COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Evidence Session with the
Minister of Health, Social Services and Public Safety
5 February 2009
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mr John McCallister
Ms Sue Ramsey
Witnesses:
Minister of Health, Social Services and Public Safety
Mr Martin Bradley )
Mr Sean Donaghy )
Dr Michael McBride ) Department of Health, Social Services and Public Safety
Dr Miriam McCarthy )
Mrs Maureen McCartney )
Dr Norman Morrow )
The Chairperson (Mrs I Robinson):
I welcome the Minister of Health, Social Services and Public Safety, Mr Michael McGimpsey; Dr Michael McBride, the Chief Medical Officer; Mr Martin Bradley, the Chief Nursing Officer; Dr Miriam McCarthy, deputy secretary of the healthcare policy group; Dr Norman Morrow, the Chief Pharmaceutical Officer for Northern Ireland; departmental deputy secretary Mr Sean Donaghy; and Mrs Maureen McCartney from the Department’s mental health unit.
Mr Gallagher:
I refer to the Hansard report of the Committee meeting of 9 October 2008 with the Minister and departmental officials. It was stressed at that meeting that there would be no compulsory redundancies in the Health Service. After that, changes were made to service delivery in Tyrone County Hospital in Omagh and Erne Hospital in Enniskillen. There is a contradiction at play here; the fact is that some nurses in Erne Hospital, albeit nurses who are on temporary contracts of two and three years’ duration, have now been told that those contracts will not be renewed.
Perhaps Mr Martin Bradley could explain the situation. The people on the receiving end cannot see how that stacks up with the statement that there would be no compulsory redundancies. Those nurses are on short-term contracts, but people with three years’ service are being told that they are no longer wanted. That flies in the face of what was said during the meeting of 9 October 2008. Will someone explain that?
The Minister of Health, Social Services and Public Safety (Mr McGimpsey):
I am happy to do that, and I am happy to repeat that the target is to have no compulsory redundancies. My Department is currently underfunded by some £300 million. That figure will rise to £600 million by the end of the period — that is, vis-à-vis provision in the National Health Service (NHS) in England. That is our starting point.
In addition, I have to find £700 million in efficiency savings over three years. We have negotiated and ensured that all the moneys that come out of the service will go back in, but the process causes a degree of upset. At the outset, I said that our target would be to have no compulsory redundancies, and that remains the case. There are several ways in which I can approach the matter, and members can see the proposals as they come through.
The trusts must bear some of the burden of the efficiencies in the process. We have already accrued a number of efficiencies up to this point, not least because of the review of public administration (RPA) and the reduction in the number of organisations: 19 health trusts have been reduced to six trusts, and four health boards to one board, and so on.
For a variety of reasons, we lose 750 nurses per annum through natural wastage, which means that we would lose 2,250 nurses over the three-year period. We plan to reduce the number of nursing posts by 750, so, rather than recruit 750 nurses each year, we will recruit 500; that is the net effect of the proposals. That remains the situation; it will not affect nursing training whatsoever. We have no plans to reduce the number of, or bursariesfor, nurses.
I am not familiar with the specific issues that the member raised about Erne Hospital in Enniskillen. I can certainly enquire and write to the member about that matter. Overall, the RPA will bring a reduction of 1,700 administrative posts, saving £53 million a year. We are on target to deliver that, and we will deliver it. That means a 25% reduction in administrative back-office staff — in other words, a reduction of one in four; we will also reduce other grades. However, to make efficiency savings and find the money in the Health Service, the burden will fall on either staff or buildings and structures. At the outset, I took the view that it would be wrong for it to fall on staff, and I have gone a long way to ensure that staff will largely be immune to the effect of those proposals, and that remains my absolute target. As I said, the target is to have no compulsory redundancies, and, at this point, I do not envisage compulsory redundancies.
Mr Easton:
I accept that there will be no redundancies, but my main concerns are that 700 nursing posts will go and that there is a possibility that residential homes will close. Minister, will you give me definitions of cuts and efficiency savings so that I can clearly understand the difference between them — I am confused by the two terms.
I accept that there will be no redundancies, but if 700 nursing positions are being done away with, agency staff will have to be employed to make up the shortfall, which will double the costs. That does not make sense. If those 700 nurses were still in post, productivity could be increased.
Minister, you gave a verbal assurance that there will be no cuts to front-line services, but I think that the proposal amounts to cuts to such services as well as to services in residential homes. Will you assure me that any resident who has to leave a residential home that a trust is closing will not be thrown out on the streets and that there will be adequate nursing cover to meet that resident’s needs?
The Minister of Health, Social Services and Public Safety:
You asked about the difference between efficiencies and cuts. The Health Service intends to conduct efficiencies over a period of time. Although some proposals are emerging faster than I would have liked them to, I am stuck with this time frame, and I have no choice in the matter. However, we will continue in the direction in which we are travelling, which involves the Bamford Review, early intervention, early treatment and less reliance on institutions and acute care. Furthermore, we will intervene earlier to keep people out of mental-health hospitals, and we will aim to have fewer long-term patients in learning-disability hospitals. We will aim to have no children with a learning-disability hospital as a permanent address by 2012, and so on. The Committee will be familiar with those matters.
After acute care, care of elderly people accounts for the largest portion of my budget — over £600 million per annum and growing. As far as the policy direction is concerned, the aim is to get support and care to elderly people in their own homes in order to promote independent living. That means less reliance on residential homes and more on domiciliary care packages and support at home. That does not mean that there will no residential places. The reduction in numbers is a small part of the total provision; only 25% of residential places are provided through statutory homes, and the remainder are independent, and trusts buy places there.
We also have the entire nursing-home network. It is a question of how we manage the care of the elderly population, who do better in their own homes, living independently and surrounded by familiar objects and people. They are happier and live longer, provided they get the support that they need. If they reach a point at which they cannot manage independent living with that support, they need another type of provision — for example, nursing-home care.
That is the direction in which we are travelling and the reason that the homes that are affected appear in the trusts’ proposals. They are by no means the majority of homes, nor the majority of places, in each trust area. Independent living is the strategic direction in which the Health Service intends to travel. Several proposals have, therefore, been made. Consultations have taken place, although nothing has been decided as yet. It is not a done deal; all of it must be brought to me for a decision. If the outcome is contentious, I will have to make a decision: if it is not contentious, there will be no decision to make.
Several other efficiencies have emerged that members wish to discuss; for example, plans for pharmacy savings and administration, which I have discussed a little. The trusts are also considering their provision. As far as nursing posts are concerned, it is a matter of delivering the service with fewer posts; that is the reality. There are examples of how medicine is progressing: there is less reliance on long periods of bed-stay in hospital; stays will more than likely be shorter. I will ask Martin Bradley, the Chief Nursing Officer, to address the matter, which Tom has also raised.
Mr Martin Bradley (Chief Nursing Officer):
All that I want to add to the Minister’s comments is that those significant changes are being driven by how we want to reform the service in order to deliver more care in the community, more palliative care and also to try to manage the workforce.
We have been working on a range of those issues. First, we have had negotiations with the independent sector to ensure that it provides viable careers for local nurses. The sector has agreed to downturn the recruitment of nurses from overseas because there are enough nurses in Northern Ireland to meet its needs as well as those of the public sector. In addition, we have not downturned the number of nurses in training. For example, more midwives and mental-health nurses are being trained because there are pressures in those areas of the system. We continue to manage those pressures as we progress through the current period of significant change.
Mr Easton:
The Health Service is wasting approximately £8 million a year as a result of nursing attrition rates. If that money were sorted out, it could go toward keeping the 700 nursing jobs. I believe that the trusts are not considering such matters.
Will the Minister guarantee that, if Committee members come up with other ideas and proposals that are not being considered, he will meet us to discuss those proposals? I believe that the trusts are deliberately not considering some matters that would allow us to save jobs and keep residential homes and nursing posts. Will the Minister guarantee that he will meet Committee members to discuss those proposals when we get them drawn up?
The Minister of Health, Social Services and Public Safety:
I am happy to do that. I keep saying that, if the Committee has better ideas, I am interested in them, and I am listening. I have not yet had any ideas. As far as the attrition rate for nurses is concerned, there are 18,000 nurses, and we lose between 700 and 750 a year, which is a small percentage. Of the people leaving nursing, some will be retiring, some will be moving on to become midwives, and some will be taking career breaks or making career improvements.
Therefore, it is not simply a matter of losing staff. One cannot simply take 750 nurses and have a multiplier and say that we can stop that — it is a natural process. It costs money to train nurses, who then go on to build up experience, so of course we will want to hold on to them. The trusts certainly see the value of doing that.
Mr Martin Bradley:
We have had focused meetings with our two universities to remind them of their responsibilities for addressing the attrition rate. There is an attrition rate across the United Kingdom for nurses at university. We must get that rate down from its current position. However, that affects all training organisations, not only those in Northern Ireland. Mr Easton is right: if we reduce the attrition rate, we will save money, and that will help the situation.
Ms S Ramsey:
I welcome the Minister and his big team here today.
The Minister of Health, Social Services and Public Safety:
There are 11 topics so someone can handle each one.
Ms S Ramsey:
Minister, I appreciate that your Department is underfunded, and it has been for years. However, we are being told that almost half your efficiency savings will come through improvements in productivity and other such changes, which no one could disagree with. We have all seen wastage in the Health Service for years.
My concern is where the rest of the savings will be made. I want to ask you a simple question. When an outcome becomes contentious, you must make a decision on that issue. When a trust submits a paper to you that states that it will achieve its 3% efficiency savings by closing down maternity services in one of its hospitals, will you explain how you, I or anyone else can tell the public that that is not a cut in front-line services?
The Minister of Health, Social Services and Public Safety:
That is a proposal. You can call it a cut if and when it happens, but you will have to wait for the decision. I still have to crunch all those matters. I presume that you are talking about the proposal for Lagan Valley Hospital, which is not to close down maternity services but to have a midwife-led maternity service. I will consider that proposal in conjunction with issues such as deliverability and safety.
The proposal is based on the service that is required; the number of babies being born at Lagan Valley Hospital is down to approximately 1,100 per annum. Therefore, it is very difficult to maintain a safe service according to the standards set by the Royal College of Midwives. I will ask the Chief Nursing Officer to take you through that because it is an important point. Obviously, we will all want to talk about these issues in due course, when the consultations are finished and when the trust comes to its conclusions.
However, let me put the matter into context. As far as the cash available to my Department is concerned, the moneys are absolutely essential. If I do not get £700 million, we do not get the new service developments that I plan and that we are all, by and large, well aware of.
Ms S Ramsey:
I appreciate that, and I appreciate that you are under pressure. However, we are being told that a service will cease because a trust has to achieve 3% efficiency savings. How can I tell people that that is not a cut in services?
The Chairperson:
The figures for births in hospitals show that the Mater Hospital had fewer deliveries than Lagan Valley Hospital. Although the Mater Hospital is in a cluster with Belfast City Hospital and the Royal Victoria Hospital, Lisburn is a city.
Ms S Ramsey:
That is disputable.
The Chairperson:
I know that that is a different argument but, if you are saying that it is difficult to provide maternity services in hospitals where the number of births fall below a certain level, why has the Mater Hospital not been examined, because it has fewer births than Lagan Valley Hospital?
The Minister of Health, Social Services and Public Safety:
As set out in ‘Developing Better Services: Modernising Hospitals and Reforming Structures’, the Mater Hospital will eventually receive local hospital status. The issue is the number of obstetricians in the Health Service and how we spread them over many sites. The Royal College of Midwives has particular standards, and we have rotas to hit and anaesthetists to provide. That is driving the current situation.
As I said, many service changes and efficiencies may be coming through slightly faster than expected. However, that is not necessarily the reason for the proposals for changes to maternity services at Lagan Valley Hospital; those changes are being driven by patient safety, as are changes at other sites. The Chief Medical Officer and the Chief Nursing Officer will explain that, because the South Eastern Health and Social Care Trust proposal is for midwife-led services, not a withdrawal of maternity services. I still have to examine that proposal, and my Department is conducting a review of maternity services in Belfast, such as the numbers of midwives and nurses, to see how the service stands. The issue in Lagan Valley Hospital is obstetrics.
Mr Martin Bradley:
The Eastern Board undertook a review of maternity services in greater Belfast. The Minister has that review’s report, which needs to be considered. The big issue is whether Lagan Valley Hospital will be able to sustain a midwifery-led unit safely, which requires serious consideration. The issues that affect Lagan Valley Hospital are not being driven by the efficiencies but by concerns about patient safety, particularly the ability to attract enough consultant obstetricians and maintain their employment. If the proposed changes are implemented, they will offer up efficiencies, but that is not driving the decision.
Ms S Ramsey:
I used Lagan Valley Hospital only as an example; it seems that there will be a cut in service.
Mr Martin Bradley:
The proposals may be perceived that way, but they are another way of redesigning the service. If there were a midwifery-led service at Lagan Valley Hospital — although I am not saying that there will be — it would be a step change for midwife-led care in Northern Ireland.
The Chairperson:
Other Committee members may want to ask questions on that issue, but time is not on our side. The next subject for discussion is Tyrone County Hospital in Omagh.
Dr Deeny:
I thank the Minister and the departmental team for coming before the Committee. The issue of Tyrone County Hospital is contentious in the west. As I said last week and on many occasions, the problem is not just a two-town one, and it never was. There is also a problem east of Omagh where I live; one hospital has been closed and another is set for closure.
Three hospitals that are adjacent to one another are losing their acute status; that was decided by separate boards. After 1 April, my family and I will not be able to reach any hospital with acute services within an hour — Altnagelvin Area Hospital, Erne Hospital or Craigavon Area Hospital. That problem is exacerbated at this time of year, because the journey will take closer to two hours. Why can the people who live in the centre of the Province not have a hospital with basic acute services to stabilise people? Such services are provided at the hospital in my hometown — Downpatrick — which I am delighted about, because it serves a large population, which increases in the summer when people are on holiday in Newcastle. Downpatrick is half an hour from Belfast, but my patients are over an hour away from a hospital with acute services.
Why can we not have a similar facility with patient-medicine, coronary-care, consultant-run, A&E and midwifery-led units in the centre of Northern Ireland?
Indeed, the problem is going to escalate if, as expected, the decision is taken to shut Mid-Ulster Hospital in Magherafelt. For those of us who work in front-line healthcare in a huge area around the centre of Northern Ireland, a safety issue arises, particularly in the wintertime.
The Minister of Health, Social Services and Public Safety:
Thank you for that, Kieran. The golden-hour rule is that patients should be within one hour of an acute hospital by blue-lamp ambulance. I am quite sure that people who live in Omagh are within one hour of Altnagelvin Area Hospital, Erne Hospital or Craigavon Area Hospital.
We have discussed the hospital model on a number of occasions. As Committee members know, we are following the Developing Better Services (DBS) model, which sets out the layout of acute hospitals and local hospitals. There are six major acute hospitals in Northern Ireland: Royal Victoria Hospital; Altnagelvin Area Hospital; Belfast City Hospital; Ulster Hospital; Antrim Area Hospital; and Craigavon Area Hospital. There are three smaller acute hospitals: Erne Hospital; Daisy Hill Hospital; and Causeway Hospital. There are seven local enhanced hospitals, which include Tyrone County Hospital, Mid-Ulster Hospital, Whiteabbey Hospital, Lagan Valley Hospital, Downe Hospital and South Tyrone Hospital.
I am following that model for a very substantial investment in the area. There is an acute hospital at Enniskillen, which is within one hour of Omagh, and we are committed to expending around £260 million on it. We also have a development plan of around £190 million to produce a local enhanced hospital, a mental-health facility and an urgent-care and treatment centre in Omagh. That hospital will take care of between 70% and 80% of all the town’s needs. However, it is a fact that people in that area will have to travel for acute services, but they are within one hour of Altnagelvin, Erne or Craigavon by blue-lamp ambulance.
I would love to be able me to keep acute hospitals in every town, because that would keep everyone happy. However, I simply do not have the revenue that is required to do that. Kieran, you know as well, or better, than I do the way in which medicine is going. To an extent, specialism is driving provision, and technological advances are changing the service of modern medicine for the better. That requires higher concentration on larger sites, rather than units being spread over many small sites.
In addition to the acute sector, there will be the local-hospital sector. Local hospitals will provide between 70% and 80% of all the hospital needs for an area, and the acute hospitals are there to make up the rest. There are services that will not be able to be provided in Enniskillen; for example, patients will have to travel to the Royal Victoria Hospital, which houses the regional trauma centre. In certain conditions and circumstances, patients will need to travel.
I shall bring in the Chief Medical Officer in a minute. I do not make those decisions simply because they are in the DBS plan but based on the advice that I get from professionals — not civil servants, but professionals. Those professionals provide advice on the basis of planning discussions that they have had with their clinicians and senior colleagues in the service.
Dr Deeny:
We are happy with what has been planned for Downpatrick. However, your reference to Downe Hospital in Downpatrick, which is my native town, as being a local enhanced hospital suggests that acute services will be lost there, too. You cannot have two types of local enhanced hospitals, only one of which has acute medicine, coronary care and so on. Will Downpatrick therefore become a local hospital along the lines of Tyrone County Hospital in Omagh?
The Minister of Health, Social Services and Public Safety:
I realise that the Committee is pushed for time. One size will not fit all. Tyrone County Hospital, for example, is not exactly the same as every other hospital, and it does not adhere exactly to the model set out in the Delivering Better Services document. Several additional services that are over and above what is included in the DBS model will be introduced at Tyrone County Hospital. As I said, the Chief Medical Officer will try to explain the situation to you.
Dr Michael McBride (Chief Medical Officer):
A number of recurring themes appear throughout today’s discussions. Those include the issue of maternity services, the reconfiguration of services and, as Sue Ramsey and Alex Easton raised in their questions, the differences between cuts and efficiencies.
Since 2003, the DBS document has been the blueprint for the future of acute hospital services and that network of care. We are conscious of the fact — indeed, we are acutely aware — that many in the local community will perceive the Western Health and Social Care Trust’s announcement about Tyrone County Hospital as a blow.
In April 2006, the decision was taken to have stand-alone acute medical services in Tyrone County Hospital. In April 2007, the Western Trust conducted a review that indicated that there were significant issues around the sustainability of such services. That has been the situation for some time. Throughout this process, the Minister has made it clear that he will sustain acute services at the hospital for as long as it is safe to do so.
Like other colleagues, the Chief Nursing Officer and I have been in regular contact with the trust to discuss the pressures on, and sustainability of, services. It became clear that it was simply not tenable to sustain those services beyond early March 2009. Indeed, senior clinicians from Tyrone County Hospital, as well as those from the Erne and Altnagelvin hospitals, made that point to us in their correspondence and during our visits to the trust.
Medicine has moved on; it is more challenging technically. In the past, we were not able to do what we can do nowadays. If we want to secure the best outcomes for patients, it is not possible to spread acute services over two sites in the south-west. That has always been clear. Skilled professionals cannot maintain their skills if there is a low volume of activity on a site. It is not possible to attract and recruit expert staff to hospitals sites at which there this is a small volume of activity, nor is it possible to retain them.
Medicine has changed for the better, and, in the longer term, it will deliver better outcomes for patients. We must change the model of service delivery in order to ensure that we secure those outcomes. The model of care must change whether it be for acute medicine, surgery, or obstetrics and genecology.
The Minister of Health, Social Services and Public Safety:
Dr McCarthy was involved in producing the DBS document, so perhaps she can speak about acute services in Downpatrick. Dr Deeny raised the issue of Downpatrick, and it is important that we get the opportunity to reply.
Dr Miriam McCarthy (Department of Health, Social Services and Public Safety):
As the Minister said, one size will not fit all. At the time of the original DBS consultation and decision, there was much discussion around the way in which services should be developed, based, primarily, on changes to medical and nursing training and, as the Chief Medical Officer said, on more specialisation’s requiring a substantial population to serve any hospital.
That has progressed quite significantly since 2002-03. Once of the key differences between Tyrone County Hospital and Downe Hospital is the population base. As you are well aware, in the Eastern Board area, the population is relatively dense, while in the south-west, the population, in many areas, is relatively small in size and geographically isolated.
At that time, the decision was taken — supported by significant data — that the population in the south-west was sufficient to support only one acute hospital. That is quite different from the situation in the eastern area.
Therefore, a certain size of population is needed to support the skills, expertise and activity around it. There are different dynamics in the south-west than there are in the east of the Province. Key parameters — responsive services, safe services and access — must be met. There is a bit of flexibility in how those parameters need to be, and must be, delivered in various parts of the Province. As you will appreciate, that is not an easy comparison to make.
Mr Buchanan:
I spoke with the Minister on the issue, and I met with the trust. There is grave concern in Omagh over the proposed closure of the medical wards at the end of this month. I cannot believe what I am hearing: people who live in rural parts of the country are, more or less, being discriminated against on the grounds of geographical location, as though they do not deserve the services that a local enhanced hospital provides. The same criteria of services should be provided for all local enhanced hospitals across Northern Ireland; however, that does not seem to be the case.
I want clarity on the removal of the medical wards at Tyrone County Hospital. I tabled a question for written answer to the Minister on 29 January 2008 to ask him to confirm:
“whether or not the medical wards at Tyrone County Hospital will remain open until the new hospital is built.”
On 12 February 2008, I received the following reply from the Minister:
“I can confirm that we plan to retain the medical wards at Tyrone County Hospital until the enhanced local hospital in Omagh is built.”
A move away from that answer appears to have been made. I am concerned that not only is there a black hole in County Tyrone, but, just last week, I heard on the radio, that, owing to a difficulty in recruiting staff, there is a possibility that the maternity unit at Craigavon Area Hospital could close. As Kieran Deeny will know, many women from County Tyrone give birth in Craigavon Area Hospital. That may be mere speculation, but the information came from the Royal College of Midwives, which states that if that unit cannot attract new staff or provide for the different methods by which women want to give birth, it could close. That would create another serious knock-on effect for the people in my constituency. Perhaps the Minister can comment on those issues.
The Minister of Health, Social Services and Public Safety:
You raised a number of issues, and I will deal with them one by one. It was decided that the medical wards at Tyrone County Hospital would stay open, and that remains the plan. The difference is that those wards are not admitting the acutely ill; however, they are still medical wards and are remaining open.
The overriding principle in Tyrone County Hospital, as it is for Downe Hospital, is to provide the same standard of care. Omagh is within blue-lamp distance of three acute hospitals. I have never discriminated against rural areas, so I refute that suggestion completely.
Mr Buchanan:
I did not say that.
The Minister of Health, Social Services and Public Safety:
Yes, you did, and you can check Hansard. However, we will not get into that now.
The same standard of care applies equally across Northern Ireland. That is our objective and that is what we are working to achieve. Services are not delivered by county but by trust area. Omagh is in the Western Trust area, which has two acute hospitals — Altnagelvin Area Hospital and Erne Hospital — a local hospital at Omagh, and a major investment is about to be made into two of those. I have had discussions, which you attended, Mr Buchanan, with Omagh District Council, and we have come to an agreement on the way forward, and you were a party to that agreement. The agreement is based on the correspondence that I received and on consultation with Omagh council. You are well aware of that correspondence, and it is disingenuous to say that you are not.
For example, on 23 October, I wrote to the council’s chief executive, Mr McSorley — I presume that he sends you the relevant correspondence — to make it clear that the population of the south-west can sustain only one acute hospital. It is simply not possible to provide the quality of care that people need if services are split across two acute sites. The letter mentioned the wide range of services provided by the hospital, and explained that I cannot commit to providing services that do not meet essential quality and safety standards. That has been made quite clear repeatedly.
The letter stated:
“Given that the new hospital will not be completed until 2012 at the earliest, it is becoming increasingly clear that the transition towards the final DBS model will be required well in advance of the construction of the new building. Indeed, I am very aware of the current situation at Tyrone County, and particularly the difficulties in sustaining the acute in-patient medical services, and the 24/7 medical cover for the urgent care and treatment centre, both of which need to be addressed if we are to provide safe care to the population.”
The urgent-care and treatment centre at Tyrone County Hospital will be doctor-led and nurse-delivered, as you are aware. The acute service will be provided at Erne Hospital. The Western Trust told Omagh District Council 18 months ago that this was what it was going to do within 18 months. If you did not know that, you were not paying proper attention.
Mr Buchanan:
With all due respect, we are not disputing anything concerning the buildings or the investment that has been made. Indeed, we welcome that. We welcome the investment that has been made into the west and its two new hospitals. We are concerned, however, about the services that the hospitals will offer. It is only but proper that the political representatives who hear those concerns — not only from the public but from staff in the hospitals — bring them before you as the Minister, and before the professionals who are sitting beside you, in order that you are all made well aware of the concerns and can act on them.
Another issue concerns recruitment. We are always hearing how we cannot recruit staff. Those wards closed because we could not get the staff. My concern is that the Department and the trusts right across Northern Ireland are far too slow to act whenever vacancies or potential vacancies arise.
A motion on Health Service vacancies was debated in the Assembly on 1 December 2008. We were assured then that there was no difficulty in nurses and doctors taking up positions, yet we are now being told that wards have been closed because staff could not be recruited. We are hearing about the possible closure of Craigavon Area Hospital’s maternity unit as well, because that hospital cannot recruit staff. Will the Minister comment on the issue of Craigavon Area Hospital?
The Minister of Health, Social Services and Public Safety:
Certainly, we can discuss Craigavon Area Hospital. The report that you have heard — that its maternity unit is to close — is a complete nonsense. We have refuted that suggestion, and Martin Bradley has been on television and radio to refute it. I know that you did not happen to hear or notice that.
I met with Omagh District Council. I have in my hand a photograph of me with its councillors, which was taken in either November or December 2008. I went through the Developing Better Services document with them, and sitting in the middle, with the biggest smile of all, is Tom Buchanan. He cannot say that he does not know the situation, because it was explained to him. The Chief Medical Officer and the Chief Nursing Officer were present, and they also explained it to him. The picture shows a very content Tom Buchanan. To try to invent concerns now, when he did not have them previously, or appeared to think that they had been addressed, is disingenuous.
Mr Buchanan:
With due respect, I must come back on that. We were there that day to welcome investment in the new hospital in Omagh, and the new hospital that had already been provided for in Enniskillen. That is why we were there. We were content with the new investment that was being made in the hospital, but we raised our concerns about service delivery at that same meeting.
The Chairperson:
It is one of those subject areas —
The Minister of Health, Social Services and Public Safety:
It is important that I make the point that it was not simply about that. I went through exactly what was happening, and all the councillors heard. I spoke about Developing Better Services and about the urgent-care and treatment centre. All that was prefaced by a series of correspondence. When Tom Buchanan left that meeting, I found myself very pleased with his very mature and pragmatic response to what had been said. It is important that the Chief Medical Officer be allowed to refute what Tom Buchanan said about Craigavon Area Hospital.
The Chairperson:
We have spent 40 minutes now on two issues, and it does not look like I will get through the tight agenda that I had hoped to get through. If issues are not dealt with today, we will put them in writing to the Minister, and I hope that the Committee will get responses fairly quickly, instead of having to wait since last November for some answers.
The Minister of Health, Social Services and Public Safety:
I am not clear about what you mean by “last November”.
The Chairperson:
I have not had a response to the letter that the Committee sent you in November. We are still waiting for a response, but I will deal with that later.
Mr Martin Bradley:
I appreciate Mr Buchanan’s concerns, because I am sure that many women around Northern Ireland also had those concerns, based on the media reports. Craigavon Area Hospital’s maternity unit is one of the most successful maternity units in Northern Ireland. It is well run, it is a safe unit, and we have every confidence in it. There is absolutely no intention that it should close.
It is, however, a very busy unit. Since September 2008, the Southern Health and Social Care Trust has been able to recruit 12 extra midwives to work at that unit. We have funded Queen’s University to recruit an extra 12 midwifery students specifically for that unit. The Minister has announced investment of £3·5 million in the unit to increase its capacity. I know that it can be seen as a negative issue, but the unit has been enabled by the trust to recruit bank and agency staff as required. The overall priority is the safety of mothers and children, and that unit is stepping up to the mark and achieving that.
Mr Buchanan:
I welcome that reassurance.
The Chairperson:
I am aware that this is an emotive issue, so I will allow some latitude with time.
Mr Gallagher:
As you know, I support the Developing Better Services model, and I want the new hospitals to be delivered as quickly as possible. We keep coming back to the concerns about the scattered rural population, to which Dr McCarthy referred. Has the Department considered the possibility of attracting investment from the EU in, for example, a mobile intensive-care unit to help with the delivery of care in rural areas? The delivery of such a service would give reassurance across the entire west, particularly to the more isolated areas. Is the Department considering the possibilities of drawing down funding for innovations from EU sources?
The Minister of Health, Social Services and Public Safety:
I shall ask Dr McCarthy to respond.
Dr M McCarthy:
In a general sense, the EU supports many health developments. INTERREG IV money has made a number of services possible, particularly in the border areas. A variety of work and initiatives is being carried out. Those cover a large scope, including primary care and mental health.
The issue of a mobile intensive-care unit has been raised with us, and informal proposals have been made through conversations. There are critical-care units in all major hospitals, and there is an effective critical-care transport service, which involves a team’s going out from one hospital to pick up a patient from another hospital, bringing them back and moving them around the system. That is a very important service. That is also supported by the Ambulance Service, as appropriate. In the western area in particular, significant investment has been made in the Ambulance Service to improve response times and provide a better service for what we recognise is a geographically dispersed area.
We are tackling the delivery of care in rural areas on several fronts, so it is difficult to see what added value a mobile intensive-care unit would bring. However, when considering future developments, we are always mindful of developing the service in the best way to meet needs. A mobile intensive-care unit is not in our programme for immediate development, but other key services, particularly in the Ambulance Service, will make a real difference to patients.
Mr Gardiner:
People have spoken about Craigavon Area Hospital, which is in my constituency of Upper Bann. I am also concerned about the — sometimes unfair — bad publicity that that hospital has received. At a recent Committee meeting, a representative from the Royal College of Midwives said that Craigavon Area Hospital was the one hospital to which an additional six midwives were recruited, while the other hospitals in Northern Ireland were unable to recruit midwives. The Royal College of Midwives’ representative said that Craigavon Area Hospital appealed to people to come out of retirement to help out with the workload in midwifery.
It is unfortunate that that hospital has received bad publicity. I have spoken to the hospital’s chief executive. There was a hiccup in the system, but I do not know exactly what it was. Are you aware of it, Minister, and is there anything positive that you can do about it? Thankfully, no babies mothers’ or babies’ lives were lost as a result
The Minister of Health, Social Services and Public Safety:
Craigavon Area Hospital ’s maternity unit, which I have visited more than once, is very good. I am aware of the pressure that its staff are under. Calculations that the Department did a few years ago about birth rates were very conservative, and they have since been exceeded.
The maternity unit is operating at a higher than anticipated level. Therefore, a number of measures has been implemented. We have recruited 12, rather than six, new midwives for Craigavon Area Hospital. We are also currently training 12 qualified nurses in Queen’s University and Belfast City Hospital to become midwives, specifically for Craigavon Area Hospital. Capital investment is being used to expand the treatment delivery rooms, and there have been other investments. I am well aware of the pressures on Craigavon Area Hospital.
I must say that Craigavon Area Hospital’s maternity unit is not at saturation point. It is still operating at below its capacity. However, I am concerned because the trend has been steadily upwards. A projection suggests that, in a few years’ time, the service will have difficulty providing maternity cover. Therefore, I am ensuring that the service is reinforced here and now. That is what we are about.
As Martin said, there is absolutely no question of Craigavon Area Hospital maternity unit’s closing its doors. A comment to that effect is very, very unfortunate and does no good at all for expectant mothers who intend to give birth at the hospital. A midwife who was interviewed said that two mothers had had to move to another hospital. I know that one of them went to the Mater Hospital because it has intensive-care beds. I have questioned why two expectant mothers moved to another hospital from Craigavon Area Hospital, but I understand that such transfers are not unusual.
Mr Martin Bradley:
The only other point that I will add is that Northern Ireland’s maternity services must be viewed in their entirety. Patients have also been moved in the opposite direction — to Craigavon Area Hospital from other hospitals — because of the facilities that are offered there, and depending on where resources are available at the time.
Mr Gardiner:
I thank the Minister for his assurance. I am confident in the staff and in how the maternity unit at Craigavon Area Hospital works. The bad publicity that was received is unfortunate. We welcome people to Craigavon Area Hospital, and we wish its nursing staff and all concerned well. I encourage people who are interested in taking up midwifery to do so.
The Chairperson:
I am sure that you will issue a statement accordingly.
Mr Gardiner:
No, I will not. I am not like you.
The Chairperson:
Sorry, I was just being —
Mr Gardiner:
Nice.
The Chairperson:
Nice. Yes, I was. [Laughter.]
Mr Gardiner:
For a change.
The Chairperson:
No, not for a change — as always. I ask you to draw in your horns, please.
The Committee has now reached the business of the Billy Caldwell case, on which I will lead. I ask the Minister to forgive me, because I have so many dates and information in front of me that I will read from my notes.
I hope that Sam will retract his remarks at some stage before leaving the meeting.
I am sure that the Minister shares my view that the management of Billy Caldwell is not about politics but about assessing and delivering the best available treatment for a child who has a very difficult and challenging condition — intractable epilepsy. It also concerns other children with the condition. At this point, I extend the Committee’s sympathy to Maureen McNicholl, whose son Callum had intractable epilepsy, and died just before Christmas.
Minister, you stated in your response to Mrs McGill’s question for oral answer in the House on Monday:
“Officials from my Department have held discussions with clinicians at the Children’s Memorial Hospital in Chicago about the treatment of a particular child who suffers from epilepsy. In addition, officials have had discussions with a recognised expert in the management of intractable epilepsy at Great Ormond Street Hospital for Children”. — [Official Report, Vol 37, No 3, p151, col 2].
Do you agree, Minister, that the leading experts in those centres are Professor Helen Cross, at Great Ormond Street Hospital, and Dr Douglas Nordli at the Children’s Memorial Hospital? A one-word answer to that question will suffice.
The Minister of Health, Social Services and Public Safety:
I took the trouble of going to Great Ormond Street Hospital to meet Helen Cross, so I can certainly confirm her expertise. I understand that Doug Nordli is a doctor in Chicago. I do not know much more about him, other than that he is a qualified physician who specialises in epilepsy.
The Chairperson:
Dr Nordli and Professor Cross are very good friends of mine. They communicate regularly and collaborate on various issues. They exchanged files on Billy Caldwell and discussed the management of his case. Minister, do you agree that they are the appropriate and relevant experts with whom to engage when seeking advice and support for children with intractable epilepsy in Northern Ireland?
The Minister of Health, Social Services and Public Safety:
I am sorry; I did not catch all of that.
The Chairperson:
Do you agree that they are the appropriate and relevant experts with whom to engage when seeking advice and support for children with intractable epilepsy here in Northern Ireland?
The Minister of Health, Social Services and Public Safety:
Helen Cross?
The Chairperson:
Helen Cross and Dr Nordli.
The Minister of Health, Social Services and Public Safety:
I cannot speak for Dr Nordli. I explained the situation and the protocol in which we work in the Health Service. The paediatric neurologists who are based at the Royal Belfast Hospital for Sick Children are the immediate point of contact — the first clinicians to whom GPs will refer. That service is responsible for managing treatment.
If the clinicians in Belfast seek further opinion, expertise or advice, they are in a position to refer within the UK — normally to Great Ormond Street Hospital. The lead in this condition is Professor Helen Cross. That process has been followed on a number of occasions. I will not talk about individual patients — I am not in a position to do so.
The Chairperson:
You did on Monday.
The Minister of Health, Social Services and Public Safety:
That is the protocol that is followed. Referring from Northern Ireland to the rest of the UK is a normal process. If treatment is available within Europe rather than in the UK, a referral can be made using an E112 form. There have also been cases in which patients have been referred further afield.
The Chairperson:
Although you said that you do not talk about individual cases, you mentioned Billy Caldwell in the Assembly on Monday 2 February 2009. I had a conversation with Professor Helen Cross on Tuesday 3 February. She informed me that the only recent contact that she has had with you or officials from your Department was your visit to her epilepsy unit in August 2008.
Indeed, to her knowledge, there have been no further discussions about policy, provision or patients since that date. In October 2008, you wrote to Mr David Hunter of David Hunter Associates — the firm that represented Billy Caldwell at the time — and stated that officials spoke to Professor Helen Cross on 7 September 2008.
To date, we have been unable to trace any further communication between your Department and the epilepsy unit — specifically Professor Helen Cross — other than your meeting in August 2008. On Tuesday 3 February, Professor Cross stated that she was rather “irritated” by the lack of communication. Professor Cross wrote to you last month specifically about the Billy Caldwell case. She had received the full report from the Children’s Memorial Hospital with regard to services for Billy. In that letter to you, she states that she had no further contact from Northern Ireland as to whether their involvement was required in Billy’s case. Indeed, she stated that — to her knowledge — there had been no other contact with her unit from Northern Ireland.
Yesterday, my staff were in contact Dr Nordli and his clinic in Chicago. They have spoken to Dr Nordli and his assistant. For the record, Dr Nordli said:
“I have not received calls from any Government agency in Northern Ireland. The only people I or my department have spoken with are Iris Robinson and her member of staff Dr Selwyn Black.”
What contact have you and your Department had with those leading experts and their staff? Or have you been misleading the House, the Committee and the families of those children? Against that background, is it not an insult to both leading experts to suggest that one asks what they can do to help, while — to use your own words — the other asks for the patient’s credit card, particularly if your staff have not done their own homework?
The Minister of Health, Social Services and Public Safety:
When I mentioned a credit card, I was referring to hospitals. Medicine is private in America and is paid for either through insurance or directly by credit card. As part of the UK, Northern Ireland has a free cradle-to-the-grave Health Service. That is my point, and it was self-evident. If Doug Nordli wants to feel insulted about that, that is his prerogative. I did not refer to him by name.
You asked about contact. I am not a clinician, and I do not become involved with what is appropriate treatment for patients. That is a matter for clinicians. Trusts usually make the contact, but we have had contact, and Dr McCarthy will respond to some of your points. I am aware of the threat of a judicial review, and, therefore, we will tailor our answers accordingly. Neither Dr McCarthy nor I will discuss the individual circumstances of individual cases. However, we will outline generally how the process works.
The Chairperson:
With the greatest respect, Minister, you have already discussed Billy Caldwell’s case in the House on Monday; you named him. We brought Billy’s case to your attention in 2007, and the only time you dealt with that case was when you visited Great Ormond Street Hospital in 2008. Therefore, a year had elapsed before anybody addressed the Billy Caldwell case. There is absolutely nothing on file or on record. Officials from your Department and clinicians — even Dr Hanrahan — have not been in touch or have not, at any stage, even tried to look into what was being done in Chicago that might help him to treat children in Northern Ireland.
The Minister of Health, Social Services and Public Safety:
I have met Charlotte Caldwell with Billy on a couple of occasions — that is no secret. Miriam will detail some of that contact. However, I must emphasise: those matters are for clinicians and the trusts, not me.
The Chairperson:
In response to questions that we put to you about Billy, your officials and clinicians are providing the answers, and that is not accurate information. I have now proven that there has been no contact other than when you called over at Great Ormond Street Hospital in 2008.
The Minister of Health, Social Services and Public Safety:
I think that you should listen to what Miriam has to say before talking about proof.
The Chairperson:
I am happy to listen, and I will listen. This is very important because it is about determining facts and telling the truth about Billy’s case. These are children who are dying because, should they return to Northern Ireland, there is no programme for them to utilise.
Dr M McCarthy:
Unfortunately, I do not have the dates, but I can confirm —
The Chairperson:
You have been given the subject matter to deal with.
Dr M McCarthy:
I first spoke to Helen Cross either at the end of August or at the start of September 2007, and we had numerous conversations at that time in order to try to organise an early appointment for Billy. Thereafter, I met Helen Cross in summer 2008 when we went — accompanied by the Minister — to Great Ormond Street Hospital. I discussed the detail of that beforehand. Moreover, I had a recent conversation with her when she called me to check some details about our services. That contact was on the basis of some previous contact that she had had with Charlotte.
As regards Doug Nordli, initially I had email contact with his department and then with him personally. At that time, I was advised, correctly, that he would not be able to speak to me about Billy unless specific permission was given by Billy’s mother. After her express permission, I had a very lengthy telephone conversation with him one around 7.00 pm or 8.00 pm our time, when he advised me of all the details of the treatment. Subsequent to that, I have had fairly regular, although not frequent, email updates. On each occasion, he requires Charlotte’s specific permission to disclose facts about Billy, and that is entirely reasonable.
When Charlotte was home last summer, we encouraged her to provide us in Northern Ireland with a copy of the medical records of Billy’s treatment in Chicago, so that, on Billy’s return home, arrangements could be put in place, and we — not the Department, but clinicians — would have access to his clinical details. She gave her permission for those medical records to be released, and they were forwarded to me. I accessed Charlotte’s permission, and spoke to Charlotte personally when she was home at Christmas, and, on the basis of that explicit permission, I have sent those medical records to Billy’s general practitioner.
There has been contact with the relevant individuals throughout that process. We now know that Billy’s records are with the general practitioner in Omagh, and it is hoped that, on Billy’s return, that will help to inform progress and his assessment, and it will help to inform the sort of care plan that he will need.
The Minister emphasised when he met Charlotte last summer during her visit home that, if she were planning to return home, she should let us know so that we could try to smooth that transition and that arrangements would be put in place so that Billy’s condition and details would be assessed and that a care plan would be put in place.
The Chairperson:
I repeat: Dr Nordli indicated yesterday that there was no contact from officials, consultants or anyone from Northern Ireland. I hope to invite him over so that that can be clarified.
Minister, the Committee welcomes the statement that you made last week, in as far as it goes, and your further statement at the beginning of this week. Do you agree that we would want to bring our paediatric facilities up to international standards, drawing on the expertise of both Professor Cross and Dr Nordli and their centres?
The Minister of Health, Social Services and Public Safety:
For a small region such as Northern Ireland, it is difficult for us to attain international standards. We are part of the UK and, therefore, we have an opportunity to access treatments that are not normally available on a regional basis. For example, for the children’s conditions that we are talking about, Great Ormond Street Hospital is a recognised international centre to which we have access. I believe that we cannot aspire to have the same sort of standards available in Belfast as are available in Great Ormond Street Hospital in London and its close association with University College London’s Institute of Child Health.
The Chairperson:
Minister, I do apologise. I have a few more points. I apologise to colleagues, but I hope that the Minister might give us a few more minutes for Sue, Michelle —
Mr Buchanan:
May I ask one specific question about Billy?
The Chairperson:
If you leave that to the end, I will bring you in. It is easy to come back to that issue. I want to get these points over so that members can ask questions.
Minister, you announced recurrent spending of £200,000 — or, in your statement, £220,000 — to reinforce paediatric epileptic services, which include additional dietetic support, paediatric nurses, scan sessions and links with Great Ormond Street Hospital. In addition, you plan to develop satellite services in the west of the Province.
You state that you and your Department are working closely with Great Ormond Street Hospital to provide that service. I find it hard to understand exactly how you will spend that £220,000 without drawing on that expert advice, which, it is now becoming clear, was never obtained. This week, you announced that you plan to inject a further £9 million to improve community support for children with complex needs. It seems rather strange that, having stated that you got advice from Professor Cross and Dr Nordli — which now seems not to be the case — that, out of the woodwork, now comes £9 million this week. Does that mean that you are, by implication, saying that the families who chose to receive treatment in the United States were right all along? The analysis in this report centres on nursing needs rather than the therapies, which has always been the central thrust of our campaign. If you had obtained that advice, Minister, you would then know two critical facts about the 3-tesla MRI scanner: first, that a further piece of diagnostic equipment is required — a MEG scanner — without which the 3-tesla has considerably reduced functionality in locating the focus of epileptic activity in the brain; and, secondly, that the manufacturers are currently selling the 4-tesla MRI scanner, an even more capable instrument, at the same price as the 3-tesla MRI scanner. Those are stark omissions from your recent statements, given the accessibility of such information.
Minister, you stated in an interview with Paul Clark on ‘UTV Live’ on 19 June 2008:
“money is not the issue. The issue is the protocol we have.”
Do you agree that medical protocols are critical to patient safety and treatment regimes?
The Minister of Health, Social Services and Public Safety:
You make a number of complex points. First, you talked about the investment, and I am glad that you welcome that. I will ask Miriam McCarthy to respond to you about the investment in regional paediatric neurology.
I am where I am: this is where I start. I was in no position to do anything about this I became Minister. Now, I am reinforcing the service. I am also reinforcing the service for children with complex needs.
This is not something that came “out of the woodwork”: it was planned. It was something I argued for in the Budget, and, had I accepted the draft Budget, we would not have had the moneys for it. This is one of the service developments that I was keen to promote. It was some time in the planning.
Mr Martin Bradley:
The work on meeting the needs of children with complex physical healthcare needs started in 2007, initially as a nursing project, but it expanded to cover the entire service. At any one time, there are approximately 250 of those children being treated and cared for in Northern Ireland. It is an increasing population of very disabled children, looked after at home by parents and carers. Often, they require ventilation. The children have expensive packages of care so that they can survive at home, and the issue of palliative care arises, particularly in relation to the role of the Northern Ireland Children’s Hospice.
The £9 million is to reinforce the community support and palliative care services that we give to those children. The sum will be recurrent over a three-year period. It is not £9 million to begin with: it will build up over the three-year period and eventually amount to £9 million in the third year. We hope that it will make a major difference to the lives of those children.
The Chairperson:
I have done my homework, and I travelled to Chicago at my own expense last year. Dr Nordli indicated that the £1∙5 million MEG scanner will allow others to benefit from it, not just children with intractable epilepsy. It could be rolled out to help with brain-acquired injuries, strokes and autism. In view of the number of children in Northern Ireland who suffer from autism in all its various forms, the £1∙5 million would be well spent. A huge number of children would be able to access the equipment: even if two or three of them could do so, that would be wonderful. Autism takes up much of our time and energy in hospital service provision because of the variations in, and extremities of, autistic behaviour.
I have a few more questions — and I apologise — but it is important to get the point across because the issue is very emotive. If we can get the process up and running, it will enable children, some of whom have been isolated, perhaps for a couple of years, to return home. We are all battling for the same thing — provision for the children. That must be paramount, but, at the same time, we can help stroke victims and people with brain-acquired injuries.
At no time was Billy Caldwell referred through the normal medical routes to Great Ormond Street Hospital by a consultant from the Province, and I believe that he was under the treatment of Dr Hanrahan. Minister, before Billy left for the States, you personally tried to set up an arrangement for Billy to be seen by Professor Cross. Indeed, you said:
“I had arranged with Professor Helen Cross, a world leading authority on intractable epilepsy, to see Billy within two weeks in August last year.”
That was in 2008, and the quote is taken from the transcript of your interview on ‘UTV Live’ with Paul Clark. We brought Charlotte to you in 2007, so there is a lapse of a year. Was that an appropriate protocol? Did you personally have the authority to overrule your own consultant, who had either neglected to refer Billy to Great Ormond Street Hospital or had chosen not to use that route? Were you not guilty of using, in your own words, the credit-card route?
The Minister of Health, Social Services and Public Safety:
First of all, Billy was first offered a referral in May 2007. My discussions with Charlotte took place before she went to Chicago; that was in August 2007, not 2008. That is when I asked Miriam McCarthy, who can fill in the detail, whether we could rearrange that date. I told Charlotte that I would try to arrange a date for Great Ormond Street Hospital with Professor Helen Cross. She asked me again, and I was able to confirm that Professor Cross was prepared to see Billy within two weeks. It was Miriam McCarthy who made the contact, as well as making the contact with the Royal Belfast Hospital for Sick Children.
The Chairperson:
With the greatest respect, Minister, in the letter that you have received — today, I think — from Helen Cross at the epilepsy unit at Great Ormond Street Hospital, she indicates that, up until 2008, there was nothing spoken of about Billy, other than when you went to see her. Those are issues that will have to be ironed out and the truth established. Billy has yet to be referred to Great Ormond Street Hospital through the appropriate channels.
It is interesting that the discussion about Billy’s case has been pre-empted by the Chicago hospital, to which Professor Cross has warmly responded. This week, she reported that she has yet to receive an appropriate referral for Billy Caldwell, and because of five personal conversations that you had with me,you discussed the case with Professor Cross in August 2008. Naturally, Charlotte Caldwell wants to bring Billy home. In my view, it would be appropriate for you to fund an appropriate referral from Dr Nordli to Professor Cross in order for the proper assessment of Billy’s needs to be made to effect Billy’s safe homecoming.
Given that there is now more money in the pot, it is imperative that the families’ expenses be met. What has been said up to now indicates that the provision was not there, and that Charlotte and her family had no alternative but to go to America to try to get lifesaving service provision from the consultant over there. That leads me to the final crucial issue. Have you and your officials conducted a comparison of the treatment that Billy is currently receiving in Chicago with what is available through the NHS?
The Minister of Health, Social Services and Public Safety:
You again raised a number of points; I did not get them all.
The Chairperson:
I will give you a copy of the report that I have.
The Minister of Health, Social Services and Public Safety:
I believe that you said that there had been no contact with Professor Cross since 2007. That is not what it says in this letter. Although Professor Cross says that she is more than willing to review Billy Caldwell’s case, it is imperative that a paediatric consultant continue to be involved at a local level. That would be appropriate as far as Billy’s treatment is concerned. It is a matter for the clinicians in Belfast, advised by Professor Cross.
You have made a number of assertions, Chairperson. It is important that we get some more detail. I will ask Miriam to supply the Committee with that detail, because she took part in some of the discussion and is familiar with the dates.
Dr M McCarthy:
I will pick up on a couple of points. The first is the appropriateness of the Department’s contact with Professor Helen Cross in September 2007. You are right, Chairperson; we would not normally be in direct contact. In the circumstances, however, we made contact through liaison with the Belfast Trust and its clinicians — not without their due involvement, consent and understanding of exactly what was happening.
Chairperson, you also mentioned that no referral has been made to Great Ormond Street Hospital at that time. When Charlotte was home last August, we explained to her that the first thing that would have to happen, if she chose to return home, would be an assessment. A fair amount of time has passed by, and a reassessment of Billy’s needs is required so that the right care and treatment are offered. A referral would probably be made at that time. We anticipate that it would be best if somebody in Northern Ireland — either a local paediatrician, paediatric neurologist or general practitioner — had the ability to see Billy and make such an assessment so that an informed referral could be made to Great Ormond Street Hospital.
The Chairperson:
With the greatest respect, what was Dr Hanrahan doing when he, as the consultant, said that Billy Caldwell had no quality of life? Dr Hanrahan did not follow up with Professor Cross or the man who was treating Billy in Chicago. Let us remember what Billy was before he left Northern Ireland: he was a drooling, vegetative child. Now, in America, he is riding a bike and speaking — he is talking. In Northern Ireland, far from asking what it is that we can do, we have been saying that we cannot do anything for a child in such a situation. In America — unfortunately, the Minister got it all wrong — they ask what it is that they can do for a child. Healthcare in America is private; that is the way that it works there — you pay for what you get. However, the end result is that no one made any attempt — particularly the consultant — to speak to Dr Nordli, or to anyone else, in order to gain some information that would help children in Northern Ireland so that they would not have to fly to America and be isolated from their families.
Dr M McCarthy:
I will answer one other question. You asked what assurance we had of the comparability of services in Great Ormond Street Hospital with those in Chicago. We have been assured by Helen Cross that the range and scope of treatments that are available in Great Ormond Street Hospital is comparable. I understand that Professor Cross and Dr Doug Nordli know each other; they belong to a very small group of specialised clinicians who are in regular contact, and they may refer to each other, including referrals to Great Ormond Street Hospital, which is a world-recognised centre.
The Chairperson:
Dr Nordli sent Billy’s file to Professor Cross, so they are taking the initiative. However, nobody seems to be doing that here. I wish to make one more point, Miriam, because I know that the Minister’s time is limited.
The Minister of Health, Social Services and Public Safety:
With respect, it is important that the Chief Medical Officer be allowed to make an observation.
The Chairperson:
Yes, surely. Of course.
Dr McBride:
Chairperson, as you said at the outset, these are important matters, not least to Billy Caldwell and his family. As you also said, it is a very emotive issue. Clearly, you have raised genuine concerns, and the Committee, and you as its Chairperson, has a due process with which to ensure that issues are addressed. It is fair to say that issues around clinical referrals of patients are matters between clinicians and are based on a judgement about whether treatment and care can best be provided in another centre.
Speaking as the Chief Medical Officer, I must say that it is important that such clinical decisions be left to the clinicians.
The Chairperson:
Yes, but if clinicians are not making any effort to ascertain how to help those children and improve their quality of life, the question of what those consultants are doing must be asked.
Dr McBride:
I fully accept that as your motive for raising that issue.
The Chairperson:
It is a fact; I am not making it up out of thin air. I want to clarify that I do not want anyone to think I am conducting a witch-hunt. I am interested only in the care of those children who have intractable epilepsy. If the Committee has been given wrong steers and information, this is the place in which to highlight that and thrash out the issues. I hope that debate will lead to an improved service provision and to moneys being spent on dealing with intractable epilepsy, and on a wider range of illnesses and problems that affect other children and adults with brain-acquired injuries, including strokes, so that the best equipment can be accessed.
Dr McBride:
It would be inappropriate for the Department to seek to second-guess clinical decisions that front-line professionals who are experts in their field in Northern Ireland make.
The Chairperson:
Some time ago, I had a meeting with Dr Hanrahan in my office. I was, quite honestly, shocked at his lack of impetus to follow up on the provision that exists in the Chicago hospital and at Great Ormond Street Hospital. He is the clinician who oversees Billy’s welfare, yet he has no contact with either hospital.
Dr McBride:
You also mentioned service provision. It is important that the trust identify any service-development needs, whether for capital investment, which we have discussed today, or for new technologies, and to produce corresponding proposals for the boards. The Department, therefore, follows due process. In an increasingly constrained financial environment, the Department follows a process of prioritising resources, and it must make difficult decisions. As you correctly say, the investment that followed the Minister’s review is to be warmly welcomed.
The Chairperson:
I am happy to give you the notes from which I am reading, because they are extremely detailed. I am almost finished.
When I spoke to Professor Cross on Tuesday, she told me that she is confident that there are favourable comparisons between diagnostic services, drugs, drug regimes and surgical procedures. However, she is unable to provide the “supportive” — as she describes them — follow-up services through other therapies at Great Ormond Street Hospital.
In her letter, she states:
“These are the therapies that, although assessment could be undertaken at this institution, we would not be able to administer this on a regular basis. Great Ormond Street Hospital offers what might best be described as quaternary services, but does not have the capacity to administer essential follow-up services. While these therapies are ideally delivered at a local level, it was unlikely that under the NHS they could deliver them at the level that Billy has been receiving them in Chicago.”
The point is that Professor Cross:
“would welcome the referral, the collaboration, and would be happy to advise when asked. To date she has not been asked by your Department for any further advice from Northern Ireland other than your conversation with her on your visit of August 2008. In my view, your statement last week, your response to Mrs McGill’s question on Monday, and the evident lack of consultation with the appropriate experts uncovered this week simply endorses the Committee’s decision to travel to Chicago in order to explore for ourselves what treatments are available to patients such as Billy Caldwell. ”
That also applies to all the other families involved who have to isolate themselves from family, friends, and so forth.
Dr McBride:
With the Minister’s agreement, I, along with other colleagues in the Department, am happy to meet the Chairperson and any other Committee members. A system of healthcare exists in Northern Ireland. A process is in place whereby, through the involvement of the Department, the board and the trust, the need for services, and for the development of services, is identified, and investment in the workforce, buildings and technology is prioritised.
That is the process that has stood the test of time. It has stood us well, and I would be concerned about any other, parallel process, which would have the potential to be misinterpreted as cutting across that process. I respect the Chairperson and the Committee’s interest in the case, which is entirely legitimate, but I would welcome the opportunity to discuss your proposal around a visit in advance of a final decision.
The Chairperson:
I have not discussed this matter with the Committee, but I think that, having previously visited Washington as part of the autism review, it would be useful were departmental officials to accompany us. When we have finalised the date for the visit, I suggest that it may be appropriate if a consultant and a member of the Minister’s advisory team were available to accompany us and see at first hand, because I think that that is important. To prevent a breakdown in communications, or a lack of communication, it may be appropriate for an official and a consultant in that area of expertise to come with us. We can kill two birds with one stone, and the Department can see for itself at first hand what is available.
I will leave that suggestion with you — it is not for you to decide now. We have yet to decide when we are going. We have an idea of when, because I will be going to Notre Dame with the First Minister and then travelling to Chicago after that. It would be a very good idea if we had officials come with us.
Dr McBride:
We welcome the opportunity to discuss that proposal with you.
The Chairperson:
We can discuss that later. I am sorry to have taken most of the time, but it was important to get those points across.
Ms S Ramsey:
Yes, it is important. However, the witnesses are probably wondering whether we have any more questions to ask. I have some questions, but I have no difficulty if I receive answers to them in writing. For the record, it is not the Committee that is going to Chicago but the Chairperson and the Deputy Chairperson. The Chairperson will agree that we also have a duty to ensure that we are scrutinising some of the issues.
Minister, you mentioned a duty of care and the cradle-to-the-grave nature of the Health Service in your opening remarks. That is something that I also fundamentally support. We have a duty of care to the 250 kids whom we are talking about, and we should strive to provide the best treatment for them here. If we cannot get the treatment here, we need to look elsewhere. If we cannot provide the treatment here, that should not mean that we close to our eyes to the situation.
Your statement of 26 January 2009 specifically mentioned a 3-tesla MRI scanner, the introduction of which will be permitted by the additional £220, 000 for paediatric neurology services. Will that scanner be available for use in children’s healthcare services? I know that it is additional money, but can we determine the baseline? On what specifically is the £220,000 going to be spent?
We have letters and information that state that some scanners cannot be used on children. The staff in Chicago argue that they can. If our people are telling us that those scanners cannot be used on children, the additional money that is available for the scanner here will not make a difference to the 16 kids, or specifically to one of those kids.
On the issue of the £9 million, again, it is important that we find out whether that is additional, and I think that the Chief Medical Officer indicated that it is. Can we have a breakdown of what the money will be in the first, second and third years, and what it will provide? That would give us more information.
Finally, I welcome the additional money. I know that it is difficult to find extra money, but we have a duty to find out where it will go. You mentioned that the investment will now mean that we have more dieticians trained to support children on a diet, and it would be useful if we had a breakdown of when those dieticians will take up their posts. Are they just beginning training and will therefore not be available to start for another three years? Can we have a breakdown across council areas, constituencies or trusts? I am aware that you may not have all the answers with you, so I do not mind if the questions are answered by letter.
The Minister of Health, Social Services and Public Safety:
I will try to provide the answers that I have. As far as the use of scanners is concerned, we are always conscious of their safety, particularly for children. I understand that the 3-tesla MRI scanner is safe for children, and the Belfast Trust has prepared a business case. It is for that trust to determine whether it wishes to purchase the scanner.
Ms S Ramsey:
I have a letter with me, dated 22 October 2008, from you, Minister, which states:
“The scanners are available for research capacity only, and not for children.”
The key argument that was being made to the Committee all along was that the scanner in Great Ormond Street Hospital was as good as the one in Chicago, but that it was not available for use on children. I do not want to name specific cases, because I am conscious that a judicial review is under way, but a key reason why people choose to go to Chicago is because they have been told that the scanner at Great Ormond Street Hospital is not available for use on children. However, we now learn that the Belfast Trust is considering investing in a 3-tesla MRI scanner, and that it can be used on children. Therefore, you can appreciate why the Committee is confused.
The Minister of Health, Social Services and Public Safety:
I will try to elicit that information for the Committee. There are around 35 3-tesla MRI scanners in the UK. Therefore, the technology involved is neither unfamiliar to nor unavailable on the Health Service, but one must always be conscious of the risks to children. I understand that a business case for the 3-tesla MRI scanner is being prepared, but I have not seen it. I will check that out, because it is certainly an issue.
As far as the breakdown is concerned, the £220,000 recurrent expenditure will pay for a paediatric neurology nurse, additional dieticians, more MRI sessions to improve access to diagnostic services, and a consultant-led outreach service to the Western Trust, because there is an access issue around its patients always having to travel to Belfast. Again, it is about reinforcing the service.
The £9 million for children with complex needs will provide additional services: community children’s nurses; physiotherapy; occupational therapy; and speech and language therapy. Those services will ensure that every child has an individualised care plan to meet his or her needs. Of the £9 million in funding, £2 million is in the system this year. I can provide a breakdown of how the recurrent moneys will be put to work.
Dr M McCarthy:
The scanners, in particular, represent a complex area. New radiology equipment, and its use, is very complicated. The scanners can be set to different modes — there is not simply one setting. When we examined what the UK Health Protection Agency had to say, it emerged that little was known about the safety of 3-tesla MRI scanners. Therefore, potential safety concerns mean that they may not often be used for young children.
Nonetheless, it appears that the 3-tesla MRI scanner is now considered reasonable to use. However, any clinician who wants to carry out a diagnostic test will want to balance the risks and benefits for the individual patient. There is no clear cut yes or no.
The other element to be borne in mind about the scanners is that they are diagnostic — they do not treat, but help to diagnose. Part of the skill of diagnosis is not only in having the most modern and effective machine but in having the expertise to interpret the information that those machines provide. We must match that expertise with the machines. We constantly develop the skills of our radiology workforce to maintain their expertise in line with each new piece of equipment that is purchased. Therefore, there are many complex issues associated with using the scanner. As I said, it is not a simple yes or no answer.
The Chairperson:
Are you aware that, after I went to Chicago, I made it clear to the Committee that Dr Nordli had volunteered to train six radiologists — provided that they came to him — to use this very high-definition MEG scanner. That offer was never followed up on.
The MEG scanner is so important because it shows up, in colour, those parts of the brain that require treatment or surgery. Different-coloured dyes pinpoint affected areas of the brain. Changes in brain patterns caused by strokes, brain-acquired injuries and autism can equally be picked up by that amazing scanner. Apart from that, they are children-friendly.
The MEG scanner that is used in America is in one piece and is moveable. It has been tested and is safe for children to use. The doctors in Chicago specialise mainly in treating children. As I said, the scanner is suitable for children and is user-friendly. I tried it, and I was content that it is not like the stainless steel one — the scary, big monster — that extends from the ceiling. It is a simple structure that is user-friendly. Susan, are you happy enough with that?
Ms S Ramsey:
“Susan” — she is like my mother.
I will check the Hansard transcript of this evidence session to clarify further some other issues. Will you provide a further breakdown of where the money is going?
I get called Susan only when I am being shouted at.
Mrs O’Neill:
I will simply pass comment at this stage. For the past 18 months to two years, the Committee has received various pieces of correspondence, which have gone back and forth, from the Department. Several issues have been raised today, and I welcome Michael McBride’s offer to attend another evidence session to discuss them further. The Committee is genuinely concerned about the matter.
The reality is that approximately 16 families have travelled to Chicago so that their children can receive treatment, and that has placed them under financial pressure. Obviously, I am most concerned about the health of the children; however, some of those families have had to remortgage their homes, and that is simply not acceptable.
The Minister said that, in America, a private medical-care system is in place; however, those families are being forced to seek private medical care. The Committee is most concerned about that issue. We want to get to the bottom of it. We want to do what we can to ensure that the proper resources exist, that the children are cared for and that they can come home.
Charlotte Caldwell would not be stuck in Chicago — detached from her entire family and support network — if she did not feel that it were absolutely necessary. Billy was sent home, and, as the Chairperson said, he is now coming on leaps and bounds. I welcome the opportunity to discuss the issue further. As the Chairperson suggested, and given that we benefited from the visit to Washington as part of our research into autism, it would be worthwhile for someone from the Department to visit the facilities in Chicago with us. I want to put on record my feelings about such a visit.
Mr Buchanan:
You covered the issue very well, Chairperson. Given that, for the past 18 months, the Committee has sought to address the issue of scanners and to assess what services are being provided, or could be provided, it is unfortunate that the matter did not get dealt with quicker. Today, we have reached a stage at which we gain a true picture of what is available and what may available.
It is also unfortunate that the Department failed Charlotte. She sought its assistance after she was told that there was no hope for her little child, but she did not get it. Only that she used her initiative to seek out treatment elsewhere — as any mother would do — and go to Chicago, the outcome could have been entirely different.
I commend Charlotte for taking the steps that she did. Not only did it help Billy, but it had a knock-on effect for those other families. They saw the results and were able to get in contact with Charlotte, who advised them about the treatment.
Should a private-sector firm build a centre of excellence to deal with intractable epilepsy, and associated illnesses and complex needs, and would the Department buy into that?
The Minister of Health, Social Services and Public Safety:
I would have to examine the detail of such proposals. Obviously, we are already stretched financially in carrying the system that we have. We have already had discussions today about various hospitals. Clearly, we would have to examine those proposals.
Clinicians always tell me that we need to invest in the services delivered through the Royal Belfast Hospital for Sick Children. We need to invest in those and in maternity services. Those are among my top priorities.
I will consider any proposal, but, as far as the Department’s priorities are concerned, we look at what is coming forward from the trust. The Royal Belfast Hospital for Sick Children is the regional centre — it is a very good regional centre and is part of a UK-wide network. That is how referrals work and how treatment and service is delivered, and that is how it stands currently. As I say, beyond that, I know little about the proposal.
The Chairperson:
Minister, you have answered the question, and I am very grateful that you have spent an additional 20 minutes with us to the one and half hours that were allocated. There is a number of other important issues, but, unfortunately, we have run out of time.
Dr Deeny:
Is it possible to ask a question about generic-medicine prescribing? It will only take five minutes. It is just that I have been approached about that matter.
The Chairperson:
You may ask the question providing that the Minister does not mind.
The Minister of Health, Social Services and Public Safety:
As I said, I was originally told that the meeting would run from 2.15 pm to 3.15 pm. I tailor my diary to suit the times that I am given — I do have a diary. I was then asked to come as close to 2.00 pm as I could, which I did, and was then asked to stay until 3.30 pm, which I did. I was happy to do that. I am always happy to come before the Committee. I have answered literally thousands of questions and have responded in dozens of debates. I am not slow about giving any information that I can. However, I must leave soon. I will answer the question if it will take only five minutes.
The Chairperson:
The Committee meeting will be cut short today because of the weather conditions — there is an alert indicating that the conditions are going to get a great deal worse, which is why we have allowed other witnesses who were due to give evidence today to leave. Therefore, I ask that Committee members be brief, because I also want to go through the minutes of last week’s meeting after the Minister has left.
Dr Deeny:
I thank the Minister and his team. First, it is important that whenever you, Michael, as Minister, and your Department make good decisions, we should acknowledge them. Therefore, I thank you for the restoration of the minor ailments scheme. I thank you also for the decision that you announced two weeks ago about people being allowed to pay for additional cancer drugs — that is a wonderful thing and is a matter that I, as a GP, had been approached about by different people.
I want to ask a quick question about that matter. A family, who are from another constituency but who approached me because I am a doctor and a member of this Committee, told me that they had had to pay at least £25,000 on additional drugs. That was over a year ago, and I wonder whether there is any way in which a retrospective payment can be made to compensate them for that. Perhaps you will answer that another day. That family had to pay that amount because they decided to pay for very expensive cancer treatment and so had to pay for every other treatment as well, which, in my opinion, amounted to penalising the terminally ill.
As you probably know, the Pharmaceutical Contractors Committee (PCC) attended our Committee meeting two weeks ago. I work with many pharmacists, and I was approached by a number of them this week to ask you and your Department about concerns that they have. I do not know whether you have seen the report by Professor Yarrow — it makes for very worthwhile reading, and I suggest that officials from your Department speak to him.
The PCC and individual pharmacists have told the Committee, as well as me individually, that they have some major concerns about the new arrangement of generic-medicine prescribing. One concern is that there was lack of consultation with key stakeholders, including, for example, the PCC itself. A second concern is that the arrangement may result in a lack of competition, meaning that the cost of drugs may rise.
We talked earlier about what the future holds, and I could not agree more that the Utopia would be to have a situation in which we can deal with patients in the community, but we must have the resources to support that. The concern among pharmacists, and what worries me most, is that the new arrangement may threaten our community pharmacies and could, eventually, lead to the demise of community pharmacy.
Speaking as a GP who has worked with many community pharmacies in my area, and as someone whose father spent all his professional life as a community pharmacist, I must say that that worries me greatly. At a time when we are talking about looking after our patients in the community, and about the need to ensure that we are all up to doing that and ensuring that the necessary resources are available, it would be an awful pity were the new arrangement to lead to a demise in the number of community pharmacies. Those pharmacies play a vital role in how we deal with patients in the community, and they have done so down the years.
The Minister of Health, Social Services and Public Safety:
Some 56% of the prescriptions dispensed in Northern Ireland are for generic drugs. That figure is substantially behind that of England, which is 64%, so we are looking to catch up with that. Having generic drugs is an opportunity to make savings. For example, up to 2008, the clinical-effectiveness programme delivered some £70 million in savings. Efficiency savings of 3% must be delivered within the current comprehensive spending review period, so it is planned that a further £40 million worth of savings will have to be found by 2011. That is my target, and if I do not find the savings in that area, I will have to find them elsewhere, which causes a degree of pain.
As far as generic prescribing is concerned, our drugs budget currently sits at £500 million pounds a year — roughly £100 million for hospitals, and about £400 million through GPs. We are considering tendering for generic drugs. We already do that for the hospital drugs, so it is a matter of extending that through the —
Dr Deeny:
The issue is not about generic-medicine prescribing, because we are all behind that. You will notice that the figures are going up all the time, even in our practice in the Western Health and Social Services Board. Everyone is 100% behind that progress. It is the new arrangements that are causing concern. How will they be put in place? Regional competitive tendering arrangements mean that suppliers will be centralised into four regions, and it may threaten community pharmacy as we have known it.
Mrs O’Neill:
The PCC is firmly behind the Department’s proposals, but the issue is with the way in which generic tendering will come about. There are fears around monopoly and shortage of supply, and about what happened in the past.
The Minister of Health, Social Services and Public Safety:
I have concerns about monopoly, but I am also concerned the situation as it stands today, which is not tenable. For example, as the Committee knows, when a drug comes on the market, it gets a 10-year patent, after which it becomes generic. Reimbursement costs are a factor. When a patent comes to an end, manufacturers can offer 90% reductions on their drugs. I am not confident that the Department and the Health Service is getting the full benefit of those discounts — they are not always finding their way through to us.
In the next few years, the patent will run out on a number of very important drugs, particularly those to lower cholesterol and to treat cardiovascular disease. We currently spend substantial amounts of money on them, and I want to ensure that we get the benefit of those discounts when the patents come to an end. Therefore, the potential exists to make substantial savings as we move closer to the GB model. I will ask the Chief Pharmaceutical Officer, Dr Norman Morrow, to talk us through the issue briefly.
I understand pharmacists’ concerns, and I am not looking to affect their bottom line. I know that manufacturers and pharmacists alike are in business and are concerned about their turnover, and so on, but I am concerned that we make savings. When we make those savings, I will have money to reinvest in the new drugs coming on to the market that are effective in ways in which we could not have imagined five or 10 years ago.
Dr Norman Morrow (Chief Pharmaceutical Officer):
Like Michael McBride, I am equally happy to appear before the Committee again to talk it through the issue in more detail. I will make a few brief points now. First, we have had considerable contact with the PCC, and we have given it several opportunities to engage in discussions on our proposals. In fact, I have a letter from the PCC, in which it declines to join a group that will deal with the matter. I want to make it clear that we have endeavoured to meet with community pharmacists to discuss the issues.
Dr Deeny mentioned lack of competition. In fact, in many ways, the proposals have engendered considerable competition, in that 63 companies have submitted bids against the tender. Therefore, rather than decrease competition, we have encouraged it. The Minister has already said that it is not his wish to harm the community-pharmacy infrastructure. In fact, the Committee may know that Northern Ireland has more community pharmacies per capita than anywhere else in the United Kingdom. Therefore, we are well served in that regard. We are not seeking to harm that community; rather; we seek to bring transparency to the process when it comes to what medicines are costing us, given the amount of expenditure in the system.
That prescription drugs are safe is at the top of my agenda. Everyone here may have had a prescription dispensed for himself or herself, or for a relative, for a long-term treatment from a community pharmacy. The tablets are one shape and one colour, but when the prescription is repeated the next month, they are a different shape and a different colour. That is the single biggest issue that I must deal with, and patients and their clinicians tell me that it is a confusing situation. I know that that is true for my family circle as well.
We have built that concern into the tendering process to try to ensure that patients have consistency of treatment, and that no confusion arises. More than that, we want to ensure that prescribing is consistent from hospitals through to primary-care providers so that both achieve the same objective. As long as I have been in pharmacy, hospitals have always employed a regional tendering approach, and it has been extremely successful. We did that with flu vaccine, and, over the past four or five years, Northern Ireland has had the most assured arrangements for influenza-vaccine supply of any region of the United Kingdom, and the most successful programme.
There is much to be said for what we are doing here. I know that the Committee does not have much time, but I am happy to return and speak at more length on this issue.
The Chairperson:
We would appreciate that. We will wind up now. There is a cup of tea available to prepare you for your journeys, especially for those who have to go out into the sticks. Thank you, Minister.
The Minister of Health, Social Services and Public Safety:
Thank you, Chairperson. I came in with an agenda of 11 items to discuss, but we have dealt with only three and a half. I will be happy to come back. The Executive are moving to weekly meetings, so timing will be difficult, but I am keen to talk about mental-health legislation, the capital budget, autism and clostridium difficile, among others. Those are big issues, and I am keen to take the mind of the Committee.
The Chairperson:
If you can give us a date, Minister, we will try to work those issues into an agenda. We do not want anyone thinking that those issues are less than important to us. Thank you.