Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Peter Jakobsen, director of regional health services and transformation in the Department of Health, and Michelle Estler, head of the transformation branch in the Department of Health. We have your presentation, so I am happy to hand over to you for some brief opening remarks.

Mr Peter Jakobsen (Department of Health): Thank you, Chair. Thanks for the opportunity to update the Committee on the transformation agenda. As you know, the session was originally scheduled for June. We issued a short briefing note at that time that focused on the three-year plan and the hospital network consultation. That information is still relevant, but I will focus my opening comments on the main developments since then.

As you will be aware, the Minister published his reset plan on 9 July. That built on the themes of the three-year plan published in December last year, which are to stabilise and reform the system and to improve how services are delivered. The reset plan focused on seven key areas in the three-year plan's overarching themes. The first is prevention; the second is investment in community care, primary care and social care; and the third is improving the efficiency and effectiveness of the delivery of services. The fourth is adopting a whole-system approach to reducing unwarranted clinical variation; the fifth is maximising digital investment and the use of data; the sixth is exploring opportunities for research; and the seventh is creating an environment that supports system collaboration.

One particular initiative to highlight is the commitment to develop a new neighbourhood model by March 2026. The intention is to develop that in partnership with community pharmacy, GPs, the voluntary and community sector, trusts, independent providers and local government. It is a whole-system approach.

Another notable development is the establishment by the trust of the new committees in common, which are designed to facilitate shared decision-making on issues that can be best resolved jointly by the trusts. The matters that are to be resolved through that structure will be determined by the trusts in discussion with the Department. In allowing for that, the Department has established a new senior leadership group that includes the trusts' chief executives and the chief executives of the Public Health Agency (PHA) and Business Services Organisation (BSO), as well as senior departmental officials and heads of professions. That group operates with a one-theme ethos and oversees the reset agenda.

The reset plan also commits to the publication of a report on the hospital network consultation. I will turn to that briefly. The consultation involved nine events. People and organisations could also complete the online questionnaire or submit stand-alone written responses. We received around 30,000 responses, so there was a significant response to it. The majority of those responses — nearly 28,000 — were from the Save Our Acute Services (SOAS) campaign group. Responses originated from citizens and a range of organisations and campaign groups.

You may recall that the consultation questions focused on the hospital structure, identifying the core services associated with it and proposing actions to facilitate collaboration across the hospital sector. The themes in the responses to the consultation were broad and went significantly beyond the narrow focus of the consultation document. Seven main themes came through, the first of which was data and evidence to measure better outcomes. The second theme was equality and rural needs impacts. The third was workforce issues, leadership and collaboration across the system, and the fourth was involvement, engagement and consultation. The fifth was the proposed hospital types and core services, and the sixth was patient travel in an emergency and for elective care. The final major theme was a broad range of specific concerns about particular services.

In pulling that together, I will say that many respondents expressed concern about potential loss of services or hospital closure. A strong view that really came through was that the decision-making process on changing hospital services is not clear and that communities do not feel sufficiently involved in that process. The Department and the trusts will need to reflect on that.

Chair, that is all that I want to say by way of opening remarks. I am happy to take questions.

The Chairperson (Mr McGuigan): OK. There are an awful lot of important issues on the agenda, and I am certain that members will have a lot of questions. I suggest that members be succinct in their questions and that you be succinct in your answers so that we can make sure that we can all get to cover it. I will, hopefully, do what I am telling everybody else to do.

Nobody can deny that we need transformation. The Minister continually talks about the shift left. You would expect GP services to be vital to that, yet the Minister is, for lack of a better phrase, at loggerheads with GPs. I speak to a lot of GPs. There is serious anger and frustration among them, and quite a lot of them are talking about leaving the NHS and going into private practice. We cannot allow that to happen, and the Minister and the Department cannot allow it to happen. How is the Minister ensuring that GP services in the community remain sustainable through the transformation and that we do not oversee the privatisation of GP services?

Mr Jakobsen: I have made this point many times when I have been before the Committee: I do not lead on GP services. There is a policy lead on that, and the strategic planning and performance group (SPPG) leads on the contracts. I am not across the detail, I am afraid. I will say, though, that there is clear intent for the neighbourhood model to involve GPs. They will have to be central to that model. That is obviously a massive problem, given where we are. The Minister and the permanent secretary have reached out to GPs to discuss how they can move forward, which will probably involve developing the model and looking at the contracts for next year and at how to change the contract. That, as far as that goes, is the direction of travel.

The Chairperson (Mr McGuigan): OK. You said at the beginning of your presentation that policy leads would not be here. That is a wee bit disappointing for us, because, I imagine, members will have detailed questions on specific issues. I will not push you on GP services, given that you said that you are not the lead, but we really need to get to grips with that issue quickly.

Mr Jakobsen: We can come back to you in writing on some of the issues. I apologise up front that I am not the policy lead on everything in the Department — I cannot be — so I am not across the detail on a lot of the issues. I lead on certain projects.

The Chairperson (Mr McGuigan): A wee bit of foresight might have been used. There are five seats for witnesses, so we could have accommodated another three policy leads, given the expectation that we would have questions on some of the issues.

Mr Jakobsen: OK. I can talk to the network consultation because I led on that, and, if there are questions on that, absolutely, I can answer them.

The Chairperson (Mr McGuigan): Given that the Committee has a bit more time as we move into the autumn, I suggest that we interrogate exactly what the Minister means when he talks about the "shift left". He says it an awful lot, and we really need to start working on the detail. I will ask you to provide some detail on what "shift left" actually means, particularly when it comes to removing services from acute hospitals.

Mr Jakobsen: The reset plan provides some direction of travel for that in the new neighbourhood model. It is clear. It says that that model will be developed by March 2026. It is being led by Cathy Harrison and Gearóid Cassidy in the Department. They have already held at least one workshop and have had discussions with a range of stakeholders. The plan is to develop the design principles around what that might look like and then engage with the trusts, and the trusts will work out what that neighbourhood model will look like for each trust area. There will be some strong design principles behind that. I think that the idea is to try to have those ready within the next couple of months. There is a full session to be had on that once it takes shape. To my mind, that is the big flagship initiative around shift-left.

The Chairperson (Mr McGuigan): We need to start seeing more detail and meat on the bone.

Ms Michelle Estler (Department of Health): Another example is Hospital at Home, which is about taking care of the older population in their own homes rather than in acute hospitals. It is about virtual wards, which, I know, the Committee has talked about in the past. That is another good example of how we shift left: treating somebody in a community and in their own home, where appropriate, rather than in a hospital setting.

Mr Jakobsen: Absolutely. I know that you have a session in October on winter pressures. We have had a big discussion in the four workshops that we have had since March. Some of the themes emerging from those are about trying to look after people in their home and in care homes as opposed to bringing them into hospital. It is about getting as much support as close as possible to people and trying to prevent hospital admissions and admissions to the emergency department (ED).

The Chairperson (Mr McGuigan): I am rattling through my issues. Your presentation includes key achievements in 2024-25, one of which is:

The Department is claiming that as a key achievement for 2024-25. When will we see the outworkings of that for the next year? I meet nurses who are extremely worried and disgruntled and rightly so. We all stood on picket lines supporting our nurses. We all support our nurses. They deserve, along with other healthcare staff, to be paid. When will the Department resolve the pay issue?

Mr Jakobsen: The Minister absolutely agrees with all that. He has given a direction to pay that, but, obviously, that has gone to the Executive, and he needs the Executive to agree to that direction before he can pay it. We do not have the money at the moment to pay that out. Until the Executive take that decision, the Minister cannot move on payment.

The Chairperson (Mr McGuigan): The Health Minister is responsible for sorting that out.

Mr Jakobsen: Yes, but, as I said, the process is that, once he gives a ministerial direction, it goes to the Executive for decision.

The Chairperson (Mr McGuigan): When the Minister was setting his budget at the start of the year, there was an agreement on pay parity. Did he not know that healthcare staff needed to be paid and that additional resources would be needed?

Mr Jakobsen: I think that the Minister made points at the time about the budget being extremely tight for this year and insufficient. That is all that I can say on that.

The Chairperson (Mr McGuigan): It is a very important issue —

Mr Jakobsen: It absolutely is.

The Chairperson (Mr McGuigan): — for the Health Minister. I suggest to him that it is coming to crunch time in ensuring that.

Another important issue that I see in the three-year plan is mental health. I had a meeting earlier today with the Royal College of Psychiatrists. There are workforce issues in that staff are not being recruited or retained. Again, there are pay comparisons between North and South, as well as with other areas. The differences are astronomical. There is an issue with the implementation of the mental health strategy. Can you reassure us that the growing mental health crisis in the North is being addressed in the Department?

Mr Jakobsen: I assure you that we are doing the best that we can with the budget that we have. That is all that I can give you. Again, I do not lead on mental health, so I am not across the detail, but we can come back to you if there are specific questions that you would like answered on the mental health strategy. I know that it is not resourced in the way that it should be. The Minister also knows that, but there are budget pressures. As you know, we are looking at a budget gap of about £600 million this year. In that context, you cannot fund everything, obviously.

The Chairperson (Mr McGuigan): I do not want to pick on you two just because you have come here, but you sent us a presentation with all those issues in it. We have to ask these questions —

Mr Jakobsen: I accept that.

The Chairperson (Mr McGuigan): — and we really expected —.

Mr Jakobsen: As I said, we can come back to you in writing. I could have brought 15 other people with me, but that was not possible.

The Chairperson (Mr McGuigan): That is something that we need to learn in future. This is one of the most important issues affecting our constituents. When we allocate time, we need to ensure that it is best used.

Anyway, something that you can answer, I hope, is the question of hospital reconfiguration. There was a lot of criticism of the consultation document at the time, saying that it perhaps did not go as far or contain as much detail as people expected and that it was kicking the can down the road. Notwithstanding that, you said, I think, that there were 30,000 responses, 29,000 of which were from SOAS or from the Western Health and Social Care Trust on the South West Acute Hospital (SWAH). There was a debate on that in the Chamber the other day. I was not able to stay for it, but I listened to it. Diane, Colin and everybody else asked questions, but the Minister did not really answer any of them, to be truthful.

There is a configuration of the Western Trust's decision on general surgery with all the other consultations and strategies. How will all that tie into hospital reconfiguration? 'The Irish News' did a piece today that said that the Minister had given a commitment to the South West Acute Hospital, but I do not think that anybody thought that that was in jeopardy. What are in jeopardy are the services in the South West Acute Hospital. How does all the reconfiguration work, and when will the Minister and the Department have a view on that?

Mr Jakobsen: There are obviously a lot of issues there. You are right: the consultation did not commit to any specific reconfiguration. It was more about a network of hospitals collaborating to deliver better outcomes. We gave examples of how that is already happening, and we are saying that there needs to be more of that to deliver the best services for people. It was meant to give a framework for specific reconfiguration decisions such as that taken in the Western Trust. That was the purpose of the document. To my mind, the Western Trust's consideration of that specific service can go ahead regardless of the outcome of the consultation; it is not contingent on it. The hospital reconfiguration document did not say anything about general and emergency surgery in the Western Trust, actually.

The Chairperson (Mr McGuigan): It was lacking in detail across the board.

Mr Jakobsen: Yes. Therefore, the Western Trust can go ahead with that consultation and take a decision that is in line with the guidance that we have on it.

The Chairperson (Mr McGuigan): OK. I am sure that everyone else will ask —.

Mr Jakobsen: I am sorry; I did not answer the question on the timescales. We are working up a final draft report that, we think, we will get to the Minister before the end of this month. That is the timescale that we are working to. It is a couple of weeks away. The Minister will agree it, and we will get it published. That will set out our response to the issues raised in the consultation.

The Chairperson (Mr McGuigan): OK. The waiting lists are a whole item in themselves. The Minister made an announcement recently about a reduction in some of the waiting lists, which is important to the people who are on them, but cancer waiting lists are still worryingly long. That is of concern to everybody. We have the new regional service for waiting lists, but it is not reducing waiting times. It may be evening them out across the North. What is the strategy for reducing waiting times, which is an important matter?

Mr Jakobsen: The Executive and the Department are committed to investing £215 million this year. Obviously, that should make a difference and start to reduce those waiting times, but we need to do that every year. We need to commit to that investment every year to get the waiting times down. We and other officials who lead on that have said before that, even if we had all the funding that we need, it would still take at least five years to start to make real inroads into the waiting lists because there is only so much capacity that you can get out of the local system with the private and public sectors.

The Chairperson (Mr McGuigan): You have moved to a regional waiting list system. Is a regional system being considered?

Mr Jakobsen: I am not sure. I do not know. For that speciality, it is, and that makes sense if there are significant variances across the trusts. It is not sustainable to have a scenario where, in one trust, you might wait for four weeks and, in another trust, you wait for 10 months.

It is really unfair, so the breast assessment was moved to a regional list to try to at least equalise things.

The Chairperson (Mr McGuigan): It is unfair and totally wrong that, when something is life-threatening, people have to wait beyond the time frame.

Mr Jakobsen: Completely.

The Chairperson (Mr McGuigan): That is the key issue that we need to resolve.

Mr Jakobsen: Funding and capacity are required to start making proper inroads into it.

The Chairperson (Mr McGuigan): I could question you for two hours, and you could probably throw it back for an hour and a half because you are not the right person for that. That is disappointing.

I will move round the room now.

Mrs Dodds: Peter, just to clarify, you are the official in charge of the hospital network consultation.

Mr Jakobsen: Yes.

Mrs Dodds: OK. That means that you understand how the dynamic of the situation works. We have a situation in which a hospital network consultation talks about the South West Acute Hospital as being one of the "General Hospitals". We have a consultation from the Western Trust about closing emergency surgery at the South West Acute Hospital, and we have an intervention from the Minister via the local press — quite why that was not put out via the Department I do not know — that said that the Western Trust must bring forward a sustainability plan for the hospital. That is welcome. It is not an issue. However, how do those three things interact, and which will come first? Will it be the hospital network consultation, the Western Trust's consultation or the Minister's sustainability programme? Do you understand why people in the south-west of Northern Ireland are confused by and are angry about what is happening?

Mr Jakobsen: I cannot speak for the Minister, so I am not able to say what he meant by "sustainability plan" in that letter — that intervention. I think that the point that he was making is that, if you are to change the service, it might be better to do it in the context of a wider plan for the hospital. I suspect that that is what he meant.

Mrs Dodds: I suspect that my colleague here might have something to say about that where the Causeway Hospital is concerned. We are changing services but not telling people what services will be under the roof of the SWAH.

Mr Robinson: That is the point.

Mrs Dodds: We are not telling them how life will be better or how their access to healthcare will be improved. We are doing it blind and in the dark. Do you understand now why you got 28,000 responses from the south-west to the consultation?

Mr Jakobsen: We completely understand why we got those: it is in relation to the general surgery issue. There is no doubt about that.

Mrs Dodds: This is one of the most unsatisfactory situations that we could imagine. We have the most rural population in Northern Ireland. We are talking about taking away one service. We are not telling people what services will be available, and we are merrily proceeding with a consultation with the Western Trust.

I will move on to the Western Trust consultation. The trust can take a decision on emergency general surgery. Who in the Department says "Yes" or "No" to that decision?

Mr Jakobsen: According to the guidance, that is for the Department to determine.

Mrs Dodds: No. Who says "Yes" or "No"?

Mr Jakobsen: If the decision is major or controversial, it is the Minister's decision.

Mrs Dodds: We know that it will be controversial —

Mr Jakobsen: Yes, the Minister will decide.

Mrs Dodds: — so, at the end of the day, it will be the Minister who says whether emergency surgery is restored.

Mr Jakobsen: He will say "Yes" or "No" to that decision.

Mrs Dodds: He will say "Yes" or "No". Thank you for that clarification. That is really important.

On the back of that, since I joined the Health Committee, I have heard how important it is to have transformation. When I look at the list of achievements, I see that we have launched a consultation on the hospital network programme. We launched the consultation on 1 October last year. We are almost one year down the line, and we do not have even an idea of what the consultation responses say or of any decision on the hospital network consultation. Do you agree that the pace of change is glacial?

Mr Jakobsen: There are changes on the way all the time beyond that particular one.

Mrs Dodds: No. I am talking about this change. It was launched as the big idea. We are 11 months down the line, and we do not know what the consultation process says.

Mr Jakobsen: You will find out shortly. Yes, I accept that it has taken some time.

Mrs Dodds: To be honest, it is pretty unacceptable to be 11 months down the line since the launch of something.

Mr Jakobsen: It closed at the end of February.

Ms Estler: Yes. It was a five-month consultation, and it closed at the end of February —

Mrs Dodds: Every time ——.

Ms Estler: — so I accept that, from the end of February till now that that has been —.

Mrs Dodds: If we had a consultation, Michelle, on the reset programme and on neighbourhood health, how long would it be before we had a decision on it?

Mr Jakobsen: We are not proposing a consultation on the reset. That was a published plan [Inaudible.]

Mrs Dodds: So you are not proposing any consultation on changes to services in the community. Some of it sounds sensible, but my point is that we were told — Professor Bengoa was brought here to lecture us and to tell us all — that change must happen. We are 11 months on from the launch of that consultation, and we have no idea of the outcome. I want to leave it there.

I may have missed this. It might have happened, but I do not know anything about it, and that is on me. You say in your list of achievements to the Minister that you have established:

Has that happened?

Mr Jakobsen: I will get back to you on that. I am not across that in detail.

Mrs Dodds: Does anybody know?

Miss McAllister: He said that he was setting up a shadow. He had already set up a shadow.

Mr Jakobsen: It is probably in shadow form. It is not actually in existence.

Miss McAllister: That is not what your paper says.

Mr Jakobsen: I will need to get back to you on that, because it is not something that I am currently across.

Mrs Dodds: It is just that, if we are going to have all these things, we need clarity on what is or is not happening. That is really important as well.

Could I ask another question on the reset programme? I agree with you, Chair, that there is so much in the reset that we will probably need a separate session just on that. It was published in July — am I right? — and it is just so big. I welcome some of it. Some of it is sensible and so on, but I am really interested in a particular point. In the Southern Health and Social Care Trust, for example, we already have an acute care at home service. Enhancing that service would be a good thing and would take many more people out of hospitals. However, some of the trusts do not have any such service, so I am interested to know how you will work that through and what the trusts are saying. I ask because we do not want to continue with the postcode lottery-type service in which you can get that care somewhere but not elsewhere.

Peter, I am disappointed that we do not know the outcome of that. I cannot express it in any other way. If we are to make any effort at transformation but take a year to take every decision, we will probably achieve very little in the mandate. That is the nub of the whole thing.

Mr McGrath: Poor Peter, with the way we are working our way around this. It would be interesting if the Minister managed to find a way that meant that the decision on the implementation of the proposals were controversial and cross-cutting and had to be taken by the Executive rather than by a single Minister. We could then see just how much of it would be objected to and how much would be given airtime. We would find that there would suddenly be a lot more quietened concern.

It says in the preamble to the report that a report would be completed by the Minister by the summer. I presume that that is the report that, you said, might be completed in the autumn, the one that would be delayed a little.

Mr Jakobsen: Yes, the report on the consultation will go to the Minister before the end of this month. That is our aim.

Ms Estler: There was a distraction. There are only three of us. We were working on the consultation report, were redirected to the reset plan and are now returning to the consultation report.

Mr McGrath: It is incoming, however, hopefully in the next period, yes?

Mr Jakobsen: It is incoming.

Ms Estler: Yes. We have a draft.

Mr McGrath: I will comment on another point. It concerns the £200 million worth of savings that has already been found. I wonder where those savings have come from. The savings obviously mean that services are being reduced, changed or not delivered in the way in which they would be. That shows just how precarious our health service is. Finding £200 million of savings must have had a massive impact on service delivery. That is the figure to date, and I am sure that the Department will be asked to find more savings —

Mr Jakobsen: Of course.

Mr McGrath: — as time goes on, because of the inadequate budget that it has been given. More savings will therefore be coming.

I also noted an interesting point about waiting lists on which I will comment. The Minister spoke to the media about a series of fabulous waiting list reductions on Tuesday or Wednesday of not last week but the week before. Then, the very next day, a round of statistics was published showing that the Department had not met targets, but there was no Minister out making any announcement about that. We will call him the "Minister of Good News". He does not want to be the Minister who delivers any of the bad news, however.

On the classification of emergency departments' waiting times, Lagan Valley Hospital and Downe Hospital were typically considered level 2 emergency departments, but, in the most recent document that was published, they have been referred to as level 3 EDs. That sounds to me like a downgrading. Has that been discussed, approved and presented, or have we been —?

Mr Jakobsen: It has, yes. I do not think that they were ever level 2 emergency departments. What happened is that, last year, we adopted the English definitions of emergency departments, and a level 3 ED is defined as not operating 24/7, which those emergency departments do not. Level 2 is a highly specialist ED, providing, for example, eye care. That is the difference. I do not think that those emergency departments were ever at level 2. They are at level 3 because they are not operating 24/7. A level 1 ED is one that operates 24/7. We are just bringing those EDs into line with the rest of the units.

Mr McGrath: I suppose that that certainly would fulfil —.

Mr Jakobsen: For clarity, there has been absolutely no change made to the service. The service is exactly as it was before. Whether we call them "level 2" or "level 3" emergency departments, they are providing the same service.

Mr McGrath: Yes, but that shows, as we have argued all along, that the emergency departments have been downgraded. We have constantly been told, "It is only a level 2 ED, and it is not being downgraded further". Going back 15 years, in arguments with the trust, we were told, "It is a level 2 ED, and we are very proud of the fact that it provides a level 2 service. It serves the community well. Do not worry. We are not going to downgrade it beyond that". Now, overnight, for those hospitals' EDs to become level 3 is a recognition of how little service is being provided in them. That underpins the argument that we have been making all along. At least it is recognition, at long last, that those EDs are not providing the type of service that they were or that we would have expected for our communities.

Mr Jakobsen: They are not 24/7 emergency departments. That is clear.

Mr McGrath: We know. We know well what service is provided and what is not.

Mr Jakobsen: There is a good model in place. I know that ED consultants in the Ulster Hospital travel down to do shifts in Downe Hospital and Lagan Valley Hospital in order to keep the service going. It is network model, and it is a good one. It works.

Mr McGrath: I do not like some of the commentary about things that have not been considered. This builds on what Diane said. We have been consistent in saying that we are up for transformation. Transformation means looking at the whole system, however, and if, during that process of transformation, you are, for want of a better term, rearranging the chairs for where services are provided, it feels a bit odd that chairs were being removed, such as Causeway Hospital's maternity department, the SWAH's emergency service and the emergency departments in Downe Hospital and Daisy Hill Hospital. Those services were being removed before we looked to see what chairs were there for reconfiguration. We have always felt that that was the wrong way to do it. I have always felt, not from what you have said, that the process was a bit underhand, because those services were being taken out of a community. We are then looking at the overall system and saying, "That service is not there any more, so it cannot even be considered as part of the way forward". That has upset a lot of people in the community. That is why there have been so many responses to the consultation.

Finally, I made the following point in the House the other night. There are issues with the South West Acute Hospital, with Downe Hospital, with Daisy Hill Hospital and with maternity services at the Causeway Hospital, all of which are rural hospitals. Please go back to the Department and shout that the rural community also deserves services.

One of the easiest ways to measure a population is to look at the constituency boundaries, because the number of people who live in a constituency is set in law. We have just undergone a boundary review that saw the constituency boundaries change in Belfast, because not enough people lived there to maintain four constituencies. The rural constituencies had to be extended. That says to me that the population in the city is starting to lessen and that more people now live in rural communities. Every significant change that has taken place in the past has been made to rural services, leaving rural people having to travel further. Can you please go back to your Department, and, if lots of them live in the city, remind staff that we who live in the countryside are also entitled to services? As part of the reconfiguration, perhaps we will see some services made available to those of us who live in rural communities.

Miss McAllister: Thank you very much. I understand, because you do not lead on GP services and thus cannot comment on all the issues, that this session is difficult. I will pick up on what Colin said. I totally agree with him, but I highlight the fact that the Mater Hospital, which is a city hospital, has undergone service change over the years.

Mr McGrath: It is one of the three hospitals in Belfast: very luxurious.

Miss McAllister: I completely understand his point, however. This is the issue: we do not have information, so we cannot scrutinise it. Where do we go from here? I speak as a member of the Alliance Party, which has fought for transformation. In council, when other parties have voted against something, we have raised our hand and voted for it, knowing that it would work out better. There are areas in which it has been illustrated that that is the case, but it gets difficult when we do not have information and cannot give our constituents across Northern Ireland confidence. I respect the fact, however, that it is a highly political issue. That is not your fault.

How many internal teams are working on the different issues? I know that it is highly political, but do you have a plan based on consultation with experts, clinicians and communities for how to fill the gaps? I am not asking you to tell us what it is — it has not got approval — but do you have such a plan?

Mr Jakobsen: By "issues", do you mean the reset plan?

Miss McAllister: Not only the reset plan but reconfiguration. I am talking about all of it. They are all one. They have different names, but they are all in there together.

Mr Jakobsen: The thing about reconfiguration is that most of it is happening in trusts. The trusts work on that, because most of that reconfiguration is for trusts to take forward. Some regional work is happening. For example, I lead on neurology and stroke services. My team and I are doing work on the reconfiguration of stroke services, which will probably conclude next year. That could be controversial, but we do not know yet, as I do not know what the outcome will be. That work will happen, and, if it leads to the closure of even one stroke unit somewhere, it will be highly controversial. Some of that work is happening, for sure.

Miss McAllister: What about the teams that are working on the issues? You said that you were diverted to the reset plan. There is the reset plan, reconfiguration and the hospital networks. They are different plans for reform and to tackle waiting lists. How many teams are working on the issues?

Ms Estler: I tried to address that the first time that we came to the Committee, because I appreciated your point that we cannot cover everything, and the last thing that we wanted to do was to say, "That's not for me but for somebody else". We therefore provided a list of all the key strategies, key areas of reform and new ways of working, and the list was accompanied by contact names in the Department. We sent that a year ago. I recognised that, should you want to do a deep dive into a certain area or to see how many areas we cover, such a document was required. There are lots of teams: the list is pages long.

Miss McAllister: I do not know how many there are — I cannot remember off the top of my head — but it sounds as though a large number of people are working on the issues.

Mr Jakobsen: A lot of people are working on policy.

Miss McAllister: Has a lot of consultation been going on with clinicians and administrators? Is that constant consultation?

Mr Jakobsen: Those things are always clinically led, so clinicians have to be involved.

Miss McAllister: The issue is therefore political. There is no change because it is political and will continue to be. We need the information in order to scrutinise everything and to sell reform to our constituents. The Minister said in the Chamber — I cannot remember the date — that elective surgery either would or could — I cannot remember the exact word — occur more frequently at the SWAH because there were empty theatres and wards there. Where are we on that? Those promises have to illustrate that we will continue to have jobs in the community and that we will continue to provide transport to get people to A&E if they need emergency surgery. I appreciate that the decision-making is political, but information need not be political. Everyone has a responsibility to realise that, if we are to fix the healthcare system, we cannot use it as a political football.

The Chairperson (Mr McGuigan): Before I bring in Danny, I have a comment to make. You said that you are responsible for stroke services. You will be aware of the report in the 'Belfast Telegraph' yesterday that 40% of stroke patients are arriving at hospital via car as opposed to ambulance.

Mr Jakobsen: Yes, I saw that.

The Chairperson (Mr McGuigan): What are you doing to ensure that stroke services are accessible? You cannot oversee them without dealing with the Ambulance Service, so what is happening there?

Mr Jakobsen: That issue is clearly an Ambulance Service issue.

The Chairperson (Mr McGuigan): It could be an Ambulance Service issue, or it could be about the location and availability of stroke services.

Mr Jakobsen: Yes, but most of that is probably to do with people phoning for an ambulance that is not available in a timely fashion. They therefore drive themselves to the ED, because they need to get there as soon as possible. Stroke is a time-sensitive issue for some of the treatments. For example, people need to get thrombolytics within four and a half hours. The advice is for people to get to the ED as soon as they can, because that is where they get assessed and, if they need it, they get that service. It is about getting patients to the ED as quickly as possible.

From my reading of the situation, it is an ambulance capacity issue. As part of the winter plan, which you will hear about next month, there are steps being taken now to tackle ambulance handover times. A stepped approach is being taken to try to get them down. At the moment, many ambulances are waiting more than two hours outside EDs. There is so much lost capacity there, and that has to be tackled. There is now a plan to try to reduce handover times over the coming months. That should free up some capacity. In the longer term, there is also a commitment to increase the paramedic training cohort to bolster capacity, but there is no doubt that the Northern Ireland Ambulance Service (NIAS) is under huge pressure.

The Chairperson (Mr McGuigan): Apologies, Danny. Is it correct that stroke services are available in Belfast during office hours essentially?

Mr Jakobsen: That is the thrombectomy service. Probably about 10% to 15% of patients can benefit from that service, so there is a business case to move that to a 24/7 service. It will cost about £5 million a year. The issue is that we have not had the funding to do that yet. We are constantly banging the drum on that one, but we do not have the funding yet.

The Chairperson (Mr McGuigan): That would be welcome.

Sorry, Danny, I have eaten into your time.

Mr Donnelly: That is fair enough, Chair.

We have moved on to stroke services, and I am interested in the stroke action plan. I know that it has not met any of the targets that it was supposed to. We were supposed to aim for, I think, 12% by March last year, and we have not hit that target for thrombectomy services, so we are lagging behind.

Mr Jakobsen: That is contingent on having 24/7 service, which we do not have yet. We will never get to that target unless we have it. That is critical.

Mr Donnelly: You raised the issue of ambulance capacity. As you rightly identified, the issue with ambulance capacity is that ambulances are stacked up outside hospitals for, I think you said, two hours.

Mr Jakobsen: Many wait for over two hours.

Mr Donnelly: When we met paramedics, they told us that they were changing shifts outside hospitals. It is therefore not necessarily an Ambulance Service problem but a patient flow problem in hospitals.

Mr Jakobsen: You are 100% correct.

Mr Donnelly: That is what is impacting on stroke patients, who are category 2 patients.

Mr Jakobsen: It absolutely is a patient flow issue. We need to get patients into the hospital in the first place. The situation is not acceptable, and we need to resolve it.

Mr Donnelly: It is more about the back door, however. It is about being able to get patients out in order to keep the flow moving.

Mr Jakobsen: Yes.

Mr Donnelly: There were 30,000 responses to the consultation. You said that there were 28,000 responses from the SOAS campaign group. A number of responses were outside the remit of the consultation: were they those 28,000?

Mr Jakobsen: No, I did not mean the responses themselves; I meant that a lot of issues raised were outside the remit of the consultation. They all addressed the consultation in one way or another, but many responses included comments that were not directly related to the questions that we had asked. They were about lots of wider problems: fears of losing services; hospital closures; not being listened to; not trusting the Department or the trusts when we go out to consultation; and thinking that everything is a done deal already and that we are just ticking boxes. It was that kind of feedback. Those are fair points to make. I am not saying that they are not.

Mr Donnelly: I will read out what we got from the Minister:

Were all those responses outside the remit of the consultation?

Mr Jakobsen: The issues raised were, not the responses themselves. Respondents might have answered the questions but added those comments. They might have written many pages on issues that were outside the remit of the questions that we asked.

Mr Donnelly: Are those responses being counted?

Ms Estler: Yes.

Mr Jakobsen: Yes. Definitely.

Mr Donnelly: OK. That is quite a lot: more than 90% of the responses.

Mr Jakobsen: Yes.

Mr Donnelly: We are sitting on a £600 million deficit at the minute, largely as a result of the Minister's promises on staff pay that have not been fulfilled yet, as the Chair mentioned. If that matter is not resolved, are services at risk and, if so, which services?

Mr Jakobsen: There is a programme under way to try to deliver savings this year. Achieving that will be difficult. I think that the Minister said that we cannot deliver £600 million in savings but we will deliver as much as we can. There is no doubt that that will impact on services. I remember the Minister saying last year that he would not make any savings that would have catastrophic impacts. I am not sure whether he said that this year. Any savings that we make will have some service impact. Savings almost cannot be made without that happening.

There is a big programme under way to reduce the number of agency staff and instead recruit permanent staff in order to reduce the bill for agency work. We can probably save a bit there, because, if agency or locum staff are more expensive, we can probably replace them with like for like. There are small savings to be had that way without impacting on service delivery. Once we start scaling back services, however, that will clearly have an impact.

Mr Donnelly: Can you say which services are at risk?

Mr Jakobsen: I do not have the detail on that. It is still being worked through. A programme is being led by the finance side of the Department, which meets weekly to work through such things. It is an ongoing process.

Mr Donnelly: You mentioned level 2 A&Es. What is a level 2 A&E?

Mr Jakobsen: A level 2 ED is a highly specialist ED. For example, if people have an eye emergency, some EDs in the UK specialise in treating such emergencies, but we do not have any in Northern Ireland. I am being told that we used to have an eye-specific ED in Belfast years ago.

Mr Donnelly: We had an emergency eye clinic in Belfast.

Mrs Dodds: Do we not any more?

Mr Donnelly: I think we do.

Mr McGrath: We used to have two level 2 EDs.

Ms Estler: The definitions of EDs were reviewed to make sure that we were comparing like with like in the other nations.

Mr Donnelly: No level 2 EDs exist here.

Ms Estler: It was not a service that was due to —.

Mr Donnelly: We do have any level 2 EDs in Northern Ireland.

Mr Jakobsen: As far as I know, no. We have level 1 EDs and level 3 EDs. A level 1 ED provides a 24/7 service, while an ED is level 3 if the service is less than 24/7.

Mr Donnelly: I have one more question, Chair.

Peter, you said that most reconfiguration decisions would be taken forward by the trusts. Which decisions will be the Minister's decisions, and which will be the trusts' decisions?

Mr Jakobsen: If any reconfiguration decision that a trust makes is major and controversial, it will be referred to the Department to be endorsed or not.

Mr Donnelly: That will likely be the vast majority of them.

Mr Jakobsen: I would suggest that many of them will be major and controversial.

Mr Donnelly: They will not be taken forward by the trust; it will be the Minister.

Mr Jakobsen: The trust board will take that decision. It will submit its decision to the Department alongside a consultation report with all the evidence that it has. All of that will then go to the SPPG in the Department, which will review it. The SPPG will take advice from the PHA from a public health perspective. It will also take advice from the Department's policy side, which links in with that. All of that will then be submitted to the Minister with a recommendation on whether he should agree with the decision. If the Minister turns it down, the trust will have to come back with a revised proposal. That is the process.

Mr Donnelly: Ultimately, it is the Minister's decision.

Mr Jakobsen: It is almost like a veto. The Minister does not decide what the option is, but he essentially he has a veto on permanent major and controversial decisions.

Mr Donnelly: OK.

Mr McGrath: Thank you for saying that.

The Chairperson (Mr McGuigan): There is currently such a situation in the Northern Trust. It is awaiting the Minister's decision.

Mr Jakobsen: Exactly. That is the scenario that we are in.

Miss McAllister: Therein lies the problem of it being political.

Mr Robinson: Peter, in the previous session, we were told that 69 responses had been received to the serious adverse incidents (SAI) consultation. It sounds as if those undertaking that consultation had an easy run. [Laughter.]

Mr Jakobsen: Are you saying that we are winning? [Laughter.]

I am not sure.

Mr Robinson: You received 30,000 responses, so I assume that those numbers are extreme in the grand scheme of consultations.

Mr Jakobsen: It is the most responses that I know of.

Ms Estler: We are not sure whether it is the most in just the Department of Health or the most across all Departments, but the figure is definitely up there.

Mr Jakobsen: Our friends in SOAS contributed heavily to that number.

Mr Robinson: I get that, but there were a couple of thousand other responses beyond the SOAS responses. Again, that is an extreme number.

Mr Jakobsen: No, it is usual.

Mr Robinson: How will the feedback from the consultation directly influence the proposed transformation plans? Will it at all? Have people responded effectively?

Mr Jakobsen: First, we will reconsider the proposal in the consultation to see whether we can still go ahead with some of it. That will be in the consultation report. There were specific issues. For example, a lot of data was shared about Fermanagh in the responses. We will share that with the Western Trust for it to consider as part of its deliberations as it takes forward its consultation.

There was information provided on transport, which was raised quite a bit, particularly for rural areas. That information will be shared with the Department for Infrastructure, which has responsibility for transport in those areas. As appropriate, we will share information with the stakeholders and partners that we work with. We will then consider the direct implications arising from the questions that we asked in the consultation.

Mr Robinson: Did any members of staff respond to the consultation? Obviously, they will be concerned about service relocation.

Mr Jakobsen: Members of staff definitely attended the consultation events. I am not sure that we know whether there were staff among the individuals.

Ms Estler: Some of the Citizen Space online responses would have identified whether they were staff. They would have responded primarily on the workforce questions or on rural aspects in their capacity as staff. That has been accounted for.

Mr Robinson: Is there funding available for delivery?

Mr Jakobsen: No funding is allocated at the moment. We need to consider what needs funding. Some of the actions on collaboration do not need funding. For example, the review of the transport policy does not require funding; it requires just a bit of resource from the Department and the cost of an assistant to review and revise the policy. Some things do not require funding.

Mr Robinson: That will do in the meantime, Chair. I am conscious of the time.

The Chairperson (Mr McGuigan): Before I let you go, I will hog a couple of minutes. You have attributed 28,000 responses to the SOAS campaign. That is fair enough, as SOAS led the campaign, but it still had to get 28,000 individuals to respond. That, in itself, sends a strong message about the strength of feeling on the issue of acute hospitals. I just wanted to make that point.

In our correspondence, we have a letter from the Department of Finance on engaging with all Departments about a five-year departmental plan. I will read out what it states, because I suspect that it resonates with what we are talking about here:

Has the Department of Health submitted its five-year plan?

Mr Jakobsen: I have certainly contributed to it. I assume that the five-year plan has gone to DOF. It is coordinated by the finance side of the Department, so I do not know whether it has been submitted. I know that I contributed to it.

The Chairperson (Mr McGuigan): That will be a very important document for all the transformation elements that we are talking about. Can the Committee get sight of that document?

Mr Jakobsen: I will need to take that request away.

The Chairperson (Mr McGuigan): OK. If the Department is saying, "Here is what we want to do over the next five years, and here is what we want to spend our money on", having that plan is crucial for all of what we have talked about on setting the direction for transformation: what the Department considers the future role of GPs to be, what it considers the future role of pharmacies to be and what it considers the future of primary care to be.

Mr Jakobsen: You are right. The money has to follow the priorities. Otherwise, there is no logic to the plan.

The Chairperson (Mr McGuigan): Yes. We need to know how the Department intends to pay its staff and how it intends to deal with the workforce issues that affect every aspect of healthcare. We would like to see that document.

Mrs Dodds: Following on from Colin's issue about rural communities, it seems to be easier to take services away from rural communities. The Minister said that all policies are rural-proofed. Can you send us information on what that rural-proofing looks like? What process do you go through? Is it a tick-box exercise? You do not have to say anything now, but, if somebody were able send us that, that would help us to understand what "rural-proofing of services" means. Many of us here come from fairly substantial rural communities.

Mr Jakobsen: We can do that. There are rural-proofing guidance notes.

Ms Estler: Yes, there is a toolkit.

Mr Jakobsen: There is a co-produced toolkit that is good. That is what we follow.

Ms Estler: We completed a rural needs impact assessment as part of the consultation for the hospital network document. We are now in the middle of revising it to take on board and reflect the feedback from the responses.

Mrs Dodds: It would be interesting to know what guidelines you have followed when you say that you have rural-proofed something.

The Chairperson (Mr McGuigan): I have a final point before I let you go. This might help us decide whom we invite to the Committee in future. We have sessions at which having one official is sufficient. In future, let us fill the chairs with officials who can speak on the issues that are likely to be asked.

Mr Jakobsen: The reset plan is so wide that it covers everything in the Department. Unless we know exactly what you are going to ask us, it is difficult to —.

The Chairperson (Mr McGuigan): There may need to be a bit of interaction between us and the Department.

Mr Jakobsen: It might be helpful for us to have a meeting with the Clerk in order to gain a sense of what the issues are for the Committee, and we can then get the right people to attend.

Mrs Dodds: Perhaps we should just get the permanent secretary —

The Chairperson (Mr McGuigan): We are getting him.

Mrs Dodds: — and the Minister to attend. They own the reset plan.

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

Ms Estler: Thank you.

Mr Jakobsen: Thank you.