Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome from the Northern Health and Social Care Trust (NHSCT) Anne O'Reilly, its chairperson; Suzanne Pullins, chief executive; Gillian Traub, director of operations; and Neil Martin, director of strategic planning, performance and ICT. Thank you all for coming to the Committee. We are probably a bit behind schedule.

We received your briefing paper, which was useful in helping us prepare for today. I will hand over to you to make some brief introductory remarks, after which members will ask questions.

Ms Anne O'Reilly (Northern Health and Social Care Trust): Good afternoon, everybody. Thank you very much for having us. I know that this is part of a series of engagements with trusts, so we welcome the opportunity. As chair, I will mention three particular things before I hand over to Suzanne, our chief executive.

From the trust board's point of view, we feel that a number of things have supported the work of the organisation in an increasingly complex and demanding environment. I will focus on leadership, culture and workforce, and partnership as three drivers that, we think, are important. On leadership, the Committee will have noted the recent departure of Jennifer Welsh to the Belfast Health and Social Care Trust (BHSCT), but I am pleased to report that Suzanne has stepped into the role of interim chief executive and will remain in post until March 2027. The trust board feels that it is vital at this stage that we have stability, particularly given the financial situation and the reform agenda that we are required to think about. I thank Suzanne for stepping up.

I will turn to culture and workforce. As you will have heard from other trusts, our staff are the organisation's most important asset. They deliver all functions 24/7, and, without them, it would be difficult to do the work. I witness their commitment and dedication across the trust every day. Shaping the culture of the organisation is a key responsibility of the trust board, and we take that responsibility seriously. We know the inextricable link that there is between staff well-being and patient safety, so taking a visible, meaningful and dedicated approach to the delivery of our open, just and learning culture is our response to that responsibility.

We retained silver accreditation in our recent Investors in People (IIP) accreditation, which places us in the top 20% of organisations in the UK. When I looked at the IIP staff survey responses, a few things offered me a level of assurance and reassurance as chair of the trust. A particular strength was the level of response: one third of our 13,000 staff responded, which was a significant increase from three years ago. The results were encouraging, and there are a couple of things that I want to get across. The organisation was seen as being led by strong values. Teamwork was seen as a strong, protective factor in managing the stresses and strains of the work as staff go about their business. There was feedback that we had a genuinely compassionate group of staff. There was a deep sense of purpose for what they do and how they do it.

As with all things, however, there is work to be done, as there should be in an organisation that is committed to continuing to make progress. We do that under our open, just and learning framework. There are things that we want to focus on, in particular the key role that team leaders and those who manage staff at the centre of the organisation play. We want to focus on upward and downward communication and engagement throughout the organisation, and there are eyes and ears to keep us informed and updated on how things are.

Finally, I will comment on partnership. The Northern Trust is in new governance committee territory. I chair the recently established partnership and population health committee, which is made up of staff, representatives of the community and voluntary sector, carers and service users, all of whom are very much equals around the table when it comes to our planning and thinking.

I know from my background that it can be difficult to access large organisations such as trusts, and that is our way of being open, being human, being transparent and truly being able to work with people in partnership.

I have a couple of issues to flag. Causeway Hospital, as you will know, has been through a lot of change. We take a good, strong partnership approach to planning and to shaping services and delivery there. We are particularly interested in the potential and potency of what we are calling a "community appointment day" (CAD) model. That is a way in which people can get same-day access to a range of statutory and voluntary community services in one place in a community setting. There is evidence to suggest a model in favour of supporting the self-management of conditions, because getting access to the trust can be difficult, and we know that there are a lot of people waiting. We are therefore focusing hard on scaling and spreading our CAD model. I will give a couple of examples. There is a model for people with musculoskeletal (MSK) conditions that supports self-management of people on our waiting lists. There is also one for people with dementia. I have been to one of the dementia CADs where I met people who told me that waiting on the list after a diagnosis of dementia can very much raise their anxiety. CADs are a way of perhaps converting some of that anxiety into hope. Those are things on which we really want to focus.

Two things matter here. First, we need to pivot our staff more into community settings. We are determined to do that. Secondly, we are determined to target and focus our work with our partners in the community and voluntary sector in order to support those waiting for access to treatment, care and support. We are waiting for a response about the Minister's offer of support for three of those community appointment days to help those on waiting lists. We want to take advantage of that to test some of the models of working.

The final initiative that I will mention is Thrive Sperrins, which has been highlighted on the BBC news. That came about as a result of one thing only, which was a conversation between Will, who is a community leader in Draperstown, and Jill, who is one of our integrated healthcare professionals. They are on the partnership and population health committee. That was where the change happened for us to think about how we might do things differently. That work represents our major shift to focus on neighbourhood, and we will build on it in the four localities across the Northern Trust.

I will hand over to Suzanne.

Ms Suzanne Pullins (Northern Health and Social Care Trust): Thank you, Anne. Thank you, Chair and members of the Committee, for the opportunity to appear before you today. I appreciate the Committee's ongoing engagement and scrutiny, and I welcome the opportunity to outline the key challenges that our trust faces and the progress that we are making on improving outcomes and patient experience across our services.

The Northern Trust covers the largest geographical area of any trust in Northern Ireland, serving a population with the highest number of older people and the largest child population. Over the next 20 years, the population of people who are 65 and older is projected to increase by 49%. Combined with the fact that almost half our population live in rural areas, the scale and diversity of our demography and geography shape demand and pose challenges and opportunities for service planning and delivery. Despite that, we are making significant progress on transforming services to meet the changing needs of our community, and those efforts are delivering meaningful improvements in clinical outcomes while improving patient experience, which is hugely important to us.

I will start with unscheduled care. The emergency system continues to experience significant demand in responding to the care needs of our entire population, particularly the older and frailer population. Often, our emergency departments (EDs) are operating beyond full capacity, but it is important to say that ED pressures often result from pressures in other parts of the health and social care system or when individuals require a pathway into secondary care. Demand for inpatient beds frequently exceeds what we can provide, which creates significant difficulties with patient flow. At the same time, community bed capacity is under strain, while securing home care packages remains challenging, which further slows down discharges and impacts on our acute and community settings. To address those pressures, we have invested significantly in ambulatory same-day emergency care, ensuring that patients are directed quickly to the right pathway, which avoids unnecessary hospital admissions and reduces waits in the emergency department. Our direct assessment unit in Antrim Area Hospital now sees around 900 patients each month. That number has risen by a further 250 following the introduction of new respiratory, cardiology and frailty pathways. Additionally, Causeway Hospital's ambulatory and frailty units see more than 500 patients each month. Those patient-centred models have been transformational in reducing ED attendances, avoiding inpatient admissions and improving patient experience.

Delayed discharges remain a major system-wide challenge, driven by limited home care capacity and high demand for dementia beds and beds for those with behavioural needs. That has been a significant area of focus for us. We have therefore restructured our integrated discharge team, secured 20 new dementia beds and repurposed two residential homes to create permanent placement opportunities. Through those actions, we are beginning to show improvements in flow across acute and community services. Demand for home care has risen sharply, by 15%, since 2022, which reflects our ageing population. The trust delivers or commissions more than three million hours of home care each year, with 75% provided through the independent sector.

Although there continues to be a considerable level of unmet need in our trust, I am pleased to report that unmet need for home care is now at its lowest level in six years. A two-year reform programme is under way to stabilise, optimise and level up home care provision. Early outcomes include a 25% reduction in waiting lists and a 44% drop in the number of patients delayed in hospital while awaiting home care. Scaling that model will strengthen discharge pathways, improve patient flow and, most important, enhance continuity and quality of care for service users. Our Hospital at Home service is another important development and is aimed at reducing pressure on unscheduled care and supporting older people to receive the right care in their own environment. Although still in its infancy, the service is active in 15 care homes and, subject to funding, shows strong potential to expand further.

I will turn to elective services. We are making meaningful progress on reducing waiting times across several specialties. Increased MRI and endoscopy capacity, supported by recurrent investment, is helping improve performance. Our outpatient modernisation programme, including enhanced triage, direct-to-test pathways and patient-initiated follow-up is embedding more efficient and patient-centred models of care. Our rapid diagnostic centre at Whiteabbey, which was launched as a pilot in 2022, has now seen more than 1,000 patients. It was established to shorten the time until cancer diagnosis, improve outcomes and streamline onward referral. It has become an important component of our elective reform programme.

Although we have made progress in many areas, several services continue to experience significant pressures and challenges, and I will briefly highlight some of the most challenged areas. Neurology is an area of challenge for the Northern Trust. We have severe workforce shortages and have been unsuccessful in recruiting consultants. Regrettably, that has resulted in a long wait for our community. We are working closely with other trusts to manage that in the short term and continue to explore a more sustainable, longer-term solution.

We operate two residential short-break units for children with disabilities, but those services remain under intense pressure due to staffing constraints and increasing demand for emergency full-time placements. We are expanding our estate to increase residential capacity and reduce waiting lists, while investing in family support. The number of looked-after children in our trust area has grown by 34% over the past six years. Kinship care — children who are placed with relatives — now accounts for 57% of our placements. A shortage of suitable placements, particularly for children with complex needs, remains one of our most significant risks, with all six of our children's homes operating at full capacity. We have introduced strengthened early intervention approaches that are aimed at reducing the number of children entering care, and early indications show that numbers are beginning to stabilise. Work is also under way on a business case for an additional children's home that would expand capacity and reduce reliance on external providers.

We have challenges in demand in the area of children with special educational needs (SEN). There has been a significant rise in the number of children requiring statements of educational need. Across the trust areas, special school capacity has increased by 25% over five years, and 10 new specialist provision classes have opened in mainstream schools. Demand for allied health professional (AHP) support, particularly for early years interventions such as speech and language therapy, has outpaced available resources, resulting in long waits.

We continue to work closely with the Education Authority (EA) to assess and meet the evolving needs.

Our acute mental health services face rising demand, increased patient acuity and workforce pressures. Inpatient units continue to operate at or above full capacity, often with extended waits for admission. Demand among our older population has increased by 57% over five years, with an average of 149 referrals a month in 2025. We have expanded dementia assessment and treatment capacity through a new memory assessment pathway and a pilot model that is aimed at reducing the time from referral to diagnosis. Demand for psychological services and adult autistic spectrum disorder (ASD) assessments remains high, but additional waiting-list initiative funding is helping us make progress.

Members will be aware that there is a requirement to replace our inpatient mental health facilities at Holywell Hospital in Antrim. Progress on the Birch Hill Centre development is paused, pending departmental funding approval. Holywell dates back to the 19th century, and the building itself is in a poor physical state and does not facilitate the delivery of current models of care. There are significant concerns about the psychological and therapeutic environments in which mental health inpatient care is currently provided. Although we acknowledge that there are considerable pressures on the available capital budget, we have a responsibility to find a suitable solution that supports the delivery of a modern model of care for mental health inpatient provision. While progress on the Birch Hill Centre is delayed, it is incumbent on me to be candid and advise the Committee that our trust continues to manage significant risk and to incur significant costs for the upkeep of Holywell Hospital until a replacement can be provided.

On transformational services, we are proud of our ReformNORTH programme, which includes the transformation of our maternity services. In July 2023, we safely consolidated hospital births and inpatient maternity care at Antrim Area Hospital, while maintaining a maternity hub at Causeway Hospital to provide enhanced antenatal and postnatal services for local women. I am delighted say that we are looking forward to a further boost to our maternity model with the opening of the alongside midwifery-led unit on track for completion before this summer.

We are also about to begin the construction of another significant capital development project at Antrim Area Hospital. Work is due to begin on the new, £3·5 million Macmillan information and support centre, which will provide enhanced support to people living with a cancer diagnosis and their families.

Members will be aware of the Northern Trust's review of general surgery. Following a public consultation, our board approved a recommendation to centralise emergency general surgery at Antrim Area Hospital, while continuing to provide elective surgery procedures at Causeway Hospital. The trust has submitted its recommendation to the Department for consideration, and we await the conclusion of that process. We strongly believe that transforming our current service model is necessary if we are to avoid service collapse and create a safe, stable and sustainable model for the future. We also believe that there is a huge opportunity for us to create an elective hub at Causeway Hospital that would have the capacity to serve the entire north-west. The hospital's recently opened MRI unit is capable of doing up to 4,000 scans a year. We now have the necessary diagnostic facilities on-site, meaning that patients no longer have to travel to Antrim Area Hospital.

We are very proud of Causeway Hospital. We know how much the hospital and its staff are valued by the local community. I take the opportunity to reiterate our trust's commitment to Causeway Hospital. It is and will remain a vital part of our acute hospital network. Causeway Hospital is a real success story for our trust. It is a shining example of how service transformation is delivering tangible benefits for the local community. We have developed a strategic vision for Causeway Hospital. We are making steady progress towards delivering on those ambitions and making our vision a reality. We are looking forward to marking the 25th anniversary of the opening of Causeway Hospital this spring, and we know that the hospital has a very bright future ahead of it.

On finances, we have delivered £33·6 million in savings and cost avoidance this year. We are progressing major initiatives to stabilise the workforce, reduce agency reliance and improve procurement. Efficiencies alone, however, will not resolve the scale of the financial challenge. We will need to continue with transformation in order to restore financial sustainability.

Finally, as Anne outlined, our people are our greatest asset. I am incredibly proud to belong to Team North. We are committed to investing in our people, as demonstrated by the results of our recent IIP survey, which Anne covered. We were glad to be able to demonstrate to Committee members our recent trial of the use of body-worn cameras by senior staff in our emergency department at Antrim Area Hospital. Members of the public have reported feeling safer as a result of those cameras being in use, and staff have said that wearing them in itself acts as deterrent and successfully helps lessen the potential for a situation to escalate.

Chair and members, thank you for allowing me to provide that briefing. I hope that I have given you all an overview of the current challenges that face our trust, but I hope that I have also provided you with reassurance that, despite the many challenges, we remain committed to delivering for our community through transformation and innovation. We are working hard to improve performance across our services. We are investing in modern models of care and strengthening our partnerships with our community. We have focused on delivering the safe, sustainable and equitable services that our population deserves.

The Chairperson (Mr McGuigan): Thank you very much. That was useful. You covered a lot of stuff, and there are a lot of questions for us to get through. I live in the Northern Trust area, and I echo your gratitude to the staff, many of whom I engage with, particularly at Causeway Hospital, during my days there in person but also as Chair of the Committee. I thank all the staff in the Northern Trust.

Before I ask questions, I will echo your sentiments about the Birch Hill Centre. I have visited Holywell Hospital, and it is absolutely not the kind of facility in which your staff should be working and, more important, in which patients should receive treatment. The sooner we can get a new building that is fit for purpose over the line, the better. I hope that the Birch Hill Centre can be progressed fairly quickly.

I have quite a few questions, and they will jump from one subject to the next. I am very interested, because Danny and I — sorry, I should also have thanked your staff, because Danny and I paid an unannounced visit one night over the Christmas period, although I cannot remember the exact date, and your staff were excellent. They ensured that we got to see all that we got to see, and they answered all our questions. I thank you and your team for facilitating the Committee's visit to see the body-worn cameras. The Committee has a clear intention to assist with that issue so that we can make sure that the numbers of attacks on your staff and all healthcare staff are reduced.

On the basis of our visit and of what you have said, I will ask about same-day emergency care. All our hospitals are under pressure for the same reasons. More people are turning up at emergency departments, and there is a bottleneck there and again when it comes to home care. I am really interested in the impact that same-day emergency care has had in the Northern Trust. For example, how is it measured, and can you measure how providing same-day emergency care reduces the impact on the emergency department?

Ms Gillian Traub (Northern Health and Social Care Trust): Take the same-day emergency care service in Antrim Area Hospital as an example. The direct assessment unit is an incredibly mature model in the region. As Suzanne mentioned, we can add pathways into it. For example, we recently added a cardiology pathway and a respiratory pathway, which builds on the same principles, which are that the pathway either can be accessed by the emergency department team, who identify a patient to come out of that department and into the unit for assessment, or utilised directly by the Northern Ireland Ambulance Service (NIAS), which can take a patient directly into the unit. Equally, our general practitioners can access the unit by making direct contact and arranging for patients to come up to the unit.

We track data on the number of people who access that service every day. We track where they have come from and who referred them. The majority of those patients will use that service and go home, but some may need to come back. We call that "safety-netting". They may need to come back within a short time, but their coming back to the unit avoids another person in the queue at the emergency department on another day. We also keep an eye on the amount of that activity.

We will track all the data associated with the throughput of the unit. At the end of that, some of those patients will need to be admitted, and that is reasonable. We will also look at what we call the "conversion rate", which is the number going through the unit and the number being admitted at the end of the process. A low admission rate may be a good thing, but it might also suggest that there is a low acuity associated with the patients coming into the unit. We look at various aspects of the data in relation to that.

The Chairperson (Mr McGuigan): Do we know —

Ms Traub: The impact?

The Chairperson (Mr McGuigan): — how many people are not admitted overnight?

Ms Traub: I do not have the numbers per day here, but we know how many people come into the unit every day who might otherwise have gone to the emergency department. Because there are so many factors that play into how many people come into an emergency department, it is hard to make a direct correlation. However, we know that, for patients who are in our direct assessment unit, if the direct assessment unit were not there, they would probably be in the emergency department. We also have a reform programme to make sure we continue to maximise that and that all our specialities have an ambulatory pathway or a same-day emergency care pathway.

The Chairperson (Mr McGuigan): So the Ambulance Service and GPs are feeding in.

Ms Traub: Yes, and our emergency department teams. If they see somebody who can come out of the waiting room and go into that service, they will do that.

The Chairperson (Mr McGuigan): That is interesting.

I will go back to elective surgery. The Southern Trust was here last week, and I was taken aback when they said that 40% of the waiting list was wiped off — that is probably a bad way of saying that — because of validation. I am interested in knowing the figures in the Northern Trust.

Mr Neil Martin (Northern Health and Social Care Trust): Our number for outpatient administrative validation is 27%. We validated 10,000 outpatients and were able to discharge 2,700 who had been waiting for over three years. In endoscopy, we validated 888 patients and were able to remove 104 patients, which was 11%. It varies depending on the speciality and the length of wait.

The Chairperson (Mr McGuigan): What are the particular challenges in the Northern Trust in reducing particularly long waiting lists?

Mr Martin: We have longer waiting lists than we would like across quite a number of areas. We are in receipt of £23 million this year from the elective care framework funding, and we have seen 13,000 outpatients, 5,000 endoscopies and 767 day-case and inpatient procedures. The biggest numbers in the outpatient world were for dermatology, gynaecology and breast procedures, which gives you a sense of where our longest waits are. We continue to work down the waiting lists. It has had an impact: the number of people waiting over four years for an outpatient appointment has come down by 27% this year and the number waiting over three years by 21%, and that is largely for the routine patients.

At the other end of the scale — red flag waits — we have either maintained or improved the position across all our specialities in suspected cancers. For example, dermatology is down from six weeks to five, general surgery from five weeks to three, and it is similar for gynaecology. We have also seen good reductions in endoscopy: there is a 66% reduction in patients waiting more than six months for an endoscopy and 40% for those waiting over a year for inpatient or day-case treatment. We have begun to see some of those long waits coming down, and that is encouraging.

The Chairperson (Mr McGuigan): Obviously, the additional funding is vital, but what are the particular factors? Is it workforce issues or other factors that impact on reducing the waiting lists further?

Mr Martin: The fundamental issue is an imbalance between capacity and demand. Demand has increased year-on-year, and capacity has not kept pace with demand, which means that we are starting a little behind the curve every year. Over a number of years, a backlog has built up that is now very significant in some areas, and that requires a particular approach. We try to bring the waits down by maximising the delivery from our core services, such as outpatient clinics and theatre specialities, and driving some of the elective reform that Suzanne mentioned, such as alternative pathways, patient-initiated follow-up and, alongside that, by using the non-recurrent funding from the elective care framework.

The Chairperson (Mr McGuigan): OK. You will be aware that the Committee has placed a particular focus over the past number of weeks on the bottleneck in home care. The North has an ageing population. The Northern Trust is the epicentre of that, and the population in the Northern Trust is the oldest across the North. I was interested to hear you say that there are 20 additional dementia beds and a further 44 planned: where will they be located?

Ms Traub: There is a new care home opening at the Loughshore Hotel.

The Chairperson (Mr McGuigan): OK. As a constituency MLA — you will know this from correspondence from my office — I think that packages for home care are a major issue. I thank all your staff for dealing with the correspondence that comes from my office. We have heard from the independent care sector — we have asked this of all the trusts — that, in some cases, it can potentially be used as a money-saving tactic at the end of a financial year in terms of not accessing. I would be interested if you could give a deeper explanation of the work that you are doing over and above the extra beds to resolve that bottleneck. The Northern Trust area is a particularly rural area. You can start by telling us how many people in hospital are fit for discharge.

Ms Traub: As of this morning, 83 people in Antrim Area Hospital and 30 people in Causeway Hospital are fit for discharge. Those are our two acute hospitals. Eight patients in Antrim and three patients in Causeway await a package of care. That is the smallest proportion of our delay from an acute hospital delay perspective. When we move into our community hospitals, you will see that most of our delays there are associated with people who are in a community hospital bed awaiting a package of care. Today, we have 24 people in community hospital beds who need a package of care. We also have 41 people in a care home who are awaiting a package of care. We do not see the impact on people in a bed waiting in the acute setting, but we see it in the community. The 600 figure that Suzanne talked about is everybody waiting. The numbers that I have given you sit within that.

With regard to whether we have sought to save money in respect of home care, we are spending more money on home care than we have ever spent. We are spending money to meet the demand where we can get the capacity to meet the demand. We set the programme out 18 months ago because of the impact that those delays have not only on the individual but on their families and on our services and flow.

Rurality is an issue for us, and we are aware of that. We are trying to take a strategic approach to how we deal with rurality with our providers. Of the 636 service users who are on our unmet need list, about 110 of them are in the mid-Ulster area. When we look at the definition of rurality, we see that 96% of those individuals live in what is defined by the Northern Ireland Statistics and Research Agency (NISRA) as a rural area. That means that there are longer travel times, and that is a disincentive in some instances for providers to come into that area and deliver care. Even with those improvements, our challenging areas are Randalstown, Toome and Broughshane. Ballymena town is also a challenge for us because of high employment rates and difficulty with recruiting into the sector.

We are doing a number of things. Fundamentally, we have looked at zones for rural areas. We have looked at the Northern Trust area and have created zones, because we think that, if we can commission blocks of hours by zones, with that reduced travel time, we will encourage provision. We have seen that work successfully. We tried it out in one particular "black spot", as we called it, which is Cushendall, Cushendun and Glenariff. We offered a block contract provider in that zone, and we have been able to reduce that unmet need to 16 hours because we have got a provider interested in doing a run in that zone. We were able to give the provider enough work, so it is more sustainable and more attractive for it.

There are 600 people effectively on a waiting list. We are now reviewing that in a multidisciplinary way and exploring the unmet need there with families to see whether there are alternatives. We have been able to reduce the unmet need and find alternatives for some families with direct payments. Our needs have also changed, so we have been able to divert capacity elsewhere. We now have an early review team that reviews people who leave hospital with a package. The team comes in at six weeks and reviews people who have come out of hospital to see how they are doing. Six weeks on, their needs may have changed. We are able to recycle 28 packages of care every week. We have seen the hours being put back into the system from getting in early and reviewing people. We also use technology. We are trying to introduce the CareLineLive app, which gives us real-time access to the time spent by a worker in a person's home and allows us to maximise that.

There are a range of initiatives, and they are all needed, because there is not one answer alone that will help us drive down the home care waits. What we have seen so far is encouraging, and fundamental to that is the relationship with the sector. We have 75% of our home care delivered through the independent sector, with 24 providers. They are key to helping us solve the problem. We are doing the work on zoning with them. As in the example that I gave earlier, we have seen where they have worked with us and said, "We can come in and do something in that area with you". We have some green shoots. Having 600 service users with unmet need is not good, but that number was 850 in July and 1,000 in March, so it is going in the right direction.

The Chairperson (Mr McGuigan): My last question is on the workforce. Suzanne, you talked about a particular problem in neurology. When we do engagement either in the Committee or individually as political parties with different spheres of the health service, every one of them tells us that there are workforce problems that are having an impact on the staff's ability to provide care, as well as on their own well-being. I am interested to know, specifically in the neurology setting, what you are doing to rectify that.

In a different sector —midwifery — there has been a change of service from the Causeway Hospital to Antrim Area Hospital. I have had a bit of engagement with midwives across the board and have put in questions for written answer. It would be good to get your assessment of how that service is going, whether there is a workforce shortage in midwifery as well and whether there is any impact from that.

Ms Pullins: Do you want to deal with neurology first?

The Chairperson (Mr McGuigan): OK.

Ms Traub: I will do neurology and hand back to you for midwifery.

In the Northern Trust, we are funded for two and a half neurology consultants, but we have long sat with half of a consultant in post. That demonstrates the real vulnerability in a service for which referral numbers have grown year-on-year. We have 6,000 people waiting for a new neurology appointment, which is a figure that is only growing. We have been flagging our concern with the service in discussion with colleagues in the strategic planning and performance group (SPPG) and the recently created neurology alliance, which is chaired by the SPPG and brings together all the trusts to look at the issue.

We are not the only trust with challenging waits, but we are one of the trusts with the smallest workforce left. As Suzanne said in her briefing, we have tried to recruit consultants on three occasions in the past year and been unsuccessful in every attempt. Continuing to try to recruit will not affect anything, which is why we need a regional approach. Currently — this is very live — SPPG has written to all trusts to ask them to support us with reviews of patients who have been seen by a consultant but need to be clinically reviewed and are on a waiting list. We are working with trusts to agree what that pathway should look like. We have worked with the South Eastern Trust, which has a stable neurology service. We believe that it will be able to recruit, and we are working with it so that if it can recruit, in effect, to our posts, it will work with us and provide the service on our behalf. There will be some success with that approach.

In the past year, we have also used the independent sector waiting list initiative moneys particularly to transfer some of our urgent new patients to the independent sector so that we can stop numbers being added to the waiting list, because, at 5,000, it starts to feel irrecoverable. That has also been successful: 450 urgent new referrals have gone out to the independent sector this year. We have had some recurrent investment in neurology that has gone into specialist nursing. We have had funding for an epilepsy nurse specialist. While we can get focused on consultants, there is a multidisciplinary workforce that we could start to grow who could provide a neurology service to patients. That is really where we are. The neurology alliance continues, with the backdrop of the neurology review, to talk through what else may be done, and we continue to keep it as a live issue.

The Chairperson (Mr McGuigan): It is a concerning issue, I have to say.

Ms Traub: Yes, it is.

Ms Pullins: On maternity, you will know from Professor Renfrew's report that the complexity and acuity in the maternity setting has really increased over the past number of years. Although our birth rate has fallen, the intervention rate is rising. That adds to the pressurised environment in which midwives work. At this point in time, we have considerable absence in our maternity service. The head of midwifery and assistant director for women's health has reviewed every person who is absent from work, and it is really genuine absence due to ill health. There is an element of stress in people's lives: there is a little bit of work-related stress as well. There are other genuine conditions that keep people out of work. We monitor that closely. We do not use agency staffing in maternity units in the Northern Trust. Therefore, we have to depend on the goodwill of our staff, which probably creates a pressurised situation for them. At this stage, we have only nine vacancies, and we are out on a rolling recruitment programme. We will obviously look to fill all those vacancies. We are at a stage where it is obviously not as attractive for midwives to accept a temporary post — we would like to backfill our maternity leave with temporary posts — and we will keep that under review.

In 2022, we used the proper structured tool to look at our staffing in maternity, Birthrate Plus. At that time, there was only a small gap. We are looking at the validation of that tool in 2026, and it continues to be the right tool with which to measure. We use it every day in our safety briefing. That is how we come up with a classification of, I suppose, red, amber or green for the unit. Yes, there has been some absence, but we continue to work at that and recruit. We are definitely not holding any posts. We would love to attract all newly qualified midwives to the Northern Trust.

The Chairperson (Mr McGuigan): You said that there were nine vacancies. How many midwives are we talking about? Is that a large percentage?

Ms Pullins: That is 6·2% of the midwifery workforce.

The Chairperson (Mr McGuigan): So there is that, and then there is a large number of staff — I think that those were your words — who are off sick.

Ms Pullins: Yes.

The Chairperson (Mr McGuigan): Is there any impact on patient care?

Ms Pullins: Every morning, we do a safety brief. That is when we classify the busyness of the unit, the acuity of the women and our staffing for that day. We will move staff around, either from community to hospital or among our departments, to ensure that our staffing remains at a level at which we can operate.

The Chairperson (Mr McGuigan): OK. Thank you. I will move to other members.

Mr Robinson: I have several questions. Some of them are quite parochial with regard to Causeway Hospital, as you would expect. We met you up at Antrim Area Hospital to look at body-worn cameras. We all really enjoyed that session up there. When do you expect to make a decision on expanding their use to Causeway?

Ms Pullins: The two leads whom you met, Dr Baldwin and Ed Smith, are currently compiling the consultation document review. Once that is presented to the trust board, we will make a decision. Our intention is then to roll that out into the next emergency department.

Mr Robinson: Good. That is a positive.

My attention was pricked by a reference that you made in your paper to looked-after children. Forgive me if I have missed this somewhere along the way, but it refers to:

Where would that be sited?

Ms Traub: I do not think that we know at this stage; we are just continuing with the business case. Our director of social work works closely with our director of infrastructure, and they are looking for potential properties.

Mr Robinson: OK. Is there no model to say where in the area would be best placed for that?

Ms Pullins: No. We had been intending to extend capacity in the Causeway area by a small number for children with a disability. As we sit here today, however, we are not sure of a specific location, unless Neil knows.

Mr Martin: No. It is often driven by what is available in the market at a particular point in time when the money becomes available.

Mr Robinson: We met Mark Taylor. I cannot remember his title — director of elective care or clinical lead on elective care.

Ms Pullins: Yes, I know Mark.

Mr Robinson: We met him several weeks ago. He referred to the number of hospitals that are performing really strongly and delivering at capacity. He also talked about hospitals that, he thought, could do more. That was not in any way a slight on or criticism of Causeway Hospital, but he thought that it could deliver more. Given that we have the MRI scanner in place, say that, in five years' time, you are presenting to a new cohort of MLAs on the Committee, what can those MLAs expect? We talk about the "Causeway vision": what is that vision? What can the people of the Causeway region expect to see enhanced at Causeway Hospital?

Mr Martin: We absolutely agree with Mark that there is huge potential for additional elective capacity at Causeway Hospital, and we have been working with the Department to look at potential investment there. There is an uncommissioned operating theatre in Causeway, essentially: one that does not run. With appropriate resources and staffing, we could run significant numbers of patients through that theatre. As you know, it is intended, through our reform of general surgery, to make Causeway Hospital focus on high-volume elective procedures. That is exactly the kind of thing that we could put through that theatre.

One advantage that Causeway Hospital has is that, because it is an acute hospital with an emergency department, an ICU and so forth, it can deal with a wide range of patients who could not be dealt with in some of the smaller hospitals. Causeway is well placed. When I come back to the Committee in five years' time, as, I am sure, I will, I would love to be able to say that Causeway has that operating theatre fully commissioned and running and serving the people of the area and of the region. It will be a regional resource, I think.

Mr Robinson: On the Causeway vision and the future of Causeway, are there any plans for the Ross Thomson unit or anything that you can provide us with as regards the future of that unit?

Ms Traub: Part of our vision for Causeway is the development of mental health services for the Causeway area. It is recognised that, if we progress with Birch Hill, that will be the centralisation of acute mental health services, bringing together the acute element of what is currently provided in the Ross Thomson unit and in Holywell. However, there are other mental health services that we need to maintain and grow in Causeway with a more community-focused element and for dementia services. We know the trajectory for dementia in the population, particularly for Causeway, with its older population. We have made a commitment to design, with our partners, what the future for community mental health services and dementia care will look like in Causeway. We said that we would do it in partnership. We do not have a plan, but we have made a commitment to plan. We have started discussions with colleagues in the community and voluntary sector and in SOS Causeway Hospital to get a bit of engagement in the design process.

Mr Robinson: Anyone who has suffered from mental health issues and their family members will tell you that one of the greatest crutches that they have is having their family nearby.

Ms Traub: I appreciate that.

Mr Robinson: I do not want to use emotive language, but it would be cruel to ship people from the Ross Thomson unit up to Birch Hill. That is just a comment.

Ms Traub: I understand that, and we have the conversation about general surgery when we are bringing services together, which inevitably means that patients may have to go further from home. They will, however, hopefully be able to avail themselves of a fabulous new therapeutic environment in Birch Hill, with all the expertise and the multidisciplinary team around them. Equally, all the other services there — maybe their follow-up care or ongoing therapeutic interventions, which are more likely to be frequent and needing to be closer to home — will be able to be delivered close to home. That is what we hope to be able to do to reassure people.

Mr Robinson: Has the Minister indicated when the decision to transfer emergency general surgery from Causeway will be made? Your document was a bit presumptuous in stating:

Obviously, the Minister has not yet made that decision. When do you expect that to be?

Ms Pullins: We are working through a process with SPPG to verify all our calculations and papers. We are not aware of an absolute deadline. We are trying to prevent a service collapse. That might be a poor use of language, but we are not pre-empting the outcome of the Minister's decision.

Mr Robinson: It is more or less a done deal.

Ms Pullins: We have to wait for the Minister's decision.

Mr Donnelly: I echo the Chair's comments about your staff, especially on the night that we arrived. We were able to speak with your staff about the pressures across Northern Ireland that you have suffered all year but particularly in the wintertime. I had cause to be in A&E, and I have heard from many people in the area who have been through A&E. They always praise the work, commitment and dedication of your staff, but the pressures in A&E are evident. They were evident to us on the night: nine ambulances were stacked up, and I think that one was waiting for five hours. We arrived on a Sunday at 9.30 pm: the A&E department was full at that time, and we were told that flow had stopped. The rest of the hospital was full. Patients were still coming, but flow had stopped in the hospital on a Sunday night, so pressures were building in the system. I have seen that with relatives and have heard about it countless times. When we were there, about 100 medically fit patients were in the hospital, and there were about 50 decisions to admit in A&E. That is roughly reflective of where you are now, so we are at the same level of pressure. Is that fair?

Ms Pullins: How many complex cases are there today, Gillian?

Ms Traub: There are 83 in Antrim hospital.

Mr Donnelly: Is that typical?

Ms Traub: When we track back to September, the average number of patients in Antrim hospital who were medically fit for discharge was 110. We have seen that figure come down over the past number of months. Taking January out, because January is an unusual and challenging month, it is on a slowly downward curve, but today's position is fairly typical.

Mr Donnelly: Your briefing paper states:

Ms Traub: That is right. Home care, as I set out, is only a small part of our challenge from the inpatient setting. It is the smallest proportion of our delayed discharges in the acute setting.

Mr Donnelly: As a nurse, I did plenty of discharges. Is it correct that eight patients out of 83 are awaiting a package of care?

Ms Traub: Yes, that is right. Thirty await an intermediate care bed pathway; 20 await a care home bed; and 15 are categorised as needing a dementia placement of one variety or another. A number need housing arrangement. The largest proportion of our delays in hospital discharge are individuals who need a care home or a community bed for rehabilitation or assessment.

Mr Donnelly: What is the typical length of wait for those patients?

Ms Traub: I would not be able to answer that accurately today. There is a spectrum. There will be some for whom it is a real challenge, perhaps because of a lack of a bed in a particular geographical area.

Mr Donnelly: Or the specific type of care that they need.

Ms Traub: Yes. It could be the bed. It could be an individual who needs a dementia nursing bed, for example. Those are particularly difficult to find, hence why we have worked to get new care home provision coming on. That would be harder, unfortunately, whereas there would be a shorter wait for a general nursing bed in Antrim. It depends on the individual needs assessment and the location.

Mr Donnelly: On a different topic, Birch Hill has been mentioned a couple of times. I had the opportunity to visit Birch Hill during planning, when you had the virtual walk-through. The facility is fantastic. When the patients look out of the rooms, they will see nature. It looks like a beautiful facility. Can you give us an update on the current timeline for construction? Are there any barriers at the minute or any funding issues?

Ms Pullins: We need funding approval from the Department.

Mr Donnelly: You still await that.

Ms Pullins: Yes, we are waiting for the capital funding list to be approved, and then there will be a decision on whether we can proceed. We have moved as far as we can at this point. You are right: it is a beautiful facility. So many service users and staff have been involved in its development; it has been really well thought through. However, we do not have a timeline as we sit here today. I said in my opening remarks that it remains the case that we spend a lot of money on refurbishing Holywell. Our estates team is marvellous, but we spend a lot of money on trying to keep it in the best condition that we can.

Mr Donnelly: Holywell is over 100 years old.

Ms Pullins: Yes, Neil reminded me that it was built in the 19th century.

Mr Donnelly: How much is the trust spending a year on the upkeep of Holywell?

Ms Pullins: We know that figure for the past couple of years. It may be better if we give you a written response. It is in the field of millions.

Ms Traub: I have a related figure. It does not quite answer that question, but there is an estimated backlog maintenance liability of £28 million over the next five years. That is what, we project, we might need to spend.

Mr Donnelly: Is that across the whole trust?

Ms Traub: No, that is for Holywell for the next five years, assuming that we do not have backlog maintenance that we are trying to clear. Obviously, we will have to carry a certain amount of backlog maintenance.

The Chairperson (Mr McGuigan): It would be a ridiculous decision not to allow Birch Hill to proceed, given that you are throwing £28 million away needlessly.

Mr Donnelly: It is a huge amount of money.

Ms Traub: Very simply, from a patient experience perspective, our staff do the best that they can in Holywell, but it is an incredibly limited therapeutic environment.

Mr Donnelly: I have one other quick question. It was good to see MRIs coming in at Causeway. I think that it is commissioned for 4,000 scans a year. Is that up and running at the minute? Is it ongoing? How many are being delivered?

Ms Traub: It has been up and running since October. Is that right, Neil? You have the figures, I think.

Mr Martin: I do. Between the middle of October and the middle of January, we scanned 611 patients, half of whom were inpatients. Previously, that would have involved an ambulance transfer to Antrim and back. That was cut out for those patients. The others were from elective lists. That is a really positive step forward for us.

Mr Donnelly: OK, so it is not at full capacity yet.

Mr Martin: It is probably not quite running at full capacity just yet. There was a bit of downtime because a little maintenance was required after a month or so. We are working really hard on getting it up to full speed.

Mrs Dodds: I have a couple of quick questions. The Southern Trust presented to us last week, and officials said that, when they started to validate the waiting lists, they reduced them by 40%. You say that you have reduced them by 27%. Will you outline exactly what you mean by "validating" the waiting lists? Is it information on how many people have gone private? Do you have figures on that? Forty per cent and 27% seems like a lot of people to take off the waiting lists.

Mr Martin: The process for admin validation is that we contact the patient and ask them whether they believe that they still need the treatment that they are waiting for. If they say no, they are discharged from the list. That is what happened with that 27% of patients.

Mrs Dodds: Is that all the 27%?

Mr Martin: That is correct.

Mrs Dodds: It is not about a clinician looking at the waiting list and saying to a patient, "This isn't appropriate. You need to go to your GP and get a re-referral". Could a patient who has sat on a waiting list for two or three years find themselves back at square one with their GP?

Mr Martin: No. There is a different process called "clinical validation" whereby consultants review referrals that have been on the list for a while and consider whether it is still appropriate for that patient to be on the list. One of the outcomes of that process may be discharge, but there may be other outcomes. For example, we have people on review lists who may be moved to patient-initiated follow-up, where, instead of being brought in for an appointment every 12 months or 18 months, they are given open access to appointments as and when, they believe, they require them. They contact the service and come in. That seems to be quite well received by patients on that pathway.

Mrs Dodds: I have been contacted by some GPs in the Northern Trust who say to me, "I have patients who say that they need to be re-referred". Do you have figures around the clinical validation of the list? You do not have to give them to me now; you can send them in writing.

Mr Martin: That is fine. We can give you those figures with the specialty breakdown.

Mrs Dodds: Is that 27% just people who simply said, "We don't need your services any longer"?

Mr Martin: Correct.

Mrs Dodds: That is incredible.

Ms Traub: That came from the patients themselves.

Mrs Dodds: Have you collated any information on the reasons for that? Is it just, "I'm not sick any more", or, "I got my hip done privately"? Do we know what the reasons are?

Mr Martin: No, we do not collect those reasons. We follow our regional process. All the trusts follow the same process, which is advised by the SPPG. The process has no way in which to capture the patient's reason for not needing the appointment any more.

Mrs Dodds: Is that 27% included in the number of people whom the Minister talks about as having been seen, or is that a totally separate process?

Mr Martin: I do not know, because I do not know the figure that you refer to. However, I said earlier that 13,000 outpatients in the elective care framework had been seen.

Mrs Dodds: OK.

Mr Martin: Those are in addition to the patients who have been validated. The list will have reduced by the sum of those two figures.

Mrs Dodds: OK.

I have a quick question on Whiteabbey Hospital. Staff have told me that Whiteabbey is not at the capacity that it could be at. I remember talking a long time ago to people about those centres, and someone said, "Oh, they should be going 24/7". You said that, from 2022 until now, Whiteabbey Hospital has seen 1,000 patients. That cannot have been full capacity for all of those years.

Mr Martin: That figure is just for the rapid diagnostic centre. There is a lot of other activity at the Whiteabbey site, such as endoscopy, day surgery, outpatients and a rehab ward. It is a busy site. That 1,000 is for one commissioned service.

Mrs Dodds: Do you have figures for the Whiteabbey site?

Mr Martin: In total?

Mrs Dodds: Yes.

Mr Martin: We could find them.

Mrs Dodds: That would be great. It might resolve an issue. Thank you.

The Chairperson (Mr McGuigan): Thank you very much. The session has been very useful. You committed to submitting some responses in writing. We look forward to that. Thank you very much.