Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome from the Southern Health and Social Care Trust (SHSCT) Mr Steve Spoerry, its chief executive; Eileen Mullan, its chair; and Elaine Wilson, its director of planning, performance and informatics. You are all very welcome. Thank you for sending us your submission, which we have all read. It was very useful. I will now hand over to you to make some introductory remarks, and we will then move on to questions.

Ms Eileen Mullan (Southern Health and Social Care Trust): Chair and members, thank you for inviting us to come before the Committee. We are very pleased to be here. You have our briefing paper, but our intention is not to go through it in our opening remarks. Steve and I would like to share a few things up front, however, after which we are very happy to take questions.

The starting point for us is to acknowledge our staff. Around 15,000 people work for the Southern Trust, and they do their very best every day, whether that be in someone's home, in the community or in an acute setting. They quietly get on with their job despite the daily challenges and the risk to them, particularly that of assault. Sadly, we had 2,769 physical assaults on our staff last year. We do not accept that as being the norm. We would prefer that physical assaults did not happen, but we also acknowledge that, in some cases, they happen as the result of medication and associated medical conditions. We cannot ignore that fact, but there are still a high number of assaults on our staff, and we do everything that we can for them.

The next important area that I will talk about is cervical cytology. On behalf of the trust, Steve and I reiterate our apology to all the women and their families who have been impacted on by the cervical screening review. We fully acknowledge the past performance issues in our laboratory and fully accept that the actions of the trust at that time were not sufficiently robust and that that was unacceptable and a breach of our governance procedures. We will engage fully with Frank Atherton. After he has completed his work, we will respond to the Minister's decision with the same approach, which will be open and fulsome.

Members will recall that the trust experienced an unexpected IT outage in September. Steve and Elaine appeared before the Committee on 25 September to talk through that. We committed at that point to share the report with the Committee. The trust board received the report on 29 January, and there is a link to it in today's briefing paper. That is the incident outcome report, which contains the findings of the independently chaired incident review group. The root cause of the outage was the result of a human process error, which happened when a member of the network infrastructure support provider attempted to install the necessary software on to the data centre hardware. By way of learning from the incident, the trust has already taken steps to strengthen existing processes and to reduce significantly the risk of a similar incident happening again in the future. Steps include having dual engineer oversight, which, in essence, is having a second pair of eyes present when work is being done on critical infrastructure components.

The Southern Trust, like other trusts, is facing enormous and rapidly increasing challenges to be able to meet the growing demand for our services from our current population of over 400,000, and we know that demand will increase further in the years ahead. Our older population is set to increase by almost a fifth by 2030, which is not too far away.

Finally from me, the trust had a savings target this year of £43 million. We will deliver those savings, and we forecast that the trust will break even at the end of this financial year. We welcome receipt of capital resource allocations of around £22 million to assist us with equipment, minor works, backlog maintenance and ICT between now and the end of March. At every opportunity, Steve and I advocate for capital moneys for inescapable pressures such as fire safety at Daisy Hill Hospital, the capital redevelopment of Craigavon Area Hospital and movement on the Newry treatment centre.

Mr Steve Spoerry (Southern Health and Social Care Trust): As Eileen said, the challenges that the Southern Trust faces are not unique, in that they are similar to those that all trusts in Northern Ireland face. Challenges include the growing proportion of the population that is elderly, workforce shortages, budgetary constraints and waiting time challenges, all of which are documented in the briefing paper. In our case, there are also challenges with some buildings that need to be replaced or refurbished in order to deliver the modern care that we want to provide.

I will pick out a few points to highlight briefly. First, we continue to experience high demand for urgent and emergency care. Consequently, our hospitals are under severe pressure. That pressure has lessened a little bit, but we still have people on trolleys and in extra beds in various areas. I take this opportunity to apologise to those patients, and their loved ones, who have had to wait a long time in emergency departments, and sometimes in ambulances outside emergency departments, and to those patients who have come into the hospital and been cared for in inappropriate locations in extra beds that we have installed in various areas. There has been a reduced flow of patients through the hospitals, and that has led to a lack of capacity for new admissions and, consequently, to increased waiting times for emergency department patients.

This predates me in some ways, but we are already implementing a number of actions, which are based on UK best-practice guidance, to improve the flow of patient care and to provide alternatives. Notably, those actions include admission avoidance through the assessment of patients at the front door and inpatient processes such as patient discharge planning meetings. We have set up single discharge teams, covering multiple professions, to try to help people find the right location on leaving hospital. In our trust, we have badged that as the timely care programme. We have brought multiple professions together and coordinated them into one programme. That has involved a lot of our staff in hospitals and community services, but, to be frank, it is clear that we need to go beyond doing that. We need to better understand the underlying causes of the problem.

The one problem that I will pinpoint now is the increasing length of stay for patients who are admitted through emergency departments. We will therefore have to think of ways in which we can reshape how we work across the entire pathway for patients, by which I mean from the very first call for an ambulance through to social care after a spell in hospital and potentially rehabilitation. It is important to make the point that such problems mostly manifest in emergency departments but are not caused there. That is why we have to look across the entirety of the pathway.

We are also aware of the impact of unacceptably long waiting times on some groups of elective patients and their families. As you know, we have included a lot of detailed information about those waiting times in our briefing paper. That information covers the range of services, including outpatient services, inpatient services, diagnostics, cancer services, mental health services and children services.

I know that members have been particularly concerned about breast cancer assessment waiting times and the latest regional quarterly waiting time statistics. We believe that the move to the regional waiting list and coordinated services will start to address some of the challenges. We are making progress towards meeting regional waiting time targets using that single list, but I will not say more than that about elective waiting times now, because I suspect that members will have specific questions to ask.

The final thing that I will highlight is recruitment and retention of staff, which remains a significant challenge in some services and among some groups of staff, notably medical consultants in psychiatry, gastroenterology, obstetrics, gynaecology and haematology, as well as among social workers. We face particular challenges because of our border location, given that, to be frank, more attractive employment conditions are being offered to the south of us.

On a brighter note, I am pleased to say that we recently appointed four consultant radiologists in one go. That will help improve waiting times for imaging. What is particularly great about that — this is the reason that I mention it — is that three of those doctors were originally recruited some time ago as part of our international recruitment initiative. Our existing radiologist worked with their new colleagues to develop their skills so that they became eligible to apply for consultant posts. We therefore now have those people in those posts, and they have decided that they want to stay and work with us. I highlight that because it is a really good example of how to address a serious issue systematically. It also highlights the fact that developing people pays real dividends for service capability.

Similarly, we have significantly reduced our use of agency nurses over the past year. To some extent, we have also reduced the use of bank staff hours. We have done that by recruiting newly qualified nurses in greater numbers and by being more flexible in the way in which we deploy people. We cannot, of course, send newly qualified nurses straight into the most difficult areas without supervision. All of that has had real benefits, however. We have reduced the overall numbers deployed on duty. That is good for patients, because it improves continuity of care, good for the youngsters whom we have taken on, because they would not have had jobs otherwise, and good for the budget. Again, I highlight some systematic work that we have done on developing people and deploying them correctly. That work pays real dividends.

I will conclude on that point. We look forward to answering your questions.

The Chairperson (Mr McGuigan): Thank you very much. I begin by saying that the apology for the cervical cytology sampling is warranted and merited, particularly given the impact that the review has had on those women and their families. It is a black mark against the work of the Southern Trust. I am not going to ask any questions about it, however. I just wanted to make that point, because I know that other members will certainly ask about it.

I will deal with some of the other areas. Each of the trusts was asked to make savings. Will you outline the level of savings that the Southern Trust has made and the impact that those savings have had, or potentially will have, on the work that you are doing.

Mr Spoerry: I will start, although I suspect that Elaine may add to what I say. As you heard, we were asked to save £43 million. We had an initial budget, and, then, during the year, that was reduced by £16 million. We believe that we will meet the reduced budgetary target for the trust for this year. How have we done that? Some of the measures that we have taken have been specific work programmes to achieve savings. For instance, I mentioned the big savings that we have been able to make through reducing our use of agency staffing by way of substitution. We have made great strides in nursing and some progress with medical staff. We have more to do, but it is that kind of thing. We have made some savings through the initial implementation of Encompass, although we expect to make more, given that we implemented it in only May of last year. We have had to achieve a range of savings targets from our procurement programmes and our use of contractors. In particular, our emphasis on sustainability has reduced some of our revenue costs, meaning that we are supporting the estate while contributing to a greener future at the same time. A lot of systematic work was therefore done.

We have, however, also had to do some things in targeted areas to slow down recruitment, by which I mean not replacing some people but, rather, asking other people to cover two jobs. We are therefore accepting some loss of activity. That is largely as a result of the second, steeper request, if you see what I mean. When something comes at us part way through the year, that makes things difficult. We do not have time to plan, so we have to look at what levers we can pull in order to save money right now.

The Chairperson (Mr McGuigan): I do not want to interrupt you, but, on the one hand, we have a workforce problem, while, on the other hand, you are telling us that in order to achieve savings we add to that workforce problem, in that we are not —.

Mr Spoerry: That is where we have to be clever about it, which is what I was trying to convey in my opening remarks. We have workforce shortages in some areas. We have the potential to substitute for existing workforce in others. With Encompass, we have not really got into the much vaunted AI yet, but we will move towards that.

We have also been able to show some savings being made in our estates provision. It is a tough call to make, however.

I have been with the trust for 10 or 11 months, and I have definitely seen an improvement in the way in which managers use financial information to manage budgets and to understand what is happening. From my experience of financial turnarounds in the big English trusts, I know that a lot of floating off the rocks happens when lots of people manage their budgets a bit better. I have tried to encourage that approach, and I believe that it is paying some dividends. Do you want to add anything, Elaine?

Ms Elaine Wilson (Southern Health and Social Care Trust): You have covered it very well, Steve. The delays were not to recruitment of front-line staff, so they did not affect recruitment of nursing or medical staff. Rather, we delayed recruitment to other specialties in order to make some savings. We have made really good progress on starting our Encompass savings programme. There is real potential there, although we have done a fair bit already.

The Chairperson (Mr McGuigan): You will be aware that the independent care sector appeared before the Committee a few weeks ago and that the permanent secretary of the Department of Health was here last week. Hospital flow is a major issue for the health service, and, because of what you have said, the Committee is trying to look at the detail. The independent care sector suggested that some trusts were trying to generate savings by not fully implementing care packages in the community. How many people in hospitals in the Southern Trust are currently facing delays in getting out because they are waiting for a care package? What work is the trust doing to resolve the issue in order to have better flow through the hospitals and to provide better care in the community?

Mr Spoerry: You are talking about the independent care sector. I do not have the latest figures for you, but, about three weeks ago, we had 840 people waiting for a care package. That means some form of help at home.

The Chairperson (Mr McGuigan): There were 840 people in hospital waiting for a care package.

Mr Spoerry: No, the overwhelming majority of them are not in hospital. At that stage, we had just under 100 people in beds. I cannot remember the exact number, but only a small number of them were in acute beds. Bear in mind, however, that we have community health beds. One way in which we differ from the other trusts is that we have a significant number of residential beds among our bed stock. One of the big pushes under way to improve flow is this: if a patient cannot go home, we can at least get them out of an acute hospital bed and into a residential bed. That was the situation about three weeks ago. I am sorry that I do not have the latest numbers, but the pattern will not have changed a great deal, to be honest.

The Chairperson (Mr McGuigan): I could ask about 10 follow-up questions, but I have a number of issues to cover. Workforce is an issue right across the health service. I spoke with a midwife last week in a different trust area. She was very concerned about staffing levels and about the impact on staff and the service itself. I know that you provided some detail about recruitment, but what is the Southern Trust doing about it? Are staffing levels in particular service areas — midwifery, for example — a concern? Are current staffing levels having an impact on service delivery?

Mr Spoerry: Midwifery was a big concern for us. It was part of the story when concerns were raised about the service at Daisy Hill Hospital 18 months or so ago. We therefore concentrated on that area and have since made significant progress. I cannot remember the precise numbers, but vacancies in midwifery at the Craigavon Area Hospital and Daisy Hill Hospital sites have fallen significantly, so we feel as though we are in a much more robust place. We have a very good new leadership team for obstetrics and midwifery, so we have moved in the right direction.

Another issue to illustrate, which I mentioned briefly, is the shortage of social workers. Our director of social services is doing tremendously well in recruiting newly qualified staff. In the past year, we have taken on just over 40 staff. He and his colleagues have made tremendous progress in reaching out to new qualifiers, providing good placements for them and so on. We still have vacancies, but we will get to a much better place. We did have a bit of a lumpy time for a couple of years, because new qualifiers, rightly, must have a lower caseload and receive more supervision from experienced staff — we are asking quite a lot of our experienced staff — but the good thing is that we can now see the light at the end of the tunnel. That is another example of what we are trying to do.

I will mention a third issue. You will be aware that the trust along with the other trusts has formed a committee in common. Two of its early priority areas of work that we were particularly pleased about were for haematology and psychiatry, which are problem areas for us when it comes to recruitment. We need to start looking at the workforce across the region as a whole and come up with a strategy to deploy staff appropriately. I am very hopeful that we will be able to provide more transparency and accountability to trusts about the numbers of medics who are being trained. I am told that the psychiatry problem was visible a long time ago but that we did not up the numbers. A solution to that kind of problem is to have transparency. Everybody needs to be clear about what is happening.

The Chairperson (Mr McGuigan): The final issue that I want to raise is waiting lists. You will have been expecting to have a conversation about them. I will ask a brief question. What impact, if any, has the £250 million made in your trust area, and on cancer waiting lists in particular? They are time-critical services. I am interested in hearing your assessment of what is impeding your trust from keeping to the time frames of 30 days and 60 days.

Mr Spoerry: I will defer to Elaine, who has the detail on how we have spent our share of the £250 million and what it has done for us.

Ms Wilson: Out of that money, we focused £6·5 million on our inpatient waits. That money will have treated 4,000 patients by 31 March. If we have a couple of waiters on the list of named procedures from the strategic planning and performance group (SPPG) at that time, there will be a very specific clinical reason for that. The rest will all be through the system. We will also have spent £16·9 million on outpatient appointments, and some inpatient appointments, beyond those people who have been waiting for four years. Those are the red-flag waits and urgent waits, which would link into the cancer waiting lists to which you referred. We will have seen just over 40,000 additional patients with that money through a mix of independent sector use and additional in-house capacity.

We have also been doing a big piece of work on validation of our lists. We always validate our lists. We start with admin validation, which involves checking whether someone still needs the appointment and that sort of thing. We then move on to clinical validation to check whether someone definitely still needs the procedure or whatever it is that they are waiting for. The piece of work that we did on that reduced our waiting lists by 40%. When we validate waiting lists, we find that a lot of people on them do not need to be on them. That has enabled us to ensure that the people whom we are treating with that money are the people who really need treatment.

The Chairperson (Mr McGuigan): That is very interesting. Forty per cent is a big percentage. Do you collect data on why patients come off the list? Is it because they have paid for treatment privately, no longer suffer from the condition or, unfortunately, have passed away?

Ms Wilson: We do not have data at that level, but those are obviously reasons that people will be taken off the list.

The Chairperson (Mr McGuigan): Forty per cent is a big percentage.

Ms Wilson: That was for a list of named procedures, so it does not cover everybody. It made us realise, however, that it is really worth investing money in the validation process, so we have been spending more money on doing that.

Mr Spoerry: I will just add that, not surprisingly, the longer the wait, the more you weed out if you then validate.

The Chairperson (Mr McGuigan): OK, fair enough.

Mr Spoerry: So 40% sounded very high to me from an English perspective, but then I remembered that the waits are shorter.

The Chairperson (Mr McGuigan): I am sorry: I interrupted you there. I have a habit of doing that.

Ms Wilson: That is OK. The numbers that are taken off those lists are going to put us in a more positive position in relation to some of those cancer waits that we have. If you look at our statistics, the 14-day red-flag breast wait — some of that money was used to reduce that list. You can see that our performance is improving, but we have still a way to go. Part of our issue is that we can see patients, and we do well against our 31-day pathway, which is getting people seen to decide whether they need a procedure. We do not do so well against our 62-day pathway, because that is when people need treatment, and that links into the staffing issues. If we look at the areas where we are not performing well in that, it is the likes of haematology, gastroenterology, dermatology — the places where we know that we have staffing issues. We have been trying to do some reform work around those areas. Not only are we targeting this investment to get the independent sector to take those waiting lists down and show improvements — that absolutely has been doing that. That is not a long-term solution for us. We need to work out what the long-term solution is. We will see, in the likes of gastroenterology, that our nine-week waits will now be complied with by the end of March, and that is a really positive position, but it is because of the significant additional investment that has been put in, and a lot of that has been in the independent sector. We are now looking at how we sustain our services and reform them as well. We are not just trying to recruit people into them. How are people being used — how do we maximise people's skill sets? There is a significant amount of work to try to reform as well.

The Chairperson (Mr McGuigan): If we are bringing down the waiting lists purely by using the independent sector, when we can no longer afford to pay that sector, and we do not get our workforce right, those waiting lists will —.

Ms Wilson: There is a risk that that will happen. Now, the numbers that I talked about are not all in the independent sector. We have also been looking, particularly in some of those difficult specialties, at how we reform and change how our clinicians are delivering their services to try to increase capacity. In some of those more difficult areas, we have increased in-house capacity as well, but it is never going to solve the issue of rising demand. We know that the demand keeps rising and, even with the independent sector, it is very difficult to keep that rising demand down. We absolutely need to sort that out ourselves in-house, but I think that we will always need some level of waiting-list initiative moneys.

Mrs Dillon: Just on the back of that last point around the need to recruit staff, was any of that waiting list money used to recruit into those specialties that you have specific issues with — gastroenterology, breast services and things like that?

Ms Wilson: We have the money to recruit into those in our baseline, so we do not need the waiting list money to do that. We have continual recruitment that goes on to try to fill those posts.

Mrs Dillon: The recruitment was not slowed down in those areas where you have —.

Ms Wilson: No. We have had some success, for example, with our breast team. We have a new breast consultant starting on 1 April, so there are successes in recruitment, but there are some areas where it is really difficult because the workforce just does not exist in Northern Ireland. That is what Steve suggested in looking at some of those areas as a whole.

Mrs Dillon: OK. The Minister has said that his first stage in breast services was to move to the regional list. Has he had any conversations with trusts, or has the committee in common had any conversations, as to whether there will be a regional service that will really bring the wait times down? Or is the plan, as you are aware of it right now, to continue as we are?

Mr Spoerry: At the moment, I think that we are continuing as we are. The committee in common is not, at the moment, looking at the breast service, because the commissioner — the SPPG — took the lead in this particular exercise. It would just muddy the waters if it got involved when somebody else is in charge.

Mrs Dillon: That is fair. I have a couple of specific questions. The cervical cytology samples were not reported on 15 and 16 May — it is in your report. I asked the Minister a question, and you referred to it in your report. You will see in the correspondence, Chair, that I wrote to the Minister to ask what happened there, and I got a response that tells me nothing, just to be honest with you.

A Member: Never.

Mrs Dillon: I just wonder: maybe we do not know yet. Was it a specific Southern Trust area problem? Was it between the GPs and the Belfast Trust, where the results now go to be tested? Do you know where the problem happened there, and, if we know where it happened, how can we ensure that it does not happen again?

Mr Spoerry: In conjunction with the Belfast Trust, we carried out a serious adverse incident review. It was a joint review. The problem was not with the GPs. We can be certain of that. The samples were collected from the GPs. The drill is that they are collected by our vans from our collection points. We collect lots of samples, most of which are processed in our laboratories. However, we also collect the samples that go to Belfast, and they are then taken on up to Belfast, if you see what I mean. There is no point in their sending out a separate collection round around Northern Ireland. The last version of that review that I have seen basically concludes that it is not possible to say whether they definitely arrived in the Belfast lab and were lost in the lab or whether they got lost in transport from the Southern Trust to the Belfast lab. That is a real pity and a real shortfall in the way in which we track the samples. We really wanted to know whether it was a problem with the transportation or whether they got lost once they had been delivered to the labs, and we cannot answer that question.

Mrs Dillon: Can we get some detail? The Minister's response does not give me detail on how that will be addressed. I assume that this can potentially happen in any trust where the samples are going to Belfast. My main concern here is that not all of those ladies have come back for a repeat cervical smear yet. I have just been through the process, and it is not pleasant. I will go back 10 times if that is what it takes, but many, many women will not, for lots of different reasons. It is not comfortable, it is not nice, it is not easy, and it is very much an individual thing as to how comfortable or uncomfortable you are with the process. My reasoning for saying that I will go back 10 times is that I have seen the outcome of not going back, but not everybody has had personal experience of that, and they may just think, "I do not want to put myself through that again".

I am really concerned. I want to know what is going to be done to ensure that that process is tightened up. We need detail on that. I am not asking you to give me that today, but I absolutely need to get detail on it. Whether it comes from you as a trust, or from you working with Belfast Trust, an answer needs to come back to this Committee on that specific issue, because I am really concerned. Thankfully, it was picked up and those ladies were offered the opportunity, at least, to repeat, but I am concerned that 18 of the 68 have not. Were you going to come in there, Eileen?

Ms Mullan: I was, if you have finished, Linda. The numbers that I have are that, of the 64 samples that were missing in total, 50 women have come back. We continue to encourage the remaining 14 to come back.

Mrs Dillon: I know that one is an expectant mother, so —.

Ms Mullan: There are obviously some personal reasons. On the process piece, if what has happened here does not instigate a major change in how samples are collected, recorded and taken to wherever they need to be — if that does not happen as a result of this, we are missing a huge opportunity. The fact that they are not being scanned, there is no barcode, all of that, in a system as small as what we have, should not be the case. There needs to be a dramatic change here in how those samples are recorded, dispatched and received, and that should be done in a very simple, electronic way to prevent this from ever happening again.

Mrs Dillon: Can we get the detail of how and when that is going to be done? I ask because, until that is done, it will be a concern for us and a concern for every trust. If it can happen in the Southern Trust, there is no reason that it cannot happen in another trust area. I will not go into the detail of the cytology review. Frank Atherton's review is happening. I want to see what the outcome of that is. Obviously, the ladies have their own concerns and want a public inquiry, so it is their issue and it is for them to lead on, in my view.

On the capital projects, have you any indication yet from the Minister about those business cases and whether the Southern Trust is a priority? I am thinking about specific projects that you identified in the report, with Craigavon Area Hospital being the main one.

Mr Spoerry: The short answer is no.

Mrs Dillon: Even a time frame?

Mr Spoerry: No.

Mrs Dillon: It is dependent on budgetary processes?

Mr Spoerry: I think that that is because of the overall budgetary issues.

Mrs Dillon: That is fine.

Mr Spoerry: We were asked to prioritise them and say which ones would be at the top of our list, and that was the last contact that we had.

Mrs Dillon: OK. On the IT outage, is there any opportunity for the trust to come to some arrangement with the provider regarding the contractual obligations that the provider had to ensure that that did not happen? Are there any opportunities for the trust to claim that back from the provider, or are there any conversations ongoing?

Ms Wilson: Our centre of procurement expertise and legal advisers are looking at the contract to see whether there is any contractual recourse and having those discussions with the provider.

Mrs Dillon: Is your legal advice saying that you should have, and is the provider pushing back? Also, is it a provider for other trusts?

Ms Wilson: Yes, it is a provider for some of the other trusts. At this stage, we have not gone down the litigation route. We are waiting for the discussions between our procurement advisers and our legal teams and their legal teams to see what the provider might offer. We will then consider whether it is worth going through the litigation process.

Mrs Dillon: That should be a consideration for any trust in future contracts —

Mr Spoerry: Yes, it would be, and their reaction to —.

Mrs Dillon: — regarding their own obligations and how they honour those obligations. That is really important, and we need to get a sense of that.

Women's health has now been moved to children and young people and women's health. Is there a rationale for that?

Mr Spoerry: Yes. It is part of a package of changes that we have just enacted. Part of the reason is that, with regard to newborns, there is a close relationship between paediatrics and obstetrics, so those are services that always have to be co-located. If you are looking at clinical synergies —. I am used to seeing it in other trusts' services that are grouped together. Another reason, to be frank, is that our leader of our children's services — who is also our director of social services — has done a very good job in a variety of ways, and I wanted to strengthen the leadership being given to women's services. It was part of that, as well as recruiting good-quality people to work with him. I think that that will produce benefits. We have also brought new leadership into our adult acute and community services to deal with some of the flow and access problems that we have been talking about. To be candid, it makes that job more doable if I take women's services and put them with another experienced leader, if you see what I mean. That was the thinking.

Mrs Dillon: If Colm does as good a job around women's health as he has done around children's services, I will be very pleased.

I had a question about social workers, but you have addressed that. I have two other questions — sorry, Chair.

It is worth acknowledging the work done by the Daisy Hill futures group, which obviously included the trust, and those conversations. That has shown that positive outcomes can happen when everybody works together, including people in the community and elected representatives. That is really important. We have seen the positive outcomes in maternity services as a result of the additional work that was put into Daisy Hill. I just want to acknowledge the Daisy Hill futures group in relation to that.

My last issue is about the number of physical abuse incidents in Craigavon Area Hospital. There is a column that says "other". Does that refer to only the community? Does Craigavon Area Hospital include the Bluestone unit in its figures? Can we get a breakdown of the areas where those incidents are happening? We can make an assumption that the majority happen in ED, but they do not all, to be honest. I would like to get an understanding. They are higher than any of the other acute hospitals, including Altnagelvin and the Royal Victoria Hospital, which is really concerning. We spoke to Jennifer Welsh last week about the Belfast Trust considering whether it would bring in body-worn cameras. They are used in the Northern Trust, which has one of the lowest incidences of physical assault. Is that something that the trust is considering, specifically for Craigavon?

Mr Spoerry: We are considering it for both Craigavon and Daisy Hill, so we are not distinguishing. At the moment, our security porters wear body-worn cameras, but they are not on. They inform somebody when they are going to turn them on, and that normally causes people to adjust their behaviour at that point. We have found that that is a more effective route. Our mental health staff also have body-worn cameras. Other staff do not, but it is expanding elsewhere. We do have CCTV, and we make prominent reference to it so that people know that there are cameras in public areas and some treatment areas. We have a policy of hot and longer-term debriefing and counselling, so, when staff are subject to incidents, they are seen immediately so that we can understand what has happened. Then there is follow-up with management, a referral to occupational health and access to a counselling service if they wish to take that up. We provide training in handling aggression, but our uptake is an issue for us, as it is very variable by staff group. Among our mental health and learning disability staff and our community staff, who are often lone workers, there is a very high uptake of 95% plus. Among acute hospital staff, there is a significantly lower uptake of 20%. That is something that we need to work harder on, to be candid.

Mrs Dillon: Is there a plan in place to look at that and have specific targeted actions to address that? Those figures are really concerning in comparison with the other hospitals. They are double the rates of some.

Mr Spoerry: Yes. The first area that we are looking at, for cameras and training, is the two emergency departments.

Ms Mullan: In addition to that, some of the incidents happen on wards, so we have to factor in that it is not all about emergency departments. Jennifer Welsh was with you last week, and she talked about going to consultation, which her board has just agreed. I fully support Jennifer, and I spoke about it. If one trust has gone through the process, why do four other trusts have to do the same thing? My view is that we should do it once for everybody, and it should just apply. We should press ahead. It should not be a case of one trust doing it and then four having to do it afterwards. I am very supportive of that. Hopefully, whatever conversations are needed to make that happen can take place.

Mrs Dillon: Can we write to the Department specifically on that? We may have done it from last week's conversation, but I am really concerned. The figures for staff in Craigavon Area Hospital are really distressing.

The Chairperson (Mr McGuigan): That approach makes sense.

Mrs Dodds: Thank you for coming. First of all, the Southern Trust is at the heart of my constituency, so it is probably the one that I know better than most. However, thank you also for all that is done in the trust area. Sometimes, when you come here, we highlight all the problems, but there are very good things happening every day. I just want to say that.

Your apology in relation to the cervical screening issue is very important. It is quite a strong and robust apology, and that is important. However, two women have died, and others have been through very significant procedures and a lot of trauma. Maybe I am missing it, but who has been held accountable? What accountability has the trust demanded from the senior managers who failed to look back and trace the programme of underperformance and the resulting issues that have arisen? There are women who have been through cancer treatment because of this issue. There are women who are not here, and there are families who do not have mums. Who has been held accountable?

Mr Spoerry: Diane, I will take that in the first instance. You will appreciate that I personally have come in at the late end of this sad story.

Mrs Dodds: Fresh eyes might be a good thing in this story.

Mr Spoerry: A series of reports has been commissioned on this. I find it difficult to understand the totality of it, because they have been done as discrete reports. The board and I will be very interested in what Sir Frank Atherton comes back with, because part of his remit is to look at the totality of it. That will enable us to form better judgments about the points in time at which things went wrong and who was involved. I could speculate, because I have read quite a lot about it, but I would not place much faith in my speculation. It is also difficult to hold individuals to account when there is a process of review going on, if you see what I mean. We could be told, "You might find out further things later". I think that that is the real reason. However, I accept and understand the strong feeling about that. We offered the 12 women who were the subject of personal adverse incident reviews the chance to meet us. Two of them did so. Both of them said effectively what you have just said to me. I take the point.

Mrs Dodds: Although I respect your explanation, I think that the answer is that no one has been held to account to date.

Mr Spoerry: Not so far.

Mrs Dodds: That is appalling. Women listening will be astounded that this has gone on, 17,500 women have had their smears reviewed, women have died, families are without mothers — I have attended some of the serious adverse incident briefings — and yet no one has been held to account. I appreciate your honesty, but that is part of the problem with the health service. Accountability is a huge issue. I have a range of other questions, but I wanted to get that in. I feel strongly about it. I have met these women numerous times. I live beside them; they are my neighbours. Reviewing the reviews is not really the issue that they want settled; they want to know why it happened and who is accountable.

There are a couple of other things that are really important. Eileen, you and I have spoken about this. When I spoke to you, I did not have the waiting list figures that you very transparently provided in the briefing. It is important. We now know that gastroenterology is now in a special framework. It is not at the highest level, but it is in that special framework because of the length of waits for gastroenterology services. The figures for red-flag appointments for gastroenterology are incredibly high in the Southern Trust.

I think that 174 people have been waiting years to be seen. What, specifically, is the intervention? How are you going to resolve the issue, and what is the time frame to resolve the issue? I know that you are going to say that you need more staff, and that is the answer to a lot of it, but we really need to get that under control.

Mr Spoerry: With regard to dealing with the red-flag patients, which is a real worry, I am pleased to say that, with the SPPG's funding support, we have contracted with the independent sector to provide additional capacity.

Mrs Dodds: Just what will that mean? You said that, in gastroenterology, there are 8,470 waits. The longest wait is eight years, and the median wait is 69 weeks. What does that mean for the waiting list?

Mr Spoerry: That is the total waiting list, so it includes urgents, routines and red flags.

Mrs Dodds: The red-flag list has 959.

Mr Spoerry: The red-flag list is the most frightening in terms of clinical risk, so we are concentrating on the red-flag group first.

Mrs Dodds: OK.

Mr Spoerry: Our objective, using the independent sector, is to remove the red-flag waits from the waiting list by the end of March, and we are on target to do that.

Mrs Dodds: So, that will be 959 people removed from the waiting list by the end of March?

Mr Spoerry: Yes.

Mrs Dodds: The highest red-flag grouping is 188 people waiting 26 to 36 months — three years on a red-flag waiting list.

Mr Spoerry: Yes, and we have to do more than that. I am just saying to you that that is the first step, and it is dealing with the highest clinical risk group. Of course, if we just stopped there, the list would grow again, and we would not address those other people. It is a first step. It is an important step, but it is step number one.

In addition, we now have an agreement with all the trusts in Northern Ireland that the other trusts are each taking 20 referrals per month from us to treat to stabilise the position a bit. They are each taking 20 per month, and that will be a recurrent pattern through next year, and we are very grateful to them for their help in that.

Mrs Dodds: How are you building the workforce, though, in Craigavon, which is the fundamental in all of this?

Mr Spoerry: It is, absolutely. That is the bottom line and the way out of this. Currently, we are just below 50% staffed for gastroenterologists. That is the real, underlying problem, and why I mentioned that group. Talking to the consultants, we have got ourselves into a doom loop, to be frank: it is difficult to recruit because the working environment is so difficult because there are so few gastroenterologists and such long waiting times. If you are coming out of training, it is a difficult environment to go to work in.

I am pleased that we got another recruit recently, who has yet to join us, but we need help with recruitment. The consultants in the trust have jointly agreed that we will invite in external reviewers to help us to understand what is wrong with the service and how we can chart a way out. The SPPG and the other trusts have said that they are prepared to help us once they see the outcomes of that review. I do not want to prejudge what it might say. That kind of intervention is the right thing to do. I have seen it used before when a service has been in trouble, so we are doing that. We are exploring further options to use the independent sector in two different ways next year because, of course, we are not going to recruit back up in time to sort out next year. I do not want to say more about the specifics because we are in negotiations about them, but we will need significant help next year to manage that workload.

Mrs Dodds: Even if the other trusts take 20 patients a month, that will be 80 patients, and on a waiting list of 8,470, which has people joining it, that is not going to make a huge difference.

Mr Spoerry: It is a —

Mrs Dodds: I am conscious of the time, but I have a couple of other points about the waiting list. I appreciate the transparency, and the more honest that we are, the more that we can get to grips with the problem and try to solve it. A constituent came to me this week, and she has waited seven years for a urology appointment. She is at wit's-end corner. You have a waiting list of 2,651, and the longest wait is eight years, and the median wait is 77 weeks. There are 60 red-flag patients, but that is a shorter waiting list than the one for those waiting for eight years. There are 10,500 people on the waiting lists for gynaecological appointments, and it is an average of five years for an appointment. Those are huge numbers.

Mr Spoerry: They are huge and shocking numbers.

Mrs Dodds: They are huge programmes of work. We need to work through those waiting lists, and the workforce cannot be the excuse for everything; it just cannot be. In some cases, it must be the way some of them are managed. I am glad to hear that you have produced the red-flag waiting list for gastroenterology, which is very significant.

Some 840 care packages are outstanding. My colleague Diane Forsythe asked a question for written answer about the number of domiciliary care worker vacancies, and I noticed that the Southern Trust had 191 vacancies. I presume that that is because you employ a lot of your domiciliary care workers, as opposed to their being outsourced.

Mr Spoerry: We provide about 40% of the packages in-house. If we actively recruit, we denude the local independent sector because that is where we recruit people from, and that is the other organisation that we contract with. There is a problem if we are all fishing in the same pool.

Mrs Dodds: Finally, a new build for Craigavon Area Hospital is becoming ever more important, and I will be there seeing family this week. I accept entirely that there are a lot of calls on the Minister's budget, but what discussions have you had with the estates team? What is the top-line thing that you need to get the Craigavon build under way, so that it can be considered for a capital allocation?

Mr Spoerry: We need a small amount of capital next year and a bit more the year after, because we need to start planning what the new Craigavon Area Hospital will look like. My pitch to the Department is that it is not very much money from the overall capital budget, but if we do not start next year, we will have kicked the can down the road for another year.

Mrs Dodds: What sort of money are we talking about from a capital budget of multiple millions?

Mr Spoerry: It is little more than half a million pounds.

Mrs Dodds: However, it allows the process to start.

Mr Spoerry: I do not want to build up expectations, because we will need several years of planning before anything happens on the ground. The first phase will be to understand the current condition of the estate and how it is utilised, and there will then be an exercise about what Craigavon hospital will do in 20 years' time. From there, we begin the process of planning the footprints and sizes. It is quite a long process, but if we do not start, we do not get there.

Ms Wilson: The important thing to say about the initial investment that we are asking for is that looking at the whole trust and how we transform our services is what will tell us what Craigavon needs to look like. The timing is good, given the financial and workforce environment. The increasing demand on our services, the growing elderly population and all those things mean that we need to start transforming how we deliver across all our sites. That work would start to give us answers on all those things, so we are really keen to move it forward.

Mr Spoerry: We are. I will add a personal observation. I came from a London hospital that was built in 1974 to a Northern Ireland hospital built in 1972: Daisy Hill.

Ms Mullan: It was built in 1971 —

Mr Spoerry: In 1971: yes.

Ms Mullan: — so it is the same age as me.

Mrs Dillon: I was born there. [Laughter.]

Mr Spoerry: It is striking how much better maintained the hospitals here have been.

Mrs Dodds: That is cold comfort for the patients —

Mr Spoerry: It is —

Mrs Dodds: — who had the windows blow in around them in the storm last year.

The Chairperson (Mr McGuigan): We need to move on — sorry — or we will get into another conversation.

Mrs Dodds: We are in a strange situation. Thank you.

Mr Donnelly: I agree with others that the apology that you gave at the start of your presentation was appropriate. You may be aware that the Committee has expressed the view that there should be a public inquiry with powers to compel witnesses. We hope that the Minister will deliver that for the women and their families and that there is truth and accountability for the women who have suffered.

I have a couple of questions. A lot of the areas that I was going to go into have been covered. You mentioned new nurses being taken on. How many such nurses are there? Are their posts full-time and substantive, rather than bank posts, part-time or anything like that? If there are different types of post, what is the breakdown by type?

Mr Spoerry: We are looking through our papers for the number. There are just over 100 posts, and they are overwhelmingly full-time, because they are filled by new qualifiers — youngsters — who want to work and get the experience.

Mr Donnelly: So, are they full-time, contracted positions?

Mr Spoerry: Yes.

Mr Donnelly: OK. Does that mean all of them or a majority?

Mr Spoerry: I am not prepared to say that it means all of them, but the overwhelming majority are full-time and contracted, and it may even mean all of them, because that is what most people want when they come out of training — one of two of them might have family commitments and so on — and we want as much of their time as we can get.

Mr Donnelly: Absolutely. We hear from student nurses that, at times, they are offered not full-time, substantive posts but bank posts and part-time posts, so I wanted to clear that up. It is great to hear that you have taken on so many newly graduated nurses at the start of their careers — that is wonderful — but it is also good to hear that the posts are substantive.

You mentioned making savings due to the implementation of Encompass. What are the savings? Are they year-on-year savings?

Mr Spoerry: I will defer to Elaine, but in doing so, I will say that we are in the first phase of savings from Encompass, so bear in mind that we have had Encompass only since May and that we will go looking for a lot more. I will hand over to Elaine.

Ms Wilson: At this stage, the savings are in obvious things such as the reduction in our printing. Not printing as much has saved us quite a lot. There has been a reduction in the use of consumables that are no longer required because of the way in which we use our system. We redeployed to other posts a big cohort of staff whom we did not need any more — we have not made anybody redundant; we have put them into vacant posts — and that provided the biggest piece of the savings this year. Those are all recurrent savings, and they will grow. We would like to push Encompass to drive significant savings out of the Southern Trust.

We also made significant savings in pharmacy this year. That is part of a wider pharmacy improvement programme that had been going on anyway, but we know that Encompass is helping us to make those savings. We made significantly more savings in pharmacy than we had projected in-year, and the contribution of Encompass to that has to be recognised. We think that there is real opportunity to make many more savings in pharmacy through our use of Encompass. One of our priorities for next year is to drive that system to get savings, because it is obviously preferable to take savings from there than to have to look at things that will impact on our services.

Mr Donnelly: What savings have you made this year? Is it £47 million?

Mr Spoerry: It is £43 million.

Mr Donnelly: What percentage of those savings came from Encompass, roughly?

Ms Wilson: I do not have that figure, but I can get it to you, Danny. I would not like to quote an inexact figure. Part of the issue is the pharmacy savings. I am not able to say exactly what proportion of the overall pharmacy savings we have directly linked to Encompass yet. We know that the consumables and the printing have reduced by hundreds of thousands of pounds.

Mr Spoerry: Bear in mind that they are all part-year figures as well, Danny. We implemented Encompass in May, and only really in the autumn got into trying to take cost out of it. The first job was to make sure that everything was working.

Ms Wilson: I mentioned the staff. I am sorry, I did not know the figures for that, but it just came back into my head. The staff costs amounted to about £1 million, taken out recurrently.

Mr Donnelly: OK. That is certainly very encouraging. It is good to hear something positive from the implementation of Encompass and that we are starting to see good results out of that. You mentioned pharmacy savings, and that is very encouraging. The thing that really struck me about what you have told us here today is the revalidation of the waiting lists and the 40% reduction. That is a shocking figure. To my mind, that means that 40% of the people who were sick enough to be put on a waiting list and sick enough to need a procedure, did not get it in a timely way. Not knowing why they did not get it seems to be open-ended. We really should know how many of those people did not get a procedure because they became acutely unwell, got emergency treatment and needed urgent care; how many of them became too frail for their procedures; how many of them went to the private sector and paid huge amounts of money for a procedure that they had been waiting on for years; and how many, sadly, died on a waiting list. Not knowing that, when we know that there has been such a large reduction of 40%, is quite shocking. Is there any way that you can retrieve that data, so that you can become aware of that?

Ms Wilson: We will look into that. The other group in that comprises people whom the consultants determined, having done the clinical validation, did not need the procedure that they had been referred for. There is a mix of other things in there that would not necessarily mean that they needed a procedure but did not get it. We will have a look at that.

Mr Donnelly: I would be very keen to see those figures. We have asked the Department and the trusts for that type of breakdown quite a few times.

Ms Wilson: It is not an easy thing to do.

Mr Donnelly: I do not think that we have ever received that. If you can provide the Committee with that, I would be very keen to see it.

Ms Wilson: It may be that we can have a look at how our Encompass system might help us to do that in future. We will get back to you.

Mr Donnelly: That is grand. Thank you.

The Chairperson (Mr McGuigan): I was just checking with the Clerk, Danny. We got a response in relation to that today, which will be our pack next week. I do not know what is in the response; it may be nothing. The point is well made that if it is not the information we want, we should go back to the Department to try to access that information for all the trusts.

Mr Robinson: I will be really quick because I am conscious of time. Linda mentioned incidents of physical abuse. That is the standout for me. The figures for Craigavon Area Hospital in that four-year period have doubled. It is not verbal abuse; it is physical abuse.

Mr Spoerry: Yes.

Mr Robinson: That is outrageous. You will be aware that the Committee visited the Northern Trust a couple of weeks ago. It was amazing to see something as small as body-worn devices having such a big impact. It defies belief that those devices, which are having a great effect in one trust, cannot be rolled out to the others. It is really important that that happens pronto. Are you capturing the reasons or drivers for some of those physical attacks? Do you have any data on the nature of those attacks? In the past, we have heard that staff have suffered broken eye sockets or have been knocked out. Is that the level of physical attack that you are experiencing?

Mr Spoerry: No. That would be classed as a very severe attack, and, fortunately, most of them are about aggression — pushing or trying to swing a punch and not landing it. What you described would be regarded as a really serious incident. As for drivers, you probably saw that we have had a dramatic increase in the number of mental health referrals by 26% in a year. That is really striking. Our bed occupancy in the mental health unit has been at over 100%. We have put in extra beds. The recommendation is that you should be averaging around 85% occupancy. That particular issue in the mental health service has caused a lot of problems. We also know that violence correlates with longer waits in ED. Of course, that is exactly what has been going on: people become very frustrated and difficult. There is an inability to take them into areas where they can be isolated with staff, as opposed to other members of the public, so it becomes an extremely difficult working environment in ED.

There is a third issue, which we are looking at right now. It is clear, when we look at our flow problems, that there is consistently a number of people — usually with dementia — who present very challenging behaviour in the wards who are not being very well cared for. We recently had two serious incidents in one night involving that group of patients. We have commissioned a piece of work to look at whether we should create a specialist location in units to take that group of people away from acute wards and provide them with appropriate care while protecting other staff and patients from their behaviour.

Mr Robinson: That is very helpful, Steve. I appreciate that.

The Chairperson (Mr McGuigan): Obviously, it is important that we highlight when things go wrong and that we probe and ask questions when we think that they are needed. It is also important to recognise that there is no excuse for violence against any healthcare staff. That needs to be condemned. We thank your staff for the work that they do in our health service. It is important that we balance those views.

Mr Chambers: The figures that you have given us about assaults on staff are really unacceptable. Do you have any sense that alcohol or drug abuse has contributed to the increase in antisocial behaviour in public areas or assaults on your staff?

Mr Spoerry: I am not aware of any specific information that we have in that regard, but it will not surprise you to hear that alcohol and drug abuse rears its head in the emergency department and the mental health service. I cannot say anything more concrete than that.

Mr Chambers: I am sure that you would welcome any legislation to minimise alcohol abuse.

Mr Spoerry: You are really asking for a personal view. I would have to see what legislation was proposed.

The Chairperson (Mr McGuigan): I think that Alan is hinting at the minimum unit pricing of alcohol —

Mr Chambers: You are on the ball, Chair.

The Chairperson (Mr McGuigan): — but I will not put words in his mouth.

Mrs Dillon: I will make two very quick points. First, on the issues in ED, it is very clear that capital is the problem. Everybody is on top of each other. It is not just the ED; it is everybody out in the foyer area. They are literally on top of each other. That is a problem that, in and of itself, creates issues. As you said, there is nowhere to take people who may be just very vulnerable at that moment and just need a wee bit of space. People with neurodiverse issues are in the middle of that as well. It is absolute madness.

The Minister has told us that he is looking at the potential for dementia-specific wards. Make your case. Be the pilot project. Let it be the Southern Trust for a change, rather than the South Eastern Trust. No offence to the South Eastern Trust, but it gets a lot of great pilots. I feel a wee bit aggrieved that the Southern Trust does not. Given the issues that you have, maybe there is a case to be made around that specific issue. I am extremely concerned by the high level of assaults.

Mr Spoerry: That is another good reason for us to actively pursue it: let us beat South Eastern Trust.

Mrs Dillon: Space is a big problem that absolutely needs to be addressed. Maybe we can make that case to the Minister.

The Chairperson (Mr McGuigan): This Health Committee supports all the trusts. [Laughter.]

Mrs Dillon: You cannot blame me for being parochial. You are the Chair; you cannot be.

The Chairperson (Mr McGuigan): No other members want to come in. We got round everybody. We really appreciate you coming here and taking our questions. Thank you very much.

Mr Spoerry: Thank you for your support.