean that our mortality work happens at a point after treatment. Through our targeted actions to address long waits, we need to move that point in order to make sure that we direct resource to the most appropriate place so that patients wait for a much shorter time.

We will always have clinical priorities. Cardiac surgery will always be a high clinical priority, as it is for the trusts, so we are looking to see what else we need to do for other lists. You make a critical point, however, which is that, when there are the waits that we have, there are repeated emergency presentations, and those have an impact not only on patient experience, quality of life and ability to work but on mortality.

Ms McCaig: Efficiency of service is also affected. Given the capacity issue, the staff have to respond to the imbalance between the planned care element and the emergencies that come in. We are mindful of that. With the Executive's commitment this year to fund us to move forward, we will be able to do other things. We are working in a different way in order to build capacity in-house. Given the report, we need to be mindful of the fact that we are managing the oversight and accountability of an issue, but, at the same time, we are trying to build the service's capacity and resilience to ensure that it is there for those who need it when they need it. There are two sides to that, and it is difficult to do. We do not want waiting lists to be the way they are; we want people to be able to access planned care when they need it. There is a significant drive, not least with the new permanent secretary in place, to do that.

Mrs Dodds: I have two more points to make quickly. The report makes a recommendation about having the high number of litigation cases in the Belfast Trust independently reviewed. That is linked to the money paid out for those cases. That is important to note.

It is also important that we look at the governance issues with capital build projects in the Belfast Trust. I hate to harp on about this, but the reason that we are not doing other capital build projects is that the Belfast Trust is soaking up money on capital build projects that have gone wrong. We will not have a complete picture if we do not look at the governance of capital build projects. We have a new maternity hospital that,15 months after the handover, is still not safe for use and will require significant work. Unless we are going to look at all aspects of governance, we will miss a trick, and we will be back talking about it over and over again.

Ms McCaig: On the capital build projects, it is not that I do not have commentary to make on them at all, but it is not an area for me. Another colleague could come to the Committee to talk about that issue.

The issue with the maternity hospital is of such significance from a patient safety perspective that we need to focus on it in order to get it moving. That does not mean that other things cannot be done alongside it. My colleague Chris Matthews from the policy side has been in with the Committee before, and I will take your comments back to him.

Mrs Dodds: Thank you.

Mr Donnelly: Like the rest of the Committee, I am very concerned about the issue. Those patients are critically ill, and they are at risk of serious incidents happening to them while they wait for their surgery. It is a frightening time to be a cardiac patient awaiting surgery, and it is even more frightening now, because significant stress has been added to patients' situations.

It is good to hear that we appear to be moving forward. I want to ask about the action plan: how much co-design input have you had from trade unions and other staffing organisations?

Ms McCaig: I cannot answer that, because I literally opened the action plan in a hotel room last night to have a quick flick through it. That is one of the questions that we want to ask, and it is why the Patient and Client Council is working with the trust. There need to be strands within it: trade unions, the PCC and others. As I said, there has to be a broad church involved.

Mr Donnelly: Has their input been sought in its design?

Ms McCaig: You have to remember that the action plan is the trust-derived action plan. One of the questions that we will ask is how it has been designed and co-designed. That will happen over the next number of days.

Mr Donnelly: I will be interested to know.

Ms McCaig: My expectation is that a broad spectrum of individuals will be involved, because, if not, we will start off on the wrong foot.

Mr Donnelly: Exactly.

Ms McCaig: That is really important, and I know that the trust has been receptive to having those conversations, so I imagine that the involvement will be broad. The updates that are provided, as well as the oversight group, will allow for opportunities for other voices to be heard.

Mr Donnelly: We are at an early stage with it, so I assume that we will hear more about that as the action plan rolls out.

Ms McCaig: Absolutely.

The Chairperson (Mr McGuigan): Thank you very much. We look forward to getting regular updates.