Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome, from the South Eastern Health and Social Care Trust, Roisin Coulter, the chief executive; Jonathan Patton, the chair of the trust; Helen Moore, director of planning, performance and informatics; and Veronica Cleland, director of primary care and older people's services. You are very welcome. Thank you very much for coming. I will hand over to you to make some opening remarks, and then we will take questions from members.

Ms Roisin Coulter (South Eastern Health and Social Care Trust): Thank you very much. Good afternoon, Chair and members of the Committee. Thank you for the opportunity to come back to the Health Committee. I am joined by my chair and director colleagues. We are happy to provide the Health Committee with a balanced overview of the work of the trust and the progress that we are making and to outline where our challenges are and the opportunities for stabilising and resetting services across the trust. First of all, I take this opportunity to publicly thank all our dedicated staff in Health and Social Care, who are working really hard in extremely challenging times, as always, to deliver the best care that they can. Their commitment to our patients and service users is valued by us all. They deserve our genuine recognition and appreciation for everything that they do. Having said that, I am absolutely appalled that, between April and December of last year, there were 1,911 incidents of violence and aggression towards our staff in the South Eastern Trust. That is completely unacceptable. I welcome the fact that body-worn cameras are about to be introduced in the Ulster Hospital's emergency department, as a first phase. That is happening on the back of learning from the experience of Antrim Area Hospital, where body-worn cameras were implemented in a very positive way. There has been great feedback about that.

The Committee will be aware that the trust provides an extensive range of services that span acute hospital care, community care, out-of-hours primary care, mental health services, learning disability services, children's services, social care and healthcare in prison across all three prisons in Northern Ireland. In addition to its many local services, the trust provides a number of regional specialist services, including the day procedure centre at Lagan Valley Hospital, the regional cataract service at the Downe Hospital, community acquired brain injury rehabilitation services for all of Northern Ireland at Thompson House Hospital in Lisburn, head and neck cancer surgery services, oral maxillofacial and plastics and our new robotic aquablation urology services.

Similarly to all the population of Northern Ireland, the Health Committee will be aware of the significant growth of our older age group. That is why frailty services and providing better services for older people in Northern Ireland absolutely need to be the priority for us all. The most notable change in our trust is the sharp rise in the number of people aged 65 and over, which is expected to grow by 57% by 2043, and of those aged over 75, which is expected to grow by 72% by 2043. Those figures are stark. We have the highest proportion of residents aged over 70 of all the trusts, with Ards and North Down recording the highest prevalence of dementia in Northern Ireland. People aged over 75 account for 21% of emergency department attendances and 40% of admissions with a length of stay of five days or more. There is, as Committee members will know, a relentless focus on the financial environment in which we all work, across our public-sector services. We are doing our best, within the resources that are available to us, to provide the best services that we can.

We set ambitious savings targets each year to drive out waste and to do our best to improve productivity and efficiency. This year, we are on track to deliver just under £30 million of cash-releasing savings, which is almost 3% of our annual budget. That takes tremendous and relentless focus from all our teams, and everybody is doing their best to make the best use of the resources that we have. The reality, however, is that many of our services are demand led and impacted on by inflation and demographics. It is increasingly challenging to have to deliver the same level of services with the same or lower levels of income. Fundamental, planned and system-wide reform remains the only long-term solution that will ensure financial stability across our health and social care system. Underinvestment is particularly marked in community services. That has an impact on the most vulnerable in our society — those with learning, mental health and physical disabilities and looked-after children in our care. That number has risen dramatically, from 587 in 2019 to 794 in February 2026.

On unscheduled care, we face significant demand for services in the emergency department at the Ulster Hospital. From 2023-24 to 2024-25, our unscheduled care attendances increased by 12%. We have the busiest emergency department in the region, with over 162,000 attendances across our three sites, and that number continues to increase. In January, the average daily use of additional corridor escalation beds at the Ulster Hospital was 60. That is on top of a hospital with approximately 550 beds. Every single bed in all our hospitals is open every single day, and there are 60 escalation beds on top of that. Our hospital and community teams are working collaboratively, doing our best to improve flow across our hospital sites. For example, we have implemented a new passport approach for our frail, older population, to allow them, where possible, to be directly admitted to their local hospital by the Northern Ireland Ambulance Service (NIAS). We are pushing to increase that, because that is the best way to have patients admitted. Some 142 patients in the area served by the Downe have the passport. About three years ago, that number was only 15. In Lagan Valley, 65 patients have a passport, which gives them direct admission from NIAS to their local hospital. We have a relentless focus on reducing how long a patient remains in our hospitals, and continue to maximise alternatives, such as ambulatory hubs and Hospital at Home. Over the past 12 months, the length of a stay in the Ulster Hospital has reduced by 0·5 of a day. All that, added up, is significant.

Being very open and honest, the challenges in our emergency department, and the, at times, very long ambulance turnaround times, are not unique to our trust: the pressure is national. I absolutely accept, however, that it is not the service that we want to provide or the service that the public, including any of our families, deserve. We know how distressing long ambulance waits can be for not just the patients but their families and our staff. There is no single solution to the complex problem of ambulance turnaround times; there are so many factors that we need to work on continuously if we are to make sure that we deliver an improvement. We are confident, however, that the answer lies primarily in increasing the care that is available to people in the community, avoiding hospital admissions, where possible. We are determined to deliver and sustain that improvement and committed to doing so. We have moved from 51% of ambulances waiting for over two hours in January to 19% waiting for that amount of time last week. We are determined and committed to sustaining that change.

As everyone knows, waiting lists are far too long. We welcome the non-recurrent funding that was identified, last March, through the elective care framework for supporting red-flag cases, time-critical cases and long waits, as well as building elective capacity. We continue to face rising demand for cancer services, with a 17% increase in red-flag referrals since 2022. That creates pressure and makes it difficult for us to meet ministerial targets. There are, however, signs of improvement. As members may be aware, the South Eastern Trust hosts the single breast assessment waiting list for all of Northern Ireland. Our first breast cancer appointments have reduced, from a 12-week wait in September 2025, to a seven-week wait. That is since May 2025. Last week, that time was down to six weeks and two days, and we are doing a lot of work on that. The number of people on the waiting list has moved from 2,500 to 1,498. We are determined to work together as a region to make sure that everybody has equal access to that service. We have been able to increase our capacity and deliver almost 80,000 referrals across a range of specialties.

There has also been a focus on people who have been on waiting lists for access to treatment for more than three or four years. On 31 March 2025, the number of people waiting for a first consultant-led appointment had reduced by 61%. That was delivered in a variety of ways, not just administrative validation but clinical validation, reviewing patients' medical charts. We have held additional mega-clinics, outpatient clinics and insourcing, for which we have worked with the independent sector. All that is significant, and it is important for people who have been waiting for a long time. We have done significant work to reduce waiting times for inpatient and day procedures. There had been a 77% reduction in day case waits and a 60% reduction in those requiring an inpatient procedure over four years, as of 31 March 2025. Since October 2020, the day procedure unit at Lagan Valley Hospital has carried out an additional 22,000 planned surgical procedures, and there is capacity there to deliver more for the region.

The trust was proud to be the first in Northern Ireland to implement Encompass, including across our healthcare in prison services, which interfaces with the Justice record. That is an incredible achievement given the unprecedented 46% increase in the prison population in Maghaberry since 2021.

We are delighted to be the first trust to have mental health staff working with NIAS in the ambulance control room. That will be significant for all of Northern Ireland. So far, that has helped 1,000 patients to be supported at home instead of in an emergency department. Our mental health practitioners sit alongside NIAS colleagues in the control room, and I know that NIAS is also keen to look at having medical practitioners in the control room to triage at the point of call.

In December, the trust opened Redwood Children's Home. The home is now operational, supporting one family. By the end of March, it will support three families. We have opened the new urgent care centre at the Ulster Hospital and new preoperative assessment in paediatrics and endoscopy. The regional day procedure centres at Lagan Valley and Downe hospitals are leading the way in providing vital day surgery.

We work continually with our teams to look at how we can develop more services for our older population and those who are at the end of their life. There needs to be a reduction in the reliance on hospital care and more treatment and recovery at home. Lying in a hospital bed is not the best place for an older person, unless it is absolutely necessary. Our aim, which we can talk about later, is to provide care at home or as close to home as possible. We have expanded our Hospital at Home service across all three sectors of the trust and are providing 40 beds. Patients have stated in feedback that they receive excellent care and have excellent experiences.

Our multidisciplinary teams (MDTs) in primary care are trust-wide and provide an excellent community fall service and palliative care hub. It is essential that those services are wrapped around so that people can receive care in the right place in their community. Those services will play a key part as we move into developing the neighbourhood model: they are important pillars. We must prioritise the development of the neighbourhood model, with the frail and the elderly at the heart of it. We will continue to work with all our partners, including with the community and voluntary sector and councils, to deliver more care in the community. Patients, as our partners, will be encouraged to take more responsibility for their own individual health and well-being. In Lisburn, a successful pilot of a dementia behaviours outreach service, which ran in 18 care homes, saw a 48% reduction in people with dementia being brought to hospital. The trust wants to try to expand that service to Ards and North Down and to work with our GPs with special interests to support up to 56 care homes in the area.

We have embraced digital platforms, Encompass, AI and innovative techniques. We are looking to expand by listening to our surgical colleagues, who need there to be more major technological advancements in surgery in Northern Ireland. We recently welcomed a new surgical robot at the Ulster Hospital, which will deliver significant benefits, including reduced complications and faster recovery. In October, we opened a new clinical trial centre at the Ulster Hospital, which provides patients across Northern Ireland with access to cutting-edge research trials and innovative improvements.

We are working with partners in the region and the Department of Health to implement the transformative "Together for Families" model, which aims to provide early help for families at their front door. The intended benefit is to drive down the number of children that require to be looked after. Key achievements include the introduction of a revised model that has reduced the number of unallocated cases from 515, in June of last year, to 157 this February, which is a 46% reduction. We have done that by providing early intervention services and crisis response services, with over 247 children receiving support. I know that the Health Committee has a lot of interest in children's support services, and one particularly successful service that has been developed is a children's disability in-reach and outreach service. That provides daytime short breaks for children and is particularly valued by our families. Feedback was received from one family to say that that service, as opposed to overnight short breaks, is now their preferred option. We need to be able to provide both services and respond to families in a flexible way. The trust aims to treble that service provision.

Mental health services continue to develop new ways to reduce reliance on hospital services and ensure that patients receive the most appropriate and timely care in the community. At the moment, acute mental health services see higher ratios of detained patients within the wards and patients with increasing complexities. We see higher referral volumes, and there are sustained caseload pressures across community mental health, dementia and addiction services. However, we hope to build on the success of the Hear and Treat service in the NIAS control room by expanding that model across the week, and we would like to see a See and Treat service, whereby a mental health practitioner responds alongside a paramedic. That will reflect effective approaches that we have learned from elsewhere in the UK, providing the right care in the community and trying to avoid hospital attendance unless it is absolutely necessary.

We continue to focus on making substantial improvements to stabilise our workforce. There has been a considered effort, and we are continuing that effort in order to reduce reliance on agency staff, prioritise our bank staff and expand the bank to include allied health professional (AHP) and social care roles. The Belfast Health and Social Care Trust and the South Eastern Trust are working together to share bank resources on a new digital and operational system that will enable bank staff to work flexibly across both trusts.

We all know that we cannot continue with constant crisis response in secondary care. The path forward demands a shift to a community model, alongside prevention and the neighbourhood model. We have exceptional staff and many excellent services, but we need to work together, at system level, to reset health and social care. Every department has a key role in leading on and effecting that change.

The Chairperson (Mr McGuigan): Thank you very much. That puts on record the vast amount of work carried out by the trust. I put on record our thanks to you and all your staff for the work that you do: you outlined a lot of positive work. Unfortunately, in scenarios such as this, we sometimes want to ask about the stuff that is not working as it should.

So that everybody is aware, we will have to be tight with time for our questions. I will, hopefully, lead by example. Everybody will get enough time, but not much more than that.

You said that there had been £30 million-worth of savings. I think that you said 2% or 3%.

Ms Coulter: I said 3%.

The Chairperson (Mr McGuigan): What areas have the savings been made in?

Ms Coulter: We have savings targets every year, so we are used to making the best use of public resources. This year, we had a more significant challenge than other trusts, and we had to use a strong governance approach to deliver savings.

Seventy per cent of our resources are spent on salaries and wages, and the key factor is to stabilise our workforce and make the best use of our resources. We reduced medical locums, our reliance on agency staff and encouraged staff to take a post on the bank, and we made a number of posts substantive. That has helped to reduce our spend on temporary staff, and it will continue to be a focus.

We have also looked at contracting and how to work better with the community and voluntary sector to join up contracting and the delivery of services. We have looked at our administrative and clerical roles to roll out the benefits of Encompass. We were the first trust to implement Encompass in November 2023, and we have delivered £1·8 million of cash-releasing benefits and replaced 77 posts. Encompass can do a lot more, but those are the main areas.

The Chairperson (Mr McGuigan): We have asked all the trusts this question. The independent care providers told us that there was some indication that trusts were cutting back on community care to save money. I will put that question to you.

Ms Veronica Cleland (South Eastern Health and Social Care Trust): From the briefing on our community care, you can see that, at the end of the last quarter, 83 people were waiting for care packages across the South Eastern Health and Social Care Trust. That figure demonstrates that we are not cutting back on care where it is needed. We are ensuring that the care is appropriate and meets assessed need.

The Chairperson (Mr McGuigan): OK. You said that waiting lists went down by 61%, and some of the trusts have said that validation has taken away 40% of the patients. How many came off the waiting list in the South Eastern Trust as a result of validation?

Ms Helen Moore (South Eastern Health and Social Care Trust): We have had a programme of work that started with administrative validation and moves through a number of steps in the regionally agreed process and arrives at a clinical validation process, some of which is record review and some requires a telephone conversation between the clinician responsible for the speciality and the patient. In some cases, there will also be a face-to-face appointment. It is quite a rigorous process, and, as you highlighted, we have had a 61% reduction in the overall number of outpatients waiting more than four years.

The validation has primarily been for long-waiting patients, but we started at those waiting four years-plus and have worked down to those waiting one year-plus. The validation process has scope for patients who do not reply to us and then ask to be reinstated, and we can reinstate them. We have adopted a very clear process.

The Chairperson (Mr McGuigan): You said that it was a regionally agreed process. The Committee is disappointed and confused that we cannot go into the specific reasons for the validation process. When we first heard about the process, the reasons for leaving the waiting list were an obvious question for the Committee to ask. I am not sure why it was not an obvious question to ask the people who are coming off the list, such as whether they have been treated privately.

Ms Coulter: We can send you the information about the breakdown. From my experience of one of the gynaecology waiting lists, the main reason is that the patient no longer requires the procedure or has had the procedure elsewhere, potentially in the private sector.

The Chairperson (Mr McGuigan): Can you provide that information?

Ms Coulter: Yes.

The Chairperson (Mr McGuigan): When we asked other trusts that question, they said that they could not provide it. How come you can provide that information?

Ms Coulter: We cannot provide the information for every specialty. However, where we have done a focused piece of work, I can give you an example of the percentage, but those are the main reasons.

The Chairperson (Mr McGuigan): Is what you are doing going beyond the regionally agreed procedure?

Ms Coulter: We have gone through the list patient by patient — every individual.

Ms Moore: In some cases, there is duplication of referral. Someone might have been referred to general surgery and ended up coming in under a specialist surgery such as colorectal surgery. It has been a rigorous process.

Ms Coulter: Moreover, they may have been referred a number of times by their GP if they have gone back again and again. You will pick up duplicates in that way.

The Chairperson (Mr McGuigan): It would be useful if you could provide that information. It would give us a starting point.

You have done good work on waiting lists. In what areas has the reduction not been as dramatic? What procedures are we looking at?

Ms Moore: Validation is one thing, but there is also seeing the patient in the right place by the right person. We have been doing reform work to look, by speciality, at what else we can do. For example, in gynae, the clinical team has worked closely with GP federation colleagues and has identified procedures that the GPs are trained and able to provide. In the past few months, more than 300 patients have been relocated to GPs for appointments. We have also used our physiotherapists to help us with specific areas of gynaecology. That is another example.

In dermatology — skins — we have identified that, whilst there is a fantastic photo triage service, there is more scope. About 55% of dermatology referrals do not come with a photograph showing their condition. They may have multiple lesions, for example. We have successfully worked with the commissioner and are starting a process with nurse consultants, working as part of the multidisicplinary and professional group, to see what we can do to look at the dermatology patients who come in. We hope that, when that is at full scale, 9,000 patients a year will go through the nurse consultant team and will not have to wait for the secondary care consultant in dermatology.

A series of reforms has gone on, as well as clearance through the validation process and meeting patients in traditional outpatient appointments. In addition, there has been a direct-to-diagnostic approach for patients rather than making them wait for an outpatient appointment before they go to that.

The Chairperson (Mr McGuigan): I have a final question. Roisin, you outlined that breast cancer delays have gone from 12 weeks in 2025 down to seven weeks and then, last week, to six weeks and two days.

Ms Coulter: Yes.

Mr McGrath: That is still an unacceptably long delay.

Ms Coulter: Absolutely.

The Chairperson (Mr McGuigan): Can we get a sense of when targets can start to be achieved sustainably?

Ms Coulter: All the trusts are working closely together on that. It is an absolute priority. We are doing a number of things, one of which is more mega-clinics. We did two in one month recently. Larger numbers of patients can be seen on a given day. We saw, I think, in excess of 50 patients in one day. We recently partnered with Forth Valley Royal Hospital in Scotland, and staff from there came over last week to support Northern Ireland breast cancer clinics. They have delivered one clinic so far, and we got confirmation this morning that another one is planned for the end of March. We will see improvement on that.

The Chairperson (Mr McGuigan): But when will we start meeting targets sustainably?

Ms Coulter: I hope that that will be week on week. The week before last, the delay was seven weeks; it is now six weeks and two days. We are happy to be held to account on the need for improvement. Having one waiting list is the way forward for providing equal access and removing the postcode lottery. All that is mainstream now. It is also about not just delivering how we have always delivered. Forth Valley has a slightly different model, in which there is a different skill mix and a greater role for nursing. It can put more patients through the clinics than we currently do. Another part of bringing Forth Valley over is to say, "How can we put more patients through?" We will see improvement.

The Chairperson (Mr McGuigan): The Minister was given £215 million to tackle waiting lists. That has been given to trusts, but £70 million was taken from it and went elsewhere. If you were given a slice or more of that £70 million, could you do much more to deal with waiting lists? What could you do?

Ms Coulter: It is fair to say that, if any trust receives more investment, we can do more. We can do more in-house and more with the independent sector. We have capacity. However, when you look across the range of services, including community services, learning disability and mental health, it is about balancing the financial constraints with the risk. We will continue to focus on red-flag and time-critical services and respond as best we can to the increase in cancer referrals and looking at how to work in greater partnership with general practice, really making sure that the people on the waiting lists absolutely need those in secondary care. There are very good ideas from general practice in some of the other areas that they would like to expand into if we can do that.

Ms Flynn: Thank you very much, Roisin and the team, for your presentation and for the written briefing. I will try to be quick. Roisin, to touch quickly on mental health, you mentioned that you are seeing higher levels of inpatient admissions for more acute mental health problems. We are probably seeing that across the trusts. However, in the briefing paper, you say that, from January 2025 to January 2026, you have seen a 28% reduction in mental health admissions to emergency departments (EDs). Can you outline any reasons for that? Have you assessed the reasons for that reduction?

Ms Coulter: Yes. Thank you, Órlaithí. We keep an eye on that every day in order to provide services for those with mental health challenges. Over the past three years, part of the focus of Rachel Gibbs, our mental health director, and the multidisciplinary team is that they have really grasped how we can deliver the shift from hospital to community. We are doing that by providing more home treatment, community treatment and crisis response services in the community so that we can provide something straight to the person rather than their coming to ED. Over the past year, we have reduced the number of ED mental health admissions at the Ulster Hospital by 26%. That shows that we can shift it, but it is about shifting resource as well, so we are focusing on the community.

Another reason for our having pressures is that the vast majority of people in our mental health inpatient wards are detained under the Mental Health (Northern Ireland) Order. Many of those who attend emergency departments voluntarily are not detained, so we always have to balance that against access to a bed, which is prioritised for someone in the community who is acutely unwell and needs a bed.

Just yesterday, I was with a team looking at what we can do differently to reduce pressure even further. Ideally, we want to find a way that someone with a mental health crisis waiting eight or nine days in an emergency department becomes a "never" situation. The response is to provide more in the community, and it links in with substance and alcohol addiction services wrapping around individuals. As you know, we have our addiction service in the Downshire Hospital in Downpatrick, and that is working extremely well. It is really about wrapping it up together.

Our community and voluntary sector partners also have a big role to play in supporting people experiencing a mental health crisis. There is a lot of good work going on.

Ms Flynn: That is brilliant, Roisin. Thank you. It is great to hear the impact that the work of your mental health team is having. Is that learning being shared across the trusts? Obviously, each trust has its own pressures when it comes to mental health. We met the Belfast Trust recently on a pilot that it is running, called the PATH project whereby it is trying to reduce admissions through taking people out of the emergency department, triaging them in a separate ward and supporting them so that they might not need to go on to an inpatient unit.

If there is learning and there are good initiatives that your trust has already put into practice, it might help other trusts. Are there any conversations or shared learning ongoing?

Secondly, you mentioned addictions. Has your trust done any work on implementing what we are calling the "co-occurrence service": the dual diagnosis, co-occurrence service, where mental health services work with addiction services? That is in the substance use strategy and in the mental health strategy. In the past, when I have asked how the service is being implemented across trusts, I have not got an affirmative answer.

Ms Coulter: Thank you for that. It is fair to say that, across all our services, we, as a region, absolutely are working together. The operational directors of the five trusts meet every week, and we share learning, challenges and opportunities. We are looking more and more at how we can deliver services as though we were one. It is about reducing variation, trying to have consistent practice and getting best practice in place. There is the regional mental health collaborative, as you know, that is looking at a number of different work streams to make improvements. In our trust, we used some of the £2 million unscheduled care investment to support mental health. We want to develop a 24/7 mental health liaison team. We also used some of that money for home treatment and community care to reduce the pressure on secondary care.

On your point about mental health and addictions, I will get that information and send it to you, Órlaithí.

Ms Flynn: Brilliant. Thank you.

When you talked about your mental health initiatives, you touched on how you are trying to shift some resource and support into the community, which chimes with the Minister's priority of moving to the neighbourhood model. When you touched on that in your briefing, Roisin, you mentioned the increasing numbers of looked-after children. That really worries me, because we are talking about the most vulnerable in our community. They are only kids.

I had a meeting with a school yesterday during which staff said that it had got to the point where they were being contacted and asked to take some of those vulnerable children home, because they cannot get a foster placement for them. There are not always places in residential care for them. I just thought, "How has it got to the stage where teachers are being contacted by social services and asked whether they can take over the care of a child?".

I know that that is not just impacting on your trust. A lot of those kids do not even have their own social worker assigned to them. You mentioned that there was a 46% reduction in number of kids who did not have a social worker assigned to them. I am glad to hear that and that you have been working to reduce that.

I go back to the neighbourhood model. You mentioned mental health, learning disability and looked-after children. What do you envisage your trust doing through the neighbourhood model to make an impact and improve the situation for vulnerable kids who need all the support and help that they can get?

Ms Coulter: That is a big question. You could talk about it for a long time, because there are so many different parts to it. There are almost 800 looked-after children in the South Eastern Trust area. We are working hard to reduce that. On the unallocated cases, all the children who are at risk of child abuse have been allocated a place. The other children are those in need of family support. I do not know whether it is just a Northern Ireland issue or a national issue, but, as you are all aware, since COVID, we have seen an increase in the number of young people requiring additional support. We have also seen a decrease in the number of people coming forward to foster. That is a real challenge for us.

In response, our trust has looked at providing more wraparound services for families in communities, early prevention, early intervention and outreach services. What can we do to keep children as safe and as well as possible? I have not heard of any teachers being asked such a question. I appreciate your concern, but I do not think that I can respond to it. It is not something that we want to hear happening too much.

Regionally, we are looking at what we can do to support kinship foster families, who are relatives of the young people. What wraparound support do those families need to keep the young person close to their home and their family, where possible? It really is about, as you say, the neighbourhood model and our work to get upstream. It also moves out into special educational needs services in our special schools and into autism and ADHD services. As I said, it is all linked.

Ms Flynn: Thank you very much, Roisin.

Mr McGrath: Thank you for the presentation, which moved at 100 mph, like you, given that you are across so many issues in the trust. It was good to get that whistle-stop tour through all of it.

Ms Coulter: You said that I should be brief.

Mr McGrath: Yes, that was the brief version. I also recognise and appreciate the good relations between the trust and elected reps. That has not always been the case, but, Jonathan, it makes life as an elected rep a lot easier when we can be confident that, when we raise an issue, it will be dealt with. I promise that that is not the good news before the bad.

I have a question about a topic that came up in the Assembly recently but which impacts on you and us. Along with previous chief execs, you were proud of the fact that we had one ED and two level-2 hospitals. Overnight, the Department told us that it had mis-designated them and would turn the level-2 hospitals into level 1s, which pushed them down. If felt as though we had lost something in that change, even though the services are still there. The level-2 designation had been the springboard from which we would try to build, so it felt as though we had been set back. How did the Department mis-designate those units for years?

I will put my second question in context. With 372,000 people, we are about mid-table among the trusts by population. However, as you pointed out, we have the highest number of people over the age of 70 — we are all getting closer to that — which increases the number of emergencies, yet we are the only trust with one emergency department. All the other trusts have two. Moreover, with a fair wind, we could throw ours from here to Belfast, because it is right on the border of the South Eastern Trust and the Belfast Health and Social Care Trust.

If you draw a circle around the catchment area of people who gravitate towards it, you will see that it includes people who live at the bottom of the hill. If they need an emergency department, they will go 300 metres up the road rather than travel further in the other direction. The Department is sometimes unfair in its expectations of you in that emergency scenario. Given all that, does the Department compensate you in any way?

Those are my questions: the designation of the hospitals and the location of our single emergency department.

Ms Coulter: Thank you, Colin. I will speak to the designation, and I will send you a written response. My understanding is based on what happened eight or 10 months ago. The five large acute hospitals all have a type 1, 24/7, full emergency department. Over the past 10 or 15 years, our local services — urgent care centres and emergency departments — were designated as type 2; it was always that way. The Royal College of Emergency Medicine — again, this is my understanding — clarified the designations of the levels of emergency departments. That clarification meant that the urgent care centres at Downe and Lagan Valley — there were centres in other trusts that it applied to, but I focused on mine — would no longer be called level-2 hospitals.

The community saw that as a downgrading. However, there is no change; it is just a cross-UK clarification of the types and levels of services. I felt that I explained that, and I received very few queries about it. Be assured that it does not change anything.

You talked about our having one emergency department. From the perspective of my trust, certainly, and, potentially, the regional perspective, that is the right model. It is clinically safe, appropriate and sustainable. When you look at the workforce and financial challenges, you see that it would be very difficult to provide more than one. The range of services required to support a 24/7 emergency department is vast, particularly given the size of Northern Ireland and our population.

People sometimes think that an emergency department is just a department on its own, with a front door and a back door. It is not. Behind an emergency department, you need access to maternity services, neonatal intensive care, intensive care services, 24/7 diagnostics — you need all that infrastructure behind it. How realistic would it be to provide more than one?

We have a hospital emergency network model that works very well. We need the three to play their part. They all have an equal but different part to play. The Ulster Hospital emergency department is supported by the two urgent care centres at Lagan Valley and Downe, and they are really important. We can admit people directly from the Northern Ireland Ambulance Service (NIAS) to the urgent care centres and to the Ulster. We can then manage pressure away from the Ulster at times if Lagan Valley or Downe can take more.

It works very well. I really am proud of the model, as it is the right one for our population. A key thing is that the medical workforce rotates across the three. Therefore, no one can say that they work only at the Ulster and will not support Lagan Valley or Downe. They will support wherever we need them to support. That is vital. Sometimes, the smaller centres and sites can be more vulnerable with rotas and so on, so that is really important. They all work right across the hospitals.

On its location, I cannot really do anything about that. It is where it is. The central geographical location of the South Eastern Trust is somewhere between Comber and Ballygowan. That is the centre of where we provide services, considering that the trust area goes as far as Newcastle, down to Portaferry, Strangford, Ards, north Down and up to Lisburn. When you ask whether there is an acknowledgement of the location, there is an acknowledgement of the catchment area and where the population uses the emergency department. Forty per cent of attendances to the Ulster Hospital emergency department are from residents of the Belfast Trust area. However, of course, a number of people from the South Eastern Trust area will access services in the Belfast Trust. That probably happens in all trusts, depending on what services people need.

For me, it is about making sure that our emergency services are absolutely safe, with patient safety being our number-one priority and that they are providing clinically appropriate and sustainable services. The model of our urgent care centres that work Monday to Friday between 8.00 am and 6.00 pm, supported by the minor injuries unit at the Downe at the weekends, is working very well, based on patient feedback. Patients can phone first and get access to an appointment on the same or the next day. They can avoid hospital attendance if need be, but they are directed to an emergency department if they need to go to it first rather than going to the urgent care centre and being sent on. Some 1,300 patients a month receive care locally.

There is more to do, of course. I absolutely accept that. In Northern Ireland, providing better services for frail and older people needs to be an Executive priority. We need to get everybody behind this, and there are things that we can do such as provide acute frailty units and access to assessment. Veronica, would you like to say a little bit about what you have been leading on to improve those services?

Ms Cleland: Absolutely. In community care, we have a range of services to provide for people in their own homes, whether through district nursing services, which provide services for the more than 8,300 people in their caseload. They look after people with the most complex needs right through to end of life. We have introduced our hospital-at-home service, which provides 40 beds. It is a consultant-led model, and people who have used the service are very complimentary of it.

Average length of stay in it is seven days. We have sites in the Ards and North Down area, a site in the Downe and a site in Lagan Valley, catering for the local populations. In the Downe, we have what we call the Downe acute frailty unit (DAFU), which is an assessment unit for frail elderly people. They have a one-stop shop, basically, where they come in and have their assessed needs met within that period and can return home with the appropriate care.

We have a number of social care packages supporting people across our community services, with an emphasis on rehabilitation and independence. We are trying to move from a model of dependence to enable people to remain as well as they can for as long as they can in their own homes. We work very closely with our GP multidisciplinary teams (MDTs), and we have social work teams as part of that that are helping our population to stay healthy in regard to building resilience and managing to reach out to the community and voluntary sector to provide support for them.

We have a range of AHPs in our community teams, from children's services through to elderly care, across acute cure and every directorate, providing services that enable people to remain in their home and as healthy as they possibly can be.

Frailty is a range of syndromes. A number of issues identify someone as being frail. We are trying to work proactively through falls, polypharmacy and managing people's medications to ensure that they are optimised for individual use. We are trying to keep people at their baseline level for as long as we can so that they can remain independent and able.

I should also say that, as part of that, we are looking to have conversations with individuals. For all of us, there comes a point at which we need to make decisions about what our preferences and options are for long-term care. Through our district nursing services and our partner organisations, we are having conversations with individuals about choice. The last thing that we want for somebody who is at the end stages of their life is for them to be brought in the back of an ambulance to an emergency room. We therefore try to be upstream from that by working with our population to identify their wishes.

Mr McGrath: It was a stroke of genius for the DAFU to get Canon Rogan in to do the advertising for it. That went down very well. I shared that, and people were happy with it.

Perception is everything. I want us to bank what we have. It is a wonderful service, but I say the same thing again: the service that people get is fantastic, but it is getting the service that is difficult. Yes, that is an issue across the region, but it may be just a bit more acute in my area. People can be waiting for a long time. People can be waiting outside the Ulster Hospital in ambulances for 19 or 20 hours. Consequently, people in the community who are waiting for an ambulance wait even longer.

I would love for us to be able to go back to the drawing board with finance and everything else and be able to move the Ulster Hospital 10 or 15 miles down the road so that it was in a more central location. We are losing out because of its location. That 40% of the people of east Belfast use the Ulster Hospital is not good for our population, because it is our only emergency department. I have nothing against people from Belfast, but Belfast has two hospitals of is own. Go to those hospitals, and let us have ours.

The model of the urgent care centre is a model that works. I would love us to have a fully staffed, 24/7 emergency department, with a full hospital behind it. The urgent care centre has fabulous staff, who are doing a great job. While it is there, however, is there any opportunity for its hours to be extended, even by an hour or two a day, in the short to medium term, on the basis that every individual patient who is there, plus any family with them, is one fewer patient who has to travel to the fringes of Belfast to the Ulster Hospital? Is that something that is not off the table? Could we have it left there? Is that a possibility?

Ms Coulter: We could say that we can leave it there, but I am extremely honest, and I do believe that the hours are those that we can provide. The urgent care centre is open from 8.00 am until 6.00 pm, and we then have the GP out-of-hours service from 6.00 pm until 8.00 am. There is that overlap with hospital hours.

What I want to try to do is to get as many patients through there as we possibly can. We will keep things under review, but we need to be realistic. It would knock staff into other shifts, so it is not just a matter of being open for one more hour. Given the workforce challenges that we have in Northern Ireland and the financial environment, it is challenging to expand anything in Health and Social Care.

We are not just standing still and taking in people with the same conditions. Our clinical teams are looking at what we can do more of. They are looking at whether we can take more acute patients or people with different conditions there. Urgent care centres, supported by acute frailty units, is somewhere that we really can go. We can then link into servicing the community. I really want to get the message across about the need to join things up in order to avoid anyone having to come to an emergency department or an acute hospital unless they absolutely need to. That is where we want to get to.

Ideally, I would love to be able to deliver the outcome that no one should leave a care home, unless they have been assessed by somebody, be it a GP, NIAS, a member of the multidisciplinary team or Hospital at Home. Veronica is looking at that. When someone has to leave their own home or care home, the experience is quite difficult . I am absolutely determined to improve ambulance handover times at the Ulster Hospital, because, again, the vast majority of patients in those ambulances are elderly. They are our own family members and relatives. We will keep a focus on that. That I can promise you.

Miss McAllister: I have questions on three topics. One follows on from Colin's question. It is very easy, as a Belfast elected rep, to access all the fancy hospitals in the Belfast area.

Do statistics and evidence show that people are missing out? Are people being denied or losing access to services because the 24/7 A&E is located at the Ulster Hospital? Are people suffering the consequences of that? Do you have any evidence or data for that?

Ms Coulter: I do not. What I will say, however, is that everyone across Northern Ireland has access to a 24/7 ED and that everybody has the choice of which emergency department they attend, irrespective of the trust area in which they live. I think that Colin was referring to rurality. The access is there, in that the facility is open 24/7. We absolutely understand, however, that, in rural areas, there are issues with public transport, meaning that it takes longer for someone to get to the facility. That is a factor. We therefore need to have the urgent care centres in Downpatrick and Lisburn in order to be able to provide that access to urgent care so that patients have to come to the emergency department only if they need to. Those centres are really important parts of the hospital network.

Miss McAllister: Aside from the urban and rural issues, does it benefit the system to detour less serious cases away from A&E to urgent care centres? Does that benefit and transform the entire health system?

Ms Coulter: Absolutely. The departmental review of urgent and emergency care services took place n the past three years. Having different tiers of emergency care services is a helpful model of urgent emergency care. We have our type-1 emergency department, but it supported by three urgent care centres: one in the Downe Hospital, one in Lagan Valley Hospital and one that opened just last year in the Ulster Hospital. Enabling patients who are most acutely ill, whether they need resuscitation or major intervention, to be triaged away from urgent care centres, which are more for people in triage categories 3, 4 and 5 in the Ulster Hospital and perhaps categories 4 and 5 in the others, does benefit the system, because it means that people get quicker access and that there is higher throughput of patients with less acute illnesses.

Miss McAllister: The Belfast hospitals, which do not have urgent care centres, could therefore learn from the more rural areas, which do. Of course, investment is an issue. It is, however, something —.

Ms Coulter: Yes. I think that other hospitals have hybrid models as well. They have not just emergency departments but urgent care pathways.

Miss McAllister: Yes, but, when one goes the emergency department in the Royal Victoria Hospital or the Mater Hospital, it is flooded with patients. It is interesting that we can learn and that it is not always a case of "urban does best". We can have learning from right across all trust areas.

My next question is about breast cancer red-flag referrals. We had quite the discussion about how people have come off waiting lists. You said that you would provide us with answers in writing. Often, however, patients with a red-flag cancer referral have to wait. It is one of the biggest issues that we hear about in our constituency offices. It is really difficult to listen to a very distressed constituent who is waiting to be seen. At the minute, many of those waits are for breast cancer assessments. Following on from the Chair's question on the two-week target, is it realistic, in the current workforce climate, that that target can be met and sustained?

My concern is that we are asking the same people to do more. At some point, will they not be able to do any more?

Ms Coulter: As you know, the breast cancer pathway is only one of the cancer pathways. It is important to retain that perspective. The target of 14 days for urgent assessment for breast care is not applicable to other cancer specialties. We absolutely respect that. It is realistic that we can improve. I cannot say today whether I feel that we can get it down to two weeks. We can model that out and make a projection, but we cannot just ask people to do more. It is the need for about additional capacity. It is about having more clinics. It is about the trusts holding their own clinics. Mega-clinics are held on Saturdays. Moreover —.

Miss McAllister: Who staffs the mega-clinics?

Ms Coulter: Our staff, but that is done at an additional cost. It is not fall within their core hours. We are therefore asking them to do additional —.

Miss McAllister: It is the same people doing more. At some point, they will not be physically capable of doing more.

Ms Coulter: Breast assessments are quite complex, in that a triple assessment is involved. Diagnostics and a medical and nursing workforce are required. There will be more done, now that we have partnered with staff from Forth Valley Royal Hospital in Scotland, which we welcome, so let us see whether we can learn and perhaps change.

Miss McAllister: What would we need to do differently to change the situation permanently? My concern is that waiting times will improve, but then, when the foot is taken off the pedal, because we cannot run our staff into the ground, they will go back up. What permanent change needs to happen? Is there a workforce strategy issue? Is capital investment required? What is required?

Ms Moore: A delivery network has been established with clinicians and operational staff across the entire region. Breast cancer is the example of a specialty that is being talked about in this conversation, and it is a one-waiting-list model. There therefore needs to be a long-term, sustainable solution. The delivery network group is looking at how to do that in the 'long term in a way that, as you said, will not place an extra burden on others.

In other specialties, such as dermatology, I referenced the nurse consultant role. That is about adjusting how we do things differently. It is important to remember that, even though referral demand is up, the conversion rate for red-flag referrals is sitting at around 3%, and that has not changed. For every 100 people, three will therefore be diagnosed. People find themselves in very difficult situations, but, for every one of those 100 people, the pressure is there. We have been there ourselves, worrying until we are seen, so we do understand that.

Ms Coulter: It is really important to monitor not just the number of people on the waiting list. Hopefully, the breast cancer piece is positive for people in Northern Ireland. We are hosting the list for all of Northern Ireland. There were 2,418 people on the waiting list, and, today, there are 1,482. We will continue to make inroads into that figure.

Through the regional cancer network, we also monitor information on the number of referrals, on how long people are on the waiting list and on the percentage of people diagnosed with a confirmed cancer and whether that changing across the specialties. That is extremely important. It is not just about the number of people who are accessing treatment. We absolutely understand, however, how worrying it is when someone is placed on a suspected cancer pathway.

Miss McAllister: When patients are red-flagged, they should be put on to a regional pathway. Even if they are in Belfast and have to travel to Fermanagh, or vice versa, they should be able to go to the first available appointment.

Ms Coulter: Yes, and now that we have that for the breast cancer pathway, that will be the way forward for other specialties.

Miss McAllister: My final question is on respite care. There is some detail in your briefing paper about Redwood Children's Home and Lindsay House. We have corresponded before on consent being given by families. Do we anticipate that the move between Lindsay House and Redwood will be complete by the anticipated date of the end of March?

There is also the question of the dedicated site for one individual, and a business case has gone to the strategic planning and performance group (SPPG). I understand that a business case can go to the SPPG, but has the human impact been mentioned to it? How can we get the SPPG to understand that it is a crucial piece and therefore needs to happen ASAP, because we are talking about very vulnerable families. There is a knock-on effect. There are families in Belfast involved, because the Belfast Trust and the South Eastern Trust share respite services. Can you provide any more detail on that?

Ms Coulter: You are fully up to speed, as that is the current position. We have worked well on making progress. I know that you have communicated with Lyn Preece about the matter. We have met the families. We communicate regularly with them, and they are content with what we are doing for them, particularly at Redwood. I put that in the briefing paper because we are supporting one family at the moment. It is important to share feedback on whether people are happy with what we are doing. That family, who are one of the 'Spotlight' families, are happy with the shared care arrangements that are in place. The family feel that the support has been very positive, and the young person is thriving. By the end of March, we will be supporting two further families. The issue that you mentioned with Lindsay House is the current position, and a bespoke arrangement will be needed, which is complex to achieve. A person's needs are a person's needs, so, irrespective of the business case or the commissioning of the service, we are responsible and will need to find a way in which to provide the service.

Miss McAllister: There have been judicial reviews involving the delays in the Belfast Trust? How can we get the SPPG to speed things up?

Ms Coulter: There are a small number of families in that position, but their children have complex needs. We can keep having regular meetings with the SPPG, and we are doing that. We welcome the focus and attention from the Minister and the Committee, which emphasises the importance of the issue. Short breaks, day breaks, respite and overnight breaks need to be part of the future wrap-around model. Lyn has been before the Committee a number of times, as have the families. The £13 million of investment is extremely welcome for the service, but all the operational leads for the services have made it explicitly clear, time and again, that there needs to be sustained long-term investment in support for children with special needs. That money is nowhere near enough to deliver the service into the future.

Mr Donnelly: We are under pressure with time, so I will bang out a couple of questions. I declare an interest as a bank nurse in the South Eastern Trust. Lots of really good things are going on. Thank you for your presentation and your briefing paper. It is great to see all those things happening. You mentioned violence against staff. All violence against healthcare staff is unacceptable. The Committee has been shocked at the number of incidents that have been reported across Northern Ireland. We visited Antrim Area Hospital and saw the roll-out of body-worn cameras there. We are glad to hear that body-worn cameras will be rolled out in the Ulster Hospital A&E. Did you say that that will happen in April of this year?

Ms Coulter: We are doing it as we speak. We are having planning meetings and working with the teams. It will happen within the next few weeks.

Mr Donnelly: I am very glad to hear that, and I am sure the staff are keen to see body-worn cameras rolled out.

You mentioned a couple of statistics about the forecasted population growth in the number of older people in Northern Ireland. We are all very aware of the statistics, and the numbers are hugely concerning. Have you modelled the need for social care for older people in 2043 by comparing it with the need now? What is the difference in the need? You are being looked at, Veronica. [Laughter.]

Ms Cleland: I cannot give you a plan on a page, but that remains a continual focus for us. As you know from the GP MDTs, there has been investment made in social work to support people.

I talked earlier about building resilience, looking at reablement, helping people remain as independent as possible and redirecting resources to the community and voluntary sector to support people at that point in time.

Our resource is our resource. As far as we are aware, we are not getting any more resources, so we have to manage them from within our current budget. We have looked at a number of different initiatives across communities to support people. That could be discharge from hospital, the support of the early review team or discharge-to-assess teams, people are followed out to their home and an occupational therapy, physiotherapy or social work service is provided there. Our focus needs to be on keeping people well for as long as we can. As I said, we have completed equality improvement work for social care and home care services that was viewed through an equality improvement lens. I have already outlined the figures for quarter 3. That remains a work in progress. There has not been just one fix that has helped with that. There have been multiple factors involved, such as early review teams, discharge-to-assess teams, continual review and assessment, support through different means for people in their own home and redirection to the community and voluntary sector. There is no more resource available that we are aware of, so we have to use our current resource as efficiently as we can to ensure that there is enough to go around.

Mr Donnelly: Significant growth in the number of older people is coming down the tracks very soon.

Ms Cleland: Absolutely.

Mr Donnelly: Your spend, and that of the rest of the trusts, on social care provision for older people will come under significant pressure. Do you have any idea of by how much it will increase, or is it too early to say?

Ms Cleland: It is too early to say.

Mr Donnelly: That is no problem.

Ms Cleland: I do not have a blueprint of associated costings associated, but we can certainly look at the projections. Every individual is an individual, and everyone's assessment of need is an assessment of need. There are lots of older people living in communities who have no need at all. It is therefore difficult to give you a figure.

Mr Donnelly: I appreciate that a lot of work is being done in that area. One of the things that jumped out of your presentation was what you said about the Lisburn dementia behaviours outreach service, which has resulted in a marked 48% decrease in ambulance conveyances and avoidable admissions. By the sounds of it, that is a fantastic service.

Ms Cleland: It is an absolutely fabulous service. When there is someone with dementia behaviours that result in difficulties and challenges in their place of residence, the last thing that we want to do is to take them from their home to somewhere else. Doing that just exacerbates their condition. The Lisburn dementia behaviours outreach service is like a hospital at home, only it is for people with dementia. It will be part of our neighbourhood model.

Mr Donnelly: It sounds very much like a neighbourhood model.

Ms Cleland: Absolutely. There is so much going on in the community. Our staff are doing fabulous work.

Mr Donnelly: Brilliant. The main issue over the past few months has been pressures on the Ambulance Service, on A&Es and on wards, with patient flow effectively being choked in our hospitals. The Chair and I visited Antrim Area Hospital just before Christmas on a Sunday night, and staff told us that patient flow had stopped. Ambulances were stacked up outside, the unit was full and the wards were all full to bursting. We have seen time and time again that there are frequently more medically fit — I think that "medically optimised" is the new term — patients in hospital wards than there are decisions to admit taken in A&E. That seems to be the most pressing issue for patient flow. What would make the most difference? What do you not have enough of? Is it care packages, nursing home placements or dementia home placements?

Ms Cleland: All of the above. On any given day, our biggest challenge is dementia and delirium and suitable categories of care in the sector for people to reside in. We keep a record and report daily on people who are medically fit and those who are medically fit for over 48 hours, and the reasons for that. We have answered a number of Assembly questions about that. We therefore have those stats. I would say that the biggest challenge when it comes to discharge and making sure that people's needs are appropriately met is having care home provision for those with dementia and delirium and providing additional support in the appropriate categories of care. An initiative has just been rolled out by the regional provider collaborative work group to see how we can get the independent sector to engage with us to open up more dementia-specific beds. We have looked at paying them a different rate — an entry rate and then an additional support rate — in order to try to get some interest in the market to cater for those needs.

Mr Donnelly: Absolutely. Dementia-specific care home beds is one of the things —.

Ms Cleland: It is one, but if you look at that issue, there are two levels of care involved. One is residential home care, while the other is nursing care. We are looking internally at our own statutory care provision to see what we can do with residential care. We are looking at whether we can in some way support that to enable people to transfer out of our acute hospitals.

Mr Donnelly: Are the nursing home placements all in the independent sector?

Ms Cleland: Yes.

Mr Donnelly: Is it true that those beds do not exist at the minute?

Ms Cleland: Twice daily, we ring around. There is a care home app in development, but we ring around to see what is available. On most days, we will find one or two beds, or perhaps no beds. It is extremely difficult to find beds.

Mr Donnelly: Given what Roisin said earlier about the projected increase in need, we are going to be under great pressure.

I will move to a different subject. Is it correct that it is now 19% of ambulance handovers that take over two hours?

Ms Coulter: Yes.

Mr Donnelly: That is quite a significant improvement, is it not?

Ms Coulter: It is. Again, I could talk to you all day about that, but I will not. I am very aware of the time.

The Chairperson (Mr McGuigan): I will not allow you. [Laughter.]

Ms Coulter: I will, however, provide you with an assurance that there is a genuine and relentless focus on that from every member of our executive management team and our clinical teams. We want to demonstrate a sustained improvement. Yes, it was 56% in January, while, last week, 19% of ambulances were waiting for over two hours.

We are doing 20 things right across the whole pathway to try to reduce ambulance handover times. We want to deliver for the right reasons, which are patient experience and patient safety, but we also want to step up and share the risk that our Northern Ireland Ambulance Service colleagues have. If an ambulance is outside an emergency department, it is not available to respond to somebody in the community. We therefore need to take ownership of that shared risk, and we do.

To a major extent, the issue is not really with the front door, which is people coming to the emergency department, or with the back door, which are the discharge pathways that Veronica mentioned. The biggest challenge is the bit in the middle, which is the length of stay: how long people are staying in our hospitals and what we can do about that. That is why we are looking at every other part of the pathway that I mentioned. That is what we are doing. There is a hospital-community flow oversight group for our clinical teams that is co-chaired by our medical director and our director of nursing. That is one of our biggest focuses.

Mr Donnelly: You said that 40% of patients who attend your A&E come from the Belfast Trust area. Are you financially reimbursed for that? Is there any agreement between the trusts? Forty per cent is a huge percentage.

Ms Coulter: My understanding is that we work very closely with the SPPG. It commissions based on volumes, so it will commission us based on ED attendances and the number of outpatients, inpatients and patients getting day procedures that we get, so it is based on volumes, irrespective of the trust of residence. There is a lot of flow across trust boundaries in Northern Ireland. That is only going to increase as we look at having more regionalisation and rationalisation of services. At the moment, commissioning is therefore based on volumes.

Mr Donnelly: I know that the geographical boundary of your trust is very close to that of another trust. The Ulster Hospital is very close to Belfast as well. That is great. Thank you very much.

The Chairperson (Mr McGuigan): Not to eat into other members' time, but I note the reduction to 19% in ambulances waiting for over two hours. You said that you were doing 20 things. Is that reduction as a result of the 20 things that you are doing or as a result of things that the Ambulance Service is doing. How much of it is just a natural reduction from the busiest time of the year to now?

Ms Coulter: It is not a natural reduction, Philip. Our teams would say that, by the end of February, we would expect to see a decrease in demand for unscheduled care in emergency departments. This winter, however, we have not seen that, and that is the case right across the region.

It is about a concerted focus on sharing the risk with the Northern Ireland Ambulance Service (NIAS). Right from the start in a person's home, it involves thinking about whether the Northern Ireland Ambulance Service needs to go to an emergency department in the first place; whether there are alternatives such as referral directly to Hospital at Home; whether there is a way to avoid admission by staying at home and maybe being visited by the community team the next morning; or whether they can go the ambulatory hub. It is about looking at every single part of that and only conveying people to hospital if they absolutely need to go.

Hospital at Home is doing a great job of —. That is where we want to get to. We want to get close to people's homes or in their homes. The Hospital at Home team is pulling directly off the NIAS stack twice a day. It looks at all the people who are sitting on the list for an ambulance and says, "If Hospital at Home supported that person, they might not need an ambulance in the first place". It is about putting a relentless focus on every single part of this. We want to try to improve that. We know that it is a national pressure, but we need to keep looking at the shift to community, because that is where the prize is.

Mrs Dodds: Thank you for the presentation. Like others, I record my thanks to everyone who works to deliver a service in sometimes very difficult situations. May I take you back to the waiting lists? I hope that I have written this down properly. On 31 March 2025, you had 22,108 patients waiting four years or more for a first consultant-led appointment. Have I taken that down right?

Ms Moore: Yes, that is correct.

Mrs Dodds: You said that, as of, let us say, the end of February, there were 8,622 patients waiting, which is a reduction of 61%. By my primitive calculations, that means that 13,486 patients have come off the waiting list. How many of those came off as a result of waiting list validation, in whatever form it took, and how many came off as a result of being treated?

Ms Moore: As of yesterday, it was 8,422, so another 200 have come off since we produced those figures in February.

Mrs Dodds: You are upsetting my wonderful calculations. [Laughter.]

Ms Moore: I know. I pay testament to the number of people who are working so hard in their departments to do that. An element of it is admin validation, and we can send you those figures —.

Mrs Dodds: All I am asking is whether you have a global figure that tells me how many came off through waiting list validation, whether that was administrative, clinical or whatever, and how many came off after being treated.

Ms Moore: A number came off through validation. The number for the totality of the trust, including allied health professionals and community care, is sitting in and around 26,000. In the hospital setting, it is just shy of 18,000. There were a lot of steps in that process and in the validation that was carried out.

Mrs Dodds: I am using the figures that you gave me in your presentation. Just for ease, so that we know exactly, you said that there were 22,108 patients. This is your —.

Ms Moore: Sorry, I gave you the figures for all in-stays and outpatients. Apologies. I have just realised that.

Mrs Dodds: There were 22,108 patients — we have it here in front of us, if I can find it now — waiting four years or more for a first consultant-led appointment. That was at the end of March last year. Now there are only 8,622. That means that now there are 13,486, just working with that figure and no other figures. How many of those patients came off the waiting list through validation and how many came off because they were treated?

Ms Moore: I will forward you that information in detail. I know that that process has been carried out. The teams back at base are monitoring that on a weekly basis.

Ms Coulter: We will send the split.

Ms Moore: We will send the split.

Mrs Dodds: I would like to see the split.

Ms Moore: You can. Absolutely. Yes, it is there.

Mrs Dodds: A reduction of 61% is brilliant, but we need to know how many of those people were treated. It also says something about — I keep harping on about this — the quality of the data that is held on waiting lists.

Ms Moore: Just to explain that by one speciality, in gynae, an inpatient chart validation was carried out of 397 patients. At that point, 52 were removed. The next stage was to look at telephone validation; that was the clinical validation. They took 284 charts at that point and removed 99 patients. The clinicians then did a face-to-face validation, which meant seeing patients face to face. Of 62 patients who came in at that point, 16 were removed. There is a lot of detail behind the figures.

Mrs Dodds: Out of that gynae list, how many were actually treated? There are a lot of figures for me to add up in my head. It would be great if you could send us that information.

Ms Moore: We can.

Mrs Dodds: The debate is, first, about how many people are treated. I know that the 61% reduction refers to a specific focus on the waiting list of four years or more, and I accept entirely that, if someone waits four years or more, things are likely to have happened in between that mean that they no longer need the service for whatever reason, but I just want to know, if we are talking about a 61% reduction, how many were treated.

Ms Coulter: Absolutely, Diane. I get that. If we want to show how true and accurate the waiting list is, we need to show how many people are being treated.

Mrs Dodds: The other element that we need to explore in detail is the data that we keep on waiting lists. We have been saying this about our waiting lists for years, and you are telling me about a gynae waiting list that came down to virtually nothing. There is something wrong with the way that we are recording —. I accept entirely that it is also about the length of time that people are on the list and that people, sadly, go private, pass away, need a different service or are no longer fit for the service that they were waiting for. We need to interrogate the way in which we hold the information. We also need to understand the number of people we treat. A lot of work has been done around scopes etc, and a lot of figures have been given in that regard. I would really like to know, of the people who have, say, a colonoscopy, how many are treated and how many go on to a treatment pathway. It is a bit like what you said about red-flag cancer referrals — only 3% of them are actually converted. We just need to understand what information we hold and what we are working with. Global reductions such as 61% sound amazing until we start to dig into the information.

Ms Coulter: Absolutely. We will get both of those. For example, to find the number of people who get a colposcopy and then move on to a different treatment pathway, you would have to look manually into an audit of the last 100 colposcopies that had been carried out.

Mrs Dodds: Would Encompass tell you that fairly quickly?

Ms Coulter: Yes. We could do that. We could pull that information from Encompass.

Mrs Dodds: I thought that that was one of the benefits — the "whizz" — of Encompass. I am looking forward to getting all this information now.

Ms Coulter: We will send that breakdown. I agree that that is important.

Mrs Dodds: It is just so that we know the real state of the waiting lists. How many people are still on the waiting list for a first consultant-led appointment who have been there for under four years?

Ms Moore: I do not have that detail with me off the top of my head.

Ms Coulter: I think that that has just been published in the quarterly reset statistics.

Mrs Dodds: I understand that. Perhaps you can include that so that we can start to understand what is happening in relation to waiting lists. That is important.

Another thing I have asked of every trust: if 2% is supposed to be transferred from your secondary care budget into your primary care budget to accommodate a shift left, what new services do you envisage? Having been around for as long as I have, as Colin said very nicely, I do not want to see repackaged ideas. What are the new things? What are the things that are going to really make a difference so that you can move your budget to the services that people will get closer to home? I agree with you, Veronica, that the aim of no elderly person having to be taken out of a care home because they need fluids or whatever is the way forward. That should not be impossible to achieve, sure it should not, please?

Ms Cleland: I cannot tell you that you are not going to get more of the same, but I think that there are some wonderful services out there. We need to expand those services to achieve greater and to be able to reach much more of our population.

Mrs Dodds: If I were to come back to you this time next year, what service would you have expanded, then, first of all?

Ms Cleland: One of the examples that we are looking at currently is our Hospital at Home service. We have invested in that, and we have our 40 beds. We have an evaluation that shows that that is very productive and good and that it is the right model and is what people want. We need to expand that service, but doing that within our current budget is extremely difficult. Therefore, we have got support from technology to help us. One of the initiatives that we are looking at is with a company. I probably cannot say what company that is, but that company is building an algorithm that will help us to determine who can be treated and who can be discharged from the hospital earlier and free up the hospital services and enable them to be treated and finish their treatment journey in their own home.

Another initiative that we are working with in regard to technology is looking at virtual monitoring and at how we deliver services differently, so —.

Mrs Dodds: We used to do that, did we not?

Ms Cleland: There used to be —.

Mrs Dodds: I remember, way back in the day, in the European Parliament, talking to people about that sort of thing. I think we called it "telemonitoring" then, did we not?

Ms Cleland: Telecare and telehealth are still part of what we deliver in health. We have recently completed a cardiovascular project, and I heard a gentleman speaking about the difference that the introduction of virtual monitoring right through to a central point made to his life. He was not coming back for review appointments and follow-ups; he was in control and had a person to speak to. We are hoping that, rather than a nurse or a healthcare professional driving down to the very end of the Ards peninsula to do a set of observations, we will be looking to see how this will help us and inform us and reduce what we are doing, making sure that client safety and client treatment and care is appropriate. Those are a couple of initiatives that we are looking at. We also need to work more closely with the community and voluntary sector. I said earlier that we need to support people, we need to support resilience and we need to look at how we do things differently. What is available in local communities and local neighbourhoods, looking after one another? As a society, how we manage this period and the period that we are going into in regard to older people will speak volumes, and we have to do this right for our older population. We have lots of great ideas, and we have so many committed people who go the extra mile all the time. They work across the various premises, and it is about how we support them to do it and to do it differently.

Ms Coulter: Just last week, I received some very positive feedback from SPPG — from the meeting that you had with it, Veronica — on some of those services where the neighbourhood model is already being done, so we are bringing new services. It is absolutely the right thing to make that shift, irrespective of the financial position. There is a lot of positivity regarding the 17 integrated neighbourhood teams that are going to be implemented in a phased way over 2025-26. I want to make sure that there is no duplication, that it is all truly integrated and that we are making sure that everybody has a part to play, appreciating the central and pivotal role that our general practice colleagues will have in the neighbourhood model. That is important. We need our general practitioners to enable us to work, and we need to continue to develop the role of community pharmacies. All of that will be important in the neighbourhood model. That is not to forget in any way the importance of the patient voice. Service users and carers need to be really listened to and engaged with in going forward with the neighbourhood model. That is recognised.

Mrs Dodds: Where are the pressures with your social work workforce? I ask you that question because people talk to me about two levels of pressures. One is the regional emergency service.

Ms Coulter: The emergency out-of-hours service.

Mrs Dodds: They say that that is very understaffed and is under a huge amount of pressure etc. The second pressure is on the allocation of social workers to families in need. I get both of those issues, not just in relation to your trust but in relation to all of the trusts. We have also been looking at the Adult Protection Bill, which talks about adult protection social workers. One thing that I think might happen — I am positive that the people who are working on the Bill will not allow this to happen — is that we will displace social workers from one area to another. We have not touched on that, but it is hugely important in reaching out to families in need, particularly those looked-after children. Like Órlaithí, I have had the experience of going into a school where two teachers took children home. Those children are still with them.

Ms Cleland: That is very sad.

Mrs Dodds: It is very sad, but how amazing that a teacher —.

Ms Coulter: That people can do that.

Mrs Dodds: Yes. How amazing.

Ms Cleland: As you outlined, Diane, it is about growing caseloads and a growing number of older people living at home with very complex needs. Some people are very lucky and are supported by families and close-knit local communities. With other people, not so much, and they are obviously much more vulnerable. We have growing caseloads, and we need to look at how we make sure that there is enough to go round. As I said, it is about reablement and making sure that people have the right intervention at the right time to help them stay —.

Mrs Dodds: Where are the pressures in your workforce?

Ms Cleland: Growing caseloads in older people's services.

Mrs Dodds: Do you have a percentage of vacancies in your social work teams?

Ms Cleland: Yes. We have vacancies across all our services, including hospital services. The discharge teams are hospital-based social work teams. We are working at 65% capacity. That is not because of vacancies; it is because people are unwell and unfit to come to work. Equally, we do not have vacancies in our community teams. There is no vacancy control with regard to front-line staff. We have a full quota of staff, but we have people who are unwell and are unable to come to work.

Mrs Dodds: It would be really interesting for the Committee, because this will be an issue going forward — well, it is an issue now — your experience of the regional emergency social work network. Either vacancies or the reasons why you think people are sick and unwell — is it workforce pressures? What is going on?

The Chairperson (Mr McGuigan): Very quickly, because I need to move on to Alan.

Ms Cleland: Obviously, I cannot speak to every individual case.

Mrs Dodds: No, but just give broad figures so that we can understand.

Ms Cleland: We can get you broad figures, but, on your final point, we absolutely welcome the Adult Protection Bill, because we think that it will bring a very positive note for social work moving forward.

The Chairperson (Mr McGuigan): Thank you. Alan.

Ms Coulter: Sorry, two seconds. The target absence rate is 7·6%, and, from April to December last year, our rate was 8·23%. The two biggest reasons for people being off sick in the health service are stress, whether work-related or personal, and mental health issues, and that is the case for both long-term and short-term absence. You are absolutely right: it is a key part of this reset. We have that relentless focus on absence every single month, really looking at how we can support people to come to work, to feel safe at work, to feel valued at work and to stay at work. We need to constantly look at that balance, because that is public money and resource.

Ms Cleland: Can I also —?

The Chairperson (Mr McGuigan): No, I need to move on to Alan.

Mr Chambers: I am very pleased, Roisin, to get an opportunity to once again pay tribute to and thank your staff across all sections for the level of care that they provide to patients in your trust's facilities. It was also good to get a trust briefing that contained so much good news. An awful lot of work goes into creating good-news stats; it does not just happen. Well done. We can poke at waiting list figures and query things, but the reality is that a lot of extra work is going on in theatres and outpatient clinics. In reality, more patients are receiving treatment, and we should rejoice in that fact.

It is always said that the health service's greatest asset is its staff. Danny mentioned it earlier — I did not catch the period — but you said that there had been 1,911 incidents of violence against staff. Does the majority of that happen in accident and emergency, or does some of it happen in ward settings or even in outpatient clinics? Have you put in place, or are you developing, a strategy to address that appalling situation? You have talked about body-worn cameras, which may help. My last question is this: do you have a system in place whereby a staff member who is a victim of violence, which may be physical rather than verbal, can summon urgent assistance?

Ms Coulter: Thank you, Alan. Thank you for your feedback, which is very much appreciated.

Your question was about managing violence and aggression. That was the figure for the period from April to December last year: 1,911 members of staff experienced some kind of incident in that time. Of the 1,911 incidents, 1,200 were physical assaults.

Mrs Dodds: Shocking.

Ms Coulter: The highest number is not in the emergency department. There are incidents of violence and aggression across hospital and community settings. The vast majority happen in the adults' and children's directorates, whether that is in mental health, learning disability, healthcare in prison — there are lots of different things. One thing that we are doing about it is making it extremely clear at every opportunity that it is totally unacceptable for this to happen to anyone working in Health and Social Care; everyone should have a safe place in which to work. A second thing is making sure that we have good governance arrangements in place to support staff. We take a regional approach to staff health and well-being. We have a framework for managing violence and aggression. We have implemented a management of violence and aggression oversight group. We are doing lots of things — about 12 or 15 responses, whether it is occupational health, training in managing stress in challenging environments, and individual support — making sure that, if anything happens to someone, they have wrap-around support. There are lots of things in our support toolkit, but what we really want is to avoid this in the first place. Body-worn cameras are a positive step, but we want to send a message to the public that says, "Please be courteous and respectful, and appreciate that people are doing their best". It is fair to say that we know that people receiving or waiting for care might be at their point of greatest need, and we recognise that sometimes it is a symptom of the place that they have found themselves in.

I go out and about as much as I can, meeting staff and listening to managers who are supporting staff who have experienced incidents. Last week, when I met staff in the Ulster Hospital canteen, I heard about some very significant incidents in which members of our team had come to harm. There was a situation in the emergency department of the Ulster Hospital in which someone was physically assaulted. The use of a razor blade caused them significant personal injury, and that resulted in a conviction. That is the level of risk where people are working. It is not just about body-worn cameras; it is about a culture. It is important to realise that it happens across the piece. There are reasons and drivers, but it is about making sure that I know exactly what is happening, where it is happening and what we need to do to support people. We have a number of toolkits available to support staff.

In the main, people find it difficult to access healthcare, but, when they receive it, they feel that it is of a high quality. It is about managing that interface. We have a security response from our teams on our hospital sites, which is important, and we are also supported by our PSNI colleagues. It is a wrap-around approach, but it is a big focus.

The Chairperson (Mr McGuigan): We will probably write to you about the information that you have promised us. There is one question that I want to ask. There is validation, there are people who are treated, and you are looking at the number of people who are on waiting lists for over four years. If you look at that every six months, you will see that people have been added to that list. It would be useful to have that information.

Ms Coulter: Yes.

The Chairperson (Mr McGuigan): Obviously, we want to prevent people reaching that four-year point, so the number of people going on to that list is another piece of information that we would like to have.

Thank you very much. That was very useful.