1 HSCB – 9 May 2019

MINUTES OF THE HEALTH AND SOCIAL CARE BOARD HELD AT 10.00AM ON THURSDAY 9 MAY 2019 AT 10AM IN THE CONFERENCE HALL, GREENMOUNT COLLEGE, 45 TIRGRACY ROAD, ANTRIM BT41 4PS PRESENT: Dr Ian Clements, Chair

Mrs Valerie Watts, Chief Executive Mr Paul Cummings, Director of Finance Ms Marie Roulston, Director of Social Care & Children Mr Stephen Leach, Non Executive Director Mrs Stephanie Lowry, Non Executive Director Mr Robert Gilmore, Non Executive Director Mr John Mone, Non Executive Director Dr Melissa McCullough, Non Executive Director Mr Brendan McKeever, Non Executive Director

IN ATTENDANCE: Dr Sloan Harper, Director of Integrated Care

Mrs Lisa McWilliams, Interim Director of Performance Management & Service Improvement Ms L McMahon, Director (Community Planning) Mrs Mary Hinds, Executive Director of Nursing & AHPs, PHA

Mr Miceal McCoy, Interim Chair, Southern Local Commissioning Group Mr Danny Power, Interim Chair, Belfast Local Commissioning Group Ms Linda Craig, Regional Leader for 10,000 More Voices (for agenda item 10 only)

APOLOGIES: Dr Miriam McCarthy, Director of Commissioning

Dr Adrian Mairs, Acting Director of Public Health, PHA

44/19 CHAIR’S REMARKS

Commencing his remarks, the Chair thanked Mrs Lowry for chairing the April meeting in his absence.

2 HSCB – 9 May 2019

The Chair referred to the Board agenda and advised that Ms Linda Craig, Regional Leader for 10,000 More Voices, would join members later in the meeting to present on the 10,000 More Voices: Bereavement Report - Experience of Family, Carers & Staff. The Chair said that these reports often acted as a barometer of health and social care services and were very interesting. The Chair said that members would recall that, at the April meeting, Mr Brian McNeill, Director of Operations, NIAS, had attended to update the meeting on the outcome of the consultation on the NIAS proposed clinical response model. The Chair advised that further documentation had since been received from NIAS with regard to the consultation which would allow members to consider this further at today’s meeting. Continuing, the Chair referred to the NICON Conference taking place between 16-17 May and said that a number of members would be attending. He pointed out that the theme of this year’s conference was ‘Leading from the Edge: Transforming Our System Together’ and said that this was in the context of the third year of the roll out of Health and Wellbeing 2026 – Delivering Together. The Chair reminded members that a Community Planning workshop would be held at the end of May when members would receive updates on the work being taken forward by the various Community Planning Partnerships and discuss how the HSCB can best contribute to this work. The Chair mentioned that, along with Dr Harper and Mr Hayes, he had recently attended a conference organised by the International Foundation on Integrated Care. He said that it had been reassuring to note that the collaborative approach being advocated in Northern Ireland was also being taken forward globally as a recognised way of developing sustainable services. The Chair said that further encouraging news was that the Department of Health (DoH) had recently announced that the funding for Integrated Care Partnerships (ICPs) had now been made recurrent. Finally, in concluding his remarks, the Chair thanked Ms Sorcha McAnespy for her contribution over the last number of years as a Local Government representative on the Western LCG. He indicated that, more recently Ms McAnespy had been the Interim Chair of the LCG and had attended Board meetings in that capacity. The Chair said that unfortunately Ms McAnespy had been

3 HSCB – 9 May 2019

unsuccessful in the recent local elections and therefore had had to step down from her LCG role. He said that he intended to write to her, on behalf of the Board, to extend our thanks and to wish her well for the future. Before commencing the meeting, the Chair asked members to declare if they had a conflict of interest with any agenda items. There were no declarations.

45/19 PREVIOUS MINUTES

The minutes of the previous meeting on 11 April 2019 were APPROVED and signed by the Chair.

46/19 MATTERS ARISING

There were no Matters Arising.

47/19 STANDING ITEM: CHIEF EXECUTIVE’S REPORT The Chief Executive commenced her report by referring to the recent announcement that the Care Home group, Four Seasons Health Care, had gone into administration and said that this had been unsettling news for many residents and their families. Mrs Watts said that the Board understood that the sale process would take several months and the company had provided assurances that care provision at its homes would continue as normal. She added that the Board and the DoH had issued information to reassure residents and their families that contingency planning was on-going and said that, during the sale process, the HSC would continue to monitor the situation. Turning to the consultations on breast assessment and stroke care, the Chief Executive reminded the meeting that the DoH led consultation process on proposals to Reshape Stroke Care and Breast Assessment Services would now run until Friday 19 July having been originally scheduled to finish on 18 and 17 June 2019 respectively. She said that the Department was committed to hosting a number of public engagement events for both the stroke and breast

4 HSCB – 9 May 2019

assessment consultations in June and also intended to publish further information relating to the proposals to assist the public’s understanding of the issues involved. Mrs Watts advised that the Infected Blood Inquiry commenced at the end of April in London. She explained that the first phase of the Inquiry would be dedicated to hearing from the infected and affected and would move throughout the UK until 18 October 2019 hearing evidence. Mrs Watts pointed out that four days of hearings would be held in Northern Ireland from 21-24 May. She indicated that the next phase of the Inquiry was expected to begin in early 2020 and would hear issues as outlined in the Terms of Reference and List of Issues to include hearing from professional witnesses. Mrs Watts advised that the Board was one of the core participants at the Inquiry, alongside the DoH, Northern Ireland Blood Transfusion Service and the Belfast Trust. Continuing, she reminded the meeting that the Health and Social Care Board had been established in April 2009 as the successor of the Eastern Health & Social Services Board which had operated from its establishment in 1972. She advised that the Eastern Board had held management responsibility for the Blood Transfusion Service in Northern Ireland from 1972 until April 1994 and had also been responsible for haematology services within the local management area until the establishment of the Royal Group of Hospitals Health and Social Services Trust on 1 April 1993. Mrs Watts said that counsel had been appointed to act on behalf of the HSCB and was also doing so jointly with the other core participants. She advised that the Board was fully co-operating with the Inquiry and providing whatever assistance required. She added that this had included identifying and collating relevant documents and records for the benefit of the Inquiry. Mrs Watts believed that one could not fail to be moved by the stories of courage, fortitude, dignity and perseverance which had emerged over the last few weeks from those infected or affected.

5 HSCB – 9 May 2019

She said that one was very conscious of the tragedies and the life-changing impacts that had resulted from the use of contaminated blood and blood products. Mrs Watts stressed the importance of those who had been infected or otherwise affected being entitled to know all of the facts which could be established and to have the truth as soon as it can be delivered. Mrs Watts said that she hoped the Inquiry would be able to proceed expeditiously to its conclusion whilst, at the same time, appreciating that it must be afforded sufficient time to consider fully and thoroughly the vast volume of evidence it would receive. She undertook to keep members updated on this very important issue. Continuing her report, Mrs Watts indicated that there had also been a number of recent and important public health advances of which members should be aware. The first, she said, related to Bowel Cancer Screening – FIT (Faecal Immonochemical Test). The Chief Executive said that, in April, the Permanent Secretary had announced that the Bowel Screening Programme in Northern Ireland would introduce quantitative FIT testing as the method of screening from early 2020. Mrs Watts advised that FIT Testing has been recommended by the UK National Screening Committee and was in the process of being rolled out to programmes in the other UK countries. She explained that FIT was considered a more sensitive test and, as such, was expected to increase the pick-up rate of cancers and adenomas by the screening programme. Mrs Watts also added that it had been shown to increase the referral rate to screening colonoscopy, as well as leading to a higher uptake in those invited to be screened. The Chief Executive said that the team was working with the Northern Trust and PaLS to progress a procurement exercise for the new FIT kits and analysers and added that this was being taken forward as a joint procurement process to introduce a service to provide FIT for symptomatic patients in line with NICE guidelines.

6 HSCB – 9 May 2019

She also advised that a FIT implementation project would be established and initial discussions with Trusts were being planned to discuss the anticipated impact on screening colonoscopy services. The Chief Executive reported that, in March 2019, the PHA published a ‘Framework for the Audit of Invasive Cervical Cancers and Disclosure of Findings’. Mrs Watts explained that this guidance for Trusts had been developed in response to high profile cases reported in the Republic of Ireland during 2018 when significant criticisms had been directed at what information women had been given and how audit outcomes had been disclosed to them. She indicated that the framework document had been developed through engagement sessions with voluntary sector and patient representatives as well as workshops and meetings with clinical staff and was largely in line with national audit documentation developed for breast cancer screening. Mrs Watts added that the framework was also accompanied by a new patient information leaflet designed to be made available to women at the time of diagnosis of a cervical cancer. She said that all Trusts would be expected to develop their own working protocols to deliver on the principles set out in the framework document and added that there were plans to develop similar documentation for the audit of interval cancers in the bowel cancer screening programme. Referring to Daycase Elective Care Centres, Mrs Watts advised that, following the roll-out of Phase I prototypes for Daycase Elective Care Centres, the DoH had announced the next phase of seven specialties to be included in this transformation programme. These include General Surgery and Endoscopy, Urology, Gynaecology, Orthopaedics, ENT, Paediatrics and Neurology. Mrs Watts advised that the Board had a key strategic and important role in this process and said that a number of Board officers were involved in the task and finish groups for each of the specialties. Mrs Watts indicated that a number of specialty-specific workshops were currently being convened to agree demand, capacity and anticipated activity in advance of options appraisals being presented

7 HSCB – 9 May 2019

to the Top Management Group (TMG) and Transformation Implementation Group (TIG) for consideration. Mrs Watts advised that the Board had recently received its allocation letter for 2019/20 and said that Mr Cummings would provide a full update on the content of the letter in his financial report to the meeting. Referring to the Chair’s earlier comment in relation to funding for ICPs, Mrs Watts welcomed the fact that funding for the ICPs’ infrastructure had now been made recurrent in the 2019/20 allocation from the DoH. She explained that this applied to both the funding for the support team infrastructure and for the backfill costs to cover retained lead and committee backfill costs. Mrs Watts said that the Board would now work to ensure that this development was communicated across the system and she added that it would be important for recruitment processes to be progressed quickly to ensure that the ICPs were fully supported and placed on a more secure footing as soon as possible. Mrs Watts referred to the transition to the new model and advised that Design Group Co-Chairs were refreshing their papers to reflect new information as issues were resolved in anticipation of an Oversight Board discussion later this month. She added that further communication was planned with staff in June. Mrs Watts indicated that preparations continued for the changes ahead, including permanent recruitment to posts where there was funding. Concluding her remarks, Mrs Watts advised that Mr Dan West had recently taken up post on 7 May 2019 as Chief Digital Information Officer at the DoH. She explained that Mr West would assume managerial responsibility for eHealth staff as well as the eHealth budget and said that a number of HR issues were currently being worked through. The Chair thanked the Chief Executive for her report and invited comments/questions from members. Mr Leach referred to discussion at the April Board meeting during which reference had been made to a summit being held on the future shape of urgent and emergency care and he sought an update in relation to this.

8 HSCB – 9 May 2019

Mrs McWilliams explained it was her understanding that the DoH intended to schedule this for June and that currently a Task and Finish Group were examining this issue. Responding to a further question from Mr Leach with regard to the Board’s involvement, the Chief Executive said that it was not yet clear what format the summit would take.

Mrs McWilliams advised however that a number of officers from both the HSCB and PHA were involved in the Emergency Regional Collaborative meetings convened to discuss urgent and emergency care as well as the Task and Finish Group. The Chair welcomed the confirmation of recurrent funding for ICPs and believed that this reinforced the DoH’s support for the work being taken forward by ICPs. Dr Harper said that it would be important for a formal integration strategy to be developed on a medium to long-term basis which recognised the complexity of the health and social care system. He suggested that it should be transformational, adopt a nuanced approach and recognise the importance of population health Dr Harper referred to plans for Sir Michael Marmot to visit Northern Ireland in the near future to present on his globally regarded views of medium to long-term strategies in health and social care and the need to aspire to improve health outcomes as well as new models and pathways. Dr Harper said that while NI health and social care was replicating work from across the world, similar problems were being experienced. He referred to the International Foundation for Integrated Care which is a global organisation with widespread input across the world and which has recently set up a network covering the island of Ireland. Dr Harper advised that Dr Tony Stevens, Chief Executive, NHSCT, recently gave a presentation to TIG on plans to integrate more closely with primary care and the third sector and to bring service users and carers on board. He explained that the Trust wanted to change from a service which was heavily focussed on hospital care to one which would be more focussed on population health. Dr Harper acknowledged the challenges in such a task and referred to the traditional hierarchy of control. He further acknowledged that, as public services, there was clearly a need for clear accountability

9 HSCB – 9 May 2019

and governance processes but said that this, on its own, would not be sufficient in terms of transforming the service. Mr Gilmore referred to the Transition Oversight Group (TOG) and sought further detail in relation to its role and the frequency of meetings. Responding, the Chief Executive explained that the oversight group had been established to oversee the closure of the HSCB. She added that it was chaired by the Permanent Secretary and its membership comprised of a number of DoH, legal and HSCB officers. Mrs Watts indicated that many of the issues discussed related, for example, to governance procedures, required changes to legislation, accountability and how that will transfer to the new group, HR issues. She acknowledged that, as the focus had initially been on EU Exit, the group had not met for a number of months but said that she now envisaged the group being reconvened. Mr Power referred to the discussions around the transformation agenda and the need to ensure input at locality level. He acknowledged that, while the recurrent investment in ICPs offered some degree of certainty, the key, in his view, was a long-term strategy. He referred to the closure of the HSCB, the new role for the PHA and questioned where ICPs would fit into the new structure. Referring to the new model being advocated by Dr Stevens, Mr Power alluded to the various levels within the model. He suggested that there was a need for further discussion at locality level as to what integration looked like. The Chair, agreeing with Mr Power’s comments, acknowledged that, while there was significant work yet to do, he sensed a degree of convergence of thinking. Mr Leach alluded to the references to integrated planning and referred in particular to the day case surgery hubs. He commented that, presumably in the operation of such hubs, the DoH was directing resources away from the existing acute hospital network. Mr Leach asked whether a plan had been drawn up to scope out the implications of this and whether this was a task which previously would have been undertaken by the Board. Responding, the Chair pointed out that commissioning, planning and undertaking needs assessment were responsibilities of the HSCB.

10 HSCB – 9 May 2019

Mr McCoy welcomed the extensions to the consultations on breast assessment and stroke services. He referred to the fact that the Chief Medical Officer had recently urged the public to engage in the consultation process because the status quo was not an option and expressed his surprise at such a comment in the midst of a public consultation. The Chair thanked members for their comments and the Chief Executive’s report was NOTED by members.

48/19 STANDING ITEM: FINANCE: HSCB FINANCE REPORT ENDING MARCH 2019 (MONTH 12); TRUSTS’ FINANCIAL REPORT ENDING FEBRUARY 2019 (MONTH 11)

Mr Cummings advised that the Audit Committee would meet later that afternoon to consider the HSCB Annual Accounts which would mirror the accounts submitted to the NIAO. Turning to the HSCB finance report for the 12 month period ending March 2019, Mr Cummings advised that the Board had reported a surplus of £26.5 million. He explained that the Board had been asked by the DoH to retain a surplus of £24.5 million to offset WHSCT pressures with a further net surplus of £2 million on HSCB budgets mainly due to Administration, Family Health Services, ringfenced funds and ECRs. Mr Cummings said that he had requested a form of words from the DoH to place on the accounts which would clearly place a context around such a significant surplus in HSCB accounts. Continuing, Mr Cummings indicated that, over the last number of months, the impact of Confidence & Supply monies and external factors had come to the fore. He believed that trying to maximise the expenditure on Confidence & Supply monies had resulted, in some cases, in underspends on core budgets. Mr Cummings reported that the General Pharmaceutical Services budget showed a surplus of £1.1 million and added that the average price per script item had fallen slightly. However, he said, this expenditure area remained volatile.

11 HSCB – 9 May 2019

Mr Cummings reported a small deficit in the General Medical Services budget and General Dental Services budget offset by a surplus in General Ophthalmic Services. Turning to the ECR budget, Mr Cummings reported an overspend of £3.2 million and noted that expenditure in March had been lower than in the previous year. He expressed surprise at this and explained that traditionally organisations would be issuing any outstanding invoices at this time approaching the end of the financial year. Mr Cummings alluded to ringfenced allocation and said that the Confidence & Supply monies had been largely retracted and that any underspends were as a result of legacy TYC funds not being spent as a result of not being able to recruit staff to posts in Trusts. Mr Cummings reported that the HSCB Administration budget was showing a surplus of £1.4 million and said that this underspend would go towards the savings target imposed on the HSCB by the DoH in its allocation letter. Turning to the Trusts’ finance report for the period ending February 2019, Mr Cummings reported that all Trusts were forecasting a break-even position at the year end, with the exception of the WHSCT which had reported a deficit of £24.5 million. Mr Cummings tabled copies of the DoH allocation letter dated 19 April 2019 and took members through the detail. Mrs Lowry referred to the General Pharmaceutical Services budget and said that, at one point, it had been thought that it would not have been possible to achieve the significant savings target set by the DoH. Responding, Dr Harper advised that there were multiple factors to be taken into consideration, for example changes in global markets and drug prices. He also referred to the input by practice-based pharmacists, in particular an evaluation being carried out by NISRA into the impact on cost. Dr Harper said that early indications were that the practice-based pharmacists were paying for themselves in terms of the savings they had been able to put in place. He added that there were currently between 200-230 practice-based pharmacists in place.

12 HSCB – 9 May 2019

Mr McKeever referred to an acknowledgement within the DoH allocation letter that ‘… the 2019/20 Budget allocation is not sufficient to maintain existing services, and steps must therefore be taken across the Department and its ALBs to ensure that financial balance is achieved…’ and believed that this would result in a significant reduction of services. Mr Cummings agreed that the DoH was of the view that it would not be possible to maintain existing services. However, he said the correspondence also suggested that, in order to make the savings required, the service would have to become more efficient or reduce available services. He stressed that the HSC system had a statutory duty to live within existing resources as well as ensuring the provision of safe and high quality services. Mr McKeever reiterated his point that there was insufficient resources to maintain existing services and that to place further savings targets on Trusts would only result in a reduction of services to patients. The Chief Executive acknowledged that, while there was a sense that the available budget would not be sufficient to maintain existing services, the emphasis should be placed on transformation. She said that, in progressing the transformation agenda, those in health and social care have had to look at how services are delivered to determine how best to transform those very services in order to continue to deliver them into the future in a more efficient and effective way. Mr McKeever said that, while he very much appreciated the points being made by Mr Cummings and the Chief Executive, he did not fundamentally agree as the impact on patients, users, carers and staff would not be a positive experience. He said that as an advocate for users and carers, he would not be willing to support this position. The Chief Executive accepted that there were significant challenges ahead and said she very much appreciated the difficulty faced by Board members. However she said that the Board also had a responsibility to voice its concerns when the safety of those services available to patients was being compromised. The Chair referred to the consideration of the Commissioning Plan by the Board and said that, in the past, discussions had clearly

13 HSCB – 9 May 2019

shown the frustrations felt by members in terms of available funding. He referred in particular to the letter which members had requested accompany the submission of last year’s Plan to the DoH when the Chair, on behalf of members, had expressed the Board’s concern at the insufficient funding available and the detrimental effect on services. Mrs Lowry commented that the DoH allocation letter had requested feedback from the Board in relation to Trust savings and she sought clarification on this. Responding, Mr Cummings clarified that the Board had been asked for an analysis on how best to apportion savings of £35 million amongst Trusts and said that finance officers were working with Board colleagues to take this work forward. He added that completion of this work would allow clarification around the available funding for the Commissioning Plan. Mr Leach commented that it appeared that the DoH assumed strategic financial responsibility periodically. He welcomed the confirmation of recurrent funding for ICPs and questioned why there had been such a delay in the DoH confirming recurrent funding. Mr Leach asked whether the Confidence & Supply monies could assist in the financial challenges. The Chief Executive clarified that, in 2019/20, funded commitments had been made in respect of those projects put in place in 2018/19 and added it would also be possible to consider a number of inescapable pressures. She reminded the meeting that a total of £83 million had been made available for this year with a further £10 million for waiting list initiatives. The Chief Executive confirmed that this would not address urgent and red flag referrals. She indicated that the balance of £7 million would be set against priorities designated by TMG as being of strategic importance. Mr Cummings said that it was important to point out to members that, had all Investment Proposal Templates (IPTs) been funded, there would be a need for funding in excess of £160 million to be provided. He indicated that, while many projects were already in operation, it was very likely that they would not now receive the second tranche of funding and would have to cease at the end of March.

14 HSCB – 9 May 2019

Responding to a question from Mr Leach, Mr Cummings emphasised the need to live within budgets and cited the example of the underspend in the General Dental Services budget which he said he had been asked to rebase to determine if resources could be released towards the deficit incurred by the Western Trust. Mr Cummings reminded the meeting that the Western Trust had been given three years within which to achieve a break-even position. The Chair referred to the IPT process and said that it was his understanding that normal processes had been waived by the DoH in terms of the consideration of IPTs. Mr Cummings explained that IPTs were to have been received and signed off by 31 March 2019, either by the Board’s Senior Management Team, if expenditure exceeded £1 million, or by individual Directors. He said that it was now his understanding that, if the IPT financial requirements differed significantly from those initially submitted, it would be necessary to complete a proforma addendum explaining how the project had changed in value or scope. Dr McCullough sought detail on how the decisions not to provide resources for a number of projects had been arrived at and asked if resources had been wasted on those projects which had initially been funded and would now have to cease. Mrs McWilliams indicated that there had been no assessment of which projects would be more beneficial. She explained that, if a project had already commenced and had staff in post, funding for that project would continue. Dr McCullough expressed surprise that there appeared to be an insufficient evidence base in terms of the allocation of resources. The Chair, agreeing with Dr McCullough’s comments, stressed that the allocation of resources should be weighed against which projects would deliver the best outcomes. The Chair thanked Mr Cummings for his report and members NOTED the HSCB Finance Report (month 12) and the Trusts’ Finance Report (month 11).

15 HSCB – 9 May 2019

49/19 STANDING ITEM: 2018/19 END OF YEAR ASSESSMENT OF PERFORMANCE AGAINST COMMISSIONING PLAN DIRECTION STANDARDS AND TARGETS

Commencing her report, Mrs McWilliams clarified that this was the End of Year Assessment against the Commissioning Plan Direction (CPD) standards and targets set out by two priority areas, ie quality/experiences and sustainability. She pointed out that, due to the scheduling, information in relation to stroke and thrombolysis was not yet available and added that information relating to a number of children’s targets would become available later in the year. Turning to quality and experience, Mrs McWilliams reported that, in relation to Healthcare Associated Infections (HCAI), in particular Gram Negative, there were 479 bloodstream infections against a target of no more than 422. She added that only the Western Trust had exceeded this target. She said that this represented a reduction against 2017/18 figures with new targets being set for 2019/20. In terms of CDifficile, Mrs McWilliams advised that, regionally during 2018/19, there were 382 episodes against a target of no more than 320 while, in relation to MRSA, there had been 54 episodes of MRSA against a target of no more than 34 with the Southern Trust achieving its target. Mrs McWilliams indicated that the PHA continued to work through the Infections and Antimicrobial Stewardship Improvement Board and Health Protection and she drew members’ attention to pages 6-9 of the report which provided a summary of actions being taken. This included, she said, a new public facing dashboard for CDiff which would be available shortly on the PHA website. Referring to GP Out-of-Hours (OOHs), Mrs McWilliams advised that 84% of calls to GP OOHs had been triaged within 20 minutes against a target of 95%. She pointed out that the performance variation amongst Trusts ranged from 75% in the Southern Trust area to 92% in the Northern Trust. In terms of ambulance response times, Mrs McWilliams said that the CPD required NIAS to respond to 72.5% of CAT A calls within 8

16 HSCB – 9 May 2019

minutes regionally. She indicated that regionally only 37% of CAT A calls were responded to within this timeframe. Mrs McWilliams said that page 11-13 of the report set out performance in relation to ED, both 4-hour and 12-hour standards. She pointed out that, in 2018/19, there were 25,326 breaches of the 12-hour target compared to 17,342 in 2017/18. She added that two thirds of these, ie 16,000 took place in the last half of 2018/19. In relation to the 4-hour standard, Mrs McWilliams said that regionally during 2018/19, 70% of patients were treated and discharged or admitted within four hours compared with 73% during 2017/18. She referred to the table on page 13 of the report which provided a breakdown of ED attendance over the last five years and said that, in total, there had been an additional 28,000 attendances since 2017/18. However she pointed out that since 2014, there had been over 114,000 additional attendances at ED. Moving to treatment following triage, Mrs McWilliams advised that it had not been possible to provide an update on performance for the full year but indicated that regionally, between April 2018-February 2019, 80% of patients commenced treatment, following triage, within two hours. In terms of hip fractures, Mrs McWilliams reported that 84% of patients, where clinically appropriate, received inpatient treatment for hip fractures within 48 hours against a target of 95%. She indicated that this was an increase of 4% against the 2017/18 performance. Moving to diagnostic reporting, Mrs McWilliams indicated that, regionally during April 2018 to February 2019, 86% of urgent diagnostic tests were reported on within two days of the test being undertaken. She added that this was unchanged from the 2017/18 performance. Mrs McWilliams turned to performance in cancer services, in particular breast cancer and reported that there had been an increase of 5.7% in patients seen on the pathway, ie from 14,942 in 2017/18 to 15,798 in 2018/19. She advised that the regional performance was 92% and said that this was an improvement on the previous year of 87%. Mrs McWilliams said that the regional performance had been impacted upon by the Norther n Trust who continued to face challenges in terms of staffing.

17 HSCB – 9 May 2019

Turning to the 31-day target, Mrs McWilliams reported that regionally 94% of patients had commenced treatment within 31 days of the decision to treat against a target of 98%. She added 10,429 patients had been seen and said that this was an increase of 417 patients on the previous year. Mrs McWilliams indicated that the 62-day target remained the most challenging with a 63% regional performance against a target of 95%. There had been a slight deterioration of 4% compared to 2017/18. Turning to waiting times, Mrs McWilliams reminded members of the additional resources received through the Confidence & Supply monies and said that this funding had enabled an additional 105,000 patients, ie 55,000 patients have been assessed; 16,000 have been treated; 22,000 patients received AHP treatment and an additional 10,000 diagnostic tests were completed. Mrs McWilliams referred to the delivery of core and reported that there had been a reduction in the underdelivery of core. In terms of diagnostics, Mrs McWilliams reported that the numbers waiting continued to increase. She said that in 2013/14, there had been 1.3 million diagnostic tests carried out compared to 1.5 million in 2018/19. She reminded the meeting that diagnostic imaging was a mixture of scheduled and unscheduled services and that demand had increased from inpatients wards. Mrs McWilliams reported that in relation to CAMHS services, regionally the number of patients waiting longer than nine weeks to access these services increased from 66 at the end of March 2018 to 487 at the end of March 2019. With regard to adult mental health services, Mrs McWilliams reported that, while the waiting time position had improved in the final quarter of 2018/19, there were still 1,529 patients waiting longer than nine weeks to access services at the end of March 2019 compared to 648 at the end of March 2018. She pointed out that the majority of those waiting, ie 1,380 patients, were waiting to access primary care mental health services. Mrs McWilliams noted that the Northern and South Eastern Trusts did

18 HSCB – 9 May 2019

not deliver primary care mental health services as a separate function. Mrs McWilliams advised that, in relation to dementia services, 263 patients were waiting longer than nine weeks to access services compared to 399 patients at the end of April 2018. She acknowledged that, while this was a slight improvement, huge challenges remained. Turning to psychological therapies, Mrs McWilliams reported that at the end of March 2019, 2,026 patients were waiting longer than 13 weeks and said that this represented an increase of 552 patients compared to 1,474 at the end of March 2018. Mrs McWilliams said that, as had been reported previously, the gap between capacity and demand in this service area had been acknowledged and a five-year investment plan totalling £18 million had been proposed as part of the mental health reform. She indicated that, as a result of the shortfall in capacity, the 13-week waiting time position is not expected to improve without additional investment. Mrs McWilliams reported that the regional target to increase the number of direct payments for all service users by 10%, ie to 4,729, had been exceeded. She indicated that there had been an increase of 284, ie 5,013 direct payments were in place. She advised that there had been a significant improvement in the number of patients waiting longer than 13 weeks from referral to commencement of AHP treatment in that regional 12,803 patients were now waiting. This represented a reduction of 10,572 from the March 2018 position. In terms of patient discharge (learning disability), Mrs McWilliams reported that regionally during 2018/19, 82% of learning disability discharges had taken place within seven days of the patient being assessed as being medically fit for discharge with 20 taking longer than 28 days. She added that this compared with 80% within seven days in 2017/18 and 36 longer than 28 days. With regard to patient discharge (mental health), Mrs McWilliams said that 96% of mental health discharges had taken place within seven days and 102 took longer than 28 days, comparing with 97% within seven days and 79 longer than 28 days.

19 HSCB – 9 May 2019

Mrs McWilliams said that it had not been possible to provide the end of year figures in relation to carers’ assessments but indicated that regional performance was on track to deliver the required increase with a 10% increase in assessments. Concluding the quality/experiences element of the report, Mrs McWilliams referred to sustainability and said that she had already alluded to delivery of core. Referring to complex hospital discharges, she reported that 78% of complex discharges from an acute hospital setting had taken place within 48 hours and 1,851 had taken longer than seven days. She pointed out that, in 2017/18, 76% had taken place within 48 hours and 1,917 had taken longer than seven days. Mrs McWilliams added that performance within the non-complex discharges stood at 94% less than 6 hours which was unchanged from the 2017/18 position. Dr McCullough commented that the performance around CAMHS service was deteriorating and expressed concern at the significant wait for access to Step 3 services. She also asked if there was any understanding as to whether the delays in access to services had resulted in deaths and added that she believed those needing the services were being failed by the system. Responding, Ms Roulston indicated that it was her understanding that there had not been an increase in death by suicide amongst young people over the last number of months. She said that work was ongoing in relation to a demand and capacity exercise with respect to the resources within CAMHS. Ms Roulston added that the recruitment and retention of specialist staff was an issue across all Trusts. She pointed out that, with the exception of one project, all other Confidence & Supply transformation projects in relation to CAMHS had been withdrawn. Mrs Hinds undertook to look into this and advise members accordingly. Mrs Lowry referred to the 62-day cancer target and acknowledged that there were two specific areas where there were delays. She asked whether the target would be achieved if these areas were not included. She said it was unfortunate that small elements of services had impacted on the wider targets and had resulted in targets not being met. Mrs Lowry added that, while there were significant numbers of patients being treated within the required

20 HSCB – 9 May 2019

timeframes, she accepted the need to focus on those patients who were experiencing delays in accessing services. Mrs McWilliams confirmed that the targets were negatively impacted by delays in Upper GI, Urology and Lower GI diagnostic and treatment waits. Mrs McWilliams alluded to the Chief Executive’s earlier reference to the introduction of FIT testing for bowel cancer and acknowledged that waiting times for access to colonoscopy services were already longer than acceptable and work was underway to assess the impact of additional scopes. Mrs Lowry asked if the introduction of the new Cancer Strategy would identify any issues. Responding, the Chief Executive undertook to clarify the position with Dr McCarthy. Mr Mone suggested that, when looking into incidences of death by suicide, cognisance should also be taken of attempted suicide. Mrs Hinds clarified that deaths by suicide would only be reported as a Serious Adverse Incidence in circumstances where the individual had been in receipt of mental health services and added that instances where individuals had attempted suicide would not normally be reported unless in exceptional circumstances. Ms Roulston pointed out that other data collated related to Looked After Children and she said that there had been no reports of death by suicide amongst Looked After Children since she had taken up post. Mr Mone sought further clarification on those instances where GPs have referred individuals but they had not yet been seen. Mrs Hinds said that it was the case that, once individuals had been referred into the system, the SAI reporting process would apply. She reminded the meeting that the designation of a SAI took place at Trust level. Continuing, Mrs Hinds commented that there were significant numbers of Adverse Incidents taking place each year and she referred to work ongoing at a local level and with NHS Improvement England to look at Adverse Incidents. She explained that an Adverse Incident was scrutinised at Trust level and said that

21 HSCB – 9 May 2019

a software project was being taken forward to gather learning from the totality of Adverse Incidents. Mrs Hinds added that a project was also looking at the DATIX system which collected Adverse Incident information to determine if there was a mechanism by which the information could be used to gain greater learning. Mrs Hinds reminded the meeting that the PHA occasionally undertook thematic reviews and often used information collated through Adverse Incidents to ensure richer learning. She cited the example of dysphagia and said that it had been assumed that the greatest risk of patients/clients choking had been in care homes. However she said, as a result of examining information gathered through Adverse and Serious Adverse Incidents, officers had been able to confirm that the greatest risk was actually in day centres. Mr Mone referred to page 37 and the fact that two Trusts, ie the Northern and South Eastern Trusts, did not have any patients waiting longer than 13 weeks and did not delivery primary care mental health services as a separate function. He asked whether other Trusts should consider this. Ms Roulston said that it was her understanding that this related to the way in which primary care mental health teams were structured. She suggested that there was potential for learning and undertook to look at this in further detail. Mrs McWilliams reminded the meeting that there was a Ministerial target to report on those patients waiting longer than 52 weeks and she added that Board officers also had information broken down into time boundaries beyond that. She referred to ongoing exploratory work with management consultants on waiting list validation. Mrs Lowry emphasised the need to ensure clear communication with patients in terms of the expected waiting time. Dr Harper acknowledged that many GPs felt that they had fulfilled their responsibilities in terms of referring patients onto secondary care for further treatment. However, Trusts often take a view that waiting pressures result from insufficient funding, an issue for commissioners to consider. Mr Leach referred to the significant increase in 12-hour breaches and asked if any information had been gathered on those

22 HSCB – 9 May 2019

presenting at ED to determine whether they required ED attention or could have been treated by GP OOHs. Mrs McWilliams advised that officers used triage categories to examine this in further detail. She referred to the ongoing review of urgent and emergency care which had acknowledged that Northern Ireland did not have a sustainable model of urgent care or minor injury. Mrs Hinds pointed out that those patients waiting in excess of 12-hours were waiting on admission to a hospital bed and added that the majority of individual would be 70 years plus. She emphasised the importance of transforming the whole system and believed that transformation should commence in primary care in order to ensure greater focus on prevention. Mrs Hinds alluded to the recent launch of the frailty network to enable greater discussion on how best to care for those individuals who are frail. She acknowledged the challenges in ensuring the appropriate allocation of Confidence & Supply monies and said that it would be important to clearly demonstrate that differences could be made, if things were done differently. The Chair thanked members for their comments and Mrs McWilliams for her report which was NOTED by members.

50/19 EHEALTH PROGRAMME FINANCIAL PLAN FOR 2019/20 (INCLUDING 2018/19 YEAR END OUTTURN)

Mr Cummings advised that, with the recent appointment of the Chief Digital Information Officer, discussions were ongoing with regard to budgetary responsibility in that the eHealth budget may transfer to the DoH. However, he said, until such discussions had concluded, it would be important in the interim to approve how the capital and revenue budgets would be allocated. Continuing, Mr Cummings drew members’ attention to page 38 of the document which set out how resources had been allocated in the previous financial year. He pointed out that the total capital spend for 2018/19 was £45 million against an allocation of £46 million, resulting in 31 million being returned to the DoH. In terms of revenue, Mr Cummings advised that the opening eHealth financial revenue figure of £17.7 million had been subsequently revised to £18.1 million. He reported that allocations

23 HSCB – 9 May 2019

against this budget totalled £17.4 million, resulting in a release of £700,000 unused revenue. Mr Cummings reminded members that they had received a detailed presentation at the Board meeting in December 2018 and at a subsequent workshop on eHealth plans for the next five years. He pointed out that the capital requirements were forecast to increase significantly over the coming years. Mr Cummings added that current plans did not have full budgetary cover and that a further £130 million was needed. He drew members’ attention to pages 2-3 of the document which summarised the plan for 2019/20 totalling £81 million and advised that a significant element of this spend related to Microsoft Licensing. Referring to the revenue expenditure totalling £17.7 million, Mr Cummings advised that this was summarised on page 20 and would fund ongoing commitments. He pointed out that this included recurrent and non-recurrent commitments for projects in-year and business case development. Alluding to the latter, Mr Cummings explained that, as the work to progress Encompass increased, there would be a need to ensure appropriate business case support. Responding to a question from Mr McKeever in relation to the purchase of laptops, Mr Cummings said that it very much depended on the value of the laptops purchased and whether that expenditure was capital or revenue. He said that practice amongst Trusts varied and added a number of Trusts had used capital resources to purchase laptops. Mrs Lowry referred to the workshop and acknowledged that this had provided an opportunity for members to receive further background to eHealth. She pointed to the reference to setting up a shared service centre for IT and sought further clarification. Mr Cummings explained that the shared service centre would be based on the same model as Payroll but focus solely on IT services to Trusts, for example, help desks. He clarified that, under the shared service centre model, the service would be provided once in Northern Ireland rather than provided on each Trust site.

24 HSCB – 9 May 2019

Mr Leach referred to the fact that the significant expenditure on Microsoft Licensing in 2019/20 would result in zero expenditure in 2023/24 and asked whether this would be funded from capital. Responding, Mr Cummings explained that the significant expenditure would ensure the most up-to-date product and support being purchased for a number of years. He added that once this expired, it would then be necessary to re-purchase. Mr Cummings reminded members of the recent cyber security incidents within the NHS and said that these had taken place because organisations had not updated their Microsoft security. Mr Cummings acknowledged that the Microsoft Licensing could be purchased through revenue but believed that capital was a more cost effective way to do so. Responding to a comment from Mr Leach regarding the use of revenue monies, Mr Cummings said that revenue funding tended to be used to allow the use of a service for a limited period of time and added that the use of revenue funding was very much built into future plans. He added that this, in essence, would mean that revenue funding would also have to be incorporated into future inescapable revenue pressures. Mr Cummings referred to an earlier point in the discussion in relation to funding to develop business cases and said that it was necessary to purchase support from IT consultants who had expertise in this area. He acknowledged that HSC did not have the necessary expertise in the writing of IT business cases. Following this discussion, members APPROVED the following recommendations: a) Scenario 1 as the opening Capital Profile for 2019/20 - as

shown in Section 3.1(p17) - recognising that this will need to be kept under review during the year as cost estimates are ‘hardened’. Scenario 1 proposes a mixed capital/revenue (managed service) approach to funding the eHealth portfolio which will require the sourcing of the additional revenue to be addressed. Approval at this stage is therefore only requested for the opening Capital position and the financial viability of the eHealth Programme will need to be reviewed during 2019/20 as discussions with regard to revenue are progressed.

25 HSCB – 9 May 2019

b) the opening Revenue Budget profile for 2019/20 - as shown in section 4.1 (p20)

During the year the budget deployment will be managed by the eHealth Directorate in response to changing/emerging priorities, individual project progress and opportunities to deploy additional funding which may become available. The Board also NOTED: a) the Conclusions, Risks and Next Steps articulated in sections 5

to 7 of the attached eHealth Programme Financial plan 2019-20 (pages 22-23); and

b) the 2018/19 Financial Outturn against budget The Chair thanked Mr Cummings for his presentation of the paper.

51/19 NORTHERN IRELAND AMBULANCE SERVICE – CLINICAL RESPONSE MODEL – OUTCOME OF CONSULTATION

The Chair alluded to discussion at the April meeting when members had received a presentation from Mr Brian McNeill, Director of Operations, NIAS, on the outcome of the public consultation on the proposed clinical response model. He said that, while members had indicated their support in principle with the clinical response model, they had requested further information on the consultation responses. The Chair advised that Mr Bloomfield, Chief Executive, NIAS, had subsequently forwarded the additional information requested. He drew members’ attention to Annex 1 of Mr Bloomfield’s correspondence which set out where substantive changes had been made to the final proposal as a result of the consultation. Having taken this additional information into account and the information initially provided at the Board meeting in April, members CONFIRMED their support for NIAS to submit its Clinical Response Model to the DoH for approval.

26 HSCB – 9 May 2019

52/19 10,000 MORE VOICES – EXPERIENCE OF BEREAVEMENT: THE PERSPECTIVE OF FAMILY, CARERS AND STAFF The Chair welcomed Ms Linda Craig, Regional Leader for 10,000

More Voices, to the meeting and invited her to present the report ’10,000 More Voices – Experience of Bereavement: The Perspective of Family, Carers and Staff’.

By way of introduction, Mrs Hinds advised that a project focusing on

the experience of bereavement had been incorporated into the workplan for 2018/19 of the 10,000 More Voices initiative.

Ms Craig advised that the story collection commenced in December 2017 and remained open until May 2018. She indicated that the report presented the findings from 277 stories collected across five Trusts. Continuing, Ms Craig explained that, overall, 49% of stories were rated as positive or strongly positive and provided insight into the good practices to be included in the care of the bereaved family/carer. She added that 23% of stories had been rated as negative or strongly negative and identified learning to be embedded into practice through the recommendations. However, Ms Craig said that overall the stories clearly indicated that the bereavement process was directly impacted by how their relative was cared for in their final days and added that this provided insight into the links between palliative care and bereavement services. Through her presentation, Ms Craig described a number of key messages which had been identified from the data. She said that 51% of the answers related to a death in the acute hospital ward setting and highlighted particular need for development of training in care of the dying patient and bereavement and added that this also included communication processes. Ms Craig said that 29% of the answers related to a death which had occurred in the patient’s home or relative's home and said that these highlighted the need for better provision of palliative care in a community setting, a proactive approach to managing the patient at home with a key coordinator for daily contact and easier access to assistance during ‘out of hours’ period including public holidays and weekends. Ms Craig advised that the recommendations emanating from the report were developed in relation to the strategic, organisational and individual context. She added that, in order to support the

27 HSCB – 9 May 2019

implementation, Trusts will work in collaboration with Regional Palliative Care Board.

Dr McCullough commended the report and those who took the time to tell their stories and experiences of bereavement. She asked how it was intended to link the reports with undergraduate education and other healthcare professionals to ensure the learning from the report was disseminated.

Ms Craig advised that there were links with universities and

undergraduate programmes and she continued to build networks. Mr McKeever said that, having experienced death at home, he

would describe Ms Craig’s presentation as ‘powerful’. He suggested that those families who had been involved in the report should be given the opportunity to become involved in any training. He emphasised the importance of staff involvement and partnership working.

Responding to Mr McKeever’s comments, Ms Craig indicated that

some Trusts did involve service users to support the delivery of their training and added that bereavement counsellors were also examining this at local level.

Mr Mone described Ms Craig’s presentation as ‘inspiring’. He

believed that the report should lead to improved training and greater awareness amongst health and social care staff, thereby improving the quality of communication. He suggested that there would be merit in discussion of the report at the TIG.

The Chief Executive acknowledged the impact of the questions

asked of family, carers and staff who had suffered bereavement and commended the report.

Members NOTED the report ‘10,000 More Voices – Experience of

Bereavement: The Perspective of Family, Carers and Staff’. The Chair thanked Ms Craig for her attendance and she withdrew

from the meeting.

28 HSCB – 9 May 2019

53/19 ANNUAL REVIEW OF MEMBERS’ INTERESTS

The Chair reminded the meeting that, in addition to any updates throughout the year, the HSCB Standing Orders required members’ interests to be updated on an annual basis. It was noted that a number of minor amendments had to be made to the Register which would then be posted on the HSCB website. Subject to the changes to be made, members NOTED the Register.

54/19 ITEMS FOR INFORMATION

(i) Minutes of Local Commissioning Groups - Western – 13/2/19 - South Eastern – 7/3/18 - Southern – 21/3/19 - Belfast – 21/3/19

Members NOTED the content of the above minutes.

55/19 DATE OF NEXT MEETING

The next meeting of the Health and Social Care Board will take place on Thursday 13 June 2019 at 10.00am in the Boardroom, HSCB, 12/22 Linenhall Street, Belfast BT2 8BS.

56/19 ANY OTHER BUSINESS

There were no items of Any Other Business.

57/19 RESOLUTION TO GO INTO CONFIDENTIAL SESSION

The Board APPROVED a resolution to go into Confidential Session to consider a number of confidential items of business.

This being all the business, the Chair closed the meeting at 1.00pm.

29 HSCB – 9 May 2019

SIGNED: ____________________________________________

DATE: ____________________________________________