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Hopefully will not put our panel members under too much pressure, but looking forward to the, the debate. So look, if I could um ask Peter then to, to kick off in terms of the hospital reconfiguration and um give a presentation in relation to that. Thank you. Thank you, Liz. You can hear me. OK. Good, good. Uh So good morning, everyone. Uh great to see you as many of you this session. Uh I'm Peter Jerson, Director of Health Service Transformation in the department. Um So my team led on putting together the hospital, um network document was launched for public consultation just a, a few weeks ago. And it's important to say that was co with the trusts, the ambulance service and the p and it was very much a joint effort. And I'd like to thank everyone who was involved in that work. And I think I see quite a few of you in the audience today actually, who was involved. So you're very welcome. So this morning, I'll briefly cover so that the contract for the document, how it was developed the key concepts within it. And then the next step and I'm told, I have to press a green button and we should move to the next slide. Yeah. Well, something has happened but there's no exercise yet. There we go. Takes a bit of time. Ok. So you'll all be very familiar with the report and the labor and together document um I with to focus on prevention and population health shift to community service, etcetera, which ministers covered this morning. And that very, very much still remains the the general direction of travel. Um And you'll heard the minister's focus on on public health and T and health inequalities amongst other priorities this morning. So the hospital document is as the title suggests, focus exclusively on our hospitals. Um The many important out of hospital service are covered for the other initiatives and we recognize the many links between hospital primary and community care services and it is reference within the document. So um this as you mentioned, um the document was coro importantly and that included a broad range of clinical input drawn from the trust and the PH A and that was overseen by a task and finish group which included the chief executives and trusts and the PH A alongside senior officials. And this group also include the chief medical officer and the Chief nursing officer from the Department Service users and representatives from the Royal College of Nursing and the British Medical Association. So once we had a draft document, we undertook a pre consultation with exercise with the, the Royal Colleges, the trade unions and a and a group of service users that involved um sharing the document facilitating discussion sessions with those groups. And then we, we sought written feedback. Um We also developed a short summary document which was co produced by, by the service user group and that's also been published alongside the main document. Given the time constraints, it's not possible to take on board every single comment we got through the consultation. And in fact, we've received, I think something like 70 odd pages of very detailed comments, but we did try as far as we could to amend the document in light of those comments. It's also important to say that a lot of the comments were actually much wider points around Book Force, et cetera, et cetera, which would be addressed through other initiatives. And um and some of them are actually more about probably about the implementation once we conclude the the consultation, and I'll say a bit more about the the next steps towards the end of my presentation today. So um this slide is hopefully fairly self explanatory. So I make a few sort of overarching points. And the first point is that the document in itself does not contain any reconfiguration decisions there. As Minister of reference this morning, it sets a framework for future decisions which might be taken by the trusts or the department itself. It also gives local communities some certainty as to the future of the hospital but recognizes that hospital reconfiguration is actually an ongoing process as we respond to changing population health needs, the documents that are some principles to guide reconfiguration decisions, which should be used in combination with extent policy guidance and chief among these principles is that all reconfiguration decisions should be driven by patient safety and better patient outcomes. There's also a clear commitment to engage and consult with the communities that use the services and of course with our staff. And as always, many of these changes will have to be clinically led. It's clinicians and the people working in the service are those that to really understand what works. The document also includes, I think it is one an a list of ongoing deeper metal Deb strategies and service of views that may inform or directly lead to future configuration decisions. So as the title of the document makes clear a settled concept in it is the focus on the hospitals working as a network that's of course already happening to some extent with pathways that run between hospitals and indeed across trusts. I know she would say a little bit more about that her contributions shortly. The document also says that's some core service that must be delivered by, by various types of hospitals. And in terms of those core services, perhaps the most significant is 30 minute maintain all our 24 7 EDS given the current pressures, not us not forever and ever. But we are saying certainly within the time span of a decade or so that we expect that to be the case. We also highlight our elective care policy which is focused on established center of elections and that has been referenced several times already today. That's a little bit better and more efficient elective care. And that of course means that some patients will need to travel further for their elective procedures. And there is a section in the document that covers patient travel. So the next two slides sets out a number of high level proposed actions within the document which I intended to facilitate a greater focus on a network approach and ultimately deliver better services for the entire population. Um I think you can group these actions into four main themes. And the first theme is uh is patient travel. As I mentioned, a second theme around the allocation of resources and services across the hospital network and indeed to circumstances where collaboration beyond Northern Ireland is required, there is a third theme then around workforce issues such as allocation of medical trainees and workforce planning on a multidisciplinary basis. 1/4 and final theme is around mechanisms to facilitate greater collaboration across trusts. So um this slide and the extent show uh uh consultation questions that we pose um again, not go over these in detail but the flow from the main concepts and issues in the document. I particularly keen to test the proposed actions through the consultation process. And that is really because following consultation, it is the actions that are really going to drive the improvements in how we deliver services for our population. It's crucial that that the actions are comprehensive and actually makes sense to all stakeholders, including yourself that work in the service just finally moving on to next steps. So the public consultation runs to the 22nd of January next year and we intend to organize a number of consultation events, uh most likely both in person and online. Um So once we analyzed the feedback, we will then draft a consultation response for, for the minister's consideration, I anticipate that we will have to revisit the proposed actions. We will need to identify action owners and set up over site arrangements to track progress against those actions. And I think both directions will definitely be refined and could probably benefit from being more specific and have associated timescales. And I think that would be the first task for those actually known us once we finalize the actions themselves. So um to that end, I would encourage you all to engage with the consultation and I look forward to receiving feedback to the discussion today. So with that, I, I'd hand over to Roisin to give you her perspectives. Yeah, warn everybody. Um I do actually know most of the people in this room. So I'm sitting out looking to smile of very friendly faces but uh if anybody doesn't know me, I'm rushing culture, I'm the chief exec in the Southeastern uh trust. I have to say I have been slightly distracted by Mark Taylor taking selfies of himself and Jennifer to the front of the room here. I thought, what are you up to honestly? Uh But anyway, uh over, over to me guys and I think, you know, the, the idea of having a parallel session for me is really about, you know, trying to have more of an informal space for sharing information. And also then maybe having time for a conversation and for listening to views and perspectives because that's really, really important uh particularly during the time uh whenever this is out to public consultation. So just really by way of background, probably two, three years ago now, um you know, many of us working in health and social care, we're very aware that services are constantly changing and evolving and developing. So this is not about, you know, starting from here going forward, it's really about trying to have something in place that reflects that health and social care models and how we deliver health and social care services to and with our population. Um You know, we have been on a journey for many, many years, many of us really be from back as far as 2007. So what we felt was missing uh really was an overall what I call a master plan or, you know, a network or a framework to set out. What exactly are we talking about uh in terms of what is the health and social care system, what does it look like for Northern Ireland, for all of our services right across Northern Ireland. And it's probably the premise for that came from, you know, many of us have been involved in leading changes in services most uh often and at probably most um times whenever there is most concern has been in terms of leading change in hospital services, but not only in hospital services. So, you know, we were asking uh for department and other colleagues and stakeholders to come together to say, you know, can we set out on, as I say one page, Peter laughs, I've never actually seen the one page but you know, on, on one page just what is the model uh for our hospital services across Northern Ireland so that we can have that open honest conversation with our public, our service users, our local politicians, our community and voluntary sector, our carers, everyone who has a, everybody's got a stake to, you know, a stake in this, haven't they? So that they can understand whenever we're talking about service change, what actually do we mean for the big picture? So I think that we've now got the space and a place where we do have a uh draft network of higher hospitals um can be structured and uh going forward. And then that sets out a framework for how we can continue to develop them. But I also think just it's important to remind ourselves always that sometimes, you know, people focus very much on hospitals and that has been just, you know, it's a history, it's part of our culture. But for us as leaders, it's, we're bringing it right back to the citizen, the person and where, where do their health and social care services input come from. So it absolutely comes from in, in their home, close to their home, with their GP practice and with community and social care services wrapped around them. So that is part of the overall system. And I think that's important to mention as well. And the other thing uh why I say is, you know, we're not where we were is that we actually have been making some really good progress in terms of new types of services being delivered across northern Ireland that we maybe didn't have some 58 to 10 years ago. So some of those examples being the development of our regional day procedure centers, our overnight elective stay centers, and then a greater focus on, you know, which sites which hospital sites are most appropriate to provide complex surgery and regional services. So in the context of an absolute desire to separate emergency from elective care, and that has been one of the clinical healthcare planning principles for many, many years, we know what that's the right thing to do. We know that there's competing pressures and priorities across the system in terms of unscheduled care, people who are acutely unwell, needing access to urgent and emergency care needs to be protected. But but alongside that, we know that we've now got the longest waiting lists in Europe. So, you know, for, for many years, we have been on a journey to really try and separate the urgent emergency care from the elective care. And we have succeeded to a certain extent but not, not always. And that has been because all of the maybe the points we've been mentioned earlier today about demand and capacity for urgent emergency care services taking um having to take priority in many instances, particularly for the more routine elective procedures and across the big hospitals, the big acute hospitals, we've had such pressure then on being able to maintain beds and capacity for elective surgery. So that model is to be welcomed and it fits alongside. Um what has been proposed in terms of the the hospital network. Um You know, I think um as well, it would be important for us. I suppose all of us working in health and social care no matter which group we represent. Um and it is good that we have patient advocates here at the conference. We have our community and voluntary sector. People look to us to, to explain, say Roisin, what exactly do you mean? You know what they want to know is if I am unwell, where do I go, what will my local hospitals deliver? What will the other hospitals deliver? And that, that needs to be a consistent narrative, I believe going forward and we need to do that by having uh really open honest conversations with our, with our public. And I do think that we have an opportunity to genuinely to, to change that narrative uh to bring people closer to um understanding why we need to develop services. So, uh I mean, starting from the top there, of that slide, what is being outlined in terms of a hospital network is that there would be four I suppose four levels if you like of, of hospitals um in Northern Ireland. So uh the first one, there would be our local hospitals and I can just give you examples of my own organization uh as we go through that. And you think about, well, how does that translate into the other sectors of Northern Ireland and how we can explain that um with our public? And that um that is something as say, I've been on this journey, my goodness, maybe before 2007 when I was young then. Uh but anyway, and, and we have been changing services with our public um as we've gone along now and it's not easy, we all know that it's, it's very, very difficult. And I suppose that for me, one of the things is that the empathy and the understanding is that um particularly in Northern Ireland, our communities feel very, very passionate and wedded to their, their local hospitals and their larger acute hospitals as well. It's something that has been really very, very important over many, many years. And there's lots of reasons why that. So we need, we need to respect that. So local hospitals um based in communities delivering primary secondary and community services and they are part of the network uh to support both the area and the general hospitals. So the idea of the network um is really, really important in terms of us giving out that message. It's not about every single hospital having their own role and working in isolation. It is about um being part of that network. So for me, in the South Eastern Trust, we have um the down in L Valley hospitals and they are an equal and extremely important part of our hospital network and how we manage and plan our hospital services is by looking at it through that lens, we then have our general hospitals um which will deliver specific defined secondary care services including unscheduled care geared to a more specific and possibly isolated geographical area across northern Ireland. And they will also play an important part and possibly an increasing, have an increasing role in the terms of elective care centers, including overnight stay centers. And my understanding from the network is that they would be the Southwest Acute hospitals, Causeway and Daisy Hill. And then we move on to the five area hospitals. We all know um the the five hospitals in terms of alt G Craig Alvan Antrim, the Ulster Hospital and the which one, the royal, the Belfast Royal, all of them. There we go. Got it. But uh so the five area hospitals, right? So the five area hospitals need to have core building blocks. So there are critical essential services that are really important to be part of an acute hospital. And we know what they are, they are defined by listening to clinical evidence, what we need to make a hospital work, particularly a 24 7 emergency department, access to anesthetics, emergency care and a number of other services including diagnostics. So a full range of services across all of the five area hospitals, delivering services not just to their local community, but also wider across the trust area, but also across boundaries. So it's not just defined to a particular area. And then we have regional centers delivering the regional inpatient services to the whole population of northern Ireland. So hopefully that ii feel anyway, and it would be useful to get feedback from the public and others in terms of this consultation, you know, is this something that our communities can understand? Um And the other thing as well is in and for me, in terms of it's not all exact, it doesn't need to be all exactly the same. So whilst we have Belfast trust obviously are a very key player in the provision of regional services. But there are other um other trusts, other sites that are and will continue and to develop more regional services within those area um hospitals. So for example, in the Western Trust, there are a number of regional services have been provided in my own organization. We are the regional Center for plastics and maxillofacial and oral surgery. Um And uh there are greater opportunities I think to look at, you know, well, how do we come together to serve the population of Northern Ireland and not everything will need to be provided on every single site in relation to some of those regional very specialist services. And there is also the potential for some of the, again for more of the area hospitals to play more of a role in er taking on some of those regional services and moving some of those um out of Belfast in due course, should there be the, the capacity and the joined up planning in relation to doing so? And then my final point really was just to re remember, I suppose, how does this work as a network? So again, you know, in my own organization, um we have the area hospital, which is the Ulster Hospital in Dundonald and then it is supported by our hospital network in the down and the Lagan Valley and it is so important. It's not one against the other. They are absolutely equal, equally important and play an equal contribution to how we manage uh flow right across our system. And so it's not one of the expense of the other. And that is really, really important. And we've been on a, a journey to try and work with um our local community and our staff. And one of the ways of trying to say that the absolute priority as we know is safety first, that all of our hospital network needs to be based on the premise that our services must be safe, they must be clinically appropriate and they must be sustainable. And we need to work together uh across trusts to really look at how we can best do that. And one of the ways that we have managed to do that in terms of working with our clinical teams is that, you know, particularly in our medical workforce, you're not appointed to work in one site, you're appointed to work to the organization. And if we, if we need and you will work right across the different sites and that there's been so many benefits for our staff and for our teams, for our patients in terms of doing that. So I think that we are in a good place now where we do have uh this framework that we can outline to the public about. It's not just about one site or one hospital, it's about this is how it's all er, structured and this is where you will receive your services and they are based on what is best for you to get the best outcome. So hopefully that's useful and I look forward to the conversation. I'm going to hand over to Niall. Good morning. Um, of course, probably afternoon now. Um, I don't know what everyone in the room like Roisin. So my name is now mcdonagh. I am the Northern Ireland Director for Royal College of Surgeons of England. I am also fortunate enough to be the Northern Ireland observer to the Academy of Royal Colleges. And by day, I am a thoracic surgeon. So I'm ready to talk about the surgical perspective and you know, be clear, not all of hospital configuration is around surgery, other services are available. Um but the ground on the sort of the scale of the problem from a surgical perspective is we have embarrassingly bad waiting lists in Northern Ireland, they are the worst in the UK. We have seen these increasing increasing over about a decade, some changes and reductions recently. But overall, our system has not dealt with the capacity and the demand that we need. So we have about 430,000 people uh on waiting list for a first consultation with a consultant, 100 and 90 or so 1000 uh waiting for some scans. So moving along the pathway having seen been told, well, this might be the problem you need to have these investigations, then around 100 and 15,000 people on waiting lists for inpatient care, which equates if you add all those numbers up to about one in four of the population. We've seen that on a lot of those waiting lists, particularly for surgery or 50% of people have been waiting for more than a year. Some up to a decade. Our worst ones are general surgery, trauma and orthopedics, ent and we've seen those waiting lists of urology of around six years and ent about 5.5 years. But I know that in my own specialty, there are patients that have been waiting for over a decade. Um We look at the, the audit office report and how things have changed. What have we managed to achieve uh in the last 9, 10 years. And fortunately, we haven't really achieved very much. We've gone backwards. We've seen our waiting lists increase by over 200% inpatient treatment grew by nearly 100 and 50%. So 1.5 times what it was before, uh on our diagnostic waiting lists again, 1.5 times what they were a decade ago. Department of Health has said that in the region of around 100 and 35 million lbs per year is required just to address those waiting lists so that equates to around 675 million lbs. And on top of that, because when we look at the hospital configurations. It's not just about buildings and people and stuff like this, but looking at our buildings is our infrastructure, buildings fit for purpose. If you've 1.4 billion lbs worth of maintenance backlog, I think any reasonable person would say probably not. We have a workforce. We've talked about workforce and the workforce delivering. We talk about how we're going to deliver this and how we have to look after people. We've got to look after people, but we've also got to look after our workforce. And again, I think we've been off plan for that for a period of time. We've seen a service that's completely under pressure. All of the time. Those of us that use X and various social media, uh constantly things coming up as please don't go to Ulster Ed. Please don't go to Belfast Trust Ed. They're under so much pressure. You see large number of cancellations in surgery as well. The college did a workforce census, uh which we published in January of 2023. And these figures are specific to Northern Ireland and the surgical workforce here. We saw that 91% of consultants in the age group, 55 to 64 are planning on retiring within the next four years. That means nine out of 10 senior consultants who often deliver high amount of very high end surgery are planning on going. 53% of uh are Northern Ireland surgical trainees which we've got to remember they are our surgeons off tomorrow. No training today. No surgeons tomorrow, uh reported a large lack of time in operating theaters, learning to do what they were going to do as a career. When we look at the amount of training that trainees have had over the last number of years, um We do look, we measure it by a thing called a log book. So it's the number of cases that you've done or you've participated in during COVID, they took a terrible hit after COVID they began to recover. We've seen that those are starting to go down yet again. And a lot of that is down to access in the NHS access within the private sector, but also a change in complexity of operations as they become more complex, the senior has to take over and do them. But it can also be the fact that the trainees as they are coming through are less experienced. And therefore in the last year or two of their training, when they're seen as being almost independent practitioners can't do that anymore. 62% of the people uh that responded to the consensus said, big problem as a surgeon was and behold, getting into an operating theater to do your job. Uh We've seen the 66% reported stress and burnout and around half of all surgeons in Northern Ireland, both trainees and consultants have given consideration to leaving the profession or sorry not leaving the profession, leaving Northern Ireland somewhere else. Uh, 48%. So again, half of them said that it was the system challenges that they faced on a daily basis, the coming to work and instead of going to an operating theater to do your job, it's trying to find beds, trying to find staff. Where is the patient going to go to after, how are they going to be managed when you do their operation? More importantly, which is the big thing that I'm very keen on is this whole wraparound idea of the fact that surgery is not in isolation. It is with other disciplines, but more importantly, it is affected by social care as well. When we have patients that can't go home, it prevents other patients getting into hospital to have operations and that's going back to the left shift social care we have seen, don't need to be doom and gloom about everything we have seen. Uh over the last number of years, the development of the surgical hopes, both the the day case centers and the elective overnight stay centers, which to date have delivered in excess of 33,000 procedures. And I think that is a great opportunity we've had and something that is a take home message to say of positivity. But we need to ramp up on those and we also need to start extending it out into other surgical specialist that can use them as well back to the same problem again. Uh, surgeons should be operating. One thing I always think about is if you went to Ryanair and you told Michael o'leary that his pilots are actually only flying 20% of their hours. I think there would be a big change. Surgeons in northern Ireland currently only deliver 20 to 30% of their job as an operating surgeon. Yes, we do do other things. We do clinics, ward rounds, managing ambulatory care. Vast majority of our work should be in an operating theater, delivering that life-changing lifesaving surgery. But we are unable to do that in the rest of the UK. That 20 to 30% is probably around at least 50%. How would you get my members and our members to engage? Well, it's whatever we're going to do, make it valuable, make it so that people actually want to be involved in it. And don't see this as just another sticking plaster over a failing health care service, make it that they say this is going to be better for my patients and this is going to be better for me to make it valuable, make it count. Listen to the clinicians. We've had a very powerful speech this morning from the e talking about knife crime. And as a public prosecutor, he didn't actually understand knife crime until he went out and spoke to the people committing knife crime. And then he understood we had Professor Bunga here last week and he said, not just in Northern Ireland, but it is a wider problem through Europe and North America as well. Is this disconnect between management and clinician being pulled in different directions? We need to break down those barriers? We need to remove those silos that professor can go. Spoke about again. It's all about doing the ground work. I was fortunate enough to be able to go to one of the Northern Trusts um uh public events this week, not as a, not as the college director, but as an individual living in the Northern Trust. And I thought it was superb, presented the problem presented how they looked at it and presented the solutions and said, when we look at it, this is the best solution. And I think that's about not selling it but engaging with the public to understand why you're actually doing something to change a service and that it's actually to the betterment people. Fortunately, in Northern Ireland, we have had too many situations of transformation by collapse as opposed to planned transformation, support the clinicians to deliver again back to talk to the people at the coalface because in general, most of them have the solutions and also be seen to be supporting clinicians in the public eye. But since I wrote that slide as well, I think there needs to be a change. Clinicians need to be seen to be supporting trust management and the politicians as well. Thank you. Niall and I think everyone would agree with three very, very comprehensive presentations. I think, certainly, even from my own perspective, it has really helped to give an even deeper insight into what to expect in terms of um the hospital reconfiguration framework and potentially what um is coming down the line, I suppose on reflection of what we've heard this morning. Um and as a local constituency MLA as well, and also someone who has worked in the health service. Um One of the things that always strikes me and Roisin and others have alluded to is that when we are trying to make change, it's often as a result of a service collapse rather than planned change. And we, we haven't really had an opportunity to, to do that here for various reasons, funding COVID, you know, you name it, we've dealt with it. Um However, I think this is a really good opportunity to, to deliver some really effective plan change. And for me, um the key to that is proper coro and proper co-sign. Um And as Niall has said there in, in his presentation, it's about meeting and talking to the people on the front line. Um But as well as that, I think we have to ensure that the public feel and have a meaningful role in that because I think Roisin said it in her presentation, when people feel that they're losing something they tend to resist. But if people feel a part of it. And I don't mean that as in a, you know, a textbook or a, you know, we'll just say, or a tick box exercise, but they feel a part of it, they understand what they're getting at the end of this. They understand what they get if they need care at any stage. And we talked about this at the Bingo conference last week. Um, then they're more willing to work and to, to shape that change and, and once they understand it, so I think this is a real opportunity to do that. Um, and, and, and really plan around that, however, the key issue um in delivering the plan change is workforce, workforce, workforce. Um, and I think that's something that concerns me and how we, er, square that circle week in week out a committee we're hearing of these issues. So I suppose maybe firstly for Peter, a question I'd like to ask is just, whilst the engagement, I mean, to me sounds like we are really delving into every aspect of our system and the public. Um, do we feel that we have the capacity to, to tackle the workforce challenges that we're currently facing, um, or will funding dictate what that's going to look like? I don't think there's any doubt that funding is going to dictate what that looks like going forward. Um You know, we need to, we need to train more nurses, more doctors, more A H PS, more, more staff generally, there's no doubt about that. Um But I think there is something about making the most of what we got as well in this, in this space. So for example, if there are sites, but there's no, no service at all. There's a question for me about what do we do about that? Do we try and, and, and, and, and share the, the, the, the resource we have a bit more thinly perhaps um to try and actually have some service on, on that site and that could be through tele mechanisms or whatever. But I think there are things we do with doing, making the most of what we got, but there's no doubt funding is going to be huge in terms of, of getting all the conditions that we need to, to, to deliver the service we want. No, thank you. Um Thank you for that Peter. And I suppose it comes in no surprise, but I think one of the things that has come out very clearly is that we can't wait on funding at this stage, we have to do what we can where we can. Um So I suppose then, I mean, maybe for yourself now and Roisin um at all levels of, of health and social care, be it clinician, be it our midwives, um be it our healthcare assistants. Um We're seeing those challenges right across the board. I mean, are there anything as part of this um framework that we could be looking at that would help in the here and now that you think would help to deliver what we're trying to do and that's a partnership there and just have to check. Can I go first now? Uh Well, uh what I would, what I would say in relation to that and obviously, you know, the workforce is such a priority. Um I mean, our health and social care service in northern Ireland is the largest employer um in Northern Ireland. So I think what we need to do uh with and for our staff is that this, you know, an example, this is just one piece of work is, you know, to set out a framework to say, well, you know, what, what exactly what, what would this, how the service has been configured that I can see a part for me to, to play my part and where do I fit into that? And, you know, it goes back to, to my point very much to say, you know, many, many of our staff are um you know, clinically or multiprofessional trained. So we need to set out a model that they can feel safe as a practitioner. They can feel that the services that they're going to be providing are going to be enough to help them support their continuing professional development and they're going to get the skills and the expertise and the exposure that they want and that they've trained for. Um and that we need to set out a model that again will keep people working in health and social care in Northern Ireland. Um So we, we look at very closely our ability to really attract the best people. You know, I think we have got a fantastic workforce in health and social care right across all of our services. Whenever you meet, lots of teams and departments, you know, everybody's here for exactly the same reason in this room, in, in every room or team that I meet with because they want to make a contribution, but they need to be supported, to be able to continue to make that contribution in a way that they feel is safe to do so. So for me, it is about keeping the good people that we've got attracting new people to come and work in health and social care in Northern Ireland. Yes, it is about more training, but it's also about making sure that we don't lose the good people that we have and then uh making sure that we are providing them with conditions in that they feel that they're able to practice uh very safely. And this particular piece of work, which is a hospital network, I think a network approach does create those opportunities um for staff to feel that they can keep up their, their clinical and their skills. So for me, that is really, really important and whenever things need to change um or and there's clear rationale we've heard um about the meeting a in Northern Trust. Uh you know, the voice of our clinical teams will have been front and center in relation to that, uh you know, alongside our management teams, uh you know, working together to really listen and engage with the public. So for me, that is really, really important and, you know, where we have been able to change services successfully and sustain them, you know, we need to, I think we need to celebrate that not to be embarrassed, not to be hiding behind. Uh You know, I'm, we're extremely proud of the models of care that we're delivering. For example, in the down Lagan Valley hospitals, I'm not going to hide behind. They're not good enough, they're absolutely excellent and they're the right services for the right population and our staff are looking at us as leaders to really come out front and center and state that. So again, that's really, really important. It's not about going back, it's about going forward in partnership. I agree entirely. You know, the workforce is the most important thing that that's what's going to deliver services. Um Clearly, we do have a very good and strong workforce. We've come through a major global disaster of COVID. The NHS provided and delivered on it and saved many, many lives. So it's just going from one problem to the next. Do we have enough doctors and nurses in the system? No, I don't, certainly don't think we do. We have multiple vacancies and that's what we've talked about. Can we do it? Yes, it will take money. But the other issue is, is, can we do it? We have a population in the United Kingdom of around 68 million people. We are reliant on international medical graduates and international nursing graduates from elsewhere to come to bolster our workforce. Are we seriously saying that in 68 million people, we can't find enough people to be doctors and nurses and train them in the United Kingdom. The other thing that we look at is and move on slightly from the surgical perspective because obviously a group that we work with very closely with is anesthetists. And at present in Northern Ireland, there's round about a 14% shortfall in the anesthetic workforce. We need them to put people to sleep for operations and so on and other services intensive care. The Royal College of Anesthetist is modeled that around over in excess of the next few years, over 30,000 procedures in Northern Ireland won't happen because there's no anesthetist. The applications to anesthesia this year were 4.73 to 1. And what I mean by that is to go into higher surgical training, to train to be anesthetist, you have to apply to get what's called a national training number. They work out the ratios of applicants to jobs available. So there were almost five times as many applicants as people appointed. So we have a problem. I can't tell you the, the figures in, in surgery because it actually goes over all the surgical disciplines. But in a discipline like mine, cardiothoracic, the application rates are around 45 to 1. So you 45 times more people want to do the job than you actually ever appoint to. And that can go down into other disciplines where it's about 6%. So there's no doubt the problem is workforce, the potential solutions are there. We need to grasp those and grasp that nettle. But unfortunately, yeah, probably a lot of that will come from restrictions on finance. Thank you. Uh Niall, I'm going to open it up to the floor. If anyone has any questions, I'd like to ask. Hi. Can you hear me? Ok. Yeah, this is I'm Ruth Barry. I'm from National influence and manager Alzheimer's society. Probably more comments than anything particularly on Ni's presentation. You talked about the impact of not having beds to be able to actually carry out surgical procedures. We've just released new research where we're trying to really influence um unchanged to be made because one of six beds is occupied by those someone with dementia. So it's really just more of a comment that it's certainly not a battle you're fighting alone, that others in the civic sector are using their own evidence to try and influence for not necessarily for better funding better structures, social care you talked about social care, social care is massive and we really need to start to look at shifting that funding towards social care. We do not have the right social care, the system will in effect collapse and it's almost at that point already. Um So I just want to really flag that point um that the, we're certainly trying to fight that corner as well, but just thank you for your presentations. Thank you. I'll take a couple more and then we'll maybe revert the panel if that's ok. Hello. Um Can I ask a question of Niall, please? Um You, you've made a comment about um surgeons in Northern Ireland only operating 20% of their job plans and we know that um but in the rest of the UK, it is up to um an average of 50%. Um Do we know how they've got there? And do we know why we're not there? Is it just purely access to funded theater lists or is it um not having enough of other multiprofessional staff to do other aspects of their job plan, like scoping like outpatients or is it a combination of both? And is there um an example of an area in the UK that we could link in with to hear more about how they or doing it better? Ok. Thank you. Uh I think the, that, that figure of 20 30% is loads and loads of factors, but I'll cover a couple of this, probably big ones, ones is Rotas, the more surgical departments you have, the more surgeons you need to cover Rotas. If so, if you're doing a one and six rota and you have two surgical departments, you need 12 surgeons. The problem then is your enumerators and your denominators. So that if you only have access, say to 12 lists a week and you've got six surgeons will each get two, you've got 12, they got one. I mean, it, it really is that simple, quite basic mathematics. Uh And it is, it's down to a lot of the estate, the infrastructure, the number of theaters that are available in, in certain hospitals, trusts where they, they're just at absolute capacity. Um Second part of your question, I think I haven't missed any out there of it was, you know, to be looked elsewhere. Yes. WW. We see this all around the rest of the UK. And a lot of that is probably down to the funding model whereby surgeons actually make money for organizations. Whereas we don't have that in northern Ireland. If you really want comparators to go to, to me always says G to get it right. First time you come in, look at a service and say, well, actually here's the best practice here where you, here is where you are and here is what you need to do to get yourself to that position there. One down the back and then I'll come to yourself. Go ahead. Um Good afternoon colleagues. My name is Michelle Tennyson. I'm Chief Allied Health Professionals Officer in the Department of Health. Um I'm really, really interested in how we partner with our public and bill long term trusting and sustainable relationships and Roisin. I was really taken by your point. Will our public understand the plans for hospital reconfiguration? I've been involved in some research recently looking at how we communicate with our public both through formal consultation and also working with our public in terms of self care, self management. And the evidence is very strong that health systems write and speak at school lever level and also university graduate level. But actually the reading age across the UK is around 8 to 10 years of age. So we engage well with those who have attained well academically, we engage well with those of our learning disabled population. But I just wanted your sense of that space in the middle where we, I think need to get better with plain English so that we can really have that transparent and open um engagement. Thank you, Michelle. I'm sorry, I have one there and then I'll come to you. Oh, hello. Uh I just wanted to ask a question maybe to Roisin about um sustaining the change that the network is speaking to. And I suppose it was in the context of where is developing the next generation of system leaders. Because if it's a leadership challenge to work in the more collaborative ways, then who's identifying what's required to sustain that change? And then how, how does that kind of workforce play into the actual system delivery? Thank you. Um I'll, I'll revert to Roisin and then I'll come to yourself. Ok. Uh No, thank you. And I do think it's important to pick up the plain English point um that Michelle made. So, um yes, I think Norman, that is also a very important point about, you know, sustaining change because, you know, sometimes I think we jump from, you know, one strategy to another strategy to another strategy. And we need to remember, you know, we're, we're continually evolving uh and learning. Um how best to work in partnership is key and how to agree that the best and safest models of healthcare delivery. So that's why I made the point, you know, back as far as 2007. So, you know, many of us, many of us have been involved in learning and in planning for that. Uh you know, and for example, you know, changes, for example, in relation to inpatient and separating out, you know, day surgery and overnight stay, that's not just new thought. Uh you know, that has been years in, in the planning. Uh and how does it stay in that going forward? You know, for me, it is about um having clinical credibility. So, you know, it doesn't need to be people who've been here for a long time. It's about really speaking with the one voice for me, that's so, so important, having a common shared understanding of what we feel are the most appropriate models of care delivery jointly together. And then about articulating that across the system and continuing that on. So whoever um are in these roles, it's very important to have a seamless transition in terms of the narrative and in terms of the approach to working in partnership and engagement. Um And I do think that there, there is a greater space available for the work that mayo and patient client council teams um are doing now and are very keen to be in that space, you know, about uh people, you know, first of all, taking more responsibility for their own health and wellbeing, but secondly, genuinely engaging and that's a two way responsibility. It's not about lobbying, it's about the public and community and local political representatives, truly engaging with health and social care. And then we, and when we get our model that we stick to it and that goes back to leadership and leading with conviction. So it's important not to be derailed. It's important to stick very true to listening to our clinical experts, our voice and our patient service users experience, but definitely not to be derailed. That's so so important because staff will judge us on that and on having the confidence that we have a system that they can continue to work in. So that's I think where we get to, you know, building supporting coaching, mentoring new leaders of the future, looking at whether that's through programs or whether it's through informal arrangements. But there are plenty of good people. Um I think who are very much involved and it's not about a top down approach. It is about that the bottom up approach, it's about our, our clinicians, our nursing teams who are working within the services. And remember many of our staff are also that live in the community and that's also important too as well that we support them to be able to um share out the message about what is appropriate. Thank you Roisin. Just to come back to Michelle's point. I think that's been well made Michelle because I know certainly with one of the most recent consultations that the department has released, we've heard the public saying that they couldn't understand it and things like that. So I think that is something particularly for something as important as this hospital Greek configuration. If we want to have that meaningful input from the broader public, then it's important. They understand exactly what what we're talking about and hopefully, maybe Peter, that's something that we could, you could take away to the department. I think we have time for just two more. So I have Charlie here at the front and, and one more. Um Yeah, thank you. This has been a very useful discussion I suppose just to bring it back to that reconfiguration piece because it's something that's very close to my, my heart. Um, because I'm very wet, wetted and I understand the problems and challenges. Clinicians, I understand the challenge of the public and what they want. And at the moment we, we're not marrying that probably appropriately together. And it is shameful, I suppose, for us to hear that we have highly trained clinicians who can only do 20% of what they do best. And that's not just surgery, it's also probably specialist medicine and all manner of things. And we get these highly trained individuals and we bring them back and we can't offer them the job that they want and they, and they live and go somewhere else where they can provide it. And that, that, that is most unfortunate for us. So the best ideas I suppose come with the management and the clinicians working well. All the best ideas that I've seen have come from front line clinicians who've told us how to do something. And if they tell us something, which we don't think is good, we'll know it also because we can read the evidence and literature the same way as they can. But, um, so it's having that Northern Trust consultation, which has been highlighted, the clinicians absolutely key to that management. Absolutely key. And these things are not easy to do because people don't trust people when they're going to do it. But clinicians know the standards, we cannot ask them to work and below the standards they're trained to do knowing that they can do better. And the other thing I think is we need to be brave and, and I'm, I'm talking to you not to you personally, Liz. But, but broadly, as the broader context of politicians, they know this reconfiguration has to take place and they talk about reconfiguration but no one wants to get into that space. Not no one, but many don't want to get into it. Um And they have to, if they recognize that something is good, they've got, they've got to lead that charge with us. They got to be there with us. Thank you. And um, I think my point follows on a wee bit from Charlie's and it's something I've mentioned when we were at the surgical network is I think we have to be really mindful of our workforce back to that. Um, because their generation shift, um and people don't want the same things as what we wanted when we were training as a nurse by trade. Um, and we have to be really mindful and I think that's probably sometimes why we're only get 20% out of surgery because they don't often want to be working to that same level in a way. But we have to be really mindful of how we manage our workforce because people don't want the same things they want better work-life balance. You know, we have to manage our, on call very carefully. We look after the wellbeing of our workforce and it's a different mindset now and that's a generational thing. And you see that across all, not just doctors, nurses, a H PS, everybody, they want different things and we have to be attuned to that. Otherwise we'll not get what we need out of our workforce. Yeah. No, absolutely. Does anyone want to come back on any of that or enough? No, I think, I mean, just to, to, to, to con grade in those, those points, they're, they're very, very pertinent. We've been hearing it in committee, as I said earlier. Um, all the time, I think collectively as in the assembly, we know the change has to happen. I suppose it goes back to my earlier point in making sure we're bringing people with us that they, they are a genuine part of that because if we don't, we're into another mess and we've seen that, um over the, over the last couple of decades. Um I suppose just to finish, I think this has been a very useful discussion. I'm very grateful to the panel um for, for their input, but also to yourselves. Um And, and Ruth's point at the very start is, is, is crucial to all of this as well. And I see colleagues from the ambulance service as well whilst we're talking about hospital reconfiguration. There's very much those external outside of the hospital factors that have to be a significant part of any change. Social care is part of that as is our ambulance um network and as a committee, we've been working with NI A as well in terms of the real challenges that they are facing, in terms of people being um stuck in ambulances outside Ed. So we have to ensure that that is all a part of this um process because if we can get the the community element right, then we will take the pressure off and people will get that work life balance. So it all sounds great and very rosy in the garden. We have huge challenges ahead, but I think people are up for it. So thank you all. And I hope everyone find that a useful discussion. Enjoy the rest of the conference. No, could I could I just remind everyone during lunch to try and visit the Camper Van of Dreams? It's an experience, a very pleasant one. After all of this talk of reconfiguration, Camper Van of Dreams the best.