Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome Professor Mark Taylor, regional clinical director of elective care; Lisa McWilliams, director of acute planning and performance; and Joanne Elliott, interim director of elective care and cancer policy. Mark has to be away by 3.15 pm, but the other two members of the team can stay on if need be. We have moved you up the agenda to get started straight away. Given the time constraints, I appeal to members to be brief with their questions and to witnesses to be brief with their answers.

We have received your briefing papers, but I will hand over to you for some opening remarks before we move to questions.

Ms Joanne Elliott (Department of Health): I will make the opening remarks, if that is OK. Chair and members, thank you for the opportunity to brief you today. I am joined by my colleagues Lisa McWilliams, director of acute planning and performance, and Professor Mark Taylor, regional clinical director of elective care. I will briefly cover our headline achievements to date on elective care, the funding position, governance arrangements and the position looking ahead in 2026-27.

Reducing waiting lists has been one of our greatest challenges. The reasons are clear: rising demand, years of financial constraint and a slower pace of reform than is needed. Against that backdrop, the Department's elective care framework (ECF), published in May 2024, sets out a five-year plan for a system that is sustainable, equitable and efficient. The plan covers service transformation, backlog clearance, productivity, workforce, independent sector (IS) engagement and patient communication.

While waiting lists remain long, there has been clear and measurable progress through the implementation of the elective care framework, particularly in relation to reducing the longest waits. Since April 2025, we have delivered more than 237,000 additional appointments, diagnostics and procedures. That exceeds the Programme for Government target of 70,000 additional treatments. We have seen reductions of between 76% and 99% in the number of procedures where patients have been waiting for more than four years. Overall, the number of patients waiting for more than four years for outpatient appointments has reduced by around 50% and, for inpatient and day-case treatment, by around 62%. While the overall system remains under pressure, there has been real progress for those waiting the longest, which was one of our key priorities.

It is, however, important to be clear on the funding position. While £215 million was identified in the Programme for Government and last year's Budget, only £50 million of that represented new funding. Some £85 million was directed towards red-flag and time-critical patients, which largely reflected our existing pressures and commitments. The remaining £80 million had to be found from within the Department's baseline. As a result, £73·5 million of the £80 million was returned to address the Department's significant deficit, with a proportion available for wider capacity building. The progress this year has therefore been achieved within difficult, constrained financial parameters and with significantly less new funding than the headline figures might suggest.

Despite those constraints, the Programme for Government commitment provided us with a clear focus. That is reflected in increases in core capacity, targeted backlog clearance and use of the independent sector as well as improvements in productivity and efficiency. It is important to emphasise, however, that, while activity has increased, demand continues to outstrip capacity, which is why, overall, our waiting lists remain long.

Waiting list validation has been of particular interest to the Committee. As members are aware, there has been considerable focus on validating the longest waits. Our waiting lists are dynamic. Patients are added and removed on an ongoing basis. While patients are continually removed from lists through their assessment and treatment and for clinical, admin or other reasons, new patients are being added. As a result, the overall size of the waiting lists might appear to be relatively static despite the significant underlying movement of significant numbers of patients entering and leaving the lists in a given period. Validation activity supports delivery by improving the accuracy of our waiting list data and enabling available capacity to be targeted more effectively. I know that the Committee is likely to have questions about validation, which we will be happy to answer.

I am aware that the Committee also wants to discuss governance. We can provide assurance that robust governance arrangements are in place. Delivery of the elective care framework is overseen by our elective care management team, which has representation from the Department, trusts and clinical leadership. At an operational level, our strategic planning and performance group (SPPG) monitors activity and spend monthly. There are regular performance meetings with the trust, and there is formal reporting to the Minister.

As we look ahead at this financial year, the position remains challenging. The proposed funding for waiting lists set out in the draft Budget is essential to allow us to maintain progress in red-flag procedures and to build core capacity. We are mindful, however, that the draft Budget has no additional funding for backlog reduction. Despite that, work is under way to develop a new plan, and the Minister is clear on the importance of maintaining momentum, continuing to prioritise our long waits, building capacity, reforming service delivery and improving productivity and efficiency across the system.

In summary, we have delivered significant additional activity and reduced some of our longest waits. That has been achieved within a constrained funding envelope. Strong governance arrangements are in place, but sustained progress will depend on addressing the underlying demand/capacity gap. We are happy to take your questions.

The Chairperson (Mr McGuigan): Thank you very much. Your highlights include some of the things that I expect us to explore. Reducing waiting lists is an Executive priority and, certainly, a priority of every MLA. I am assuming that because our constituency offices are continually contacted by distressed patients or the families of people who are suffering on lengthy waiting lists. We wish you well in your work and hope that you succeed, but the Committee's role is to ask questions in order to scrutinise how a substantial amount of public money is spent and whether it is being spent efficiently. We will, hopefully, get the balance right today.

Some 100,000 validations have been completed. It is difficult for the Committee to understand whether waiting lists are reducing as a result of validation or of patients having operations and other treatments. Can you give us an unequivocal answer to that question?

Professor Mark Taylor (Department of Health): First, thank you so much for accommodating me today. Secondly, I thank you for the scrutiny, because we very much welcome that. It gives us an opportunity to thank everyone in Health and Social Care (HSC), because, as we will demonstrate, there is real activity on top of validation. It is about patients. Often when we talk numbers, we forget that people are suffering, and your constituents are a timely reminder of that.

Validation is, in its simplest form, something that, as clinicians, we do all the time: we are always triaging on the basis of need. However, when you have long waiting lists, it is extremely important to ensure that you have administrative validation. That simply means that an individual on the waiting lists of five different trusts is counted as five instead of one; and administration where people are still on a waiting list but have sought treatment elsewhere needs to be rectified as well. I will bring Lisa in with all the granular detail and breakdown of the number that you mentioned, but, when we look at the clinical detail, we see that someone waiting five or six years for surgery or a procedure may no longer need that. It may not be still indicated, or, more importantly, they may not want it. If you have not had any symptoms relating to the gall bladder or tonsils or a hernia in five years, do you really want the risk of surgery versus what is perceived as having no benefit?

Validation is extremely important. It is definitely not some way of artificially making our numbers look better, because that does not benefit any patient. You are here today with an operational lead, a policy lead and a clinician, who all want to see every patient get timely access.

Chair, if you do not mind, I will bring Lisa in.

Ms Lisa McWilliams (Department of Health): Thank you. Chair, the number that you mentioned — the 102,835 records that have been validated — is targeted work, as Mark described, to have a look either administratively or clinically. As a consequence of that, we have a validation figure of those patients who were removed, so we separate that from activity. I will give you those.

As a result of those 102,835 records and individual patients having been looked at — we have outpatient information; we do not have ins and days treatment because of coding. The 102,835 figure relates to the totality of what I am talking about. The admin validation for outpatient removal sits at 42,992. Clinical is at 4,515. Those are captured as true validation. We are not claiming activity with those. That is an exercise.

It is probably helpful for me to talk about activity and give you assurance. We have a number of pockets of money with activity ascribed to them. For the £85 million, which is the red-flag and time-critical area, the 237,536 patients are all activity. We have a breakdown of just over 44,000 new outpatients and 11,000 review outpatients. I am rounding the figures down. Diagnostics is just over 149,000; inpatient or day-case treatments is 15,000; and allied health professional (AHP) assessment and/or treatment is 17,376. That activity has been done through additionality in the trusts or insourcing or IS. We can attribute spend to every piece of that activity, so that is true activity in that pocket.

The Chairperson (Mr McGuigan): What is the total if you add all those figures up?

Ms McWilliams: It is 237,536. That is the January position. We have unvalidated figures for February, and we will still get March. We are not in a position to give you a total year, but that is true additionality.

We then have mega-clinics, where individuals have been seen. The April to January position for mega-clinics, which is for an assessment and sometimes a diagnostic test, is 8,474 patients. That is only a part-year effect, but it already exceeds what we did in the previous year, which was 7,034.

As Mark talked about, we also targeted a cohort of patients for treatments explicitly: four years for some of the adults and different targets for the paediatrics, recognising the developmental aspect. We have information that shows that movement. Joanne has gone through some of the high-level reductions in that. However, sitting alongside that, because some of that would have been validation, we have actually captured what was additional backlog activity. That includes those procedures and anything else that we have been doing. The actual backlog activity for January is some 28,858, and that is news, reviews, diagnostics and treatments. We are trying to be as clear as that on true activity.

We then have primary care elective activity that, for the year to date, is just over 12,000, with 10,500 of those face to face and 1,500 remote. That activity is in gynaecology, dermatology, musculoskeletal (MSK), minor surgery and vasectomy.

That is true activity, excluding validation, so —.

The Chairperson (Mr McGuigan): I will jump in there, because I want to ask a number of questions.

Such news is always very positive, and we are delighted to hear it. This subject is a bit like a see-saw: when you read one table, the news seems great, but the next table provokes more questions. I am not arguing that it should not be done in that way, but what is happening is that those who have a four-year wait are being dealt with first. That is appropriate, but it seems that the number of people in the middle, who are waiting one, two or three years, is expanding. Whilst the activity is reaching those who are at the far end of the waiting list, which, as I said, is ultimately very appropriate, the waiting lists are not really getting any shorter, because the section of people who are waiting a very long time is getting longer. Am I correct?

Professor Taylor: You are absolutely right, Chair, in that, if our strategy were simply to look at the people who wait for over four years, we would simply be looking at that cohort of people — the longest waiters — and would be forgetting about all those people who are waiting for what are, let us be honest, totally inappropriate lengths of time. That is why the elective care framework has a multiple-pronged attack.

It is important, for all our clinicians and administrators, that we recognise that, despite the many pressures, of which the Committee is familiar, there has been a sense of urgency. That sense of urgency was facilitated by additional money, but with a focus on having to do all that we can on theatre productivity, outpatient productivity, insourcing — people in-house coming in at nights and weekends — and the use of the independent sector. Yes, there are those four-year waits, and it is important to say that, but the other area that we have been looking at absolutely ferociously is levelling up any variance of practice. I saw that Alan was looking through the breakdowns of numbers for the individual trusts in the papers, and we are going through all areas of variance in practice to ask why. Quite often, there are clinical reasons. I am a surgeon who does one operation a day. Am I a very lazy surgeon? No, it is an operation that takes eight hours, as opposed to a surgeon who does much smaller procedures.

The focus is now on how we build up capacity using the elective overnight stay centres. As an example, if you were to go into an ambulatory unit today with gall bladder pain, I would not want you to go on a waiting list; I would want you on the list to have your gall bladder done on Tuesday of next week. That is one end, and the backlog is the other end. The bit in the middle, to which you referred, Chair, is what we trying to focus on, specialty by specialty, asking, "Do we need to see everyone in outpatients?", "Do we need to see everyone before they get the test?" and "Do we need to see those individuals afterwards?". There are 1·3 million outpatient appointments in Northern Ireland every year. We are asking whether we are sure that every single citizen is meant to be in those seats. We have the wonderful opportunity, with Epic, for patient-initiated follow-up, advice and guidance and enhanced triage to deal with it.

In summary, you are absolutely right: if we were dealing with just the four-year waits, we would just be moving the chairs on the Titanic. We are, however, trying to look at all avenues.

The Chairperson (Mr McGuigan): You mentioned focus a couple of times. Red-flag treatment needs to be a particular focus, and it is certainly a focus of the Committee. Cancer Research published a report today, and it does not make for great reading, to be honest with you. We are still the weakest part of these islands, and probably of western Europe, in having the longest waits for cancer diagnosis and treatment. Only 31% of patients are treated within 62 days of a red-flag referral. That is not great. What is your focus when it comes to ensuring that we meet targets for red-flag referrals?

Professor Taylor: I will bring Lisa and Joanne in on that, but first I will say that cancer is on the rise — that same report refers to a 14% increase. It also states that outlook and outcomes have improved. It is important to say that the problem is with access, not treatment when you get to the clinicians who are there to administer the care. As a cancer surgeon, I stand proud of the care that we give to cancer patients in Northern Ireland.

Ms McWilliams: I will pick up on a couple of points. There are investment priorities for the red-flag and time-critical area. The time-critical component of that is cardiac surgery and vascular work. In the main, however, it is the red-flag component. A lot of the investment is about speeding up access to diagnostics, use of the rapid diagnostic centres and having more timely diagnostics. With the 14% increase in incidence, we have a pick-up rate of about 3% for more referrals. The referrals are also substantially higher, so the diagnostic component is really important.

You asked about what is happening in the middle with the routine emergents. By tackling additional diagnostic activity, the wait for more than two weeks for red-flag CT scans has reduced by 23% and waits for MRI and non-obstetric ultrasound for all categories have reduced. MRI waits are down by 18%, despite an 8% increase in demand year-on-year, and non-obstetric waits are down by 14%, despite a 4% increase. We are really targeting diagnostics.

There are lines of investment at specialty level as well, including demand management actions. With dermatology, for example, we are investing in additional clinical nurse specialists (CNS) but also in an AI tool that should see 9,000 suspect red-flag referrals that get into the system not coming into the system, because the AI technology is so good that it would put people's minds at rest almost immediately. We are investing in all those. Dermatology is a good example because of the sheer volumes: 9,000 people could be taken out of the number who absolutely need to be seen, going straight to test and biopsy as opposed to having a very long wait.

We have current investments from the £85 million in endoscopy and diagnostics. I talked about dermatology and gynaecology. There are also investments in general surgery and urology. A lot of it is about having a skills mix to be smarter with what we have and be clear in our resourcing. Urology is a good example of where we have invested through collaboration, because scopes are being done in regional day procedure centres, which include urology. The South Eastern Health and Social Care Trust does laser and aquablation for the region; the Southern Health and Social Care Trust does stomas for the region; Belfast Health and Social Care Trust has the robotic for the radical prostatectomy; and the Western Health and Social Care Trust treats penile cancer. By doing that, everybody on those pathways can be seen in a more managed way. There is good and important collaboration across the system.

The Chairperson (Mr McGuigan): That is really good. Professor Taylor, you said that, when a patient gets into the pathway, they get a really good service, and I concur totally with that.

The earlier a person with cancer is diagnosed, the better chance they have of success, and probably the more cost effective the treatment. Screening and diagnosis are obviously vital. I could pick any type of cancer, but I am going to pick bowel cancer, because the age for screening in the North is 60. It is 50 in Britain and, I think, 57 in the South, so we are an outlier. If a person can be diagnosed earlier, treatment is less complex, it saves resource, and the person spends less time on a waiting list. It would, in my view, be much more efficient if people with bowel cancer and all kinds of cancer were being screened earlier. How can the Department rationalise screening at 60 and not earlier?

Professor Taylor: The management of cancer is preventative. Early diagnosis and successful monitoring afterwards are important. With any one cancer that we could choose today, there is so much work that we need to do in the preoperative area, the neighbourhood and all the reset plans that have already been described, and then, obviously, in the diagnostics. One of the challenges is that we are now seeing a dramatic rise in the number of requests for CT scans. We are looking at the issue with the imaging board to see whether it is appropriate to get a CT for everything, and I mean in the unscheduled environment. There are conditions that do not need a CT, but we seem to be in a world now where they are used more. In some ways, that is robbing Peter to pay Paul, so we have to be clinically specific in the diagnostics that we are using. It is a bit like with outpatients. In a limited financial world, with a limited capacity and a rising demand, we have to use them in a better way.

On bowel cancer screening, there is absolutely no doubt that we are behind our colleagues in the United Kingdom, but any one particular subject today will come to the same conclusions: we have a finite budget, we have a massive backlog, and we have the now to treat. I absolutely agree that we have to think of earlier diagnostics that might save us money down the line but, more importantly, save patients down the line.

Ms Elliott: I will come in on that from a policy perspective. As Lisa alluded to, in the elective care framework, there is considerable focus on the cancer red flag through the funding that is available there. Alongside that, we have our cancer strategy. A huge infrastructure sits below that cancer strategy, with clinical reference groups for tumour sites. It is clinically led and driven, and a huge volume of work that sits beneath the cancer strategy goes on to drive that forward. Aligned with that, we have our public health agenda, with screening, prevention and messaging. Cancer is not seen in isolation; it really is an umbrella.

The Chairperson (Mr McGuigan): On the specifics of all that work, will the Department consider reducing the age for screening, for example, for bowel cancer?

Ms Elliott: I do not have the answer to that question at the moment, I am afraid.

The Chairperson (Mr McGuigan): OK. Moving on, I have two very quick questions. You talked about value for money and cost. Obviously, the Executive have given a lot of money to reduce waiting lists, and some of that is being spent in the independent sector. We are in a needs-must scenario. I was sent a job advert prior to Easter. I do not want to mention it too specifically, but a private clinic here in the North was advertising for a consultant, and it was offering a £400,000 salary. I nearly fell off my chair.

When it comes to the efficient use of money and dealing with waiting lists, do we have the balance right here in sustaining our NHS, where patients can access the treatment that they need free at the point of delivery, and not funding an ever-expanding private sector where we reach a tipping point? I want to be assured that what we are doing and the money that we are spending is being done sustainably to protect our NHS, as well as our patients.

Professor Taylor: I have one line, and then I will bring Lisa in with the granular detail. The whole emphasis of the multi-pronged attack to dealing with our waiting lists is that in-house is much better for a multitude of reasons: same staff, working conditions, looking at productivity, efficiencies, early starts, late finishes etc and using those same staff for overtime. There is no doubt that, when you have the backlog of the waiting lists that we have accrued over a number of years, you need all the help that you can get. That is where the independent sector has been coming in to deal with those long waits. We are also using that as a model for how we can bring about the same types of efficiencies in the NHS that you see in the independent sector. That is the goal.

The second issue is that, unfortunately, we are in a market where you can easily go to the South of Ireland as a consultant and earn two to three times the salary. Our waiting list reimbursement scheme was hindered by increasing tariffs in Southern Ireland, which prevented people from going down to utilise it.

That competitive market is there. Yes, the fact that independent-sector providers put out ways of attracting staff causes us concern, because we want the staff, all of whom were brought up in the NHS and have stuck to its core values, to continue to deliver in the NHS. We are actively and constantly looking at ways of innovating so that our staff continue to deliver for us.

Ms McWilliams: A lot of the actions that we have been taking come from a desire to build the core capacity. That cannot happen overnight, so we continue to use funding on a short-term basis to target backlogs or buy capacity. My team is responsible for managing that budget, making those assessments, doing the allocations and monitoring the performance. We always look for in-house additionality, and then we look for insourcing, because there are tiers of cost involved in this. Have we exhausted the potential of a company coming in and using our facilities, because we do not have a workforce to match the facilities that are vacant, normally in evenings or on Saturdays and Sundays? The third call is to the IS, but even with that, we do a value-for-money assessment. We have refused to send patients out, because we are unwilling to do so when the cost is so different from what we are prepared to pay. Our buying power is better with multi-year budgets, because you can really drive the NHS tariff. You can give a certainty of volumes. We have been having conversations with our IS providers about principles of working, such as, where possible, not to poach nursing or surgical staff. Can we work together? Can we work together on training? Is there a research option with industry and private companies that the HSC can benefit from? One of the principles is to be as close to the NHS tariff as possible. That reduces the profit margins. Those conversations are much easier if you are negotiating a three-year contract, but we cannot do that in the absence of a multi-year budget.

We will still have to use the IS, but we are trying to change the balance. Every bit of core capacity that we are growing should squeeze that. As Mark said, there is a lot of learning. IS colleagues would not thank me for saying this, but some of the procedures that they do can be done in more of a factory chain run-through, which is not always possible with the case mix that we have in the HSC. There is learning from working with the IS, but, whilst there is a commitment and an acknowledgement that we need to use it, we do not just accept the highest tariff willy-nilly, because that is not good value. We prefer to look to our NHS colleagues in England, Scotland and Wales — unfortunately, that means that patients may need to travel, or the team may come to us — or to the contracts that we have with the ROI, because of the value-for-money assessment. That is the model that we are approaching.

Professor Taylor: An example of that, Chair, is the breast cancer triple assessment and the waiting lists when they became a single regional waiting list. In addition to our own clinicians, we have clinicians coming over from Forth Valley Royal Hospital in Scotland to add to the capacity to meet the demand. That uses in-house staff but also uses our colleagues. It is the same when it comes to an all-Ireland agenda. We had the most fulfilling paediatric gastroenterology arrangement. Every Committee member will be aware of the difficulties of paediatric gastroenterology, including percutaneous endoscopic gastrostomy (PEG) tubes in children and babies. The Minister and I had the joy of an all-Ireland agenda whereby our paediatric gastroenterology colleagues in Dublin are now even looking at sharing the rota here in the North and at how they can allow access in Letterkenny, Donegal, because it is a long way from there to Dublin. That kind of North/South and east-west working is all in the mix. I hope that we are demonstrating that we need certainty. One of those certainties is the budget: the £80 million that needs to be ring-fenced to add to the capacity.

The Chairperson (Mr McGuigan): That was on my list of questions, but I have gone way over my time. No doubt some of my colleagues will pick up on that.

Mr Donnelly: Do you want to expand on the £80 million that needs to be ring-fenced to continue that capacity, to pick up on what the Chair was saying?

Professor Taylor: As a clinician, it is always wrong for me to make bold statements about money, but we are here with an elective agenda, and that is to deal with waiting lists and the Programme for Government. In the absence of a Budget, there is still some uncertainty. Obviously, we know from last year, as Lisa articulated, that there was the initial £215 million and the earmarked £80 million that was, rightfully, needed to manage other pressures. Given where we are at the minute, the £85 million of recurrent funding will be for time-critical and red-flag patients, but, in my humble opinion, the £80 million needs to be ring-fenced so that we can add to the core capacity. That is the uncertainty at the moment in the absence of a Budget.

Again, as clinicians, we have said continually that the more we have in the recurrent budget, the more that we can plan recurrently. The current start-stop momentum means that any impedance of progress will be felt in our waiting lists. They will go up again. We have seen that in the history of our waiting lists. The plea is to ensure that we are able to continue the momentum.

Mr Donnelly: That was where my questions were going to go. How sure are you, and how sure do you need to be, that we can maintain that level of recurrent funding, so that you can get it and have that additionality in the core group? Are you not sure at all of that?

Ms Elliott: The position is that we need approval of the Health budget as soon as possible to enable that money to be invested as we envisaged in the elective care framework and to maintain and build on that momentum.

Mr Donnelly: If that does not happen, what will be the impact on the waiting list work?

Ms McWilliams: I will come in on that. Of the £80 million, we spent £6·5 million in-year last year, and there is a recurrent tail of that, which is just shy of £15 million, so we use that money —.

Mr Donnelly: Can you explain that bit again, sorry?

Ms McWilliams: With the £80 million, we only slipped £73·5 million back to the centre, and, as Mark articulated, that aided with the core pressures. However, it also enabled us to contribute to pay awards, avoiding strike action that would have reduced activity. In that, we had approval of £6·5 million, so we have protected the primary care elective, as I mentioned — the 12,000 patients who went through the primary care elective pathway. We invested in pre-op assessment, because having enough patients who are ready for surgery at short notice is one way of countering late-notice cancellations and "Do not attends". We deliberately focused on where we had the ability to spend money. We have invested in the phlebotomy hubs so that not everyone has to come to an acute setting to get blood tests. That can be done at local health and care centres.

We also invested in training. The training commitment from the elective care framework is that by March 2027 — the end of this financial year — we will have committed to an additional 25 training posts. Not all of those posts will need full consultant salaries to be paid, because there will be attrition through retirement, but there is a profile who are additional trainees for additional capacity. We were already profiling the seven-year spend for some of those. Last year, we invested in seven anaesthetists. That also came out of the £6·5 million. Two schemes with our third-sector partners — the waiting well initiative and the cancer charities grants — came out of that £6·5 million. The training numbers are now an additional 28 on top of those seven, so the full-year effect of those for 2026-27 will be an additional 28 trainees where we have single-handed practices or vulnerable specialities, such as in radiology, urology, general surgery, paediatrics and haematology. That has a bigger cost, because there is substantially more volume. Next year, we intend to have an additional 25 trainees, so we will far exceed the elective care framework training numbers. We have to grow. We cannot depend on attracting from elsewhere. We need to be able to grow our own trainees and then we have to try to hold on to them at the end of the training programmes. We also used the £6·5 million for three trainees who came off the training programme, who would have gone elsewhere in very vulnerable specialities: two oral surgeons and one oral medicine consultant. We employed them straight from the training programme without any risk of them getting a better offer from anywhere else.

For the likes of those posts, it was not a full year that we were paying for their salaries, and now we are paying a full year. That is where we get to a requirement to spend £14·9 million, so that is the recurrent from that. The absolute desire is that we use the rest of the money for core capacity — making sure that we can deal with the long waits, the red flags and the people in the middle — but that does require budget certainty. Whilst we were putting that recurrent capacity into investment, we would use the money non-recurrently to do more waiting list additionality for that backlog. The desire is to have it, but it is subject to those discussions.

Professor Taylor: Danny, as you know, when we have money, when we have urgency and when we have the ability to max up on the ground, we deliver 262,773 episodes, or 237,000 episodes, sorry —.

Ms McWilliams: Have you not a validated number? [Laughter.]

Professor Taylor: It is just as well I am not in charge of the budget. Also, when you look at the main procedures, colonoscopy is down 100%. Paediatric squints, lap choles, tonsillectomies and primary hip procedures — those are all successes, but the bigger success is that, in 10 years from now, we are not going to be going over the same thing: we have these horrendous waiting lists and we never planned for the future, or that we did not plan the capacity and the different ways of doing things. It is the same theme. We used to do it all this way but we do not have the luxury of that now because of financial burdens, an increased elderly population, rising complexities of treatment — the burning platform of 2016. That is why every single strategy has to be right. Regional diagnostic centres to get rapid access for cancer patients and the vague symptom pathways to get rapid access — all those things are in the mix.

Mr Donnelly: Is the hope that we get to a certain point whereby demand will actually be met by non-additionality and you will be able to cope with the demand coming in and people will be able to get timely treatment in a timely way? When you say 10 years, is that the —?

Professor Taylor: I think, for any patient listening in, one day is one day too late. I think that every part of the world is trying to deal with that imbalance with rising demand. In a way, it is a celebration, because we are all living longer. By 2050, we are going to double the population of those living over 80. That is a celebration on one hand, but with it comes a real struggle around how to keep meeting that demand. I cannot say, and I think that it would be wrong of us to say today, that we are ever going to get to the stage where we are able to match the whole demand with the capacity on the ground without the need of help, but we have got to be sure that we are going in the right direction.

My recent disappointment is that, for the first time, we are seeing those first outpatient numbers drop, and that is even with people being added every day. My colleagues up and down the country are seeing people and referring people for outpatient appointments every single day, but with that urgency of activity, for the first time in a number of years, the official statistics are starting to go down. I would love for us in Northern Ireland to recognise some of the success for all those people who are spending extra hours at night and at weekends doing the work.

Mr Donnelly: Personally, I am very aware of the extra work that is being done, and I know that great work is being done by the NHS every day that maybe does not get the celebration that it should. When people do get the treatments that they need, the reports that we get from constituents are that the care is excellent. I know lots of constituents who are on waiting lists for long periods. They are suffering and, in many cases, getting worse. A lot of them are driven into private medicine and spending a lot of money. We see private medicine booming in Northern Ireland, with new hospitals being built and huge clinics that are really busy all the time. People are spending huge amounts of their financial resources on accessing healthcare, because they cannot do so in another way. However, I am reassured that things are starting to change.

I will ask about validation, which I find complicated. The Committee has asked questions about it. How can you reassure patients who have been validated that they no longer need treatment? If you are on a list for surgery — you mentioned a couple of examples, Mark — why would you not need it? Why would you not need a tonsillectomy, a gall bladder operation or — I cannot remember the other examples that you gave.

Professor Taylor: That is a great question. First, it is important to give the reassurance that no administrator or clinician is in the business of wanting people to be artificially removed from a waiting list if they need an intervention. The difficulty is unique to our having those really long waits. They are all unacceptable, and, Danny, we are conscious every day of the people who are waiting and waiting, getting worse and presenting for unscheduled care, and of the burden that that places, which the Committee is aware of. However, if you have been booked for a procedure or an intervention and have been waiting for a length of time —. This is about the small number of clinical validations. Administrative validation is about one simple thing: making sure that the list accurately reflects what we think it should. That means making sure, in other words, that "Mark Taylor" does not appear on six lists and is not counted as six people, or that Mark Taylor — I should say that nearly 6,000 people had actually passed on, but were still on outpatient waiting lists —.

Mr Donnelly: Did you say that 6,000 people died while they were on a waiting list, without —?

Professor Taylor: Yes. They were still waiting. In essence, the system was trying to get them into an outpatient environment.

Mr Donnelly: They never got the procedure for which they were on a waiting list.

Professor Taylor: Not necessarily. Outpatient lists can be many, many things. Most of those people will almost certainly have passed on for other reasons. The simple reason is that, if you take very sick with whatever condition you have, you do not wait until you are called to come in for the procedure; you go to unscheduled care. That is why we see the pressures in unscheduled care. To the critics who ask why you would put waiting lists in the Programme for Government, I say that the waiting lists are a symptom that will further burden unscheduled care. We need to deal with them in the here and now.

Mr Donnelly: And primary care: GPs.

Professor Taylor: And primary care as well. People constantly contact GPs, saying, "Will you ring in? Can you see where I am on the list? When will I be having that procedure?"

I will come back to there being a group of individuals. This is a clinical engagement. It is not about me or my colleagues sitting in isolation, looking at the records and saying, "Mrs Dodds is coming off the list, but I'm not engaging with her". This is where the mega-clinics come in — many political representatives have visited them — with a consultant anaesthetist, a consultant surgeon and senior nurses. As one of the individuals, you come in with, for example, a hernia, and you say, "I'm now 81. I've been waiting five years for this hernia surgery — inappropriate; wrong — but it is not giving me any more problems".

Mr Donnelly: Why inappropriate? Why wrong?

Professor Taylor: The wait is wrong.

Mr Donnelly: The wait is wrong. OK.

Professor Taylor: It would be inappropriate then to say, "It is giving you no problems, but we will put you through an operation where there might be complications". A child might have outgrown their tonsillitis and no longer need to have their tonsils out, given the nature of that window of opportunity. Those are small examples. We sometimes see in the breakdown, "Patient seen separately but for the same condition"; "Transferred to another trust"; "Not required"; and "Patient no longer wants". Patients are happy to say, "I don't want that intervention any more". As long as the clinician is in agreement, that is where the validation comes in.

Mr Donnelly: Just a quick question: are patients always told? Is there always contact with the patient and they are told? Are they always informed that they have been removed from a list?

Professor Taylor: Clinical validation is a two-way process: the clinician and the patient are together. When it comes to administrative validation —.

Ms McWilliams: There are cohorts where the administrative validation has, despite repeated attempts, resulted in no response, so the GP is advised that, due to the admin process, a patient is being removed. The GP is advised, and they have the mechanism back in to say, "I am unhappy" or, "You have been sending information to the wrong telephone number. They have updated the system and it has not been updated through". There is a cohort, particularly of admin outpatients, where there has been no response despite repeated engagement to make contact with individuals. The GP is advised. The patient will also receive correspondence to inform them that they have been removed, with the information to contact back in within a window. However, there are patients who do not respond to the admin process. It would be wrong of me not to indicate that there is a cohort of those patients who are removed.

Mr Donnelly: So some people may not know that they have been removed.

Ms McWilliams: They will then get correspondence to say, "We have removed you because we have attempted to contact you". The GP is also advised, so, even if they have changed address, the GP should know. There is that fail-safe and then there is the loop back in. That is on the admin for outpatients as opposed to for treatment.

Mr Donnelly: And the clinical validation —.

Ms McWilliams: Clinical validation has to be more engaging.

Professor Taylor: Do not forget, Danny, that, as we progress with Epic, the patient-initiated follow-up, which puts our patients in the control seat, will be helpful, too — "I want to come back and see Dr X or Dr Y because I need to", not that it is just the default.

The Chairperson (Mr McGuigan): We need to move on to others. Diane.

Mrs Dodds: Thank you, Chair.

First of all, I want to say, "Thank you", because I think that, while Northern Ireland still has over 500,000 people waiting on a first appointment with a consultant — I was looking at the figures this morning — most of us are heartened that the issue is at least being grasped and dealt with, albeit there is an enormous amount of work still to do. I do want to say, "Thank you".

Now, down to business. I have no idea whether you have the same paperwork that we have, but a response to the Committee dated 13 February 2026 gives a breakdown of the total number of patients who have been treated and the current update. I think that it was as of the end of November 2025, so it was not completely up to date.

The Chairperson (Mr McGuigan): You will not have that, by the way. It is from the Southern Trust to the Committee.

Mrs Dodds: Yes. It actually says that the Belfast Health and Social Care trust had 55,000-odd patients, the Northern Trust had treated 31,000, the South Eastern Trust had treated 54,000, the Western Trust had treated 27,000, but the Southern Trust had treated only 18,543. Why was that? No ideas?

Ms McWilliams: We might need to see the information.

Professor Taylor: Is that validation, Diane, or active treatment?

Mrs Dodds: It states:

It then says that these are the "treatments and diagnostic tests" that "have been delivered". The breakdown of activity by trust shows that the Southern Health and Care Trust was the poorest by a long margin. It is fine if you do not have it now. Somebody can come back to me on that. Obviously, the Southern Trust is the trust in my area. I would just like to know why that information is as it is. That is quite important.

The Chairperson (Mr McGuigan): We will share that information. We wrote to the trusts and got that. We are happy to share it with you.

Ms McWilliams: We are happy to come back on that.

Professor Taylor: I am actually really happy to do that, because looking at variance is one of our roles within the ministerial direction. It is important just to say, Diane, that sometimes the number that looks like an outlier may not necessarily equate to poor performance or inactivity etc, because, as I say, in many cases, we are not comparing apples with apples. There is a combination of reasons for variance. One will be workforce. If you were looking at gastroenterology in the Southern Trust, where we have had a major problem with our workforce, you will see an anomaly compared with, say, Belfast, which has a fully active multipurpose gastrointestinal service. Therefore, there are nuances around those specialties.

Mrs Dodds: I know that there is an action plan in place to deal with that in the Southern Trust, and I am glad to hear that. I do not shy away from those kinds of difficult issues, but it is an outlier by a long way, and —.

Ms McWilliams: Sorry. Not having seen the detail, it may be that we transferred Southern Trust patients to one of the IS contracts, if it was for additionality — that the other trusts are holding the contracts so that patients are not disadvantaged. I am happy to have a look and see whether we can come back to you on that.

Mrs Dodds: The biggest reduction has been in endoscopy treatments and facilitating that initial investigation. I have asked almost every trust that has presented to us how many of those patients proceeded to treatment. That information does not seem to be available, because we do not have that full pathway in Northern Ireland. Why do we not have it, and when will we get it? We were told that, when we got Encompass, everything was going to be amazing and we were going to be able to tap a few buttons and that information would fly off the shelf to meet us. It is amazing that we have done so much in relation to that, but how many patients have proceeded to treatment and been able to access appropriate treatment? I cannot find any information that helps us with that.

Professor Taylor: We can come back to the Committee on that. Suffice to say that endoscopy is the treatment in the largest number of cases, particularly if you have been waiting four years. If you have been waiting for four years for a camera test because you have heartburn, or you have been waiting for four years with mild gastrointestinal symptoms and you have a colonoscopy, in the majority of cases, those diagnostics will be the treatment. You will have a biopsy taken and be given tablets or, in the majority of cases, you will have the recognition that, thank goodness, it was normal. If not, that is why I say that an individual with illness does not sit in isolation. Our GPs know it and our EDs know it. If I have a colonic problem and I am on that four-year wait but I start bleeding, I will seek help. That is the difficulty in looking at numbers in isolation. The question that you are asking is an important one, which is, if you have had a cystoscopy, how many go on to need something done with their prostate, and if you have had an oesophago-gastro duodenoscopy (OGD), how many go on to need surgery.

Mrs Dodds: Yes, and how many have accessed the surgery? We do not have what in England and Wales is called the full referral to treatment — knowledge, pathway and information — so we have no way of knowing how many of those patients have been treated. As you say, the treatment might be simple, and a lot of those patients may require no treatment at all, but there is no idea of that in any of the information that we are given. If they have had their procedure, do they just go onto another waiting list, or do they actually get treatment?

Ms McWilliams: We used that approach for the cancer-tracking system that we used to have prior to Encompass. We would have captured closed episodes as the patient was no longer on a red flag because there no indication that they needed to continue on that pathway. We are working through the process with the Encompass and Epic build to replicate all those previous reports, and some are taking longer than they should. You are absolutely right to say that we need to understand which ones are closed episodes — the ones where, as Mark described, the definitive treatment is the biopsy, and the pathology said that there was nothing to worry about — or you get a medical intervention because, depending on what it is, it can be treated with drugs as opposed to surgery, or it is closed because there is nothing to worry about.

It is then about how they continue on that diagnostic pathway, because a scope will not be the only investigation that —.

Mrs Dodds: The point that I am making, Lisa, is that we still do not know whether people have had their diagnostic test, whatever that diagnostic test may be, and then accessed the appropriate treatment. I accept that the test may be all that some people will need, but many will require further treatment. Do those people go on to another waiting list? What happens to them?

Professor Taylor: That is a really important point, but there is a subtle difference. All are waiting to see a clinician, but that may be a nurse, an allied health professional or a doctor. Once the diagnostics have been done, the clinician then knows that person. If the person has had a cancer diagnosis, the clinician will not put them on an elongated waiting list. The difficulty arises with those for whom we do not yet know the diagnosis. Those are the people whom I worry about the most. We talked before about access, but when someone is in the system for a diagnostic OGD, a diagnostic cystoscopy or a diagnostic colonoscopy that they have been waiting for, and I, as the clinician, do it that day and subsequently see something that is critical and time-dependent, I then have ownership of them. As a clinician, I would not put them in a situation that would cause them harm. That is the moral distress that every clinician faces at the moment as a result of long waiting lists. We have a set of skills and can therefore do something, but the system is struggling to meet demand.

To give you some reassurance, Diane, I will tell that you are right to ask that question about the pathway. We need to know every single person and what they need when they have had the diagnostic test. When they have had the diagnostic test, however, they are known to us and to the system. If it reveals something that is time-critical, such as a cancer, even given the reports today, no clinician would stand over their going on to another waiting list, because they have suddenly become the advocate for that individual.

Mrs Dodds: On the subject of cancer referrals, I have asked about this many times and will now ask about it again. I have looked up the latest stats, and only 29·5% of those referred for cancer treatment started treatment within 62 days, compared with 80-odd per cent in the other nations of the United Kingdom. Only 5·5% of women with breast cancer, which is a reduction from 6·8%, were seen by a consultant within 14 days, when the target is 100%. I accept that we are experiencing a rise in cancer cases, but those percentages are abominably low. They really are incredibly low. Is the elective care framework therefore failing cancer patients? Should we have a prioritised, targeted plan to deal with the rising number of cancer cases and the length of time that it takes for people to get treatment? I take your point, Mark, because I have heard it from many constituents, that, once someone gets into the system, the system works well for them. The problem is getting into the system, and the elective care framework is not addressing that. Cancer Research UK is calling for a specific cancer plan that deals with the emergency situation that we are experiencing. Is the elective care framework failing those cancer patients? Should we have a specific plan for them?

Professor Taylor: I will start. With the greatest respect to all, I do not think that we need any more plans or strategies. We need to change the culture of how health and social care is delivered in this country. We have known that for quite some time. No matter what we say today, Diane, we all have family members who are on those cancer pathways and are waiting for far too long. A day is too long. There are also a number of individuals who have the fear of having cancer but who do not actually have it. With a lot of the strategies, the focus at the minute is on trying to triage those people — the lady with the breast lump, for example — who, until they are reassured that everything is normal, will assume the worst. We all are humans in this room. It comes back to having a collective strategy. The sooner that we know the funding situation, the sooner that we can look at all avenues for raising capacity. I will now bring in Joanne.

Ms Elliott: Through the work that we are doing on the elective care framework and the cancer strategy, there are targeted areas of focus. We know where those areas of focus are, because of our engagement with clinicians and the work that we are doing through the cancer strategy. Diane, you mentioned the breast. Particular work is being done on the breast to drive down the waiting times for initial appointments with breast assessment clinics, and there are cancer reference groups that are looking at how cancer pathways can be streamlined.

Mrs Dodds: Sorry to interrupt you, but the situation is getting worse, not better. The previous quarter's statistics show that people in 6·8% of cases were seen within 14 days, but that percentage is now just over 5%. We are failing more women. We are getting worse, despite all the grand plans. That is why we need to separate everything out and really focus our attention. We are being faced with a terrible situation. There are 29 new cancer cases every day in Northern Ireland. Despite all that you are doing, Joanne, the situation is getting worse. We are not making improvements.

Ms Elliott: There have been considerable improvements on the breast, albeit not from a strong starting point. Work was done to regionalise the list to remove the inequality in provision across the Province, and that has addressed inequity in access.

Mrs Dodds: We have made everywhere equally bad, have we not?

Ms Elliott: We have —.

Mrs Dodds: I am not being contrary. I feel strongly, however, that it should be the highest level of our focus, yet it is not. No one wants to be in this situation. This is not an issue between us. There are issues that we really need to deal with.

Ms McWilliams: Diane, I will come in on the issue of the 14 days, if I may. Out of the recurrent investment of £85 million, £5 million is for recurrent investment into making the elective care framework a stronger, more responsive model. We have a breast operational delivery network that is learning from our Scottish colleagues and from the trusts that had shorter waiting times at one point to see what our optimum service model is. That is important, because — you are absolutely right — we have too many waiting too long for breast. The situation is better than what it was at its worst, but it is still not where we want it to be. After triage from a GP, an ED or elsewhere, we are listing 1,563 women on to a breast red-flag pathway every month. That number has gone up. At this time, we have only 1,293 slots. That means that we are short by 300 slots every month. Before Easter, we were down to just over five weeks for an average wait. Since Easter, however, we have gone up to 6·2 weeks.

The operational delivery model has to work out how we deliver the 1,563 on the list, plus whatever increase in demand there will be. We are using the £5 million non-recurrently to do the additionality. The reason that we have had to use that, and we are very grateful for the learning from our Scottish colleagues, is that a lot of the workforce is a female workforce with childcare commitments and young families, and they therefore do not want to do a lot of additional work.

Our model is to have enough core capacity to minimise additionality, so we have to learn how to do that. That is about, for example, using a skills mix, working out whether our linear pathway is still the right thing or whether people with breast pain should go to different areas. We do a two-weekly report on breast for the Minister. My team and I present that. We go through all the numbers and set out all our actions. There is a very high focus on that, because the current level is not acceptable.

Mrs Dodds: May I ask a final question?

Professor Taylor: Diane, what was also not acceptable was the postcode lottery. Some ladies were waiting up to 14 weeks. You will be familiar with that in your constituency. It is not appropriate that some trusts meet a target while others do not.

A second issue is that we have people with benign complex conditions that are challenging as well. Although we all know that it is really important to do so for cancer, we have some cancers where we have not really changed the prognosis in the UK and Ireland in 40 years, and —

Mrs Dodds: Yes, that is a long time.

Professor Taylor: — we have to focus on them. We are seeing, as Cancer Research UK said today, that there has been an increased prognostic benefit, which is great, and that is a as a result of taking a multidisciplinary approach. Whatever way in which we deal with this, we of course want all people in Northern Ireland to get timely access. One example, as Lisa said, is that, in one mega-clinic, 600 people with routine breast referrals were seen. By that, I mean that the doctor was not worried that there was something sinister. Only two of those individuals had anything that might have been sinister, but 598 got reassurance on that day and therefore came off the waiting list. Those are the types of strategies that we need to employ, and we are grateful to our colleagues for helping us with that.

Mrs Dodds: It was so long ago now that I have forgotten how much money was allocated to the waiting list reimbursement scheme. How much was allocated to it, how much has been spent, and what were the reasons for the spend?

Ms McWilliams: When we did the initial profiling of the £50 million for waiting list reimbursement, an indicative £10 million was allocated out of the £50 million. Mark alluded to the fact that Republic of Ireland scheme's prices have gone up, so it is now more expensive, and we are getting less than when we had a previous ROI scheme. The first tranche of that was to expand waiting list reimbursement to Europe, but it became clear that the demand was not at the level of the previous scheme, and that was probably because of the price differential. We therefore agreed with the Minister to re-profile the scheme and release money to the targeted procedures, so the £50 million has been fully spent, but we changed the initial profile.

Mrs Dodds: Why did we have £10 million out of that?

Ms McWilliams: A total of £4·9 million has been committed as of February, because we are not at the year end, and that is 490 patients who have been approved, with an average unit cost of £9,000 for treatment. That is what we are reimbursing, and 80% of all applications are, unsurprisingly, for orthopaedics.

Mrs Dodds: Yes, I would imagine that.

Ms McWilliams: That is the breakdown. That £4·9 million might go up to £5 million for the full year, but we have not spent the other £5 million. I have already committed it elsewhere so that we have committed the £50 million to be fully spent in-year.

Professor Taylor: That was an early decision, Diane. The Minister has us meet him every two weeks, and when it became clear that all the money for the waiting list reimbursement scheme was not going to be spent, a decision was taken very early that we need all the money that we can get.

Mrs Dodds: That money therefore came into the system again and has been re-profiled and used for cases here in Northern Ireland.

Ms McWilliams: Yes, for additionality.

Mrs Dodds: OK. Is the £9,000 —

The Chairperson (Mr McGuigan): Very quickly, Diane.

Mrs Dodds: — that you pay per patient an average cost?

Ms McWilliams: It is the average cost, yes. We reimburse the NHS equivalent, so what may be paid is —.

Mrs Dodds: Do you not know what the actual charge would have been for patients?

Ms McWilliams: We confirm only the tariff amount.

Mrs Dodds: It is then up to the patient to pay the additional amount.

Ms McWilliams: Yes.

Mrs Dodds: OK. Thank you.

Professor Taylor: It is fair to say that the scheme is still important, because x number of people had a knee replacement, a hip replacement, a gall bladder operation or a hernia operation. The difficulty is that we talk about our health inequalities, and people have to pay up front, and if they are getting only the tariff back and thus incurring a financial loss, they are suffering that loss. It is therefore already selective, so we need an approach that deals with people no matter what their worth is. That goes back to the ethos of the NHS.

The Chairperson (Mr McGuigan): Five hundred people will think that it is a very useful scheme and —

Professor Taylor: Absolutely, and —

The Chairperson (Mr McGuigan): — that it should have been less than one year.

Professor Taylor: — it is going to stay.

Mrs Dodds: Those are 500 people who could afford it.

Mrs Dillon: I will start from where you just finished. This is not for you, but I am making this point because I want it to be on the record. The reason that the number of people who are going to the South on the reimbursement scheme is down has very little to do with the additional cost and more to do with the two-year implementation time at the beginning, which I raised at the Committee with officials, and it was reduced to one year. I told them that it should be no years. The majority of people doing that come from two cohorts, the first of which is people who work in physical jobs and need treatment quickly so that they can get back to their work. They are in a position to pay for it, but cannot afford to pay for it. What I mean by that is that they can afford to pay if they get some of it reimbursed. The second cohort is older people who know that they will not ever get that surgery otherwise, so they use their pension for it. That is the truth of it, and it needs to go on the record. That is not on you.

Professor Taylor: That is a really important point, Linda.

Mrs Dillon: Rather, it is a departmental —.

Professor Taylor: That goes back to my point that we need all the help that we can get.

Mrs Dillon: To be fair, that is not one for you, but I wanted to put it on the record.

I have a couple of quick questions to ask you before you have to go, Mark. The three areas that I want to focus on are breast cancer, gynaecology and endometriosis. You talked a significant amount about breast cancer. Like Diane and others, I have serious concerns.

The Minister has talked about the need to address inequalities being part of the big plan. I wonder whether we can identify anywhere in our health system where the waiting lists for diagnosis and treatment are the same for issues that affect men as they are for issues that are as debilitating to women as the gynae and endometriosis issues are. I may be going in the other direction, but I do not think that there is anything comparable. Nuala may speak to this, so I do not want to get into it in case she kills me, but robotics in Belfast have been used almost exclusively for prostate issues. That is great, but they are not being used for endometriosis, where they could make a real difference. The reason for that may be because we do not have the specialists. If we do not, what are we doing to address the fact that we do not?

Professor Taylor: I will take the question on the robot, because that is close to my heart. The good news that I can tell the Committee is that the robot is not just being used for urology now. The robot in the Belfast Trust is now being used by gynaecology, upper gastrointestinal (GI), colorectal and urology. They are all using it, to the extent that a second robot has just arrived in Belfast. The Western Trust has just acquired a robot, as has the South Eastern Trust. Lisa is putting together a task force to look at ensuring that all the clinicians in Northern Ireland get the necessary robotics training.

Dealing with endometriosis is really important. Lisa will talk about the operational delivery of two centres of excellence. As you have said, and as we all know — as a liver surgeon, even I am sometimes involved with ladies with endometriosis — endometriosis is a dreadfully complex condition that affects the entire abdomen and elsewhere. Treating it requires a combination of gynaecologists, colorectal surgeons and upper GI surgeons, so multidisciplinary teams are involved. There is a massive amount of work involved when it comes to those ladies who have really complex endometriosis. I will hand over to Lisa and Joanne to talk about the operational delivery.

Mrs Dillon: Before they come in, is that specifically to do with excision surgery? I know lots of women who have had lots of surgeries. Although they may have given them temporary relief, they have not made a significant difference.

Professor Taylor: Endometriosis is a really difficult condition, because it keeps coming back. In the work that I was doing, I was taking the disease off the diaphragm. That is a long way from the uterus, but the condition was causing problems in the diaphragm. Endometriosis is a horrendous condition. We have amazing clinicians who want the service to deliver for those individuals affected and who are driving the service so that it can deliver for them. That goes back to my comment to Diane. Do not get me wrong: cancer is important to treat, as it is life-limiting. There are, however, other complex, benign conditions that are also life-limiting for lots of different reasons.

Ms McWilliams: I will be a bit more specific about gynae, mesh and endometriosis, Linda, if that is OK. You may be aware that we have had a gynae provider collaborative that focuses on working together as part of one system. When the collaborative was working on targeted actions, through ECF funding, it was working on anyone who was waiting for gynae procedures and on outpatients who had been waiting for more than three years.

Three years is still a long time, but we have seen the number of people waiting longer than three years for outpatient procedures reduce by 52% and the number waiting for inpatient or day-case gynae procedures reduce by 58%.

For the cohort of patients of the regional gynae mesh removal service, which is delivered in the Belfast Trust, the outpatient wait for any new assessment is below the ministerial target of nine weeks, and all patients who are awaiting review appointments are seen within their planned month. That represents progress for that smaller cohort.

For endometriosis, trusts are working through business cases for local expansion in areas other than those where the two specialist hubs will be, as Mark said. In parallel with those two pieces of work, our endometriosis clinical task and finish group has concluded its work, which has defined the clinical pathways for what can be managed in primary care, what can be managed in secondary care — our district general hospitals (DGHs) — and what requires regional tertiary intervention. You will not be surprised to hear that tertiary intervention will involve the other specialties: colorectal, hepato-pancreato-biliary (HPB) and urology clinicians. The pathways cover assessment, investigation, testing, medication and self-management, and they include the referral thresholds. We do it once, and we standardise it.

We expect the business cases for the regional tertiary centres, which will be in the Belfast Trust and in the Western Trust, to be submitted to the SPPG in the next couple of weeks. We are having to take a phased approach, given the gynae allocation that we have within the £85 million — the £3 million — and we expect to use some of the £80 million to ensure that we can deliver those pathways and those sites. That is our expectation.

A really good multidisciplinary approach has been taken. With respect, Mark, it is not all about surgeons. It is also about nurses, physios and psychology background services. Those relate to chronic pain management, because some of what we see will be chronic pain, and we do not want there to be dependency on addictive drugs. We have therefore had to take a multidisciplinary approach, and the clinical task and finish group has delivered an excellent piece of work.

The Chairperson (Mr McGuigan): Before you come back in, Linda, I will have to allow Professor Taylor to go.

Professor Taylor: Chair, I am so sorry. My apologies, Committee.

The Chairperson (Mr McGuigan): We appreciate your giving of your time, and we do not want to hold you back from your other engagements.

Professor Taylor: I am leaving you in capable hands, I can assure you.

The Chairperson (Mr McGuigan): As Lisa said, it is not all about surgeons.

Mrs Dillon: Lisa, I will probably come back to you about endometriosis, because there is a significant conversation to be had about that. Mark got away before he had to answer that one. Is there any men's condition that is comparable to it when it comes to the length of time to diagnosis? We know that, for endometriosis, it is nine years. That is not even the maximum — it is almost the minimum — and that is just for diagnosis, never mind anything else. When we look at gynae waiting lists for endometriosis in particular, can you think of any comparable male-only health condition?

Ms McWilliams: I would need to look for that. I have a profile of all the specialties but not of the sub-specialties. Sometimes, it is about the sub-specialty level, because endometriosis is almost hidden in there. We have a profile of specialty-level waiting times for assessment and for treatment, so we can certainly have a look. In orthopaedics, there are very long outpatients lists and treatment waits, but those are not gender-specific.

Mrs Dillon: Absolutely not.

Ms McWilliams: I absolutely get your point.

Mrs Dillon: The answer is therefore no. As somebody who represents constituents, I cannot think of any issue on which men have come to me on the same scale as women have come to me about not being able to access diagnosis and treatment, and, having got treatment, about its not being suitable or right, because the expertise is not there. It does not exist. That needs to be said, and we need to be straight about it.

Ms Elliott: From a policy perspective, I am sure that you are aware that work is under way on developing a women's health action plan. There has been a huge listing exercise with stakeholders. It is being led by Queen's, and Derry Well Woman is taking forward that bit of work there. Endometriosis is coming up as part of that engagement process and will feature in the women's health action plan. Endometriosis is therefore in there. People are being listened to, so it is on the radar and being supplemented by the detailed work that Lisa said is happening in the system.

Mrs Dillon: I understand. It is not a criticism of you. Rather, it is something historical. We have an awful lot of catching up to do, which is why I want to keep the issue on the agenda. It needs to be prioritised, because —

Ms Elliott: Absolutely.

Mrs Dillon: — women are being failed day and daily.

You may want to get back to the Committee about my last question, which is about movement on the lists. Can people who have passed away potentially still be on the lists? We have heard the answer, and it is that they can. I am concerned about their still being on the list, because their families are then getting appointments for somebody who has passed on. If an appointment relates to the reason that they died, that will be really traumatic for their family. If they are waiting on a test for a heart examination, for example —.

Ms McWilliams: It is not necessarily the case that a family of a deceased patient will have been contacted for an appointment, because we do pull the death notification information into our health systems. There is a small window between that update. I cannot say that a patient has died and the family has not been contacted, but, for the vast majority, it is because we have been notified through other health systems about that individual. We were therefore being open. We remove patients from waiting lists for reasons other than validation or treatment. They may have passed away since they were added. That is what we were talking about regarding deceased patients.

Mrs Dillon: The reason that you may want to come back to us on that is that we need a plan for how we identify that movement: where it is going, who it is, who has been seen and who, as Professor Taylor outlined, no longer requires treatment. Whether that plan is used through Encompass —.

Ms McWilliams: It will be an Encompass build, replicating what we previously had. I managed cancer services for a long time a long time ago. It is that cancer-tracking system, so it is replicating some of those reports. They are on the list for builds, but there are other reports that are being built in parallel. That is what it will be, and we are happy to take that up with our Digital Health and Care Northern Ireland (DCHNI) colleagues.

Mrs Dillon: I wish that Mark were still here for this one, because I do not know whether you will be able to answer it. It is about endoscopy, which Diane mentioned, and particularly about colonoscopy. We have had presentations previously on that, not in Committee but at different events. It is quite an invasive procedure. It is certainly not a pleasant procedure for anybody to have. There is potential for the faecal immunochemical test (FIT) to deal with some of those cases. When I have asked the question, I have never understood fully why we are not making more use of FIT, rather than doing a colonoscopy. I am happy for you to come back to the Committee on that.

Ms Elliott: It is probably for a clinical reason. I will have to come back to you on that.

Mrs Dillon: That is fine. I have no problem with that, but can we get something back on that in writing? I know that it is not straightforward. Diane raised the issue. Even when people have an endoscopy and are on a pathway, they may well have to be sent for a colonoscopy. It may be a closed case, but another test will then identify whether cancer is somewhere else. It is about a multitude of things, as this is complex. For that reason, you will not necessarily be able to get that information. I understand all of that, but I ask that we get an answer to that.

Ms McWilliams: We certainly have the outpatient waits. The reason that we do not just take our outpatient waits, diagnostic waits and treatment waits and add them together to get people a referral for treatment is that lots of things happen in parallel. For example, when a scope confirms a need for further investigation, that is recorded. There are planned appointments with the team, and, at a point in time, people move to being treated and are therefore captured in that treatment list. There is, however, an overlap between outpatients and diagnostics, and, in some cases, we use diagnostics before we get anywhere near an outpatient, because a straight-to-test may be the appropriate thing to do.

A long time ago, we moved from doing a prostate biopsy first to doing an MRI first. Why do an invasive procedure when evidence shows that the MRI is better? Sometimes, patients go straight to that before coming to outpatients to have a conversation about a biopsy.

It is important. That is why I think that we need that Encompass build to give you the answers that you are looking for. It will capture closed episodes at diagnostic of patients who may have been on a red-flag pathway. It will capture closed episodes that are urgent stage and actually in very small numbers, as well as anybody else who was diverted on to a pathway because of an incidental finding when nobody expected it to go that way.

All those reports are important, because they help us to design our clinic templates better and to do our scheduling better. Service management and teams have a lot of the information, but where we probably are at the moment is being able to extract it and give it to you in a format that our statisticians can stand over and that meets their requirements.

There is a lot of management information. My team uses management information every day, as do the trusts, but we are restricted in what we can put into the public domain, because it would not meet the official statistics standards needed for the Northern Ireland Statistics and Research Agency (NISRA) and our information and analysis directorate (IAD) colleagues have to stand over it. We can certainly get an update on the Encompass builds, however, because that is what our official statistics pull from to make a formal, public document.

Miss McAllister: Thank you for the presentation and for answering our questions. I will go back to a couple of questions that people asked, starting with Linda's question on the da Vinci robot. I hope that the new robot in the Belfast Trust is being targeted at gynae, rather than being more targeted at and weighted towards other areas, because there was an overwhelming gender imbalance in how the robot was applied: it was just for urology. There are obvious reasons for that, but it would be good if, in the future, it could be utilised to address waiting lists for surgery.

Before Linda's question, Diane brought up the breast cancer window. Is there any long-term planning for how we might see that be sustainable into the future? I know that we are trying to get the waiting time down; it improved previously only to get slightly worse again. What does that mean for the long-term planning of the 14-day target?

Ms McWilliams: The long-term plan is the work of the operational delivery network to design the optimal service model; that is where we will put the £5 million recurrent investment. That will ensure that we have the right number and the right skills mix. That is the long term. Easter was a holiday, so fewer additional clinics were done. That is not the long-term model. We should not be delivering a service that is so dependent on additionality. The operational delivery network's optimal service model will give us the workforce and the pathways. It is learning from those other high performing and resourced —.

Miss McAllister: In that optimal service model, are you planning to recruit into the additional workforce? You mentioned the £5 million. What are the plans for when that will happen so that we can see the long term and when this might get better permanently?

Ms McWilliams: The expectation is that that model will be defined in this financial year, with spend being incurred. As there is a lead-in time for recruitment, you would expect, or at least hope, that there would be some Q4 recurrent, with people having been recruited. We are, however, using that money to ensure that we do additionality in the short term, because we do not want the six weeks to go all the way back out again. There is some expectation that the additionality, at the numbers that we are doing, is not a long-term, or even a medium-term, solution. We need to make progress, and we have all the right people in the room to talk about that.

Miss McAllister: Could you come back to the Committee to keep us updated on when the additional workforce has been implemented? We will ask that as well, but it would be nice if there were a proactive approach whereby you said, "Great news! This is what we've got", so that we do not always have to go back about it.

Just to go back to the £80 million that has been discussed out of the over £200 million, as well as the £73·5 million that you said went back to the centre as it was non-ring-fenced. When I think back to the original sums in the Programme for Government and in the Executive — only £50 million was additional — there was an agreement for additional appointments. What was that baselined against? I know that you wanted to deliver for 70,000 additional patients, and we have delivered more than that. Of that 70,000, and say it was a nice number that fit, how much of it was additional and what was the previous baseline?

Ms McWilliams: The £85 million and therefore the £50 million additional in the Programme for Government were targeted for the delivery of the 70,000. The £80 million was for core capacity. The 70,000 figure was just a confirmation of an additional 70,000 patients that previously would not have been treated. The previous year, we used £75 million for additional new-review outpatients, diagnostics and AHP for cancer and time-critical referrals. The £75 million provided for about 197,000 additional patients.

I am not sure where the calculation of 70,000 came from. I know that 70,000 was articulated, but we have more than delivered on the figure of 70,000 of additionality. There is the £85 million that already covered 237,000 additional patients, as well as the backlog activity, primary care elective and the waiting lists. Even without using the £73·5 million, we would not have stopped at 70,000. It would have been entirely inappropriate for us to stop after delivering only 70,000 additional patients.

Miss McAllister: OK. The 237,000 patients, they are not additional?

Ms McWilliams: They are. The 237,000 are additional patients. We have receipts and invoices that correlate to the activity for those patients. That is true additionality, as is the backlog activity and the primary-care elective and the waiting lists reimbursements.

Miss McAllister: What would the full total be?

Ms McWilliams: Full total. As the economist, you would have thought that I would have added up all those numbers, but I have not. Sorry. I can tell you that total spend has been £141·5 million. That calculation I did do. My apologies, Nuala. You have caught me on the hop there.

Miss McAllister: If it was the same as the previous financial year, how many would you have seen?

Ms McWilliams: In the previous financial year, we used baseline funds to use £75 million for red-flag and time-critical referrals, which means we have exceeded, pro rata, what that would have been. Then we would not have had the backlog additionality. We would not have had the 28,000 last year — the 2024-25 financial year.

Miss McAllister: So you do not know how much of the £75 million for the previous year is for people?

Ms McWilliams: It is probably in this pack. I will have to come back to you. Sorry.

Miss McAllister: I know that it is important to look at resource and the amount spent, but money and people are not a direct comparison. What type of improvement are we looking at here, and is it sustainable long term? We know that if it is additional resources, we cannot do it every year. We might be able to cut waiting lists now, but at what stage do we return to three- or four-year waits? I ask that because, when we are scrutinising the figures, we can say "OK, that fixes it for the next two to three years, but, actually, in three years we are going to be right back where we started". That is why we need those numbers.

Ms Elliott: That is why capacity-building is so important. It is a multi-strand approach, so, yes, we have the investment through the waiting list initiatives and the additional procedures, because our waiting lists are so significant, but without capacity-building, we will continue to be in the same situation. However, building our own core capacity will allow us to move towards managing the demand/capacity gap. Through building our core capacity, we should see reliance on additional funding come down.

Miss McAllister: Where are you getting the core capacity, not the funding, but the actual physicality of it? Where are those people?

Ms McWilliams: That is either additional training programmes that we are earmarking for additional consultants at the end or the recruitment exercises that we are doing and the skills mix for those recruitments, going out and making sure that we have multidisciplinary team. Capacity-building takes time. Sometimes, it requires additional decontamination equipment and capital refurbishment, but it is really about recruitment and trying to attract and retain.

Miss McAllister: On recruitment and trying to attract more training places — the training places will be the longest; it is a matter of fact — are we talking about an increase in salaries? How will we make it attractive and sustain it when we are looking at the Republic and how it is attracting people from here?

Ms McWilliams: We are not looking to match ROI salaries; we would not be following that model.

Miss McAllister: I completely understand why.

Ms McWilliams: Retention and recruitment can be very difficult if a service is seen to have an unattractive on-call rota, because you have too many vacancies, so, each time you signal additional training places or you go out for a number of vacant posts to be filled, you are more likely to attract, and you are also more likely to stop people who do not want to be on a one-in-four rota but who will be happy to be one in seven and would be more likely to stay.

We look at retention and recruitment as the same thing: hold our workforce and also attract. That is what we are doing with training numbers. We have a couple of examples in specialties where we should be going out to the rest of the UK to say, "Northern Ireland wants to recruit a substantial cohort of surgeons in this specialty". We do one exercise, and they work together as a network. It is an important signal because, often, people will look to see whether they can have a different on-call rota and whether they can be paid more elsewhere. Recruitment and retention have to be done hand in hand but not at the expense of blank cheques because that is not value for money.

Ms Elliott: As Lisa said earlier, looking at the skills mix is also an important factor. Moving away from traditional models and bringing in more advanced practice and giving other professionals a part in that multidisciplinary team. It is looking at different ways of working, at a different skills mix and building different teams. That can be attractive for career progression and giving staff the opportunity to develop new skills and training in advanced practice in particular areas that will also help their service delivery model overall.

Miss McAllister: I understand. The multidisciplinary levels are also important, but a lot of consultant-led posts will need to be recruited for. Has that been successful anywhere else in health services that have a shrinking workforce and that are competing with other markets? Have you looked at whether they have been successful in attracting people back?

Ms McWilliams: England, Scotland and Wales have bigger populations and bigger workforces, and there is competition between regions. However, we have the NHS Scotland team helping us with breast because it was experiencing the same level of challenge across a smaller population. That is where the skills mix will be really important. We are learning where it is appropriate, but it is not always easy to find a comparator in recruitment and retention for a cohort that serves a population of 1·9 million with your sub-specialties below that.

We look at how others have attracted individuals, and, to be honest, the availability of a robot is one way of ensuring that our trainees do not go elsewhere as they will often not come back. Robotic development is important. It is probably more of a retention tool because it takes quite a lot of volumes to get through. There are some consumable savings, but you have to do a substantial volume to see a change in length of stay. We have not invested in robots for efficiency and productivity. We are absolutely clear that they are safe, but it is about keeping our workforce and attracting the best of the best to work in our services. The robot is one of those examples. We learned that the number of robots that were appearing in England, Scotland and Wales were critical for foundation training.

Miss McAllister: Do all the trainees want to go there because they all want to do what is most popular and the newest style of medicine?

Ms McWilliams: Yes.

Miss McAllister: That is why the consultants here were fighting for it — and over it at times.

I recognise that it is very hard to get our waiting lists down to a more acceptable and sustainable basis, but I have concerns about reaching long-term sustainability.

My final question is about theatre utilisation to target waiting lists. I have asked this question a number of times at various Health Committee sessions about the maximisation of utilisation of theatres. There is a concern about whether we are talking about theatre utilisation with regard to the number of patients or the fact that there are patients who have to wait in theatre spaces before they can move into the ICU, and that theatre, on the face of it, is seen as being used. However, a patient might have been in that theatre in post-op recovery for quite a few hours, so it is not optimisation; it is just being used. Have you done a piece on whether we are using theatres and optimising the number?

Ms McWilliams: We have very robust data on theatre utilisation. Theatre utilisation is operating time and run time, and Mark mentioned the late starts and early finishes. We have a lot of information on treatment in theatres. We do not include time spent waiting for an ICU bed as theatre utilisation. We work on the run time and the operating time, and we use the same methodology as NHS England, Scotland and Wales.

We also look at the utilisation of commissioned sessions, which is our trust using the appropriate number of sessions that we have paid for. We have all that information as well, but we look at operating time and run time. One takes account of the anaesthetic prep —.

Miss McAllister: Are the trusts using the utilisation of commissioned sessions?

Ms McWilliams: We are sitting at 85% or 86%, depending on whether it was January or February, against a target of 90%. We still have a bit of work to do, but it is better than it has been. That is all theatres. We have information on commissioned sessions being used. If I focus on those sites that are in our elective care framework, the Omagh day procedure centre has used 98% of its commissioned sessions; Lagan Valley has used 87% with a trajectory; and the South West Acute Hospital (SWAH) has used 100% of its commissioned sessions. Theatre time and surgeon time are the most expensive resource, so we have to make sure that we fully utilise it.

Miss McAllister: How many are we talking about? It is maybe not for now, but 98% is a fantastic figure, and so is 100%, but are we talking about hundreds of patients and not just 10 or 20?

Ms McWilliams: Since our day procedure centres in Lagan Valley and Omagh became operational, they have treated 23,283 patients, plus —.

Miss McAllister: In theatres?

Ms McWilliams: That is in the day procedure centres, so, yes, they are theatres. Some of them may be outpatients having procedures in that setting, but that is the day-case work. They have also done 19,000 scopes in those sites. That is a substantial volume.

Our elective overnight stay centres are for slightly more complex cases. Daisy Hill Hospital, the Mater Hospital and SWAH have seen 24,962 patients go through those centres. The patients might otherwise have waited for a main theatre on a different site, in competition with the ICU or HDU. Alongside the investment in elective overnight stay centres, we have post-anaesthetic care unit beds, which are for patients who need some monitoring but not an ICU or HDU bed. That is a way of getting more elective patients through, because you are not competing with unscheduled care patients for the highest level of ICU beds. Our robust theatre productivity programme looks at all this, and, through our support and intervention framework, we have escalated actions with various sites to improve productivity and efficiency across elective care.

Miss McAllister: Does the success — 98%; 87%;100% — achieved by using sites as targeted day procedure hubs and elective overnight hubs speak to a fact that could be key to the success of the transformation of the entire health service, which is that some sites are better utilised in that way, and not every service could or should run in every hospital? Does it also speak to the possibility of protecting some specialties by saying that procedures can be performed only at certain sites, such as the Royal Victoria Hospital? Do you see evidence building that that needs to happen and that the change needs to be permanent?

Ms McWilliams: That is certainly the premise of the elective care framework. I sat on the original task-and-finish group that looked at what elective care centres should look like and how better to protect elective care. In our conversations and planning, we are saying that we would ideally like to use the £80 million to put as much elective activity as possible through the Daisy Hill, SWAH and Causeway Hospital sites to make sure that we can do more activity. There are uncommissioned theatres, and we want to buy the workforce to use them. That is exactly in keeping with the elective care framework and the work of the previous task-and-finish group.

The Chairperson (Mr McGuigan): OK. We need to move on.

Miss McAllister: OK. Thank you.

Mr Robinson: I am conscious that we are almost two hours into this, so I will be as quick as I can. Last week, the Royal College of Emergency Medicine published its report detailing the large numbers of people who died due to long waits in EDs. In the validation section of your paper, you refer to the removal of patients:

Does that include those who have died? Lisa, you talked about being able to pull down numbers on deaths. Do you have figures? Annually, how many people, particularly those on a long waiting list, die while waiting?

Ms McWilliams: Are you asking how many people died on a waiting list — the totality of information?

Mr Robinson: Yes.

Ms McWilliams: We have information that shows removals from a waiting list due to death. We have that information, but, as I said, that does not mean that we have contacted them; it just means that that was the reason for their removal from the waiting list.

Mr Robinson: What are those figures?

Ms McWilliams: This is from a report that covers last year: the records of 5,994 patients had a code that indicated that they had been removed from an outpatient waiting list because they were deceased.

Mr Robinson: Does that cover a one-year period?

Ms McWilliams: Yes.

Mr Robinson: How far back are those figures collated?

Ms McWilliams: I imagine that we have legacy information — that report comes from the Encompass system — in the legacy systems. I do not remember seeing previous reports on that, but I can have a look.

Mr Robinson: It is natural that people will die on a waiting list —

Ms McWilliams: Yes.

Mr Robinson: — but is there information on those who died as a result of their wait?

Ms McWilliams: No, we do not have that level of information.

Mr Robinson: Fair enough. OK.

My other question is one that Nuala and other members touched on. At our previous informal session — you were at it, Joanne — Mark talked about a number of hospitals that were performing very well in elective care. He mentioned a couple of them that, he thought, had the capacity to do more. He said that Causeway Hospital could do more. Are we any closer to seeing Causeway being ramped up to the capacity that, we all know, it can deliver?

Ms McWilliams: That is the work that we have been doing. Causeway could do a lot of the north-west elective work and could do so with Western Trust colleagues to use resource once, either by taking patients or by having an inreach. We have been looking at Causeway, but we require being funding to do that. It is part of the £80 million for expansion. Causeway is in that space, as are Daisy Hill and SWAH, of saying, "We need to maximise what we have. How do we do that?" There are plans and conversations. The Southern Trust is putting forward its proposals for Daisy Hill, and the Western Trust is doing the same for SWAH. I am working with the Northern Trust and the Western Trust to look at the options for Causeway.

Mr Robinson: One of the keys is ring-fencing that £80 million that Mark mentioned.

Ms McWilliams: There is an element of general surgery that was part of the red-flag and time-critical aspect. That is the cancer general surgery. Some of Mark's work falls into that category. To do everything that we want to do, however, such as general surgery, gynae and ENT procedures, an element of the funding has to come from the £80 million for expansion.

Mr Chambers: Over recent days, members of my family have been called in at the weekend for diagnostic tests and have come away with good news, which is a weight off people's shoulders. I can see that the drive to bring down waiting lists is for real. It is happening. I would be disappointed if the morale of the staff who work overtime and at weekends was in any way impacted on by external cynicism about the improving activity figures that we are hearing.

We all realise that there is lots of work still to be done to get to where we need to be, but we need to be careful that we do not give staff the impression that they are damned if they do and damned if they don't, because they are definitely making the effort. I want to record my appreciation to them for their efforts to date.

However, a worrying bit of news has come down the track in recent days, which is the potential for a doctors' strike. The British Medical Association is proposing to ballot its members on strike action. What would be the impact of that on the improved waiting list figures and all the good work that you have been doing to date? Would much of that good work would be liable to be undone? We do not know how long a doctors' strike would be or how it would work out, but any delay or impact, I am sure, would be negative. What is your assessment?

Ms McWilliams: The previous single-day junior doctors' strike had an impact on acute elective delivery. The monitoring information shows that, from that single-day strike, some 4,049 outpatient appointments and 270 treatments were cancelled or not scheduled. That is the junior doctor component. That is elective, because, with the junior doctor absence, we manage the unscheduled work with senior decision makers. That is the information from the previous strike. It would probably be in that region, depending on the day of the week of the strike.

Mr Chambers: Let us hope that it does not happen. Thank you.

The Chairperson (Mr McGuigan): That was two hours. The reason that I allowed the session to go on for two hours is that this is not only an Executive priority but a priority for every citizen in the North. It is important that we give it the time to allow everybody to ask the important questions and allow you to give us the answers that, hopefully, will reassure people that good work is being done. Thank you very much for allowing us to keep you for so long.