Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome the Minister of Health; Gearóid Cassidy, director of primary care at the Department; and Professor Cathy Harrison, the Chief Pharmaceutical Officer (CPO). You are all very welcome. I will hand over to the Minister or whoever to make some introductory remarks.

Mr Nesbitt (The Minister of Health): Cathy and Gearóid will talk you through the bones of the neighbourhood scheme, but I will take just a couple of minutes to make my opening remarks, Chair.

Since I took up post, I have made it my business to get out and about. I have now visited quite a significant number of health and social care (HSC) facilities. I have listened to members of the workforce, be they social care workers, social workers, nurses, GPs, consultants, surgeons or administrators, and I have found that there is a universal desire for change and a universal recognition that, if we simply continue with what we are doing, we will be hurtling towards some form of collapse. The change has to be the almost fabled shift left.

I know that, this winter, we will, inevitably, be looking at a queue of sick people waiting to be treated at our acute hospitals. We have to shift left and try to think about prevention — in other words, we have to keep healthy people healthy — so that, when people begin to get sick, we can get in early with prevention. The neighbourhood model is the way to go. It is not just about general practice; it is about all four pillars of primary care, including community pharmacists, dentists and ophthalmology services. Beyond that, it is also about local government and community, voluntary and social enterprise groups. It is a comprehensive set of involvements. GPs are central, however. Without GPs, it cannot be done.

I will bring you up to date with where we are with GPs. I wrote to the Northern Ireland General Practitioners Committee (NIGPC) last week, and I have had a response as of yesterday. I am now reasonably optimistic that we have the opportunity to have a three-phased approach to resolving differences. The first phase will be the NIGPC engaging in short order with officials to seek clarity on the latest offer that it has received from us. In phase 2, they will take that back to the NIGPC, and, if things go well, we will open a new round of negotiations and discussions on a new contract.

If I may, Chair, I have a couple of other topical points to make that may be of interest to you and your Committee. A small number of GPs have talked about a hybrid model. To be clear, a hybrid model means that some people pay to access general practice: not on my watch. The tenet of the National Health Service is that it is free at the point of need. I am not moving off that. I do not think that having that model is a universal view or anywhere near being a universal view in primary care. Also, probably the toughest decision that I have made in 18 months was to go back on my promise to introduce the real living wage for social care workers on 1 September. I ask the Committee to accept that that is a sign of just how desperate the finances are and how big the gap is between what we have and what we need. Since I made that announcement, officials have told me — we know this from monitoring and surveying — that the majority of staff in the sector, who are employed not by us but by care homes, are already earning on or above the real living wage. However, that is no comfort to the minority who earn less than that.

The final point that I want to make is on the funding gap. You will know that the Executive are promising up to £100 million that will go towards pay. That will leave us with a gap on pay of at least £109 million — £108·7 million is, I think, the exact figure. Beyond that, we still have pressures that amount to £91 million, which we are still trying to drive down, but that still leaves us in a precarious position for next year's budget. The waiting list initiative was not £125 million; it was up to £125 million in three pots. There was £85 million for red-flag and urgent cases, but that was not new money that the Executive gave us; they ring-fenced £85 million in our baseline budget. There was £80 million for capacity building, so that, effectively, we would be less reliant on the independent sector. That was not new money; again, the Executive ring-fenced it out of our baseline budget. There was also £50 million of new money to address waiting lists, particularly those who have waited a long time. That was new money, and it is being spent. The £85 million is being spent, but the majority of the £80 million, sadly, needs to be put against the deficit in our budget.

Chair, those are the broad headlines. I will now ask Cathy and Gearóid to talk you through the framework of the neighbourhood model. My ambition is to get everybody who is involved on to the starting line for 1 April 2026, but after we fire the starting gun, for some it will be the equivalent of a 100-metre dash to get to the finish line, but others will be doing a 5-kilometre or maybe even a 10-kilometre run. We will not all get there in one go.

Professor Cathy Harrison (Department of Health): Thank you, Minister. I will talk a little bit about the neighbourhood model for Northern Ireland that we have started to develop. The commitment to develop a neighbourhood model came in the reset plan that was published in July this year. I will read it out, because it is helpful to frame what we have been asked to do. The commitment in 'Health and Social Care NI Reset Plan' states:

I will tease out the key things from that. We are looking to describe a neighbourhood model that has an associated funding model that can support its development by the end of March next year in order to allow the beginning of the development of a neighbourhood health model in Northern Ireland. As the Minister said, our ambition is that the system starts to move, that there will not be pilots in certain areas and that we start to see system change while recognising — as I go into it, you will see this — that parts of our system will be ready to move much quicker than others.

Gearóid and I are working together on and co-leading the model's development. We have split the work into three phases. At the moment, we are in the design phase. Since the end of the summer, we have been spending time — we will do this right up to the end of this calendar year — speaking to and meeting stakeholders in the system, looking at models from other countries and, on visits out into our system, meeting community and voluntary groups and service providers, including those in general practice.

In this phase, we aim to articulate a vision around neighbourhood health, along with some underpinning principles that will support it to grow. In this period, we are also looking for examples of neighbourhood health that are already happening in Northern Ireland. We launched a call for evidence on 8 October, and that is open until 25 November. We extended it, on request, for another week. It is on Citizen Space. We have already had over 80 responses to it. We are really pleased. It has confirmed what we thought, which is that a lot of excellent work is already being done. The design phase is all about listening, and that is where we are at the moment. At this stage, we have deliberately not rushed towards solutions and a favoured model, because it is about listening and genuinely trying to understand what we will need in Northern Ireland.

From January next year, we will move into what we call the "build". We will have to put a little bit more detail into what it will look like, how our health and social care system will adapt to working in a neighbourhood model of health and social care and how we will work with the partners that the Minister mentioned, including, very importantly, our voluntary and community and social enterprise partners. That will bring us up to April 2026, when the programme will commence. In that, we will have thought through what really is a growth programme that will take us into the future.

One thing that we have seen from our research of neighbourhood models in other parts of the world and across the UK is that they did not happen overnight and certainly did not happen in six months, so I reassure everyone that we will not have a full-blown neighbourhood model by April. We will be at the beginning of a journey of change and growth in how we do things. Some of the examples that we have seen demonstrate that. There are some mature international examples, such as the Nuka system in Alaska, which took 30 years to develop. There are also some closer-to-home examples from Wigan and Manchester that were 10 to 15 years in development.

Why are we doing this? We are doing it because we have a very complex system of health and social care that includes voluntary and community sector involvement, but our current practice is frequently siloed, and a lot of our focus is on dealing with demand in our hospital settings. The main sources of our service pressure are, as you know, demographics, given our ageing population, and the socio-economic aspects of that. We also have specific challenges due to rurality. Our health behaviours do not help. Long-term budget and resource issues also do not help.

Those are our main sources of service pressure, and they have an impact on our service users. At the moment, that impacts on access to healthcare services. We know that there is dissatisfaction among service users about access to, for example, GP appointments and reliable access to care for long-term conditions etc. Where service user experience is concerned, that is also manifesting in increased waiting lists, poorer health outcomes, unfortunately, care that is very much fragmented and low patient satisfaction, as well as, I would say, maybe lower trust in and access to services. It impacts not only on service users but on service providers through workforce satisfaction and the highly complex models of working and working with multiple agencies that cause increased costs, duplication and inefficiency in the system. There are now also challenges with communication and data sharing etc, as well as with increased administration, and those are really questioning sustainability.

Over the past few months, we have been really challenging ourselves through our stakeholder engagement by asking, "What do we actually need from a neighbourhood model in Northern Ireland? If we are embarking on this, what will be the functions of the new neighbourhood model and what will it bring?" When we talk about a neighbourhood model, we mean service providers working together at a more grassroots local level with a system that supports different services that perhaps work best alongside one another, or they may overlap, to work more collaboratively. The model is inclusive in that it includes providers from primary care, our community trust-led services, our voluntary and community sector and social care providers, because they are all the providers that are in our neighbourhoods already. The model will enable them to work together to focus on both the delivery of care and improving health and well-being.

The purpose of the neighbourhood model and what we would like to see it support is, first and foremost, collaboration. It is about allowing providers to come together, collaborate and agree on — this will be at the heart of it — the consistent delivery of the core functions that matter to the people who live in the community. Again, the sorts of things that we are hearing about that will not be a surprise. They include not only reliable access to a GP if people feel that they need one for an acute health need but reliable and well-understood access to care for your long-term conditions that is more coherent and makes sense to you as a person who lives in that neighbourhood. In addition, we hear that it is about having more space, time and focus on prevention and more proactive care in order to avoid the huge demands that are being placed on our acute services.

The second area that is emerging that we would like to see in a neighbourhood model in Northern Ireland is the ability of those provider alliances to collaborate with health and social care trusts in order to offer their population access to more advanced specialist care and services that are closer to home. That would truly enable a shift left through working together at provider level and supporting that. We also need a model that will support those provider alliances to strengthen and build their alliances over time by responding to opportunities for their population through, for example, the commission of the services and invest-to-save initiatives. Finally, we need the neighbourhood model to allow our provider alliances in Health and Social Care to connect with wider public services to tackle the wider determinants of health. That is where there will be links with areas such as housing and poverty that are the domain not of Health but other Departments.

Some benefits from the neighbourhood model that we would like to see are improved health outcomes; reliable access to same-day urgent care and improved continuity for complex care; a focus on preventative healthcare that the system struggles to have at the moment, with earlier detection of disease; and some other outputs such as higher uptake of vaccination and screening programmes, reduced unplanned admissions to hospital and reduced attendance at ED and out-of-hours services.

We would like the model to bring more trust and greater patient and carer satisfaction so that people feel listened to and receive coordinated care; more care is delivered in the community rather than in our secondary care services; and more care is provided in-hours through the use of all our available services. We believe that that would lead to a more efficient and sustainable use of the resources that we have, with less duplication, fewer gaps in care, better value for money and stronger community resilience. We have empowered communities and individuals in our neighbourhoods, and they are engaged more in their own health, with more holistic approaches to tackling health inequalities and potentially even getting into tackling issues such as supporting local workforces, supporting people back into employment and catalysing economic regeneration. In summary, the key benefit is that the model will go beyond health and into well-being.

As I said at the start, we have been tasked with describing what a neighbourhood model will look like, and, to do that, we will have to think about an operating model for health and social care so that we can begin to work in this way with our partners, as well as about an associated funding model. I will share with you where our thinking is on that at the moment. We are in the design phase. We have been sharing our thoughts with stakeholders, and they have certainly told us what they think, so we can get into that as well. At the moment, we do not have in our health and social care system a structure that allows providers to come together in this way, particularly at a more local level, so we need to think about the interventions that we may need to place in the system. One of the proposals that we have been testing with our stakeholders is building a model, for example, around what we are calling "integrated neighbourhood teams". Those would be teams of teams of people who come together but who represent wider and bigger teams in the wider community. Those teams of teams would come together under an ethos of joint leadership; it is important to say that from the beginning. They would operate in the trusts' or area integrated partnership board (AIPB) footprints, which are the same, and we are testing the idea of working at a population level of around 115,000, which is at our GP federation footprint level, because that is a strata that we have in our system.

Those integrated neighbourhood teams would act as the core component of the provider alliances and help to bring together those currently siloed professional teams and organisations, and they would link with the voluntary and community sector. Importantly, they would fully understand the populations that they serve, have a high level of connectivity to those populations and work together in a team of teams to drive the delivery of those core functions and the priorities for moving care closer to home as they evolve. If those integrated neighbourhood teams worked at that level, with around 100,000 people, it would involve working with smaller neighbourhood groups within that footprint. They are the natural communities to which people already say that they feel they belong. It has become apparent to us, while doing this work, that we need to not disrupt those natural communities, which we are so rich in. Gearóid and I had the opportunity to visit a number of different communities, and we found that we do not want to disrupt them. We definitely want to enhance them.

I will move on to the funding model. First, a lot of this is about mobilising what we are already doing and helping people to work together better and to collaborate better. We are seeing what we are calling a "mixed-funding model", but it very much involves mobilising existing funding and allows what is maybe a more proactive approach than we have had before to invest-to-save initiatives. It is also about looking at opportunities from outside our normal traditional health sources to accelerate improvement in growth. We see that happening at four different levels. First, there will be a need to identify some funding from the beginning in our Health and Social Care budgets to support whatever we use. If we use integrated neighbourhood teams, they will be able to come together and begin to focus on collaborating and using their existing services to reduce and manage demand in those services.

The second area is to use money from HSC budgets to put into what we are calling "invest to shift". Shifting left means shifting clinical care and responsibility from one part of the system to another, and resource needs to follow that. However, we are not in a position of being able to double-fund. We need to have a very highly collaborative model between the trusts and the provider alliances that says, "If we're going to shift activity, the resources will also go". It also means that that activity will have to stop at a point in time in the trusts, for example.

Where other elements of funding are concerned, I am confident that, because of the nature of the work that they do, the provider alliances will identify opportunities for invest to save. As a system, we need to support that and have mechanisms in place so that, if money is saved in part of that system, it can be reinvested in that neighbourhood and the provider alliance has some purchase over how that is done. Finally, those provider alliances will be encouraged and supported to attract funding from other sources that becomes available to us from time to time. That money could come from social finance models, innovation, research or other investment opportunities. I have to say again that, in our engagement with stakeholders, we found that people in our voluntary and community sector are experts in accessing funding and using it to sustain tremendous work and growth in their communities and to serve those communities.

I drove up here today from north Fermanagh. I had the opportunity to visit Ederney Community Development Trust. I told the people there that I would give it a wee shout-out. I had to leave early to get here. What I saw there, and what Gearóid and I have seen elsewhere in Northern Ireland, gives me confidence about the idea that we need to change what we are doing. The Ederney Community Development Trust really understands its community and tailors the services that it provides. It is already working well with Health and Social Care in that very rural area. Equally, we have been to the old hospital trust in the

and to west Belfast, Ballymena and other places, so we have seen some of that working.

Hopefully, that has helped you to understand where we are. It is very much in the design phase, so we are interested in feedback, of course, and we can answer any questions. Thank you.

The Chairperson (Mr McGuigan): Thank you for that. Essentially, we are in a design phase, but we hope to have something operational from March 2026. You are engaging with stakeholders and discussing funding packages. Minister, you talked about workforce being key. I would be surprised if anybody in the room disagreed with you about the need to change. Key to change is having a workforce that is compliant and wants to change along with you. You talked about GPs. From what I heard from Cathy, and from what we saw in the presentation, GPs will be crucial in the roll-out of any new proposals for neighbourhood models, yet we are in a scenario in which the Department and GPs are at loggerheads or in dispute — whatever way you want to frame it — over core funding for this year and core funding moving forward. We are designing a model that GPs will be crucial in leading, even though we do not have agreement.

Thankfully, you have put on the record today that there is some light at the end of the tunnel, which everybody welcomes. To be frank, there has been a dispute that there should not have been, and we want to see an end to it.

I will not ask you about the details of the discussions that you are having with GPs about core funding for this year, other than to say that I hope that they bring about success, because we need to see a resolution to the dispute. When it comes to what we are discussing here — the shift left and the additional workload — what conversations have taken place with GPs in this phase that can give the Committee some satisfaction that they are on board with what you are suggesting? The last thing that the Health Committee and society in the North want is a design phase, followed by an announcement in April, after which GPs say, "Hold on a minute. We have not been part of that conversation. We are not in agreement. Where is the funding that allows us to do the things that the Department wants us to do?". I will leave the current funding negotiations for now, but I want to be secure in —.

Mr Nesbitt: OK. I get it. As a final comment on what I said about hoping to get to negotiations, I got a letter back from the chair of the British Medical Association's Northern Ireland general practitioners committee yesterday outlining what, I hope, will be the three phases of the talks and making it clear that the committee wishes to treat the elements of our proposal as confidential until it finishes its internal discussions. Those discussions are at phase 2. I hope that we are all happy to accept the validity, reasonableness and sensibleness of the process.

On the discussions with GPs, yes, the committee is in dispute with us, but that has not prevented us from talking to individual GPs. I am now going around some of the GP federations. Yesterday, it was the southern federations. We are discussing the neighbourhood model and how GPs view that. It is incredibly important that they feel that they have ownership of it. We are all familiar with the principle of co-design. We are very open, and I take you back to what Professor Bengoa said to me when he was here last October, which was, "You need to be really tight on your outcomes but really loose on how you achieve them, because you are not a nurse or a doctor". In saying that we want to shift left to a neighbourhood model, I mean that that is the outcome that I am looking for, but how we achieve it is not down to me, Cathy or Gearóid. We can have input into it, and we can facilitate discussions about it, but it is GPs who will do it.

You may wish to come in, Gearóid, but, finally, I want to mention the sort of thing that, having already been done, works. Vasectomy services were taken from secondary care and put into primary care, and the money went with them. Such things can therefore be added, but I do not want us to be prescriptive. I want the people who will deliver the neighbourhood model to say, "This is what we can do". When I talk to people, they always say, "We could do so much more", so let us let them do so much more.

The Chairperson (Mr McGuigan): The resource will follow.

Mr Nesbitt: Wherever possible. Remember the ambition: if we can do prevention and early intervention, we may take some of the pressure off acute services, where all the expensive stuff happens. If we do fewer of those expensive procedures, we will start a money flow. That is swimming against the tide of an increasingly elderly population, but it is possible.

Mr Gearóid Cassidy (Department of Health): As the Minister said, we have not been in formal contractual discussions with the GPC, but we have been engaging with individual GPs, and the Minister has been engaging with the federations and their support units. We had a workshop specifically with GPs, including representatives from the BMA, the Royal College of General Practitioners (RCGP) and the federations, as well as individual GPs, to try to bring them with us by explaining to them what we are trying to achieve and getting their feedback. What we presented to the GPs and other stakeholders is along the lines of what you have heard here today. We are not starting with a final product and asking them to tell us where they see themselves within it. Rather, we want them to work with us on achieving the best fit for Northern Ireland.

We want to set the objectives for what we want to achieve, the ways that we want to work and a mechanism or structure that will allow us to work in that way. We are not going to impose it centrally; some of the feedback shows concerns that the shift left will mean that work will come their way, but without the resource attached to it. There has been criticism of that in the past. As the Minister outlined, the vasectomy service is a good example of the lift and shift, where a specific service is moved from one place and the funding goes with it, but, as Cathy outlined, one of the big strands is about working more efficiently within what we already have. Through the neighbourhood model, if practices can work better, either together or with community and voluntary partners, to provide better outcomes and access for patients, a large cost will not necessarily be attached to that and there will not necessarily be more work for anyone in the mix. However, it will mean working with more purpose to achieve agreed objectives and outcomes. We hope to be in a place where we can have further formal engagement with them about the model. So far, there is interest, some see opportunities, and some see threats. We want to make sure that we understand all that so we can arrive at a place where everyone has agreement.

The Chairperson (Mr McGuigan): We are not in an ideal scenario. Cathy said that not everything would be agreed by April, but that is only five months away, which is not a long time. I do not want to repeat myself, but you talked about engaging with individual GPs, and we have heard about the decision 90% of GPs made last Saturday. First, the priority needs to be finding a resolution with the GPs on the core funding to allow the neighbourhood model aspect to have the flow that it needs, because five months is not a long time.

Mr Nesbitt: The meeting with officials is imminent, and, after that, it is up to the NIGPC to do the internal work. We are ready and the door is open.

The Chairperson (Mr McGuigan): Thank you. I will not push that point again. You mentioned the domiciliary care issue and social care staff. It is important to put on the record the disappointment with the decision.

Mr Nesbitt: I agree.

The Chairperson (Mr McGuigan): I asked you, the permanent secretary and others at various Committee meetings about the commitment, and people expected to get their pay in September. I am obviously very disappointed for the staff, because nobody should work in our health and social care service and not be paid the real living wage. Also, the shift-left policy and the winter preparedness plan mean that the social care staff and domiciliary care packages are crucial. Today, we received a letter from the independent sector that expressed disappointment and asked various questions, which we will forward to you. It would be useful to get your sense of any potential impact on the sector, winter plans and any of the strategies as a result of a disaffected workforce, and not being able to retain and recruit staff who are key to our health service.

Mr Nesbitt: First, the decision is counter-strategic. Nobody in their right mind would make that decision unless they absolutely had to, and there was no choice because the money did not exist. It is hard to say what the impact will be. You have identified the real and present dangers, which are attracting and retaining staff. However, we have to look at it in more detail because it has just emerged at my level that the majority of employers — 70% — already pay the real living wage, or possibly more. The impact will be 100% on those who are paid less than the real living wage, but the percentage who are paid the real living wage may be a lot lower than was anticipated. It is not possible at this stage to tell you the impact, but those are the areas that might be impacted on.

The Chairperson (Mr McGuigan): I am confused because you have taken the decision that you cannot pay the real living wage because you cannot afford it, but you now say that the impact may not be as great as you first thought.

Mr Nesbitt: It is the number of people who will be impacted on, but it still needs the £25 million.

The Chairperson (Mr McGuigan): It is £25 million, even though it is not for everybody. OK.

My last question is on the workforce issues. I asked a question for written answer about the number of people on the waiting lists. Nearly 22,000 people are on the waiting list for occupational therapy. A key component of shifting left is that there is a clear need to address the capacity challenges within occupational therapy and allied health professionals (AHPs), who currently deliver community-based care. What steps are being taken to build that workforce to help to address the strategy that we are talking about today?

Mr Nesbitt: I do not have the specifics on OTs. I know that, in this financial year, we put significant investment into AHPs. Off the top of my head, I think that speech and language therapists did very well. If you would like, I can certainly get that information to you.

The Chairperson (Mr McGuigan): That would be useful. As I said, all of that — ensuring that we have an adequate workforce to do the things — is vital to the strategy of shifting left.

Mr Nesbitt: Absolutely.

The Chairperson (Mr McGuigan): Allied health professionals are just as key to that as doctors, nurses and all other aspects of our health service.

Mr Nesbitt: There are just so many stats that my little brain cannot absorb them.

The Chairperson (Mr McGuigan): It would be useful if you came back to us on that.

Mrs Dodds: Thank you Minister. I am glad to hear that there has been some movement forward on GPs. I do not think that what happened earlier in the year was sustainable, and it is regrettable that those relations broke down. I am glad, however, to hear that we are where we are, and I wish you success with that. Without GPs, who see over 90% of us and who have the most healthcare interactions with people, we would not be able to manage the health and social care system. I wanted to place on record that I think that that is very good, and that it is very important.

I also completely agree with you on another point: I will give no political cover for any kind of hybrid model that moves away from the core objective of the National Health Service, which is to be free at the point of delivery. It is important to have that on the record as well, because I think that the chatter is just that: chatter. Political will is needed to deliver that, but I will not be serving that up.

Try to help us to understand this. Is it right to say that the negotiations will be about the contract for 2025-26?

Mr Nesbitt: I will respect the Committee's desire for confidentiality around the elements of the package.

Mrs Dodds: I do not want you to say anything about money or anything; I just want to understand —.

Mr Nesbitt: That is an element of the package.

Mrs Dodds: I just want to understand what the impact on the budget will be. If the budget is in significant difficulty, will it add to that significant difficulty? That is all that I am asking.

Mr Nesbitt: To answer that would be to divulge part of the package, which the Committee has asked be kept confidential, and I think that it was right to request that.

Mrs Dodds: I do not expect you to negotiate in an open forum — that is fine — but we will need to understand what the impact will be on the budget, whether it would create an overspend and, if it did, what the impact of that overspend would be on the 2026-27 budget.

Mr Nesbitt: What I can say is that, if it did not have an impact on budgets, I do not think that it would fly.

Mrs Dodds: Neither do I. I am just trying to tease it out.

You quoted a figure of £25 million for health and social care workers. I take it that you would be paying that £25 million irrespective of how many people needed it in order to achieve the real living wage, yes?

Mr Nesbitt: I think that that was a calculation that officials made about supplying it. What I was not aware of was that a significant number of people are on the real living wage already, but that it is being paid by their employers. We were proposing to put money into the system to allow employers to pay their people the real living wage, so we were not —.

Mrs Dodds: So, the Department was taking responsibility for paying the real living wage, not the employers?

Mr Nesbitt: We were giving them the funds that they needed in order to achieve that.

Mrs Dodds: I am finding that difficult. You are saying that 75% are already on it. I think that it is the right thing to do. To expect people to do that difficult work without getting at least the real living wage; that is a very important issue. I am just trying to understand. You say that 75% are already on it.

Mr Nesbitt: The figure is 70%.

Mrs Dodds: You say that 70% are already on it, whatever number that is, yet you still intend to pay them the £25 million. Could we get some clarity on that? One thing that comes up in my office on a fairly regular basis is the issue of top-up fees for nursing homes and the amount of money that people have to pay, over and above. It is important that we get a sense of that budget and how it is worked out.

I am a bit like the Chair in that I am concerned about the timescales, if we are only designing something now. I have spoken to a number of GPs and so on who agree with the approach and think that it is the right thing to do, but the timescale is very short. I worry about that. How can we have confidence that we can deliver within that timescale when, 14 months after the hospital network document was launched, the Committee has not received — unless it has been delivered, and I have not seen it — the consultation responses from that? I have just been reading the delivery commitments in the reset plan. I cannot find what I was reading just now, but it says that we will know the outcome of the hospital network paper by September 2025, yet we do not.

Professor Harrison: Without a doubt, the timescales are challenging. That is why we stress that we want to get to a starting point by April. I think that we will be in a position to articulate the funding model, as asked, but, as I said during our remarks earlier, we will not have a full-blown neighbourhood model for a long time. It will take a long time to develop that, but this is the beginning of doing that. That is what we are working with.

Funnily enough, our stakeholders' views are mixed. Some stakeholders say, "As long as you are given to do it in, that is as long as you will take. You could be at it for years, and years, and years" — there is no doubt that we could be at this for years — "Please can you get on with it and get started?" Other stakeholders would like a lot more detail at this stage, and others still, even those who are within the same stakeholder group, say, "Do not give us too much detail. We want to inform how it develops". All that I can say is that we are focused on it. We are focused on describing a model and the funding to support that model, and we are focused on delivering it by that time in order to allow something to commence. It will very much be a case of beginning from there.

Mrs Dodds: If I have got this right, you have identified four types of funding that will be needed. The first is to mobilise what you are already doing — I do not quite know what that means, but I am sure that you do. Another is identifying funding from HSC budget money to invest to shift. Is there an agreement from the trusts to move that money across? I always think that that is the big issue, and it is a difficult issue. There are also the provider alliances — GP federations, say. I talk to representatives of the southern federations fairly regularly, and they have some brilliant ideas about how to improve community health in that —.

Mr Nesbitt: Respiratory?

Mrs Dodds: Yes, exactly. That is quite exciting to hear.

Mr Nesbitt: It is fabulous.

Mrs Dodds: For some reason or other, the Armagh City, Banbridge and Craigavon Borough Council area has some of the worst respiratory health in the whole of Northern Ireland, and they have really good ideas for what could be done about that. That is quite exciting.

On provider alliances, it mentions getting funding from other sources, but is pretty hard to get funding from other sources — it is difficult. That is vague.

Mr Nesbitt: At the moment, part of it is necessarily vague because we do not know what our budget will be. We are anticipating a three-year, multi-year budget. It is difficult because every penny that we try to carve out of that for the shift potentially has implications for current service delivery. You get that.

My colleagues are making the point that some in the service see it as opportunity, and some see it as threat. They are right to, because there are a lot of models. Cathy and I were in England a couple of months ago, looking at some of the models. One of them, frankly, I really disliked, because it was a really commercially driven operation. England does not have federations; it has primary care networks (PCNs). A network in London corralled the services together. Triage was online. To achieve scale, someone may have said, "Well, look, Mrs Dodds, your nearest GP — the one you normally go to — is Dr Cassidy, but I want you to go to Dr Harrison because she specialises in what you want. We are so commercially driven that we're just sending people". There are three pillars — emergency care, planned care for people with long-term conditions, and preventative — and PCNs try to get each practice to specialise in one of those pillars. I do not like that model, and nor do I think that you could apply it in Northern Ireland, because our practices are all independent practitioners. We need to overcome the fear and the concern of the GPs who are thinking, "Oh, I wonder whether they're thinking about that model" and reassure them by saying, "No, we're not. We're talking about a model that works for you, with a role for the federations".

On scale, all that I will say is this: in England, they reckon that, once you have 40,000 patients, you can predict your demand really accurately. Federations are nearly three times that size, at 115,000. We should be able to sweat that to predict demand much better than we are doing at present.

Mrs Dodds: Providing care closer to people in their community is the right way forward. I genuinely wish you well with that. The timescales are almost impossibly challenging, but we will leave that up to you.

Mr Nesbitt: There is very little time left in the mandate, so we cannot really be relaxed.

Mrs Dodds: I accept that, and I wish you well with it. It is important. You cannot do it without GPs or the hubs that we have the allied health professionals in etc. There is a huge job of work to do in that regard. I am a huge fan of women's centres. There is an open door when it comes to utilising community facilities. There is a brilliant one in Craigavon. I know that you have been to the one in the Shankill.

Mr Nesbitt: I have been a few times. It was delivering the Live Better initiative to try to tackle health inequalities.

The point that I forgot to make was that we were able to bundle existing services and, without any real additional budget, deliver that initiative in places such as the Shankill Shared Women's Centre. That neighbourhood model can absorb that sort of thing and say, "We're already doing this, but let's repackage it and deliver it as close to people's front doors as you possibly can get".

Mr Cassidy: The timeline is very challenging, but it is not the timeline to a finished product; it is a timeline to a concentrated starting point. It will grow as we develop. We are not looking to try to emulate every good service that we see, but it is important to make a start. We have been talking about shift left in Health for a long time. We have started it in different ways, but this is a real concerted effort to try to move forward as one across the entire system. By springtime — by April — we will have the playbook for how it will work. We will not have the fully built product.

Mrs Dodds: Can someone come back to us about the social care workers? I am really keen to see their being rewarded appropriately. I would really like to work out how that is being done, and have an idea of when we will see the outcomes of the hospital network consultation.

Mr McGrath: Thank you, Minister, for your presentation. Call me cynical, but I think back to when I was studying health and social care: we looked at how the trusts were realigned and how the Department's boards were realigned. Since then, we have changed the boards again and moved functions to the strategic planning and performance group (SPPG), which is different. We have flirted with integrated care partnerships, and now we are talking about a shift left. Yet, the front page of 'The Irish News' has a story about Ernie Irvine, who has stage four cancer and was treated on the floor of a hospital for 48 hours.

Sometimes, it feels like we talk about a system and then we get really excited about a new system and go through phases and plans. However, just like a set of gears, we do not get the connect that leads to change on the ground. I am not talking only about your time as Minister; there have been many Ministers before you. People are interested in being able to see a doctor when they need to see one; getting an ambulance when they need one; and, when they go to an ED, receiving treatment there and being moved onto a ward. What comfort can you give us that, when the plan is implemented, people like Ernie will not be treated on the floor for 48 hours in what is supposed to be our health service and people who need to see a doctor will be able to see one? What will be the tangible outcomes, so that we can prove to people that the plan has worked?

Mr Nesbitt: I will start with another reference to Bengoa. You will remember that his report was called 'Systems, Not Structures'. You began by talking about a lot of the structural changes that have happened, and I have said that I will not engage in structural change during my time as Health Minister. I would love to, by the way. Rather than having five geographic trusts, we should have a paediatric trust, a cancer trust, a mental health trust etc. That is our best bet at getting regionalised, standardised services, but, if I called that now, with a year and half to go in the mandate, the whole system would grind to a halt. Therefore, shift left is about a system change. It is about saying, "Let us think about prevention", and, when people start getting sick, "Let us get in as early as we can".

Regarding the man who was lying on the floor, I apologise for that. That should not happen. The best chance of preventing it is to take a bit of the pressure off the acute hospitals. The best way to do that is to get in early on the ground. We know that, when you deliver health and social care in somebody's home or as close to their front door as possible, the uptake is so good. For example, Shankill Shared Women's Centre held some drop-in sessions at which people could get various tests done. Every time I went to it, the place was buzzing. It was the same up in Derry. Also, just to digress, those two demonstration areas were asked what they wanted, and they picked different things because they understand their people.

The shift left will work because it is about system rather than structure. How will we know? When there is a bit less pressure on EDs, when ambulances are not sitting for so long in the car parks and when we have a better flow out into community care. The big challenge is capacity in community care in respect of care home beds and domiciliary care packages, which brings me back to the care workers being paid the real living wage. The current situation is counter-strategic.

Professor Harrison: You asked a really important question on outcomes, and we have spent some time thinking about that. What do we need to see first? What do we need to start to see from the beginning of next year, bearing in mind that we will have to work through large programmes, such as shifting activity out of hospitals, that will take time? We need to bring provider alliances together and use all the resources that we are already investing in. That is what is so apparent when you are out in communities: you see all the services that are already funded. I am not just talking about Health and Social Care; I am talking about voluntary care as well.

We hear all the time from stakeholders that we need to work more together. We call it "working with purpose", which is what we did during COVID, when we worked together with a smaller number of priority areas. We all need to work together and focus on keeping our people out of hospital. By understanding the needs of those in the neighbourhood who are at the highest risk and getting them into proactive care, we can keep them out of hospital. That will reduce unplanned admissions to hospital, reduce unnecessary ED attendance and reduce conveyances to hospital and, therefore, the pressures on the Northern Ireland Ambulance Service (NIAS). That is what we see happening in neighbourhood models, which is why we say that we need to start to work together like that.

As Chief Pharmaceutical Officer, I am familiar with the role of community pharmacy. We have invested in more services in that sector, and we want to invest more. We will have a lot more prescribers in that sector soon. We have invested in more services, but, when you look at the system, you see that it is still not utilising those services effectively. We hear the same thing from voluntary and community sector representatives. They say, "We are funded to provide services, but there is duplication in the system". There might be a trust-led service that looks a bit like their service. We have an opportunity to get started with the provider alliances. The evidence shows that, when people start to work in that way, there are key outputs.

Mr McGrath: There are nine members of the Committee, and I am sure that I am not speaking out of turn when I say that we are all behind you. We want to see changes to the system, because it is so broken and does not work for people. I refer to the experience of Ernie.

I know that you have to do this for the purpose of presentations and documents, but I am hearing a lot of terms that I have heard before, such as "circling the environment", "thinking of new ways", "scanning the horizon". Is there a way that we can start to get some concrete information into the reports? When you talk about community pharmacy, I go, "Yes, you put x amount of money in through the front door of that service. Then, people who would otherwise have gone to hospital will not do so, because they go to community pharmacies instead". That keeps people out of EDs, which means that there is more space there. You can start to see progress when it is tangible. Is there a way for us to get some information on that, even if it were an example under each thing? We do not want people to say that it is just buzzwords.

Professor Harrison: That is a fair point.

Mr Nesbitt: It is a fair point, but, if we said, "There it is; there is the plan. It is really solid and concrete", the GP committee would say, "Oh, thanks for asking".

Professor Harrison: We can definitely provide information. That is the next —.

Mr McGrath: Yes, even if it were at a headline level as to what the change could be.

Mr Nesbitt: We can have a menu that shows what is possible and what is not.

Mr Cassidy: We are building that as we speak. If we had presented to you a month ago, there would have been less detail in the presentation. It is growing and growing. We are mindful of the timelines, but that is a fair comment, Mr McGrath. The next iteration of our presentation design will be more concrete on the outcomes and the shift that we want to see.

Miss McAllister: Thank you for the presentation. I have a few questions. I start by picking up on that last point. It is really good to see agreement on wanting to transform the health service. However, do you agree, Minister, that, while transforming the health service should not be political and we should have buy-in, ultimately, the shift-left agenda is not new? As you said, it was an idea long ago: Bengoa talked about it many years ago. However, it is about taking the politics out of health and moving forward. Do you agree?

Mr Nesbitt: Yes. It was around even before Bengoa.

Miss McAllister: It was indeed. I will go back to the hybrid issue. I also agree that the creation of the NHS after the Second World War was a massive change for society when it came to tackling health inequalities and poverty. We should not have any sort of hybrid model for GPs; that should not be an option. However, do you accept that we already have that model in dentistry, which is also a part of primary care?

Mr Nesbitt: Yes. A hybrid model for dentistry was implemented not long after the launch of the health service. My understanding is that, had that not been implemented, the whole NHS would have collapsed.

Miss McAllister: Our constituents cannot get access to dentists. They sometimes cannot get access to a GP, but they cannot even register with a dentist. How will your shift-left agenda aim to tackle that issue?

Mr Nesbitt: We have put several million pounds into a dental access scheme, but dentists are independent traders and we cannot force them.

Miss McAllister: What else can we do to get more people seen? Dentists tell us that they cannot offer services when they are not paid the cost of delivering those services.

Mr Nesbitt: There is no agreement about what it costs to run a dental chair, so we have commissioned a cost-of-service survey. That will lead to results, which will lead to discussions with the British Dental Association (BDA) Dental Practice Committee. Hopefully, we will agree, first, that the cost-of-service report is accurate, and that will lead to a discussion or negotiation.

Miss McAllister: Where are we on that?

Mr Cassidy: We have commenced the process. We appointed someone from Queen's University to lead the review, and they have started their work. I have not had an update. We are working towards having the report finalised for the springtime. As the Minister said, that will form the basis of policy formulation and negotiation with the BDA.

Miss McAllister: Many of our constituents cannot access the dental access scheme, because of its criteria. I understand that it is limited by the number of dentists who sign up to it, but is there any way in which the criteria or the way that they are applied can be changed?

Mr Cassidy: We review all our schemes on an ongoing basis. I have had discussions recently with the Chief Dental Officer on reviewing that scheme, although not specifically for that reason. We can look at that. Practices sign up to the scheme and deliver what they signed up to do. If a practice is unwilling to sign up to the scheme, we cannot make it. The scheme seems to have been successful, judging by the uptake, but we want to make sure that we understand exactly how it is working.

Mr Nesbitt: The cost-of-service review is being conducted by a Queen's professor who is due to report by the end of the 2025-26 financial year. I put in my usual proviso: we are not world leaders in meeting our deadlines.

Miss McAllister: We are not. We should be, but we are not. We can all agree on that point.

Can you elaborate on the £1·6 million that you announced for dentistry and remind us what that additional money will do? Have I got that figure correct?

Mr Nesbitt: There is £7 million for services including enhanced child examination. Of that, 30% is for additional fees for services such as fillings, extractions and root canal treatments. The £1·6 million is to support dental practitioners who continue to provide health service dental care to patients, and £2·5 million has been made available for general dental practitioners to offset the increased costs of National Insurance contributions.

Miss McAllister: I do not really understand the £1·6 million. We have submitted a question for written answer on that, so I am fine to get an answer in that way.

Mr Nesbitt: OK. That is probably best. I think that it is for dental surgeries that can prove that they have done a certain number of health service treatments.

Mr Cassidy: It is akin to the old commitment payments. It is not exactly the same as the old scheme, but we can provide the detail on the intention behind it and the uptake of it.

Mr Nesbitt: The more you do, the bigger the slice of cake that you get.

Mr Cassidy: Yes. It is to incentivise an increase in dental treatments.

Miss McAllister: Is that to incentivise increased activity in NHS dental work?

Mr Cassidy: Yes.

Miss McAllister: If the payments do not cover the cost of carrying out that NHS dental work and dentists pay for it out of their own pockets first to be reimbursed later, is that an incentive? Dentists tell us that they carry out work but the money that they recover from the NHS does not cover the cost of carrying out the work. You say dentists will be incentivised to do more NHS work, but it costs them money to do that work. Where will the additional —?

Mr Nesbitt: Hence the cost-of-service review.

Mr Cassidy: We have enhanced by 30% the uplift in fees across the biggest category of activity. We have increased the key rates for what is being done, and we have added an incentive for people to do a higher volume of that work. All those things are subject to review.

Miss McAllister: We have submitted a question for written answer, so I am happy to carry on in that way.

Mr Nesbitt: OK. Does anybody have Kilrea in their constituency?

Mr Robinson: Yes.

Mr Nesbitt: The dental service in Kilrea is fantastic. It does magnificent NHS work. It is well worth a visit, Alan.

Mr Robinson: OK. I will look it up.

Miss McAllister: Minister, in January 2025 you were at the Committee and said that the cost of providing the real living wage for home care workers was estimated to be £50 million. Now you say that it is £25 million.

Was it £50 million or —?

Mr Nesbitt: Both.

Miss McAllister: How?

Mr Nesbitt: It was £25 million from September to the end of the financial year, and it was £50 million for the whole year.

Miss McAllister: You said that in January, so it was never going to be —.

Mr Nesbitt: I was hoping to do it from September of this year until March 2026 for £25 million and then to do it for the whole of the next financial year for £50 million.

Miss McAllister: Is it £25 million, regardless of the number of people who need to get it?

Mr Nesbitt: That is the number that the officials crunched out. I was not aware that that did not represent everybody who is delivering social care.

Miss McAllister: So it was always £25 million, because the officials — not you — knew that not everybody needed a rise in order to receive the real living wage.

Mr Nesbitt: That is my understanding, yes.

Miss McAllister: How many people are we talking about in total?

Mr Nesbitt: I do not know that off the top of my head. Does anybody else know the number of people who deliver social care?

Professor Harrison: No.

Miss McAllister: You can understand our confusion. We do not know the statistics for the finance that is needed to deliver the real living wage for those workers. If a decision was made not to pay the real living wage to those who need it, without knowing how many people needed an increase in order to receive the real living wage, how can we have confidence in that decision? I say that notwithstanding my complete respect for the difficulties with all budgets. How can we have confidence in the decision if we are not confident that we know all the issues that lie behind it?

Mr Nesbitt: The officials came to me and said, "If you want to do it, it will cost £25 million this year because it is a half year, and it will therefore cost £50 million a year thereafter". Subsequently, I have been told that that does not cover everybody, because a lot of people already receive the living wage.

Miss McAllister: Did the officials know at that time that it did not cover everybody?

Mr Nesbitt: As far as I know, they knew whom it had to cover. Let me bring you a paper on that.

Mrs Dodds: We need clarity on that.

Miss McAllister: We do. It raises questions about why the decision was made in the first place without having all the information. I recognise that your budgets are difficult and that £25 million might not seem like a lot in the grand scheme of the Executive —

Mr Nesbitt: It is a lot.

Miss McAllister: — but it is a lot.

A report by the Comptroller and Auditor General highlighted that the cost of restricted procedures was £22 million a year. Those restricted procedures were carried out without the assurance that they complied with government policy. I am not saying that people do not deserve to have those procedures, but there absolutely must be prioritisation. If, on the one hand, the Comptroller and Auditor General says that £22 million was spent on restricted procedures and, on the other, the cost of ensuring that home care workers receive the living wage is £25 million, how many other things are going on across our trusts and health service from which that £25 million could be found?

The report on the performance of restricted procedures stated that the cost of £22 million was for 2023-24. In a response to a question for written answer, you and your Department said to me that you were using restricted procedures under that guidance to evaluate whether people should access a waiting list. That is despite the fact that, a year before that, the Comptroller and Auditor General said that recommendations needed to be implemented. It seems that there could have been a prioritising of measures to save money.

I go back to the point about £25 million not being a lot, but that example provides a snapshot of one issue that involved £22 million. Do you understand why there are questions about why home care staff are not getting the living wage when there could be prioritisation? Again, I respect the fact that budgets are difficult.

Mr Nesbitt: There are a lot of judgement calls to be made in the delivery of health and social care. On the question of whether there are other examples of where money could have been saved, all I can say is that we started with a funding gap of £600 million — £400 million excluding pay — and that gap is now £91 million. That is an unprecedented effort that was made not exclusively but particularly by the trusts. Is there still a bit of slack? There may well be, but, my goodness, people are working supremely well at trying to find the inefficiencies and cut them out. Saving over £300 million in one financial year is pretty impressive.

Miss McAllister: It is impressive, but the point about prioritisation stands.

Mr Nesbitt: It is a judgement call.

Miss McAllister: As Minister, you are the right person — it is not just you, to be fair; it is your whole Department — to provide with the information on where priorities should be and where money should be spent. It is difficult, but it has to be done by the Department.

Mr Nesbitt: Yes

Miss McAllister: I have no further questions.

Mr Donnelly: Like other members, I am confused about the 70:30 split and the fact that 70% were already getting paid the living wage but 30% were not. I appreciate that you are going to bring us a paper. I look forward to understanding how that works.

We all want to see investment in prevention and early interventions, because we know that that will keep people in our communities healthier, keep them out of hospital and reduce the pressure on A&Es and wards. I hear regularly from healthcare workers who are concerned about patient levels in our hospitals. All summer, we had ambulance waits, pressures on A&E departments and corridor beds on wards. Staff are concerned about going into this winter under those conditions. A lot of them did not have a lot of confidence in the winter preparedness plan, because they were not able to see the light at the end of the tunnel this winter. You came here on 7 January, I think, and promised us that this winter would be better than last winter. We are concerned that the plans that have come forward will not deliver. On the plan for shift left that you have given us today, what specific metrics will be used to measure progress? How will you know that it is working and delivering?

Mr Nesbitt: We have not populated shift left, as we said. I take Mr McGrath's point that we need to put some more granular detail in it. Until we say, "It is this: the next vasectomy is x, y or z", it is difficult to say that there is a matrix by which we will judge it.

Professor Harrison: The types of metrics that we will use are those that I have mentioned. We will focus on key metrics that indicate demand in the system.

Mr Donnelly: For example?

Professor Harrison: Unplanned admissions to hospital; the rate of ED attendance; and conveyance rates from NIAS. We are working with NIAS on conveyance rates. That is about how current demand is managed. We will look at the difference that shift left makes, as we have done with other models. That is the right question. We have to look at what difference it will make and how quickly we will start to see that.

The activity shift almost needs to happen specialism by specialism. We need to go, "Where would you start? Where would have the biggest impact, and how would we measure it?". Some of the models that we have looked at have been able to demonstrate the benefit of GP referrals to specific specialisms without having to involve a trust, because GPs, through the neighbourhood approach, hold more care for longer in the neighbourhood. Those are the key metrics that we will look at.

We are interested in whether we can keep the plan quite high-level. There is no shortage of metrics in the system. Everyone is measuring lots of stuff — there is lots of data — but it is about what we want to see first. The areas I mentioned are the ones that we want to look at, because people can see the impact that their coming together will have on them.

Mr Donnelly: Those are the things that people in the health service have described to me: unplanned admissions; pressure on A&Es; the length of time that people have to stay in A&E; corridor bed waits; and the length of time that medically fit patients have to wait on a ward before they are discharged. I asked you a question in October — I do not know whether you remember — about how many medically fit patients were waiting on wards in Northern Ireland: the answer at that time was nearly 400. It was not even winter then, and those pressures were already there.

There needs to be a shift left to community workers. I have heard from carers who are really disturbed that they are not getting the real living wage that they were promised. What will you do to reassure them that we are investing in the community sector and will make the flow through hospitals easier by building capacity in communities?

Mr Nesbitt: There were three things that I wanted to do. The first was more pressing, not more important, than the others, and that was pay for nurses and doctors, because, as you are aware. the Royal College of Nursing (RCN) and some of the unions were very close to balloting for industrial action. The RCN wrote to me to make it clear that industrial action meant strike action without derogations.

I was sitting beside the Chief Nursing Officer when we had that meeting. I was scared, and she looked scared, because "no derogations" was a serious escalation from last time. That was the first thing, and I think that we have got there on pay.

Mr Donnelly: No derogations at all?

Mr Nesbitt: "At all", they said.

Mr Donnelly: Right.

Mr Nesbitt: I found it hard to imagine, but, when I imagined it, it scared me. They wrote that; they put it on paper.

The second thing was the low-paid workers. I am very unhappy. I am not content that there are people who are earning even less than the real living wage. I would like everybody to earn more than the real living wage, so I want to address that, and we are in the foothills of a plan that will address that no later than the start of the next financial year. That is my ambition.

The third thing — you will know this — is that it is not about the pay per se but about banding and where you are. You can qualify as a nurse and quickly become a band 5. You can have a career of 20 or 25 years and leave as a band 5. The RCN has made it clear to me that that is a really big issue, plus the band 1s and band 2s. Pay, career progression and development; those were the three things.

When it comes to winter preparedness, I went to, I think, seven of the type-1 EDs last January, and it was awful. I thought, "I am ultimately responsible for this". That is why I said, "Let us take a blank page and get everybody in the room". It is back to the Bengoa thing. I said, "I am tight on the outcome. I want better next winter, but how do we achieve that? I do not know, but you are the nurses, the ED specialists and the emergency care workers". We had everybody in the room, so I will not criticise the plan, because, if that is the best that the professionals are coming up with, I accept that. However, I also accept that other people are looking at it and saying, "That is not much better than last year. I am not particularly hopeful".

Mr Donnelly: Minister, it is your plan.

Mr Nesbitt: Yes, I am owning it, but I did not write it. I said, "Get everybody who knows how to do this into the room with a blank page".

Mr Donnelly: You did not write the winter preparedness plan?

Mr Nesbitt: No, I did not write it. I signed off on it, and I will own it. If this new flu that is coming early knocks us for six, the buck stops with me.

Mr Donnelly: OK. Minister, you mentioned workforce there. Something that has come to my attention recently is the rise in vacancies across the health service. You may be aware that there are 6,310 vacancies across the health service, which is a vacancy rate of 7·3%. I think that that has gone up by about 15% in the last year. Nursing and midwifery account for most of the vacancies, with 2,098, which is one in three of the vacancies. What is driving those rates? Is it lack of recruitment or problems with retention? What are you doing about it?

Mr Nesbitt: I discuss various issues with the workforce directorate all the time, including vacancies and retention, but I am afraid that I do not have any information with me. Is it core to talking about shifting left?

Mr Donnelly: Of course.

Mr Nesbitt: Having the right workforce is, yes, but I do not have that granular detail with me.

Mr Donnelly: No problem.

I will ask another question, if you do not mind. Community pharmacy is mentioned in the reset plan and the winter preparedness plan as being a key pillar of the shift left. Can you tell us how much funding will go into community pharmacy and what the roles and responsibilities may be?

Professor Harrison: The funding is already in the system for community pharmacy this year. That funding was agreed at the beginning of the year, and decisions were made earlier in the year to extend access to the Pharmacy First service, for example. A small amount of money was put into that earlier in the year, but that was all done in advance of winter, so that is why the winter plan represents community pharmacy very well in relation to its contribution to the health system this winter. Those decisions were already made.

Community pharmacy will benefit from the recent decision on the pay uplift because, in Northern Ireland, it is aligned with the Review Body on Doctors' and Dentists' Remuneration (DDRB), so it will benefit from that, and it will benefit from the 4%. That will be the additionality that will go into the system in the next few months. Other than that, the money has already been in the system for community pharmacy from the beginning of the year, with maybe some additional changes, such as extending some of the Pharmacy First services for shingles and sore throats. That is all articulated in the winter plan.

Mr Donnelly: Can you tell us anything about investment next year when the new neighbourhood plan comes in? How much are you investing in community pharmacy, which will be a key part of it?

Professor Harrison: In the past month or two, we agreed the commissioning plan for community pharmacy for the next three years with Community Pharmacy Northern Ireland (CPNI). That sets out some ambitions around service development. Like everyone else, we in the Department will look to see what additional funding we can secure, in particular if that is in the context of a three-year budget. However, right now, I do not have figures that I can share with you on that because, as the Minister said, the budget for that is not yet known. However, we have a clear, agreed direction with the stakeholders regarding what we would like to invest in first. They are well set up in the context of neighbourhood. Also, from next summer, we will have our student pharmacists coming out as prescribers. We are already designing the services that will allow them to prescribe, for example, within Pharmacy First. They will be able to use those prescribing skills. They will benefit from having a clear strategy and the commissioning plan for that sector.

Mr Nesbitt: The budget for this year is £158·7 million, which is £11·7 million up on the previous year.

Mrs Dillon: Thank you, Minister, for your answers so far. I want to raise something that I raised in the debate in the Chamber the other day around cancer waiting times, and that is the Encompass system and the investment in it. If we are talking about shift left, that investment must deliver more than just, "We have new IT infrastructure. Isn't it great?". I can see my results, which is a good thing. I am certainly not being negative about the system, but we have not integrated primary care. Therefore, GPs, pharmacists and the people whom we are talking about in the shift left are not included in Encompass. That means that we do not have a single, accurate view of every patient's journey. Without that, how do we create really good pathways? That is our biggest problem, and shift left will work only if we have really good pathways, because it is about doing everything that you can on the left but making sure that the left has somewhere to send people who need to go to the right. That is not happening right now. I am sure that everybody here can give examples, but I can give you two examples in the past week where people have had repeated visits to GPs and EDs and were sent away and now are costing your health service a fortune because they have had surgeries to stabilise them, PET scans, MRIs, CTs and repeated visits to consultants. Now we do not know where their journey will go or where they will end up. That is really concerning.

I do not know how we manage to get those pathways right and ensure that the highest-risk cases go where they need to go and that the backlogs are managed safely. We need to look at the diagnostic treatment stages and see where the bottlenecks are. Encompass should allow us to do that. If it is not, why is it not? When will it be able to? For me, Encompass is absolutely vital in the shift left, and I am 100% behind the plan to shift left.

When we see the plan, I would also like to see some specific mention around how we will better look after women's health in the shift left because, at this point, they are being failed daily.

Mr Nesbitt: I recall from when I got the first-day brief being surprised that Encompass did not cover primary care, but there was a good answer to that: it was partly because they are all independent operators.

Mrs Dillon: It was, Minister. I met the Department before the Assembly was re-established, and I raised that issue at that time in those meetings. Yes, it said that. I said to the Department, "If you are serious about this and if you do not give any additional funding to GPs for anything else, why would you not look at some way of funding GPs to be part of that system?". It was the Department that came up with the idea of Encompass. It was seen by the Department as a good idea that was going to work and would improve the health service, so why did the Department not work with GPs to find out how GPs could be included in it and how it could be made to work for everybody?

Professor Harrison: In Northern Ireland, the Encompass programme brought in a single system for all of our trusts. All general practices are moving to one system: EMIS. It is not strictly my area, but I have an interest in it because of the neighbourhood work. We are looking at that, and you are right to point out that the digital infrastructure will be absolutely critical. My understanding is that EMIS and Epic can work together, and there is a programme of development that will allow that. Also, we have ambition around the electronic transfer of prescriptions. We also have ambition around digitising community pharmacy services, which are all paper-based at the moment, remember. We have real challenges there on scale, and those changes will take place over the next few years.

I stress again that the neighbourhood model will be one of long-term change. As those changes come in, we will need all of those digital systems working together, and we will need a programme to support that. That is on our radar, moving into the next stage. Building a programme to support the neighbourhood model will include working closely with our chief digital and information officer and his team to have a dedicated digital programme to support that, and it will include the data, which has not been mentioned. We have so much data in the system, but we do not necessarily have the data to hand that can clearly articulate the impact that that will have. It is out there, so that will be another ask of that team, and there will be a focus on improvement. It is a critical component of progress; you are right.

Mrs Dillon: This is my last point on this. Apologies, Gearóid, but, if you do not mind, I will make this point first. You may have been going to answer some of this if I got it across right. I understand that the people who are in the room are not necessarily the ones who absolutely understand how Encompass works, but can we get a written paper on it? I know that GPs are moving to one system, but I need to understand how that will work together in terms of data collection and how we will have better pathways. I need to know that that is absolutely 100% clear. I want to see that this is what will happen here, this is how we will get the outcomes and this is how it will create better pathways because we will have the information. I want to understand that, and, if there is a problem with it and if there is going to be some blockage somewhere along the line, tell us that. If we know about it, I will not come back to you asking why you did not tell me that. Tell us if there is going to be an issue with getting that information, because the system needs to be used to collate information that will make life better.

Mr Cassidy: We can come back with more detailed information on that. Each individual GP is the owner of their data, and that presents challenges with sharing it with other systems. I am not saying that that is necessarily a hard stop on a single system, but it will need to be navigated. We can provide more information on that.

To add to what Cathy said, we are at the early stages of this. Having good data on where patients are, what their conditions are and how they have been accessing services is really important. Our roadshows included early demos of this around mapping. We have pretty good maps on a federation level, drilling down to individual practices: what their list size is, what their key morbidity indexes are. We also know that the Public Health Agency (PHA) has some really good data on patient need and morbidity. In bringing those things together, we are creating a really powerful tool that will enable those neighbourhood teams to really understand at the touch of a button or with a few clicks of their mouse who is in their neighbourhood, what their needs are and where they are in relation to key services such as nearest GP service, their nearest community pharmacy and their nearest ED. That all helps to bring together into one place some of the disparate strands around what services are out there for people. It is incomplete, because, for example, we do not have really good, reliable information on the community and voluntary sector, so we will look to build that into it. As a decision-making tool and a planning tool, it will be really powerful. We can come back on Encompass.

Mrs Dillon: We need information on Encompass and the pathways. I appreciate that you are looking at that as a Department, but I definitely want more information on it.

The Chairperson (Mr McGuigan): Apologies. We have three members left. I will have to ask the three of you for succinct questions, and I ask for succinct answers. It is my fault, as Chair, that I have allowed things to overrun. Apologies to our last two members.

Mr Nesbitt: Relax, Chair.

The Chairperson (Mr McGuigan): I know that Alan is not going to quiz you for too long. [Laughter.]

Mr Nesbitt: Whatever do you mean?

Mr Chambers: Minister, my party and I certainly welcome your outright rejection —

Mr Nesbitt: Which party is that again? [Laughter.]

Mr Chambers: — of the introduction of the new hybrid charging model. I have been listening carefully to GPs on the media over the past few days, and they have raised different views on the issue. Is it your view that, rather than that being the agreed view of all GPs, many, in fact, are wholly opposed to the idea of a medical card-type scheme?

Mr Nesbitt: There is the whole spectrum of opinion from individual GPs desiring that for themselves through to, "Over my dead body would a GP support anything other than an NHS free at the point of need", and everything in between. I cannot quantify that or give you numbers from A to Z, but I am absolutely convinced that opinions go from A to Z.

Mr Chambers: Certainly, not everybody agrees on that.

Mr Nesbitt: I welcome the fact that the royal college said that it would not support a hybrid system.

Mr Chambers: Cathy, the focus of debate on the shift left has centred on GPs, but I also see community pharmacists playing an important role. What appetite are you detecting among pharmacists about working with the shift left? Am I correct in saying that, under a new community-orientated model, the financial sustainability of pharmacies would be much enhanced?

Professor Harrison: As part of our workshops, we have met lots of stakeholders' groups. We met Community Pharmacy this week and had an excellent turnout after work of busy people, which we really appreciated. All the discussions with stakeholders are fairly robust, and we expect that. In the room with Community Pharmacy, we had leaders from the profession who had already been through local commissioning groups and are involved in the area integrated partnership boards at the moment. They have already seen different models that have attempted to support change. Overwhelmingly, they support the need for change. As a sector, they have a clear vision of what their contribution could be, because of the work that has gone into working with the sector in recent years. The sector has a clear vision, supported by investment in the workforce and by clear ideas around the services that we would like to offer the public through that sector.

I will not answer the question of whether community pharmacists think that the model will be more sustainable; I will be back next week to talk to you about something like that. They may have their own views. As the Minister said, there will be a spectrum. However, it will certainly raise even more the public's awareness that you do not need to go to just one provider for your care but that elements of your care can be appropriately and safely provided for by community pharmacy, for example. Recognising that fact is at the heart of the neighbourhood model. There is an opportunity for the sector there.

Mr Chambers: Thank you. Chair, was that short enough?

The Chairperson (Mr McGuigan): You get a gold star, Alan.

Ms Flynn: The pressure is on to beat Alan. Thanks very much for the presentation and all your answers so far. I will be quick.

Cathy, you mentioned that you hope to have the associated funding model drawn up by March of next year. Will that funding model target areas of highest deprivation? Will there be any prioritisation or special focus on objective need and our most deprived areas?

Professor Harrison: It is an excellent question, and it all depends on how the model develops. One of the interesting views that are being shared is that there is a desire for all parts of Northern Ireland to be given an opportunity to be involved in a change like this in terms of neighbourhood. That is perhaps not how we have operated before, when we would have started pathfinders or pilots in some areas. If we use that approach, there are lots of ways that we could look to our most deprived communities, and we naturally would.

We have been impressed by the work that was done by the Public Health Agency on the Live Better programme to really understand the level of need in two of our most deprived areas in Northern Ireland: west Belfast and the Moor area in Derry. We are very much looking at building on that. At the heart of the neighbourhood will always be tackling health inequalities, but, right now, we do not have the detail of how that manifests into funding etc. However, it is at the heart of this, and we have some of our strongest community and voluntary sector representatives in some of our most deprived areas. Using those assets will be critical to this.

Ms Flynn: Thank you so much, Cathy.

Finally, Minister — I referenced this in the last session as well — you will be aware of the NI Statistics and Research Agency (NISRA) announcement today on the suicide stats for 2024. I know that, when speaking publicly about the issue, we have to be extremely sensitive and sensible. First and foremost, let people know if you are struggling and if you need help, because there are so many services out there, and you can pick up the phone and get help. We are talking about prevention, early intervention and areas of highest deprivation, and the 2024 figures show that 290 people have lost their lives. We also know that the rates continue to be highest in our most deprived communities. Do you want to comment on that?

Mr Nesbitt: I have seen the figures, as you have, Órlaithí, and they are shocking: up 30 on the previous year. As officials say, it is important to take a three-year average, because the numbers from the first two quarters of this year are more encouraging. However, every suicide is one too many, and they are all avoidable up to the point when they are actioned. I am aware that suicide is more prevalent in areas of deprivation, and I assure you that, while I am in this role, tackling health inequalities will remain my number-one desire.

I will make an appeal to the Committee. It is maybe not for this mandate; it is maybe for the next mandate. There are three really sticky issues that we face that we have never really taken a lump out of: health inequalities measured by healthy living expectations; educational underachievement, which affects the same communities generation after generation in areas of deprivation; and economic inactivity, which means that 27% of people of working age are not in work or seeking work. Those issues are interrelated, and health has a role to play in all of them, because healthier children do better at school. The biggest reason for people being economically inactive is poor mental and physical health. It needs a whole-government approach, and I am willing to work with the Economy Minister on economic inactivity and with the Education Minister on educational underachievement. As an Assembly and an Executive, we all have to work together, and, if we committed to that journey, although we might not see results until the next mandate, my goodness, what a positive impact we could make on society.

Ms Flynn: Thank you, Minister.

Mr Robinson: Thanks, Minister. I will be brief. I like the multidisciplinary team (MDT) model. From speaking to GPs, I know that many of them like it too. They see it as taking a bit of pressure off them and off EDs. They like the idea of going into a facility and being directed onwards, under that one roof, to another sector of the health service rather than being directed here, there and everywhere. The paper refers to MDTs commencing in a number of federation areas in the next five years and the full roll-out taking around eight years. It is a bit of an open goal when it comes to taking that pressure off GPs, which we all want to see. We know the pressure GPs are under, and it takes some pressure off EDs. Why can that not be ramped up further? Is that a stupid question? Are you going to say "funding"?

Mr Nesbitt: I am going to say, "funding" and "workforce", which go together. I would love to click my fingers and have MDTs everywhere, because they are the poster boys of transformation. There are many good examples in secondary care, such as the rapid diagnostic centres and the overnight elective care centres at the Lagan Valley and Mater Hospitals. The MDTs' excellence stands out, and I acknowledge the advanced nurse practitioners in primary care, because they also take a huge amount of pressure off GPs, and they were there first. We tend to forget the advanced nurse practitioners because we are bigging up the MDTs.

The roll-out is going as fast as it can, but the speed is dictated by the funding and the ability to train and attract the workforce. It is horrible that there will be an inconsistency for eight years.

Mr Robinson: We are at the stage where none of us in the room can be shocked any more, but the image on the front page of a newspaper of a 55-year-old man with stage 4 cancer lying for 50-plus hours on the floor at Altnagelvin Hospital was incredibly heartbreaking for all of us. We know that bed pressures drive a lot of the problems in the EDs, but is it being tracked? What I am about to say is not a criticism of GPs, because it reflects the pressure on them, but could the people presenting at EDs have been seen at the primary-care level but could not get an appointment with their GP? Is that a factor driving some of the pressure on EDs? Also, is the current pathway with the South West Acute Hospital arrangement to transport patients to Altnagelvin another factor driving the insane pressures at Altnagelvin?

Mr Nesbitt: It is worth recording that Altnagelvin Hospital has the oldest of the type-1 EDs, and it looks it. When I went to the ED at Altnagelvin Hospital, it was shocking, particularly the toileting facilities. A tranche of money has been found to do some temporary work with the existing ED, pending the building of the new ED, but that is years and not months away.

Does a lack of access to GPs play into that? I cannot give you empirical evidence of that, and I should not determine health policy on anecdotal evidence. However, I went to see the minor injuries unit in the Royal Victoria Hospital, and there were people with packed lunches, flasks and podcasts. They said that they had not gone to their GP because they did not want to make 140 phone calls to get through. They knew they would have to wait five, six, seven or eight hours, but they had everything they needed to do that and were happy to wait. There has to be an element of it, but I cannot say whether it is in the top tier of significance. I am reluctant to say something that could come across as an accusation against GPs, and I am not doing that. Some unspecified number of people are making that personal decision.

Mr Robinson: You are right: it is not a criticism of GPs. We do not want to go down that road, because we all recognise the challenges that GPs face.

Mr Nesbitt: Altnagelvin Hospital has the respiratory unit, which is opening extra hours, and the minor injuries unit. We are doing everything we can to find pathways to avoid using the ED where possible.

Mr Robinson: Thanks, Chair.

The Chairperson (Mr McGuigan): Thank you, Minister, and your team. You have been generous with your time, and we appreciate that.

Mr Nesbitt: It is important. Thank you for your interest, and thank you for respecting the need not to get into any detail about what is happening with the GPs. That is helpful, and I appreciate it.

The Chairperson (Mr McGuigan): Thank you.