Official Report: Minutes of Evidence

The Chairperson (Mr McCrossan): I welcome to the Public Accounts Committee (PAC) Mike Farrar, accounting officer in the Department of Health; Heather Stevens, director of mental health services in the Department of Health; and Dr Ciara McKillop, interim director of community care, strategic planning and performance group (SPPG) in the Department of Health. A very happy new year to you.

Mike, congratulations on your appointment to the post. We wish you well with all the challenges that exist, and we appreciate your time here today to take questions from us. That said, I have a number of opening remarks to make before passing to you, if that is OK.

The Public Accounts Committee published its report on mental health services in Northern Ireland in June 2024, and the Department of Health has provided regular updates to the Committee. However, the timescales associated with the report's recommendations continue to be extended by the Department. In light of that and the publication in October of the review of the deliverability of the mental health strategy, members are rightly concerned at the pace of progress against the recommendations that were made over 18 months ago and the impact that that is having on those suffering from mental health issues in our communities. It is a point of great concern not just to the Committee but to Members across the House. We hear about the issue often, and it is one of great concern.

Our inquiry was productive, and we got a lot out of it. We engaged with a number of witnesses and produced a strong report with strong and necessary recommendations that, we felt, were entirely appropriate. We had a fairly positive launch event in the Building that was attended by the mental health champion and many other guests, and that was appreciated.

The focus of today's session will be on progress and delivery: what has been achieved to date; where timescales have changed; how decisions to re-phase actions have been taken; and what that means in practical terms to the people who use mental health services in our community. Members recognise the challenging financial context, and we, as the Public Accounts Committee, have been fair in recognising that Departments are under immense pressure, but this session is intended to examine governance, realism and accountability for delivery. We were told by the previous accounting officer and departmental officials that the delivery of and access to mental health services were absolute priorities for the Department. You can appreciate how the Committee is concerned that such a statement conflicts with the action that we have seen more recently. That is a point of great concern for us.

I have laid out fairly clearly where we are. We will have questions from members, but I will pass to you, Mike, to brief members on where things are, and we will go from there.

Mr Mike Farrar (Department of Health): Thank you, Chair. First, thank you for the opportunity to come along and talk about this. It is a hugely important area, and I very much share your sense of the role that mental health plays in communities here and its impact on a variety of areas. As you know, I am joined by Heather and Ciara, who may come in on some of the detail.

By way of contextualising, when the mental health strategy was produced, Northern Ireland was spending around 52% of its allocation on its health and social care budget. That had gone up from 46% in 2016, when Rafael Bengoa produced 'Systems, Not Structures'. The point that I make is that, at that time, it looked reasonable to set out an ambition to spend £1·2 billion of extra funding on mental health.

Why was it sensible to do that? It was because, unless you get the balance of expenditure right between mental, physical and social health, you will find that you drive extra demand for physical healthcare and extra pressure on public services, whether that is from offending, in criminal justice, or from educational problems. It is important to understand that increasing expenditure on mental health as a proportion of our total spend is a really important aspect of resetting our health and social care system. I came to this role with the express purpose of trying to do that, simply because I do not believe — the Minister is sympathetic to my views; we are as one on this — that we can continue to ask Northern Ireland to spend more and more of its allocation on health and social care at the expense of education, the environment and policing, which are the wider determinants of health that drive more spending in health and care. Effectively, we have set out in the reset to manage the money that we have and get added value from that spend. The mental health strategy and its introduction, which looks at funding, makes it clear that, in order to implement the strategy, you need to have more funding than is being allocated to the Department.

The challenge that we face is to get better value for the money that we have. One thing that we are committed to doing is producing a set of priorities for the first time in, I think, about 13 years. Without being critical of what has gone before, there is a sense that a number of areas are described as priorities, which the Committee may have heard, but the truth is that, if you set something as a priority, you need to have a vehicle to deliver it. People have worked incredibly hard to implement the strategy. It is a good strategy, but it requires us to reset our system overall. When you look at the aspects of our overall resetting of health and care in Northern Ireland so that we can live within that budget and allow for a broad spend of public money and when you look at the areas covered in the strategy — prevention; earlier intervention; developing a neighbourhood model of care, which is about trying to move the focus into secondary prevention and deal with people in community settings; multidisciplinary teams (MDTs); and standardising care, which was the principle of the mental health regional service to take out variability in serving Northern Ireland's rural and urban populations — and at efficiency and value for money in what we spend, you see that the reset is consistent with delivering the strategy. I make it clear that the reset is holistic, which means that the reset plan is not just about delivering access to physical care, which is one of the Programme for Government (PFG) targets, but about improving the mental health, social health and physical health of the Northern Ireland population. The reset is similar. Our issue is that we do not have significant resource to spend. You can see that, if we get a three-year Budget, the percentage increase that we will get is challenging, and, indeed, we had a significant challenge this year.

In passing, I will say that I heard the discussion about the direction. I am happy if you want to raise anything while I am here about my intention and procedure, but I want to make it clear that, at all stages, my intention has been to manage within the resources available. I have put great effort into that and emphasis on it. I believe that that is similar to the Minister's position.

I will wrap up by saying that there are positive things going on, despite the fact that we want to make faster progress; there is no doubt about that. One is to make clear that the strategy itself is right. It is exactly the right strategy, and the evidence base continues to affirm that. We do not have to revisit it, even though it was published three or four years ago. The second is that there are things that do not require extra spending. We can talk to you about those in due course. The third is that we are exploring every opportunity to find additional resource to bring into the sector. We are looking at social financing that could complement the public sector and at R&D funding. If we get a chance to talk about workforce issues — the struggle to recruit people — I can say that my experience is that one way of attracting specialities, particularly psychiatry, into areas where we struggle, such as the far west of our patch, is through R&D and investment in research. It is important to bring in commercial clinical trials and opportunities for research. We continue to bid for transformation funding in Northern Ireland and on an all-island basis alongside the money that we currently have available.

The last thing that I will say is that we will publish our guidance on priorities for the service, and that will echo the need to make progress on the strategy and to continue to do so over the three years. This is for discussion with the Minister, but one proposal is to absolutely commit to spending more on mental health as a proportion of our total expenditure as we go through the three years.

The Chairperson (Mr McCrossan): When will that be published?

Mr Farrar: We are looking to publish that at the end of the month. That will give the trusts two months to produce their plans for us.

The Chairperson (Mr McCrossan): It will obviously be published for the public, but will you ensure that it is brought to our attention as well?

Mr Farrar: Absolutely.

The Chairperson (Mr McCrossan): A lot of the Committee's questions will focus on things that you have touched on, but we will go ahead and then filter back.

When the strategy was originally published, delivery was costed at £1·2 billion, and you have already referenced that cost. To date, only £12·3 million has been spent. When we took evidence from the Department in April 2024 — 18 months ago — the then accounting officer, Peter May, said, when asked about deliverability:

That was said 18 months ago, during our inquiry. Was the strategy ever going to be deliverable?

Mr Farrar: It was produced with the best intentions and with the view that, if spending carried on on the basis of the level of growth that the health service had received historically, it would be feasible to put new money into mental health while maintaining other services. My background is in mental health. Committee members may not know this, but I spent a lot of time working in that area. I closed a lot of long-stay institutions, providing community care, and I wrote the four steps model for child and adolescent mental health services (CAMHS) back in the day. That is my background. The aspirations here were right, and, in theory, it was deliverable in terms of service. I have some questions about the extent to which it was naive when it comes to recruiting workforce. Northern Ireland has challenges in that area. I think that the strategy was written to put greater emphasis and that the expectation was that there would be a continuation of funding at the level that the health service had been experiencing. I think that the Minister at the time genuinely believed what he said in his foreword, and he would probably say that he continues to believe that it was the right thing to do.

The Chairperson (Mr McCrossan): There is a trend across Departments but in the Department of Health in particular of publishing great strategies with the best of intentions but nothing ever materialising that benefits the public. Is the strategy simply a wish list from the Department of Health, as opposed to a strategy intended to deliver and to benefit people?

Mr Farrar: That is a fair challenge. I inherited a number of strategies, all of which have merit. Some of them have been overtaken by the fact that we want to reset in the way in which we do, putting the emphasis on developing out-of-hospital services and prevention, which is the only long-term strategic solution to health spending. By the way, we are not alone in that: the massive increase in demand for health and care spending is a feature across the world. We will be clear with the public about what specific recommendations we can take forward on an annual basis so that we are clear about what we cannot do, as opposed to allowing everybody to believe that everything is possible.

The planning guidance that we are about to issue will be much more specific about what is doable within the resource. You described the intention to account for pay as a first port of call. I personally believe that that is exactly the right thing to do, but that is 65% to 68% of our budget. You then have to be clear about what your 32% that is left can afford. Although it might be difficult in some areas to say, "This is going to be a time sequence before we can deliver it", it is right that we are clear about what we can deliver within the resource available. Despite some of the things that you have heard, it is absolutely my duty, as accounting officer, to live within my means.

The Chairperson (Mr McCrossan): Yes. I do not want to put words in your mouth by any means — you can correct me — but what I hear is that the strategy was probably overambitious in what it was intended to do and not entirely realistic about what was possible within the financial restraints in Northern Ireland plc.

The other challenge — the concern that I have — is that Northern Ireland Departments have a habit of creating an expectation with glossy, attractive strategies that attract headlines in the moment but leave people upset and disappointed in the long term. There was a great hope for this strategy. It created significant expectations. Costings were applied to it, which does not always happen; look at Bengoa and other things. I hope that you agree that the strategy created an expectation among our public that many of the problems facing mental health services would be resolved. There were consequences of not acting that increased pressures on our community and voluntary sector.

Mr Farrar: It was ambitious. I will come back to it. In the financial context of its time, it probably did not look unrealistic to assume that it would be affordable over 10 years with that increase in funding.

Your general point about setting expectations for the public is a legitimate one. There is still a strong commitment to achieve improvements in mental healthcare. My colleagues to my right and left will perhaps be able to give examples. We are working flat out to do that. Perhaps we have to be more creative about how we do that, but, as I said, the commitment to spend a higher proportion of our total spending on mental health may be a way to release additional resource to support the implementation of the strategy.

The Chairperson (Mr McCrossan): I appreciate that and that £1·2 billion spread across 10 years should have been achievable. Is it simply the case that mental health services just have not been a priority for the Department, given that only £12·3 million has been invested?

Mr Farrar: It is hard for me to comment in hindsight. I believe that people genuinely see mental health as a priority area. You are probably aware of the phrase that is often used about mental health services, which is that they are "Cinderella services". Most of the power tends to be around large physical and highly specialised services. If you look at soft power across the health service and at funding levels for different aspects of health, such as physical and social, you will see that social and mental tend to lag behind physical health need. That is an error. You can evidence-base the fact that, if you do not fund mental health services properly, you will get additional demand not just in health but in the other services. I tried to cover that in my opening remarks.

Whatever the intention has been in the past, which I cannot speculate on, I assure you that, moving forward, we do not see mental health as a second- or third-order priority. Indeed, as I say, we want to spend more on it, because we believe that that will help us manage some of the challenges from the physical weighting. More important, it will help other Departments, because, if we can provide the ambition that we have in the mental health strategy, it should reduce reoffending and help with educational attainment. It will certainly help with social cohesion and ending violence against women and girls. We know that a lot of that is driven by underlying mental health problems. It is it hard for me to comment on the past, but it is not hard for me to comment on the future. Going forward, this will be a priority.

The Chairperson (Mr McCrossan): I appreciate your saying that, Mike. Given your experience in the area, I have no doubt that that is a well-intended statement. You will forgive me for saying that others who had the privilege of holding your role have said similar things in the past. The concern that I have about the public service at the minute is that we hear that all the time, but it delivers no tangible benefit to the public in this area in particular.

Mr Farrar: The one thing that I will say in defence of my ambition is that we have a reset plan in place that is designed not to be rhetorical but to address the practicality of how we will do that. The planning guidance that we will issue will confirm, in terms of resource and commitment to the priorities, that this is clear. However, I accept that others may have had the same ambitions.

The Chairperson (Mr McCrossan): To play devil's advocate a wee bit, is it a reset plan or a retreat plan?

Mr Farrar: A retreat plan? No, not at all. I started this year with a £600 million deficit. That is what I inherited. We cannot carry on asking Northern Ireland to spend more and more of its money on health and care. I have worked with the other permanent secretaries to understand that the only way that we will manage that is to make sure that health and care spending adds value. That requires us to work collectively; move money into prevention and early intervention in neighbourhoods; standardise our pathways; make sure that our clinicians follow evidence-based medicine; and use the data — Northern Ireland has the best data platform in the world — to target the resource where it needs to be. I have said this before and will say it again here publicly: Northern Ireland could have a world-leading health system.

The Chairperson (Mr McCrossan): And it should have.

Mr Farrar: I believe so.

The Chairperson (Mr McCrossan): Mike, I appreciate your being forthright with us. At the beginning of the session, I outlined members' concerns regarding the pace of delivery against the recommendations of the PAC report. As the Committee considered the most recent memorandum of reply (MOR) update on 9 October, the deliverability review was published. It is not clear how that will impact on delivery against the recommendations of the PAC report. Can you provide the Committee with an update on delivery and provide an assurance that there will be no further delays? Can you give us that absolute assurance today? The public and people in the sector who are watching this are hopeful that it will move at a much swifter pace. Despite the commitments that we were given, I really do not see much change, 18 months down the line.

Mr Farrar: Heather, do you want to comment on the deliverability?

Ms Heather Stevens (Department of Health): I will. It is important to say that the findings of the deliverability review absolutely support the Committee's recommendations. For example, the review highlighted in a transparent way the lack of funding that has gone into mental health services, and the Committee had highlighted that in its recommendations. In addition, it is clear that the immediate priorities are, for example, a focus on workforce — when I say "workforce", I need to emphasise that that includes the voluntary and community sector, because we see it as a key part of the mental health workforce in Northern Ireland — and a focus on crisis, together with a subsequent focus on CAMHS and trying to remedy inequity across the system through the regional mental health service. Those all echo the recommendations that the Committee made, so, in taking forward the review, we are in fact taking forward your recommendations.

Other recommendations that the Committee made but which were not highlighted in the review will be taken forward in any case. That is because they relate to areas that have already been receiving recurrent funding, albeit a small amount. That work will continue. We will not take funding away from areas that already receive less funding than the original strategy envisaged. In other areas, we already have staffing resource in place. They need to continue to do their work on outcomes, for example. That is important. Thirdly, there are areas, such as the Committee's recommendation in relation to Right Care, Right Person, that will happen in any case. We will take that forward. In general, the findings of the review support the direction that the Committee was heading in.

The Chairperson (Mr McCrossan): OK. Further to that, do recommendations 1, 2, 8, 10 and 15 of the PAC report — you have already touched on some of those — remain as live commitments of the Department, following the deliverability review? Will you confirm that? Have any of those been deferred or deprioritised?

Ms Stevens: I will go through those. Recommendation 1 is the review of deliverability. We have undertaken that: it was produced in October 2025. We will start to take those forward through the delivery plan that we will produce for 2026-27. There are pieces of work that we can do in the absence of receiving additional money for workforce. We will obviously prioritise those. If additional money is found for the strategy or for a reprioritisation in the Department, however, those are the areas that have been identified for us to put that money to. We are committed to that.

It is important to make the Committee aware that, in addition to reviewing the deliverability of the strategy, we are working closely with the all-departments officials group (ADOG) and the Executive working group on mental well-being, resilience and suicide prevention to raise awareness of the fact that all Departments have an interest in and an ability to impact on mental health. We want to secure their cooperation in taking some of this forward.

Recommendation 2 relates to workforce. We have been taking forward a number of actions here. The Committee's recommendation was that we implement the workforce review published in July 2023. We agreed an implementation plan in December 2024 and decided that, in the context, the most important things to focus on were the first three recommendations: costing a mental health workforce; creating a service prioritisation framework so that we can work out what areas of the mental health workforce we need to focus on first; and more closely integrating the community and voluntary sector in our delivery. There were two ways to take all that forward. We brought in an associate to produce a costing and prioritisation report. That report came into the Department just before Christmas. It is detailed, because it rebases the workforce numbers from the July 2023 report. That needs to be quality-assured and checked. Significantly, that gives us a new mechanism — a multi-criteria decision-making framework — to help us and the service more broadly to prioritise how to go forward. It gives us a structured way to do that using weighted criteria that look at need, impact, how we deliver value and deliverability. We can use that mechanism to prioritise, in a structured way, how to take that forward.

There have been other developments. For example, we have been able to put in place a Chief Psychological Professions Officer who started in the Department in March, initially on a two-year interim basis. Professor Rooney's role is to come up with a framework for the raft of psychological professions that we have in the mental health workforce so that we can utilise that capability to its optimal effect and start to introduce more skills mix into workforce discussions.

We also have mental health practitioners in the new MDTs in primary care, and we are starting to see those making a difference as well.

I could go on. Lots of things are being taken forward on workforce. Have I answered your question, Chair? Would you like me to go back?

The Chairperson (Mr McCrossan): You have answered it. You were touching slightly on a question that Diane will raise with you shortly, so we will hold it there. That was fine, however; you covered a fair amount of what I focused on.

I appreciate your answers so far, but I will say this before I pass to Diane for questions. Either last week or at the beginning of this week, some elected reps were on the radio talking up the £300 million of efficiencies made by the Department of Health. We hear that £300 million has been made through efficiencies but that the little being invested in mental health is not to the degree that was committed to. Those two statements do not align, do they?

Mr Farrar: We are starting the year with a £600 million deficit that may well be greater as we go into next year, depending on what is in the Budget once it is finally settled. The issue with that is that I have to balance my duty to ensure that we live within our means with improving service outcomes. We have been clear from the beginning of the year about what is affordable and what we would attempt to do. We have a systems financial management group that is looking at efficiency rather than savings. That group is, effectively, trying to look at every pound that we spend.

We are now into looking at effectiveness. Northern Ireland spends more on health and care per head of population than the other jurisdictions. In the coming year, that will, I think, dip under the spending of some of the other jurisdictions, but, even then, we will still be up at that level. Despite that, we are not getting the same outcomes. We have to look at the effectiveness, but we also have to live within our means and try to balance our budget. The £350 million of efficiencies are aimed at taking cost out in a technically efficient way while supporting allocative efficiencies to improve the care that people get. Those statements may seem to be in contradiction, but we can evidence where we have made efficiencies that have not compromised the service and can show how, if we do the reset in the way in which we hope to, it will improve how effectively we use the money that we have.

We are battling that constant tension. This Committee produced a report on GP access, and the Health Committee's report on palliative care came out in the same week. Both of those state, "If you could spend a little bit more money here, we can get better value or a better service". We only have so much money, and that amount will depend on what the Assembly eventually gives us.

The Chairperson (Mr McCrossan): I sort of agree with what you said, Mike. Equally, however, I would say that we are throwing good money after bad, because we are not implementing the strategy that was committed to and costed. The purpose of the strategy was to — this phrase has been used quite a lot by MLAs — "invest to save". It was about investing in the system in order to save in the long term: a preventative measure. We are not doing that, but we are throwing good money after bad. The reason why the service is not as effective as it should be, even though we spend more per head than other jurisdictions, is that we are not following a proper strategy. That is the issue at the core of this. We are in a retreat situation, because we are walking back from the strategy. I am concerned about the costings in the long run and the implications for our public, particularly for the many impacted on by the issues with mental health services.

Mr Farrar: I agree with most of what you have said, but I fundamentally do not agree that we are walking backwards. The only effective way to get better value for the money that we have is to follow the reset plan. The reset plan moves to prevent the additional cost of people whose health deteriorates because we did not get to them early enough. The neighbourhood model has evidence from across the world. I can point to places that have followed similar strategies, such as New Zealand, Sweden and Spain. They have been able to demonstrate how they can manage their budgets better than we have. Had we not published a reset plan and had I said that we are simply doing what we have always done in trying to make savings, I would have said that that is a fair criticism. However, the whole point of having a reset — it is not a retreat — is that it is the vehicle by which you will be able to afford the public services that people deserve within the resources that we have available at this time.

The Chairperson (Mr McCrossan): Thank you.

Ms Forsythe: Thank you very much, Mike, Heather and Ciara, for being here.

In early 2024, the Committee agreed that mental health services were our number-one priority. That was the subject of our first inquiry, such was the strength of feeling about it, and the Committee was united in picking that subject. Access to mental health services means a lot to all of us as constituency representatives because it is such a serious thing. When people come to their MLA to look for support to access mental health services, they are never in a good situation. It may be parents who cannot access services for their child, a young adult at school who has not received a diagnosis and is struggling with the pathways or an adult who cannot access services. There are people who are deemed as being in crisis or in immediate danger, yet they are told that there is a six-week wait to be provided with services. It is terrible, and the outcomes are absolutely catastrophic. It is heartbreaking, and many lives have been lost. It has been devastating for families, such is the severity of the situation. I want to make sure that we bring the humanity of that into the discussion. When it comes to access to services, we see that devastation and frustration as constituency representatives when we deal with people. From where I sit as a constituency representative, it is difficult to see any improvement. I am not an expert on it. Is there any evidence of improved access to services being delivered through the strategy to date, so we can convey that to the Northern Ireland public?

Ms Stevens: I will start with multidisciplinary teams. Even though MDTs are still relatively new, mental health practitioners are now based in MDT practices, where those have been put in place. We have about 71 mental health practitioners in there. The evidence that we get from those practices is that 55% of patients who utilise their services are held there and do not need to be referred on. However, if they need to be referred on, they are mostly referred to the community and voluntary sector or, alternatively, into statutory services, if that is what their need is. That is a practical example of the MDT provision that we have currently. In those areas, there should be an obvious improvement, and they will be rolled out over the next few years.

We also have the Minding Your Head website, which is hosted by the Public Health Agency (PHA). That is a really good source of information and direction. There are apps on that website that people can use. The PHA has been working on a refresh of the website and is trying to raise awareness of it so that help and support is more easily accessible, even from people's own homes. There is more there than there was. That is on a more general level, but there is also more on the statutory side and in community health provision.

Dr Ciara McKillop (Department of Health): We have invested a lot in early intervention and prevention services for children and adults in order to reduce the need for people to present to crisis services or community mental health services. We are beginning to see great success with some of those services, but that does not take away from the fact that we have challenging waits for mental health services, psychological therapy services and CAMHS that reflect workforce availability — it is not always about funding — in some of the key professions. We cannot recruit them, and that is a UK-wide problem. We are in a challenging position, which we accept.

We also accept the challenging financial position that we are in. We accept that our society has people with poorer mental health than those who live in the rest of the UK. We appreciate the challenging circumstances that we face, so we — the mental health clinicians, the workforce and the community and voluntary sector — have adopted the approach of asking, "What can we do? How can we make this better?". It is about addressing inequality by making sure that early intervention and prevention services are immediately available and by working with schools, GPs, teachers and parents to make sure that all of the building blocks of good mental health are in place for children. Although we might not see benefits today, our hope is that we will begin to build them.

Ms Forsythe: Is there any reference in your work to regionality and barriers to access to services in rural areas? I represent South Down, which is very rural. Often, people who are in crisis and are trying to access mental health services are not capable of getting two or three buses and travelling an hour and a half for those services. Has there been any improvement in that situation? Have you considered regionality and rurality?

Dr McKillop: During COVID, when people were not as able to access face-to-face appointments easily, we learned about the usefulness of being able to access appointments over Teams or Zoom or by phone. Those methods would not have been the first port of call prior to COVID, but we learned about them during COVID. We are very much working on the area of digital mental health.

One of the focuses that came from the deliverability strategy, on which the PAC reflected, was the development of accessible regional crisis services. That matter and workforce issues are our immediate priorities this year. It is about standardising access to mental health liaison and crisis resolution home treatment and very much addressing issues of rurality. It is a particular challenge in the west and the south; there is no getting away from that. That continues to be an area of our focus, but we are doing that in line with actions to see how we can squeeze as much benefit as possible from access to digital solutions.

Mr Farrar: Within months of my arrival, we established a committee in common. All trusts have a subcommittee, and all subcommittees meet at the same time. They can make a decision on a single paper, and that decision then goes back to their trust board for the final decision. That allows you to take a decision about the distribution of services, rather than each trust advocating for their own service. Psychiatry is one of their topics: they are discussing the distribution of psychiatric services so that it supports a consistent service across Northern Ireland.

Ms Forsythe: That is great. There is a crossover of trusts in my constituency, and that issue is prevalent. It is good to hear that.

My next questions are about waiting times. At our previous session, the Committee was advised of significant breaches of waiting time targets in adult mental health services, dementia services, CAMHS and psychotherapy. Will you outline the current position in respect of those targets? Has there been any improvement in those waiting times?

Dr McKillop: One of the challenges in answering that question is about the implementation of the Encompass programme. The trusts are still moving their mental health services to Encompass. Although performance and management data on the waiting lists for all services is available, it has not been validated to the extent that the trusts are in a position to publish it with high confidence.

Ms Forsythe: The roll-out of Encompass came up in our session as well. It is so important that we understand the detail of the waiting lists when it comes to accessing mental health services. In anything that I worked on in previous jobs, dual systems were always run so that data was not lost during the transition. Do you have dual records? While you move across to Encompass, do you not still have sight of that data?

Dr McKillop: We do. To reassure the Committee, the data is not lost; it has just not been validated to the extent that we would be confident in publishing it. To give you an example, the Southern Health and Social Care Trust recently reviewed 4,683 records and found issues with 10 of them. For that reason, it is reporting only medium confidence, not high confidence, in the data. Nothing has been lost.

Having spoken to the trusts and the Encompass regional reporting group, which are implementing Encompass, I think that they would want me to make sure that the Committee understands the complexity and extent of what they are doing. It has not been done before, and Northern Ireland will be the only place in the UK where you are able to see someone's physical health records and their

community and inpatient mental health services and have immediate access to real-time information. Immediate access to that data will be an absolute game changer for clinicians and the quality of their work.

If we step back, we see that achieving that has not been done before. Mental health services are not linear services in the way that physical health services are. You might go back to a physical health service every four weeks to see how you are getting on. Mental health services have multiple entry points, and there are multiple specialist services for those in the system. We need to build a computer system that can match a patient journey, particularly in mental health. People might engage with or withdraw from services. They might be referred to specialist services. They might access crisis services. For us at the centre to be able to talk to the Committee about outcomes and data, we need to be 100% sure that what the Belfast Health and Social Care Trust, the Southern Trust and the South Eastern Trust are measuring along the patient journey is exactly the same.

England is about 14 years ahead of us in its mental health outcomes. We have been guided by its experience as to how it implemented an outcomes framework. The one piece of advice that it reiterated again and again is that you put something in place and make sure it works and is being delivered consistently, and then you move on to something else; you do not introduce wholesale a raft of measures because, ultimately, you end up with data that is not reliable or valid and cannot be used for benchmarking. That is the approach that we have taken. We are on track to meet the timeline of having the performance data in place for June 2026. The regional reporting group has been up and running since December 2024, and it is going through each metric as it goes along, making sure that each one is confirmed, consistent and reported on before it moves on to the next one.

Mr Farrar: May I make a point about waiting times? This needs to be understood: waiting times are a measure of stock and flow. It is entirely possible that we might have a higher level of demand, with people being added to that. We could improve the amount of activity that we do, but the waiting list could still increase. That is one of the reasons that we look at prevention and management. At some point, I would like to give the Committee a sense not just of bald waiting times or whatever but of what we are doing to get ahead of and to effectively manage demand. We know that the demand for mental health services is increasing, so it is about how we deal with it. In general, I would say that we know that waiting times have an impact on care outcomes, so we are seized of the fact that we need to get our waiting times down. It might be that we get better benefits from investing in prevention in order to allow the capacity that we have to deal with the people who are waiting rather than focus on more activity. You need a balance of those approaches.

Ms Forsythe: Thanks, Mike. I fully appreciate the complexity of the matter. It sounds as though Encompass has the potential to enable you to gather a wider range of data and use it better in mapping the journey.

To go back to my previous point, given the existing waiting times for those on waiting lists, surely some sort of data, whether it is from Encompass or elsewhere, can be published here and now around waiting times to have comparability across the board. To us in the Committee, it feels as though the Department is hiding behind Encompass and saying that it cannot publish waiting lists. We know that the waiting lists exist, and people deserve to know what they look like across Northern Ireland. Is there nothing that can be published?

Mr Farrar: That is a fair challenge. As you know, we have made strides around elective care with our work on that with an elective clinical leader. To go back to the point about whether it is a priority and whether there is equality in how it is experienced, we will look at how we can make more data available.

Ms Forsythe: Will you publish any numbers?

Mr Farrar: Do we not have any data through the My Care app? I am not sure. We will get back to you on that.

Ms Forsythe: Collectively, the Committee would like to see that, and the public deserve to see it.

Mr Farrar: I may be doing us a disservice, but we will look at your point, because it is a good one.

Ms Forsythe: Thank you.

My final point, which Daniel had begun to discuss with Heather, is about how the deliverability review will improve waiting times and access to services. You touched on that, but is there anything more to say on it?

Ms Stevens: Do you mean our focus on service prioritisation?

Ms Forsythe: I mean how the review will improve waiting times.

Ms Stevens: If we focus on the workforce and prioritise the services in that area so that we fill vacancies and maximise the workforce that we have, we will start to see an impact on that. The early intervention and prevention work will continue alongside that. As colleagues said, that will also help us to deal with people and help people to contain their issues earlier, which will stop the demand from escalating.

Mr Delargy: There have been so many questions so far, but the key point for me relates to recommendations 7 and 9 and better understanding the fact that, when people are not treated in a timely manner, their health outcomes worsen and the impact on them increases. I want to understand what early interventions can be put in place. The reality is that we have longer waits and worse outcomes: what early interventions can be put in place to support people immediately when they become involved with the health services?

Dr McKillop: Pádraig, recommendation 7 relates to referrals. The Committee was concerned about the number of referrals that were made to CAMHS but were not accepted by it. We went back from the Committee and reviewed over 6,000 referrals to CAMHS. Some 53% of the referrals that were not accepted were not appropriate referrals to CAMHS and should have been directed back to the community and voluntary sector or an alternative service in the trusts. The learning that we have taken from that is that, while there is a Working Together referral pathway for children's mental health services, people were obviously not fully sighted on it, otherwise those referrals might have gone to the correct place the first time.

To address that, all the trusts' referral coordinators have made sure that the pathway has been reissued to our biggest referrers, and emotional well-being teams in schools have undertaken to make sure that schools are fully sighted on where they can access support for children at the earliest point at which they need it. They produced a report at the end of last year. They have had great success: they have been in 70 secondary schools and have engaged with thousands of children and hundreds of teachers, making sure that they know where they can access support. One benefit of that has been that the youth wellness hub has had an increase in use. The number of kids who have accessed that increased to 20,000 last year. We are helping children to be directed to the correct place.

Broader early intervention and prevention is a family of responses, a lot of which are in the community and voluntary sector.

Ms Stevens: The PHA funds a lot of early intervention and prevention work, and a lot of that is directed at children and young people. For example, it has mental health awareness training programmes such as Mindset, which is delivered by Action Mental Health and is aimed at 14- to 17-year-olds. We have Mood Matters, which is delivered by Aware NI. There are lots of others. There are targeted prevention services that are aimed at young people at risk of drug- and alcohol-related issues. There is a youth engagement service in each trust aimed at 11- to 25-year-olds.

Ciara mentioned the emotional health and well-being framework that we have in partnership with DE, which is a really powerful mechanism for engaging young people early so that they understand emotional and mental health issues. That is attracting £5·6 million this year that is not included in the mental health strategy funding envelope. That is additional resource that is going into that important area, and about half of all schools in Northern Ireland are engaged with that in some way through those six projects. It is a really valuable addition to what we do.

Mr Farrar: I will make a quick point. This applies more to the general population, but what keeps us mentally well is having someone to love, somewhere to live and something to do. It is simple. The Department of Health does not control access to some of those, which is why — I know that the Committee is strong on cross-government working — we have been really clear in talking about Health having a horizontal budget that, effectively, supports things such as reducing economic inactivity, avoiding reoffending and improving school attainment. The quid pro quo is that our colleagues work to support families in children's early years and, indeed, adults around those three components, because all the evidence shows that, if people have them, their mental well-being is much stronger and fitter. We take responsibility as a lead Department, but preventing mental ill health is a wider issue for all Departments.

Mr Delargy: There is a huge amount in there. I have a slightly different opinion on the community and voluntary piece, because the community and voluntary sector in Derry, rather than supporting the work of the trusts and statutory services, is stepping in and doing the work that is expected and that I, as an elected representative, expect of those statutory services. The community groups in our area are the only point of access that many young people and adults and most of our community have to those health services, because they cannot get in the door. They are consistently told that they cannot access CAMHS, because the waiting list is too long. They are stuck in that cycle, so the only support that they get is from our community sector.

I appreciate that the aim of community groups is to get downstream in order to support people in communities. That absolutely is the aim, but the reality is that they do the work not just of community groups but of statutory services. That is where I have a slight problem. They are picking up the pieces because statutory services are not working. They are not meeting their raison d'être, because they are stretched so thinly. I recognise that, in the instances that you mentioned, you are bringing real opportunity and support, but community groups are often an afterthought for many Departments, and the way in which they are supported locally causes me a lot of difficulty.

Mr Farrar: I take slight issue with what you said, Pádraig. Community groups should not be trying to provide the statutory level of service that you get from those with professional expertise. If that is the case, we should provide more funding. That is an issue, and it is also quite dangerous.

I will tell you where I take issue with what you said. The CAMHS model is stepped, and the first layer of intervention is generic professionals, be they teachers, youth workers or community workers, identifying the situation early. You want to try to keep people away from statutory services, despite the fact that we have made massive progress on managing stigma in recent years. People really do not want a mental health diagnosis, if they can avoid it, because that has a consequence. The voluntary service and the role that it fulfils is not a substitute for that, but it is a massively important first port of call.

If you look at the work that Wigan Council did through the Wigan deal, you see that, by supporting its voluntary sector to intervene early, it reduced the total expenditure on social care, reduced the number of people reporting to A&E departments with alcohol-related harm and started to reduce the prevalence of coronary heart disease. Although I know what you are saying, I do not accept completely that we should not think about the voluntary sector as a first port of call. However, we need to fund it, and we need to make sure that we can get added value by having longer contracts with our voluntary sector as a matter of process because, often — I know that you will know this — they are chasing next year's contracts and all the rest of it.

I do not quite share your whole view. There is real merit in the first port of call being community groups and people working as partners and being supported by peers. If they are not able to deal with the problem, you start to look at statutory and professional engagement that is perhaps more biomedical in character. I take your point in part.

Ms Stevens: May I add to that? This Committee made a recommendation about how we might better integrate the community and voluntary sector into our provision. We are really committed to doing that. We brought EY in to do focused work with community and voluntary sector colleagues on their scope, capability and capacity to do that. That report has just been cleared by the Minister and will be published very soon. It has some really interesting information in it, such as, for example, the level of funding that trusts provide to the community and voluntary sector under contract to do particular work.

The report also talks about the barriers that need to be overcome in order to optimise the potential of the sector. They include things like streamlining the procurement processes in order to make things as easy for the sector as possible. It is about inviting the sector to training opportunities, so that we upskill sector organisations in the same way as we upskill the statutory workforce, in order to see them as genuine partners in that regard. It is about looking at how we might have more equitable funding across the trusts, because there is a disparity at the moment, and how we can engage them more, particularly in steps 1 and 2. That is what they are really good at, and that is deliverable where people live. I support what Mike has said.

Dr McKillop: May I come in on that, Pádraig? I managed CAMHS for many years. When the community and voluntary sector and the statutory sector complement each other, that is when children and young people have the best experience. They should be complementary and not a replacement for each other. When a person's involvement with CAMHS is complete, they will be in their community, and they will be engaging with community and voluntary sector services in their area. It is in everybody's interests that all parts work and complement each other well, because that is what will work best for children and families.

Mr Delargy: I agree with that. The difficulty that we face — I am sure that everybody here faces it — is that, every week, we hear from people who have been trying to access CAMHS since they were 16 but have been put on a waiting list. When they turn 18, they are taken off that waiting list and have to start again. The community and voluntary sector has been their only port of call and their only support. I absolutely agree that those services should complement each other and should work in conjunction. The barrier for those young people is not in the community and voluntary sector but in the statutory services. That is where I have a real issue.

As you know, I chair the all-party group on mental health, which launched a report about a year and a half ago about trying to provide a better framework for mental health in schools. I appreciate that you have done quite a lot of work with secondary schools. For me, however, it is something that needs to be on the curriculum. It needs to be used throughout schools. There needs to be development of clear curricular progress through it as well. I worked in schools that did a great job, but I also worked in schools that did not do such a great job. It is about trying to build a baseline. "Uniformity" would be the wrong word, but there should be, at least, a baseline for schools to provide that support. Obviously, if schools want to go above and beyond that, that is great.

Some fantastic groups came into some schools, but they might have been funded for only six weeks. By the time the young people got to know them, they had to leave again because they only had six weeks of funding. That is what I mean about the cyclical process, which does not work because the work is not carried out over long periods, meaning that relationships cannot be built and you do not have progression. You could have the same information every year, because they do not have the funding and the sustainability to do more.

I welcome the progress, but there is an awfully long way to go. For me, this will only be resolved when there is a curricular agreement and something is in place on the curriculum in schools, because that is the best way of doing this.

Mr Farrar: We agree.

Mr Gildernew: I have a quick follow-up question on the important issue that Pádraig was teasing out there in light of your remarks about how massively important that sector is. The elephant in the room is that, as we speak, application forms are going out amid slashes to the local growth fund. It is a tsunami that started with Brexit but is now washing up right here, right now. I note the recent EY — Ernst & Young — scoping exercise. Do you have an assessment of what the impact will be on those groups or on the work that they do, as you say, to divert people away from statutory health services?

Mr Farrar: We might be able to give you an answer on the EY bit, if we can. I will just make the point that, when you look at each of the Departments, their relationships with the voluntary sector and the resource that goes in, there is an opportunity to really add value in the way in which we coordinate income into the voluntary sector. There are areas of duplication and gaps where people assume that someone else is doing something. In my experience, Northern Ireland has a strong voluntary sector when compared with other countries. It is a great asset that we have. We need to exploit it further. I am not sure what the EY report said.

Mr Gildernew: Do you have concerns about what is happening currently? Do you have any assessment of what the impact of that might be on you?

Ms Stevens: I do not have the figure on me for the percentage of funding that the community and voluntary sector gets from government, but it is significant. It will be in that report, which is published. We would be concerned about any diminution of the funding that goes to that sector because those organisations are such key partners. They need to be part of a neighbourhood solution to tackling mental health. We will do everything in our power to support them to do that.

Obviously, the amounts are different. At the moment, however, there is a mental health strand in the core grant scheme. Applications have come in for that, and that process is under way. The results and outcomes of that will be known next month. Hopefully, that will enable some support to be given to those organisations. Obviously, we are concerned about any wider reduction of funding.

The Chairperson (Mr McCrossan): I will just touch on that point slightly for clarification purposes. Is the Department concerned that delays in access are resulting in people presenting with more acute and complex needs by the time they are treated, with poorer outcomes and increased costs for providing health and social care to support those who struggle most?

Mr Farrar: I am as deaf as a post, sorry.

The Chairperson (Mr McCrossan): Sorry. It is the Strabane accent [Laughter.]

Is your Department concerned that the delays in access are resulting in people presenting with more acute and complex needs by the time they are treated? Pádraig touched well on a number of those aspects. Specifically, have those delays led to poorer outcomes and increased costs in providing health and social care to support those who struggle most? Are the delays costing more and leading to poorer outcomes?

Mr Farrar: The sense that we have more acuity is largely anecdotal because people will say that we have more. I will give you a recent example. It is not a mental health example. Recently, we have seen an increase in the number of fractures that have come into our services, largely, I suspect, as a result of the cold weather and ice. We have an increase in demand. It is not always because of added acuity. What you can demonstrate — the evidence is clear — is that people, as they age, get more conditions that they live with daily. We call it "multiple morbidity". You will be aware of that. There is the complexity of dealing with an individual who presents with coronary vascular disease who may also have diabetes and be suffering from dementia. When that individual presents to services, that is challenging for services as opposed to somebody who might just need managing for coronary vascular disease.

I agree that we probably are seeing an increase in the level of acuity that we face. We know for a fact that the longer someone waits for care because they are waiting on a bed that someone else is occupying, the more that will reduce the benefit of their outcome. That is well known. We are trying to tackle those outcomes by way of resetting our health and social care system. If we can keep the people who do not need our hospitals or secondary services out of them, because we intervene early through a neighbourhood solution or prevention, we can manage higher acuity with the resources that we have.

The Chairperson (Mr McCrossan): Yes. I was referring to the mental health strategy specifically. It is difficult to get an accurate assessment of waiting lists because the system is so broken. People often cannot see a GP, and the emergency departments are a bloody disaster. The last place where most people who are not in a good headspace — if I can use that term loosely — want to be is in an emergency department. It is difficult to determine the scale of the problem. The delays to waiting lists add to that, but, equally, they prevent the Department from having an accurate measure of the demand for the service. Is that a fair statement?

Mr Farrar: It is not unfair to say that there are issues with accurately counting that. When you have severe and distressed mental illness and you are in a chaotic state, you are a risk to yourself and others. There is a cost to managing that and trying to keep secure an individual who might harm themselves or frighten other people. Nurses would be involved, as would, in some cases, sadly, security people. That consumes a lot of resource that would otherwise be available to other people. The more we can get ahead and manage people, so that they are not in a distressed state — although they have a mental health problem, it is being managed because we have compliance in medication and we are on top of that and are seeing them regularly — the less likely they are to get into a distressed state, which has a significant impact, particularly on emergency departments (EDs).

Mr T Buchanan: Thank you for your answers so far today.

Mike, in your opening remarks, you talked about the strategy being absolutely the right one. In order to measure whether the strategy delivers as it should, we have to measure it against patient outcomes. Can you provide any evidence to the Committee today of improvement in patient outcomes as a result of the strategy to date?

Mr Farrar: I am not sure that we can, but we are building a system to do that.

Dr McKillop: I appreciate the Committee's frustration in that regard. Patient outcome measures — not activity data — are built into Encompass. The first one is the universal one and is called the Warwick Edinburgh mental well-being scale (WEMWBS). That will be available from your GP, on your My Care app and to your mental health professional. Behind that, we have a library of reliable and valid tools built into the Encompass system that clinicians will be able to access. We have patient quality measures, which is about your experience: were you listened to and respected when you were dealing with your mental health professional? We then have a set of personal ones that will not be used for outcome measurements, such as the recovery star and the addiction star. Those will help people on their recovery journey, but we do not need to have them as part of the performance data. They are built into Encompass, but, if they are to be reliable, valid and useful for us and for patients, clinicians, teams and trusts, we have to get the patient journey built correctly on Encompass first. If we do not, they will not be reliable and valid measures that we can use. We are building it, but we are not there yet. I understand the frustration of the Committee about the time that it is taking to do that.

Mr T Buchanan: When will that be complete?

Dr McKillop: The activity measures will be completed in June. We are working with Queen's University and the impact centre to make sure that the governance framework around the use of the outcome measures is robust. That will be the phase from June to December.

Mr T Buchanan: Do you have any idea of the number of patients who have benefited from the direction that you have taken over the past 18 months?

Dr McKillop: That is a challenging question. Encompass is not yet able to answer that question for us. We measure the individual level outcome for patients in terms of their interactions with clinicians, how many times they are re-referred into the service and how many times they come back, but that does not really answer the question about whether mental health interventions are making people better. However, when we have those recognised, reliable, valid tools built into a system, we will be able to do that in a reliable and valid way that allows us to benchmark our services nationally and internationally.

Mr Farrar: It is an important question, and our move towards the outcome framework will help to answer that. If we are invited back, we will be able to give you a clearer answer. It is hard to know how many people who came to our service were prevented from having a mental health problem. To a certain extent, there is a belief that, if we put the processes in place, they will lead to improved outcomes. Again, I am not comfortable with the idea that I cannot answer that as straightforwardly as I would like, because why would we pursue it, if we did not know that it was going to [Inaudible.]

We are reliant on process measures that say, "In other cases, these interventions have led to improved outcomes for people", but, hopefully, by the time we do that for Northern Ireland, we can show that.

Ms Stevens: We will be able to use the outcome measures from a population-level health survey to track individuals' experience of mental health, and we can monitor, at that high level in the population, whether mental health in Northern Ireland is improving over time. That is a macro way to do it, but it is something.

Mr Dunne: Thank you, folks, for your presentation. I want to touch on the issue of workforce. The three of you have referenced it.

Mike, you talked about some of the challenges with recruitment, and I am keen to tease out with you, given your considerable experience across the UK and so on, whether there are any unique challenges in Northern Ireland compared with anywhere else.

Mr Farrar: Rurality presents a particular problem, as does travelling distance in Northern Ireland. There are sparsely populated areas in other parts of the four jurisdictions, but they tend to have transport links. Rurality is a particular challenge, and the more specialist you get when it comes to experience — a psychiatrist as opposed to a community mental health worker — the harder it becomes to recruit. That is why I referenced at the beginning our strategy for reset, including getting inward investment from R&D and linking that.

In the past, I have looked at places that could not recruit consultants, and we worked with the local university to create an initial job with a clinical/academic split. When you have, let us say, five sessions in academia doing research, leading a department or honorary professorial posts alongside a clinical role, you can attract eminent people because they are attracted to an empty space of opportunity to research. Once you get your eminent person in post, you find that other consultants will follow because of the reputation of that individual. That is a strategy that I have used.

The other thing that we are looking at is recruitment post qualification, but, in the public domain, I am slightly reluctant to give you any degree of certainty that that is possible. As you know, we fund people to go through education into clinical roles. When they come out, one of the questions that we ask is whether, in return for that, there might be a way of steering their early years career post qualification to certain parts of Northern Ireland as a condition. We have to be careful about human rights, but we know that other countries have taken a view that, if they fund part of someone's education, that person has some obligation to be directed to do some early years of their practice in a place that helps to manage need.

You could present the case in a positive way for people, because, sometimes, when you go into a sparsely populated service, you deal with more complexity and more interesting cases. When you go into a fully staffed area, you are often lower in the pecking order and do not get that experience sooner. We could look at a something-for-something deal to help us, particularly in parts of Fermanagh and the areas where we struggle. The west is certainly up for looking at some of the pilots.

Mr Dunne: You are talking very much about the whole health service and not just about mental health provision.

Mr Farrar: Not just mental health provision.

Mr Dunne: Your points are well made.

I will turn to the other issues around training and the recruitment of skilled staff. That issue has been highlighted by the Committee for a number of years. We are keen to establish what has materially changed in workforce planning since the Committee reported in June 2024, positively or negatively.

Ms Stevens: We have some statistics. For example, pre-registration nursing places have increased by 50% to 165, although that figure dates from a few years before 2024. This year, we have six additional core psychiatry places out of 26 new medical posts. This year, there has been a significant investment in the local, grow-your-own psychiatry workforce. We have an extra 10 postdoctoral clinical psychology places, and that is a significant increase in the psychology workforce. Some developments have taken place that can give us some optimism.

Mr Dunne: OK. My final point is on the deliverability review and the impact that it will have on staffing. Some of the earlier questions touched on it, but, given the ongoing funding challenges, which we are all well aware of, how will it impact on staffing and the strategy?

Ms Stevens: The workforce component will help us to focus on the services that we will prioritise in mental health. The costing and prioritisation report, which will be published later this year when it is finalised, gives us the tools to do that and was a direct product of the review of deliverability. It will help us to prioritise, and our efforts will be focused on getting the workforce into the prioritised areas.

Dr McKillop: Across the mental health service, in line with the grow-your-own method of developing the psychological professions and the grades of practitioner psychologists before the clinical psychologist, we are looking at how we use nurse prescribers, advanced nurse practitioners and nurse consultants to support mental health services. Again, we are looking at how we can develop allied health professions (AHPs) and social workers to build multidisciplinary teams to call on when we cannot immediately access a consultant psychiatrist, because they take 10 years to develop. We can build a multidisciplinary workforce and career development pathways so that, when we train qualified staff, we can give them a career pathway that keeps them in the mental health service and in Health and Social Care (HSC) NI.

Mr Dunne: Thank you, folks.

The Chairperson (Mr McCrossan): Some of the responses are extremely well intended, but they use the phrase "We will do" and "We are going to do", and we need to hear about the here and now and when things will be implemented. It is a point of great frustration for me and others when people talk about what they are going to do. I have heard similar statements to what we have heard today as far back as 2020, and we need to see action following some of those well-intended statements.

Mike, I am throwing down the gauntlet to you in your new role. We appreciate that it is a challenge, but the Department is not moving at pace.

Ms Forsythe: Mike, I will pick up on post-qualification training because I have asked some questions about that. The Public Accounts Committee is keen to keep up to date with post-qualification training because, in a previous response from the Minister, he said that, through the Department of Health, over £40 million per year is spent funding university courses in Northern Ireland with no requirement for any of those people to work in Northern Ireland’s health service. Therefore, £40 million is spent year-on-year on tuition fees, and we know that a lot of those people get their qualification and go abroad, to the Republic of Ireland, mainland GB and Australia. They get their qualifications here at a cost to the Northern Ireland public purse but with no requirement to ever work here. It is an absolutely criminal use of public spending, and I have never seen anything like it. I worked for the Audit Office and trained to be an accountant, and then I had to work there for three years. That is standard in any organisation. The mainstream Civil Service graduate scheme has, I think, a requirement to work there for a while to repay.

In response to my question, you said there was an ongoing review. As soon as possible, some response should be given. We owe it to the people here, because the Department of Health's investment is from a tight budget. Some £40 million a year goes into fees, and the people who benefit might never work in the health service here. Can we be kept up to date on that matter, not just on the mental health service? I am keen to get up to date with that.

Mr Farrar: The Minister and I are keen to take it forward.

On the Chair's comment, we would be in a worse situation were we not well intentioned.

The Chairperson (Mr McCrossan): I am a critic by nature; it is OK.

Mr Farrar: The proof of the pudding is in the eating. We will be able to set out our sense of that in the next few weeks, once we have whatever budget we will have and assuming that we are clear on our pre-commitments, which may or may not include the ability and requirement to pay back any overspend; future pay awards; support for some of the invest-to-save initiatives that we need; and all the rest of it. It will be challenging, but we intend to make good our word.

We have not come with glib answers or rhetoric today. We have come to be honest with you about where we are — where we are deficient and where we need to continue — but we are also realistic about the pace at which we can do that, depending on where we get to with our budget. With reference to your previous discussion, at no point have I intended and nor will I ever intend to encourage anybody to overspend.

The Chairperson (Mr McCrossan): Yes. OK.

Mr Honeyford: Thank you for your presentation. I want to look at recommendations 13 and 14 on the community and voluntary sector. One of the things that came out when we did the report nearly two years was the absolutely shocking divide: the Department did not have the first clue about what was going on in the community and voluntary sector. The first part of recommendation 13 was:

Has that been published?

Ms Stevens: No, but it will be very shortly.

Mr Honeyford: Is it finished?

Ms Stevens: It is finished, absolutely. The Minister has cleared it, and it will be published in the next few weeks.

Mr Honeyford: OK. That is good.

The next bit of that recommendation was to review how to best provide funding to that sector: has that been published?

Ms Stevens: Do you mean in the wider sense, other than mental health?

Mr Honeyford: No, the recommendation said that the Department:

Ms Stevens: We are working on how best to integrate the voluntary and community sector into mental health service delivery. That will include whether we contract with that sector and how we enable that to happen. That is part and parcel of that work. We are setting up a task and finish group that will be jointly chaired by a community and voluntary senior leader nominee from the Health Collective and me. Together, we will put in place a process for taking forward the report's recommendations.

Mr Honeyford: Is the answer, "Yes, that review of funding has been done"?

Ms Stevens: No, that will be part of the outworking of the report. The report recommends that we find a way to create more equitable funding for the sector, so we need to work through how we do that.

Mr Farrar: On funding and influence, the voluntary sector is at the heart of the neighbourhood model that we are building, which we anticipate becoming available from 1 April, in respect of governance and equal partnership to deploy the resource that we use in community settings. I want you to focus not just on our ability to fund that sector to make sure that it can deliver but on the influence of that sector that we will see under that model.

Mr Honeyford: OK. Recommendation 14 said:

Has that been done?

Ms Stevens: Yes. Again, it is all tied up with the EY report. We want that sector to be with us as we make decisions on its role and how we commission it to address gaps in waiting lists and what have you. The outworking of the report and the task and finish group that will be set up will be the vehicle for that work.

Mr Honeyford: OK. We will all have examples of community and voluntary sector groups in our areas. In my area, Lagan Valley, there is a charity that does incredible work. It is not funded, but it provides so much support to the health service. With the report, are you saying that that group and groups like it will be funded?

Ms Stevens: We cannot commit to any particular funding model.

Mr Honeyford: Not to an individual group — take the individual group out of it. On the principle of those community and voluntary —.

Ms Stevens: We have to enable the community and voluntary sector to be part of the service delivery mechanism in Northern Ireland, whether through core funding or contracted arrangements whereby they are contracted to deliver certain things. That is to be worked through.

Mr Honeyford: So, to follow on from what Colm said, their capacity will be sustained.

Mr Farrar: It is not just a mental health issue; it is a broader issue, because a lot of our voluntary sector is about cancer etc. It goes back to my point about the percentage expenditure within our total budget. I could give you a figure, but we will see the voluntary sector being in receipt of a greater amount as a proportion of our total spend by the end of this multi-year settlement than it is now. We intend to grow the sector, and we can improve its value through looking at contracting mechanisms.

Mr Honeyford: You intend to grow the community and voluntary sector.

Mr Farrar: As a percentage of our total spend, yes.

Mr Honeyford: As a percentage of your total spend. OK.

Mr Gildernew: I will focus on crisis services and crisis systems interfaces. Diane touched on those. As part of my training and education in social work, I had the benefit and honour of working in one of the crisis teams in the Southern Trust. It was a well-put-together multidisciplinary team that demonstrated the benefit of good multidisciplinary working. I was going to ask how regional consistency is being ensured while pilots continue. You answered part of my question, but when will decisions be taken to move from crisis service pilots to permanent regional arrangements?

Dr McKillop: Thanks for your question, Colm. We are working with the Royal College of Emergency Medicine and the Royal College of Psychiatrists to have regional standards for mental health liaison and crisis response. That work is about consistent training across all those teams. CAMHS is involved so that we take a lifespan approach. We have pilots in the Northern and Southern trusts that are taking direct referrals from the Northern Ireland Ambulance Service (NIAS). We have Hear and Treat and the multi-agency triage teams (MATTs) up and running. Those pilots are not due to complete until the end of March, but the initial findings are that Hear and Treat seems to be taking more referrals and working more effectively than the multi-agency triage teams.

We are still in the sense-making stage. We link closely with substance use teams — we know that working with co-occurring problems is a real challenge — and with our personality disorder services, because those are the groups of people who present in crisis most often. The two networks are up and running. There is a regional oversight group that makes sure that we have regional operating procedures. That is where that is.

Mr Gildernew: Do you have a time frame for when it will move from pilots to being permanent?

Dr McKillop: We will need a bit of time come the end of March to evaluate completely where we are with the pilots for Hear and Treat and See and Treat, the direct referrals from NIAS and all that continuing work. I will probably be in a better position to answer that question in April or May. I will be happy to write to the Committee about the work plan going into next year for the regionalisation of crisis services.

Mr Gildernew: OK. I look forward to getting that follow-up information.

I move on to how the deliverability review will affect the delivery of recommendation 12 and the theme of Right Care, Right Person. It has been drawn to my attention that, in recent weeks, under severe weather emergency protocols, some homeless people who sleep rough were recommended to take or were provided with beds in Belfast, which takes them away from their statutory services and any informal support that they might have. Clearly, that is not the right place, and they are being moved away from some of the right people.

Ciara, you touched on dual diagnosis, which is a really important issue. Recent figures indicated that 24% of people who died on the streets as a result of homelessness had mental health issues. I suspect that there is also a lot of dual diagnosis there that is not even being captured. When we were doing our report initially, I raised the issue of dual diagnosis and improvements to that service. The reason that I raise it here is that, even in the health service, there is a challenge in getting the right person at the right time. When I raised it at that time, it was indicated that there was a huge interest in that and that work was being done on it. Has work on that been progressed? What will be the knock-on impact of the deliverability review on ensuring that the right person is available?

Dr McKillop: OK. I will answer on the co-occurring issue, and then Heather will answer on where we are with Right Care, Right Person.

One of the Committee's recommendations was that there should be a person who deals with co-occurring issues, because, as you know, historically, there have been silos of mental health services and substance use services, even though someone could be known to both. From your experience, you will know that it will take a big cultural shift to get people working consistently and in an aligned way, rather than in a silo. I am pleased to say that that person has been in post since May 2025 — so, for over six months — and is working across all of the stakeholders: homelessness services, Justice, Health and the community and voluntary sector, which is also key.

The work plan has been guided by Scotland, which is more advanced in addressing co-occurring issues. Healthcare Improvement Scotland has really guided us on how to take that forward. The five work streams that are in place are early intervention and prevention, which you have heard referenced a number of times today; how we manage the interface and make sure that a person gets to the correct service, whether that is from the community and voluntary sector, the mental health sector or substance use organisations or a joint response of all three; how we respond to people in crisis, which you mentioned; how we build recovery; and how we hit this early in CAMHS and make the best use of drug and alcohol mental health service (DAMHS) practitioners so that we can cut it off early. The priorities that have been worked up in the sector include a consistent training approach; timely access; how we make best use of peer support, because that is one of the most effective interventions; how we help professionals and people to navigate our system; and, going back to our discussion about data and outcomes, how we measure that, given the fact that you can say that 24% were known to health services but we do not know if that was for mental health, substance use or dual diagnosis.

Mr Gildernew: Are you saying that that work is protected?

Dr McKillop: Yes, that work is protected, and it is being jointly delivered by us, the SPPG and the PHA, supported by our policy colleagues. That person is in post, and it is protected work.

Mr Gildernew: OK. Thank you.

I want to note the concern about workforce in the Western and Southern Trust areas. My constituency covers both those areas, and the issue is very apparent and worrying. Robust planning is needed. As you say, even if the money is there, there are challenges around training and recruitment. We need robust planning to get ahead of that. I am very concerned about it.

Ms Stevens: Right Care, Right Person is a specific policy that the police are seeking to introduce whereby the police would pull back from attending calls if they are not the right agency to respond. It relates to, for example, concerns for welfare; walkouts and people who are missing from healthcare; conveyance; and mental health order assessments. It has been implemented in England and Wales, and the police are keen to implement it here. We have been working in close partnership with the police and HSC colleagues to manage its introduction. The police have agreed that they will not set a go-live date for that until we are in a position to facilitate it. Those discussions are ongoing.

Our first focus has been on producing a partnership agreement, which is almost finalised. It will set out the commitment across the sector, with the Ambulance Service, the Fire and Rescue Service and the police working together to make it work. We are also working on a memorandum of understanding that will contain the practical arrangements of how that will be taken forward, clarifying roles and responsibilities and who will do what. We have already agreed the governance arrangements and the escalation processes, if there is a disagreement about which is the right agency to respond. Visits are being made across the water to see how it works in practice and to learn from the experience there. Some regions adopted it more quickly than others, and we have a considerable body of learning to draw on.

Mr Gildernew: Thank you.

Mr Boylan: I am glad that you answered on that, because, when I was on the Policing Board, those are the issues that we got, and it is about Right Care, Right Person. I am glad that you talked about a memorandum of understanding, but we need to see what that is. The sooner we address that, the better, because it involves the Ambulance Service, GPs — everybody. I am not saying that the police should not help, but it does not work the way that it should. It impacts on budgets across those Departments, and it has been done outside them. Therefore, I would like to see that. You have answered fairly well, but my question is this: how soon will we see that on the ground? You talked about the memorandum of understanding, but how soon will we see progress, with you working with partners to deliver it?

Ms Stevens: We are conscious that we need to move at pace, but, at the same time, the system needs to be ready. Police colleagues understand that. We will have a silver operational group meeting at the beginning of February at which we will discuss a potential go-live date for phase 1, which is concern for welfare. In parallel, we have a Mental Health Order code of practice out for consultation. That will clarify a lot of the roles and responsibilities in a different phase of Right Care, Right Person. That code will come on stream probably quite soon. We hope to launch it towards the end of March. The code will deal with articles 129 and 130 of the Mental Health Order assessments on responsibility and whose role it is to do what: what the police's role and responsibility is; what the role and responsibility of the Regulation and Quality Improvement Authority (RQIA) is; and what forms need to be in place. It will bring together a range of other guidance documents that are confusing for those who operate the system.

We have a couple of strands of Right Care, Right Person that are coming to fruition, but, at this point, I cannot commit to a date, because it needs to go through the process. We need to have that discussion and make sure that we are ready.

Mr Boylan: That is a big discussion, but the process has started.

Ms Stevens: It is a big discussion.

Mr Farrar: The good news is that we are working constructively with other Departments and on the ground with the PSNI, NIAS and the Fire Service, which has also been very helpful.

Dr McKillop: There is a real appetite to get this right and make sure that, for the people who need a response in a situation of crisis or emotional distress, care is provided by the right person.

Mr Boylan: Thank you.

Mr Burrows: I will follow up on that with an observation. I was in the police for many years, and I saw a culture develop of other agencies saying no and the PSNI feeling that it could not say no. When it came right down to the first level of supervision and a sergeant making a decision, there was this fear: "If we say no and do not sit with and look after that individual all night and then something happens to them, we will be investigated, for years, for manslaughter or other disciplinary stuff, and we will go through a world of stress". It is easier for the police to say yes, take resources off the ground and sit in A&E all night or elsewhere, because they are worried about their own back. That is a powerful culture, which I do not blame the police for, because they have been thrown over the coals many times.

Mr Farrar: What we are trying to do, Jon, is put in place the protocols that allow people to do the right thing and that protect them. There are two functions to perform in respect of individuals who are in a distressed state: one is to calm them and understand the nature of the condition that they are experiencing, and the other is to offer physical support and safety. This week, we saw the sad figures on the amount of violent activity against staff — ambulance staff, other healthcare staff and the police. We are trying to give people the right protocol to protect them in doing the right thing.

Mr Burrows: Risk has to be collectively shared, not just left with the most junior people who make the real-time decisions.

I want to turn to the mental health strategy. You have said that there is increasing demand for mental health services: is there an understanding of why that is? We are wealthier than we have ever been, although, by the way, I was a food bank volunteer until six months ago, so I know that there are pockets of real deprivation. Why are mental health issues increasing?

Mr Farrar: That is a live debate. In Northern Ireland's case, it is possible that there is additional need that has been unmet. It might be that people who previously thought that mental health problems were stigmatised will come forward now, because there is less stigma in presenting with those. There is more of an awareness of mental health problems at an earlier stage, which is a positive thing — people are recognising that they may have something other than a mood change or an anxiety. There is also a vexed and complex question around the diagnosis of young people. There is a debate about whether we under-diagnose or are about to over-diagnose ADHD as a condition. I have four children, and my youngest would define one set of experiences differently from the way that I would have defined it. I will not go beyond that and into personal details, but there is a level of defining it as "a thing", as opposed to just living life.

Mr Burrows: We are short of time.

Mr Farrar: I am sorry, Jon.

Mr Burrows: My fundamental belief is that, sometimes, we need to understand why. Before you fix it, you need to diagnose what is causing that increase. That brings me back to the preventative model: if we are talking about "the cradle to the grave" and the very start of the NHS, we need to go right back to just after you are born.

Dr McKillop: Before that.

Mr Burrows: Before that. There is a massive increase in the number of children coming into schools with behavioural issues. Strip away all the diagnosis labels, special educational needs (SEN) statements and official figures. I go into primary schools and speak to headmasters and teachers who have been teaching for 20 years. They tell me that, in the past five years, there has been a dramatic change in the behaviours of many children. When I went to visit a school yesterday, it was in lockdown. One class was evacuated, because a child was in a serious state of dysregulation. Staff are being assaulted in increasing numbers. I have figures from the Department of Education that demonstrate exponential increases in the number of assaults. Members of staff have told me that they have been kicked in the throat. One principal told me that he was kicked between the legs. They are fearful of doing their job.

Here is an issue that we need to understand. Why is it that, in the past five years, we have had an increase in the number of P1 and P2 children who have behavioural problems and are behind where they should be? A teacher will say, "I would normally expect a child to be able to do x, y and z at the age of six, but these children are behind that". We need to ask really hard questions, because that is the mental health for the present and the future.

I will bring this right back to a fundamental: the scandal of our times is the impact of devices on children. I am not saying that that accounts for all mental illness, by the way, but devices certainly have an impact on young brains. If that is the case — see Jonathan Haidt, 'The Anxious Generation' — our prevention needs to go right back to allowing parents to understand how to bring up children in an era where they instinctively want to scroll on a phone. When a teacher tells a child that they cannot have a phone in school, the child dysregulates because they feel that they need their phone. The device is the only thing that keeps them quiet. If we strip all that back, what are we doing around parental awareness training and support to deal with the issues at recommendations 2, 3, 4 and 5? I am sorry: that is a big question.

The Chairperson (Mr McCrossan): You are grand. I get what you are saying, but we have to talk about the strategy.

Mr Burrows: Is the strategy dealing with that? The strategy is about prevention. Are we stripping it back to understand the causes of mental ill health and what it is that we are trying to prevent? I have gone a bit off-piste there.

Dr McKillop: I do not know that anybody could directly answer your question about why children's behaviours are more challenging now. My mind goes immediately to the impact of COVID on some of those very young children and what it was like to be out of social situations for two years, as a lot of them were. I do not know that we can answer that question yet. I was a CAMHS manager at the time, and the referrals for eating disorders increased sixfold while we were there. COVID has had an effect. I do not know that we fully understand that effect yet, and we may not understand it for years.

You will get no argument from us at this table about the use of devices and the impact of social media on children. I cannot wait to see the outcome of what Australia has done in banning access to social media for under-16s. I am delighted to hear that that debate is going on in the UK.

On early intervention and prevention, we provide Sure Start programmes along with the Department of Education. We invest £26 million a year in 38 Sure Start programmes in areas where there is social deprivation, which do exactly what you described: they focus on interaction and behaviour management. Parenting is hard, and it is about how we support people to parent with all the societal challenges that are around. I am not a clinician so —.

Mr Burrows: A strategy has to be agile enough to pick up those changes.

Dr McKillop: Early intervention and prevention are for the lifespan, and they start with parents. Mental health at primary school is referenced in it. I will not have the opportunity to talk about emotional well-being teams in schools, but I will send the Committee the annual report about the reach and range that they have had with parents, kids and teachers and the impact that that will have.

Mr Burrows: Thank you for that helpful answer.

Diane asked about the £40 million that is spent on students who do not have to promise to stay and work in Northern Ireland. A lot of Queen's University dentistry students, for example, are overseas students — that is for financial reasons, as it is more economically beneficial — and, therefore, a lot of Northern Irish students have to go to England, and then they stay there. Will that be a challenge for the mental health workforce in the years to come?

Mr Farrar: It is a multifactorial issue, Jon, but, undoubtedly, there is that potential. I would argue that you have to be at a particular level, because you will pay more to go to England. Given the level of fees that we charge here and the reputation of Queen's University and Ulster University, you would be taking a conscious decision to move to England, which might be about relatives or lifestyle choice.

Mr Burrows: Or because you cannot get in here, as there are so many overseas students.

Mr Farrar: Undoubtedly, some people will leave our shores, and we should try as hard as we can to keep them.

Mr Burrows: Thank you.

The Chairperson (Mr McCrossan): Thanks, everybody. There were a lot of questions there, Mike. It was a baptism of fire for you at the PAC.

Mr Farrar: I really welcome the opportunity. Democratic scrutiny and challenge is what we should be about. We are accountable, and we want to be accountable. I will be happy to come back with colleagues to give you a progress report in due course, if you feel that we are not being honest enough. We would certainly do that. The PAC is important. It gives power to our elbow in the distribution and spending of resources, so thank you for your questioning. It is not a problem for me to be here.

The Chairperson (Mr McCrossan): I thank the three of you for being with us and taking questions for just over two solid hours. We had a wide range of questions. At times, we digressed slightly into other areas, but that is easy to do when the topic at hand is of such importance to us. At the end of the day, beyond the Committee, we are constituency MLAs, and we reflect at all times the interests and concerns of the people whom we are elected to represent. It is a very important issue for us all, personally and publicly, so we appreciate your answers and your being forthright.

I take some reassurance from your history of dealing with the issues. I hope that you bring that expertise to the important role that you hold and that we see tangible benefits for our public in this important area. I have no doubt that the intentions are good and that the focus will be there, but, as I said, it is about what we see playing out on the ground. That is why, at all times and with all witnesses, when we hear, "We are going to do" and, "We are doing", we ask, "When?" and, "When we will see the benefit of that for people across Northern Ireland?".

Mike, Heather and Ciara: our sincerest appreciation to the three of you for being with us. We do not underestimate the difficult challenges and tasks ahead of you. We wish you well. We will reflect on the evidence that we have received today alongside the information set out in the table before us. We will consider any further information that you kindly provide. We look forward to that document being published at the end of the month, and we will follow up from there.

Mike, we wish you well in your new role. You have the support of the Committee in your difficult job, but we are never shy in holding people to account when it comes to it. We look forward to seeing you again, and, no doubt, we will. Thanks to you all.

Mr Farrar: Thank you very much.

Dr McKillop: Thank you.

Ms Stevens: Thank you.