Pressures on Emergency Departments and the Northern Ireland Ambulance Service.

Question for Urgent Oral Answer — Health – in the Northern Ireland Assembly at 2:45 pm on 2 November 2021.

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Photo of Alex Maskey Alex Maskey Sinn Féin 2:45, 2 November 2021

Mrs Pam Cameron has given notice of a question for urgent oral answer to the Minister of Health. I remind Members that, if they wish to ask a supplementary question, they should rise continually in their place. The Member who tabled the question will automatically be called to ask a supplementary.

Photo of Pam Cameron Pam Cameron DUP

Mrs Cameron asked the Minister of Health, in light of the unprecedented demand and waiting times for patients and the risk to life, to outline the actions he is taking to mitigate pressures on emergency departments and the Northern Ireland Ambulance Service (NIAS).

Photo of Robin Swann Robin Swann UUP

I thank the Member for tabling the question. Our emergency departments are operating significantly above capacity. The pressures on our trusts during the summer and into the autumn were unprecedented, often having been akin to the most difficult winter pressures previously witnessed. That is what makes the situation so serious.

As Members will recall, I stated on 22 September that a hospital emergency department could be forced to close as a result of the pressures.

Obviously, I do not want that to happen, and nor does anyone working in the trusts. However, we must realise that we are facing levels of pressure as never before.

For several years before the pandemic, too many people were being forced to wait for over four hours and 12 hours in emergency departments. The current pressures have been exacerbated by the pandemic, but they were not caused by the pandemic alone. On 22 October, I made a statement to the Assembly that set out my approach to winter preparedness. I have also published individual trust winter and surge delivery plans. All that has provided information on what actions have been taken to support our emergency departments through this autumn and winter.

The Health and Social Care Board (HSCB) continually works with the Public Health Agency (PHA), the Northern Ireland Ambulance Service and the five trusts to address waiting times at our emergency departments with enhanced flow through the system and the facilitation of timely discharge. The Health and Social Care Board is also coordinating smoothing to manage our Ambulance Service flows better.

Following a further allocation in the recent October monitoring round, which was confirmed and announced on Friday past, I am investing a total of £21·2 million in the No More Silos action plan this year. The key initiatives that will be supported will manage the unscheduled pressures. That includes Phone First in urgent care centres, the timely discharge initiative, ambulance handover bays and Hospital at Home.

Phone First is currently available in the Northern, Southern and Western Trusts, with an interim service in the Downe Hospital in the South Eastern Trust. The service was also recently introduced in Lagan Valley Hospital. From 1 December 2020, more than 134,000 patients have utilised the service. Of those, 29,500 — 22% — were discharged with advice to refer to their GP. Around 60,400 — roughly 45% — were scheduled for an appointment at an emergency department or the urgent care centre alternative pathway. Some 40,300 patients — 30% — were referred directly to an emergency department.

I recently announced a package of £5·5 million to support service delivery in primary care throughout the winter. That includes £3·8 million to support additional patient care, covering general practice and out-of-hours services, and up to £1·7 million to improve telephone infrastructure. Again, those measures will help to alleviate pressures on our emergency departments. However, I must stress that we all have a role to play to support our emergency departments and our wider health system. I encourage everyone to take up the COVID-19 vaccine, the booster and the flu vaccine when offered. There is a real tangible step that we can all take to support our emergency departments now and into the winter.

Finally, it is important to recognise that the issues that we are seeing in our emergency departments cannot be resolved with one-off non-recurrent funding. What is needed is recurrent investment over a number of years to improve capacity and bring forward meaningful change.

Photo of Pam Cameron Pam Cameron DUP

I thank the Speaker for accepting this question for urgent oral answer and the Minister for coming to the Chamber today.

This is not about party politics; this is about people. On all sides of the House, we need to be in this together. We need to work together to fix this. Through the media, we have heard an ED consultant from Altnagelvin Hospital apologise for the appalling service over the Halloween weekend due to the huge pressure and lack of capacity. Yesterday, the Northern Trust stated:

"We are on the cusp of an emergency department in Northern Ireland having to close its doors."

What action is the Minister taking to ensure that EDs remain open for life-saving emergency services? For example, has he asked for any further assistance from the military for EDs or other areas of the health service to free up vital resource? Is there any further update on the most recent workforce appeal?

Photo of Robin Swann Robin Swann UUP

I thank the Member for her comments. The two consultants to whom you referred, from Altnagelvin and the Northern Trust, were reiterating and reinforcing the statement that I made on 22 September. We have seen this coming; we knew where this winter was going to take us. That is why I made a bid in the October monitoring round for over £20 million to support the No More Silos structure, which predates the COVID-19 pandemic. It is about the work that needs to be done to direct and rectify the challenges that we have already seen in our EDs. Unfortunately, the pressures that we are seeing now are not new. They are a direct result of underinvestment in the health service, both financially and in the workforce over the past 10 years.

That money will bring forward specific functions, but I stress that the money became available to me only on Friday when the monitoring round was agreed. The money will be spent on increasing Phone First in urgent care centres, the timely discharge initiative, ambulance handover bays and Hospital at Home.

Those are the steps that we have taken directly.

We have not made an additional request for Military Aid to the Civil Authorities (MACA) support, because, as the Member knows, that serving unit returned only a week ago and is not currently available for redeployment. We monitor continuously whether and when MACA is available and how we can use it. I spoke with some of the serving medics before they returned home. Hearing phrases like, "I was glad to be here to be able to support my own in their time of need" was testament to the additional service and support that they provided to our health service.

Photo of Alex Maskey Alex Maskey Sinn Féin

Before I call the next Member to speak, I remind Members to go directly to their question. A dozen Members still want to contribute, and they cannot all do so within the limited time available to us.

Photo of Colm Gildernew Colm Gildernew Sinn Féin

Minister, in June, I asked about the publication of the report of the review of urgent and emergency care. I have not received an answer. Will you advise when the report will be published?

Also, has the time not arrived to convene a health summit, as requested by the royal colleges and unions, to get into one room everyone who, through their awareness of the problems here, can be part of the solution?

Photo of Robin Swann Robin Swann UUP

I thank the Member. The royal colleges and trade unions have requested a summit. Since that request was made, I have met most of them, individually as royal colleges or through the trade union workforce structure. I indicated to them, and to some Executive colleagues, that I am minded to do that once I see an ongoing Budget settlement for Health. It would be premature to bring everybody into the room at this stage when, in two to three weeks' time, we will find out what our long-term funding will be. That is the wider discussion that needs to be had at that health summit.

I expect to see the updated report of the urgent and emergency care review shortly. It blends into the No More Silos work that was instigated a number of years ago but has been reliant on piecemeal, hand-to-mouth funding. As I have said many times in the Chamber, that is no way to resolve the structural challenges that our health service faces after over 10 years of underinvestment.

Photo of Daniel McCrossan Daniel McCrossan Social Democratic and Labour Party

Minister, you are well aware of the pressures that exist in GP surgeries. Phone lines have been jammed, and, as a result, more people have been presenting at A&E and creating a crisis there. We saw at the weekend how that unfolded. Has the Minister given any thought to putting in place a system, similar to that in England, of "walk-in clinics", where you walk in, be triaged there and then, and it is determined whether you go to a hospital, see a GP, a nurse or a mental health consultant? It takes away that pressure, and it worked quite well in England. Has the Minister given any consideration to that system?

Photo of Robin Swann Robin Swann UUP

We consider all systems as they are developed elsewhere. However, our challenge is always that of workforce and who is able to deliver the service in a timely fashion. There is no point in displacing a patient from one section to another. That is why we introduced the Phone First system. In my original answer, I told the Member how many people utilise that system, which allows them to be directed to the correct place at the correct time.

In the week ending 15 October, our total practice teams — multidisciplinary teams (MDTs) and GPs — had consultations with 233,412 people, which is 116 per thousand of our population, and over 50% of those were face to face. I have often said in the Chamber that the narrative of our GPs not being open is incorrect.

Yesterday, the Member stated in the House that I had no plan to tackle elective care. I refer him to the elective care strategy that was published at the start of June. It might inform him of the work that is being undertaken, but it needs funded, and that requires cross-community, cross-Executive support.

Photo of Alan Chambers Alan Chambers UUP

I especially welcome the recent announcement of additional funding for No More Silos. Primary care has a huge role to play before people make the decision to present at an emergency department. A well-resourced primary care network is therefore essential.

Will the Minister provide an update on the number of GPs coming through the training pipeline currently? I once again place on record my continued appreciation for the efforts of all our health and social care staff.

Photo of Robin Swann Robin Swann UUP 3:00, 2 November 2021

I thank the Member for his question. On the GP workforce pipeline, I reiterate that, a few weeks ago, I announced £5·5 million of additional funding to support primary care through the winter.

It has often been said in the House, and this is supported by all parties, that the crisis in the workforce that we are currently experiencing is not solely because of COVID. It is due to the underinvestment that there has been in our health service in the past 10 years, not just in bricks and mortar but in the people working in it.

My Department has continued to invest in our GP workforce, and, in recognition of the increase in demand for primary care services, there has been a steady expansion in the number of GP training programme places over recent years. That has culminated in an intake of 111 students for the 2021 programme. That represents a 71% increase on the 2015 intake, when there were only 65 trainees. Although that investment in the workforce has seen the overall number of GPs working in Northern Ireland increase, more GPs are choosing to work less than full-time hours, with the result being that the overall GP workforce, as measured in whole-time equivalence, has decreased by 8% since 2014. That having been recognised, I have asked for a review of GP trainee places to make sure that there are enough GPs to meet our primary care needs into the future. I reiterate, however, that it will take time to get those medical professionals in place.

Photo of Kellie Armstrong Kellie Armstrong Alliance

Minister, given the pressure on emergency departments and the predictions of a winter crisis in our hospitals, will you explain why you were content to support the reopening of nightclubs? I understand that nightclubs are under a lot of pressure and that they need to open at some stage, but, without any mandatory mitigations in place, and having witnessed the queues at the weekend at our hospitals, does you still believe that it was the right decision?

Photo of Robin Swann Robin Swann UUP

I thank the Member for her question, although it is slightly off the subject of the original question. I will refer back to the autumn and winter contingency plan, which all Ministers supported. It refers to the fact that the development of appropriate enabling infrastructure to underpin a system of COVID status certificates is under way. As the Member will be aware, and as I said earlier, we launched that yesterday. The Department of Health has committed to bringing forward the domestic COVID certificate. Where and when it will be deployed is a policy directive for the entire Executive to make.

Photo of Jim Allister Jim Allister Traditional Unionist Voice

Is part of the problem not the lack of coordination on the handover of patients from the ambulance to the hospital? We have cases in which ambulances sit for hours with patients on a trolley, but if they were to be transferred to a hospital trolley, the ambulance could get back on duty. Do we not need proper coordination?

Photo of Robin Swann Robin Swann UUP

I thank the Member for his question. It is a valid point, and one that I have seen in operation where we have the hospital ambulance liaison officer (HALO) system in place, through which a member of the NIAS is in the emergency department in order to coordinate the handover. Although patients may be transferred to what the Member calls a hospital trolley, they remain patients of the Ambulance Service until they are fully integrated into the trust and all the necessary checks are able to be undertaken. That handover is therefore being done.

I referred to this in my original answer, but one of the changes that we have seen recently in the Ambulance Service is "smoothing", which is a clunky term. A patient is taken to an ED that has a shorter waiting time rather than to the closest ED. Doing that smoothes out the pressures that our EDs are witnessing and releases the ambulances quicker than they would have been released had they simply gone to the closest ED. The Northern Ireland Ambulance Service covers the entirety of Northern Ireland and, as a result, is not constricted by the make-up of the five geographical trusts.

Photo of Gerry Carroll Gerry Carroll People Before Profit Alliance

The situation faced by those who work in and rely on EDs is stark and concerning. I am concerned that we will keep on doing what has been done and get the same results again.

What proportion of the new money that the Minister announced is being spent on the private sector, private organisations and private healthcare?

Photo of Robin Swann Robin Swann UUP

The £21·2 million that was announced to support No More Silos is solely for the health service.

It is to support the work that needs to be done, as indicated by No More Silos, with regard to how patients are transferred through the entirety of our system. It is all about investing in the Northern Ireland health service. That includes Phone First, urgent care centres, the timely discharge initiatives, ambulance handover bays and Hospital at Home.

Photo of Carál Ní Chuilín Carál Ní Chuilín Sinn Féin

I thank the Minister for coming to the House. With respect, I do not think that anybody who has been waiting on a hospital trolley for 30 hours is going to understand what No More Silos means. I think that we all accept that, and I am not being pernickety but, if the £21·2 million is for emergency care, say so, because families are sitting in cars outside hospitals in which their elderly parents are waiting on a trolley for 30 hours to get a bed. We need to be clear.

I ask the Minister to be mindful of another thing. At the weekend, I spoke to a nurse at the children's hospital in the Royal who had worked in Africa. She said to me that both the emergency department and the children's hospital in the Royal were akin to the scenes that she saw in Zambia. Our health and social care staff are under massive pressure. If they are getting additional support through that £21·2 million —

Photo of Carál Ní Chuilín Carál Ní Chuilín Sinn Féin

— I want the Minister to clear that up.

Photo of Robin Swann Robin Swann UUP

I thank the Member for her question. To be clear, the £21·2 million is for investment in No More Silos, which was the Department's strategy before I became Minister to address pressures in our emergency departments. I will make it clear to the Member: that investment is going towards those steps —

Photo of Carál Ní Chuilín Carál Ní Chuilín Sinn Féin

Is it for nurses? Is it for doctors? Is it for beds?

Photo of Robin Swann Robin Swann UUP

It is for all those services that are actually there.

Photo of Robin Swann Robin Swann UUP

It is for early discharge, first and urgent care centres, ambulance handover bays and Hospital at Home. It will support the entirety of the system as it works through. However, that is only part of the monitoring round moneys that I got on Friday. That bit specifically addresses the problem that was raised in the initial question for urgent oral answer. I got £70 million that will go to giving our health service workers the 3% pay rise that was indicated by the independent monitoring body that looks at that matter. It allows me to take that to the next step as well.

Additional investment is needed. I have said that many times from this place, but monitoring round money does not solve anything when it comes at this time of the year to be spent in March to address a systemic problem that has been getting worse over the past 10 years, rather than doing the structural reform that we all know needs to be done now. We need that recurrent budget, should it be for three years or five years, to give us the surety to make the transformations that we need to make.

Photo of Trevor Clarke Trevor Clarke DUP

Minister, in one of your comments, you said that you saw this coming. I think that we all saw it coming. I know of an infant who a GP refused to see on three occasions over six weeks. The parents took that child to A&E, and the A&E doctor was appalled that the GP had refused to see the child. How many examples are there where GPs refused to see children or tried to diagnose them over the phone, and parents decided to take their children to A&E, where A&E doctors told them that the GP should have seen them in the first instance?

Photo of Robin Swann Robin Swann UUP

If that is a specific case, I encourage the Member to either contact the Patient and Client Council or refer it directly to the trust on an individual basis so that that case can be looked into. In relation to the narrative about GPs not being open, I reiterate to the Member that £5·5 million will be invested in our GP primary care structures over the winter. I also refer the Member to a comment that I made earlier about the number of people who are being seen by GPs. In the week commencing 15 October, 233,000 people came forward for a GP consultation with regard to how they could be best directed.

Photo of Matthew O'Toole Matthew O'Toole Social Democratic and Labour Party

Minister, the strongest reason for vaccination certification, which my party has called for, specifically in hospitality settings, is the fact that our health service is close to buckling. As we have discussed today, it is buckling. One reason that was given by some, including you, for not recommending vaccine certification was that the app was not ready. As you have said today, the app is ready. Will you now advise the Executive to move speedily to require vaccine certification in specific settings in order to protect our health service?

Photo of Robin Swann Robin Swann UUP

I thank the Member for that point, which his party continually raises. We are here to talk about emergency departments, but the SDLP wants to go in a different direction. On certification — I am sure that his Minister has briefed him on this, given that she seems to have briefed others on it — he will be aware that the head of the Northern Ireland Civil Service has said that that policy development work is being taken under its direction. That is where it lies. I have always been clear on that. Health is supporting them in that.

The Executive's autumn and winter strategic plan, which was supported by all Ministers, clearly stipulates that the initial work in developing the app should be done. We delivered that yesterday. Legislation on what it will look like is being drafted and prepared. The Member and his Minister are aware that the timeline for drafting that has been laid out. As I indicated in the earlier debate on the regulations, a small team in my Department has been left to draft those regulations on behalf of the entire Executive.

Photo of Paula Bradshaw Paula Bradshaw Alliance

Minister, you will be aware that the Royal College of Emergency Medicine is keen to see the introduction of the Getting it Right First Time programme, which relates to the sharing of clinical best practice across EDs. Can you give us an update on that? Also, will your Department work with the Public Health Agency on its messaging this winter so that people go to the right place for their healthcare?

Photo of Robin Swann Robin Swann UUP

In response to your last point, very much so. We want to make sure that people go to the right place to be seen. That is part of the benefit of Phone First: before somebody presents to an ED, they have the opportunity to engage in that way. One of the directions of travel in No More Silos is that we have a single number for the entirety of Northern Ireland, akin to the 111 service in England and Wales. That amalgamation across the entirety of the service would take some of the pressure off out-of-hours.

The Member will be aware, if she has been talking to the Royal College of Emergency Medicine, of the review of urgent and emergency care. Unfortunately, the publication of the report that sets out the findings and recommendations of that review was delayed by the pandemic. However, I plan to publish the report and consult on its findings shortly, because it ties in with the recommendations from No More Silos.

Photo of Órlaithí Flynn Órlaithí Flynn Sinn Féin

Minister, you said that 233,000 people had been seen by their GP via an appointment, which is great. Does the Department have evidence that the lack of GP access or provision contributes to the crisis in urgent and emergency care?

Photo of Robin Swann Robin Swann UUP

We do not have any direct evidence of that. I know that your party conducted a GP survey, and I thank it for sharing the findings with me. Of those 233,000 people, 50% were seen face to face. The rest were triaged by telephone or the online service, and the GP directed them to where was most appropriate. That work continues to be progressed. Again, we are putting additional moneys into telephone and online consultation so that people do not have to wait to get an initial consultation with their GP.

Photo of Deborah Erskine Deborah Erskine DUP

I thank the Minister for coming to the House. Does he agree that the deficit in GP cover for out-of-hours is adding to the pressures faced by emergency departments? What is his Department doing to address that? For example, a constituent of mine tried to access their GP out-of-hours service on Thursday, but, I understand, there was no GP out-of-hours cover, hence they attended an ED on Saturday night.

Photo of Robin Swann Robin Swann UUP

I thank the Member. I am aware of the continuing pressures faced by GP out-of-hours services across Northern Ireland, with increasing demand and difficulties in filling GP shifts. An effective out-of-hours service is a priority for me. My Department continues to work closely with the Health and Social Care Board and the out-of-hours providers to address the current challenges. Service improvements continue to be introduced. Those include adjusting the skills mix of clinicians; increasing levels of nurse triage provision; employing more nurse practitioners, paramedics and pharmacists; and increasing flexibility in shift times. My Department continues to work closely with the Health and Social Care Board, the out-of-hours providers and key stakeholders to address the challenges in the out-of-hours service across Northern Ireland and to redesign it in line with the recommendations in No More Silos. The aim of that is to have a more stable, sustainable and integrated service that will better meet the needs of the whole population. That will include consideration of a regional model for delivery of the service.

Photo of Justin McNulty Justin McNulty Social Democratic and Labour Party 3:15, 2 November 2021

I thank the Minister for coming to the House to answer this important question. Minister, what hope can you give to patients and the families of patients who are waiting for cancer operations, hip replacements, scans, gall bladder operations or consultant appointments?

Photo of Robin Swann Robin Swann UUP

I thank the Member for raising the issue. In regard to the elective care strategy that was published in June, once again I needed money from monitoring round bids to fund it. That is why I was thankful to the Finance Minister for funding my bids for Health and not diluting them in any shape or form. That allows me to continue with the work in the elective care strategy.

Over 65,000 people have been seen through waiting list initiatives; 1,800 people have been seen through mega-clinics; and another 4,000 have had preoperative (PO) assessments through GP federations. The hope that I can give is supported by the funding of monitoring round bids that I have made for my elective care strategy.

Photo of Mervyn Storey Mervyn Storey DUP

The Northern Trust has the lowest number of intensive care beds and a business case for 49 additional beds that has been sitting for months. In its winter plan, it states that the initial projections show a potential shortfall of over 200 beds across the acute hospital sites in the Northern Trust. Given all that, what practical steps is the Minister taking to ensure that the situation with ambulances that he described is brought to an end by the provision of beds in the hospitals?

Photo of Robin Swann Robin Swann UUP

I thank the Member for his question. He makes a valid point, and I have often said here that it is not just about investment in infrastructure — bricks and mortar or physical beds — but about investment in the staff that it takes to support those beds. That does not just mean the doctors and the nurses; it means the porters and the administrative workers who are there to support them. When this place came back in January 2020, the promise of an additional 300 nursing training places over a three-year period was welcome. That increase saw the number of nursing training places rise to 1,325 a year, but, like everything else, it takes time for those nurses to come through to support the beds.

There are a capital bids in from the Northern Trust on how it can expand. As the Member is aware, as a constituency MLA and the Minister of Health, I am supportive of those bids at all times. The Member will see that through the monitoring round bids that I continue to make to improve long-term investment in our health service. It cannot be done with short-term, non-recurrent budgets, which is why I look forward to having a longer and sustained budget that allows capital and revenue. That will mean that we can do the planning and recoup some of the underinvestment of the past 10 years.

Photo of Alex Maskey Alex Maskey Sinn Féin

That concludes this item of business. I ask Members to take their ease until we move to the next item on the Order Paper.

(Mr Deputy Speaker [Mr Beggs] in the Chair)