Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Jennifer Welsh, chief executive, Belfast Health and Social Care Trust (BHSCT); and Tracey McCaig, chief operating officer, strategic planning and performance group (SPPG). You are both very welcome. I will hand over to you for some opening remarks before we go to questions.

Ms Jennifer Welsh (Belfast Health and Social Care Trust): I will begin and then hand over to Tracey. I thought that it would be helpful for Tracey to be here to give the SPPG perspective. I have been in the job for three weeks, and you may have questions about the intervening period since the first cardiac surgery report and the interactions with the trust. I am happy to say a few words about my experience of the first few weeks. Tracey, do you want to say something first?

Ms Tracey McCaig (Department of Health): No. You may remember that I was before the Committee in June, around the time when the situation was unfolding. We talked about an accountability and oversight process in line with our performance accountability, support and intervention level 5. If members wish, I can give you some information about that, what has happened in the intervening period, the interactions with the trust prior to Jennifer taking up the post and the departmental view. I have nothing more to say at the moment.

Ms Welsh: I will give my reflections of the first few weeks. I have had a very warm welcome into the organisation. I have very much got a sense that the majority of people want to draw a line under the issue and move on. That is not everybody, of course, but I get a great sense of people wanting to distance themselves from poor behaviour, being very clear that it is unacceptable and wanting to tell me about the good work that they and their clinical teams are doing in their services. I have had the opportunity to be out and about a lot in the past three weeks.

I received the report on Tuesday afternoon, and I have had the opportunity to have in-depth conversations with Peter and Jennifer. One thing that I wanted to do yesterday, when the Minister published his written ministerial statement and the report, was to put something out to the organisation — I have now done that — to recognise the fact that, as Peter McBride said, there is a cohort of people who have been very damaged by some of the processes in the past few years. I want to recognise that, acknowledge it and say to those people that they have been heard and that I am very sorry that they were placed in that situation. I know that there are people who have felt unsupported and let down by some of the processes that have taken place.

There are almost two strands of work in that a lot of people want to draw a line under this and move on in a positive way, yet we have to find a way to look at how to support individuals who have been deeply impacted on by it. I can talk about that in more detail, but I am happy to pause there to take questions, Chair. Thank you.

The Chairperson (Mr McGuigan): OK. I wanted you to make your opening remarks before I welcomed you and congratulated you on your new role as chief executive. We all wish you well in the role. I have been the Chair of the Health Committee for eight months, and a lot of that time has been taken up with issues in the Belfast Trust. It is in all our interests that there is change, with new procedures and policies, and that we have fewer issues of the nature of those that we have been dealing with over those past eight weeks. Everybody wishes you well in your new role, Jennifer.

You had the opportunity to listen to Peter McBride and Dr Jennifer Hill as they gave evidence to the Committee in the previous evidence session. You have seen the report and their recommendations, and you have heard Committee members ask questions about those recommendations. Will you set out your thoughts on the report and your view on whether you and the trust will implement the recommendations and, if so, how?

Ms Welsh: First, I will say that I think that Peter and Jennifer have done a really great job. The report is very balanced. They acknowledged the many examples of excellent behaviour and where people have intervened to address situations. Clearly, they have also looked at all the areas of concern, and the Committee explored that in great detail with them this afternoon.

I fully accept the recommendations. They are very helpful to me, and I embrace them fully. I know that the chair of the organisation feels the same way as I do. We have shared the full report with the trust board. There is a formal process that we have to go through in considering the recommendations as a trust board. We will do that, and our recommendation will be to accept the recommendations in full. I fully expect that the trust board will do that. That is certainly the message that I have been getting.

There is nothing that I would dispute in the recommendations. As I said, we need to take time to consider them as a full board. It is not just the board that needs to consider them, however. We need to consider them as a wider senior leadership group across the organisation with our senior medical staff and other heads of departments, as well as with our trade union colleagues. We should develop the action plan in partnership rather than it being developed by the trust board and handed out to the organisation. That is part of the people and culture approach that Peter was talking about: we must do this with people, not to people. I am keen, therefore, to get out and about, as I have been doing in the past few weeks, to work with people to look at how, together, we can pull an action plan together.

There are things that we need to do at pace, of course, and I can make a start on those. There are other things, particularly around the people and culture strategy, that we need to do together with colleagues.

The Chairperson (Mr McGuigan): I am glad that you mentioned the trade unions. You have been in your role for only a few weeks. I was going to ask whether you had had any engagement with trade unions on that and other subjects, particularly the culture piece. You will have heard us asking Peter about issues beyond those with the cardiac surgery unit. What kind of engagement have you had with the trade unions, and what are your concerns about issues beyond the cardiac surgery unit in the Belfast Trust?

Ms Welsh: I have had engagement with trade unions. There is a regular meeting with the executive team. That happened to take place yesterday morning. The report was not published until 2.00 pm, so I alluded to it and gave some high-level information on it, but, obviously, because it was not published, I could not go into detail at that time. We will certainly follow up on that. I found it a constructive and positive meeting. There were really good exchanges between the executive team and the trade union members who were there. There is a real, genuine desire to work in partnership. I heard examples of ongoing work in which trade union members are part of working groups on various projects. It is early days for me. I have a meeting coming up with the chair of trade union side, and there will be further meetings with the trade unions as we work our way through all this.

The Chairperson (Mr McGuigan): You talked about working at pace. I understand that there is a procedure to go through and that the board needs to look at what the outcomes will be. Over the next six months, what can be implemented to make a difference? As I said, the public have heard constantly about issues in the Belfast Trust, as have the staff, so, working at pace to restore confidence, what will be the key priorities, and what can you achieve in the next six months to a year?

Ms Welsh: There are practical things such as reviewing the HR function. That may not be completed, but it will certainly be under way in that time. The same applies to the recommendations that were made on the structure. I hope that that work will be completed in that time as well. Those are the types of practical things that can be got under way while we have ongoing engagement across the organisation.

The Chairperson (Mr McGuigan): I have one last question for you before I speak to Tracey. Recommendations were made about the size of the board, its structure and the number of interim positions. I think that there are 25 interim positions, which seems a lot. Are recruitment plans in place? Will those positions be filled? I imagine that, at that level, if staff are doing something over and above their current role or are doing something in the short term, that is not the ideal scenario.

Ms Welsh: No. Ideally, you want to have a stable team with permanently recruited people. I understand why there has been a delay in getting that. There has been a separate review of senior executives, so trusts have not gone forward to appoint to permanent posts in the past number of months. The other aspect was my appointment and coming into the role. It was right to wait until the organisation had a new chief executive in post and I have the opportunity to shape the team that I want to see there. I accept the recommendation about reviewing the board's structure and, in particular, looking at the size of the executive team. I very much want to look at that. As the chief executive of the Northern Trust, I had a different structure that was more in line with the structure suggested in the report, and I will look at that.

The Chairperson (Mr McGuigan): I have one further last question for you. There is an interim chair of the board: is there any indication of when that position will be filled permanently?

Ms Welsh: Yes. You might want to answer that, Tracey.

Ms McCaig: Yes. A memo went round the Department the other day setting out the scheduling of a number of public appointments. That is under way through the Commissioner for Public Appointments. We have taken it forward, and I hope that it will not take too much longer. Such things sometimes take a bit of time, but, hopefully, in the next six to eight months, someone should be in post.

I give absolute credit to Patricia Gordon for her work in the meantime. Having worked with Patricia over the summer, I can say that she has been really positive and willing to have the difficult conversations. She really has helped to drive that process, along with Maureen Edwards, who was the interim chief executive. The board is in safe hands in the meantime, and I really welcome Jennifer's appointment.

The Chairperson (Mr McGuigan): OK. Tracey, now that we have the report, the Department has raised the level of intervention to level 5 for the Belfast Trust. What role will the Department play in supporting and overseeing the implementation of the recommendations?

Ms McCaig: There are a number of strands. Two of the recommendations in Peter McBride and Dr Hill's report relate to the Department, and I can talk to you about those as well. As I advised in June, we set up the enhanced oversight arrangements that we have at the moment, which were set up due to the trust being at level 5, in two parts. One part was specific to the cardiac surgery unit, because of the specific actions relating to that and the need for an action plan specifically for it. At that point, however, we recognised that there were elements of the DCO Partners report that probably had wider applications for governance, processes and accountability. We therefore split it into two parts. There is slightly different membership for those two parts, but the chair, chief executive and interim roles are involved in both.

We have had 17 meetings since I was before the Committee in June. Those meetings have been held fortnightly. There have been long Friday afternoons spent working through that with the team. The trust has an action plan for the cardiac surgery-specific elements. On 26 September, we had an open meeting with the Patient and Client Council (PCC) and the Regulation and Quality Improvement Authority (RQIA), because both have been involved, and they have comments to make about other elements of this that will be helpful to the trust as we move forward.

We also thought about how to get to the next stage. I shared a letter from me and Aidan Dawson, my joint commissioner and the chief executive of the Public Health Agency (PHA), which was about what we would wish to see before de-escalation. That will be the piece of work from now to then. We have sustained levels of stability in the cardiac surgery unit. The need for that stability is what started it, so we want to see that. That work will include all the recommendations.

I want a significant proportion of the recommendations to be implemented and for there to be sustained positive outcomes before I even consider de-escalation. We monitor it in a number of ways. There is a sitrep process that continues weekly with the trust. We monitor planned surgeries, cancellations, reasons for cancellations, waiting lists, safety and quality outcomes. A wide range happen weekly, and we are over that.

We want there to be independent oversight. I do not want to come back to the Committee at the end of this to say what "I" have seen and, "From what the trust has told me, here is all the implementation". That is not what, we agreed, it would be about. We have had experts supporting the process: Dr Jennifer Hill and Peter McBride, as well as Mr Steve Livesey. He is one of the report's authors and has been really helpful to the cardiac surgery team in developing its action plan to have that challenging and checking of, "Is that what you meant?", "Is that what you've seen?", "Is this going to address what you established wasn't there?". We have also had a conversation with RQIA and PCC, notwithstanding RQIA's statutory role to inspect if it feels that it is appropriate to do so. It was also about having a conversation at an appropriate moment about how that might work.

We want independent assurance and will have to feed that in when we feel that an appropriate body of work has been done for recommendations that are specific to the cardiac surgery unit. All that will be part of it, but we will also receive a level of assurance from the trust on the people plan. We recently had a really good presentation from the HR team about staff engagement. Trusts and all other arm's-length bodies (ALBs) routinely consider culture: what they do normally and whether it needs to be enhanced with this process and underpinned by a people plan. We will be doing lots of things, including the practical things in the cardiac surgery unit.

There are 15 recommendations in the DCO report and an additional recommendation that was added by the trust, which was to work with Northern Ireland Medical and Dental Training Agency (NIMDTA). There are seven recommendations from the 2019 Royal College of Surgeons review. Some of those are similar to those in the DCO report, so it is clear that the work that was done did not hold. Those are all on a big database for us, and we will look for evidence of implementation and independent assurance across all of them. We will have one of our fortnightly meetings tomorrow. Now that the report is here and Jennifer is in post, we will consider how to take that forward. It is likely to be slightly different, with slightly different membership, but that will continue as part of a regular oversight process.

The Chairperson (Mr McGuigan): Notwithstanding Alan Robinson's comment in our previous evidence session about expecting everybody to get on well with everybody else — I do not think that anybody would expect that in any health scenario — we expect to see teams in the health sector function, as we would in any organisation. If a team is not functioning, we expect management to step in to ensure that it does.

Jennifer, you will have heard me ask Peter McBride and Dr Jennifer Hill, in the previous evidence session, about my concern that their report indicates that there is still dysfunction in the cardiac surgery unit. We have the cardiac unit action plan; we have had the third or fourth inquiry report on that unit; and we are now a number of years down the road. How concerned are you? There is a difference between not getting on and dysfunction in a very important unit in our health system.

Ms McCaig: Absolutely. That is why we continue the sitreps. There may be individuals who have difficulties with each other, but what is the outcome of that from a patient perspective, and what is it doing to the level of activity and outcome for patients? A significant process continues around that, and we will keep that going. We have seen nothing since we set that up to give us more concern, but that does not mean that Jennifer will not be addressing issues to do with the culture of the team, working well together, being civil and understanding the processes. It is certainly set out in the action plan, but we have had quite a lot of conversation about how we will know that it has worked and that it has resolved itself to a degree that we will not be back here next year or the year after. That is a lot of what we have done.

It will be tough. I do not think that any of us think that, if there are issues that have been there for a while, those will be resolved overnight. We understand that cultural improvement takes time. From a departmental perspective, we will be there to support Jennifer and the team and to challenge Jennifer and the team in that space, but we are looking at it very much from the patient perspective. We will oversee the outcomes of those reports for the staff and ensure that those have been picked up. We also want to see that the governance processes that should overlay this from floor to board are well in place and are as good as everyone would expect them to be, including some of those recommended in the report.

Ms Welsh: I think that we are all agreed that relationships in the team will not change overnight. However, without getting into specific detail, it has gone from a situation where people were not willing to be in the same room to one where they are part of a functioning multidisciplinary team. That is progress.

The appointment of the interim clinical director from outwith the unit has been a hugely important move. I have had one meeting with him so far. He has also met the chair and our medical director. I am really impressed with that individual, given the reflections over his own career; what, he believes, he can bring to the team; and what, I believe, he is already bringing to the team. One of the recommendations is that I meet him and review all of that at a three-month and a six-month point. We cannot afford to be complacent about this, by any means. I fully understand the concerns that Jennifer and Peter expressed and why they expressed them in the way in which they did. We need to keep a close eye on it, but it is an improving situation.

We have had interaction with the NIMDTA — the Northern Ireland Medical and Dental Training Agency — and the General Medical Council (GMC), who were doing a review of the cardiac surgery unit. That took place earlier today; I received a text about it while I was sitting back there. They are clear that, from their perspective, there are no patient safety concerns and no concerns about trainee safety. We report data into a UK-wide database of cardiac surgery outcomes. Two of our cardiac surgeons are in the top 10% in the UK. There are some incredibly strong individuals in that team.

Mrs Dillon: It is a terror. If they are such capable and gifted surgeons, they should have some people skills. However, that is an entirely separate issue; it is not for us to get into. Others have that job.

Congratulations, Jennifer, on your new post. I wish you all the best. I worked closely with you while you were in the Northern Health and Social Care Trust. We are sorry to lose you. I really wish you the best. You have a lot of challenges to take on in the Belfast Trust.

The issue is not unique to the Belfast Trust. I think that Peter McBride referred to that in his final remarks. In another single unit, you might not get those behaviours to such an extent between people who are so integral to what is, essentially, a small team, but it happens across the region. Peter's final remarks were about learning from what has happened. I have a question for each of you, Tracey and Jennifer.

We now have the committees in common; that is an opportunity. You said that some of the recommendations in the report are things that are already in place in the Northern Trust. Why, in the name of God, in this day and age, are trusts not saying, "This is better"? I understand that the committees in common process is new, but work between trusts had been going on. I just do not understand it: there is a small number of chief executives, and they should be working together and saying, "We're having this problem. Why do you not have it in your trust? Why is it not crystallising in the same way? How do we work that out better?". I would like a sense of whether the committees in common are an opportunity to look at whether the recommendations can be implemented across all trusts. I previously asked what other trusts are doing to make sure that they do not have the same issues: I can tell you, a hundred per cent, that some of their teams have them.

Ms McCaig: You are right that there is learning for others in this space. While I do not have anything else on my desk that looks like the Belfast cardiac surgery unit issue, there is an awful lot of learning for us. We have a senior leadership group that I attend. Committees in common are very much about the trusts, and we can be in attendance, but that is a different procedure. We have asked to discuss the interim learning with all the chief executives. We have departmental officials there because, again, there are two recommendations for the Department. Those tie into pieces of work that are under way that you will probably have heard about, such as the Being Open framework, but it is a timely moment for us to check that process to see whether the report tells us something different about the direction that we are going in, and we will take that forward. We had a conversation this morning about how we might do that check of our process and how to give the Minister the assurance that we have done what we need to do from a departmental perspective.

There is an opportunity to consider the learning. Our conversation about it went on all summer, so it is not just about now, with this report, but about the whole process. We have been asking what learning others might need to see and how each of our trusts considers culture. We could almost have calculated an engagement score — if you have worked in Health, you may have seen the surveys — by asking, "How is that done? Are we doing it in the best way? Are we benchmarking ourselves nationally? Across Health and Social Care (HSC), are we really looking to be the best?". It has been an ongoing conversation, but — I give you this assurance — that has certainly been part of my discussions this week since I saw the report. It is about what we pick out from that and how we go about it. I know that Jennifer will be a very open and transparent partner in that process with us and other colleagues not just in trusts — we have other organisations — albeit it may be more pertinent to trusts because more of our staff are in the trusts. We are committed to doing that across our organisations, and the Minister is very committed in that space.

Ms Welsh: As soon as I had the recommendations, I shared them with my chief executive colleagues. We will discuss them at our next meeting. I will say a little about the focus in each organisation. We are all ultimately arm's-length bodies of the Department of Health, but we have our own trust boards and governance structures. I agree that the committees in common give us an opportunity to move closer to perhaps having a single set of objectives. Each organisation currently has slightly different objectives, so everybody will have something about quality and safety, something about resources, something about partnerships and so on.

A number of years ago, the Northern Trust chose to put a huge focus on people, which included setting up a people and culture committee. Different organisations do it in different ways, but putting that strong focus on staff is one of the best things that we have ever done in the Northern Trust. It is about all aspects of your people: how you recruit them; how you train them; how you challenge them to be even better; and how you support them when things go wrong and in dealing with difficult situations. There is no doubt about the importance of team dynamics and how people work together, because we know that, as was mentioned earlier, when people work well together in a functioning clinical team, their outcomes are better. If they work in another area, productivity and innovation are often better because people trust each other and have the confidence to experiment and try new things. I very much echo what Peter McBride said about focusing on people: if you get that bit right, the rest will follow.

Mrs Dillon: I agree with you. That is the point that I am trying to make. I understand your caution because you are chief executive of the Belfast Trust and you do not want to impose what you think on other trusts. However, Peter is right: every trust needs to put its staff at the heart of it, because they are the people who deal with patients.

Ms McCaig: We are going into a process of reviewing what the Department will put in the trust objectives for next year. There is always planning process, and we have had a bit of a conversation about how we put that in. It does not mean that everybody will have to do it in exactly the same way. You want the best outcome, but everybody could be at slightly different levels and different places. I worked in the Northern Trust, and there was a big focus there on the people plan at the time. It is about looking at the best of what you have and where the issues are. It is about getting to that outcome and making sure that it is being driven and that it runs through everything that you do.

I am trying to drive performance with Jennifer and the team and with all the other chief executives and teams. We are pushing performance. The evidence shows what can be achieved if you have a good team. Having the psychological freedom to try and, if you make a mistake, learn from it has to be part of how we operate. It has fallen short in places. I will set it in context: while we absolutely agree with the report, there is evidence every day of great practice and teams being really engaged and delivering great work. We have to bring everybody up. It might look different in each place, but the outcomes need to be the same. There needs to be common learning, but it is not necessarily about everybody doing it in the same way.

Mrs Dillon: I accept that. I will ask the same question that I asked Peter, although it probably was not really for him. How will we track the outcomes in relation to the recommendations? I will not ask you to define that right now, Jennifer, because you have said that there are conversations to be had with the trust board and others. However, I will ask that you have conversations with one another — the Department, the trust and everybody involved — in order to give us, as a Committee, a plan so that we can track the recommendations and the outcomes. These things become so complicated. The Department has one part to do, the trust has another part to do, and then it will say, "That is for the cardiac unit", and it will deal with it. We need a simplified way of doing it. With previous reports, everything has got lost in the ether. Everything is dealt with by somebody, but we do not know who is dealing with what. It is really difficult to track, and it becomes impossible for you and for us.

Ms McCaig: I agree with you. What is different now is the support and intervention framework. We have a contained process. I talked about the 17 meetings, and we now have an action plan for cardiac. As Jennifer has just come into post, she will wish to reflect on that with the knowledge of the report that has come out and that we have been talking about today. That set of actions includes all the recommendations from the Royal College of Surgeons report, the new ones from the DCO report and the additional one that the trust has added in for NIMDTA. Those are being tracked. We have them all sitting on our database, and we will track them. That is more for independent assurance for us: "The trust says that its latest progress is this: do we see anything through our monitoring that either agrees or disagrees with that?". We have a clear process sitting behind that. There are no surprises between the Department and the trust. What is different now is that there will be two for the Department. I will have to work through a process with the permanent secretary. Ultimately, we will have to report to the Minister on those two specifically. We will track every one of them, and, then, it will be about how we give you that information. When we have considered the de-escalation process, I will have to show that evidence. I will want to be transparent in the judgement that we make, particularly on commissioning, with the support of the Chief Medical Officer (CMO), the Chief Nursing Officer (CNO) and all the others who are involved in each of the elements. There should be nothing hidden. We have been pretty transparent to date, and we commit to doing that.

Mrs Dillon: Will we be able to see what the de-escalation process is based on?

Ms McCaig: Absolutely. The Minister has committed to being very transparent on the issue, hence the opening of the report. The timing of that was quite difficult for the trust, but we wanted to make sure that, when it was there, everyone saw it transparently. Jennifer will have to take that forward with all her team. There have been a few conversations about making sure that Jennifer had enough time to talk to her senior team and her board. Jennifer might wish to speak to the cardiac action plan and where that has gone. That will go through Jennifer's trust board before it comes to me, and then the board papers will be shared.

Ms Welsh: I talked earlier about how I want to develop the action plan. It is important that we develop it with people across the organisation. It is also important for me that I am signalling out to the organisation how we are making progress. That has to be open and visible to everybody in the organisation as well as to all of you.

Mrs Dillon: I appreciate that. Your plan is to work with the unions, the people and everybody else, but I suppose that the biggest challenge for you is breaking down that culture at every level. The unions need to feel, when they are in the room, that they have an equal say, are genuinely part of the conversation and are not there so that it can be said, "Well, the unions were there, so you were covered". It is about making sure that the unions reflect staff views and that they are going back to the staff. All that is really important. The important part for me now, Chair, is how we track and scrutinise the accountability of the trust and the Department around this.

Mrs Dodds: Jennifer, you know that, like colleagues, I wish you every good wish in leading the organisation. It is a huge and complex organisation, but it is also a regional centre of excellence for Northern Ireland, and every one of us has an input to trying to make sure that it is the best that it can be.

I want to follow up on Linda's point about tracking, and maybe Tracey you could answer this. We had the 2019 Royal College of Surgeons' report, which, if I picked you up right, reported almost the same issues as were picked up in the 2023 report and the 2025 report and now the report that we have on our desks today. Why did the Department not take any action before now?

Ms McCaig: The thing to remember is that, in the 2019 review — I think that the report was in 2020 — the recommendations were cleared at the time by the GMC to say that there was sufficient progress. When I was with you in June, the question to us was why it did not hold. As we see now, relationships probably meant that it did not hold as well as it needed to, and that is why we were back to where we were. We are not quite back to the beginning because other elements held. The report was signed off. The General Medical Council saw the progress, and the report was cleared, and I think that that is within the trust's action plan, so it is difficult. We then had a situation that meant that it came to the fore again. That is why, when I talk about de-escalation, it is about truly understanding that it is different this time. It has to be, and we do not want to be back here again. That is about all of the assurances that we have. We are dealing with individuals, however, and sometimes, unfortunately, things happen, but all the work that will be going on — the people strategy and the culture; all those elements — should make a difference. However, we will have to track to make sure that it does.

We are in a different process now in the way that we are working. I can give you an assurance from me and Aidan in the Public Health Agency that this is at the top of our agenda and we will track it through. I do not want to get to the end and say at Christmas, "There's x number of recommendations, and I'm content"; this is about sustaining it and how we take that through. That is the conversation for tomorrow with Jennifer and Patricia. This has to be a partnership. We will have to have a conversation about how we all get to the level of confidence where we can give an assurance to the public, staff, you and the Minister that this is sustained and we think that it is in a much better place.

Does that mean that, in time, something could happen? We all have to be honest and say that things happen every day, and it is about how we respond. It is about knowing, when and if something happens, that we have the right procedures, that the staff are absolutely sure as to how they operate them and that the organisation will have a consistent response to those procedures. All those things have to happen, and they all need to move forward together, not just one at a time.

Ms Welsh: A structured and robust process has been put in around cardiac over the past number of months. The appointment of the interim clinical director has been a really important move. There is a formal recommendation for me about following that up. Even without that, this is so important that it needs to be tracked at our trust board meeting. I fully expect to be held to account by the SPPG, the Department and the Committee on that. We cannot afford for it to slip back. There needs to be constant gardening. Constant attention needs to be given to that type of thing.

Mrs Dodds: The cardiac surgery unit is one of many issues across the trust. My understanding is that the chair of the trust briefs the Department on ongoing issues either every week or every month. I cannot help but feel that it is not just that the surgeons and clinicians across the trust were let down by what Peter McBride has described as an abuse of power but that you let the Minister down by allowing the situation to escalate to the extent that it did, and everyone is now holding their hands up and saying, "What can we do now?". I do not understand the dynamic between the Department and the trust, but, if we are to go forward and not end up with the Minister having to intervene again, there needs to be a much more robust process between those two.

I will skip on, as there are a couple of things that I wish to ask. Jennifer, one thing that struck me from the report was the number of serious adverse incident (SAI) reports that were outstanding and mortality reviews — over 900 at November 2024 — that were still not completed. Committee members attended a meeting with people who had outstanding SAIs with the trust. There is not just harm because of the SAI process; there is ongoing harm to families. I was quite emotional coming out of that meeting; it was one of the toughest that we have had. Can you give me an assurance that those SAIs will be completed? I attended an SAI review in the Belfast Trust a few weeks ago. Frankly, I was exhausted by the time I came out of it at 5.00 pm on a Friday, and I was only there to record what happened. It is a matter of ongoing harm, and it needs to be dealt with. Delaying action on this is harmful and comes on top of the harm that has already been caused.

Ms Welsh: I fully accept that. A lot of us struggle with having SAIs completed in a timely way. That is partly to do with resource and how we support teams to make sure that it is done properly. I completely agree that it is so important for families that we do that in as timely a way as we can. That is part of the support and intervention framework on which we are held to account by the SPPG, so I assure you that there is a huge focus on that area.

Mrs Dodds: If the trust is held to account by SPPG, why are an unusually large number of SAIs not completed?

Ms Welsh: I cannot speak to the history of that; I can talk only about what we intend to do going forward.

Mrs Dodds: I appreciate that, Jennifer, but it would have been helpful if some of the leadership team in charge of that were here to answer some of those questions. I appreciate that you want us to focus on the future — I want to focus on the future too — but, as I said to Peter McBride and Dr Jennifer Hill at the Committee's previous evidence session, unless we expunge the hurt and harm of the past, we will go round in circles and be back to talking about that Royal College of Surgeons report again and again. Anyway, I cannot really understand it.

I will move on — not that I am fixated on this issue, but it is important — to the process of maintaining high professional standards (MHPS). On 12 June 2025, the Committee took evidence from the senior leadership team at the Belfast Trust, and I asked about the MHPS process. On that day, I asked about the process — I am looking at Hansard — and your medical director jumped in to say that a review of MHPS had been commissioned by the chair of the trust and was under way. I asked, "When will that review start?", and Mr Hagan said that it had just started. We went on to talk about the need for external input to the review and about how the review would be conducted. Having heard nothing from the trust about that, I wrote to it at the beginning of September and asked, "You have been conducting that review, as you stated on 12 June. Can you tell me what its outcome was, please?". On 8 October, I got a letter from the trust stating that the review had not started, that the trust had not appointed a person to conduct it and that the review would no longer be an investigation of individual files but an anonymised review of a select number of files. Should the Belfast Trust apologise for misleading the Committee and correct the record?

Ms Welsh: I can speak from my perspective. The latter bit that you outlined is what, I understand, is being taken forward, namely that an external company has been appointed to carry out a review, that the review will be of a randomised selection of a number of cases to determine whether they were carried out according to the appropriate process and that the review will take approximately 12 weeks, after which we will receive a report. The external company has been appointed, and that review will start. It is my understanding that it has not started yet.

Mrs Dodds: OK. Do you understand why I am aggrieved that we were told on 12 June that it had started? It is in Hansard; I am not making it up.

Ms Welsh: I appreciate that. I fully understand —.

Mrs Dodds: It is not an issue with you, because you were not there. That is why the leadership team that was there should be here to answer questions. The trust, as a corporate body, should apologise. We were clearly told that the review had started. I asked, "When will that review start?", and Mr Hagan said, "It has only just started." That is part of the problem. It is important, and the trust should consider that position in relation to the Committee.

Ms Welsh: May I apologise to you, Diane, on behalf of the trust? I appreciate that you may also wish to hear from others, but —.

Mrs Dodds: It is not a personal issue.

Ms Welsh: I agree.

Mrs Dodds: This is a Statutory Committee. Witnesses giving inaccurate information to a Statutory Committee is an issue for us to deal with. We need to understand that, when trusts make a statement, the statement is correct.

Ms Welsh: Yes.

Mrs Dodds: On page 13 of the report, the sentence explaining the figures for legal claims states:

My understanding is that those cases relate to MHPS. How many claims have been lodged? How many claims have gone to court? How many claims have been settled? How many claims are still in an industrial tribunal situation? I understand that you do not have the figures, but I know that someone at the back is writing notes, and it would be great to have those figures. How much has been spent by the trust, and how much is pending in settlement of claims? I will ask a further question, which is this: where did that money come from? We know, from a response to a question for written answer that I asked the Health Minister, that, at £63 million, the management costs for the Belfast Trust are more than the combined costs of the Southern Trust and the Western Trust. The Southern and Western Trusts together do not spend as much on management as the Belfast Trust. We understand, as a management issue, that the figure for settling legal claims will be high. I make it absolutely clear: everyone has the right to pursue their personal employment issues in every way that they see possible, but my view is that, if the trust had managed this properly, we would not be in this position. It would be great if those figures could be sent to the Committee.

I will ask a last question. Peter expressed the idea that things are lost in translation between managers and board, and then decisions are taken, which to me, are inexplicable. I understand that the water usage group did not recommend that the handover of the Royal maternity hospital should take place but that the handover went ahead. That was in March 2024, and we are coming up soon to 2026. The last that I heard, when I asked about it, is that the solution favoured by the trust could take another two years and perhaps another £10 million to put it right. I need to know whether the trust board got all the information that it needed in a way that the members could understand it so that they were making a decision that was clear and coherent. I know that you cannot give me that answer —

Ms Welsh: I cannot answer it, but we will look into that.

Mrs Dodds: — and again I make the point that this is why we should have had people from the trust leadership here who understand what happened.

I will make a final point. It may sound as though I am on a bit of a rant; maybe I am. It is a habit. The Belfast Trust has harmed people seriously. I have spoken to people who have been harmed and have left the Belfast Trust. If we are to build a really good regional speciality in Northern Ireland, goodness me, we cannot afford for that to happen. I have spoken to people who feel that their careers are over. I do not want to see the legacy issues being hived off and to hear the trust saying, "Well, that is for another day". You cannot go forward unless you make right.

Ms Welsh: I agree with that, and the message that I put out to the organisation yesterday morning acknowledged that. I agree, Diane, that we cannot let that go, and I agree that people have been damaged. There need to be individual conversations about what helps those people to move on and whether we can help them to move on. It will not be the same answer for every individual.

Mrs Dodds: I accept that.

Ms Welsh: However, I agree with you that it is hugely important that we address that as an organisation.

Mrs Dodds: OK. Thank you. I look forward to someone coming back and having a conversation around that. It is massively important.

In a reasonable period, I really want to have a conversation about the issue of outstanding SAIs, which is really causing harm to people.

Mr Donnelly: Welcome to your new role. As you have had with other members, you and I have had engagements in the past while you were at the Northern Trust. I am sorry to lose you from the Northern Trust.

Ms Welsh: Thanks Danny.

Mr Donnelly: Obviously, for you coming into this role, there are a lot of issues, and, as the Chair alluded to, the Committee has spent significant time dealing with those issues. They include capital projects, poor staff morale and, as we have heard today, a lack of confidence from the public because of various issues. What are your key priorities? What are you focusing on?

Ms Welsh: People. It is people and culture, because that relates to every other aspect that you are talking about. We know that there are concerns in the organisation because of dysfunctional teams. There are other concerns where, perhaps, we have not trained people properly and not given them the support that they needed. I am firmly of the view that we focus on the people. We have to do all the other things, of course, in relation to performance management and financial management, but having people very much as the focus — how we wrap around them and support them as a good employer — is very much at the heart of it.

To reassure you, I say that I have had several briefings from Peter McBride and Jennifer Hill, and the chair of the board and the directors in the organisation have been open with me about the areas of concern. I know where I want to focus. People is the big one, but that takes you into different areas and different teams where you would want to do a bit of work. The organisation has been open with me. I have welcomed the engagement that we have had with the SPPG, the Public Health Agency and the trade unions.

Mr Donnelly: One of the key issues that we have dealt with again and again is our runaway capital projects. I want to pick up on what Diane was talking about on the maternity hospital. We have had various briefings, and we even visited the maternity hospital in February; we were inside it. It looks fantastic, but the idea that women cannot have their babies there is frustrating. It is unbelievable that we are in this situation. The trust recommended option 2, and the Minister had an investigation of that and agreed with your decision. I think that it will cost in and around £6 million.

Ms Welsh: I do not know the precise figure, but it is around about that.

Ms McCaig: I do not know off the top of my head, sorry, Danny.

Mr Donnelly: In nine to 12 months. You are progressing a design team at the moment: when will the work start?

Ms Welsh: I cannot say specifically when that work will start, Danny. I presume that the design work will have to be completed, properly considered and signed off. My understanding is that it will take about a year to completion, once the project starts.

Mr Donnelly: Is that just the design work, or does it include the work?

Ms Welsh: My understanding is that it is just the work, but I am happy to check on the details of that. I will not go into the details now, because I would rather check the facts. Thank you.

Mr Donnelly: OK. I appreciate that you might not be able to answer this, but it was suggested that, during the work for option 2, it may become apparent that it is not enough and you may have to revert to option 3, which is a pull-out of the entire water system in the building. I think that it was initially deemed as excessive, but it may have to be done. If that is the case, do you have a ballpark figure for the price or the time that it will take?

Ms Welsh: No. I could not answer that at this point in time, Danny, but I am more than happy to get you that information.

Mr Donnelly: OK. No problem. Thank you.

Certainly, other projects are ongoing, such as the inpatient mental health unit at Belfast City Hospital, which, again, the Committee visited more than six months ago. It is progressing at the moment, but can you give us an update on that and the impact on patients?

Ms Welsh: No. I am sorry: I cannot. I am just three weeks into the job. My understanding was that today was to talk about the report, so I apologise that I do not have all that information to hand.

Mr Donnelly: That may be my fault. I noticed that we had strayed into other areas, and there are quite a lot of other areas that we wanted to talk about. I am happy to go back to the cardiac report.

The Chairperson (Mr McGuigan): The trust has responded to some of those questions on the timetable and cost etc; it is in the pack.

Mr Donnelly: No problem. I am happy to leave it there then, and I can pick up with you on the other points.

Ms Welsh: Thanks, Danny.

Mr Robinson: I will go back to Dr Hill and Mr McBride's report, Jennifer. In his questioning of Mr McBride, Danny asked whether there were issues at any other surgery units in our trusts. You are a former chief executive of the Northern Trust. Were there any similar issues in the Northern Trust, and, if so, how did you deal with them?

Ms Welsh: I do not believe that there were any issues that were as serious as, for example, instances of instruments being thrown. I did not come across anything like that in my time in the Northern Trust.

It was fair for Peter to reflect that not all team members will always get on, and there is a range of interventions that can be taken. In the past, I have been involved in, for example, organising mediation for teams and team-building events to try to ensure that staff can work together constructively and positively. There is also something to be said about having good managerial intervention and trying to nip things in the bud before they go somewhere. Having the confidence to do that is part and parcel of people development and of making sure that people are properly trained. Often, when things do not happen in that way, it is perhaps because managers have not experienced such an issue before and do not have the confidence to tackle it.

Mr Robinson: I have another comment to make about the report. I will skip back to the Minister's public comments on 5 June, when he said that he wanted the report to bring about:

Has the Minister privately given any timeline for making tangible improvements?

Ms McCaig: I go back to what I said about the de-escalation process. The Minister has been given all the minutes from the 17 different processes, and we have kept closely engaged with him. He has had a personal interest in the matter since the summer. There is no timeline, and Jennifer and the trust board will now have to consider how quickly some of the recommendations can be implemented.

Widespread cultural change is a longer-term process, and none of us can put a specific time frame on that. I will, however, assure you that the conversations that Jennifer and I have had to date have been about how it needs to be done with pace and urgency, but that does not mean that we will get to the end point quickly. We have to show determination to our staff, trade unions and everyone else involved that we are moving, taking action and continually working through the process, but we, along with all the independent experts who have been involved to date and who may well play a role in the future and with the RQIA and others, will have to keep assessing that as we go forward. Nobody has a timetable for doing that, but my conversations — certainly those that have taken place in the Department — have been about tracking how many recommendations have been implemented and how we can independently verify that they have been.

Our meetings will continue to be regular, but we do not have a time frame for the process. There will be continuous assessment, but Jennifer and I and others need to see lots of activity in that area. Jennifer will want to reflect on what the people plan looks like. It will set out some time frames. There is no specific date, however. Having a date would probably be unhelpful at this point, because that might almost suggest that, if we get there, it is done. It will not be: the work will be continuous.

Ms Welsh: There are some underlying actions in the specific recommendations on which we can put a time frame, and it is important that we challenge ourselves in that way. Cultural change will take much longer, as everybody has reflected. To be honest, achieving proper cultural change is a three-to-five-year process. I really think that it takes that long. I was, however, struck by what Jennifer and Peter said when you asked them what change they expect to see in a year. That is when we should be looking for the green shoots or a few flowers. It is very much about what people in the organisation are saying. How does it feel to them? How is what they feel reflected in a staff survey? Will people have more confidence to speak up and raise concerns? Will people be confident about going to their managers to engage about such matters? Those are the things that I will be looking for. Rather than something being escalated to the Department, to one of you or to the media, I want my office to get a call and for someone to say, "I think you need to know about x, y or z".

Mr Robinson: Say that, in three to five years' time or less, members of the Committee, whoever they may be in the next mandate, receive correspondence, messages and emails from healthcare staff who feel that the culture still has not changed, who, ultimately, will then be accountable? Will it be the Minister, hoisted high on his own comments, or will it be you?

Ms Welsh: I see myself as being accountable and responsible. I am the accounting officer for the Belfast Trust. We will be in real trouble if, in three years' time, you are all still getting messages to say that things have not started to change. I would like to see change, certainly in a year's time. We will not have finished the process by then, but it is really important that we give hope and optimism to people inside the organisation.

I started my comments by saying that I have received a really warm welcome, and I really have. I feel a real sense of energy in the organisation. People have welcomed the report, and they are keen to get on with implementing change. I have heard people talk proudly about the services that they provide, despite the challenges. We have to grab the opportunity that those people are affording us and for people in the organisation to move forward together. I am clear, however, that, as the accounting officer, I am accountable.

Mr Robinson: May I ask a question about the maternity hospital? The update that we have received states:

Are we any further forward on the issue of liability? I know that Diane and many others here have asked questions about who will ultimately be liable. For many months now, we have had the same response.

Ms Welsh: Apologies. I cannot answer that question, but I will certainly take it away with me, Alan.

Mr Robinson: Thank you, Jennifer.

Miss McAllister: Congratulations, Jennifer, on your new role. There is no doubt that you have taken up post at a difficult time, but hopefully you can enjoy it while providing fresh leadership, which, to be perfectly honest, is needed.

I have a couple of quick questions. There are a few letters in today's Committee pack, some of which are from retired consultants and some of which are from your predecessor. My first question follows on from Diane's question about an internal review — not the external review of MHPS cases — that found that there had been no misleading of the Committee. After everything that has been said, are you willing to look at that review again? I ask that because transparency is key, as is accountability, in order to move forward. The role and remit of all bodies must be recognised in order to ensure that we have that transparency.

Ms Welsh: I honestly do not know the detail of what you are talking about, but I am happy to look at it.

Miss McAllister: Thank you. The letter that we received from your predecessor stated that an internal review found that the Health Committee had not been misled. To achieve confidence, it is important that there be that accountability.

My second question is about the MHPS cases. Why was that a sample review of cases? From my engagement with people involved, I have discovered that there was a high volume of counterclaims made, particularly from those who initially chose to put their head above the parapet and sign the letter to the trust back in October 2023 that raised their concerns. Would an external review be more beneficial if it were to look at all those involved in that report incident?

Ms Welsh: My understanding of that is that, at the time, there was a large volume of cases. That certainly has changed. The view was that taking a random selection of those cases would be sufficient to indicate whether we had a problem with the application of the MHPS process so that we could then make a judgement on what we needed to do.

First, it is important to determine whether there was a misapplication of the MHPS process. We know from the harm and hurt that has been done to some people that there are probably some cases that are of concern, and the audit is an important step. Again, I do not know all the detail, but that is certainly a first step in that process.

Miss McAllister: OK. After that, it would be beneficial if we could receive correspondence. A number of us on the Committee were contacted from October 2023 to December 2024 about complaints that were either handed over in person or emailed to members of staff in that overall unit, as I shall call it. There were concerns about the way in which the review was handled. The complaints were not dealt with in the previous report, so we had talked about how it was important that they be dealt with moving forward.

Are any negotiations taking place between the trust and the individuals involved in the collapse of relationships? If so, are any of those negotiations about settlements? I ask whether there are any negotiations because we have heard — it is not verified by evidence — that there may be negotiations taking place between individuals involved and the trust and the Department about, I assume, their moving on or vacating roles.

Ms Welsh: I will have to look into the detail of that. I am aware that there are cases ongoing on which I will require a briefing. I cannot speak about that at the moment, however. Apologies.

Miss McAllister: Do the cases that are ongoing — I am not talking about an individual case — involve settlements for disputes?

Ms Welsh: I do not know the detail yet, Nuala. Apologies.

Miss McAllister: Can we get the detail of that and information about whether any settlements enter high six- or seven-figure sums?

Ms Welsh: I will take legal advice on that. I am not sure what I can disclose in the public domain or what I can disclose to the Committee in closed session, but I will take advice, because I imagine, given what you describe, that the details are probably sensitive.

Miss McAllister: OK. I understand if you cannot do so in open session, but it is important that we have a staffing complement that gels, works together and, as many people have said, does not put patients at risk. It is still an important issue.

In their previous report, Peter and Jennifer stated that there are current examples of where the trust is intervening when it comes to risk, and they may or may not have said that the trust is intervening when it comes to behaviour. You obviously cannot talk about individuals, but can you expand at all on what the interventions look like? Have you had the opportunity to direct those interventions? Are they being made at board and chief executive level?

Ms Welsh: I have been briefed on a number of areas that are also known to the trust board. Arrangements have been put in place. The issues are not of the same standing as those in cardiac surgery, so the arrangements that are put in place are not as formal as reporting to, for example, the SPPG. I am satisfied, however, that there are arrangements and interventions in place. Furthermore, this is a watching brief. In an organisation of that size — 22,000 people — there will be such issues, and it is important that we keep a close eye on all of them. Again, it goes back to the people bit. It is about encouraging people to come forward, in the hope that they will have the confidence to share information with my office so that we can manage things as best we can.

Miss McAllister: You probably cannot talk about a lot of the issues in public session. Does the report give rise to the need for a duty of candour at an organisational and individual level? in the previous evidence session, I mentioned Mr Justice O'Hara and the report of the hyponatraemia inquiry in 2018. We then had Dr Watt. We also have the Muckamore Abbey Hospital inquiry. Not all the issues are in the Department of Health. I am dealing with other issues, particularly in my role as a member of the Policing Board. A lot of the issues go back to a duty of candour. In your role as chief executive, do you think that a duty of candour should be pursued at an organisational and individual level?

Ms Welsh: I reflect on what Peter said earlier, which was that we can have the mechanisms in place, just as we have the mechanisms in place for whistle-blowing, but that does not mean that they will work, so we have to find a way to ensure that people have the confidence to speak up. My understanding is that the Minister has committed to a duty of candour from an organisational perspective, which I absolutely support. There is an ongoing debate about having an individual duty of candour, and there are different views on that. I am clear about my requirement, however, which is to be completely open and honest with all of you.

What strikes me when I read the report is that people were afraid to speak up. What particularly concerned me — I know that it concerned all of you — was that, when people witnessed poor behaviour or issues of concern, they were still afraid to speak up. Even though we have a process in place that allows people to speak up, they were still afraid to do so. I am concerned that, even if there were a duty of candour, we might not have the right support mechanisms in place to allow people to speak up. I am supportive of the need for an organisational duty of candour. We need to do something in the organisation to make sure that we give people the confidence to speak up in the knowledge that they will be supported.

Ms McCaig: I will add to that. We are following the Public Office (Accountability) Bill at Westminster, which contains provisions on an individual duty of candour and looks at the processes involved. I know that the Department briefed the Committee on the Being Open framework, and the consultation has now closed. The conversation that we were having in the Department today was on the opportunity that we have to implement the findings of the report in front of us today, along with the consultation responses, so that what we do makes sure that we take all the opportunities that we have.

I was talking to some of my SPPG colleagues recently, although not on that issue. As professional staff, we have responsibilities. I already have a duty in my professional career, and those responsibilities extend to individuals. Jennifer talked about the organisation setting out the landscape so that we can be confident that the processes will work in the way in which we intend them to work. There is, however, still a personal duty on professional staff to follow them. That will be supported by a duty of candour at organisational level and by an individual duty of candour, if it comes. The Being Open framework will help bring a lot of that together. There is a lot of work being done in that space, and the report affords us an opportunity to set out that work alongside the responses that we got to the consultation, which policy colleagues will be considering.

Miss McAllister: It would be great if its implementation coincided with the implementation of the Hillsborough law on an individual duty of candour so that the two can work in tandem.

Ms Flynn: First, I give you a warm welcome to Belfast. As a West Belfast MLA, I am delighted to have you in your new role, Jennifer, so congratulations. I sincerely wish you all the best in overseeing what is critical work. You have come into post at a critical but opportune time, and hopefully you can make a change for the better.

Bad culture — how processes are followed and things are dealt with and managed — has become embedded over a long time.

I do not know about this, but is it fair to say that, with some of what has been happening, processes have not been followed and the bad behaviour has crept in right across the trust? You are talking about a lot of individuals in departments.

I am also conscious that the health service has been under a lot of strain over the past number of years. I am thinking about how people who have taken up leadership roles are under additional pressure and strain and about how that can impact on the way in which a person deals with their staff, performance and all those things. I am not sure whether there is a correlation between the pressures that the trust has been under and how its staff, leadership and management have been able to respond and deal with things in the most effective way.

My question is this: how will you go about implementing the recommendations? You obviously still have to discuss them with your board and sign off on them. Tracey touched on the role of the Department and the SPPG. It is important from the outset that, as a trust, you feel supported in the short, medium and long term to get a lot of this work over the line. I am not sure whether that would involve additional resource. An example is the HR situation. I do not know as much of the detail about that as you and your team, but will the pressing issues in HR mean taking on additional support, resource and finance to try to get the right type of team and types of people in place? I do not know. I am also thinking about staff on the ground and local team leaders up to the more senior leadership positions. Jobs need to be doable so that staff can carry them out properly. Will that mean that there will need to be a conversation about how jobs and roles are commissioned in the Belfast Trust, as a local trust? I am interested in getting some feedback on that and on any conversations that you might have in the time ahead with the Department and the SPPG about how they might be able to support you practically with resources, if there are such practical means, or in other ways so that you can get some of the recommendations off the ground.

Ms Welsh: Thanks, Órlaithí. I will start, and Tracey might want to come in. The culture right across the organisation and the poor behaviour that we have seen in some places are definitely not right across the organisation. I have been out and about a lot in the past three weeks. I have joked to everybody that I have had no problem getting in my 10,000 steps every day, which is a good thing.

I met so many teams that are really proud of the service that they deliver even in challenging circumstances. Clinical directors tell me proudly how well they work as a multidisciplinary team and how they work with their nursing and allied health professional (AHP) colleagues and so on. Therefore, I definitely do not think that poor culture is everywhere. That means that different teams will potentially move at different paces. We have to be mindful of that as we go forward together on the organisation. Some teams will perhaps need more support than others. I feel supported by the SPPG, the Public Health Agency, the RQIA and the Department. Tracey talked about the support and intervention framework. That is deliberately so named, because it is about support and intervention.

You are right to mention something such as HR. It is under-resourced, and I am mindful of management costs, which we talked about earlier. The Belfast Trust is hugely big and complex, and, because it delivers the regional specialties, there is a complexity and volume in it that does not exist in the other trusts. We are Health and Social Care, so we are delivering community services that are also regional services for the rest of Northern Ireland.

This is the case for all trusts. A Getting It Right First Time (GIRFT) report was done into what are often called the back-office functions. It found that HR was quite light. Therefore, if we want to do this properly and to support our managers properly, HR is one of the areas that we need to look at. There is a specific expertise in the world of medical HR. It is crying out to me, through this report, that that is where some of the concerns have come from about the specialist knowledge of medical HR and how we make it as robust as we can in the organisation. I am really mindful of the challenging financial situation that we are all in, so I will have to think carefully about the resource that is needed. It is needed in some places, however, to try to improve things.

Ms Flynn: OK. Thank you.

Ms McCaig: I spend a lot of my day worrying about the financial position and the pressures that we have. I will set that to one side before I talk about the next element, but, before that, I will say that not investing in the right places sometimes costs you more in the long run. That is what we have to balance.

What we have done to date on support and intervention since the Minister called a level 5 intervention, which is the only time that that has happened since the framework was started in November last year, has very much been about support. Even the report on the cardiac unit is a support: it is about being open, learning and understanding and not being frightened to look at things. The sourcing of the colleagues who are probably in the Public Gallery — Peter McBride and Jennifer Hill — is support. Steve Livesey's continued work is support. We have, hopefully, been supportive and challenging in equal measure.

There have been a lot of challenging conversations this week as we have pushed this forward. Initially, I saw what I would describe as a bit of a shock moment, which was difficult for the team. I do not underestimate that. It is really challenging for there to be such a public exploration of a lot of these matters, and we have to be mindful of the fact that people needed a minute just to let that sit. They have really moved on, however, and we have had good engagement. We have had challenging conversations with people, but they have moved on respectfully over the summer, and we are in a much better place than we were at the start of the summer.

Jennifer and I had a conversation about management skills. We talk about leadership, but what you sometimes need is good old-fashioned management and the confidence to take things forward and to take advice when you need it. In many of my jobs in health over the years, I have worked in pressured teams. It is about not losing your humanity when you are in tricky situations and about knowing where you can get support when you need it. Even now, I often rely on my HR colleagues and on having conversations with my trade union and other colleagues. It is about all that confidence. There is certainly something in that for complex organisations such as ours, with the numbers of employees and professions that we have. It is not easy, and we cannot tick that box and say that it is done.

Jennifer talked about "constant gardening". That is needed in every successful organisation. I was in the Northern Trust many years ago when change there was being brought through, and that was constant. Everybody understood it, and we all understood what we were trying to do together. I am confident that Jennifer will be able to do that for the Belfast Trust, and we will be there to support and challenge — that is our role — behind the scenes. It is also about applying that change across the system. You do not want A N Other organisation to go the same way as before if there are lessons that we can learn today.

Ms Flynn: Thank you.

The Chairperson (Mr McGuigan): Jennifer and Tracey, thank you very much for giving your time. No doubt, we will have ongoing engagement on the issue. I appreciate that. Thank you.