Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Mr Mike Farrar, permanent secretary at the Department of Health; Ms Tracey McCaig, interim chief operating officer of the strategic planning and performance group (SPPG); and Mr Peter Toogood, deputy secretary of the Department's social services policy group. You have sent us a briefing paper. I will hand over to you for some introductory remarks and any further information that you wish to give us, after which we will go straight to questions.

Mr Mike Farrar (Department of Health): Thank you, Chair. What a great way to start the afternoon; the presentation by Dr Betty Carlisle was really inspirational. It very much reflected the kind of ethos that we are trying to build into the idea of neighbourhood health. It was really special. It is great to be here, and, as always, I welcome the opportunity to attend Committee and account for the way in which we are trying to manage some of the issues in health that we face in Northern Ireland. I very much welcome the opportunity to talk to you this afternoon.

The area that you are particularly interested in this afternoon is hugely important. Community care and patient flow are sentinel indicators as to whether the system works, as they give a sense of how people progress through the system when they need it. We are learning from some really important pointers to understand how those will inform what we need to do next. None of us believe that the system is working in the way that it needs to. We know that people are not getting the experience that they deserve, although when they get to our services, they get high-quality care. We have some brilliant staff who are incredibly good at what they do. Given the way that the system is working at the moment, however, I assure anyone who is listening to or watching the session or who reads the transcript that we are working incredibly hard to make sure that people's experience of urgent care and the management of their problems throughout our hospital system back into the community etc is at the standard that we would all want to experience for ourselves and our families. I assure people that we are working incredibly hard in that area.

Health and social care is quite a complex system, and I am sure that we will get into that this afternoon. It covers people's managing of their own problems, access to care in the community, the process of referral and/or conveyancing, appearances at an ED and management of ED patients through to admission. Then, of course, you have discharge, rehab and, for some people, sadly, palliative care. That is a complex set of operations that, ultimately, need to correlate. We know that community services and patient flow need to be fixed. The way to fix that, however, is to see the overall system and not to think that applying capacity to just one bit of the system will solve the issues. Ultimately, you need balance in the way that the system operates to make sure that there is a smooth transition through people's care. We can sometimes be fooled – I am not saying that anyone around this table is — into thinking that investing more in one bit of the system will solve your problem. Very often, it can cause impacts later on, unless you have had that balance of investment.

Your attention to the idea of flow is critical. I encourage you to think about how it fits in with wider issues to do with who ends up needing our services in the first place and what we are trying to do to improve prevention and manage people so that they do not need to flow through a hospital system because we can manage their care in a community setting. I will give you an illustration of that. We are working hard on the Programme for Government commitment to deliver elective work. If we were to invest in more diagnostic capacity so that we can get to people sooner, that, by definition, would increase the number of people who require treatment. Having more people who require treatment puts pressure on admissions to beds, and having more people going through our beds puts pressure on our ability to discharge them and on what we need in order to sustain them in their own homes. Therefore, if you are actively trying to get more people through diagnostic processes, you also have to think about the commensurate impacts on other areas. This afternoon, we will discuss some of the specific issues around the community care agenda. We need to do better in that area of care when it comes to relationships with services, because, as you know, a lot of community and social care services are not provided by Health and Social Care (HSC) but commissioned by it. Getting those relationships right and managing that flow is hugely important, and we need to do that.

Ultimately, the solution is to get the right people into the right place in the system so that you can understand what is needed and to manage that process of flow. We often describe that issue — I am sure that you will ask about it this afternoon, and we are happy to answer those questions — as being a kind of winter thing. Actually, it is not a winter thing; it is about having a baseline of care that we need and that we think of as our routine level. It has to be adequate to manage the problems that we face, but we need to be able to surge our capacity up and down. That includes beds, workforce and the processes of admission and discharge in order to get that balance right. If we were at, as I always say, that world-leading edge, we would have a really agile system that can flex up and down, depending on demand, so that, effectively, no one would be impacted in any bit of our system because of additional demand due to a respiratory or communicable disease problem. That is really important and needs to be discussed today, and I really welcome that.

Tracey McCaig is with me, and, as you know, she is our de facto chief operating officer when it comes to how the HSC works. She can get into the detail on that bit of it. I also have Peter Toogood, who is my lead official with responsibility for social care. Again, we can get into any of those areas, and if you have questions on the details, I will ask them to lead on some of those answers. It is an important area, and we are really happy to be here to answer questions.

The Chairperson (Mr McGuigan): Thank you very much for that. We will get straight into it. Hospital flow is a major issue. Every day, including today, reports in the press depict horrific stories of patients' experiences in EDs. They could probably do that every day of the week from every one of our hospitals. We have had conversations with you on that and on the winter plan before. Prior to Christmas, we heard from the Minister and others about capacity issues in the home care sector and the reason for delayed discharges. However, we also started to hear — certainly, I did — from those in the home care sector that we and they were hearing some things that were at odds with their experiences, in that they have lots of capacity. Some of them were saying, "We could take many more patients, if they were discharged from the hospital".

I understand exactly what you are saying about the complications. It is not as simple as that, and there are many surrounding factors. I want to use this session as an opportunity to explore those factors and, more importantly, what the Department is doing about the issue, because it is not a new problem. Our health system has been experiencing it, and we should have had long-term plans in place. I would not like to think that the Committee will hear the same types of arguments in a couple of years' time.

I want you to explore the detail of the capacity that we have heard is available in the home care sector and why it is not being utilised. Notwithstanding the resource issues in the Department, what are the immediate plans to overcome some of those problems?

Mr Farrar: I will pick up the first point, and then Peter will comment on a lot of the work that we are doing with the sector to try to get into a different place.

The truth is that, in my experience, we have not had a strategic relationship with the sector. It is quite varied, as you know. When we look at the home care sector, we see that there are places that can take people with high levels of acuity and dementia and others that cannot. There are some geographic limitations in how capacity meets the demand in a particular area. We might have capacity in one bit of Northern Ireland, but we might not necessarily meet demand.

We have to be quite careful about speaking as though the home care sector is a completely homogenous group of services. It is not. The truth is that we need to have a much more strategic ongoing relationship with the sector. That means looking at the capacity that is required, the profile of beds that are needed, the relationship between domiciliary and residential support, which is another factor, and what is needed for individual patients. If all that we do is spot purchase every now and again when we need that level of service, it will be hard to match capacity with demand.

The work that we have been doing — I will ask Peter to comment on that, because quite a lot of work is in train — is to get that strategic relationship. We have increased capacity generally. Look at our workforce numbers. Significant numbers of additional staff have been put into the health system over the past five years. That has levelled off a little, but we have seen 15% increases in the medical, nursing and midwifery workforces. It is perhaps disappointing that, although there has been a lot of capacity increase, we still face that problem.

The Chairperson (Mr McGuigan): Is there a workforce issue in domiciliary care?

Mr Farrar: I will let Peter talk about the way in which we are trying to get into that. I come back to the point about commensurate increases, because nearly 90% of that sector lives on commercial income and has to generate a profit. Issues around balancing the workforce and to whom the responsibility for doing that falls require us to have a strong relationship with the sector and communicate what we need from it, as opposed to just a spot purchasing arrangement. People cannot increase or reduce staffing on an ad hoc basis; they need to have some certainty on and an understanding of our need.

My final point before I ask Peter to talk about the process of engagement with the sector is that the data that we are now getting because of having Encompass and GP data really should allow us to be very good at that. In the past, however, we have not been as good as we would want to be. That is why it is really important to understand the work that Peter has been leading in collaboration with the sector.

Mr Peter Toogood (Department of Health): Hopefully, the Committee is aware of the social care collaborative forum that we set up in 2023, which I chair. It has been mentioned probably a number of times through written or oral briefings. It was based on the principle that such is the breadth and complexity of the issues in adult social care that no one sector can address them. That is why we have statutory colleagues around the table, along with independent sector colleagues from either the private sector or voluntary and community sector. We also have trade union representatives and our registrar in the Northern Ireland Social Care Council (NISCC), so it really is a collaborative effort.

It has been a process. We have had to build relationships and trust, and we have had to get comfortable with working with each other, because that was not always the case, and quite a lot of relationships were quite adversarial. When we formed the forum, we recognised that we need reform. There was the 'Power to People' report. We had the consultation on the reform of adult social care. We knew that we needed to reform the system, but we also knew that we needed to address the immediate issues facing the system.

When we started that work, we wanted to do the big picture stuff, but we picked out immediate issues that we wanted to address collectively. The briefing paper sets out some of that work, such as the early review teams, which look at whether care packages are still needed at the same level as that for which they were originally commissioned. There is also the protection of care packages, so that individuals' care packages are protected when they go into hospital. Such packages are now protected for 14 days across all trusts. That was not the case last year, so we have brought in consistency there. We have looked at block home care packages and at how we commission our services differently where there are challenges of rurality. There is CareLineLive, which is aimed at our statutory sector provision and at mobilising our resources in the most efficient way possible.

Lots of individual pieces of work are going on, because no silver bullet will fix the issues. We have to work on multiple fronts and take the incremental gains to try to address the issues. We are not there yet. We have lots to do, and you heard about the challenges. Sorry, I cannot forget the trusted assessor model.

The Chairperson (Mr McGuigan): I am sorry; I will probably interject while you are all speaking.

Mr Toogood: That is fine.

The Chairperson (Mr McGuigan): The sector said that the trusted assessor model is a great idea, but it is not operational right across the board. If we have good ideas, why are they not being implemented across the board?

Mr Farrar: Inconsistency is a problematic issue for Northern Ireland. We have some brilliant examples. The whole point of building the committee in common, which can take a shared decision, is to allow us to standardise what we do. There is a raft of areas in which care could be standardised. Work on a single job description for the trusted assessor is now in progress. That way of working is becoming much more the way in which we do things than would have been the case historically, when one trust would have had an idea, come up with something and progressed it. I reassure the Committee on that. Through that committee in common, which is a government structure, the chief execs work together, and networks of people from each trust look at what we describe as "sensible care" so that we standardise pathways. There is so much more of that. That is just a cultural thing that we are really pushing hard. Specifically on the trusted assessor, there is the move to a single —.

The Chairperson (Mr McGuigan): The trusted assessor model will be universal across all the trusts in a short time. Is that right?

Mr Toogood: That is the intention. Again, we had a piecemeal start to that process. There is a trusted assessor operation in each trust, but it is not consistent yet. We have been working collaboratively with trusts and independent-sector providers over the past year to standardise the job description and look at governance structures. We will, hopefully, bring in the consistent approach that is needed by quarter 1 of 2026-27, which is the next financial year. Work is well progressed on that.

Again, achieving consistency across trusts is a challenge for us in the Department and the SPPG. We want to bring about consistency where we can and where it is appropriate to do so, but we also recognise that there are specifics in each trust area that must allow for a degree of local focusing.

The Chairperson (Mr McGuigan): Sorry to interrupt you again, but that inconsistency is another issue that we hear about. In some scenarios, some trusts perform slightly better than others when it comes to discharge. Can the Department do things on that in areas in which trusts are, maybe, less adept? What actions are you taking?

Ms Tracey McCaig (Department of Health): I will speak a little to that. The Committee might remember that I was with you previously on the winter plan. This year, the only investment that we had from our base budget, which was £10 million, was put into flow, unscheduled care, community care and discharge. Different trusts had different planks in place when it came to what "good" looked like. We have tried to move more of them to the same point. For example, the Northern Health and Social Care Trust did not have a Hospital at Home model. We have now put that in place. We are trying to bring everyone up incrementally. Conversely, the Northern Trust had a better suite of same-day emergency treatment. We are trying to bring other trusts up in that. We are working to try to standardise what "good" looks like. If we can bring everybody up to that same platform, we should get more consistent results.

On discharges, some trusts are ahead, and others need to follow where those trusts have tread. We are pushing them in that regard. We use support and intervention, Getting It Right First Time processes, peer support and an awful lot of other things to try to do that. We have a role in trying to direct what "good" looks like. However, we are not on our own. The system is not working, so, where we get that view and oversight of things that are better elsewhere, we will try to bring others with us.

Mr Toogood: We completed a series of round-table discussions on home care. Calling them that does a disservice to what went on. It was not a talking shop; it did not involve people just sitting around and saying, "What shall we do?". It involved the same principles as the collaborative forum. We had independent-sector and statutory-sector providers talking about what "good" is, what is best practice, what works well, how we identify opportunities for efficiency and what the opportunities are for regional consistency. The paper sets out the issues with things that have been done in the South Eastern Health and Social Trust, the Northern Trust and the Belfast Health and Social Care Trust, and the feedback from those sessions was immensely positive across the board. When you go into those sessions, you never know whether they will be positive, but the intent of the endeavour was to say, "Here are some practical things". There was a mutual challenge around the table. People said, "Why are we not doing that? Why can we not do that?". There was mutual accountability that fit into the governance structure and the principle of having committees in common at the top level. At the operational level, there was a desire to do something, and that set the tone as to how we want to move forward with the broader reform process.

The Chairperson (Mr McGuigan): My next three questions will be very quick, and I hope to get quick answers, because we have a lot to get through. Peter, we were at an event in February or March last year, and we talked about the Minister’s good announcement about the living wage. We all expected the living wage to come into place. In the Minister's answer to a number of my questions, he has said that some of the decisions that he has had to make are counter-strategic. That is disappointing, because we all know the impact it will have. As a Member, I get frustrated when the Minister says that he has to make anti-strategic decisions that impact the health service, though I take the permanent secretary's point about how success in one aspect can be more costly to another, because things are put under strain. However, we have heard about the cost of a secondary-care bed versus the cost of a domiciliary care package, and the differential is substantial. Surely we should be in the position to invest in aspects of our healthcare that could save money. When will we get to a point at which the Minister can make strategic decisions, rather than anti-strategic ones?

Mr Farrar: I am sure you will come back to the real living wage in more detail, and I am happy to answer questions on it.

The principle that we set out in July about moving resources from hospitals into neighbourhoods is all about exactly what you have asked about. It is based on the principle that many people could get care at home, meaning that they could maintain their independent living, be supported to avoid any deterioration of their health problem and avoid the risks of communicable disease and deterioration of conditions that hospitalisation can present. That is exactly why we are trying to move to a neighbourhood model.

We are finalising our planning guidance for next year, and I hope we can get a three-year Budget. One of the statements we have made is that, over the three years, we will invest more as a percentage of our total spend in primary care, general practice, social care, mental health and the voluntary sector. We do not know what the total package will look like over that period, but that is the only way to do it. Therefore, it will allow us to do exactly what you are saying that the Minister could not do this year. He wanted to do that, but the planning for that year meant that we were on the back foot. We will not be on the back foot next year, and, although the neighbourhood model is a bit of a catch-all term, it is precisely about taking strategic decisions. It cannot just be announced; we have to put into place the workforce, the funding flow, the estates, the organisational development for those groups to work together, the strategic relationship with the independent provider and better contracts with the voluntary sector, GPs and community pharmacies to make that work. That is precisely what we are trying to do. I would welcome our coming back to the Committee when we start to see those aspects of the neighbourhood model in place so that we can explain the difference that they will make.

The Chairperson (Mr McGuigan): We would be happy to have you back. I could spend more time asking you questions, but that would be unfair. I should have asked my final question first, but I have deliberately left it until the end. Do we know, as we sit here today, how many people are in hospital beds who are fit for discharge?

Mr Farrar: We know exactly what is happening on this day.

Ms McCaig: We publish that information now, should members want to see it. It is on www.hscni.net, if I remember correctly. We have recently started to publish snapshots of a range of information, including complex delayed discharges, the number of surge beds that we have and the number of attendances at our EDs etc. You can see that on the website, along with other information on our waiting lists.

As of today, 550 patients with complex discharge needs are medically optimised for discharge. We got that snapshot at 10.30 am on 3 February, which is the last time that we published that information, but someone told me yesterday that it is now 558. It is around 550.

The Chairperson (Mr McGuigan): Is that across all our hospitals?

Ms McCaig: That is across all our hospitals.

The Chairperson (Mr McGuigan): Does it give the details for each hospital?

Ms McCaig: The information is broken down by trust.

The Chairperson (Mr McGuigan): OK. So, there are nearly 600 —.

Ms McCaig: There are around 550.

The Chairperson (Mr McGuigan): That is a lot.

Ms McCaig: It is a lot. You always expect to have a number of people in that category at any one time. It will never be zero. There will always be a process to move through. The issue for us is how long such patients are delayed, because that means excess bed days, and we are trying to work better and more efficiently in respect of those.

The number of delayed discharges impacts on the overall flow of our hospital and the overall management of our emergency departments, as well as further back in the Northern Ireland Ambulance Service (NIAS) space. All those things have to work at the same time. We have to invest in a wide range of areas, and we have to focus on productivity and efficiency across that wide range to make it work.

The Chairperson (Mr McGuigan): How long are people delayed for? During our walkabout at the South West Acute Hospital, I was told of a man and woman who had been in the hospital for over a year: they were fit for discharge but could not get a package.

Ms McCaig: You could always find a case involving particularly long delays. In any of our hospitals, you could have a particular case like that. I cannot go into the case that you mentioned, but we have all the information on the dates and length of time that people are in hospital. If someone is in hospital for longer, it is usually because a very complex package is required. There is a direct correlation between the complexity of the package and the length of time in hospital.

The Chairperson (Mr McGuigan): I do not have a question on the minimum living wage, but I just want to get delivery of that over the line as quickly as possible. It is absolutely necessary.

Mr Farrar: We are committed to that. In our planning assumptions for next year, we are saying that we will do that as quickly as we possibly can. It is a priority, and we are committed to making pay the first call on expenditure, not the last call, as it has been in previous years. That is a great step forward, and it has to happen, however tough the finances are.

The Chairperson (Mr McGuigan): People who work in the sector will be happy to hear that, but it would be really good if you could give a date.

Mr Farrar: We will try to give that, but we do not have a budget as yet, so we will have to work through that. In our planning guidance, we signal that it is a pre-commitment, in the sense that it is one of the things that we are committed to as a priority. I know that the Minister would say very clearly that it is a big priority for him, given what we had to do last year, which was very sad.

The Chairperson (Mr McGuigan): The Health Committee has a duty to question and cajole the Minister and scrutinise his decisions. We also have a duty to facilitate and help the Minister. A three-year Budget is essential for all our public services but particularly Health. As Chair of the Health Committee, I want to see Executive agreement of a three-year Budget.

Mr Farrar: I will not go into too much detail, but we face a great challenge going into that. I am talking to colleagues about a decision around that. They are very positive about it, and they are talking to the UK Government and the Treasury about the difference, as an accounting officer, between having to recover in one year and being given a three-year recovery period. That is the difference between taking action on short-term, counter-strategic issues and being able to invest in that change to make strategic decisions. I am arguing very strongly for us to have a plan across our three years that will allow us to recover, invest in the change and get into a financially sustainable position. At the moment, that has been received pretty well, but we have no commitment as yet that we can do that. I am sure that if Comptroller and Auditor General, Dorinnia Carville, were in front of you, she would say that the accounting officer's duty is to ensure that Departments live within their means. To do that, we would end up having to make something like a double-digit efficiency in one year, whereas, over the three years, we could make that more manageable. That is a great point. We would really welcome your support for that.

Mr McGrath: Thank you for coming here today. Permanent secretary, you said at the start that the way in which patient flow is working is an indication of the state of the health service. Are you presiding over a failed health service? It is not working.

Mr Farrar: I really do not want to describe it as that because of how hard people are working in our service. Very often, however, our people are working really hard despite the way that we are organised at the moment. To me, it is certainly not a failed service; we save lives every day that would otherwise be lost. I do not agree with that statement. As I have told this Committee before, we spend a lot of money per patient. It is pretty much equal to, or slightly above, the money spent in the other nations. We do not have that resource quite in the right place, hence we need to reset. At the moment, it is not as good as it needs to be. We are aware of that. We are not here saying that everything is wonderful. We recognise what we need to do now to make it better.

Mr McGrath: My sympathy is with the 550 people who are sitting today ready to go home but are not able to. My concern is about people who are dialling 999 for an ambulance — right at the very start of that journey — and cannot get it. Do you know what percentage of category 1 calls hit the target in my constituency of South Down? When you dial 999, the target is around eight minutes. Do you know the percentage for South Down when it comes to achieving that target?

Mr Farrar: I will ask my chief operating officer.

Ms McCaig: I do not have that information broken down for South Down, but, with category 1 calls, our December position was a mean attendance of 13 minutes. That is against an eight-minute target. It will be different across different areas and may depend on whether it is a rural area or a more inner-city area. For category 2 calls, it was 107 minutes, but the aim is 18 minutes, so that service was under very severe pressure during December. That will not have improved during January.

Mr McGrath: I wish that, for the residents of South Down, we could achieve that target 13% of the time, but that is not the case: it is 10% of the time. When my constituents ring 999 for an ambulance — category 1 — in only 10% of cases does the health service get there on time. That is why I think it is a failed service. It is not because of the people. They are worked to the bone and cannot give any more. It is the system that is not working, and that is the system that you are delivering. That is why, as I say, my concern is for the people who, in their moment of need, cannot get help. That is why we have to get this right, because not achieving a target 90% of the time is not success.

Mr Farrar: I agree with you on that. The challenge that we face is this. Let us say that you said to me — you have not — that the key thing is that we need to have more crews on the road, more ambulances or more facilities to admit people faster when they present to A&E. If we are to do that as a system — it is certainly not me — we then have to make choices about where that additional resource or support comes from. My argument is that that would make it very difficult in other areas of care. Obviously, we want, at the most urgent point of care, it to be guaranteed that you can get your ambulance within that time. That becomes our priority. In our planning guidance, we signal that we want to reduce the timetable for ambulance handover, because the faster you reduce your ambulance handover times, the quicker you can release a crew and the faster we can get to the next case. The question is this: how do you then get to a point at which we can move people through our hospitals? Ambulances are usually waiting because they cannot get the patient admitted. We do the triaging pretty quickly, but the question is this: how do you fix the system? I would love to tell you that I could fix the system really quickly, but it takes time, unfortunately.

Nigel Edwards from the Nuffield Trust used a great phrase: you are trying to fix the engine while the car is running. That is hard. If we had additional growth money, which we do not —. We have a deficit that we are trying to manage, and it becomes harder to do that as fast as we would like. We have talked to people in London about the speed at which they have improved ambulance services. There are some good-news stories about ambulances, but we have to work harder on that.

Mr McGrath: It is interesting that you mention that. Do you know what the longest wait by an ambulance has been outside the Ulster Hospital today?

Mr Farrar: I do not.

Mr McGrath: Fifteen hours.

Mr Toogood: That is not acceptable.

Mr McGrath: Somebody was in the back of an ambulance for 15 hours. That is not fair on the crews.

Mr Farrar: No.

Mr McGrath: That is at least two shifts and may go into a third shift, and it has a knock-on effect on the people whose need for an ambulance is less acute. The waiting time for an ambulance for some people today is 24 hours. That means that they rang for an ambulance yesterday, and, if we do not get to them in the next lock of hours, it will be tomorrow before we do so. Again, it is not about the people, because the people in our health service are worked to the bone; it is about the system.

I have a final question on the system. We know that spending on domiciliary care has gone up, because we can see that more has been spent year-on-year and that extra hours are available, but, if it is not working and not able to deliver the service that we need, and that is down to commissioning. Who — the Department, through SPPG, or the trusts, one of which we will hear from after this session — is getting the commissioning wrong ?

Mr Farrar: "Commissioning" is an interesting word because it means a lot of different things to different people. We allocate resources, and, for the first time in about 11 years, we have set priorities against them. If you are asking who pays for social care, however, the trusts buy that out of their allocation. There is no straightforward or simple answer, unfortunately, Colin.

Mr McGrath: Say, for example, that a hospital has a patient whom it could send to a care home place, but it does not have the money to do so. The service is commissioned, but the money is not available. Is that because the Department does not give the money, because there is not the correct SPPG commissioning or because the trust decides not to spend it?

Mr Farrar: Let me describe it. From 2016 until about 2022, the Department's total budget went up by 6% of the Northern Ireland allocation, so more and more money came in. I have talked about some of the workforce numbers. We were having those problems then, and, if you compare some of the challenges — ambulance times and waiting and triage times in EDs — you will see that there has been only marginal improvement on last year. That is despite the fact that we have been able to make about £400 million of savings, which we had to do to balance our budgets, given what we were given. I have said to the Committee that I do not believe that it is right to keep going back to Northern Ireland's overall Budget and saying that we need more for health and social care, because, in essence, that would mean taking money away from young families starting out in life, leisure, housing, transport and community cohesion, so we have to do better with the resource that we have.

I will come back to the question. The answer is not to think that we should argue for more and more funding but to ask how we will realign the funding that we have so that we spend it better. Commissioning is failing, but it does so because our current system is designed to get the results that it gets. I believe that the reset will start to change that, but it will not happen overnight. It is difficult to say that our neighbourhood model will manage away a number of people who have ended up in hospital because there is no alternative in our neighbourhood settings. However, I can demonstrate that, if we could make the management of frail elderly people in the community better than it is —. The flip side of pressure on one bit putting pressure on others is that releasing pressure on one bit relieves it in another. I argue that we have a plan; we need time to deliver it.

I recognise what you are saying. It is not acceptable. Even with the current state of play and the engine running, we can and should do better than that: an ambulance having to wait at A&E for 20 hours is not acceptable. It is regrettable, and we are working hard to try to fix that.

Mr McGrath: Chair, I will conclude on this. I appreciate what you have said, permanent secretary: it is not about more money; it about how we spend it. It is funny that Bengoa said that 10 years ago, but here we are today, and we are no further forward.

Mr Farrar: Let me come straight back in on that. Bengoa had the plan. The question is about what we did to change the system to deliver the plan. What did we do to change the mindset that stopped us doing what we are currently doing and thinking that that was the right thing to do? I have been asked on a number of occasions what the difference is between now and Bengoa. We have a plan to deliver our vision, and we are challenging the mindsets that say, "Someone will come and bail us out" or, "It does not matter enough to us", and all those kinds of mindsets on what we are doing. I believe that we are starting to see some real change in people's attitudes. We have to spend our money differently because there will not be new money. We know that we are letting patients down. People hate that; you know that. The worst thing that can happen for staff is when they have to say, "We can't do what we know is the right thing to do". I know that you will be speaking to Jennifer Welsh and her colleagues in the Belfast Trust. Everybody is really trying to make the situation better than it is now. I am not certain that Bengoa was not just seen as a nice strategy description; there was not the attention to detail to implement it that there should have been. That is what we are determined to change this time.

Mr McGrath: Thank you very much.

Mr Donnelly: Thank you for the presentation today. I want to take you back to 9.00 pm on a Sunday night in December 2025, just before Christmas, when the Chair and I visited an A&E in order to see what the pressures were like. When we arrived at 9.00 pm, we were told that flow in the hospital had stopped. In a major hospital in Northern Ireland, flow had completely stopped at 9.00 pm on a Sunday night. There were nine ambulances outside, one of which had been waiting for six hours and 21 minutes, but obviously that wait was only going to lengthen. There were 114 patients in the department, with 52 trolley waits for admission and no beds available in the hospital at all. There were over 100 medically fit patients in the hospital who could not get out. Some of them had been there for weeks while waiting for care packages and placements. The longest wait in the A&E at that time had been four days and 16 hours. Somebody had been in A&E for four whole days and 16 hours, but there was no flow. There was no movement, so ambulances that came in subsequently or anybody else who came into the A&E that night were going to have to stay there, because there was nowhere else for them to go.

I cannot get my head around those numbers. If you have 50 patients who need to be admitted and you have 100 who are medically fit, even if you remove half of the medically fit patients, I do not see how flow will start again. Why are we not investing more in building capacity in the community? Why has that not been fixed? We have known about that for years, but it has gotten worse. Why have we not done that, and what are we doing now?

Mr Farrar: Tracey, do you want to pick up on that?

Ms McCaig: We have invested in that and we are doing so. We were trying to push that £10 million investment into the best places that we could at that time.

Mr Donnelly: Where is that?

Ms McCaig: We put that to the Committee last time. In general, we were talking about increased Hospital at Home provision across our sites; additional short-stay inpatient beds and additional step-down and intermediate-care beds, all of which were required for flow, frailty assessment at the front door; the expansion of ambulatory and same-day emergency care; multidisciplinary teams (MDTs) in the ED in order to get the appropriate care started from the front door; enhanced capacity for early review teams, which we have talked about; and further discharge coordination.

In parallel with that, it is not just about commissioning or buying our way out of the position that we are in. It is also about being more productive with what we have. When we looked at our domiciliary care, it was about our early review teams and those hours. Some people had an early review and needed more hours, while a lot of people needed fewer hours. It was about rebalancing those hours in order to recycle them into the system much more quickly to assist us to use them productively. There is more for us to do, and we have to push into the complexity of the types of beds and packages that we need. Some of that requires investment, and some of it will require significant change.

It is not just one thing; as we have discussed, you have to be able to move lots of things forward at the same time. I remember saying to the Committee at the time that we would absolutely like to have more in order to do more. We have to make the best of what we have, however, and bring everybody up to a level so that they can all use Hospital at Home or pull other levers. The Ambulance Service, for example, has Hear and Treat. If you are waiting for an ambulance but are not in a life-threatening condition, you have access to advanced paramedics, with support over the phone or face to face. All of those levers are being pulled. Discharge is only one part of a very complex patchwork that we are trying to change.

Mr Donnelly: The bottleneck in the system is clearly at the discharge stage. If you have 100 medically fit patients and 50 patients who need to be admitted — we have heard today, I think, that you have 550 medically fit patients.

Ms McCaig: For us, that is a significant problem — I am not going to say that it is not — and it is a significant area of our focus. When you are thinking about flow, it is the rate of people coming in and the rate going out, so we have to look at who can be managed in a better way and more proactively, anticipating care needs, and keeping them close to home or in their home, wherever that may be. If you ignore that, all you do is bring more people into hospital, and they go through a process. We are trying to manage both parts of that, but it is a major problem and a major focus for us.

Mr Donnelly: I appreciate that, and that has become an all-year problem.

Ms McCaig: It has.

Mr Donnelly: We talk about escalation beds, but, in reality, the escalation beds are there 12 months per year.

Ms McCaig: They change at different times. For transparency, we have given out the number of those beds that we have at the minute, and that was part of the plan. When we talk about surge and pressures all year round, that is part of what we do. They are higher than we want them to be, but we had about 268 surge beds in the system as of 3 February, which is when we put the figures out there. We are open to saying that that is what they are. We are being entirely transparent on those numbers.

Mr Donnelly: In my experience, those beds are open all year.

Ms McCaig: They are not open —.

Mr Donnelly: Corridor beds are on wards, and they are open all year. They have patients in them all year.

Ms McCaig: It is the volume and the number depending on when there are more pressures. In winter, we have more requirement for our services because of winter viruses and other things, so that will flex and change, and you will be able to see those numbers because we will put them out regularly for you to see.

Mr Farrar: I will make a point about discharges and the maths if, as you mentioned, you have 100 people. What was interesting about this year was that it was really clear to us where we needed to focus our energy. We did not have additional numbers coming to the front door. In other words, we seemed to be able to manage the flow in. We really struggled after the four-day bank holiday weekend with getting people back out. If you lose two days of discharge, the way the system works is that the bottleneck then becomes a big issue, and it takes, probably, three or four weeks to clear. That assumes that there are no additional pressures at that later point.

We were also able to look at the causes of discharges, because they are often different. It could be waiting for a care home place for an individual. There might have been a place available, but if it was someone who also had dementia, we could not take that bed. We have the waiting for domiciliary packages. Sometimes, families do not feel confident about taking an individual back home. That is a small group, and I am certainly not blaming anybody for that, but it is a factor. There are then things to do with the processes of the hospital. We have said — and our chief executives and trusts are very happy to respond to that — that if it is anything within the gift of the hospital, we will move quickly to eradicate the delay. Sometimes, even the smallest delays can be because we do not have the pharmacy aspect ready for people to be discharged with their medication.

Mr Donnelly: That is usually a couple of hours.

Mr Farrar: There are a lot of discharge areas so that people can be released from a bed but still be waiting in comfort. This is not a case of dealing with 100 people where you can just click your fingers and say, "Bang. That's the solution". We need to think about how we look at all those areas. If there is a silver lining to that cloud, it is that it is giving us more information about where we need to focus our attention, and that is what we have tried to react to.

Mr Donnelly: I was pleased to hear that you appreciate the importance of the strategic direction of that. We have talked about the social care collaborative forum. Last week, we had a briefing from the independent health and care providers, which paused engagement with the social care collaborative forum due to frustrations about outcomes. Will you tell me about their engagement and what you are doing to re-engage with them?

Mr Toogood: The Minister met the independent providers last November. They explained their frustrations, and it was an opportunity for the Minister to hear those frustrations and to offer some way forward to try to resolve that. From a personal perspective, I have worked closely with those individuals for the past three years, and I hold them in the highest regard. Their knowledge of the sector, their expertise and their desire to want the best for their patients and service users is second to none, so the fact that they have paused their engagement is a great personal disappointment. The debate on reform and how it goes on is also much less because they are not there, but we have to move on, and we will move on, to move things forward. They raised and agreed a number of issues with the Minister. Hopefully, we have movement on those.

I would like to think that that would start to shift the dial with regard to their re-engagement. We agreed the justification paper that the fair work forum had prepared for the real living wage — basically, on why they should be paid a real living wage. That has been through the Minister and he has agreed to publish it. We will publish that, which was an ask of the Independent Health Care Providers (IHCP), at the start of next week.

The providers talked about the need for an independent economic review of the cost of care to determine the fair cost of care. We have a meeting scheduled with them for later in the month. That is an important piece of work that will enable us to understand what is going on in the system and what it is costing. However, it has to be done in the context of everything that we have talked about — a reformed system — and the fair cost of care in a reformed system. We have to work through that with them. We now have a meeting scheduled for that.

They were concerned about whether the money that they were getting would meet the Government-imposed costs of rising National Insurance contributions, for example. Again, we have committed to meet them on that. In fact, I think that they are meeting this afternoon —

Ms McCaig: They are.

Mr Toogood: — to hear about that. Again, we cannot do anything in-year. The pressures that Mike talked about are real. The financial pressures —.

Mr Donnelly: Can I just check that you are meeting the providers' association this afternoon?

Ms McCaig: Yes, the finance team is. My director of finance, and possibly somebody from the community care team, will meet providers this afternoon. Those meetings are a long-standing arrangement that we have continued annually or a couple of times a year. Indeed, a meeting is happening today.

Mr Toogood: That is with a view to improving our model in order to try to address some of their concerns, because it is not possible to do anything in the current financial year. We have corrected the record with you on the percentage figure that was quoted for those who are in receipt of the real living wage.

Mr Donnelly: It was 54%.

Mr Toogood: Like you, Chair, they want to know when the real living wage will be implemented. They want that. As Mike said, it is just not possible for us to do that at the moment because we do not have a budget and we need to work through the process.

Mr Donnelly: There was a lot of hurt, and a lot of trust was lost, when that promise was broken. A lot of stock had been put into it. When the U-turn was made and that promise was broken, a lot of trust was lost. It was regrettable. Certainly, the sector felt that.

They have also raised with us — well, they have alleged — that one of the reasons — the Chair mentioned it — is that, when it comes to a certain point in the year, trusts are not using their budgets to buy up capacity in the system in the independent sector in a way that would be beneficial, and are, in fact, lessening it in order to save money in their budgets. We heard that allegation directly from the independent sector. Have you any evidence that trusts are not using up their budgets to buy up the care that is needed by the patients who are lying on hospital wards?

Ms McCaig: I have no evidence of that at all. It is certainly something that our trusts could speak to, but I have no evidence of that.

Mr Donnelly: Would you be able to refute that at all with any figures?

Ms McCaig: I cannot give you that, but we do look at the number of care home packages that we have each year. We look at our domiciliary care packages. I am not seeing anything evidentially from that higher-level view that would indicate yes or no. However, it is a complex picture, so I can neither confirm nor deny the position in any trust. We do look at that and the rising costs in those areas. I do not recognise the situation you have described and certainly have not had a conversation with the trusts in that position. Now, there are different packages, and it is about what type of package that we are talking about. If there was a vacancy in a particular home in a particular place, it is about matching need. Do we have the right beds in the right places to meet the needs of those 550 individuals? There could be perspectives on that. It is certainly not an issue that I personally recognise.

Mr Donnelly: Certainly, people who are held in the highest regard made the comment to us that trusts are not using their budgets to buy up capacity in a way that would be most conducive to care. It is quite an allegation. It is the winter; the time when we have those increasing pressures. The suggestion is that people are lying in hospital much longer than they should be in order to save money from budgets.

Ms McCaig: I am sure that our trusts will want to comment on that, but it is certainly not something that I have heard repeated to me.

Mr Donnelly: No problem.

I have one, last question. The independent sector has been asking for the trusted assessor role for a long time. It said that it has had issues with some of the assessments that are being carried out in hospitals. I think that one in seven assessments is rejected pretty much out of hand. The paper states that the trusted assessor role will come into force in quarter 1 of 2026-27, which is April this year. Are those assessors in place?

Ms McCaig: Sorry, I do not have that detail. I just know about the work and its reach. Some of the trusts have a trusted assessor. I met one in the Ulster Hospital recently to find out how it is going and whether it is working in the way in which we intended. The feedback from that individual, who works very closely with providers in their local area, is that it has been a positive experience. In quarter 1 — I will not commit to a particular month — we want all our trusts to have assessors. We have an ambition to make it a seven-day week, but that will require investment, so we will have to work through that. However, it is absolutely the right thing to do. It is really important to us to try to get that regional consistency, and that is what we are trying to do in quarter 1.

Mr Toogood: There are people there —

Ms McCaig: Yes, already in place.

Mr Toogood: — but it is not consistent and not yet seven days a week. That is why that work is ongoing. The quarter 1 deadline is about having an agreed model and way of working. We need to start implementing that, and trusts need to implement it. It may mean looking at existing job roles, because there will be overlap with someone in another bit of the system who could work on this. That change process — or management of change, as we have called it — will bring other roles in to fulfil the regional job description that has been agreed over the past year. I do not think that it will be fully up and running in quarter 1, but we know what we are aiming towards, which we did not know until now.

Mr Donnelly: Does that job description match the independent sector's requests?

Mr Toogood: Yes. It has worked on the task and finish group that combined the roles.

Mr Donnelly: Thank you.

Miss McAllister: I have a few quick questions. Why will the trusted assessor role make a difference? What benefits do we hope to see from it? It is important to set that out.

Ms McCaig: For me, and certainly from the conversation that I had in the Ulster Hospital, trust is the important thing. It says it in the title — "trusted" assessor; it does what it says on the tin. It is about trust with the independent sector providers and saying, "If you are assessed in the hospital, this is someone I can trust to come out with the right assessment and make the right match with the provider". That makes for a much speedier process, in which we are not waiting on two parts of the system to agree but, instead, it can be done once and we can work together.

When the regional job description goes in and when get the role, we will watch to make sure that it delivers what we expect, which is much faster matching of need to availability. We have other things in that as well. We are trying to digitise the capacity in our care home sector, for example, so that we have much more information to make the whole thing work a lot more efficiently. That is really what we are trying to do.

Mr Farrar: I will talk briefly about something that we are doing that will be a bit of a game changer. At the moment, we do not use clinical decision-making tools to help the clinicians make decisions on referral, admission or discharge. Therefore, it is variable. Some practices will refer different people for different problems that are being managed by one practice and not by another. A resident doctor may well admit somebody about whom a more senior doctor would have said, "We can manage them outside hospital". Also, at what point are we ready to discharge? We do not necessarily have procedures that trigger a discharge process. Introducing clinical decision-making tools will allow us to standardise all that. You can manually override those tools. You can say, for example, "The patient met the criteria, but I was not confident that the care was there and ready in order to avoid an admission". We will never leave anybody's granny outside hospital. At that point, you understand, "Why did I override? What was missing?". It may be that that resident doctor did not understand the system well enough — they might be just coming into practice — or it may be that we genuinely did not have the service outside hospital that the patient needed, and that will help us to put it in place.

Variability is not just about different interpretations of a job description; we have a variability problem. However, the software now allows us to ask, "Does this individual meet the criteria for admission? Does this person require discharge because we have got to that level?". That is clinically evidenced. It is not telling doctors to do something that they are uncomfortable with; it is what the evidence says about the presenting problems and the vital signs. That will make a huge difference. It will really help the clinicians to make the right decisions.

Mr Toogood: I will add something on a very practical level. Before we had trusted assessors, we had to wait for care homes to send people out to assess patients. There was that delay. Now, rather than waiting for various care homes to send people in, we have an individual on the ground five days a week — we need them there seven days a week — who is ready and doing the work, which speeds up and oils the process.

Miss McAllister: Thank you; that is helpful. I want to ask about flow plans in the winter preparedness plan. There was, I think, a figure of 10,000 additional GP hours in care homes; is that right? Was that delivered? Was there capacity to deliver it? Have we been able to evaluate the impact on patients who were able to receive that care and whether GPs were able to carry it out?

Ms McCaig: That figure related to the proactive care plans that our GPs are putting in place. We have already increased funding to allow more of that to happen, and we are looking to see whether we can squeeze any more out of the budget to make even more of it happen. That is a critical plank of what we are doing now and what we need to continue to do more of into the future. Being proactive and managing people in their own homes, wherever that may be, with our primary care function, is an important plank of our neighbourhood care model. It has been invaluable this year. I want to express our appreciation for our GPs, who have done not only what we set out to do but more than that.

Miss McAllister: Is it possible that that could become recurrent? If it is working —.

Mr Farrar: I will say something very positive. I want to acknowledge that, even though we have had discussions with GPs and they have taken collective action, they have worked really hard throughout this period. I want to recognise just how hard they have worked, despite the fact that they are in dispute with us. I want to let the Committee know that we received correspondence from GPs this week to say that they will be coming back to the table to look at the opportunity for a new contract and to discuss next year's contract. We see GPs playing a big part in the leadership of the neighbourhood model. That is really positive. We were still in dispute when I was last here, but we have that start now, even though it is fragile. I want to thank GPs for the work that they have been doing this winter, despite the fact that they have been in a contract dispute with us.

Miss McAllister: It is important to note that Committee members also received a letter from the British Medical Association (BMA) to let us know that it is re-entering negotiations. The general funding allocation to our GP services is crucial and core to this work.

Mr Farrar: That is why committing to increasing the percentage of money that we spend, as a proportion of our total spend, is exactly the right thing to do over the next three years.

Miss McAllister: I have another couple of quick questions. Mike, you said that, for the first time in 11 years, we have put priorities against allocations. Will you expand on why that is?

Mr Farrar: On why we have done that?

Miss McAllister: Why is this the first time that we have done it in 11 years?

Mr Farrar: I do not know why it stopped. There is a commitment that an annual plan will be produced. We have had that in a variety of forms but not in the sense that —. The system that I grew up in and was a chief executive in for 15 years produced annual planning and priorities guidance, which effectively set out, "Here are the key things that we expect you to do with the money that we are giving you". We have not really had that. We have had a series of measures that we were trying to get to — Tracey has been a part of that — whereas we need to have a clear sense of what our priorities are. This year, given that finances are very tight and we wanted to pre-commit on pay, the real living wage etc, I felt that it was really important to have that sense of our priorities, once we have netted that money off. If we are in an overspend position at year end, we might have to fund that. I wanted to be really clear and say, "These are the areas that we would like to deliver next year".

There are four strategic objectives in there. One is to take the action to deliver the reset, which goes back to the Chair's question about funding strategic change. The second objective is to look at the implementation of inquiry reports and improved patient safety and quality. The third objective is to continue the work that we have done this year with our system financial management oversight group to get efficiencies, so that we are not wasting a single penny. We are looking at every line when we do that, and we have had a lot of success in efficiency this year, which we intend to carry on. The fourth and final objective is to get more productivity with the money that we have for routine services and to look at the key areas of focus in that regard. I felt that, without that, we were having a slightly abstract conversation with our trusts on what we do not have enough money to do.

Setting out our priorities, which include commitments to —. I have to tell you this now, and you will probably get me back at some point to answer on it, but we have a lot of strategies that —. For example, when the mental health strategy was written, there was an assumption that there would be £1·2 billion of additional expenditure over a 10-year period to support its implementation. In the current financial situation, we do not have that, so we have asked, "What aspects of the mental health strategy do we want to see next year, and what aspects will we have to fund in future?". We are being a bit clearer about our promise. That is set out in the guidance, and, as it happens, the regional mental health crisis service and workforce planning are the two big areas that we want to focus on and signal as priorities. It is tough to do because, effectively, you are saying, "This is what we are going to do with the money that we have", but it is the right thing to do, because we are trying to be transparent and realistic about what we can do and how quickly we can do it.

Miss McAllister: That is really important, and I very much welcome it. We have spoken during many debates in the Assembly Chamber about how we have never seen priorities. If you do not have priorities, you are constantly wading through mud with no direction or idea of where are you going.

Mr Farrar: The risk is that, while a lot of the parliamentary Committees come out with things that they want us to do more of and that I would love to be able to do more of, when you add it all up, it is not all possible. The most recent report that the Committee published on palliative care was really helpful. It was a very good illustration of how you can spend the money that you have better. However, on the ask of improving GP access, we will have to manage that money. There are a few areas in which particular interest groups would like us to spend more money, and I would love to be able to do all that, but we have to —.

Miss McAllister: As would everyone, of course, but that is why transformation is key. That leads me to my next question. Alliance has always advocated for transformation and has never been afraid to take difficult decisions across the health service. The shift-left agenda — the neighbourhood model — is not new; it has been around for years. You have talked for some time about the committee in common. What has it changed? Can you give examples from which we can have faith that that is the way forward? Are there tangible examples of that committee making changes already?

Mr Farrar: I will give you an example. On that committee's next agenda, one of the items — it is a long-standing item — is the distribution of psychiatry across Northern Ireland. Some parts of Northern Ireland have a lot more psychiatry services than others. The committee in common is looking at the distribution of psychiatry and how we make sure that we get an even spread of psychiatrists. That is about looking at, for example, putting in a stipulation about where people practice for a short period post qualification. That conversation has to be had by the committee in common, because some people have adequate services whereas others have the best services. That is exactly what the committee in common is starting to do. It is a practical example. We will report back on where the committee gets to with that.

Miss McAllister: It would be good if we could be kept updated on such examples.

This is my final, quick question; I say without looking at the Chair. Was there a recruitment campaign for domiciliary care workers during or prior to the winter months? Was there a coordinated recruitment campaign to get more people to carry out that service?

Mr Toogood: Not to my knowledge, Nuala. Such are the recruitment and retention challenges in the sector, the reality is that recruitment is constant. That goes back to the Chair's earlier question — are there challenges in the workforce? — which I noted down but did not get to answer: Yes, there are, but that is at all times during the year, which, again, is reflective of pay, terms and conditions and all that. Recruitment and retention is a well-known problem. It never really stops. The trusts are constantly recruiting for their in-house provision, and some of the larger independent providers certainly have dedicated and focused recruitment machinery in their organisations to keep going at it. However, there was no dedicated campaign as such, because the issue is just so prevalent throughout the year.

Ms McCaig: From personal, family knowledge, I know that the larger providers have open recruitment all year round. While it might ramp up in the winter, it certainly continues throughout the summer. There is a constant need to support staff.

Miss McAllister: It sounds like we could and should coordinate that and find out who is recruiting best, whether because of attractiveness or apprenticeships and other models.

Mr Toogood: I can assure you about the broader work. We have talked about pay, but the real living wage, when it comes, will not, in itself, fix the problem; it is also about the broader package of career progression, qualifications, job security and feeling valued. We have a social care workforce strategy to take forward things like that, and it is a key part of the collaborative forum. It is longer-term work. As I said earlier, NISCC and our social work colleagues sit around the table, and they have put the care and practice framework in place, whereby people can see a career in social care. The complete package needs to happen, and we are taking that work forward.

Miss McAllister: Thank you.

The Chairperson (Mr McGuigan): We have only got through half the members who have indicated, so we have another half to get through.

Mr Farrar: We will keep our answers short.

The Chairperson (Mr McGuigan): Can we make the questions and answers a wee bit more concise? We are due to receive another important presentation afterwards.

Mrs Dodds: Thank you for the presentation. In many ways, in the midst of dark days for patients and people on waiting lists, the session has given me hope as regards timescales and so on. We are looking at making some of the right changes, although I suspect that those changes will happen only over a long period.

You talked about the shift left and the neighbourhood model. You have not got a budget yet, but you will have had preliminary discussions. Have you indicated to the trusts the percentage of their budget that they should leave aside to make the shift left? I realise that it has to be incremental, but, if we do not make some stipulation on that, it will not happen.

Mr Farrar: The ambition, rather than target, which will be followed through very strongly, is a 2% shift. That money will probably still go through the trusts' bank balances. However, we will want trusts to move services — whether that be diagnostics and what would have been outpatient treatment with hospital treatment — into providing physician support, advice and guidance to GPs. I will give a very good example. I was with cardiologists from the Southern Trust last week, and we asked, "Why is cardiology a hospital-based service here?". In some of the best health services in the world, cardiology sits alongside general practice. Primary and secondary prevention of cardiovascular problems can be managed in the community, provided that you have some reach into hospital. Our ambition is to audit it, track it and be able to come to the Committee and say, "This what we have moved". That 2% could be anything, depending on whether we exclude tertiary services, which you would not expect to go into a community setting. There could be an opportunity to spend £100 million to £150 million in community settings to support the neighbourhood model.

We are looking for additional funding from social finance. We have talked to Macmillan Cancer Support about having £10 million to £12 million to support end-of-life care. We have talked to companies about the wrap-around care for glucagon-like peptide-2 (GLP-2) drugs to manage obesity — we know that there needs to be lifestyle support around that — which could be worth £7 million. There are a number of transformation fund projects involving young people and families. I cannot announce those projects, but I can say that they are at an advanced stage. One project adds up to around £60 million for children and young people and families, and it will be focused on through the neighbourhood model. We are trying to get as much resource as we can to fix the problem, whilst still managing our hospital care.

Mrs Dodds: I have two questions that lead on from that. Different trusts in Northern Ireland have different budgets. How will you make sure that, across Northern Ireland, there is equity in the delivery of care? That is very important. How will you make sure that trusts do not add in things that they are already doing and call them neighbourhood care? Forgive me for being cynical, but I have been in politics for a long time.

Mr Farrar: This kind of idea was not present when Bengoa reported. We did not have the commitment to do it in the way that we do now. We will publish guidance to help and support our trusts to understand how to set up the neighbourhood teams. There will be a degree of consistency in what the teams look like. We will probably have to do it in three waves throughout 2026-27. I do not know whether you were around when fundholding came in. I was the person who signed off on the abolition of fundholding, so I do not have a personal commitment to that way of working. However, one of the things that fundholding did really well was that it had waves in which teams received support, and they were then able to inform the teams that came along in the next wave. If we were to do it in three waves, our starting group would contain the better teams — the ones that are the most ready — and that group would be able to pass on what it is doing to the next group. We are in-building the sharing of practice as the neighbourhood teams are rolled out. That is very different to what we did with the multidisciplinary teams (MDTs), for which it was very clearly, "One third. One third. One third". This is about getting everybody there and learning as they go.

It is a good point. We are mindful that, in the Western Health and Social Care Trust, with its big rural area, it might look very different from how it looks in Belfast, but there is no reason why we cannot have real consistency of opportunity for those neighbourhood teams to learn from each other and reduce variability. I say "reduce" because I do not think that you will ever eradicate variability in what they produce. In some cases, we might want to experiment. We might say, "We're really interested in the development of that service and seeing whether it could work in a neighbourhood model". However, if we do that, we will learn from it very quickly because of the process of sharing and transferring information.

Mrs Dodds: That is a really good aspiration. I would really like to see how it works in practice. I hope that we will start to see some of it next year. The roll-out of the MDT model has left inequalities in the system that will persist for a very long time. If you do not get help for MDTs in this tranche of funding, it will to be into the 2030s before you get to the next stage. I do not want that kind of inbuilt inequality to happen again.

Mr Farrar: That is a really well-made point. Eradicating inequality is one of our key, overarching aims for the coming period — the first year and then the next two years. It is not easy: we know that. We have talked a good game on inequalities for a long time, but we have never delivered; in fact, they have widened. I would be very happy to come back to the Committee to report on how it is rolling out, whether we see that kind of problem and what we will do to fix it. I will come back and talk about it as it gets rolled out.

Mrs Dodds: You mentioned in your presentation that one of the ways of sorting out crowded A&Es and so on is to have more interventions at a much earlier stage, including diagnostic interventions. Yesterday, on World Cancer Day, Wes Streeting issued a cancer plan for England, in which he said that there would be earlier diagnostic tests and that, by 2029, all cancer targets would be met.

We have never met cancer targets here.

There is a moral issue over the way that we treat cancer patients in Northern Ireland. We have the longest and worst waiting lists, and we have some of the worst outcomes, because we are not in the diagnostic space at a much earlier stage. Wes Streeting is advocating for a specific cancer plan: are we going to do that here? I think that we are at that stage. We need that.

Mr Farrar: We have an approach here that Tracey can comment on. There is some better news on cancer. We are nowhere near, but we are getting closer to meeting those targets than we have been in a number of areas. Next year, we want to specifically target some of those, and cancer is one of our priority areas.

I am slightly hesitant to follow Wes Streeting because that cancer plan delays some of the things that they said previously they would do before then.

Mrs Dodds: Interesting.

Mr Farrar: So, it is worth having a look at the detail of that. However, the one thing that we are trying to do, which would revolutionise things, is to look at genomics and profiling, because you can identify the risk of cancer very quickly now. Although that will lead to more people needing treatment, it will lead to better outcomes for people because we will get earlier stage presentation. Cancer then becomes a chronic disease rather than an acute, fatal disease. That is where we have to put our energy.

It may not be for today because of the time constraint, but we are working with Queen's University and Ulster University on an academic health partnership, which, I believe, will attract more research and more income into Northern Ireland for those kinds of new technologies. I am really thrilled with the progress that we are making there. You will be able to see that we have a commitment that is at least in parallel with, if not superior to, the one that England is committing to in that space because we have two brilliant universities. Given our size, commercial companies with cancer breakthrough drugs and cancer breakthrough technology would want to come to Northern Ireland if we could show that we have a joined-up offer. You will have representatives from Belfast Trust in the next session, and I do not know whether you will ask them about that, but some of their research opportunity is very strong.

Mrs Dodds: I will leave that one there because I think that it deserves a separate Committee session at some stage.

You talked about the financial recovery of the Department. I presume that you talked to Treasury or the Department of Health and Social Care in London to try to get that recovery over a three-year period. How hopeful are you about that?

Mr Farrar: I am very hopeful that the case is understood. In Northern Ireland, there is a lot of interest in pursuing that. Some of that will be Northern Ireland's ability to manage the re-profiling of spend within its overall allocations to each Department. I do not think that they could unilaterally say that they could do that without some compensatory effects.

The crucial thing is the conversation with HM Treasury about whether it recognises the situation that we are in and our responsibility and how quickly we could get out of that. They push hard on whether you are transforming your service. The argument that I am feeding to our finance colleagues to feed into their conversation is that, if they are keen on us transforming, re-profiling allows us to transform much faster. The case is very strong, and we will continue to make it.

At permanent secretary level, I feel that I get a very fair hearing, and we have had some bilateral meetings over recent weeks, as have all Departments, with the Minister of Finance. Those have been very positive in understanding the importance of re-profiling.

Mrs Dodds: It is good to hear that that work is ongoing. In trying to work out what the issues would be, it would be quite grave if that were not the case —

The Chairperson (Mr McGuigan): Do you have a quick question, Diane?

Mrs Dodds: — and it would be important.

There were some really good nuggets in the winter pressures plan but not a lot of scale. One of the things that interested me was the project that, you said, was in operation in six care homes in east Antrim where you go in and work much more intensively to try to keep those patients out of hospital. Has there been any evaluation of the feedback from that, because that seems to be an important element of keeping people out of hospital?

Ms McCaig: The interim chief executive and I were discussing that only a couple of days ago. After the end of this month, we will go into a full evaluation as to what that delivered compared with the rest of the population. We want to look at that to see whether it can be scaled up. It is in only one location at the moment.

Mrs Dodds: Yes.

Ms McCaig: They chose the location that, they thought, had the right space and staff and everything to do it, but I do not have the evaluation yet. It is just not the right time. We need to let the trust continue through this month, and, at the end of this month, we will start to pull that together. We have had a lot of conversations. If it is working, we need to do more of it. If it is not working, it needs to be adjusted, adapted or something else tried. We will look at that. There are also supports that our Ambulance Service colleagues have given in maintaining people in their care home, because it is not always pleasant for someone to come and wait in the back of an ambulance. If we are able to work with GPs on proactive care, and with community pharmacists, Ambulance Service and trust colleagues, and our independent sector helping in that support, that is a better outcome, mostly. Sometimes it will be unavoidable, but we will be looking at that to see whether it worked well and whether it is scalable.

Mrs Dodds: I presume that the delivery of that will depend on the outcome of your negotiations with GPs in order to deliver that service in the community at a much wider scale.

Ms McCaig: GPs have been working really hard on the proactive element of the care planning piece. That is a vital part of that. Indeed, we have increased the amount of spend even since I was with you in November. To their credit, despite all the other ongoing negotiations, that work for patients on the ground has continued, but it needs a decent evaluation. I do not mean a long one. I would not be a fan of spending six months thinking about it. We will have to look at it to see what objective evidence we have and whether that improved maintaining people in their own home, where appropriate.

Mrs Dodds: Thank you.

The Chairperson (Mr McGuigan): We have to move on, but, before we do, we need to take a short break. There is a technical issue with our output, and we need to take a pause of about one minute to fix the sound.

The Chairperson (Mr McGuigan): Apologies for that. We are back in action.

Mrs Dillon: You will be glad to hear that most of my questions have been asked and answered, but I have a couple. Peter, you talked about if and when the living wage will be implemented. To be honest, I am a wee bit concerned to hear the "if", because we were given assurances about that. If that is not addressed, it will be pretty difficult to have conversations with the independent sector and to get it to come back to the table, given that, in particular, the decision not to implement it was based on the incorrect information, if we go by what the Minister initially told us in the Chamber. I would just like to get a sense of that.

I want to know whether any further work has been done on direct payments. I have raised that continually. I am not sure that it is a massive piece of work, but everybody seems to be talking about it as though it will have to happen way down the line, and that does not fill me with confidence. It has been implemented in different ways in different trusts, so that is not good enough.

I have concern for all families who rely on direct payments for the care of their loved ones, but I am particularly concerned about families who have loved ones — children and older people — with life-limiting conditions. They are spending their last months and weeks — that short period — with the people whom they love, fighting for the care that they need. I am going to a wake of a child today. Her parents spent the past year fighting for the hours that the child needed: that is not fair. I want an understanding of it.

That is one case, and I am raising it not to be emotive but to make the point that not dealing with issues such as how direct payments are implemented has massive implications. In that case, the issue was about the need for nursing care. Only so many hours of nursing care were allowed for, with the rest said to be social care, but direct payments were not allowed to be used for the social care because the child needed nursing care. That just does not make sense; it is just cruel. We could end up in legal challenges on that stuff, so it does not benefit anybody. I just want to get an understanding of those two issues.

There are lots of other things, but everybody else has touched on them, and we are not going to gain anything from going any deeper into them today. I would like to ask further questions about patient flow — the permanent secretary has said that you are happy to come back to us — and about committees in common and what services we can provide differently. If providing the service differently means that doing so regionally is better, that is as long as everybody can access it. All that I have ever asked is for everybody, no matter where they live, to be able to access the service without challenge. However, you mentioned psychiatry in particular, and there are massive challenges in one of my trusts — my constituency straddles two — that the Southern Health and Social Care Trust has raised with SPPG. It has said, "We're really struggling here, and we need help". If that means that some services, particularly acute ones, have to be regional, so be it: people need the best service. They need what will keep them out of acute settings; they need what will give them the best support. The trust can then commission what can actually be delivered through what we call "the neighbourhood model".

Mr Toogood: I will deal with the first two issues, Linda. When it comes to what I said about the real living wage, the Minister is absolutely committed to it. As Mike said, when you look at the planning guidance, you see that it is one of the pre-commitments that we are asking the trusts to consider alongside the HSC pay. I say "if and when" because we do not have a budget for it, so we cannot give a date, but the Minister is fully committed to it, and we fully reflect that in the basis on which we ask trusts to plan; it is just not possible to say when at this point. The case for it is well made in the document that we will publish at the start of next week.

I will turn to direct payments and self-directed support (SDS) more widely, because there are managed budgets and things like that as well. Mike talked about focusing on a number of key priorities for some of our key strategies, and, for reforming adult social care, promoting and increasing self-directed support is one of our key priorities. We recognise that, if we get it right and do it properly, it will be a game changer in the system's working better and delivering better outcomes for the people who need to use it. Work is ongoing in the SPPG, and the collaborative forum took a presentation on that work recently.

Mrs Dillon: May I interject? You do not have to give me all the details today. I am happy to have those in writing. I am conscious that other members might have questions.

Ms McCaig: We can do that.

Mr Toogood: We can do that. I give you that assurance that we are seized of the importance of SDS in the system of reform. That is why you will see it as one of the four key priorities that we want to focus on. We will be issuing a broader reform around adult social care, because, again, that is not just about these issues. I am mindful of what Mike said earlier; we are trying to focus on a small number of key priorities, and that is one of them.

Mrs Dillon: What about that regional approach, potentially? You gave psychiatry as an example, and it is grand to say —.

Mr Farrar: There are some areas where the solution is that we should have a regional service. We have a population of 1·9 million people, and travel distances are difficult. However, you can manage transport if you believe that the service is properly located in the right place. That goes back to the question that we have teased out all afternoon about variability and consistency and having a regional service. We have to get the right service at the right level. There are some services that we are trying to provide regionally that really could be more accessible locally. Everybody always fears centralisation in health services because it means that you travel further. A lot of things are decentralised as well. Twenty or 30 years ago, if you needed an MRI scan, you probably had to go to a specialist centre; now, MRIs are available locally. These things ebb and flow.

We have to get the right things in the right place. Things such as psychiatry are not necessarily about having a regional centre; it is about how you deploy psychiatry to parts of Northern Ireland that are under-provided for and about whether we can link opportunities. Getting psychiatry services is quite hard at the moment. Could we do something with our universities in order to create academic roles and posts that attract psychiatrists? Once you attract a big-hitting psychiatrist, you get a lot of people who want to follow. We are looking at everything that we can. A regional approach, however, does not always mean that we end up with —

Mrs Dillon: — a regional service.

Mr Farrar: — a regional service. We are keen to work as one system, and that is evident in the way that we are working now.

Mrs Dillon: I appreciate that; thank you.

Mr Robinson: Thanks, Mike, Tracey and Peter. I want to take us back to the meeting with the independent care providers that we had a week or two ago. It was a very interesting meeting. Some of the issues that were brought to us were quite stark. One of the providers indicated from their figures that 73% of their staff who are leaving are not returning to the sector altogether. They also said that some of their staff are having to go to food banks. They said that their staff felt "totally devalued". Now, they have been told that their real living wage will be paid when it is affordable. The question is this: when will it be affordable, given the financial challenges that the Health Department faces?

Mr Farrar: I will go back to what Peter said a moment ago. When we get our budget clear — in the planning guidance, you can see that the real living wage is there alongside HSC pay — we will be able to say, "These are our priorities". Our pre-commitment into next year, given what we have said this year, will be to make pay our top priority. We are seeing the real living wage in parallel with paying HSC staff. Last year, as we have to, we were able to meet the national living wage. We want to do this. Strategically, it comes back to the Chair's initial question. Strategically, it makes sense to create the capability of the sector in the flow of patients to have the level of capacity that it needs. I repeat: once we have a budget, pay is the first call when we are spending our money next year. We will be looking to do that at the earliest opportunity. The Minister's phrase was, "at the earliest possible opportunity". That is what we are committed to doing.

Mr Robinson: We hope that that happens.

There is another issue, Peter, that Danny was trying to tease out: the trusted assessor model, which the independent sector spoke highly of. That is currently a Monday to Friday, nine-to-five arrangement. I do not think that you definitively answered Danny's question. When do you expect that to be a 24/7 service across all trusts?

Mr Toogood: I do not have a definitive date, Alan, but I can say that the preparatory work to get to an agreed position to allow that to happen has been taking place and will come to a conclusion. It will then be for trusts, working with the independent sector, to deliver against that agreed model and governance structure. I do not want to underestimate the work that it has taken to get to this point, because it is right and proper that time has been spent on getting the right model. If we get the right model, it is a case of all shoulders to the wheel to make sure that that model is implemented. It is there, and we know that it is a really important mechanism when it comes to flow. Tracey and her colleagues will be looking to work with the trusts over the year to make sure that that happens as quickly as possible, because we now know what we are working towards, whereas, in the past, there was a mismatch of different approaches.

Ms McCaig: As with a lot of the things that we are doing, that seven-day-working piece is critical. We want to make sure that things can continue over the weekend. That is challenging and is often about capacity and having the right people in the right place. Having trusted assessors is a high priority, but there is no funding source at the moment to push it into that space. We will continue to work on that. It is a priority for us.

Mr Robinson: This is my final question. It is not a trick question or an inflammatory question. Are the trusts that are underperforming when it comes to flow held accountable?

Mr Farrar: Yes.

Mr Robinson: They are. In what way?

Mr Farrar: We have a framework called "support and intervention". It is really important to say that no one fails on purpose. I argue that, in the past, there has been a culture in Health of holding people to account by effectively shouting at them without having any sense of what the solution is. Therefore, we have to be clear about where we have underperformance in the sense of what the trusts aspire to provide and what standards we set. We have a support and intervention framework that takes people up the levels and through the processes, and one of our trusts is at the highest level for some of the things. However, we have to have an answer as to what we are doing about it. It is a bit like someone speaking a foreign language, and you are just shouting louder in English. When it comes to the solution, we need to join them at the hip. Sometimes, the solution involves looking at what another trust is doing, and we encourage that. Sometimes, it is about providing evidence from elsewhere or giving them additional support to enable them to manage and then become self-reliant after that. The performance management accountability framework is very clear. It is about support and intervention, and the consequence is that boards are accountable for doing things. Ultimately, if there are questions about individual capacity or capability during the appraisal process, we expect them to be dealt with in the proper way.

The Chairperson (Mr McGuigan): Thank you very much. The session has gone way beyond time, but it was important that we got the opportunity to ask all the questions that we asked. Thank you very much for coming.

Before you go, I want to say this: when it comes to the conversation about our overall health service, it is important that the GP issue be resolved. I am glad to hear that they are back in negotiations with you, because access to primary care and GPs is a major issue. It is not good for any patient outcome that GPs are at odds with the Department, so I wish everybody good luck. Hopefully, we can get a good outcome from that negotiation.

Mr Farrar: Thank you very much.