Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): I welcome the Minister of Health, Mike Nesbitt; Mike Farrar, the interim permanent secretary of the Department of Health; and David Keenan, the acting finance director for the Department of Health. You are all very welcome. I believe that we now have 90 minutes with you.

Mr Nesbitt (The Minister of Health): Yes.

The Chairperson (Mr McGuigan): Thank you. We appreciate that.

I will hand over to you for a brief introduction, Minister, and then I will open up to members.

Mr Nesbitt: Given that the agenda changed and broadened, we were able to adjust the diary, so we have 90 minutes now, but that is a hard deadline.

Before turning to the wider budget position, I will say that I am conscious that the GP contract situation is of great interest to the Committee. It is a matter of regret that the Department was not able to reach agreement with the BMA on the 2025-26 general medical services (GMS) contract. As I said in my statement to the Assembly last week, my door remains open. I want to discuss how we can secure the future of general practice, and I believe that we can move forward and work together to develop a shared vision for primary care: there is a lot that we agree on. I am heartened by the fact that the BMA's general practice committee had a very constructive discussion with my permanent secretary, not on the contract issue but on how to build up primary care as a central part of resetting the entire health service.

I will make three points about the contract and the subsequent controversy around my decision to implement the package for this year. The first is that I simply do not have an extra £80 million to meet the BMA's demand. That, I am afraid, is an unavoidable fact.

Secondly, the additional £9·5 million in the new contract is only part of the picture of GP funding for this year. We have also secured significant funds to expand the multidisciplinary team (MDT) model and primary and elective care. Last week, I also made clear my intention to deliver the Review Body on Doctors' and Dentists' Remuneration (DDRB) pay award, so GPs will receive a further £11 million. It simply is not the case, therefore, that we are disinvesting in primary care; the opposite is the reality. However, I wish that we could do more and that we could do it more quickly.

Thirdly, I fully intend to invest more in GP services and primary care in the future, which will involve developing proposals for a new neighbourhood health model that delivers more care in primary and community settings in order to enable people to stay healthier for longer, reducing the demand for expensive, hospital-led care. That shift in care would necessarily be accompanied by a shift of resources from secondary to primary care. GPs and others stand to be the beneficiaries of that shift, and I want to work with GP representatives to ensure that stable general practice is at the heart of that neighbourhood model.

There is the also the wider issue of improving patient access. I want to be clear that I recognise the complexities and challenges involved in doing that. That, undoubtedly, is a source of huge frustration for patients, as we all know from our daily contact with constituents. I regularly receive letters from MLAs urging me to do more on primary care access. Whilst additional investment is part of the long-term answer, there are further improvements that we can put in place now to help to make a start. The GP contract for 2025-26 includes measures to remove some of the access friction points that can make the experience worse for patients and practices alike. In many cases, practices here already do those things, and we are simply looking to spread their good practice across the region. The reality is that some practices struggle more than others with access. I want to address that constructively and collaboratively, but, as MLAs, we must recognise that the issue was always likely to be a source of debate. I know that GPs want the best for their patients and are extremely frustrated at the current mismatch between demand and capacity. I meet and engage with enough GPs to see how hard they work, and I salute the work that they do and the commitment that they have to public service.

Let me now turn to the overall financial position. With our final budget now confirmed, we will be faced with an incredibly challenging financial position. We will again have to manage a significant funding gap and will not be able to do all that we need to do or all that I want us to do.

I recognise the importance of attempting to align funding with the Programme for Government (PFG) priorities and that that has driven the ring-fencing of a significant proportion of the funding available to me. However, the additional pressures that the final budget adds — the ring-fencing of some £165 million of the general allocation for waiting lists and the difference between the allocation for the rise in National Insurance contributions and the original planning assumptions — have increased that funding gap further. When we take account of the latest pay review body recommendations, which, I trust, we, as MLAs, can all support, that pushes the overall funding gap north of £600 million. I would like to be in a position where I could put substantially more investment into primary care, social care and public health to best meet the needs of our population, but, unfortunately, that will not be possible with the funding allocated.

The final Budget settlement leaves me in a position where I genuinely struggle to see a way through to financial balance. It is easy for some to stand on the sidelines and say that, with a budget of over £8 billion, significant further savings must exist. However, I invite any MLA to sit with the local director of finance in their trust to identify areas where savings can realistically be delivered. Given the quantum of the £600 million gap, I cannot see how it can be bridged this year through efficiency and service reconfiguration alone, although I will, of course, ensure that as much progress is made as possible. Realistically, it is extremely unlikely that we will receive significant in-year allocations in the coming year to resolve the shortfall. I will submit bids for additional funding in June monitoring, but I recognise that there will likely be limited funding available for the Executive to allocate.

I recognise that my Department has to do its bit to put Health and Social Care (HSC) on a more sustainable financial footing. In that regard, the permanent secretary and I hosted a financial summit with trust chairs and senior executives at the end of April. That was designed to look at actions that could be taken to improve the in-year position and our medium-term financial sustainability. That generated several actions, and a new systems financial management group has been established to take those actions forward. Mike may have further comments on that.

I was also asked to briefly touch on the legislative programme for the mandate. I am pleased to confirm that, before the summer, pending Executive agreement, I hope to introduce an adult protection Bill. I also hope to introduce up to five other Bills during the next two years. Those that I have prioritised are the control of data processing Bill; the safe and effective staffing Bill; the alcohol minimum unit pricing Bill; the pharmacy technician Bill; and the duty of candour Bill.

Chair, with your permission, I will now pass over to Mike, who will provide some more information on the new systems financial management group.

Mr Mike Farrar (Department of Health): Thank you, Minister. I welcome the opportunity to speak to the Committee at this early stage in my tenure. I really welcome the chance to give you some initial observations on what we need to do.

The first point is a large one, and it will not be the first time that the Committee has heard it. When you look back to Rafael Bengoa's report in 2016, you see that he talked about the problems associated with Health and Social Care's ever-voracious appetite to draw on the Northern Ireland Budget. The health budget stood at 46% of the total allocation in 2016. As we speak today, it is over 50% and touching 51%. If we continue at that rate and do nothing to address it, Northern Ireland will be looking at 75% to 80% by 2050. That, of course, is at the expense of other Departments' budgets, such as Education, Communities, Environment etc. In that sense, it simply is not tenable to carry on in the same way, and we have to be mindful of that. In that context, my role is to address that. That means that we have to get better value for the money that we have, and we have to effectively reset the way in which our system works.

I will put this simply: largely, we have tried to tackle some of the problems of increasing demand on healthcare by increasing supply, which is really not sustainable. Across the world, countries that face similar challenges have a very different approach and are starting to look, as we will, at the demand side of things. In that context, we are keen to produce two documents that will be helpful to the Committee. Both are completely designed to underpin the vision that the Minister set out on stabilisation, reform and delivery. It is not a new report. Basically, it says how we will achieve that. There are two elements to the time frame. One is the most immediate element, which is about how we effectively deal with our in-year financial problems this year — the £600 million — which is really important. The systems financial management group is now in place and is overseeing 13 work streams. It is on an emergency footing. As some of you will be aware, we talk about our sitreps, which are how we report on emergency situations. Those 13 work steams are looking at every aspect of our expenditure: our central budgets and the local trusts' budgets, which is where the vast majority of money is spent. They are designed to get as close as we can to balancing that £600 million figure. With the best will in the world, however, I have inherited the plan at the end of May, and giving ourselves 10 months of activity means that we will struggle. Therefore, as you are aware from the Minister's statement to the Assembly, I have had to use my accounting officer duty to point out that the immediate pay award that we face, which is a £200 million bill, is not affordable under the current budget arrangements. There will be a process that follows that.

The most important aspect of this is that we are absolutely looking at efficiency across our system, but that is accompanied by the second bit, which is the resetting of the health system. In that, we will look at increasing our focus on prevention and using citizens as assets. There is some good work that we can plagiarise, which is about getting citizens to be responsible for their own health, working with our voluntary sector and supporting people to, where they can, manage their own health problems and access care through, for example, pharmacists and general practitioners.

The second bit is about the neighbourhood model of health. Again, a lot of systems have that. We have pieces of the jigsaw but have not put them together in a coordinated way. In fact, I am having a conversation this week with the Department for Communities to look at how we connect what we are doing on health with the care planning process in order to make that more coherent. This is about trying to get people care in the community in an effective way that avoids their losing their independent living or going into hospital. Some of our services are currently provided in hospital settings, and our intention is to move those into an earlier access position where we can diagnose and treat people sooner and more effectively.

We will also look at how, thinking about the whole system, we use our resources to support other government initiatives. Members may be aware that Canterbury, New Zealand took the whole of the public expenditure and was able to get better value out of that. I am working on things such as economic inactivity, young people's mental health and trying to increase the opportunities for inward investment through life sciences and innovation etc.

We then get into some of the more significant areas, such as using our data. Encompass provides, I think, one of the world's leading health data platforms. I know only of Singapore that has something similar: all the service providers there are on the same platform. Singapore, however, does not include social care; we do. We have a world-leading opportunity to use our data and digital engagement to transform care. We are also looking at the cost base, which is our approach to costs.

Unwarranted clinical variability is a big issue for us, particularly in looking at primary care. Some practices manage a whole bunch of chronic diseases, whereas, with other practices, those flow through into our hospitals. Looking at that unwarranted variability needs clinical engagement and leadership, and we have to address that culture as well.

Finally, we need to be much, much faster at innovating. The technology innovations that everybody talks about — things such as AI — can definitely be helpful, but, if we do not have a culture of adoption at pace and scale, that will sit there and potentially even cost us more than it should.

Those are the seven areas that we will look at in the reset. Alongside that, we have to change the operating model, and I know that the Committee has been concerned about the way in which the trusts work together. I can tell you that, even in the first seven weeks, we got a commitment that there will be an approach called "committees in common", which all the trusts have agreed to and through which they will work together to take shared, binding decisions so that we see the whole system as a system with its workforce and its estate and are able to capitalise on that. Obviously, I am getting into detail that I do not want to get into at this stage.

Thank you for the opportunity to speak to you. I am happy to go into more detail on the short-term financial management and the reset. However, my stark point is that Northern Ireland cannot keep on demanding more of the public expenditure for help. We have to reset our system now to be more effective and efficient in what we do. It very much supports the Minister's vision for what the Health and Social Care system should deliver. Thank you.

The Chairperson (Mr McGuigan): Thank you very much, both of you. I should have given you a special welcome, Mike, as this is your first Committee meeting.

Minister, I have had a lot of engagement with GPs in the aftermath of last week's statement, as you would expect. They were hurt and upset about two things: the nature of the core funding being given to them and the tone of your statement, which upset them, probably, even more. It is not good for anybody interested in the health of our population to have the Minister at loggerheads, as it were, with general practice and GPs, who are instrumental in providing healthcare for our citizens. I think that I welcome a shift in, at least, your tone today, which is good. I accept and welcome the fact that the BMA GP committee had a positive meeting with the permanent secretary, but that leaves the issue of funding, which, I assume, they are still extremely concerned about.

We asked a number of written questions last week and got a written response from you in advance of this meeting that addressed some of the issues. We specifically asked about the cost of locums and trust-run services compared with independent GP practices. The figures were a bit of a shock to me. Even though I expected them to be higher, they are substantially higher. Trusts and locums cost substantially more. That is according to your own figures. Are you worried that, in essence, not giving additional funding for core services for GP practices, thereby putting GPs under pressure — they say that they are under pressure financially and in what they can do to provide extra access — pushes more GP practices to hand back contracts, perhaps? We may then end up having more trust-run practices, which is totally inefficient and undoes your stated policy of shifting left, because we would then have less patient access and a substantial, additional cost to the public purse. Your policy is, in effect, undoing what the stated endgame of your policy is. Are you concerned about that?

Mr Nesbitt: I am concerned that I cannot do all that I want to do as Minister, particularly all that I want to do with that shift left into primary and community care. However, I put another £9·5 million into the system.

The Chairperson (Mr McGuigan): It is only £1 million, Minister.

Mr Nesbitt: It is £1 million into the core envelope to be used as GPs see fit, but it is also £5 million for indemnity, which had become a highly toxic issue before I came into post, and £3·5 million — actually, a minimum of £3·5 million — to cover the additional hike in the National Insurance employers' contribution. GPs also made the point to me that they did not think that that would cover it. In response, I made the point that they would be able to prove what it cost through their receipts, and, if the receipts were more than £3·5 million, I guaranteed that we would cover that additional cost.

We have done what we can, but I have to go back to the point that I wanted to help more, so, when I first heard about the additional £80 million or 1%, I asked, on a number of occasions, for a one-pager setting out what they would do with that £80 million. I did not get it, and the reason that I did not get it was that there were going to be no additional services.

The Chairperson (Mr McGuigan): We met the BMA's GP committee last week. We do not dispute that £9 million is going in, but only £1 million of that is for core services, which is what we are having this conversation about. The GPs say that they need additional funding to provide more access. It is as simple as that.

According to your figures, we are paying an additional £4 million for trust-run GP practices. If we pumped that money into supporting GP practices, we would have fewer trust-run practices and more access for patients.

Mr Nesbitt: It is a complicated picture, in that, certainly, locums are expensive. One of our focuses in this financial year is to reduce the spend on locums. However, you then have salaried GPs, and there seems to be an established trend, particularly among younger GPs, of saying, "We would rather be salaried GPs than practice owners or business managers". There are three different areas at play. Do you want to add to that, Mike?

Mr Farrar: If you look at the number of practices handing back contracts, you see that it has been going down over the past two or three years. It is a big decision, obviously, for a general practitioner to hand back a contract. Where the trusts have taken such practices on, they have been able to recruit salaried GPs. In essence, therefore, there is a question mark over the comparison between the costs of care. I do not fully accept the BMA's position that trust-run practices have increased costs compared with general practice. That is testable, and we could certainly explore that.

One of the problems that we have is that, in the context of what practices receive, GP earnings can be very flexible. Practices are independent businesses. A practice can choose to employ more GPs or nurses. As long as there is one GMS-registered practitioner, it can operate as a practice. The extent to which a practice takes money out of its contract — that is, the extent to which it has a lucrative business that it can afford and that GPs can get a good salary from — is variable across practices. Some of the indicators of those claims are testable.

I will say one thing about something that I absolutely support, as does the Minister: if we are to invest in general practice, that investment has to not be for more of the same. I say that because, even when we were substantially funding general practice in previous years, we saw difficulties and the trend of people passing back contracts. I have figures in front of me on how many practices have been in crisis over the years. It was happening before we got into this year. Really, the solution for general practice has to be investing in a new model of care: we support it with a bigger workforce and put it at the heart of communities as a navigator, with pharmacists and multidisciplinary team professionals alongside it. To me, that is what we should invest in. Sadly, we have a difficult financial position, but, if we look at future investment, the question for the BMA is whether it supports that new model of care. I think that, as the money allows, we will invest in that, because it really reduces demand.

The Chairperson (Mr McGuigan): I am sorry for cutting in, but everyone is limited by time. The Minister has talked about "more of the same", and you have now said it too, Mike. Essentially, GPs provide primary care to patients. More funding would allow them to provide more of the same. They said that more funding would allow them to do more of what they do, including the additional stuff that you want them to do, but they need more funding in order to do that. I am not asking for a rebuttal — I am sure that other members will come in on that — but I need to make that point.

I turn to my next point. I declare an interest: I was a patient in the cardiac surgery unit in the Royal Victoria Hospital.

Mr Nesbitt: Me too.

The Chairperson (Mr McGuigan): I should say, at the outset, that I was treated very well. I also need to say that I have not seen the report, but it has been widely reported. The contents, if what has been reported is accurate, are shocking. Health Committee members have not seen the report, or, at least, I have not seen it. When will the Committee and the public see the contents of the report and the recommendations that it contains?

Mr Nesbitt: We were discussing that earlier today. Previously, I made a commitment to Mrs Dodds that I would lay the report in the Library. I have now been informed that I was slightly premature, in that we need to take legal advice about the report, because it may identify individuals. We need to be careful about not provoking legal action. That is the problem.

As a more general point, it was a devastating report. A bad culture was allowed to develop, and that demonstrated itself in behaviours and in the fact that there was a terrible breakdown in relationships, with one surgeon walking into the building and others walking out and saying that they were working from home.

First, I have written to the chair of the trust, and the language that was used in that letter was robust, to say the least. I hope to meet him tomorrow, because I want to be able to look him in the eye and assure myself that he understands fully how seriously I am taking the issue and that the expectations that I have defined in that letter are equally understood. We will meet again next month, because he is assuring me that the recommendations are being implemented, that an implementation action plan and oversight group is being formed and that the independent group that came out with the report will still be engaged to make sure that implementation is happening. Therefore, I am treating it extremely seriously.

I should also make the point, because there are people who are imminently going to the cardiac unit for procedures, that we believe and the report suggests that, at the moment, it is clinically safe. It would be allowing the behaviours to continue that would take us into an area of risk. I declare that I have had two procedures, potentially life-saving, from that unit, and I am grateful.

The Chairperson (Mr McGuigan): Minister, you talked about the seriousness of it. There were rows, abuse, bullying of junior staff by more senior staff, surgeons not coming to work, throwing of medical instruments during operations and one consultant allegedly being told, "If the patient dies, I will tell the family it was your fault". It is stated that it was behaviour putting patients at risk of harm. Reportedly, when staff made complaints to Belfast Health and Social Care Trust, it was extremely slow to investigate. That is what has been reported as being in the report. It is shocking and extremely concerning. It is difficult to assure the public.

The investigation commenced in December 2024, so I assume that you were aware of it in December 2024. I am maybe a bit incredulous that we still have not had sight of the recommendations. We do not know what you suggested to the trust and what the trust was suggesting whilst that investigation was going on. Those are behaviours about which, clearly, when you are told about them, you do not need six months to become alarmed enough to try to address some of that.

I thought that you said in response to a question from one of us the other day that you were meeting the chair of the trust that day. I am a bit disappointed to hear that you have not met the chair of the trust. I want you to give us assurance that you are taking it seriously and that the Belfast Trust is taking it seriously. The public need to see those recommendations to be assured of their confidence in that life-saving unit in one of our publicly funded hospitals. You need to go a bit further than you have on your assurance that people are safe.

Mr Nesbitt: The bad behaviour was among staff; it was not by staff towards patients. That is an important point. It does not make it acceptable, but it is important to say that no bad behaviour was reported between surgeons or other members of that 250-strong team and the patients whom they were dealing with. I accept that, if I am due to go for a procedure tomorrow, next week or next month, I am now looking at it differently from before the reports of the report came into the public domain. I can only assure you that, in the year that I have been in post, I have not signed off on a letter as strongly worded as the one that I sent to the chair. As I said, I will meet him tomorrow, and then I will meet him for a follow-up, giving him two or three weeks to make sure that the actions are in place. The independent people who wrote the report are the same people who will be coming to me and saying whether the action plan and the recommendations are being implemented as they should be.

The Chairperson (Mr McGuigan): I accept what you said about the legal advice on the report. I would have thought that the action plan and recommendations could be made public. That would go some way to assuring the public.

Mr Nesbitt: I will certainly take that point away. I have no desire to prevent you from seeing the report, but I have to take the legal advice that I am given, which is to seek legal advice.

The Chairperson (Mr McGuigan): You made the point that it was not staff against patients but staff against staff. I have questioned the violence from the public in emergency departments (EDs) and other hospital and healthcare settings and the threats of violence against our hard-working healthcare staff. The levels of that behaviour are extremely high and need to be addressed. I was particularly concerned that, in some of our healthcare settings, some of our staff are being bullied, threatened and harassed by their colleagues. It is extremely upsetting and worrying.

I have asked you about engagement with the unions. Today, I heard on media outlets further concerns that the situation is not isolated. I do not want to go into the allegations. However, if there is a pervasive situation across all healthcare settings with junior staff feeling bullied, harassed and intimidated, you need to engage with the unions and that needs to be addressed seriously.

Mr Nesbitt: I have two more points to make briefly. I am also asking for an urgent meeting with the Royal College of Surgeons (RCS), because I want to know whether it will take a view, particularly with regard to any ethical codes that it may have. Secondly, I cannot look you in the eye and say, "That unit is an outlier". It was a cultural issue. It would not surprise me if cultural issues existed in other units in our arm's-length bodies (ALBs), including the five geographically defined trusts.

Sometimes, when something like this comes into the public domain, as you know, it effectively gives permission to other people in other units to become whistle-blowers and to put their hands up. We are on standby for that eventuality, without any knowledge that it is coming, but the logic says that it is highly possible.

The Chairperson (Mr McGuigan): Thank you.

Mrs Dodds: Thank you, Minister. Welcome, Mike. I am sure that it will be the first of many encounters in the Health Committee.

Following on from the Chair's questions, I would like clarification on a couple of issues. The report talks not only about bad behaviour between staff but the failure of the Belfast Trust to manage that bad behaviour and to take action in support of staff who felt bullied etc. That is a huge failure by a large organisation, and that is clearly stated in the report. I have been contacted by various people since Tuesday, and it is becoming clear to me that it is not isolated to one unit in the trust. It is exacerbated by weak management and a failure to deal with issues as they arise. I am interested to know when the Department and either Minister Swann or you, Minister, became aware of the mismanagement in the trust.

I have been told that Peter May commissioned a report on the weak management structures in the trust and the failure to deal with bullying and such issues and that the report was written by Professor Peter McBride, who has presented to the Committee on the Being Open framework. I understand that the report was presented to the trust, but I am unsure about whether any actions have been taken. Certainly, the fiasco in the cardiac surgery unit in the first quarter of the year indicates that little has been done. When did you know that it was a cultural issue in the Belfast Trust? Have you had sight of the report commissioned by Peter May? Will the Committee be able to see the report commissioned by Peter May? What will be done, bar strong letters and, Minister, I have to say, some plausible deniability from you on the matter?

Mr Nesbitt: Will you expand on the plausible deniability?

Mrs Dodds: I do not know. I want you to set out clearly when the ministerial team in the Department knew about the issue, how long it has been going on and why action was not taken, meaning that we arrived at the crisis point in the first quarter of this year that is described in the report.

Mr Nesbitt: I would need to go away and come back to you, because I do not want to commit myself to saying, "I knew on such-and-such a date". In my role, almost daily, however, one of the things that I get briefed on is a problem. There are a lot of problems. There are 70,000-odd people delivering healthcare, and, inevitably, there are problems.

I have not seen the other report that you refer to and that, you believe, Peter May commissioned. I am not aware of it, so I have not read it. It is important to say — this is not to deflect from my responsibilities — that my responsibility is to make sure that the trusts and trust boards do their job. There is a question mark over the Belfast Trust and whether it has been doing its job in this instance. However, the trusts are effectively the employers, and, if there is to be action taken to remedy a situation such as the one that has developed in that cardiac unit, it is primarily for the trust to take that action. It is for me to make sure that I hold the trust to account and that it takes appropriate action.

Is there anything that you want to add, Mike?

Mr Farrar: This is the first that I have heard about a report that Peter commissioned from Peter McBride, so we will, obviously, look into that. I have not been made aware of that.

Mrs Dodds: That is fine.

Again, for clarity, being able to read that report would be helpful. We, as a Health Committee scrutinising the Department and the trusts, want to know that people are doing their job, that staff are being looked after and that patients are safe. I, too, have read, according to the metrics, that the unit is safe. I am not querying that at all, and I do not want to have anybody feeling fearful about going into any serious operation in that unit. I am not saying that in any sense, but it is important that we are given the information in the interests of openness and transparency to be able to do that.

I have a more general question about the Belfast Trust. Over the past year, we have seen a fiasco around the maternity hospital, the children's hospital, an energy centre on which we spent £10 million of public money that, the Department — in your answers to me, Minister — openly says, cannot be delivered and now the acute mental health inpatient centre at the Belfast City Hospital site. I have called and continue to call for your Department to put some kind of special measures into the Belfast Trust so that we stop the litany of problems coming from that trust. When will you get a grip of the issue and put the trust into special measures? I noticed your interview yesterday, Mike, when you talked about that possibility. I welcome that, but we are beyond the time for action.

Mr Nesbitt: May I just go back to that Peter McBride report?

Mrs Dodds: Yes, of course.

Mr Nesbitt: I will go from here and find out whether it exists —

Mrs Dodds: That is fair enough.

Mr Nesbitt: — with a view to sharing it with you. However, so that I do not have to correct myself again, I say that it may need again to be looked at by the lawyers, just in case there is identification of individuals.

Mrs Dodds: Yes.

Mr Nesbitt: My hope would be that, if it exists, you will get it in a timely manner.

There are five points on the scale of interventions, and the Belfast Trust is at point 4. Point 5 is what you are calling for, but that is not a punishment; that is assistance. I am reluctant to do that at this stage, not least because we are approaching the final stages, I believe, of appointing the permanent replacement chief executive. That person needs to be given an opportunity to put the house in order, if that is an appropriate phrase. That is fairly imminent, Mike, is it not? It is well advanced.

Mr Farrar: We are shortlisting today, and interviews will be in early July. That is a key appointment.

There is one point of principle. I really understand where you are. Actually, there are two points of principle. One is that, if there is learning from this, which there is, it is about creating cultures that are healthy in a preventive and positive sense. That is something that we have to do with our workforce, and we will push hard, as part of resetting the system, that the cultures that have existed in trusts cannot be tolerated. That is not where we want to be. Whilst having things such as the duty of candour in the mix is helpful, we should never have to legislate a duty of candour. If you think about professionals in the healthcare business, we should never have to, but we are where we are, and we will promote that.

Secondly, the level of intervention in the systems intervention framework, in essence, places the responsibility on the boards to manage it on an ongoing basis. When we come to level 5 — you made the point that we might be at that level already — if we are not careful, it takes away the responsibility for the trust board to really get to grips with the issue. In my view, it is committed to doing that. It commissioned the review and is now trying to action it. At the very least, we should give it the opportunity, because it is closest to it.

As the Minister said, if there are disciplinary issues, that is within the jurisdiction of the trust, not with us in the Department. However, if we are absolutely clear that it is not fulfilling its promises to deliver on this, I do not think that we would have any hesitation. Placing the responsibility with the trust board is the right place for it to be, and, if it fails to deliver on its duties, I do not think that we would have any hesitation in saying that we go to the next level. The Minister is absolutely right in saying that it is not a punishment; it just means that we have to put more assistance into that. We have offered a huge amount of assistance, but it is still within its gift to resolve it and to do it quickly. The Minister will hear about the progress on the action plan tomorrow, and we will have continuing monitoring meetings to make sure that it is on top of that.

The Chairperson (Mr McGuigan): We have to move on to the next member, but I will come back to you if we have time, Diane.

Mrs Dillon: Thank you. I am following on from those last comments anyway. For me, the accountability mechanisms between the trust and the Department are more important. I would like us to get an understanding of exactly what the accountability mechanisms are between the trust and the Department, particularly given what has gone on. I am happy to get that in writing, because I think that we would probably have to get it in writing.

I seriously hope that, in the appointment process, you are looking at anybody who was involved in any part of what happened in the cardiac surgical team. I understand what you say about it not being abuse of patients, but it was abuse of staff. They are human beings; they are people. For someone who potentially had some part to play in a management role in the cardiac unit to go into a higher management role would be extremely concerning. I am putting that out there. It is an HR issue — I know that we cannot get involved — but there needs to be a conversation about it, and it needs to be considered, particularly in your meeting with the chair. For a senior clinician — that is what it sounds like — to say, "If this patient dies, it is your fault", is abuse of a patient and their family. That is horrific. I cannot even imagine what any family would think if they knew that that was their loved one. That is abuse of patients and their families.

You said that, coming out of this, there is potential for other people to come forward. The Chair is right that the unions were clear this morning on the radio when they said that there is a culture and that it is happening in other hospitals, other units and other trusts and they have evidence of it. Speak to them. Do not wait for people to come forward; do not wait for people who are just trying to do their job and to cope with getting through the day. Some of them will not want to report it, because they just want to look after their patients. They are prepared to put up with it in order to look after their patients. Do not wait for it; go and look for it. It is the trust and the Department's responsibility to go and find out.

If there was ever an argument for legislation on the duty of candour, honestly, I think that this is it. I was never totally convinced about whether there was a need, but, for me, this is the absolute. We need to find out whether there is a pervasive culture and not wait for it to come looking for us. I would like the Department to come back to us in relation to what work the Department or trusts are doing to ensure that this is not an issue. That work needs to be done with the unions and staff.

My last point is a question. Would there ever have been a review of this, had those surgeons not left when that surgeon came back? Do we know the answer to that?

Mr Nesbitt: I do not know the answer to that.

Mrs Dillon: Can that be a question that is asked of the chair?

Mr Nesbitt: Yes.

Mrs Dillon: If the trust wants to prove its candour, this is its opportunity.

Mr Nesbitt: I briefed the Executive this morning on the situation at the cardiac unit. One of my concerns is that, because it was the only unit providing cardiac surgery in Northern Ireland, there is a potential implication for the other acute hospitals, such as the Ulster, the City and Craigavon. I want to know what the relationships with the cardiac units in the other acutes in the other trusts were like. Clearly, there is a suspicion that those in the unit at the Royal, which was the one doing the surgery, were the "big beasts" in cardiac care. There is that issue.

I am more than happy to commit to meeting the unions as a matter of urgency to see what they have to say. Certainly, we will ask the trusts for their opinion about the extent to which the culture in that unit is representative of the culture in other units in the five geographically defined trusts. I will not sit back on this, but I anticipate that some people will come forward. That is to be welcomed, because it is a valuable, rich source of information, if a whistle-blower chooses to inform us that we need to look at x, y or z unit.

Mrs Dillon: Can we also get detail from the trust, if you do not already have it, on what it has done in the interim? That is the question that I asked the other day. I understand that it probably lies within the responsibility of the trust, but it is information that we need to have: what has it done in the interim while the report was making its recommendations? If the trust knew that this was bad as it was, it should not have waited for recommendations. You would be in there immediately. It follows on from much of what Diane said. Can we get that information through your meeting with the chair, if you have not already been given that?

Mr Nesbitt: As I said, it is my intention to meet him tomorrow, and I am more than happy to send a debrief to the Committee on foot of that meeting.

Mrs Dillon: I will ask one question that is not related to the cardiac unit. In the financial plans, the objectives for the domiciliary care and social care work streams are still to be decided. Is there a reason for the delay? When can we expect that they will be decided?

Mr Farrar: That is probably with me.

Mrs Dillon: I am sorry. I know that you have a lot to deal with today. It is about the financial plans and the objectives in relation to domiciliary care and social care.

Mr Farrar: When that group was put together, they were the work streams that came out of the financial summit. At that point, a particular piece of work had been going on in social care, done by the social care collaborative forum. Before committing in that document at that time, we were keen to make sure that we were not saying something that we already had in hand. That has now been updated, and we will send you an updated version. There is a clear set of objectives of what the social care work stream will do in domiciliary and social care, in looking at economies, efficiencies and, I would also say, trying to improve the service. We will send you an updated version of that. Apologies. You have got a version —.

Mrs Dillon: Improving the service is probably my focus, to be honest.

Mr Farrar: You got a version of the grid as it was at the time, but it has been updated since, because we have already started meeting. We can send you that.

Mrs Dillon: Thank you.

Mr Nesbitt: You mentioned the accountability. I think that we could share that.

Mr Farrar: Yes, absolutely.

Mr Nesbitt: We have a document that gives the five levels and what that entails; we are happy to forward it.

Mrs Dillon: Thank you.

Mr Donnelly: Hi, Mike. Good to see you. Thanks for coming to the Committee. I want to take you up on one thing that you said early on: you said that GP contract hand-backs had been going down. That is in conflict with what we were told by the Minister a couple of weeks ago. In the Chamber, you were asked, Minister, about contract hand-backs; maybe you remember.

You said that:

They appear to be ramping up. There have been 16 since 2023-24, with 11 in the past year. There seems to be an increase in the number of GP hand-backs. We also heard last week that 17 practices across Northern Ireland are in crisis management. Can you confirm for us whether GP contract hand-backs are going down?

Mr Nesbitt: The 16 hand-backs are a split of five this year and 11 in the previous year. There were 11 in 2023-24, and last year, in 2024-25, there were five. In 2022-23, there were 13; in 2023-24, they were down to 11; and, in 2024-25, they were down again to five.

Mr Donnelly: Those figures are not the same as those that are in my notes. Maybe we need some clarity on that. To hear that that number of GP practices has closed over a couple of years is incredibly shocking. There are 17 practices now in crisis management. How many more GP practices will close here? How many more will we lose?

Mr Nesbitt: I cannot answer that question.

Mr Farrar: This is an observation rather than a specific point, but, if you look at the English context, you will see that a lot of practices have changed hands and become part of bigger groups, effectively. Modality, Operose, the Hurley Group and AT Medics have taken on practices, so, although individual GP practices have not handed back their contract, they have been taken over. The key thing is whether we are able to support those populations, and that is a legal duty that we have. When a practitioner hands back a contract, we are obliged to make sure that that population gets primary care coverage. That is what we have been doing.

Of the 32 contract hand-backs, 30 were immediately secured by the strategic planning and performance group (SPPG). Where there are unusual ones or where there are one or two that have not been done, that largely results in the practice not being viable, so it has, effectively, been amalgamated. I do not want people to believe that that means that no one has primary care. We have a statutory duty to make sure that that happens.

In an English context, you might not see that as a hand-back, because those GPs have sold out to a bigger practice group. That is a trend across the world. In Northern Ireland, we have a profile of practices with a lot of small ones that are good for continuity of care, but sometimes scale is important as well.

Mr Donnelly: We have seen quite a lot of hand-backs. A lot of GP practices are at risk and are in crisis management. When the trusts have to take over contracts, the figures are staggering, as, I am sure, you are aware.

A practice that cost £760,000 to run in 2022-23 cost £1,419,000 in 2023-24. That is double; it cost twice as much. Another practice might cost more than three times as much to run. When the contracts get handed back, there is a huge cost, as the Chair mentioned.

Mr Farrar: I am not sure that those were the figures when I saw them. They might be exactly the case. I am not sure where those figures come from. It is something that —.

Mr Donnelly: You sent them to us.

Mr Farrar: Are those my figures? OK. I am not sure how we counted them, in that case. You have to shoot yourself in the foot in your first appearance.

It is hard to say how the trust is running those practices on the basis of that specific figure, because trusts get a general allocation. I am not sure how they have attributed the cost to those practices and what they have done, but I will happily look at those figures.

The most important point of the discussion is the point that you raised, which is that general practice has to feature strongly in our model. The model of general practice and its financing really need to align with the model of care that we need to deliver, which is an integrated neighbourhood model. We are very seized of that fact. If, in the short term, we are having some issues with that, we need to accelerate the pace at which GPs feel confident that their future and practices sit at the heart of what we want to do. This country should have the best population health management arrangements in the world, because we have 99% registration, so we know all our people. This is a real opportunity for us. We will not lose general practice. It will sit at the heart of what we do. We just need you to bear with us while we invest in that new model. That is what we need to work.

Mr Donnelly: I am glad to hear that. I hope that the GPs who are listening to the evidence session will be reassured by that.

We have heard lots of times from the Minister about his desire to shift left in the Bengoa direction, but that means investment in primary care. We have not seen that investment in GPs, dentists, community pharmacists or community groups in, for example, the core grant funding. We are losing a lot of community groups that are able to do all those things. GP and dental practices are closing, and community pharmacy is under big pressure. It seems to be that it is not working and that the shift left is not happening at the moment. How do you explain that?

Mr Nesbitt: It is not accurate to say that there is no additional investment in those services, because the GPs got £9·5 million and the dentists got just over £7 million, plus another couple of million pounds for National Insurance. The core grant scheme was moribund when I came into post. The advice from officials was to let it go, and I brought it back, albeit at only £1·8 million. We reconfigured it, because any charity that had been established in the past 20 years could not even apply. I am not satisfied with the way that it worked out, but it was designed by the voluntary and community sector, and we are working with that sector to see how we can do it in a way that might be seen to be a bit more equitable.

All of that having been said, is £9·5 million what I want to put into enhancing GP services? Of course it is not. I would love to give GP services the £80 million. I would love to give dentists what they want. They have taken a really practical and balanced approach by saying, "We understand that the Minister has all these financial pressures, but, as a consequence, the money that he has given us is not the amount of money for the radical transformation of dental provision that we need". I agree with every word of what they say.

I have a quadruple challenge. The Executive have said — I agree with them — that we should prioritise waiting lists, so they ring-fenced £215 million this financial year to spend on waiting lists. However, because £165 million of that is not fresh money, I have to mitigate the fact that money will not go on other services that might have expected it.

The third challenge is transformation. We have to press on with reform; otherwise, once we have spent the money on waiting lists, they will go back up when the money has run out. Where do we find money for transformation?

The fourth challenge is balancing the books. Can all four be achieved? I am not entirely confident that they can, but I am certainly up for the challenge. The biggest disappointment in all that is the fact that the speed of reform will be dictated by the funding gap. I think that everybody is ready to do the shift left —I certainly am — but it needs that pump-priming. Once you start that and put more emphasis on prevention and early intervention, you might relieve a bit of the pressure on the acute services where all the expensive stuff happens. If you do that, you start to free up more money and the money starts to shift left.

Mr Donnelly: Absolutely. I hope that we can start to see that.

The Chairperson (Mr McGuigan): Quickly, Danny, because I have to move on to your colleague.

Mr Donnelly: I have one other question, and I agree with Diane's questions about the cardiac unit. Those issues are concerning. Will you provide an update on the maternity hospital? We have heard that there was going to be a decision on the way forward for the maternity hospital. Can you give us an updated cost for what is happening and tell us what the decision is? Can you tell us when it might be open?

Mr Nesbitt: All that I can tell you is that I have been told, as of today, that a decision or a recommendation from the trust is imminent, but I do not know what it is, and, therefore —.

Mr Donnelly: Imminent now?

Mr Nesbitt: Imminent, yes. I do not know what it is, and, therefore, I do not know what the cost is.

Miss McAllister: Thank you very much, and welcome, Mike, to your first appearance at Committee. I have quite a number of topics, so, hopefully, my questions will be quick to cover.

I want to follow on from what was said about GPs and the higher costs of trust-run practices. One of the issues is that they have to cover indemnity too. That is in contrast with non-trust-run practices. Another issue on which we, as an entire Committee, have had feedback is salaried GPs and the fact that there is a difference between salaried GPs and those who run the business or the practice managers and whose names are across the door. Comments were made about what goes into their pockets.

GPs do not have that static income until they give everything out to everyone. It is a bit of an unfair comparison to make, because GPs' wages go down if they need to put more money into their salary to cover their indemnity, which they had to do last year. It is a bit of an unfair system, and, hopefully, we can now move forward with a different tone in the engagement with the BMA in particular on that.

My first question is not just about the cardiac unit but follows on from what Diane asked about the issues at the Belfast Trust. Muckamore was run by the Belfast Trust. Dr Watt was in the Belfast Trust. However, it is not just about the Belfast Trust. We have had serious respite and adult safeguarding concerns at the South Eastern Health and Social Care Trust. We have had the cervical cancer screening issue at the Southern Health and Social Care Trust. There are many more issues that we all work on. Whilst the initial fault might not be with management, the reason that it went on for so long and was ignored was because of management errors and the fact that management was not doing its job. Do we have a problem with the way in which our trusts are run? There are failures again and again, and there are more scandals each year. Minister, are you content that we do not have a problem that means that the way in which our trusts are run leads to more of those issues surfacing each year? The cervical screening one is not over, and we know that there are still issues with it being transferred to Belfast. Do you have faith and confidence that our trusts are run efficiently and are being managed as appropriately as they should be?

Mr Nesbitt: I am assured and confident that the vast, vast majority of people who deliver healthcare in this country are well intended and well motivated, but there are also people — you mentioned Dr Watt — who deliver bad outcomes.

Miss McAllister: I agree with you. I am speaking not about the individuals who deliver healthcare on the ground but the management and the management ethos across all the trusts. Those issues rumble on and on until a scandal breaks. At some point, we always find out, either in Committee, through an inquiry or a statement that you make in the Chamber, that the trusts knew about it, that management knew about it and that there was a failure to tackle it.

Mr Nesbitt: Yes. I have concerns at times about the information flow and the speed at which information comes to me. Often, other people get that information anecdotally from whistle-blowers or whatever, and I do not like to be in that position. I also do not like to sit in a room full of 27 people whose loved ones were damaged by Dr Watt and have to listen to the human cost of what happened. That is not just about an individual clinician; it is about the whole system. In that specific case, the belief of all 27 in the room that day was that this was a systemic failure that was allowed to happen.

Miss McAllister: How can we get a grip on that now? How can we get a grip not just on that failure but on some of those that I outlined that involve the management across all trusts? What can the Department do?

Mr Nesbitt: All that I can say to you is that I regularly meet the trust chairs, and they can be in no doubt that I do not want to hear about another scandal or another episode where things are not done properly and patients or service users come to harm. I will bring Mike in on this, because this is an observation that he shares with me, but, as a broad point, we sometimes feel that issues that arise in a specific trust are issues to be dealt with by the board of that trust, that is, by the chairman and their fellow board members. On probably too many occasions, those issues are sent straight through to the Department, and that should not happen.

Mr Farrar: I will make a general point and then give a specific answer. Quality is the thing that happens when no one is looking. It starts with people being really concerned about the care that they give and making sure that, in every intervention with a patient, whether it is a nurse at a bedside, a doctor diagnosing or a surgeon in a theatre, they do the best that they can.

That is where we start.

This is where talking to the chief execs and the chairs of the boards comes in, but I then expect there to be real scrutiny and for them to be more ambitious about having the highest-quality standards, standards that are higher than anyone else's. I expect that to reside with them, so that they monitor and are on top of it and so that, where there are problems, they confess to them, are open and say, "We have an issue". You could argue — I am not arguing this — that it is a good sign that we have a number of areas that are being investigated, because it shows that those issues are being raised. Sadly, too many of those perhaps come through whistle-blowers. I am not trying to defend that. We have to give quality.

I genuinely believe that our management works hard to prevent the failure of quality. As I said in response to members' questions, including Diane's, we will look to get a culture of strong care — what many people call "compassionate care". I do not think that there is any pushback on that. There are no excuses for poor care, and I do not think that any of our leaders at a local level would defend or hide that. That is not the case. Although I am new to the system at one level, I have heard positive commitment from all those leaders to tackle poor quality.

One thing that we struggle with that is interesting, although Operation Encompass will give us this, is benchmarking the quality of care in one bit of the system against that in another bit. That could be about understanding whether a six-day stay or a readmission for a particular procedure was necessary or could have been tackled. I mentioned one or two areas of clinical variability. The data will start to highlight where we have problems and give us preventative information about where we can intervene and where quality starts to deteriorate. There are two components to a system that could address that. One is being smart about understanding where quality is at risk, and the other is making sure that managers are able and feel confident to report when something goes wrong, because, as you know, healthcare goes wrong sometimes. We have to assure the public of Northern Ireland that, when those things happen and are brought to the public's attention, we will take action to address them so that they can feel confident.

Such things are the exception rather than the rule. The vast majority of clinical professionals are incredibly good at what they do. That goes back to our conversation about the cardiac unit. It would be wrong if, on the back of some high-profile failures, the public got the impression that their expectation should be that care will be poor. I do not think that that is the case; I think that the people of Northern Ireland get good care.

I have one last point. I absolutely believe — I said it when I took this job — that Northern Ireland can have one of the best health and care systems in the world, but there are some things that we need to do to get there. One of those is to address some of the quality failures and to prevent them happening in the first place.

The Chairperson (Mr McGuigan): You can have one quick question followed by a quick answer, Nuala.

Miss McAllister: That brings me on to respite. Like I said, there have been a lot of issues with respite in the South Eastern Trust in particular, although the problem is across all trusts. Is there any further update on the number of additional beds and/or nights, preferably with examples of actual families, that have been helped with the £10 million investment that was allocated to respite services? We hear from families that it is not making a difference. We know that that would not have been quick, but there was still an expectation that there would be at least some alleviation of the problem. The families knew that it would not be quick, but they expected some alleviation.

Mr Nesbitt: It would be best if I wrote back on that, Chair, because there is a level of detail behind that issue, and it was not on the original agenda. Over the summer and coming into the autumn is when we will see more beds being made available for longer, meaning seven days a week, in some cases, rather than five days a week. The number of beds will be very limited, but issues such as Redwood needing a staircase —.

Miss McAllister: I raised that issue with you at the last meeting.

Mr Nesbitt: That has either been done or is in progress. When Redwood opens, that will then release Lakewood. Is it Lakewood? Anyway, I will write with the detail.

The Chairperson (Mr McGuigan): We appreciate that.

Mr Farrar: Chair, may I make one brief point?

Miss McAllister: Sorry, it was £13 million, if that is what you were about to say. I got the figure wrong.

Mr Farrar: We will get back to you on that.

Carers' support is a key factor in the reset of the system and in managing the money in the best way possible. If you look at where carers have been supported for things such as managing relatives with dementia or Alzheimer's, you will see that, with basic training, support and allowances, they are able to have a major impact on the cost of the stay. Look out for carer support featuring in the way in which we deal with the public, the dialogue about health and how we can help ourselves. That will feature strongly.

Mr McGrath: Thank you, Minister, and welcome, Mike, to the Committee. I will follow on from what others said about the Belfast Trust. It certainly feels that, every other week, we discuss another scandal regarding the Belfast Trust. I am not entirely convinced that what we have heard from you today shows that the Department will get to grips with it. From what I hear from you, it feels as though it will be down to the appointment of a new chief executive. However, even from chief executive-level down, there has always been a trust board, and the trust board has not been managing itself properly if it has allowed those cultures to permeate its structures. It is a bit fantastical to think that a new chief executive will come in and sort all the woes out.

You mentioned the systems intervention model and said that we are at level 4 of five on that. We have got to level 4, given all the problems that there have been, so is that systems intervention model fit for purpose? It feels as though there is only one level left, which is to take control from the trust board and bring it into the Department. It feels as though not an awful lot has been done yet and since with all those problems. We think about the maternity hospital, the children's hospital, neurology, hyponatraemia and those workplace issues. Things seem to be constantly going wrong, but we do not seem to get any resolution. Is that model fit for purpose, therefore, and is it taken completely under the Department's control at stage 5?

Mr Nesbitt: Stage 5, as Mike said, is an option that is still live. To reiterate, it is not simply about appointing a new chief executive; it is about the board taking more control. I will discuss that with the chairman when we meet. It is about the board saying, "This is on our watch, and we have to fix it". Preferably, it will say, "This is on our watch, and we have to ensure that nothing adverse goes wrong". Things do go wrong, but I am talking about the big scandals such as the persistent bad culture in the cardiac unit. It is not just about one person coming in as chief executive but about recalibrating how the board deals with the day-to-day running of that and the other trusts, of course.

Mr McGrath: Is somebody specifically monitoring the board to make sure that it carries out its responsibilities correctly? If somebody is not monitoring it, it has maybe long gone past the time for it to step down and a new one to be put in place to take control of the issues.

Mr Nesbitt: Our only vires is in the appointment of a chairman, not the ordinary members of the board.

Mr McGrath: Minister, that feels as though you have no control of boards. Who are the people who run our hospital services so badly yet we have no control of them? That is not acceptable. We need to have proper control, and, if people are not doing their work correctly, they need to be shifted. If you cannot do that, that is worrying.

Mr Farrar: You make a strong point. The issue is that, in the event of our taking a view that we are at level 5, one of the things that that may allow us to do is change the nature of the board by looking at the chair. In circumstances that I have been party to in the past, the chair usually says, "I need to look at the executive, which is responsible, not just the board". As happened in many instances in England during my career, chief executives are removed. The fact is that we have a new chief executive who is about to arrive, so, in that circumstance and by volition, if you like, the trust is at a point where it is looking at its executive leadership. I think that, in the conversations that the Minister will have with the chair, questions about whether we are fit for purpose and about what actions we are taking about the strength of the board and of the executive will feature strongly.

Mr McGrath: Mike, it is relevant to say that a colleague of mine said in the Chamber that there is a culture of "pass buckery": you keep passing the buck on. It is not the Department; it is the board. It is not the board; it is the chair. It is not the chair; it is the chief executive. Eventually, there is somebody further down the line. You do not change cultures by going way down the line and dismissing the people at that level.

I hope that you have it contained.

I know that we are under time pressure, but I would like to ask, Minister, about GP practices. There have been references to the funding model. I took the tone of the reference to a "one-pager" as an insult to the GP profession here. It felt like you were saying to GPs, "Define your entire workload in a few sentences, maybe with a couple of pictures to make it easier". It felt to GPs as if their profession was being attacked. Many of us felt that that tone was disappointing. Do you feel that that language was regrettable? Would you offer GPs an apology for that tone, so that we can reset relationships and start to work together to strengthen our GP practices for our communities for the future?

Mr Nesbitt: I said in my opening remarks that, when I came into post, I was not looking for a fight with anybody. When I first heard about the ask for the 1% — the £80 million — I asked, "For what?", and that is when I said, "Give me a one-pager". I was not asking GPs to define the entire body of their work; I was asking them to give me some indication of what they intended to do with the £80 million. I asked that with the intention of being able to say, "Hopefully". Had they given me a list of 10 things, I might have been able to say, "I can certainly support you on five, six or seven of those. I will go away and fight to get you the money". However, it was not practical just to ask for £80 million, and I made that clear in my statement. If people do not like the tone, that is a matter of regret to me. All that I was trying to do was to state the facts: that, on a number of occasions, in trying to be helpful, I asked for a one-pager.

Mr McGrath: Minister, if that was you not looking for a fight, I would be careful on a night out with you in case we got into trouble. You used the word "regret": I hope that that will be heard by the sector. I hope that we can reset relationships and move forward, because, as you mentioned, the primary care sector is so important to the delivery of healthcare. We all want to support you, but it is really difficult if relationships are bad.

Thank you for the answers that you have given.

Ms Flynn: Hello, Mike. It is nice to meet you also, Mike.

I am sure, Minister, that you and your officials will have listened in last week and heard Frances O'Hagan speak on the GP issue. Alan asked questions about GPs producing a one-pager. They seem to be of the view that their funding asks have been clear throughout. The point is how you move on. You say that your door remains open, which is great. It is maybe now just about how you get to the next step. Hopefully, you can resolve a dispute in which we hear one thing and then another. Hopefully, it can be worked out, because, as Colin said, the GP sector is crucial to all the work that you are trying to do to shift left.

Minister, you and Mike spoke about the reset of the system. It is great to hear about the 13 work streams that you have set up. You referenced the system financial management board, Mike. It would be great if the Committee could see what actions that board hopes to take and what outcomes it hopes to achieve and whether there is a timeline for that work. I know that there is a lot in it, but could we, as a scrutiny Committee, get a breakdown of that to take a wee look at it? Hopefully, we will see things progress there.

You are basically saying, "Bear with us as we try to move to this model. Everyone is on board. It is about how we get there without us having the finances in our hands right now". I know that you need the money to make that big shift. Have there been any official or structured conversations or engagements with GPs, community pharmacy and the community and voluntary sector on people being cared for in the community and how we roll out that plan? Danny made the point that funding pressure has been an ongoing issue for GPs, community pharmacy and the community and voluntary sector. How do you plan to get all those crucial people and groups on board to help with the shift left?

Mr Farrar: The great news is that we have already started. This is probably week four. We pulled together a summit of all the primary care interests including pharmacists; the voluntary sector; care homes and care providers; and GPs and GP Federations. We also had trusts there because a lot of the opportunity to work in communities is about bringing hospital services out into the community. In Alzira in Spain, the cardiology department is community-based and sits alongside general practice, with patients reaching beds only where necessary. We can do that with paediatric and geriatric care — sorry, those are horrible terms, aren't they? We can do it with children's care and older people's care.

There is a great appetite to design that model. We have some jigsaw pieces: MDTs — multidisciplinary teams — are one piece, and area integrated partnership boards are another. We have GP Federations and pharmacists, who are working really hard. A huge amount that goes into general practice at the moment could be dealt with by pharmacists. That would release time for general practice to focus on more complex chronic disease and enable access to specialist opinion sooner. At the second meeting that the Minister referred to, Frances O'Hagan spoke to me about a scheme that runs in her area in which they get support from a paediatrician. That allows them to manage a lot of those children away from hospital, which is a great outcome.

We have a lot of appetite and buy-in for that model. My plan is that we start to put it in place next year, at scale rather than just as a pilot. I call it the "neighbourhood model". Hopefully, that is not just a catch-all term. It is really about people looking after themselves; getting immediate support when they need it; and, if they have a condition, getting the right decision in the right place — in the community setting, with GPs as their care navigator. It is not rocket science, but it is a really good model that we should put in place.

Ms Flynn: I am sure that the Health Committee will discuss that with those groups and sectors when we engage with them. Hopefully, you have them all on board. I will not quote you on it, but, hopefully, next year, we will see some of that stuff progressing at scale.

Mr Farrar: You probably will quote me on that.

Ms Flynn: Yes. [Laughter.]

Mr Farrar: I should also have said that we have templates for those work streams. Within two weeks, we will have the detail of what each of those 13 areas is covering. We intend to publish that by the end of June, and you will be able to scrutinise it.

Ms Flynn: Great. I want to ask about the work stream on sick leave reduction. That is a big issue that impacts on the health service and its finances. We are having conversations about the issues in the cardiac unit in the Belfast Trust, and we may be talking about a culture of bullying across all the trusts. I have no doubt that those issues will have fed into the sickness levels. The sooner we deal with the broader issue of duty of candour and the immediate issues around the cardiac team, the better. Those issues are bound to be causing staff to take sick leave, which has an impact on the levels of staff available to treat patients and an impact on finances. Hopefully, some of that work will help with those bigger issues.

My final question is about the income generation work stream. Mike referenced work on life sciences, and it mentions looking at all-island funding. Minister, this question is for you. Obviously, the Minister of Finance has the overall remit as regards the funding that comes from the British Government. However, we have had conversations previously in the Health Committee and in the Chamber, and you have talked about making a special case, particularly given our high levels of mental ill health. Is any specific work being done on that? Is there work that you and your new permanent secretary can undertake to press our special case for additional funding from the British Government?

Mr Nesbitt: I have made that case to the Secretary of State on multiple occasions. I have made the case to Prime Minister Starmer. To be honest with you, I do not think that it is landing, even though I think that they understand the logic. To my mind, the beauty of it, as it were — that is probably the wrong expression, because we are talking about mental health. It is such a strong case because the legacy issue of poor mental health coming out of what we so euphemistically call "the Troubles" is a public health issue in Northern Ireland but not in Scotland, England or Wales. Yes, there are people in those countries who are suffering poor mental health as a result of the conflict, but it is not a public health issue there. For us, it is a public health issue, so, if you invest in that here, there is no Barnett consequential: there is no repercussive need to spend money on the same thing in the other three countries of the United Kingdom. That is a compelling argument, but it is certainly not landing in such a way that people from Downing Street or the Department of Health and Social Care in London are saying, "Tell me more". That is a matter of regret, but I will not stop pushing, because it is a fact. You know that, if you take a hotspot map of the Troubles and superimpose a contemporaneous map of mental health issues, you will get a match; for example, in north Belfast.

Ms Flynn: Thank you.

Mr Robinson: Thanks, Minister. Thank you, Mike; it is good to finally meet you.

Like others, I was aghast when I heard about the issues at the cardiac surgical unit. It was a bombshell moment. Seasoned performers in this Building who have been here for years were absolutely aghast. It is up there as one of the poorest news items that have ever broken. Minister, you intimated that other stories may break. Can I ask for a commitment from you that, in advance of you or your Department's knowledge being made public, you will bring it to the Floor of the Chamber, rather than it being the other way around, with the information coming to us by way of a question for urgent oral answer? I do not think that any of us wants to bring you to the Chamber to pose gotcha questions to you; that is not the right way to do government. It is much better that you show your hand to us so that we can scrutinise the information. From the description that someone gave me of the surgical unit and from the news items about it, what was happening is more akin to a Wild West bar than a surgical unit, particularly a key surgical unit that is so important to the lives of people across the Province. I hope that you can give a commitment that you will show your hand if — I hope that it does not happen — there are other cases or other instances. As far as I am concerned, that situation demolishes the argument of those who come to the Committee and present a view against having a duty of candour.

The other question, Minister, is a local one. You and I have spoken about Causeway Hospital. I have raised it multiple times. It is now, I believe, either in your in tray or heading there. When do you expect to make a decision on it? I ask you politely to make the decision on the basis of the facts. Drill down into those facts. Drill down into how the current bed pressures in Antrim will be dealt with; how ambulance provision, which is a well-documented issue, will be dealt with; the pressures that will fall on Antrim Area Hospital and the subsequent pressures that may fall on Altnagelvin Area Hospital; and the potential, as some former surgeons have said, for the change to kick away a key pillar of Causeway Hospital. I plead with you to look at the facts.

Mr Nesbitt: OK. I will take those in order. I make the commitment to get information out as soon as I am aware of it. I do not want to sit on bad information, because that makes it worse; we know that. I give you a commitment: as soon as I am aware, I will instruct officials to make it possible for me to get that information out, whether that is in the House or wherever.

On the specifics of the Causeway Hospital, the Northern Trust has made its recommendation. That has gone to the SPPG in my Department for assessment, so it is en route to me but has not arrived yet. My decision has to be made on clinical safety grounds. Will it deliver better outcomes? What is the downside? You have enumerated some of the potential downsides. Does the Antrim Area Hospital have the bed space? Does it have the capacity? Does it have the workforce to look after those patients? As for the Ambulance Service, do we have the transportation that will be required if we do that transfer of emergency general surgery? Absolutely. We are not there yet, but we are heading in a certain direction. I have to make the final call, and I do not want to make a bad call that delivers worse outcomes for anybody.

Mr Robinson: The 1,415 people who responded to the consultation do not want you to do that either. Thank you.

Mr Chambers: Mike, you are welcome to the post. Are there any learnings from your extensive health experience in England that you hope to see rolled out in Northern Ireland? This may be an unfair question, because you have been in post for such a short time and are probably still struggling to find your way around Castle Buildings, but what are your initial views on the timescale to get our Health and Social Care system to where we want it to be? I have heard timescales of five years and 10 years being kicked about. What can we, as politicians, do to help expedite the process?

Minister, I welcome the swift action that you took last week in accepting the pay review board's recommendations. I understand that it is now going up the line to the Executive, where a final decision will, hopefully, be made. If we cannot find the budget to deliver those recommendations, how damaging would the industrial action potentially flowing from that be? Would it limit the current efforts to deliver improvements in waiting times?

I was not going to mention GP practice, but I feel that I have to ask a question given the remarks that a member made earlier. We talked about the one-pager, where you asked for information about how the £80 million would be spent. When I asked the BMA questions last week, it was very vague. Would it have been reasonable for your Department to have been presented with a costed business case to support that £80 million ask?

Mr Farrar: We can start making progress now. We have assets that England, in particular, does not have. We have a scale whereby we can get our arms around it. I can get all the chief executives around the table, and we can agree on a strategy. Our clinical colleagues have been looking for support and leadership on the change agenda. We have some exciting bits. I am confident that, if we can get through our short-term issues, which are largely financial —. I wish that I had a growth budget, because, then, I could really motor. However, we will use the financial challenge as a catalyst for change. By the time that the current mandate is served and people go into the next election, you should be able to see significant impacts on waiting times; that we are starting to put in place the demand management model; and that we have made improvements on culture, which has been revealed as a big issue for us to tackle. Culture does not change overnight, as you know, but we need to lay a platform for that.

One thing that I have not had a chance to say but will say now is that we need to invest in our leadership capability. We perhaps underinvested in that five or 10 years ago. We really need to make sure that, for every leadership role that comes up in Northern Ireland, we have four or five talented people — yes, we want them to be tested against international opposition — coming through our system who want to take on that role and are really capable of taking the vision forward to delivery.

I would say to look for improvements in the short-term. This year is tough, but, by the time that we get to the next election here, we should be able to see general improvements. I know that that is where the Minister is coming from. I asked him, "What is the first thing you want me to do?", and he said, "Urgency". In my position, I really appreciate the pressure.

Mr Nesbitt: We will both — hopefully; touch wood — be here for a couple of years. The idea is to set a direction of travel that the next Minister feels compelled to follow, because, then, with a whole mandate on top of these two years, you really will see differences.

On pay, I sat with the unions last year and said, "I want this to be the last year when you have to wait until the twelfth and final month of the financial year for certainty about whether you will get pay parity". Now that the recommendations have been made public, I have honoured that commitment and said, "I want to do it". That is taking us down the route of ministerial direction, which is not an event but a process that has a way to run. On the implications, given what I heard last year, which included one body saying, "One penny less than parity and it's industrial action", we have to assume that, if we do not deliver, there will be industrial action. That industrial action will have an impact on our healthcare delivery, not least on tackling waiting lists.

Your other point was about the one-pager becoming a fully costed business plan. I think that, sometimes, we put too much effort into promoting an idea when the best thing to do would be to say, "Here's my idea: what do you think?". If the answer is going to be no, there is absolutely no point in wasting a lot of time and resource fleshing that idea out, costing it and talking to people about it. When we talk to the Shared Island unit, for example, it is better to have a one-pager, because it sometimes comes back to us with a no. On the mother-and-baby unit, for example, the answer was a no, and we are doing it ourselves, which is fair enough. There is no point in doing all that intensive and detailed work if you are going to get a hard no. All that I was looking for was a one-pager.

The Chairperson (Mr McGuigan): Before you go, Minister, this is a bad news day for you, but, yesterday, you opened two excellent centres: the Fire and Rescue Service centre, which we were at, and the regional cancer therapeutic treatment centre in Enniskillen. I need to ask about the £85 million that is ring-fenced for red-flag and time-critical cancer treatment. Can you give us a sense of when you expect to see those targets reduced and patients to see the benefits and the delivery of that?

Mr Nesbitt: I hope to sign off before the day is out on the more detailed plan that I promised on waiting lists generally. I promised that by the end of the month, and I hope to sign off on it later this afternoon. I have a couple of meetings to go to now, but I hope to sign off on it after those. That should give you more detail on red-flag treatment and the whole £215 million package. The £10 million waiting list reimbursement scheme goes live on Monday.

The Chairperson (Mr McGuigan): Thank you, all, for coming.

David, that was the easiest time that you will ever have in front of the Committee [Laughter.]

Mr Nesbitt: You got away with that, David.

The Chairperson (Mr McGuigan): I appreciate that it was about budget and that few of our questions were —

Mr Farrar: He was my backstop.

The Chairperson (Mr McGuigan): Thank you very much.