Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome from the Department of Health Mike Farrar, the interim permanent secretary; Jim Wilkinson, the deputy secretary for the healthcare and policy group; and Tracey McCaig, the chief operating officer of the strategic planning and performance group (SPPG). You are all welcome, and thank you for coming. You have sent us the reset plan and the business plan, so I will hand over to you, Mike, to make some introductory remarks, after which we move straight to questions.

Mr Mike Farrar (Department of Health): I will try to keep my opening remarks really brief, and we can then take questions. The previous time that I was here, I talked a bit about how I viewed Northern Ireland and about the need to reset our system. I said that we would publish the reset plan, and we have done that. There are things in the plan that, hopefully, the Committee will be able to support. The proof of the pudding is always in the implementation, and you will, no doubt, ask me about that. In essence, we are placing more emphasis on primary and secondary prevention in order to keep people well and on responding quickly when they need help.

The plan describes what we have called a "neighbourhood model" of healthcare. That is consistent with most health systems in the world, which are trying to get to people earlier and to standardise their care in order to make sure that it is of a high standard. Where people need secondary care, we are looking at delivering the pathways in an evidence-based way. Programmes such as Getting It Right First Time (GIRFT) point to areas in which we can do better and achieve more productivity. We are also looking at using the data that we have, which is a great asset for Northern Ireland, to understand where we need to target efforts and focus priorities. We may say more about that in due course. We are thinking about what signals we will send to Health and Social Care (HSC) and to the people of Northern Ireland about our priorities over the three years, when we get our settlement, because, in a sense, we have not really been as clear as we might be or want to be about the priorities for expenditure.

In the plan, we have also talked about life sciences. I have just come from a meeting with a large number of potential funding bodies about opening up Northern Ireland's system to be much more innovative much more quickly. Doing that will bring financial benefit. Crucially, alongside that, we are looking at efficiency. I have been trying to say that it is not a sensible strategy for Northern Ireland to assume that we just can carry on at the pace at which we have been going, just increasing spending. That has flatlined since 2022, but the overall trend is still going up, at the expense of things such as education, transport, housing, the environment and community cohesion, all of which will impact on health in wider terms. It is therefore about trying to get value out of our spend.

We are doing a couple of things that it may be useful for the Committee to know about, and we are happy to answer questions on them. We now have a system financial management group meeting weekly that looks at all our expenditure across the whole system. The Department of Finance is on it, and the Northern Ireland Audit Office (NIAO) comes to meetings if it wants to. There is open access. We are also looking to make savings. You know and will, no doubt, want to ask about the fact that we are asking for support on the pay element, which is £200 million. I know that dialogue is ongoing about that.

We are absolutely trying to change the way in which we work. One of the reasons that we have not got things over the line previously is that some of the cultural elements that we need have perhaps not been in place. I will mention three elements on which we are focusing most. The first is to operate as one team. That sounds like common sense, but, sometimes, we have not quite operated in that way, and we now do so. The second is to get our clinicians to lead on some of our general management challenges rather than for them to feel that their job is just to manage the one patient who is in front of them. The third is to devolve some of the decision-making from Stormont, where, by default, it has ended up, in order to empower our trusts to take and be accountable for some of the decisions much closer to patients.

That brings with it a richness of good decision-making, but it also puts the responsibility in the right place. We are trying to change the operating model.

As the Committee might imagine, when stones are turned over to try to reset, things are found that need fixing in the short-term, but we have tried to set out a longer-term vision. I believe that this is a three-year plan not a 10-year plan, as England is saying. In three years, it would be nice if we had a little more resource to oil the wheels of change but not continue to spend money that should be spent in other areas. As always, I am optimistic. I have a lot of support for the vision for the reset, and, although there is a lot to do and we are starting behind the curve compared with England, Scotland and Wales on some things, there is no reason to believe that we cannot leapfrog them and be in better shape. That is quite optimistic. I could have pulled out some of the things that are more challenging, such as our financial ability to meet the pay award this year. We are also dealing with some quality issues, but every one of those things gives us an opportunity to think about how we can avoid encountering them in future, while still trying to deal with them in the short term.

I will leave it at that, if that is OK, Chair.

The Chairperson (Mr McGuigan): Thank you. I promise, with the exception of my first one, that my questions will all be relevant to the reset plan. I just want to raise the issue of capital projects and capital builds, which is in the news today. I looked at the Department's draft budget, and there are 14 projects under that £79·2 million. They are under the heading of "contractual commitments" and are projects that are reasonably well advanced or for which contracts have been signed. The children's unit at Altnagelvin Hospital is one of the 14, yet we hear on the news today that there has been a decision taken to halt that. The Department has not commented on it. When was that specific decision taken, and when will another decision be taken about whether that project is to go ahead? For the other 13 projects that are listed under that heading have similar decisions been made? I am concerned about, for example, the Birch Hill Centre in Antrim, on which I have followed up. All the projects are important. Can you give me an assessment of the other projects and where they are, as well as what the way forward with capital projects is?

Mr Farrar: I will start with a general point, and then Tracey may want to come in. The issue for us is that we are having to look at every pound that we have. As you know, in the past, capital was sometimes used to support revenue and resource problems. That has been consistent practice across the NHS over the past 10 years, and it has been no different here. We have been looking at whether that is something that we need to bear in mind. In a sense, there is a constant review being done of our capital programme. We have been asked to submit our proposals into an even bigger set of planning proposals for the Northern Ireland footprint to determine what capital allocations there may be for the Department of Health in the longer term. Ideally, that might have been a 10-year plan for capital, and we know that the investment strategy for Northern Ireland (ISNI) has not quite got there yet. That is the wider government piece. We are having to look at our entire capital programme and ask what the cost of any delay is versus what we may be able to offer as an opportunity for supporting resource use. That may be because of bartering between Departments that may need more capital but have resource to spend across with us. That is really why there has been some scrutiny of the projects, and we are looking at them on a case-by-case basis.

Ms Tracey McCaig (Department of Health): To add to that, there has been no firm decision taken on all those projects. At the minute, they are all on a pause list so that we have a chance to have the conversation about whether we have opportunities to have a capital surplus that will help us manage our revenue position and whether, looking to the future and the three-year budget plan that we might have, that matches the revenue consequences that come with such capital schemes.

Every one of those projects is on the list because it is a priority. We want to support all the projects. There is not one of them that we do not wish to support. The reality at the moment, however, means that we have to take a moment to look at them. That is the position now. There is no firm stamp on any of them. About all the plans, we are asking, "If we don't proceed at the speed at which we plan to progress, what will that mean?". It is all in the modelling. I know that that is disappointing. We have had lots of challenging conversations. The projects are in there because we need them and want them, but it is about whether we can afford them, given the projected numbers coming into the Department on the capital side and on the resource side. It is a challenge for us.

The Chairperson (Mr McGuigan): I am a wee bit confused. The Department of Health's draft budget states:

You seem to be saying to me now that that is not the case.

Ms McCaig: I am not going to comment on specifics, because I heard the news literally as I walked into Stormont today, so I will have to check that one out. On general principles —.

The Chairperson (Mr McGuigan): Does that refer to all 14 of the projects? There is a list of 14.

Ms McCaig: For the Birch Hill Centre, for example, there will have been a contractual commitment to the design principles, but there will not necessarily have been a contractual commitment to the rest of it. It is therefore perhaps about how it has been expressed in the draft budget document. I have used Birch Hill as an example, because I know about it. Where we have not had a contractual commitment, projects would have been classed to us as having been partially committed to, and we might have had to relook at them. They would have been in a category of partials. I cannot talk to you about every one — I do not have the details with me — but we can provide an update in due course.

The Chairperson (Mr McGuigan): I do not want to paraphrase what you say, but are you saying that, in the Department's budget, £80 million was set aside for those projects that you now may no longer spend on them and that you may instead divert the money to meet revenue costs?

Ms McCaig: We are looking at the options to determine whether that is even something that could be done and exploring that with the Department of Finance in order to manage the fact that we are overspending. We will have to make some decisions about how we manage that, which may mean the slight delay or deferral of a scheme on that list if we do not have a contractual commitment.

Mr Farrar: We have had no promise that there is a capital-to-revenue transfer available to us, but, given the situation that we are in on the revenue front, we felt it prudent to look at projects for which we are not going to incur additional cost to see whether there is a possibility of making that money available. To give the Committee a sense of the scale, around £25 million to £30 million of the £80 million could be in that space, if it is available, for

revenue transfer would be

capital expenditure that there is, but that is the kind of scale that we could use.

We may get certainty that that facility is not available to us. At the six-month stage, I asked everybody to make sure that we would not lose that resource if we did not have a capital-to-revenue transfer —in other words, we would still be able to spend up to the maximum of £80 million — and I was assured that that would be the case. We are not in danger of losing money, but we are reviewing the schemes, and we have around £30 million worth of schemes in our sights for which we are asking, "Would it be possible for them to contribute to our revenue problem as a short-term thing?". Again, that is not to say that we have ruled out any of the schemes receiving long-term development and support.

The Chairperson (Mr McGuigan): It is welcome that they have not been ruled out. When will we hear whether the children's unit at Altnagelvin Hospital in the Western Trust is likely to proceed? Will the same date apply to all the projects?

Ms McCaig: What we are outlining now is how we are in an evolving situation with the financials. We will have to see how the situation plays out over the next month before we project until the end of the year and determine whether an opportunity is there.

I need to review the Altnagelvin scheme specifically, so my comments are general at this point. I heard about it only as I came in the door, and I cannot remember the detail of it. We are looking at all the projects on a case-by-case basis. You mentioned Birch Hill. The Northern Trust and others call us constantly. That project, however, is in a group for which we are saying that we have to wait. We have to use every lever to manage the financial position, and we are doing the best that we can. Each of the projects comes with a future revenue cost. There is an in-year cost and a projected future cost. With the budget that, we have been advised, we will have, we have had to relook at our ambitious plans. To be clear, we want all the schemes to proceed. That is our ambition. We have taken them through lengthy business case processes and invested significant time —

The Chairperson (Mr McGuigan): And money.

Ms McCaig: — and money to get them to this stage.

The Chairperson (Mr McGuigan): That is one of the public's criticisms. They will expect us, as politicians, to convey on their behalf the fact that the Department does not have a great track record — I put that mildly — with capital projects. As you rightly point out, Tracey, those 14 projects are all absolutely necessary. The Department has deemed them to be so. Staff have invested significant time in them, while outside bodies have invested significant amounts of money. It would therefore probably be unacceptable if money and time were wasted and if those projects, which are needed, were not progressed. I am disappointed that we are not getting some firm answers today. The Committee should be furnished with —.

Mr Farrar: We can come back to the Committee on the specifics of the Altnagelvin scheme. I can give you one firm answer today. The Public Accounts Committee (PAC) has, as you know, been critical of capital planning generally, and we have put ourselves forward for a departmental review that will be supported by the Strategic Investment Board (SIB). We are open to looking at how we improve the process by looking of the schemes that we have had. I am hopeful that that will help you.

One of the things that I have noticed and that is an issue for us — I cannot give you a randomised GOAL trial stance on this — is that the building cost for some of our schemes looks high compared with what I would expect in an English context, beyond the differences in labour market supply or whatever. Again, we are prepared to look at that. If driving down the cost of some schemes means that we can do more of them, we are prepared to do so. We have taken action to improve our approach. I was surprised to hear the news about the Altnagelvin scheme, because it had not come across my desk.

The Chairperson (Mr McGuigan): OK. I will move on.

You talk in the departmental business plan, Mike, about taking a preventative approach to health, of which I am in favour. It states:

It is now October 2025, and I have not heard much about it, so I am not sure that the public will have heard about it. Will you provide a bit more detail about the engagement and what it entails?

Mr Farrar: I will explain. In the past, we have had a lot of fairly traditional public health messaging about people getting their five a day, monitoring their alcohol unit consumption and doing exercise. To be frank, just giving out information is not a very effective way forward. What we have to do is communicate with people about how they feel about their health and what they understand to be normative for their health. We are trying to have a rather different dialogue with them, rather than just preach to them, "Please be healthier". The idea behind the This is Health programme is to get people to define in their own terms what health means to them and then find a mechanism by which we recognise whether they are taking action to improve their health. If they are, we can reward them by saying, "Thank you" or connecting them to a reward. We have not ruled out the idea of giving people a reward for taking action. That might be in the form of vouchers for healthier food or whatever. There might be a way in which to do that.

It is about using behavioural science information rather than public health information. We have just recruited a behavioural scientist who will work with the Public Health Agency (PHA). The individual was a global behavioural economist for Lululemon. As I often say, if someone can persuade people to spend £150 on a pair of jogging bottoms, that person knows how to influence public opinion. We have now gone through the process of contracting that individual. We have set up a group that is pulling together all the key people. We had a round-table at Hillsborough Castle that was run by the Patient and Client Council (PCC), which represents our formal way into the population. We have started to get in people in each of our trusts who are connected to that.

I appreciate that a lot of that is process stuff, but we will try to use some of it at an early stage to influence our winter plan and to help us think about how staff come forward for vaccination and immunisation, for example. It is, however, the beginning of something, so we have to frame it right. It is a work in progress. It probably has not hit the public yet, because it is not a campaign in the way in which you might imagine. We will, however, start to make sure that that way of working is how we communicate with the public about their health.

The Chairperson (Mr McGuigan): It would be great to get an update on the real living wage for social care workers. The plan states September 2025, I think, so I wonder when we will see progress.

Mr Farrar: At the moment, that is in the same space as pay generally. I have not been able to say to the Minister that he can afford to do that at the moment, given the budget that we have and given the risk of overspending on his current arrangements. We are making huge inroads into making savings to address the £614 million funding gap. We have been consistent that that is the figure that we have to get to. Introducing the real living wage would, I think, add around £25 million to that. At the moment, it is a bit like when the Minister said that he intended to make the pay award: I had to say to him, "You will have to direct me, because I do not have the budget to make it". Introducing the real living wage is in that space. He has not asked me to do it yet. That is where we are in the short term.

The Chairperson (Mr McGuigan): You said that you are making inroads into meeting the savings target of £300 million.

Mr Farrar: It is £600 million.

The Chairperson (Mr McGuigan): It is £600 million. How far off the target are we? Where have those efficiencies been found in the Department?

Mr Farrar: I will let Tracey take that.

Ms McCaig: We are talking broadly about savings of £600 million. We have quoted savings of about £614 million, but it may be a bit easier to follow if we talk in general terms.

It is important to establish where the £600 million of pressures were coming from: the full-year effect of last year's pay; our projection for this year's pay; the 6·7% increase in the national living wage, which we will give to domiciliary workers who are not directly employed by us, care workers and others; the increase in National Insurance; the real living wage, of which we have spoken; some money for growth in demand; and money for the projected high-cost drugs that will be coming through from the National Institute for Health and Care Excellence (NICE) that we have to pick up. That is the £600 million, keeping it rounded.

We have been working through savings. We indicated at the beginning that we thought that we could get to £300 million. We knew that that would be challenging, and we are broadly in that space at the minute. The first £200 million is from trusts managing cost containment; managing changes in skill mix; managing the agency and locum position; and trying to drive out the additional staffing or temporary staffing costs in the system. That means changing from using agencies and locums to looking at the rotas to ensure that they are as efficient as they can be in using permanent staff or at least directly employed temporary staff.

We have made other central savings that contribute to the £200 million. We have had some opportunities, such as with some of the drugs costs that the SPPG manages. We have no direct involvement in how the prices are set: they come to us from the Department of Health and Social Care (DHSC). We have a bit of movement on a couple of things there. From the June monitoring round, £25 million came in that, we said in our plan, we were expecting to receive, although that amount is lower than what we got in previous years.

To save the next £100 million pounds, that is where our capital revenue — the £30 million that we discussed earlier — comes in. We have identified other savings and advancements through the Department of Finance's strategic finance management group that Mike spoke about. That has taken us to about a £300 million shortfall.

Saving the next £100 million will take us to £400 million. Pay is broadly £200 million, so, excluding pay, we have to get to £400 million. Hitting that next target — £400 million — is much more challenging for us. We are working across all the budgets, but tough decisions, like those on capital and many more besides, will have to be taken now. At this point, we have not made decisions to implement a vast range of savings. Meetings are ongoing. We will have to assess the impact on service and how far into that £100 million we can go without having a serious impact on what we deliver daily.

Trusts have risen to the challenge. Through the second wave of savings that we have been carrying out with the strategic financial management group, they have added an additional £30 million to £40 million to the pot. They are trying to drive through those savings. I have been assured that they are working hard, as are our departmental teams. Hitting £400 million is not guaranteed, because there are very difficult decisions to be made. I do not want to rehearse them openly at the minute, because we are still working through them, but it would still leave us short of saving £400 million, excluding pay, as I said, which is £200 million of the £600 million.

That is the position that we are in, and that is why we have to think about not introducing the real living wage and other things. We would not normally wish to have to do that, but we are struggling to break even. I assure the Committee, however, that tremendous effort is being put in behind the scenes. It took a significant effort to get to £200 million-plus of savings last year, and we are now pushing much further.

Our baseline is made up of staffing costs and running costs — those are for large units, which are largely hospital-based — and the direct drugs and other things that our patients require. It is difficult, but we are working our way through the final £100 million of savings to get to £400 million.

Mr Farrar: I will mention one aspect of which the Committee should be aware. You may remember the money that was set aside to help us to make progress on elective care. There were three elements to it: red-flag and urgent care; additional capacity; and a further £85 million. Is £85 million correct?

Ms McCaig: It was £80 million.

Mr Farrar: It was £80 million. That was the money with which, ideally, we would have been building more capacity in order to be in a better ongoing position. We got good news about what we have been able to do with the first two chunks of money and about the HSC trusts stepping up, so we have been able to suggest that £73 million of that £80 million could go towards our savings. That means, however, that we have not been putting that resource into investing for our future, because we have to live within our means. That is a consequence, but it does not mean a service reduction. It is about being able to hit the Programme for Government (PFG) targets this year, but it does not mean that we will be able to do that in future years, because capacity is an issue. We were hoping to build more capacity.

The Chairperson (Mr McGuigan): It is my understanding that that £80 million was part of the £215 million that was ring-fenced.

Mr Farrar: The £80 million was set up slightly differently. I think that the word is "earmarked", which —

Ms McCaig: Not officially.

Mr Farrar: — means that, ideally, it would have been, but it is not ring-fenced in the same way as the other two amounts. The Department of Finance is aware from our savings plans that we were going to do that.

The Chairperson (Mr McGuigan): OK. I am sure that other members will delve deeper into that issue.

I will ask about the new neighbourhood models that the Department is keen to implement. The models seem to rely heavily on GPs. Currently, there is friction between GPs and the Department or between GPs and the Minister. Today, the Committee received correspondence alerting us to the fact that eight GP services — I do not want to put words into their mouth — are in a serious condition. I am sure that that reflects the situation across GP practices. It is good that the Department has plans, because there needs to be reset and change, but you need buy-in from pharmacists, GPs, dentists and so on and to co-design with them. All of them, particularly GPs, tell us that they are in crisis because of the Department's funding arrangements. Can you give us any update on how negotiations are going with GPs and how those feed into implementing the neighbourhood model?

Mr Farrar: You are right to talk about the importance of GPs. GPs have an opportunity to lead the neighbourhood model. That is not the way in which they work now, however. At the moment, they are doing work that could be done by community pharmacists or patient groups. They are managing work that they should not be managing; it should be sitting with secondary care instead. I have been talking to the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA), whenever they will talk to us, about the best models for primary care.

Primary care provided by a small practice is chaotic, in that that practice does not know what will come through the door.

When you start to get scale, you can be highly predictable about what is going to come through the door: urgent care, elective care, planned care and preventative care. Therefore, you can start to manage the GP workload. Also, you can employ and work better with a pharmacist; about 35% to 40% of what GPs are dealing with currently could be dealt with by a pharmacist. A lot of GP practices will have pharmacists, because we have been supporting them to have those pharmacists in place. If we bring people out of hospital, it enables those consultants who are in medical specialities to be more available. In fact, if you ask Frances O'Hagan, she will tell you how much she enjoys the paediatric support that she gets in our advice and guidance model. She says that that has made a huge difference to her having to use hospitals to care for her patients who are children and families.

This model is different from the one that we have. One of the risks that we have is that the GPs have asked for more money for the same, and I am saying that I am really happy to look at the business case to spend more money. In fact, this requires us to spend more money as a percentage in the neighbourhood. To give you a sense of that, 2% of the money that our hospitals currently spend on services where people have to go to hospital rather than getting the care close to home is worth about £160 million. That money would be available to put a range of services around the neighbourhood, bringing in community pharmacy, voluntary groups, GPs, social care, local government, which is a big factor there, and trusts to provide a better service. I offered, and I was slightly disappointed that, after a letter had gone asking them to look at a new contract with us for the future, they went into the press, which was sad, saying, "We have not had that". I could prove it, but I do not want to go into that. There is a real opportunity for us to talk to them about the future and invest in a model that I think would be better for GP workload and for patient care. It would also solve a lot of the financial issues that some of the people have.

I am very sad that we are in the position that we are in with them. I have an open door — the Minister is absolutely party to this — for them to come and talk to us about what we could do. I do not think that it serves the population of Northern Ireland to put more money into it. I was with the Royal College of GPs recently, and we had a very good conversation. We have GPs, through their federations, who are engaged with us and are talking about the neighbourhood model. I would love it if the BMA came back.

I have one final observation, which is that, in 2002, when I negotiated a move from fees for service to population health, which is when we updated the contract, GPs were saying to me, "This is all wrong. We should not be putting money into a new way of working — the population health management approach. Just give us more for fees for service, because GP numbers are starting to decline". When we eventually got to the end of that negotiation, we had 83% support in favour from the GPs. They got more money. It is the only time in NHS history when a higher percentage of growth funding went into primary care than secondary care. There was 83% support, and patients benefited because we had a population approach. I am hopeful that GPs will have some faith that we want to put more money into general practice. We see those practices as the heart of the neighbourhood. We would love to co-design the neighbourhood with them, but, at the moment, they do not want to play. They want to stand and say, "No, you cannot do that". When I have asked, "What do you want from your £80 million?", the biggest thing that I get back is, "More GPs". I will give you the figures for how many GPs we have per head of population. We have 71 GPs per 100,000 people in Northern Ireland. In Wales, it is 64·5 GPs per 100,000 people; and, in England, it is 59. Even if I agree that we need more GPs over time, because I believe in the role of a specialist generalist — that is part of our vision: generalism helps people to avoid the cost of a specialism — stop taking one chunk of them and think you can do that. If you were able to do that, we still could not get GPs in overnight. I am really struggling to do things in the sense that I would love to have that conversation with them. We are very committed to opening negotiations and to looking at funding streams into general practice for next year, but I will come back to this: I do not think that it serves the population in Northern Ireland to put more money into the same system that we have as opposed to investing in a new way of working.

My last comment on this will go on the record. It has never been on record before. In 2002, I had money set aside in the contract negotiations to give GPs a sabbatical, because, when you become a principal GP at around 28 or 29, you then face maybe 40 years of a career that looks fairly similar. I said that, every five years, we should give GPs the opportunity to have six months doing research or management training or even have an unpaid break. The other opportunities would have been paid. I said, "Please can we do that?", and, at the very last minute, the GPs came back and said that they would like that money taken away from that and put on to a quality and outcomes framework (QOF) point so that they would get more in take-home pay, because they thought that that was an issue for them. I do not want to make that mistake again where we feel that, in order to manage the short term, we have put money into the wrong thing. I absolutely guarantee you that, if we had a sabbatical for GPs, their morale would go up, they would be happier, we would keep them for longer and more people would be attracted to work in general practice, which we need.

Sorry, you put me on my hobby horse. We are in a poor place. I am a great friend of GPs. I am an honorary fellow of the Royal College of General Practitioners. The door is open, and I am very happy to talk to them. To be frank, I think that we will be proved right that, over the course of the next three-year settlement, more resources will be going into general practice for a different way of working. That is all I can say, really.

The Chairperson (Mr McGuigan): If I were a member of the public listening, I would be a bit disconcerted with that. GPs are vital to everything that the Minister is outlining in the Assembly about shifting left. They are the public's first point of contact with the health service, so this is a situation that we need to resolve. I am not making a political point about who is responsible, but the Minister's statement in the Assembly that has ended the contract negotiations did not do any good for the mood of GPs regarding the Department. The Health Committee wants to see that resolved, because it is absolutely vital for every other aspect of our health service that GPs are not handing back contracts. We need GP practices that are open where the population can access them. Whatever way it needs to be resolved, it needs to be resolved.

Mr Farrar: I take the point, but I ask the Health Committee to think about what where it wants us to invest our money in primary care and the neighbourhood model going forward as opposed to what we have now. I ask you to look at the evidence about what primary care will be in the future. On the point about the public appetite on this, the BBC website asked how hard is it to get an appointment with a GP, and about 75% of people said that it was hard and 25% said that they found it easy. We do have an issue around access to GPs, and the question is of whether the best way to solve that is to try to grow the GP workforce over what would take us a longer period of time or to think about whether we can get GPs working together in a neighbourhood arrangement where you go to the right professional sooner so that, when you do need a medical generalist or a specialist, you can get to them faster. The current system is not working. We diagnose the same; we just have a different solution.

The Chairperson (Mr McGuigan): The Committee, a couple of weeks ago, committed to look at that specific question where we do intend to look —.

Mr Farrar: We welcome that. I will come along, and I will back up all my rhetoric with the evidence. I can take you to places that have gone down a different route. They have higher patient satisfaction and better access, and, actually, they are getting better outcomes.

The Chairperson (Mr McGuigan): To be clear, what we have agreed to do is look at the shift left and what it means for community care. I have taken up enough time.

Mr McGrath: Will we pay our nurses the money that they are owed?

Mr Farrar: I hope so. I have done everything that I possibly can to ask for the money that we need. I also have a duty as accounting officer. I do not think that I would go to jail, because I do not think that it is a criminal offence, but I think that it is a civic offence. With huge regret, and, as you will see from the Minister's previous statements, with regret to him, I have to say that, at the moment, we do not have the money to guarantee that we can afford that.

Mr McGrath: What is the process for that, given that the Finance Minister said the other day that he hoped it would be sorted out? As permanent secretary for the Department that is responsible, if "nurses' pay" is on your to-do list, does that mean that you have meetings with the Department of Finance? Does it mean that you give the Minister a poke and say, "Get in and talk to that Finance Minister"? What are the nuts and bolts of what you need to do?

Mr Farrar: You know the process of ministerial direction. That had to go to the Department of Finance, which said that it was too big and it had to go to the Executive, and the Executive have not decided on that. The Executive have been asking both Ministers to speak constantly about this, and they have asked me and the permanent secretary to look at what we can do. One of the issues is that this has become tied up in not just the nurses' pay award but awards for wider staff groups and the potential financial position of the Assembly — the Executive overall. It has become a sort of wider conversation, but that is ongoing. I promise you that I spend an awful lot of time talking to colleagues about what our options are to do this, but, at the moment, I cannot take away that letter in which I said that you cannot afford it. I do not have a financial solution as we speak.

Mr McGrath: A monitoring round is due this month, but I think that it has been pushed back to November. Does that mean that there might be a Christmas present for our nurses? Is there an opportunity for money to be made available in that monitoring round for nurses to get the pay that they are owed?

Mr Farrar: I hope so. I think we can certainly move forward. As you know, the nurses are potentially balloting, and we absolutely want to avoid any industrial action if we can.

Mr McGrath: I think they said that, if there was no agreement by 30 September, they would progress to balloting, so we are in what feels for nurses like the annual place of them not getting their money. However, I will take the hope that you have. Having hope is better than not having hope, so, hopefully, the November monitoring round will bring some money.

There is one bit that I do not get. It is not that I am disagreeing with you; it is just something that I do not believe in. I do not think that our trusts — I know many of the chief executives — are so inefficient. Some have said to me occasionally, "Oh, but they are". I do not think that they are so inefficient that they are racking up hundreds of millions of pounds of inefficiencies and that you can just click your fingers and say to them, "By 1 April next year, find me all that money out of your inefficiencies". I firmly believe that, if they have to come up with hundreds of millions of pounds of savings, then, among those hundreds of millions of pounds of savings, things are not being done that were being done. That is a cut. Are there any headlines of the cuts that are actually happening, or is it the case that trusts are just so inefficient that they can find hundreds of millions of pounds in savings?

Mr Farrar: I will let Tracey come in on that.

Mr McGrath: I appreciate that that is a loaded question, but you saw where it was going. You get the point.

Mr Farrar: I will try to illustrate some of the dynamics of it. When we are paying temporary staffing, we are paying at a premium compared with substantive posts. There are a whole set of vacancies that we carry. With some of those, we probably have to say, "Well, we're going to delay them" or "We're not going to need them and we'll try to find better ways of working". Some of them we should fill as best we can, because it avoids us having to have temporary labour. All the time, we are looking at that. We are looking at sickness absence and what we can do about that. So we are really low as a system on vaccination and immunisation uptake by staff. Going into winter, our vaccination and immunisation uptake is nowhere near what it should or could be. Of course, if you have not been vaccinated, you are more likely to get flu, and if you get flu, you are off work. A lot of the things that we are doing you would not call inefficiencies, but they are things that we could do better.

There are then other pieces that are about service change, and I will give you an example of that. Ambulances get called to care homes to take older people into hospital. Usually, it is because they have fallen, become dehydrated or whatever. The latest piece of information that we have about those who were taken to hospital is that around half get admitted, and, of those, 80% are admitted for something that was not the cause of the ambulance callout. In other words, once they get into our system, someone says, "Now you are here, we'll do bloods. We'll have a look at that". People who worked in the profession will know that that is what — you know. Those are conditions that were being managed OK in the care home setting. We might say, "That's great, because that's preventive and it's going to stop a problem down the line". Actually, some of that is people being admitted who probably do not need to be. We are looking at every area and standardising practice. We could show you the data from across Northern Ireland, but you probably already have it. A person in one trust might have a three-day hospital stay, while a person with the same condition and level of need in another trust might have a six-day stay. It is not that we are cutting there. It is that we are saying to trusts, "If you can be as good as the one that is doing that in three days, we can have three days' worth of benefit from that, which we can take out as saving, or we can effectively give you more operating capacity to reduce the waiting lists further".

There is a whole raft of different things in that, but, as Tracey said, when we start to get beyond the obvious areas where we are taking cuts from the central budget and we are asking them to do —. Our starting position was, "Can you live within last year's out-turn?" I am sure that the Committee knows that, with Agenda for Change pay rates, because of incremental growth, it is not just about the headline pay rate. Even if we had a pay freeze, the pay bill would go up by about 2% every year. There are costs that you cannot prevent going up, so, even as we have been debating whether we can pay the nurses this year, our payroll has gone up by 2%. How do we offset that? When you start to get into what we could do to get £600 million out of our budget, when you start with that as a budget, as we did in the middle of April, even if you say, "We will take headcount down", given that that is our biggest expenditure, we would have to make redundancy payments, as is only right and proper. Assuming for now that the redundancies are voluntary — I am not announcing any redundancies; I do not want to give the wrong impression. In a voluntary severance arrangement, you have to pay for the redundancy and you do not get that back in-year, so that does not help us with the cash planning. It might help us to manage our budgets better next year, but, this year, that is why we cannot go all the way to get the pay, which is the biggest chunk of the £200 million, but we can get as far as we possibly can towards it.

Tracey might want to give some examples of where the next £100 million of savings, beyond our £300 million, would be.

Ms McCaig: The illustration is that it is in-year, so it is what you can effect in 12 months. You look at the things that are variable or flexible, or they are demand-driven and you just happen to hit a lucky spot and do not have to spend as much as projected. Those are the things that we contract for at different levels, which is why, unfortunately, you often hear about the domiciliary care with the independent sector or care homes. Those are the last things that we want to touch, because they are the bedrock of how we manage on a daily basis, but those are the things that we have to look at.

For the next £100 million, all the trusts have come forward, and they are looking at some services on which they would have to hold a line and maybe not deliver the same volume as before. That could hit our elective care, which we do not want to happen. We have been really successful in driving our elective care in the first months of the year, and we do not want to lose the effort that we have put in for the people out there who have been waiting for their operations, but it is about things like that. It is about reducing the headcount more, because that is our biggest bill. As in any business, there is no other option. You look at every line of your business and say, "How could I?", but it is about all those things. We have not given permission to go there; we are still trying to work our way through all those things.

We have done our financial planning very differently this year in that we have taken some risks at the front end of the year that we might have waited for the back end of the year to take, in order to try to avoid getting ourselves into that situation, but getting to the next £100 million is tough. It is about reductions; it is about holding the line; it is about containment; and it is about delay. Those are all the types of words that we have in, but we have not given permission for those things at this point. We are still sitting with a very complicated conundrum to work out that ties in with the capital conversation, the real living wage and all the other elements. Our time is short, and we are aware of the pressure in that. It is going to be a challenge for us, and, in my conversations with the permanent secretary, I do not see an easy route. There is no easy route on this one, because the scale of it, inside 12 months, is just so big. That is absolutely why the pay conversation is so vital to us.

Mr McGrath: Would it be OK for the Committee to ask for a breakdown of where those cost savings are coming from? It would not have to go right down to the individual budget line. You have given us a few examples of where there could be a saving of half a million here or a quarter of a million there, but is there something that could tell us where the hundreds of millions are being saved?

Ms McCaig: We can certainly give the breakdown of the £300 million. On the other £100 million that we are still debating, I might have to be more general while we work through that so that we do not frighten people with something that we might not decide to do. We can set it out in such a way as to give you a little more information. I am happy to —.

Mr McGrath: I have a question about the Ambulance Service, which is for a short answer, rather than a big long one. I have constituents with family members who have taken a stroke. They dial 999, explain the symptoms and are told that it is a stroke, but it takes six and a half hours. You could literally dispatch an ambulance from Glasgow, and it could probably take a boat over and get to my constituency quicker than that. Our ambulances are stuck outside the hospitals — we know what is going on there. Is there a plan? Are we heading towards a two-hour waiting time? Is that on the horizon, as a minimum at least?

Mr Farrar: We put in a lot of effort and brought people together on that. We looked at how London got down the 45-minute standard. We are looking to do that. Some of doing that is about costs, and some is about logistics. Wherever we can, we have said, collectively, that we are committed to getting to that two-hour standard.

Ms McCaig: We had colleagues from London with us. The way in which they moved in that space was quite inspirational. I do not think that there is any great difference between what they had and what we have. We have had agreement across the region — remember that this is not a case of growing to four hours — that we do not want anything over four hours during September. I will be writing to our colleagues across the trusts with the results, which are being collated at the moment. I suspect that a couple of sites have struggled, but a few have shown great progress.

We do not want those that are already at 45 minutes to get worse in the process of fixing the other problem. It is about two things: holding the line on what we have done well and, for those that fall above, bringing it down. It was four hours in September, and then we moved to three hours and two. We are seeking to get to the least worst position before heading into the winter. We have kept a tight monitor on that. On Monday, we will have a conversation with our chief executive colleagues about where we are and where further improvement may be needed. For example, Belfast Trust has made a good push into that. That is helpful, given where it is sited and the tertiary services that are behind it.

Mr Farrar: One last point, which is a very positive thing, is that the Ambulance Trust has made much greater inroads into its sickness absence than we get across the board. It is trying hard, and that is good news.

Mr McGrath: Thank you to everybody for driving that down. It is important to do that, especially for rural constituencies. Representatives of rural constituencies hear regularly about those long waits, and it is frightening — it is really, really scary. Thank you for that.

Mr Donnelly: After Health Committee meetings, we tend to get a lot of phone calls from people who have been watching. I imagine that we are going to get a lot today, particularly from GPs, who will have been listening to what you have been saying with some surprise, and maybe trepidation. We will see where that goes.

Your delivery outcome 6 is the winter preparedness plan. Initially, we were told that that would come in August. Your name is against that, Jim.

Mr Jim Wilkinson (Department of Health): Yes.

Mr Donnelly: We were initially told that it was coming in August, and then we were told that it would be September. I think that the target is now September.

Mr Wilkinson: It is September, and we are into October.

Mr Donnelly: The most recent update said that it had been delayed to September. We are now in October, and there is no plan. What can you tell us about that?

Mr Wilkinson: The conversation that we have just had is an integral part of the plan. Part of the plan is to look at ambulance handovers and all aspects of urgent and emergency care. We have touched on another part of the plan, which is vaccine uptake amongst staff. The plan is at a well-advanced stage. Members know that we have a plan every year. It is well advanced and will be delivered earlier than it has been delivered in any previous year.

In addition to what we have done in previous years, we are looking at the work on which the Chief Nursing Officer (CNO) and the Chief Medical Officer (CMO) have been leading under the "big discussion" label. With that, what we are effectively doing, in addition to everything that we are doing on ambulance handovers, early discharge, hospital avoidance, vaccine uptake and public health messaging, is saying — again, some of this has been touched on — that there is a particular cohort that we need to look out for this winter: the elderly and the frail.

We need to look out for that cohort because we know that those individuals are major users of urgent care services over the winter. We know that an ED is not that cohort's preferred route of attendance to achieve their care. That came from that "big discussion". In primary care, GPs are keen to be involved in that discussion, and they have the best knowledge of their patients. Secondary care is involved in that discussion, alongside the Northern Ireland Ambulance Service (NIAS), the voluntary and community sector and social care. That is one area in the plan where we really want to indicate what we are going to do or can do differently this year that provides a focus for that cohort. We believe that, in that area, we can make some differences to the pressures that we get. Those are not differences around ED attendances: they are about the best possible urgent care in the way that that cohort wants it.

The key question is what are we doing about timing? We hope to publish that winter plan imminently, because those plans and proposals are coming to a conclusion. We have a bit more work to do in order to be a bit more specific, so that we can be clear about what we will achieve and clear in the public messaging that needs to go with that. We are working to get that published before the end of October. There is pressure from the Minister to get that done, and we will get it to the Committee as soon as it is published.

Mr Donnelly: It was August, and then it was September, and now you are saying that it will be published before the end of October. You have it as an amber on the red, amber and green (RAG). An amber status means "some delay" but should be done at the end of this year. The end of this year is 31 December. Are you saying that that is

?

Mr Wilkinson: An amber for that means that it should be done, with some delay. Our delay is October from August.

Mr Donnelly: That is not quite an accurate description of where it stands on the RAG, then?

Mr Wilkinson: It is amber, in that it was not in September, which it said that it would be, and was not in July, but that it will be with delay. The delay, at the moment, is until October. We will have it in October.

Mr Donnelly: Hopefully, you will have it by the end of October. It was produced in mid-November last year. The Royal College of Emergency Medicine said at the time that that was "too little, too late". What is going to be different this year? What is it that will improve? You mentioned things such as care of the elderly and vaccine uptake. What is going to make the big difference? As I see it, the main issue is social care. We have a lot of patients who are in hospitals and cannot get out, and that backs up patients who are lying in beds in corridors. A&Es are full of patients who should be on wards. Ambulances are stacked up outside that cannot discharge patients in. As Colin mentioned, people are waiting for hours at home for ambulances that are stacked up outside hospitals. What in the report is going to build that capacity in the community?

Mr Wilkinson: I will call on Tracey in a moment. The main thing to say is that we will continue to look at all the angles, from ambulance delays right through to early and timely discharge. There is a constant focus on how to achieve discharge and create places. One of the key elements of the "big discussion" has been what we can do to avoid ED attendances. We can do that by providing the right care at the right place. That goes from the Ambulance Service doing increased work on Hear and Treat and See and Treat to working closely with GPs on early engagement and medical care planning, as well as some of the work that we are doing around frailty and falls. We are looking across the system, but, this year, we are looking in particular at what we can do for that elderly population to help them stay healthy and meet their care needs in their home. In so doing, you avoid ED attendance and admission, which Mike has talked about, and the delay in the discharge. As well as that, you avoid the deterioration. That will be one of the key areas.

Mr Donnelly: We talk to staff, patients and families all the time. I know that the pressures on our health system over the summer have been very high and have continued. There have been beds in corridors and A&E waits, and there have been ambulances outside A&Es all summer. The high pressure that we normally feel in the winter is now felt all year round, including in the summer. We are now moving into a period of extreme pressure. There is a lot of apprehension among the public, and people are very concerned. We were told that the plan would come in August, then September, and now you are telling us that it will be October. We are very concerned to see this plan and see it implemented, so that it will make a difference this year.

I was at an event today, which was put on by Voice of Young People in Care (VOYPIC), called Show Us You Care. VOYPIC has produced a report on children's social care reform — the Ray Jones review. Have you seen that report at all?

Mr Farrar: I have not read it, I have to say. The original report or —

Mr Donnelly: This is the update. The original report was more than two years ago.

Mr Farrar: I am sorry; I have not seen the update.

Mr Donnelly: The original report was June 2023.

Mr Farrar: I have had two meetings with Ray.

Mr Donnelly: OK. So, this update comes more than two years after the original report. It is about young people in care with lived experience giving their impressions of what needs to change within the system. I do not see anything in the reset report. I know that you have a reform section, but is there anything about children's social care services reform?

Mr Farrar: We have referenced social care generally with regard to reform, but we have not picked out the children's bit. That is not to say that we would not be interested in continuing to progress that. I think that we have done 46 of those recommendations; seven relate to setting up the agency, which is, perhaps, the most controversial in the sense that Northern Ireland is very proud of its integrated services, and this would actually disintegrate them, but I know that there is a commitment to do it. We are really aware of some of the areas that, if we had more resources available, would have been a priority for us.

Mr Donnelly: We have increasing numbers of children in care. As I am sure you know, it is more than 4,000 now, and the trend is going up. We have a reform plan here that is more than two years old, and, as you said, there are recommendations. Some of them are at a very early stage, and when you say that they have been achieved, we have had questions about that, similar to the RAG colour coding. I encourage you to read that report and act on it, because it is a very important issue.

Mr Farrar: Before you finish your questioning, I want to put the record straight. You paraphrased my answers on primary care as though it were negative. I am not at all negative about primary care. I am a very proud fellow of the Royal College of General Practitioners. I support independent contractor status, and I support the GP federations. We need to actually find a model that will work in everybody's interest, and that is why I am interested in a conversation. The door is open. If any GPs who are watching feel that I have misrepresented or misunderstood, I am very happy to speak to them.

Mr Donnelly: I will certainly be talking to local GPs, as I am sure other members will, about their opinions on what we have heard today.

I have a third question, if the Chair does not mind. With regard to research, which I think is delivery number 7 in your delivery plan, what specific progress has been made on the establishment of the strategic research partnership?

Mr Farrar: We have a coordinating group, which is basically the two pro vice chancellors from the universities and pretty much anybody who invests in innovation in, for example, city deals and/or technology pots. We have written a clear approach, which will involve three stages. The first is discovery, and, at our last meeting, we committed to setting up what we are describing as an academic health partnership, very similar to the ones that you might have in some of the more advanced systems. That will involve the universities and ourselves looking at how we can attract more research, particularly commercially funded research, because it offsets our costs as well.

The next area is development, which is about how you convert ideas, particularly for those areas where we have spinouts from our universities, into practice, and how you would decide the priorities there. To do that, we are looking to expand on the Health Innovation Research Alliance Northern Ireland, which we have, but it operates on a bit of a shoestring, and what can we do with the Department for the Economy around building that capacity to look at those ideas and bring them through. We are also talking to potential funders, who, if we had oven-ready ideas of new jobs that we could create and new ideas to improve health outcomes, would come on board. I have just come from a seminar where we had a number of funders who are prepared to look at our options and who want to fund in Northern Ireland.

Finally, the last bit, which is the key to it all, is delivery, and the idea there is to use our committee in common to try to have a single proposal around innovation, which can be heard by all the trusts at the same time, so that the whole system can actually pick up on innovation, rather than an innovator having to go to six separate trusts; they can do that once. We have an idea that we have not landed on quite yet, but we will, I am sure, which is that each of our trusts will have a research and innovation committee tracking their ability to adopt innovation and to come forward with innovative ideas.

We are creating an ecosystem. I did a report for Northern Ireland about three years ago called 'Health and Wealth in Northern Ireland', which went to Economy and Health, and, actually, it is starting to put in place that effective ecosystem.

We are really pleased about the progress that we are making. Everyone is on side, and there are already tons of people who are interested in investing in us. I will not mention them now because, if we do not get them over the line, you will ask me when I come back why we did not. However, there are a number of parties, private and social investors, who are really interested in putting money in, which can help us alongside our financial position to bring more resources into Northern Ireland. Therefore, we are not just looking for more from the public purse: we are looking to generate jobs and growth in Northern Ireland on the back of health and life sciences.

The Chairperson (Mr McGuigan): Can I just follow up on that, very briefly, before I bring in other members? There was an issue about the sharing of secondary data on an all-island basis, which was hindering research. The Minister gave a commitment in the Assembly a while ago that it was something that he thought that he would bring —.

Mr Farrar: We are bringing legislation forward.

The Chairperson (Mr McGuigan): Yes, he would bring in legislation. I cannot remember when he said it. I think we are into the amber stage you now, probably, so it would be worth —.

Mr Farrar: We have the best data platform in the world for research because of Epic and the GP information platform, but a piece of legislation is hampering us. It does not completely stop us, but it is hampering us, so we need to change it.

The Chairperson (Mr McGuigan): Absolutely, and I think that that is the case, particularly in the sphere of cancer and other issues like it. We can all benefit from all-island research. It can also, as you say, bring in money.

Mr Farrar: Having a population of 7 million rather than one of 1·9 million is very helpful for research purposes. Even 7 million is too small, in certain cases.

Mr Donnelly: Can I just make a point about the monitoring diagram? We have talked about the RAG colour-coding system. We have 23 greens that are on track to complete this year. Do you seriously think that we are going to get them all?

Mr Farrar: Jim loses his head if — [Laughter.]

Mr Wilkinson: As you know, this is a business plan. The challenge that has happened this year is that we have adopted a strategic document as a business plan, which puts a new rigour into the delivery of a strategic document. It puts business plan rigour to it. That is why we apply the RAGs to it. Normally, you would not see that against strategic commitments. This is our assessment of where they are from the policy teams that are leading them.

A lot of our greens are in the preparation of guidance. Some of our greens are in the delivery space, some of them are what we will do to push reform forward to the next stage. Our challenge is this: as it stands, the teams are saying that they can deliver this within the timescales and commitments that they have. It will be monitored quarterly because that is the way that we do business planning. However, the reds are the biggest problems that we are dealing with. You will see that the finance one is there. I think that our neighbourhood model is in the red space. Our neighbourhood is to come up with, "What is the model for neighbourhood in Northern Ireland? How would it work?". The operating environment in which we can land that into delivery has to take account of the challenge of the GPs. We are working to try to resolve those contractual issues and deal with such matters as we can, as well as shape the future. That is the same for elective care, as we work to, "What might happen in the operating environment if we end up in a difficult space with our consultants, nursing workforce and our social care workforce?" Those would all have impacts on delivery. Therefore, it all has to be continually monitored in the context of the operating environment.

However, as it stands, we have applied business plan rigour to a strategic document, and that is where we are.

Mr Donnelly: Thank you.

Mrs Dillon: I am sure that it is not your intention but, if we are talking about a reset, the first thing that we need to do on the GP issue is a wee bit of a reset in tone. I understand that your door is open, and I do not doubt that. I do not doubt that you are serious about what you want to do here. I do not question that. However, the door of my office is always open, every day. However, if I do not build a relationship and trust with the people who come through it, they will not come to me. They go to somebody else, and that is OK because I have not built that relationship. I have not invested my time in them. They do not feel that they can trust me with things that matter to them.

That is just a comment, and I am just throwing it out there. You do not need to respond to it: I do not expect you to. I do not doubt your commitment to this. I just think that there needs to be a reset in tone because GPs say that they want a deal. The Department says that it wants a deal, but nobody is bringing them together to say, "Let us work this out, we can work together. I am for you; I have your back. Let us sit down and have a conversation.". I am going to leave that there.

On children's social services, it is in the reform plan and in our briefing. I think it is SS5. Am I right? Even with my glasses, at this stage of the day, my eyesight is not great. It refers to funding being:

That is positive, and you have a business case with the Department's economists, and:

I would definitely like an update, particularly on the back of Danny's comments.

My question is about the engagement with the Reimagine Children’s Collective because, unlike Colin, I think that there are efficiencies to be found. Money is being wasted daily, and that is not exclusive to your Department, but it happens every day. I sit on the Policing Board with Nuala and others, and we challenge the requests for additional resources by asking whether the best use is being made of the allocation. For example, there can be two social workers in a hotel with a child, and rightly so, because a child should not be in a hotel on their own. However, if you were to work with the community and voluntary sector, there could be a better solution for the child at a lower cost. We are not working efficiently as a system or a Department, not just the trusts, but across the board, and it does not deliver good outcomes for the child. A child in care should not be cared for in a hotel. It is a good example of how working with the people who know what they are talking about could deliver the best for our children. Money can be saved and efficiencies made to give better outcomes. I would like an update on the Reimagine Children’s Collective when it is available.

Mental health services are under the neighbourhood model of care, and I welcome the vision for regional delivery. How will that be delivered? I live in the Southern Trust area, and it does not have the people. It is not about investment; the trust just does not have the psychiatrists. All the resources have been pulled into boosting the residential psychiatry service, and there is little to nothing in the community. It is not because the trust does not want to deliver in the community but because they cannot do it. How do we plan to fix that?

The status is green, but does that mean that the plan will happen quickly? How will it be done? I need to understand that because it feeds into everything else that we have talked about. It feeds into the ambulance issue because ambulances are repeatedly called out to people in mental health crises who do not need an ambulance. They need the right service — they need a pathway. When I talk to families with a loved one in that position, I never get an answer when I ask about the pathway for another crisis. They do not have a pathway, and that is the problem. If the model is a pathway, that is great. However, is that what it is? How quickly will we see the model delivered regionally? Are mental health services being regionalised, and I am not saying that I am opposed to that. I just want the best service for people. If the service is in the neighbourhood, it does not matter whether it is centralised because people will be seen in their homes, the GP's surgery or a place close to their home. I need to understand a bit more about that.

Mr Wilkinson: I will pick up on the mental health services.

Mrs Dillon: I understand if you cannot answer that in detail because other people may be responsible, but can we get the information?

Mr Wilkinson: You will need a detailed briefing on the mental health strategy, and the team will be more than happy to do that. When you look across it all, it will be clear that all our strategies have three elements. First, what can we do today, and what can the system do to work better? For example, we now have mental health practitioners in NIAS call centres, and they can deal with some of the queries that are mental health calls rather than ED calls. Some trusts are working closely to make mental health professionals available to move individuals from the ED, which may be the worst place for them to be, to the help and care that they want. As we roll out the multidisciplinary team (MDT) programme, we are making mental health services available at the primary-care level.

That covers the tactical and operational elements. There is, then, a strategic place where, if you like, we have developed our strategy and co-designed it with users and the voluntary and community sector. That is the long-term objective and the one where we will continually say, "Here is where we want to go. The pace and impact of what we do will be affected by the budget that we have available". There is then the responsive element and the change element — the elements that you were asking about. What are we delivering and what can we achieve? That is why those targets are interspersed, a bit like children's services, across the piece.

I know that Peter Toogood and his team are doing a huge amount of work in the mental health space from a strategic perspective. That is matched by Tracey's team on the operational side, and, in this instance, I think that the Committee would benefit from a much more detailed briefing on that subject rather than the overview that I can give you at this stage.

Mrs Dillon: I will go back to the efficiency issue. We talk about how the trusts can make efficiencies and about how, even as you go down into primary care, everybody can be more efficient. However, some of the problems and challenges are because of the Department. When trusts are saying, "If we change how we do this", they are not able to change it quickly enough. This is not about any individual in the Department or SPPG, but they are not dynamic enough. The wheels turn too slowly, so let us, maybe, have a wee bit more of an open relationship with the trusts and allow them to make changes quickly. You still have to have proven —. The slowness of being able to —.

Mr Farrar: I will make a point that I think is implicit in your challenge to us. If we think about these problems in the context of the whole system rather than think about everybody in isolation, you will struggle, or you might be able to find better solutions. That is precisely why we have set out the idea of committees in common. A single paper can be heard by six subcommittees of each trust at the same time, and they can come to a decision that is then taken back to their own boards, because the boards remain the ultimate decision makers. If you take something like psychiatry and the regional service, there is a much speedier way that we can get all the trusts to make a contribution in what they do. I know Steve Spoerry from the Southern Trust well, and he has been saying, "We are really struggling with our psychiatric service. We are struggling to recruit". That is an area where the trusts can now, together, start to think about how they support that and whether that takes us more into what a regional service would look like, over and above what is available locally. We have mechanisms to deal with that, and, in my experience, the trusts work together really closely on some of these challenges in a way that perhaps, 10 years ago, they were not doing. I am very heartened about that.

Mrs Dillon: I know that they do, and I am aware of the committees in common. That is a good move. We will have to see how things pan out, but if we can even get written briefings on those two issues, that would be helpful.

The Chairperson (Mr McGuigan): Two more colleagues want in. We will try to accommodate everybody, so keep questions and answers shortish. Nuala, you are next.

Miss McAllister: I do not know whether that was directed at me.

The Chairperson (Mr McGuigan): No, I am just conscious that —

Miss McAllister: I am only messing.

The Chairperson (Mr McGuigan): — we might be coming to —.

Miss McAllister: I have a few questions. I will start with commissioning of services. As I understand it, the commissioning of services is done on a trust-by-trust basis, and we have heard from medical professionals and patients that that leads to inequalities across trusts. I mean commissioning of services as a whole, whether that is equipment, staff or a particular service. You are shaking your head, so I assume that commissioning of services is not done on a trust-by-trust basis.

Ms McCaig: It depends on the situation. When it comes to equipment and services, the trusts will have a budget and will manage it themselves. They have a bit of flexibility in their budget depending on the outcomes that they are delivering. That could be right, but, equally, when we are working as commissioners through SPPG and when the Public Health Agency is implementing the strategies, we look at that as a whole-system approach and try to maximise where we can deliver it, but it would be a whole-population approach now. In the past, we very much looked at the local population and worked very locally, but we are evermore working as a whole system. I do not know anything that my team is working on where the first conversation is anything other than, "What is the regional need and how can we level the position for patients?". There are occasions when we will invest in one trust as opposed to another.

However, we are trying to get much more regionalisation. In your colleague's example, we are looking at psychiatry for a single trust but also regionally. Commissioning is not about saying, "Let's get into that trust", but there are also capitation reasons. Capitation is about levelling everyone up. Depending on where areas start from, you might have to invest slightly more in one area than another to balance out inequalities. It is about all those measures at one time.

Miss McAllister: That is definitely helpful for moving forward. To me, any form of service reconfiguration would include a review of the services that operate on a trust-by-trust basis to make them regional. We do not really get much of an insight into how much that happens. From our engagement with the sector, whether it is the royal colleges or trade unions, we know that they do not feel that they get to input into how that happens, even though it will be their members who will deliver the services on the ground. Is that led by you or the Department? Surely someone needs to be in control.

Ms McCaig: I am the Department as well, but I am the operational arm of it. It is slightly different.

Mr Wilkinson: It varies. If it is a regional service, the Department will lead regional service reviews, as it is doing in neurology and stroke services. It will look at the regional service. Separately from that, with the SPPG and PHA, the Department will set the context in which hospitals or trusts should look at how they organise their services. Mike has added a third layer, in that we are now increasingly giving trusts collectively the opportunity through their committees-in-common structure to collaborate to improve how they deliver the services for which they have responsibility and take those decisions through that structure, as long as it does not impact on what we have asked them to do.

Tracey is right: it is probably fair to say that there is a big difference between the commissioning of new services and the legacy of how most of the services have been commissioned. In many ways, they are distribution bases from which to deliver a service that has changed.

Ms McCaig: I will pick up the point about the colleges. Jim and I co-chair a number of the strategic advisory groups. There is different representation, including from the Royal College of Emergency Medicine and the Northern Ireland Cancer Charities Coalition, throughout that group from the strategic level down, which informs some of our plans. It is a broad church, and it starts at the beginning of the process, but, at its core, commissioning is about planning for your population need, looking at what is there, looking at performance management and how efficient it is and bringing the partners together to make those decisions.

As trusts have grown over time, however, they will have changed services. I might commission x and go back to find that it has morphed slightly into y. The service never stays the same, because trusts are trying to meet the need on the ground as well. It will never stay the same. It has to be dynamic to meet the needs that are there, so it will be slightly different, but we look at it as a global picture. Our Public Health Agency colleagues are mindful of health inequalities and of how we manage that within those planning dynamics.

Miss McAllister: One example of that is the referrals for breast cancer in the South Eastern Health and Social Care Trust. The cancer waiting time statistics that came out today said that, shockingly, only 6% of people began treatment within the target time. That is horrific. I am not asking you to do this, but I do not know whether we could name a service where, no matter where you live, you can get it within the target time. I do not know whether we could name a single one that is doing well. How long will it take for the breast cancer figures for diagnosis and treatment targets to start to go the other way?

Ms McCaig: I hope that you will see significant improvement through quarters 3 and 4. We have a lot of investment. Lots of things happened at once. We put a regional breast cancer waiting list together, and, at the same time, two of our trusts brought in the Encompass system, so you almost would have expected a downturn. Unfortunately, we always see a bit of a downturn in the summer period. That is not acceptable; we do not want that. The energy is being put in. I have a team, and Jim has a team, and this has been an absolute focus of what those teams have been doing. We have a number of significant regional clinics that will work from an assessment-diagnosis base over the next period. We are really pushing those through the next quarter. We have been working with our clinical colleagues, including a lot of the colleges — you had Professor Mark Taylor with you last week — to see how we can generate those at pace and at scale. A number of the clinics will be coming online over the next period, so, if it all goes the way that we have planned it, I will expect to see a significant improvement. Things happen, and we have to react to them, but that is the plan going into quarters 3 and 4.

Mr Wilkinson: It is a three-stage approach. The first stage is considering what is best delivered regionally. Part of the regional approach is to try to minimise inequalities, acknowledging that there is a service under real pressure. The second is considering what can be done today for a service that is under pressure, and that is about how best to make use of any additional capacity that you can bring — the mega-clinics. The third is considering what you need to invest today to improve the workforce and the capability and capacity that you have. That could apply not only to workforce but to equipment and imaging. That means that, in two years' time, you will have increased capacity and will not have those issues.

Miss McAllister: You mentioned equipment. I have mentioned robotics in the Belfast Trust to the Minister many times. I cannot remember its fancy name. It was commissioned for urology because they are specialists, but that has now skewed numbers on women's and men's health. There are real-life examples that show that, when you do commissioning trust by trust rather than regionally, it can have an effect of inequality across the system.

This question is based purely on anecdotal evidence. I completely understand the use of the private sector to meet the waiting list targets that we talked about. However, has any work been done on the number of staff who are employed by the HSC and are also working in the independent clinics that we, essentially, send patients on to? We hear anecdotal evidence where patients say that they have just gone private but the consultant whom they see is the one whom they were supposed to see on the NHS. Is that a problem? Are consultants being lost because they are choosing to cut down on NHS work and work in the independent sector (IS)?

Ms McCaig: We would not answer you in the way that you have asked the question. A lot of our consultant colleagues put in a full-time job in the NHS. A lot of what we are doing with waiting lists, including the £50 million that we have within the £215 million that we talked about, is about cutting the numbers of the longest waiters. Those consultants are working probably in the IS and, potentially, also for us to do additional clinics to move the numbers down, or they are working in one or the other. We are asking for additional time because, with the workforce that we have, we are having to look at an appropriate skill mix and at where working with our primary care colleagues provides a better pathway to make sure that we maximise at all points the use of advanced practitioners and allied health professionals (AHPs) where appropriate. It is about all of those things. I do not necessarily see the use of the independent sector as a bad thing.

Within the waiting list money we had three pots, which we talked about. With the £85 million, the first plank was about capacity building, and that is about capacity building in the HSC. This year, because of the way that we have run into the year, we used more IS — the figures ran from last year — in the first quarters, but that starts to switch through the back end, when we have more recruitment and investment coming in-house. We want to build the capacity as far as we can in-house, but, where we have a vulnerable specialty where we cannot recruit — psychiatry is maybe not the best such example of an area in an acute space — and we can get it from somewhere else and we need it for our patients, we will always try to maximise the use of the independent sector. It is a mixed economy, but building in-house is where we want to go, as far as we can go.

Mr Wilkinson: It is worth adding to what Tracey has said by saying that all the contracts are what the contracts say. The consultants work the hours that are part of their contract. As part of the work on waiting lists — Tracey's team is clear on this — we only pay for additionality once we have received the service and the service levels that we expect through the commissioned level. If x number of operations is what we have commissioned and what we expect, we will not pay for additionality until the system is able to show that it is delivering x.

Ms McCaig: You must be efficient in your day job before you get access to the additionality from within the HSC. That is one of the planks that we put in. It is part of our drive for efficiency of the whole system. It is one of the levers that we put in this year.

Mr Farrar: When you spot purchase from the independent sector in a sort of crisis, you will pay a higher price. We will be working with the private sector for some time as it supports us to reduce those waiting lists. We are trying to negotiate what a longer-term arrangement would look like to help us to manage the price of our work with the private sector. We are mindful that it is an important relationship, because, when we spot purchase, as has happened in the past, we end up with higher cost.

Miss McAllister: I completely understand that you have to use it.

If it works for consultants in that sense, it should be the same for GPs. GPs are working to their maximum capabilities too. I do not have the figure off the top of my head, but the volume of patients that they see each week and each month is bigger than that of any other medical professional. They cannot physically squeeze any more patients into their day. A GP, who has obviously been able to watch the Health Committee, has already reached out to me. We have GPs who work full-time hours, but we also have locums. If we had more money, we would be able to get locums and, more important, allied health professionals who can do the work so that GPs will not need to do it to work in GP services. If it is good for one; it is good for the other. We expect consultants to carry out their jobs before they work in the IS. GPs are already carrying out their jobs and cannot physically fit any more patients into their day.

Mr Farrar: General practice is, effectively, independent, because GPs are contractors in the same way; they just have a national contract. You raise a really important point — one that we have not talked about — which is that general practice and primary care is largely multidisciplinary now. The fact that we are investing in and continuing to roll out multidisciplinary teams is really important for primary care. I agree with you completely: there are so many areas in primary care where an allied health professional like a physiotherapist is exactly whom you should see alongside, say, a specialist generalist when you need one. I agree with you. We could do more to support that. Multidisciplinary support is very much part of the neighbourhood model. That gets the best out of general practitioners. I call them "specialist generalists": they are generalist medical practitioners, but they are specialists at that — they understand multiple problems. If you are a specialist in secondary care, you might understand only one aspect of care in great detail.

Mr Robinson: Thank you. I noted that the stabilisation piece referred to trusts now working as one financial unit for the first time. What obstacles or stumbling blocks are there to having a single trust? In the past, we have been told, "Now is not a good time". When would be a good time?

Mr Farrar: I will be honest with you. First, I do not think that there a single trust in the world that has a budget of £6 billion, which is kind of what it would be. Secondly, if we had a single governing body for that, the first thing that would happen is that you would have to have separate divisions covering different geographical areas. You may remember that there was an aspiration that local government reform in Northern Ireland would save a lot of money by going to smaller numbers. That has not quite ended up delivering what people anticipated. There is some thought that, if you go to a bigger governing unit, you reduce cost, but that has not been proven by any means. You would also have a huge amount of distraction with people effectively going through processes due to uncertainty about their jobs. We would still need to get the right decision at the right level, so you would not want all those decisions to be taken by one trust at Northern Ireland level. The committees-in-common approach allows them to take shared decisions, so we think that we have overcome that issue without structural change and distraction.

My view is that the Northern Ireland model should be more devolved but that we should be clear about what decisions need to be taken once. That is the key. It is not about having a single board; it is about getting the right decisions at the right level, with the minimum disruption to do that. The evidence suggests that. Lots of people have said that the answer is to have just one trust and that that would make it all go away. I do not think that it would, and the evidence does not suggest that it would. If the Assembly said, "We absolutely want you to deliver a single trust", it would be my job to do that. However, if I was asked for advice on it, I would say that it is a false hope that it would take cost out and improve decision-making. You are much better following the line of getting the right decisions at the right level. Certainly, trust boards need to be empowered to take more of the decisions that we take on a Northern Ireland footprint at the moment.

Mr Robinson: That is a fair enough summary, Mike.

I note the piece on prescription charges. From memory, when prescription charges were consulted on in the past, there were objections by Health Ministers. How will the consultation look? There is a proposal to consult. Will it be similar to the last consultation that specifically referred to specialist drugs that would be funded by the introduction of prescription charges? Given that there was opposition from previous Health Ministers, what is the current Health Minister's thinking?

Mr Farrar: The Health Minister has agreed to consult on prescription charges. He is open-minded about what will come back. What we are exploring this time that we perhaps have not done previously is — we are proposing charges in a number of areas, as you know, to help us offset our financial problems and put us in a better long-term position — whether we could hypothecate some of those sums? For example, if some people have to pay prescription charges, could we say that we will divert the money that we raise from that to support mental health or children's cancer services? That would make it really clear what the public of Northern Ireland are paying for. Of course, it would be progressive in the sense that we would make sure that the people who cannot afford it still get their prescriptions. You would expect that to be part of anything that we did. The point is that, if we raise money from that, can we give the public confidence that that will then help with children's services or mental health services? We are looking at that route. It might change people's opinions in the consultation if they could see that, by contributing in that way, it goes immediately to that area of care. We are exploring that.

Mr Robinson: Four years of the MDT model that you intend to roll out will be funded through the transformation fund over an eight-year period. Will there be a cliff edge thereafter?

Mr Wilkinson: As part of the bid for the transformation fund, we used a lot of the evidence that we have talked about today. It is really important that primary care has multidisciplinary teams for consultations. It is about what that mix should be. In order to draw down transformation funding — this goes to the first question that Mike asked about the investment in primary care — part of the commitment was that the Department would prioritise investment in primary care, with a call on the budget in year 4, both to fund what we put in and to allow the completion of the remaining five. Part of the commitment of transformation is that you fund and invest in it, and then you get the benefits. The Department has recognised that that needs to be maintained and supported. The financial sustainability question had to be answered up front. How we answered that was to give a commitment to prioritise primary care MDTs in the budget in year 4. That was part of the discussion that we had.

Mr Farrar: Alan, in a way, that is an exact microcosm of the reset plan. The big proposal here is that, by reassessing our healthcare system and managing some of our demand better, along with looking at inefficiencies where we have them, we will be able to live within our means, because those are transformational in character. Having a multidisciplinary team that can manage more people who end up in hospital allows us, per case, to reduce the cost of care. There are two options there for Northern Ireland: one is that we use the capacity that we create to eat into our waiting lists without having to pay more money for it, as we would if we were to use the independent sector etc; or we say, "We'll take that as a saving", which would then be available for other Departments to improve economic inactivity, educational attainment or whatever. That is the kind of principle that the reset works on, but it is not without difficulty. We have to have people committed to it.

The Chairperson (Mr McGuigan): Is there one committee in common, or are there different committees in common?

Mr Farrar: Each trust appoints a subcommittee, which is made up of its chair, its chief exec and one other person of its choosing. Those subcommittees meet at the same time, so there are six subcommittees from our six trusts around a table, like this. There is a single paper put to them that says, "We should come to a shared agreement". It might be on pay rates for locums or how we standardise a particular pathway or whatever. They all debate it and come to an agreement on what they are going to recommend. They then go back to their trust boards, which are the ultimate decision-making body in law — that is what you would judicially review, in a sense, if you were worried about it — and say, "Our subcommittee's recommendation to the board is that we accept that this is the way we're going to go forward". Effectively, it is one paper to one meeting, but it is agreed by six boards.

The Chairperson (Mr McGuigan): Who decides the paper that goes to the meeting?

Mr Farrar: The agenda is set by need or the areas that are relevant for the committee in common. It comes back to what decisions the trusts make in their own right because it is nothing to do with anybody else, or what decisions trusts take together because that makes sense as the system is best placed to make that decision. It is so that one trust does not say, for example, "We're going to employ 10 radiologists", which would denude the others; instead, you can have a discussion about how to develop a radiology service. That does not always guarantee that they will come to a shared view, but it is the most straightforward way in which to do it. It is very simple governance. It has the same effect as the single trust that Alan mentioned would have. It is tried and tested, and it is within our vires.

The Chairperson (Mr McGuigan): That is interesting. You have been very —

Mrs Dillon: Chair, I am really sorry. When are we likely to get some more information on what you were saying about prescription charges? I am so old that I remember why they were proposed in the first place and the reasons why they were not put in place — if you were on a low income and all the rest —.

Mr Wilkinson: Our timelines for prescription charges and other revenue-raising consultations are being developed. They are there, but, ultimately, we will be engaging with the Minister. I am conscious that many Departments —

Mrs Dillon: We do not have a timeline or anything.

Mr Wilkinson: We have a timeline for completing the work, in that the consultation will be ready to engage on, but, when the consultation is launched —

Mr Farrar: We have consulted other Departments so far. We have started that process by asking —

The Chairperson (Mr McGuigan): Am I right that there is no guarantee that the Minister will even take it out to consultation?

Mr Farrar: It is his choice.

Mr Wilkinson: Lots of Departments are looking at revenue raising.

Mr Farrar: Given the state of the finances that we are trying to manage, as well as the reset plan, we have to think about asking about charging. We may hypothecate for particular areas of care. It comes back to your first question about dialogue with the public. It is about whether we can get the public to understand that, when you need us, we have to be there, but that, in order for us to be there when you need us, we might have to do some things differently.

Mrs Dillon: I am starting to think that I am the oldest person on the Committee, apart from Alan Chambers, who is the Father of the House. Will I be the new "Mother of the House", or the "mother of the Committee"? [Laughter.]

The Chairperson (Mr McGuigan): The three of you have been generous with your time. We appreciate that. Thank you very much for taking our questions.

Mr Farrar: Thank you very much.