Northern Ireland Affairs Committee
Oral evidence: Funding priorities for the 2018-19 Budget: Health, HC 1147
Wednesday 28 November 2018
Ordered by the House of Commons to be published on 28 November 2018.
Members present: Dr Andrew Murrison (Chair); Mr Gregory Campbell; Maria Caulfield; Mr Robert Goodwill; Lady Hermon; Kate Hoey; Conor McGinn; Nigel Mills; Ian Paisley; Jim Shannon.
Questions 169 - 264
Witness
I: Dr Michael McBride, Chief Medical Officer, Department of Health (NI).
Witness: Dr Michael McBride.
Q169 Chair: Good morning, Dr McBride. It is a great pleasure to see you here today. Thank you very much indeed for coming to better inform our deliberations this morning. I wonder whether you might like to give us a very brief run down on where you see the situation before we launch into questions.
Dr McBride: Sure. Thank you, Chair, Committee Members. Good morning. Thank you for your kind invitation to join this morning. I am Michael McBride. I have been the Chief Medical Officer for Northern Ireland since September 2006. My particular responsibilities are for policy and strategy in relation to public health quality and safety, and research and development. I also provide strategic advice to other Government Departments, and indeed our former Ministers, on health-related matters.
I suppose I am fortunate to have experienced health and social care in Northern Ireland from a variety of perspectives over the years. I was formerly a practising clinician within one of our acute trusts. Prior to being Chief Medical Officer, I was also a medical director within the Royal group of hospitals. In 2014, at the request of the then Health Minister, I took up the post of the chief executive of the Belfast Health and Social Care Trust. I combined that with the role of Chief Medical Officer. As chief executive, I was responsible for heading up an integrated health and social care trust providing hospital-based services for the population of Belfast, but also most of the regional services for Northern Ireland. During that time, I was responsible for key ministerial priorities, for the trust’s 23,000 employees, overseeing a budget of some £1.3 billion.
I would like to thank the Committee for the opportunity to come before you today to discuss some of the pressures within health and social care provision in Northern Ireland, the steps we are taking to address those and the steps we are taking to improve the health of the population in Northern Ireland. As Chief Medical Officer, the guiding principle for me, and I know for those working in health and social care, is to protect and improve the quality of services to all those we serve. In Northern Ireland, a former Health Minister described the health system as a 20th century model delivering services for a population with 21st century needs. This is having an increasingly negative impact on the quality and experience of care. The longer term solution can only be through the transformation of health and social care services as outlined in Delivering Together.
As for the current pressures within the Department, the funding we receive falls short of that which is projected to be required to support the current service model or, indeed, to bring about the changes we require in the longer term. Transformation can only be achieved with sustained investment. The £100 million provided by the confidence and supply agreement is being invested in transforming how we deliver health and social care services, reducing health inequalities, and improving access across services and across the region. Long term, additional investment is needed if we are, fundamentally, to transform what we do and how we do it, and to improve the health of the population in Northern Ireland.
Q170 Chair: Can I start with an observation? Outcomes from common illnesses, cancer, stroke and heart attack, in Northern Ireland fall significantly short of those that could be expected in the rest of the United Kingdom. The determinants of ill health are well known. However, what is perhaps not easily explicable is why the chance of a good outcome for people who have those conditions is significantly worse in Northern Ireland than in the rest of the country. I wondered why you think that might be.
Dr McBride: It is important to look at the figures. If we take cancer, for example, we know that the decisions we make on a daily basis about levels of physical activity, our diet, levels of obesity, social and economic deprivation, which is linked to all the above, have a fundamental impact on risk factors for cancers. If we look at the data from our cancer registry in Northern Ireland, across the four main cancer groups we compare very favourably, in terms of outcomes, with the rest of the United Kingdom.
As a matter of fact, while we must be cautious in comparing regional outcomes, because there is some variation across the UK in how we measure outcomes, if we look at the four main cancer groups, so that is breast, prostate, colorectal and lung, our overall survival rates in Northern Ireland, as assessed by the Northern Ireland Cancer Registry, compare very favourably with and, indeed, are better than the rest of the United Kingdom. In terms of cancer, if we look at five-year survivals in Northern Ireland, six out of every 10 people are now surviving more than five years, and five out of every 10 more than 10 years. If we look at colorectal cancer, we have seen an 11% increase in survival over the last decade. If we look at prostate cancer, we have seen a 28% increase in survival. We are treating more people with cancer, despite more cancers being diagnosed, and our outcomes are better than they have ever been.
Q171 Chair: What about the cancer strategy, which was written in 2008? It is 10 years old now. Clearly, it is pretty much out of date. The World Health Organisation makes it very clear that a well-conceived cancer strategy is essential for improving outcomes in cancer and cancer care. We are way behind in Northern Ireland, are we not? I accept the lack of a Minister makes it very difficult to sign off such a strategy, but I assume you have a strategy ready to go when Ministers appear. Would that be correct?
Dr McBride: It is also fair to say that strategies themselves do not treat patients, do not prevent cancer and do not improve outcomes.
Q172 Chair: With respect, that is not what the World Health Organisation says. I think we all accept that bits of paper do not improve patient experience directly, but they are pretty essential on a population basis.
Dr McBride: That is the point I was going on to make. It is all about implementation, what we do on the ground to improve interventions to prevent cancer, early diagnosis, more timely and effective treatment, what we do to audit our performance in cancer, benchmarking against peers, across the best in Europe and beyond, and what we do to improve it. It is all about what we are doing.
The Department has now made clear that matters that commit it to long-term strategies and long-term resources are rightly and normally matters for a Minister. However, the Department has indicated that, in the context of the Northern Ireland (Executive Formation and Exercise of Functions) Act, it will now consider, as was the commitment of the then Minister, keeping the situation in regard to a cancer strategy under review.
It would be wrong, however, to create the impression that we have been doing nothing. The outcomes we have seen, the improvements I have just mentioned, would reflect that. Building on the cancer strategy in 2006, we have our cancer framework, which sets out to 2024 the actions and priorities for improvement, actions around prevention, right the way through to audit and research. We have a cancer service framework that was published in 2011, which is currently being refreshed, along with the cancer framework action plan, which is being updated. Those are very live and ongoing documents. We have also recently, under Delivering Together, announced a major review of oncology—that is a non-surgical cancer service—around service improvement, looking at improving patient pathways and outcomes.
There has been significant investment in cancer. Last year, the investment in cancer drugs was £38 million, 10% up on the year before. We invested, working with Macmillan Cancer Support, in 42 cancer nurse specialists. We invested £60 million of capital in the North West Cancer Centre, and £2.5 million of capital to update the equipment within our regional cancer centre within the Belfast Trust.
I understand the frustration of the cancer charities: I have met with them. I can say that the Department is fundamentally committed to improving cancer services in Northern Ireland. We know the challenges we face with an ageing population. We are shortly going to move into a situation where instead of one in four of us getting cancer, or expecting to, one in two of us would, again because of the ageing population. That will create a significant burden, not only on public health services and what we do to prevent cancer, through cancer screening and earlier diagnosis, but also on cancer treatment.
Q173 Chair: On screening, the UK National Screening Committee has recommendations that are followed by the United Kingdom, other than in respect of cervical and bowel cancer in Northern Ireland. Faecal immunochemical testing and tests for human papillomavirus for cervical cancer are not followed in Northern Ireland, uniquely. I am wondering why you think that is.
Dr McBride: The only part of the United Kingdom that at this point in time uses faecal immunochemical testing is Scotland, and that has been the case since 2017. You are quite correct that the other parts of the United Kingdom, England and Wales, have given a commitment to introduce that--England from the autumn, I understand, and Wales from January next year. In the absence of a Minister, the Department has directed, because it is a significant policy change, a significant financial commitment, with other significant financial constraints—
Q174 Chair: It is not, is it? It is reckoned to be more cost effective than faecal occult blood tests.
Dr McBride: Indeed, but there are still significant additional costs for us to put that in place. The Department has directed the Public Health Agency to put in place all the necessary preparatory steps in advance of a departmental decision, or for an incoming Minister to make a decision, in respect of the introduction of the FIT. That, for instance, includes specifying the procurement of the tests and looking at the call and recall pathways, any changes that are required there, in terms of IT investment.
Q175 Chair: Can I ask when that will be up and ready to go? The reason I am asking this is because at some point a ministerial decision will have to be made, I imagine, to give the green light to this. I imagine also it would be possible for a calculation to be done of the lives saved through this particular intervention. The question would then arise, inevitably, of how many lives are being lost by virtue of a failure to make a ministerial decision in these matters.
Dr McBride: There has not been a decision not to make a decision. There has not yet been a decision. I am saying to you that all the necessary preparatory steps are being made. The Department has directed that those happen. There will come a point, quite correctly, where the Department will either have to make that decision or decide that it is appropriate to wait until such time as there is a Minister to make that decision.
Q176 Chair: Would you be content with the current level of guidance the Secretary of State has issued to the Northern Ireland Civil Service? Do you think a decision on whether to go ahead with FIT could be made within the constraints of that guidance?
Dr McBride: Certainly the guidance is helpful. I would just reiterate the point in your introductory comments that civil servants are no substitute for democratically elected, accountable Ministers.
Q177 Chair: I think we can all agree on that. I am sorry to push you on this, but what I am trying to get at is whether the absence of a Minister is going to delay the introduction of this particular screening test in Northern Ireland.
Dr McBride: It certainly has a bearing on it, but the Department is looking at each of these scenarios, each of these policy decisions, on a case‑by‑case basis. If the Department, based on legal advice, looking at the new guidance, feels that there is a compelling public interest in introducing a new service, it will make that decision. If, however, we determine these matters are not critical, we should rightly wait for an incoming Minister to make that decision. We will not, as a Department, delay or avoid administrative decisions that will have a fundamental impact on public health and wellbeing.
Q178 Chair: Not least because, as you rightly pointed out, there are set-up costs around this, which presumably imply opportunity cost elsewhere in the service.
Dr McBride: There are indeed, yes.
Q179 Ian Paisley: For the record, I need to declare that my daughter works in the NHS. With the absence of an Executive in Northern Ireland, is staff morale impacted? Do you have any indicators on that? Do you do any work around that?
Dr McBride: I do not; that is the honest answer. I can say that, in meetings I have had with clinical and managerial colleagues and clinical teams throughout the health service in Northern Ireland, certainly in recent months, I detect a growing sense of enthusiasm and ambition for the transformation journey we have embarked upon under Delivering Together. That was a blueprint for transformation that the last Minister, the last Executive, left us with. We have been getting on, building, I believe, strong foundations for the implementation of that.
We have seen a number of changes to how we do things. We have looked at, for instance, better systems and more support in primary care. We have rolled out prototypes in multidisciplinary teams, so that is physiotherapists, mental health specialists, practice-based pharmacists, all working in primary care to support more people in the community closer to home, supporting general practitioners, freeing up general practitioners’ time, giving them more access to skills.
We have just recently announced a move to prototypes for elective care centres for cancer. We know that, when you try to provide unscheduled emergency and urgent care, and elective services, on the one site, both get compromised. Despite this, two-thirds of all elective care in Northern Ireland, surgical procedures, is provided on sites where they have emergency care facilities. We have announced new elective care centres, which will be treating people with cataracts, with varicose veins. We have a 30% increase in productivity. That will mean staff moving from hospitals to other hospitals and patients, yes, travelling further.
We are beginning to see tangible signs of change. We announced a new review of emergency departments earlier this week. The Department announced that based on work where we looked at the population needs of an ageing population, basically saying our current model of services is unlikely to be able to meet that demand. I think people feel engaged in that transformation work. We see an opportunity with the transformation fund to build momentum, to test new models, new ways of working. That has buoyed up spirits at a time when, in the absence of an Executive, in the absence of Ministers, that could have had a potentially damaging impact.
Q180 Ian Paisley: I have no doubt that most of the public see the work of the NHS and that it is making valiant efforts under very difficult circumstances. For most people, the outcome when they go in and use the NHS is that it works for them, but there are then these challenging issues and people feel those pressures. Is there any point at which transformation is really being held back because there is no Executive, or are you just getting on with it anyway? Is it a fact that, without ministerial push, it does not get the turbocharge it really needs to make it happen?
Dr McBride: As I said before, there is no substitution for democratically elected, accountable Ministers. It has been challenging in the absence of Ministers. We can do much preparatory work, through the collective leadership strategy and workforce strategy, to put in place the foundations for a transformed health and social care system. I have given you some examples. There are other examples around what we are doing in imaging, pathology review and a number of significant other areas. Making permanent changes to the service model, making fundamental commitments to change in policy or strategy, or committing resources in the long term, will require the machinery of government and Ministers to be in place to make those decisions.
Q181 Ian Paisley: What about the issues right at the coalface, in terms of nursing pay and things like that? That is a thing we come across every week. It would not be a week that went by without service staff contacting us and asking us about this. Where does that lie with you?
Dr McBride: Obviously, as both a doctor and Chief Medical Officer, pay and matters in relation to budgetary priorities and funding do not fall within my specific professional policy remit. I think it is fair to say that the rewards staff feel they receive, in terms of both remuneration and how they are valued, are very important to your first point, which was around motivation. The perceived pay disparity across the United Kingdom has been a source of demotivation to an extent.
Q182 Ian Paisley: You can spare my blushes on this; we get it every week. Assembly Members are being paid and they are not doing a job. That has been said to us. But nurses are not being paid enough and they are working 24/7. That is the way it is put to us. Surely that has an impact on your staff. We get it. Do you get it? Are there things that you can do?
Dr McBride: Undoubtedly, feeling valued, whether it is the patient who says thank you for a job well done, whether it is a senior colleague who says thank you for a job well done, whether it is a sense when you go home at the end of the day of having contributed to making a difference to someone’s life, through what you have said, what you have done, or just being there to listen, that is important. Also, how you are valued in terms of your remuneration is crucially important.
One of the advantages of the Northern Ireland (Executive Formation and Exercise of Functions) Act was that the Department was able to, in mid‑November, make an offer in relation to pay within the health service. That was following the Department of Finance being able to put in place the public sector pay award. The Department moved very quickly to make an offer, and I understand that is under active consideration by the unions. Pay is important; of course it is important, and it is increasingly important where we are competing in a global marketplace for, in many respects, very skilled professionals whose skills are increasingly in demand across all parts of the world. We are engaged in international recruitment in nursing and in a number of other professional groups.
We need to be able to ensure that Northern Ireland remains an attractive place to work, that people feel appropriately remunerated and valued. Indeed, that is why the workforce strategy, which was launched back in May, is so crucially important. The ambition within that is not only that we have the workforce we require to work within a transformed health and social care system in 2026, but that we are actually meeting the needs of that workforce. That also requires us to look at what we are doing in terms of staff health and wellbeing, occupational health services and non-financial remuneration, so we in Northern Ireland can be an employer of choice in health and social care.
Q183 Ian Paisley: I want to come on to an issue of policy. There are going to be changes to the abortion law in the Republic of Ireland. A pathway has opened in NHS England, which has been quite controversial, for the provision of abortion services by NHS England for citizens of Northern Ireland. What challenges and confusions does that throw up to your staff in Northern Ireland, if any?
Dr McBride: From March 2016, we have had guidance in place. It took us a number of years and several judicial reviews to put guidance in place in relation to the law on termination of pregnancy in Northern Ireland. That guidance is clear. It is unequivocal in terms of the law in Northern Ireland and the very restricted circumstances where termination of pregnancy is permissible. That said, there have been changes in relation to making termination of pregnancy publicly available to residents of Northern Ireland. We have seen an increase in women travelling from Northern Ireland to England and Wales for termination of pregnancy. Our guidance, which is there for all health and social care professionals, makes very clear that it is lawful for health professionals in Northern Ireland to advise on services that are available in other parts of the United Kingdom. There is no equivocation about that.
I was tasked by the then Health Minister, at the request of the then First Minister, to undertake a piece of work looking at the law in respect of the termination of pregnancy in Northern Ireland. I chaired a cross‑departmental group, which recommended to Ministers a change in the law, in terms of when there was a diagnosis of fatal foetal abnormality. Unfortunately, that recommendation was not considered by the Executive before the collapse of the Executive, although the recommendation was then placed into the public domain, in view of the wider public interest test. Based on that, I would recommend to Ministers that the law in Northern Ireland in relation to the termination of pregnancy needs to change, at least in the narrow terms that I was asked to look at it as Chief Medical Officer, in terms of fatal foetal abnormality. Ultimately, that is a matter for Ministers. It is not a matter for me. It is for the legislature in Northern Ireland to make that determination in due course.
Q184 Ian Paisley: Can I come on to the issue of community pharmacy? They have been with us and they lobby us all very extensively, but last week they issued a statement that wholesalers will no longer supply community pharmacists because of their inability to pay for certain drugs. Surely that is going to put massive pressure on the service delivery by the NHS.
Dr McBride: I do not know the specific details of that particular issue, in terms of retailers and supply. Community pharmacists are a vital part of health and social care in Northern Ireland. There has been basically a financial envelope indicated by the Department, which is, for 2018-19 and 2019-20, some £104 million, with an additionality of, I understand, as I recall, some £11.1 million. As Chief Medical Officer, I do not have direct professional policy responsibility for this area, but I work very closely with the Chief Pharmaceutical Officer. I know there is absolute recognition of how integral community pharmacy is to the delivery of health and social care.
There is an absolute commitment by the Department and the Health and Social Care Board to work with community pharmacy colleagues and their representatives to ensure we sustain community pharmacy in all our communities. That package, that £104 million and the additional £11.1 million, included £9.1 million to support rural pharmacies. It included additional support for services that had not previously been commissioned, to ensure adherence to medication of individuals who are receiving social services such as domiciliary care. We have also invested £2.1 million of transformation funds in a pharmacy first scheme, which will start this winter, recognising that pharmacists are probably the most frequent point for contact of the public with the health service.
Q185 Ian Paisley: That point of contact is the very point. The wholesalers will no longer supply certain drugs because pharmacists cannot pay for them any more because of the historical lack of funding, which £9 million goes a very short way to trying to fill. If they are not able to pay the wholesalers, the patient is no longer going to go to the community pharmacy. They are going to go to the NHS. That is bound to have a pressure. Are you putting anything in place to cope with that, in the absence of pharmacists getting an adequate and proper payment in line with the CoSI recommendations?
Dr McBride: The CoSI recommendations were one part of the assessment of what the financial envelope would look like for community pharmacy. The margins survey, which was also looking at the profit on drugs, was the other element of that. The CoSI in itself, which we commissioned as a Department, was never designed to determine what the financial envelope was like, but to inform it along with other inputs.
Q186 Ian Paisley: But it was your work.
Dr McBride: It was our work, but it was always—
Q187 Ian Paisley: It was your work and it said community pharmacy was short changed by, what, £100 million?
Dr McBride: It was never meant to determine the financial envelope. We have also looked at the margins survey, which is the profits on drugs. There is no doubt that over the last period of time there has been significant fluctuation in that profit on drugs because of costs of drugs. That has created some very significant financial challenges for community pharmacy.
Q188 Ian Paisley: If you were a pharmacist, and I had commissioned work, which told me the value and the gap, then I said, “That is only part of the story”, would you not feel a wee bit annoyed? “Actually, your own work has shown where the gap is and now you are not prepared to put the money in”.
Dr McBride: You understand I was not intimately involved in this.
Q189 Ian Paisley: I know. I am just saying, in those circumstances, that is the dichotomy.
Dr McBride: I understand the heads of agreement were agreed in relation to a draft contractual agreement. There was an agreed process in terms of the various elements that would inform that financial envelope. The cost of service investigation that you mentioned was one element of that. The margin survey was another.
As I have said already and has been acknowledged, the Department faces significant financial constraints and many priorities across a number of budgetary areas. With what we spend here, we essentially have to make difficult decisions about what we do not spend there. We do not have the luxury of spending money that we do not have. Some difficult decisions have had to be made of late. Difficult decisions will continue to have to be made. I can assure you of the absolute commitment of the Department to working with community pharmacy colleagues to have an agreement in place, and the complete value we place in community pharmacy for the contribution they make.
Q190 Ian Paisley: Finally, you said in one of your earlier answers that it is important that your staff get gratitude and thanks from senior staff. I think it is important that publicly we say thank you to the NHS in Northern Ireland and to all your staff, whether at management level, grassroots level or whatever, who are delivering that. In a very particular area, can I say thank you for the work you have done around the milk bank and making sure that service is now available again? I know for a while it had broken down. There had been a problem there.
Dr McBride: There had been, yes.
Q191 Ian Paisley: I know staff in the Antrim Area Hospital in particular went to very long lengths to make sure breast milk was available to premature babies. I know those efforts have been greatly appreciated. Importantly, they have the service up and running again, and efforts were made to do that. It is important that we publicly say thank you to the NHS for doing that and for achieving that.
Dr McBride: Those comments are greatly appreciated. Thank you very much indeed. I shall relay them to colleagues.
Q192 Mr Campbell: I just wanted to ask a general question around Bengoa. At the time I left the Assembly, there appeared to be an emerging consensus. Up until that point, at any stage when radical change was suggested in the health service, it became very political. The party of the Health Minister would obviously rally behind the Health Minister and other parties would criticise the suggested change. Bengoa appeared to signal some sort of political change. Is that your view of where we still are, in the absence of a Minister?
Dr McBride: I believe so. Professor Rafael Bengoa had many skills and attributes, and previous experience, which placed him well for the role he was tasked with. He was a former general practitioner, public health expert, worked for the WHO. He was a former politician.
Mr Campbell: You cannot have it all.
Dr McBride: He certainly had most of it. He understood many worlds. He understood the world of healthcare delivery at the sharp end, as a professional. He had himself been responsible in the Basque region for significant reform on health. He had the scars to show that. He was very clear that there was a need for a political consensus, as far as a political consensus can be achieved, that recognised the unassailable case for change. I think that case was accepted.
It was a very powerful visual expression of that when we had the Health and Wellbeing 2026: Delivering Together, a process launched by a former colleague of yours, a former Health Minister. It was then launched by the Health Minister at that time, Michelle O'Neill, flanked by the First Minister at that time and the Deputy First Minister at that time. That basically said this was the Executive owning the transformation of health and social care, indicating this was a 10-year journey of transformation we were on, agreeing it would require additional funding over and above that used to maintain existing services. That message was not lost on the public, nor indeed was it lost on those working in the health service.
As Ian mentioned earlier, there is a sense of being all aligned, all pointed in the one direction, “must do, no alternative”. As I said some years ago in my annual report, I think in 2015, “no” and “slow” are not options in terms of the need for transformation. If we continue to provide health and social care services as we are currently doing and we do not change that, we will not be able to meet the needs of the population.
We announced, for instance, a piece of work looking at how we provide urgent and emergency care, a major review of that across Northern Ireland, earlier this week. A large part of that was driven by a population‑needs assessment. If we look within the next eight years, we are going to see 74,500 more people living in Northern Ireland over the age of 65. That is twice the population of Ballymena, in Ian’s constituency. If we continue to deliver services as we are currently doing that would translate into somewhere in the region of 540 additional beds, because we will see 13,000 or thereabouts additional admissions to hospital. We have somewhere in the region of 770,000 attendances to our ED departments every year, translating to over 200,000 admissions. We simply will not be able to cope. We simply will not be able to provide the quality of care, the experience of care, that the ageing population requires.
Therefore, we need to do things very differently. That is why, as I alluded to earlier, we are doing some of the work on transformation, building support in primary care with multidisciplinary teams, acute care at home, so we have experts, physios, occupational therapists, care of the elderly physicians, managing people in their home, rather than them coming into hospital. When you do need to come into hospital, if you are an older person, there must be a direct assessment unit, so you are not sitting in an emergency department waiting. We know the majority of those people who wait longer than 12 hours are very old and probably least best placed to wait that length of time. We need to do things very radically differently.
Q193 Mr Campbell: I am glad to hear you saying that, Dr McBride. Each year, particularly each winter, we hear about the winter pressures, and there is usually some extra money found for A&E, etc. By and large, we, as politicians, still get lobbied. I get letters every day from relatives of elderly people who are in the position you have just described generically. The waiting lists are there and they are getting longer. People do not see any material improvement year on year. In fact, they see it deteriorating. This is my question to you: do you detect, in the wider political body, as I do, there is the appetite for the transformational change that needs to happen, which will get support within the wider community?
Dr McBride: My answer to that is yes. I believe so. While we do not have an Executive or an Assembly, we have elected representatives and we engage on a regular basis with those elected representatives. They very actively continue to engage with us on a range of important and key issues, as you have described. In those conversations, I believe there is an absolute understanding of the case for change and the need for change. I am confident that, when we have the Assembly and the Executive restored, we will be able to build on that. I am confident that eventuality will occur, although I suppose as Chief Medical Officer I should not be making any political predications of that nature, so I would heavily caveat that. Perhaps it is my pathological optimism, in terms of seeing restoration of the Assembly and the Executive.
I would hope that, in the interim, in terms of the foundations of transformation under Delivering Together, working on the blueprint we were left, we will be able to demonstrate to incoming Ministers and elected representatives that we have worked with the people who use our services, worked along with the people who work in our services, and developed some new models and new ways of doing things that command the confidence of all. I would hope that would create a different conversation with political representatives, elected representatives, whereby they can see the real benefit.
You know better than I that it is sometimes difficult even to make the right decision politically because of other considerations. We have a responsibility, using this time effectively, to create the circumstances where those political decisions can be better informed, because of the evidence we have accumulated, and more readily supported, because of the confidence we have commanded among those who use the service and those who work in it.
Q194 Mr Campbell: This is my final question. Given the scale of the change we need to contemplate and undertake, and given the significant resource that will entail, what is your sense of the Department of Health’s concept of what is going to be required? Then obviously it will come back to an incoming Executive to try to fund.
Dr McBride: Again with the caveat that matters of funding and budget priorities are outwith my professional competence and remit, I think we have a clear understanding of what we need. That includes maintaining existing services in the interim, because we will need to maintain how we currently do things while we transform. In many respects, there will need to be a period of double running, because we cannot just turn off how we are currently doing things and switch to a new way of working. We have to test those new ways of working. We have to build confidence in those new ways of working. We will need, and continue to need, in my view, ring‑fenced resource to support transformation. At the same time, we need to be on a sounder financial footing in respect of our recurrent baseline funding.
Unfortunately and regrettably over the last number of years, we have been largely dependent on in-year monetary rounds and non-recurrent funding. It is very difficult and challenging to bring about change in the health service in a financial year. It is very difficult to bring about transformation when you have money that is non-recurrent. You need to recruit staff. You need to put new services in place. Longer-term budgetary cycles, more certainty, examination of what our baseline budgetary position is, and a continuation of moneys to allow us to transform the health service and that being ring-fenced, would be very advantageous. Nobody has a money tree and I am realistic about the challenges and constraints we face.
Q195 Jim Shannon: First, may I thank you for all you have done so far and will continue to do? We appreciate your efforts. Just to follow on very quickly on the issue of Community Pharmacy NI, I met Gerard Greene four weeks ago when he was in Westminster here. I will just quote his words: “It is not surprising to learn that several wholesalers have contacted the Department regarding this. We have been telling them for some time that community pharmacy is on its knees and cannot pay its bills”. The £9 million that has been allocated is far short of what is needed just to keep it going. Ian has made points on it, points I would endorse. We are going to have a meeting with Richard Pengelly as a party collectively on this matter, because we feel very strongly that the pharmacies have a key role to play in the early diagnosis and early intervention that you have clearly expressed in answers to others.
I just want to make this point very quickly, again because I have met these people. It is the BDA, the British Dental Association. They referred to the HPV vaccine. They have also referred to the fact there has not been an oral health strategy in Northern Ireland since 2007. I have met them a few times as a member of the Assembly but also as a member of Westminster. How do we hurry those things on? Very quickly, on the type 1 diabetics and the insulin pumps, these are all issues I am meeting every day in my constituency. I am meeting them because I have a number of constituents who fall into that category. The number of type 1 diabetic children is the highest in all the United Kingdom in proportion to the population. How do we make money available for those things?
Just very quickly, on the supply of medicines, to go back to the pharmaceutical thing, last weekend, I was made aware by some of my constituents that there seems to be a sort of quota system in relation to medicines and pharmacies at this present time. People have told me they went down to get their diabetic treatments and were told, “We have run out of our quota this month”. I cannot quite understand how that works and how that could be. This is in my constituency. The honourable Lady for North Down is here, and some constituents from her constituency as well have informed me they have not been able to access their diabetic drugs because of a quota. What quota is this? They are told, “Come back on Monday. We do not have any in place”. Is that because they are not able to buy the drugs, or because there is something else happening? Those are the questions, very concisely. I will never do this again. You will probably never hear me doing this again.
Dr McBride: I am not even sure I got to write all those down, but please prompt me as I go through. To the last point about supply and quota of diabetic drugs, I am not familiar with that issue, Jim. Certainly if it is something you wish to raise with us, the Department, I am happy to seek to respond in due course. I am not familiar with the details of that.
Jim Shannon: I will do that.
Dr McBride: In terms of HPV vaccinations, gender-neutral vaccination, as I have said before, these are policy decisions that have long-term financial commitments. We are mindful of the recommendation by the JCVI. We again, as a Department, have directed the Public Health Agency to put in place all the necessary preparatory work pending a decision on that. We must recognise the incidence of the HPV types covered by the vaccine has been declining in the population because of the really good uptake among young girls. That is to be commended. There is also the vaccination programme with men who have sex with men, which has been in place since the recommendation in October 2016. There is no doubt that, in terms of oral cancers, and other non-cervical cancers, HPV vaccination in boys is something we are actively looking at and PHA is actively planning for.
In terms of diabetes, you will be familiar from our previous correspondence that we have a diabetes strategic framework in place from 2016. That was based on a review I did for the then Minister back in 2014. We have a diabetes oversight board, which looks to the implementation of that, and a Diabetes Network, comprised of clinicians and service users, that sits beneath that and is largely responsible for its implementation. Just to reassure you on the issue of insulin pumps, there is an investment plan for somewhere in the region of £3 million to £4 million over the next number of years in diabetes services. The action plan for the first three years includes improving access to insulin pumps, improved diabetic foot pathway and improvements to structured diabetic education, for both type 1 and type 2.
Q196 Jim Shannon: We really need to make some effort on access for the children and for their parents who have to personally fund that at this moment in time. That is just a point.
Dr McBride: There is no doubt that is an area that needed to be improved. I said earlier that we are very live to that and are seeking to progress.
On the oral health strategy, the chief dental officer has again met with the British Dental Association. Historically, we had some of the poorest dental health in the United Kingdom. That has improved significantly over the last 30 years. We have seen a 65% improvement in oral health, particularly in our children. I appreciate this is still not where we would want to be, but in a 2013 survey we saw that, for under-fives, six out of every 10 were free of dental caries. For over-12s, four out of 10 were free of caries. A lot of that has to do with factors that are less related to an oral health strategy and more related to dietary intake of sugar.
We know in Northern Ireland that our children take in three times the amount of dietary sugar in soft drinks. It is also related to less frequent visits to dentists, which we know is the case, and less frequent use of fluoride toothpaste. Other parts of England have benefited from fluoridation of water. I proposed that as Chief Medical Officer at a point in time in Northern Ireland and I still receive emails on the subject. It was not well received by the public. In terms of particularly the disproportionate impact in relation to health inequalities in deprived areas and poor oral health in more deprived communities, fluoridation of water would remain a significant advantage, were that acceptable to the public and were our Ministers in agreement with that. I am not sure I covered all those, Jim. Were there a couple of others?
Jim Shannon: Perhaps we will correspond, to be fair.
Q197 Chair: I think so. Can I just ask very quickly about radiologists? I know this is a problem right the way throughout the country, but particularly in Northern Ireland. What are you doing to address that? To what extent do you think the shortfall could be made up by having remote radiology—that is to say, reading tests hundreds or thousands of miles distant potentially—to deal with the fact you seemingly cannot attract radiologists to actually work in Northern Ireland?
Dr McBride: As you say, it is a problem right across the United Kingdom. It is not a made in Northern Ireland problem, but we do have significant vacancies in radiology in Northern Ireland. I will maybe start with your last point first. There is no doubt that remote reporting, distance reporting, has significant potential and is something we are looking at, but in the future as well, as we look to artificial intelligence. In terms of reading at volume and numbers of images, there is significant potential there, as there is in looking at histopathology and all the rest of it. The future, in terms of artificial intelligence and computer assisted technology in that area, is significant, in replacing some roles that some disciplines, in terms of radiology, currently do.
In terms of radiology, we have a significant problem. We have been working over the last four years in the development of an imaging strategy. It was published in June. We committed £10 million of resources in 2018-19 to make up the historical gap there was between the demand for the service and our capacity to deliver. The imaging programme board, which was with frontline clinicians in a multidisciplinary way, identified issues as they went along. One of the issues they identified was that we did not have sufficient trainees in training. Over the last four years, we have increased the number of radiology trainees from 35 up to 70. The first of those will be going into the workforce this summer.
We have also identified a number of strands of work for improving networks, for instance around paediatric radiology, obstetric radiology, cardiac radiology, improving ICT. We are currently taking forward arrangements to put in place a new Northern Ireland picture archiving system so we will have digital imaging that can be transferred across Northern Ireland. That is replacing an existing system, which I was the senior responsible officer for, that was rolled out previously in Northern Ireland. We are looking to standardise care. The imaging review itself had eight key guiding principles, including that imaging services should be provided as locally as possible and that there was an ethos of research. It made 19 recommendations, which we are currently working our way through in a strategic way. Obviously the pace at which we implement that will be dependent on resources.
Q198 Chair: Do they just depend on resources, or, again, do you think there is a need for ministerial decision-making in the process?
Dr McBride: On this one we are making progress. We have committed resource. For instance, building over the next three years there will be £3.3 million of recurrent resourcing.
Q199 Chair: The absence of Ministers is not a roadblock in this particular instance.
Dr McBride: We are making progress. We will make progress. One of the recommendations within the review was the creation of an imaging board because at the moment imaging services are really provided within the five health and social care trusts in not such a co-ordinated way as they should be. The establishment of an imaging board and an imaging service for Northern Ireland will require a ministerial decision. In the interim, we are proposing to maintain the project board for the imaging review to ensure oversight of the implementation of recommendations and to maintain the very significant clinical engagement there has been. They have shaped and informed this, and pointed to where new technologies can assist. They have also pointed to the here and now issues we really need to get on and address.
Q200 Chair: I certainly encourage you in that. It does seem remarkable, for those of us perhaps who have intimate visibility of healthcare within the rest of the United Kingdom, that there should be five health boards dealing with radiology in a relatively small population. That is clearly not sustainable and needs to be unified. I am sure you appreciate that.
Dr McBride: That was a key recommendation within the report.
Q201 Maria Caulfield: Just to follow on a point by the Chair around staffing and staff resources, although funding does not necessarily come under your remit, we have heard from the Chartered Society of Physiotherapy in Northern Ireland and other health groups to say pay for health workers in Northern Ireland is significantly less than the rest of the UK. That is contributing to staffing problems and low morale. Is that your sense? Do you agree with those who say that?
Dr McBride: I cannot disagree with that. It is clearly a view that is expressed and held. I have no doubt that is a sincerely held view and opinion. Across the NHS and the health service in Northern Ireland, there is absolutely no doubting the commitment and dedication of staff. As we head into a particularly challenging period across the NHS and the health service in Northern Ireland, the importance of staff being motivated and feeling valued is crucial. The remuneration and pay of staff is a crucial measure of that. As you look to the disparity of pay with colleagues working elsewhere within the United Kingdom, setting aside the money in your pocket, I can see how staff interpret that as being a reflection of how much they are valued.
Q202 Maria Caulfield: While, say, a nurse in England will be looking to get a pay rise, and the Government have lifted the cap on that, is that happening in Northern Ireland?
Dr McBride: As I mentioned earlier in response to a previous question, the Department of Finance has now set the public sector pay for Northern Ireland. For each Department now, that cap has been lifted to fund a pay offer in line with resources we have available. We did make a bid in October monitoring for additional resources in relation to the agreement in England around Agenda for Change and the three-year deal. We secured some but not all that money and we have been able to, in mid-October, make an offer to the unions in regard to pay.
Q203 Maria Caulfield: Typically, that would be done at a ministerial level, would it not?
Dr McBride: Yes.
Q204 Maria Caulfield: Are you having to pick up the pieces, in a sense, because there is not a Minister in place, to push for a pay increase and pay review? Is that falling on your shoulders without a Minister in place?
Dr McBride: It is probably falling on the shoulders of the Permanent Secretary, and the Permanent Secretaries across all Government Departments, more acutely than on mine. There is no doubt that those decisions would normally be made by Ministers, democratically elected, and by the Executive. Decisions on the budget and the allocation of budget to Departments would normally be proposals made by a Minister and agreed by the Executive, following debate in the Assembly. Matters in relation to pay would be similarly agreed.
Obviously, as was referred to earlier, the Northern Ireland (Executive Formation and Exercise of Functions) Act gives some additional powers to Departments. Following the implementation of that, on 1 November, the Department of Finance felt able to proceed to and indicate a public sector pay award on the back of that, almost immediately. In recognition of the points you were making about frustration of staff, we moved to make an offer on the back of that.
Q205 Maria Caulfield: I have also been contacted by Community Pharmacy NI. They say there is a specific issue around community pharmacies, that, because they are underfunded, drug companies are reluctant to provide them with medication because their credit history or their creditworthiness cannot be guaranteed. Is that something that is realistically happening in Northern Ireland?
Dr McBride: Again, I apologise. I am not really across the details of that specific issue, in terms of the standing of the credit rating of pharmacy owners.
Q206 Maria Caulfield: Are you finding that community pharmacies in Northern Ireland are struggling financially to keep going, to provide services to patients? Is it having an impact on primary care?
Dr McBride: From discussions I have had with colleagues who are pharmacists, who provide community pharmacy services, I know they, at a personal level, are feeling the strain and the pressure at this time. There has been, as I said, a fluctuation in drug prices. That has not, in recent times, been to their favour. There is a commitment for us to work to ensure we have an affordable financial envelope that will provide for maintaining community pharmacy services, because they are so essential, and is aligned with delivering the best patient outcomes that we can. The difficulties in all this are the conversations we have already had about many other competing priorities, all of which require resource in the context of the very financially constrained budget we have within the health service.
All these things are important and, in the absence of sufficient baseline recurrent funding, we are in the situation of having to make extremely difficult choices, and not necessarily always being able to fund fully or totally all the things that we wish to fund. Some of those things may then have to—
Q207 Maria Caulfield: Across the NHS, across the UK, there will always be funding pressures. Specifically for Northern Ireland, is it that the funding is adequate but there cannot be the decisions made to divert it to the appropriate places, or that the lack of an Assembly means there is no one putting pressure on Treasury in Whitehall to say there is a desperate need for more funding specifically for health in Northern Ireland? Is it a combination of both? Is there a lack of decision-making locally in order to prioritise that funding, or is it that Northern Ireland, as a whole, needs more funding and there is no one pushing Treasury for that?
Dr McBride: Again, these matters are probably more appropriately directed towards the Permanent Secretary, who I understand is coming to see you in January and, if it would be helpful to the Committee, I am happy to provide a briefing paper on those very issues, so that it might inform that discussion. I can give you my professional view, as a doctor, as Chief Medical Officer, not as someone with policy or professional responsibility for such matters. I am beginning to extend the conversation and discussion well outside my remit. In my view, Northern Ireland does not have the baseline recurrent budget required to provide the service as currently configured. It needs to reconfigure how it provides services. I do not think that that reconfigured service will allow significant and sufficient savings to be built back into how we deliver services in a different way.
Q208 Maria Caulfield: You need more funding.
Dr McBride: Let us take one practical example, waiting times. We have discussed them here and they have been discussed in earlier evidence to the Committee. We made significant progress between 2005 and probably the midpoint of 2014, and I was there for some of that. That was largely dependent on non‑recurrent funding, which was made available to us by the Executive, and was directed into in‑house additional capacity within our hospitals and in the independent sector. In the latter part of 2014, that money dried up. The financial constraints on the health service became increasingly acute and since that time we have seen lengthening waiting times, which have been a source of huge frustration to patients, who are waiting unacceptably long times for treatment and care, but also for the staff working in the health service.
We need to get into a position where we have a sustainable funding baseline for the health service. In my view, as I said earlier, we need to be able to transform how we do things and that will require, as we have had the benefit of the moneys under the confidence and supply agreement, ring‑fenced money to do things differently while we continue to evolve and change how we are currently doing things.
Again, pointing to one of the key findings in Professor Bengoa’s report, as the Minister indicated when launching Delivering Together, the health service has the potential to, in Northern Ireland, bankrupt all other Government Departments and all other public services. This is due to the change in demographics, ageing population, innovation, rising public expectations, rightly so, with all of us living longer, but not necessarily living longer, healthier lives. A lot of what we do, as well as doing things differently, as well as reconfiguring how to provide services, new drugs and new treatments, needs to be looking to spend more on prevention.
On primary prevention, what are we doing in terms of public health policy on alcohol, obesity, physical activity, addressing some of the contributing factors that Jim mentioned in relation to type 2 diabetes? We project that, by 2026, which is not very far away—within the next eight years, I think, but that is why I am not in charge of the money—within the next decade, we will have 45,000 more people living with diabetes in Northern Ireland, at a cost of some £400 million. That is why prevention programmes and early intervention are so crucially important. We know they are effective. We know from research by Public Health England that diet‑based, intensive physical activity‑based programmes for individuals at elevated risk of diabetes, who can be identified by their GPs from a simple blood test and assessment, can reduce that risk by some 26%.
That is the span, I suppose, of the competing priorities we have. It almost feels, at times, like whack‑a‑mole. We are over here, and we need to do more and spend more on treatment and care; of course we do. Equally, we spend, probably, across the United Kingdom 5% of our healthcare budget on prevention and we need to increase that percentage spend if we are to have an impact on the pressures we are currently seeing in the health service.
Q209 Mr Goodwill: You just touched on the issue of obesity and I know that is one of the factors that will be front and centre in your public health dashboard. Indeed, the figures show that this is a battle that we are losing. Northern Ireland seems to be suffering an Ulster fry‑fuelled obesity epidemic. Indeed, when you look in the newspapers, hardly a day goes by without another condition being linked specifically to obesity, whether that be, obviously, diabetes, or things like dementia and cancers. What are the long‑term consequences of this situation if we do not manage to turn the trend around?
Dr McBride: We know that being overweight or obese reduces life expectancy by nine years. We know that in Northern Ireland it costs the health service alone some £250 million—that is the figure I have in my head—each year to deal with the consequences. That is because of the impact it has on increased rates of certain cancers, but also the problems it creates in pregnancy in terms of complications, prematurity, et cetera. We face a stark future. The latest health survey shows that some 64% of the adult population of Northern Ireland is either overweight or obese; a quarter of our children under the age of 12 are either overweight or obese. In our obesity prevention framework A Fitter Future For All, we have a significant number of actions relating to that; it runs through to 2022. For a period of time, we felt that we had seen a levelling off in relation to rates of overweight and obesity in children, but from the latest figures that does not seem to be the case.
We talked earlier about diabetes. We know that, for instance, type 2 diabetes accounts for some 90% of cases of diabetes. It is not the type where, basically, your immune system attacks your pancreas and you lose insulin production. Generally speaking, it is a hereditary predisposition, but it is associated with being overweight and insulin resistant. We used to call it “adult onset diabetes”. We do not call it that any more because, unfortunately and sadly, it is increasingly affecting young men and women, and now those in their childhood years. We know that 35% of 16 year‑olds are at an increased risk of developing diabetes; 5% to 10% of those at risk will go on to develop diabetes, on average, per year. The lifetime risk of those individuals is some 70%.
In Northern Ireland, we spend £1 million each and every day dealing with the consequences of diabetes in the health service. That is setting aside the impact it has right across society in terms of productivity and sickness absence. We have up to 10 new individuals with type 2 diabetes diagnosed each and every single day.
We are working effectively across Government, working with our colleagues in the Department for Communities, the Department of the Environment. We are working with Sport NI. We are putting in place programmes within schools and local communities. We need to do much more.
Q210 Mr Goodwill: Some of the initiatives that we have seen introduced may have an effect on that. Transport for London recently announced it was not going to advertise fast food on its buses and on the Underground. We have had planning restrictions on fast food outlets near schools, for example. Some of those require political decisions. Are some of the factors that we need to put in place to address obesity being held back by the lack of an Executive in Stormont?
Dr McBride: The Department of Health in England has recently published chapter 2 of its childhood obesity strategy. That, as you have indicated, contains commitments to prohibit the sale of sugary drinks to those under the age of 18 and to prohibit the sale of multi‑buy foods, high salt, sugar and fat. Those matters are devolved in Northern Ireland and if we wish to keep aligned with that—and, indeed, we are supportive of those initiatives—it would require us to have a Minister and an Executive to make those decisions.
That said, I work very closely with my CMO colleagues across the United Kingdom; officials in the Department are working with colleagues in England, Scotland and Wales on the childhood obesity strategy. We work to share evidence about what works and share policy initiatives in that space. We are very actively engaged, using the learning that colleagues in Public Health England and the Department of Health have extracted from this work.
Q211 Mr Goodwill: Have you already had situations where you want to introduce an initiative but are being held back because of lack of political decisions being made?
Dr McBride: A recent example of that is the sugar in drinks levy. We have no mechanism, at present, as I understand it, within policy in the Department of Finance to hypothecate a tax. The income generated from the sugar levy is estimated to be some £1.5 billion over the next three years and, obviously, in England it has been determined that it will be directed to increasing physical activity in schools. Some £14.5 million or so of that came to Northern Ireland, but we had no means of hypothecating that to particular interventions that were cross‑cutting. Again, it is an anomaly; we do not have a policy vehicle to do that.
That does not prevent and has not prevented us from working across Government, at the request of respective Perm Secs and Departments, to look at innovative initiatives, drawing on experience of what works in other parts of the UK. Take, for instance, the fit football fans in Glasgow, where we have coaching, mentoring and team‑based activities, which have been very successful in increasing physical activity and reducing alcohol consumption. We have ambition to roll that out in Northern Ireland. We already have a very effective programme around weight to a healthy pregnancy, addressing overweight and obesity in pregnancy, because of the risk of complications, and we have ambition to roll that out.
Within the context of our programme for government, which is our next outcome framework, we are working to identify priorities on which we agree, as Government Departments, we can do more in this space while awaiting incoming Ministers. I can assure you there is absolute commitment in Government Departments and we just need to find innovative ways of combining our resources, while recognising each Department has its own pressures. Many of the solutions to the health consequences and the problems we face sit outside health. As a former Minister in Northern Ireland once said and it has probably been said by many former Health Ministers elsewhere, all Ministers are health Ministers and Ministers for health, because all have a contribution to make in that space. It is about addressing poverty, unemployment, educational attainment. Those are the things that will improve the health of the population and ensure that we are addressing some of the significant health inequalities.
Where you live, your socioeconomic group, determines how long you live and how many years you live in good health. The most deprived men Northern Ireland live in good health, on average, 13.7 years less than those in the least deprived, and for women it is 13. That is just indefensible. It is the same across all the developed world and, as I made my point earlier, we need to do more in that space about prevention, in a cross‑Government and cross‑sectoral way. Otherwise, we are increasingly going to see the downstream consequences of that in terms of pressures on our health services.
Q212 Mr Goodwill: One of the very politically charged areas that I come across in my constituency is where people are obese and they are being denied orthopaedic surgery, or they smoke and they are being denied their heart op. Is that an issue in Northern Ireland? Often, I am told these are driven by clinical decisions and outcomes, but the suspicion is that some accountant or politician behind the scenes is sending out these messages.
Dr McBride: Speaking as a clinician, everyone has a right to access healthcare and I believe it is a fundamental human right. I am a fundamental believer in the ethos of the health service, which is based on need rather than ability to pay. There are often situations where obesity, particularly for major surgery, can increase the risk of complications, in terms of not just anaesthetic risk and chest infection, but also wound infection. It is right and appropriate that patients are advised of the increased risk of complications and take steps to reduce that risk in advance of surgery. We need to work to support individuals to ensure that they are ready for surgery and have put in place interventions.
Q213 Mr Goodwill: Are people being told, “You can have the operation when you have lost two stone”? That is what people in my part of the world are being told, basically.
Dr McBride: Again, I would not want to comment on that clinical discussion. The discussion is between a patient and a doctor, nurse or other health professional. A clinician is best placed to advise that patient in discussion, in partnership, on what the most appropriate intervention is and at the most appropriate time. To fully consent someone for a procedure you need to advise them of both the benefits and the risks, but also the modifiable risk factors. There are modifiable risk factors, such as weight, smoking, and it is right that clinicians seek to reduce those modifiable risk factors before exposing someone to a procedure. No medical intervention is without risk and it is important that in maintaining the balance between risk and benefit, as clinicians and as doctors, we seek to reduce that risk as best we can.
Q214 Lady Hermon: Chief Medical Officer, it is very good of you to be here this morning. It is enormously helpful in the continued absence of a Northern Ireland Assembly, a Health Minister and a Health Committee that you are here to provide some transparency and some accountability for what is happening in the health service back home.
I was very struck that in a number of replies you used the words “progress is being made”. I have a number of areas in which I want to establish how much progress has been made. These are issues that affect people in their everyday life, so they are very important. Can we start with the suicide prevention strategy? Would you just confirm that there is a new suicide prevention strategy sitting in the Department of Health in Northern Ireland, which is ready to be rolled out and implemented?
Dr McBride: We have developed a new Protect Life 2 suicide prevention strategy. Like all strategies, particularly given it is a long‑term commitment, there are financial resources associated with it. We will be keeping that strategy under review in terms of whether it is in the public best interest for us to launch that strategy at this time or defer the launch until such time as we have an incoming Minister.
Q215 Lady Hermon: Why could there be any query or any delay in saving lives through suicide in Northern Ireland, which I do not need to remind you has the highest suicide rate of anywhere in the United Kingdom?
Dr McBride: No, you do not.
Q216 Lady Hermon: Why on earth would we dither over introducing that policy?
Dr McBride: We are not dithering.
Q217 Lady Hermon: We are not dithering, but we are not implementing it either.
Dr McBride: We are not dithering. We continue to provide suicide prevention services, in a very structured and co‑ordinated way, under the existing Protect Life strategy. Regrettably, I had to make public commentary, in recent times, in relation to speculation about the Protect Life 2 strategy. The assertion that lives were being lost as a consequence of not having the Protect Life 2 strategy is factually incorrect. It is potentially dangerous to suggest to vulnerable people and vulnerable communities that, somehow or other, as a consequence of a strategy not being launched, people are unable to access the services they require today, tonight or this weekend. That is, quite frankly, not the case. We have a very robust Protect Life strategy currently in place. We have effective governance arrangements. There is implementation by our Public Health Agency. We have a cross‑Government group, which looks at the steps we are taking across Government to address the social determinants and wider societal issues that increase rates of suicide in Northern Ireland.
If it would be helpful, we have also taken a number of the recommendations within the new Protect Life 2 strategy and are implementing them using transformation money. For instance, we know that 70% of suicides are by individuals who are not known to mental health services. In the 30% who are known to mental health services, we are adopting a zero-suicide approach, to ensure safer mental health services. In the Belfast area, we are rolling out a crisis de‑escalation service. We are also part funding a crisis de‑escalation service, which is supported and led by Derry and Strabane Council. We are rolling out a crisis intervention team in the South Eastern Trust area for those people who contact 999 in emotional distress. We are putting in place a programme of emotional resilience building in our primary schools. We are also putting in place an emotional resilience building programme in our universities and higher education facilities.
As well as what we were currently doing, including our 24/7 helpline Lifeline, we are putting in place a number of new programmes and initiatives. It would be wrong, misleading and injudicious if we put out a message that, somehow or other, as a result of a strategy not being launched, lives were being lost. That is not the case.
Q218 Lady Hermon: That is a very detailed reply. I welcome everything that you have said. I am very encouraged by everything that you have said. As Chief Medical Officer, as so much is being done at the present time, you have given the impression that you are not putting any pressure on the Permanent Secretary in the Health Department to introduce this new suicide prevention policy. Is that the case or would you like to disabuse us of that impression?
Dr McBride: It is not a question of putting pressure on anyone. I discussed this matter no later than yesterday afternoon with the Permanent Secretary. We keep important policy matters like this under almost weekly review in terms of priority.
Q219 Lady Hermon: What was the outcome of that discussion with the Permanent Secretary yesterday?
Dr McBride: I am not going to, here, disclose conversations that I have with the Perm Sec in the Department, in the same way that I would not disclose conversations or advice that I provide to a Minister here, at the Committee. What I will say is this. Would it be preferable to have the Protect Life 2 strategy launched? Yes, it would.
Q220 Lady Hermon: Right, so why are we waiting for it to be launched?
Dr McBride: There is normal convention that strategies that commit Departments to long‑term strategic policy and change, and longer term investment, are matters for Ministers. If, at any time, we feel that there is a wider public interest to be served, that there is the potential of services not being provided or an adverse outcome to the health and wellbeing of the population of Northern Ireland, with legal advice, bearing in mind the additional powers we have under the Northern Ireland (Executive Formation and Exercise of Functions) Act, we will do so. We are keeping that under active review and consideration.
Q221 Lady Hermon: Can I just translate that? That is a commitment that, in the continued absence of the Northern Ireland Assembly, a Health Minister and a Health Committee, the Permanent Secretary and you, as the Chief Medical Officer, may well come to the conclusion that we need to implement this suicide prevention strategy before we have a Minister in place. Could you confirm that?
Dr McBride: That may well be the case and, if that is the case, we will announce that in due course. But I would assure you, in the same way we discussed earlier about the cancer strategy, we are keeping all these matters under review and we will not be found wanting. We will not be found wanting if we feel the public interest is best served in launching a strategy or making a change in policy. But, even with the Northern Ireland (Executive Formation and Exercise of Functions) Act, that does not seek to make us Ministers. We do not have the powers of Ministers and those decisions are, rightly, the preserve of Ministers.
Q222 Lady Hermon: Yes. Could we have, then, some good news in relation to sufferers of what is a dreadful condition, and that is cystic fibrosis? We had family relatives here, at a function at Westminster last week, very concerned about the continued delay in the availability of Orkambi, a very effective drug in the treatment of cystic fibrosis. It has been adopted and used in the Republic of Ireland and, very successfully, in 22 other countries around the world. In the United Kingdom, we are still dragging our heels in terms of being able to access this very valuable and effective drug for cystic fibrosis sufferers. What progress is being made for the families of cystic fibrosis sufferers in Northern Ireland? Could you give us some encouraging news on that front?
Dr McBride: Good news—
Lady Hermon: Oh, good news?
Dr McBride: No, I was just reflecting.
Lady Hermon: We want good news. We need good news.
Dr McBride: Is it ever my lot to be a harbinger of good news? Let us put this in its broader context. You know as well as I do, and I am sure the families told you, that cystic fibrosis is perhaps one of the most common life‑threatening conditions. Yet, despite that, because of the advances in treatment—you have mentioned the drugs—we have seen significant improvements in life expectancy, with many people, who are diagnosed usually before the age of two, living now into midlife, and that has been a huge success.
Q223 Lady Hermon: But with the threat of deterioration hanging over their heads.
Dr McBride: Exactly, and the respiratory complications and digestive tract complications.
Q224 Lady Hermon: How long do we have to wait for Orkambi within the NHS?
Dr McBride: Despite all that, we did see last year some 132 individuals who died with cystic fibrosis in Northern Ireland.
In terms of new drugs, we have a very robust process across the UK around the NICE technology appraisal of new drugs. That is designed to ensure that individuals can benefit, in a timely way, from the most effective treatments, but at a cost that is affordable to the health service and builds in incentives to the pharmaceutical industry to responsibly price their drugs. You alluded to negotiations and agreements that have been secured between the Republic of Ireland and the American company that produces Orkambi, Vertex. There are ongoing negotiations at a UK level with Vertex. Obviously, those negotiations are commercial and sensitive.
Q225 Lady Hermon: I take it, as the Chief Medical Officer, you have been able to feed into those negotiations.
Dr McBride: NHS England is leading on those negotiations, because our power and our capacity to negotiate drugs at a reasonable price are greater when we seek to have discussions at a UK level.
Q226 Lady Hermon: As the Chief Medical Officer, what has been your recommendation and suggestion to the Department of Health and the Health Secretary here at Westminster?
Dr McBride: I do not make recommendations to the Health Secretary or the Department of Health here.
Q227 Lady Hermon: That is odd, in the absence of a functioning Assembly since January last year.
Dr McBride: I do not make recommendations to the Department of Health here or the Health Secretary.
Q228 Lady Hermon: I did not ask about recommendations. Presumably, you have fed into those discussions. How many sufferers do we have with cystic fibrosis in Northern Ireland?
Dr McBride: To answer your first question, before coming to your second one, have we? Yes, we have. Officials within the Department have been liaising with officials within the Department of Health in England and NHS England in terms of those ongoing discussions.
As for exact numbers, I do not have that figure, but I can provide it to the Committee if it would be helpful. We do have more. As in Scotland, we have more of the so‑called Celtic gene G551D and a number of mutations in that respect, which means that we have a higher percentage of individuals living with cystic fibrosis. Professor Stuart Elborn at Queen’s University pioneered much of the research that has led to these new drugs and treatments. We have pioneered the way in Northern Ireland in terms of these treatments.
Q229 Lady Hermon: Yes, so are you hopeful that we will have Orkambi available soon within the NHS, not just in England, Scotland and Wales but also in Northern Ireland?
Dr McBride: I am absolutely committed to ensuring we have effective drugs available to people as soon as we possibly can, whether for cystic fibrosis or for the treatment of cancers. We have made significant strides in fast‑tracking new drugs—you have heard about the new Cancer Drugs Fund—fast‑tracking promising drugs to treat people with cancer, assessing that in real-life situations and then making more rapid decisions around NICE appraisals. Equally, where there are promising drugs in the treatment of cystic fibrosis, we will seek to negotiate with pharma reasonable, responsible pricing—and let us bear in mind that the cost of Orkambi, I understand, is somewhere in the region of £100,000 per patient per year—to allow the health service to ensure that patients who can benefit, on the basis of evidence from clinical trials, do benefit, but at a price that is affordable to the health service.
Ian Paisley: I have a question on cystic fibrosis, if you are finished on that.
Lady Hermon: Could I complete and come back to cystic fibrosis in a minute, or would you like to go with cystic fibrosis? Yes, go ahead.
Chair: If you are happy, Lady Hermon.
Dr McBride: You are ganging up on me now.
Q230 Lady Hermon: No, no. It just affects so many families. It is enormously worrying for those families.
Dr McBride: I appreciate that. I have met with the families and I know the frustration. I met, with Ian, a number of the families.
Q231 Ian Paisley: Yes. It is this issue of pricing. When cystic fibrosis families hear about pricing, they then compare it to quality of life. You will know. I brought to you a constituent of mine, who is a GP, but she is also a cystic patient. The only reason why she can be a GP is because of the miraculous development of drugs that have allowed her to be that. I recently met another constituent, a young woman aged 19, who is training to be a midwife, the first ever cystic fibrosis patient training to be a midwife in Northern Ireland, only because of these specialist drugs. It is about that quality of life. When patients across the whole of the UK hear about this issue of pricing it really frustrates them, because they know they can have a far better, fulfilled and complete life if these drugs are available.
Dr McBride: I have met with many patients in that situation, along with you and other elected representatives, and I know that frustration. When we start to talk about cost in the context of quality of life and avoidance of complications, it diminishes that interaction, almost as if we are putting a price on someone’s health, future life and continued wellbeing.
We have a process in NICE technology appraisals, which has served us well in ensuring that we have effective drugs available at a price that is affordable to the health service. It is the envy of the world in terms of the negotiating power, the lobbying power and the leverage that we have. But I do appreciate the huge frustrations that there are when, somehow or other, we are applying some formula of quality‑adjusted life years, with a ceiling above which drugs are not deemed to be cost effective, in terms of the added life years at a particular cost. Those individual cases are extremely hard. For us, within health, our challenge is to provide health and social care services at a population level, which meets the needs of all. Some of those needs are more challenging to meet in terms of the required resources than others.
Q232 Lady Hermon: Reflecting on what you have just said about treatments and trying to do one’s best, the issue that I want to raise next is to do with MS, another absolutely dreadful condition. It is not to do initially with treatments, but I do want to hear that there is progress in treatments for MS sufferers. From your introduction, not only are you Chief Medical Officer but you were—and correct me if I am wrong—the chief executive of the Belfast Trust, so you know that I am going to put to you the published statistics for the waiting times to see a neurologist within the Belfast Trust. I am absolutely horrified. This is an urgent referral where it has been suggested to someone that they may have MS. They will have to wait 68 weeks for their first outpatient appointment to see a neurologist in the Belfast Trust. Is that correct or is it longer?
Dr McBride: Those figures are in the public domain and they are unacceptable, completely unacceptable, and I will not sit here and seek to defend them.
Q233 Lady Hermon: How are we going to reduce them?
Dr McBride: One of the approaches that we announced back at the end of July was that we would carry out a regional review of neurology services, one of a series of reviews that we are conducting as part of Delivering Together. We have worked very closely with the neurological charities in drawing up the draft terms of reference from that. We will have the chair of the neurology charities in Northern Ireland working with us within that core team. We are putting together that programme.
Q234 Lady Hermon: We are putting that team together, so the review has not started; is that right?
Dr McBride: The group has met. The terms of reference are in draft form. I have met with the members and the first meeting of the group is happening on 11 December, so that work is underway and we are still committed to producing an interim report early in the new year.
Q235 Lady Hermon: Is it the shortage of neurologists?
Dr McBride: There are many factors. It is that. When I was young—and I am rapidly ageing—neurology used to be almost a diagnostic challenge and, thereafter, there were very few investigations or treatments available. It has transformed in recent years in its diagnostic capacity, the imaging technology that we discussed earlier, but also in the treatments we have available.
At a point in time many years ago, we had no treatment for MS. Depending on the type of MS, whether primary progressive, intermittently progressive or otherwise, we have disease‑modifying therapies, a whole cadre of new drugs, which can interrupt and slow down the progression of the disease. Many of those drugs are required to be administered on an outpatient basis, by infusion, et cetera. We have not been able to keep pace with the advances in the development of neurological treatment by matching that with the development of the workforce, the skill mix in terms of nurse specialists across not just MS but Parkinson’s disease, movement disorders and other areas, and how to best deliver that service. We discussed earlier the fact that imaging is delivered by trusts. Currently, we have neurology services that are delivered by trusts. We need a much more integrated approach to a neurology service for Northern Ireland, which is appropriately staffed and appropriately resourced. It is not, at the moment.
Q236 Lady Hermon: Do we have a shortage of neurologists?
Q237 Lady Hermon: By how many, do you think?
Dr McBride: I do not know the exact figure. We also have a shortage of neurology nurse specialists. We also need to look at care pathways. For instance, if we talk about those waiting times, 30% of the patients who are referred by their general practitioner into neurology are never seen again in neurology, because they do not need to be seen again.
Q238 Lady Hermon: Is that because they go elsewhere?
Dr McBride: The assessment is that there is no underlying cause that requires ongoing neurological follow up or intervention.
Q239 Lady Hermon: But you would accept that 68 weeks—
Dr McBride: Yes, absolutely. The point I am making is that we need to look at the entire pathway and ask questions. Why is it that up to 30% of people who are referred to neurology services from primary care do not need to be seen again? Are we providing sufficient support and advice to general practitioners on the management of common neurological conditions to allow those conditions to be managed in primary care? Why do they have to be added to a queue to get a neurological opinion? Are we using sufficient technology, like e‑triage, where GPs, increasingly, in Northern Ireland can ask for opinions of specialists? Do we have sufficient numbers of general practitioners with a specialist interest in neurology? Do we have pathways for common conditions, such as headache, and the investigations thereof? We need a root and branch fundamental review of how neurology services are structured across Northern Ireland, the pathways and the support we provide for people living with long‑term conditions. It is not just about more neurologists, more nurse specialists; it is about that and much more.
Q240 Lady Hermon: That is very helpful. Are you expecting the interim report from the review team to be published in the early new year?
Dr McBride: Yes, we have given a commitment to that. It is an ambitious timeframe but, in light of those figures, time is not on our side. We need to press ahead with this and we are absolutely committed to that.
Q241 Lady Hermon: Will that be before Easter?
Dr McBride: I would be confident it will be before Easter, yes.
Q242 Lady Hermon: Excellent, okay. Could I just then bring you to a very controversial and sensitive issue? That is reform of abortion legislation in Northern Ireland. You will be well aware, as the Chief Medical Officer, that there was a Supreme Court ruling earlier in the summer and, while the case brought by the Northern Ireland Human Rights Commission was dismissed on a technical point, a majority of the judges in the Supreme Court described the abortion law in Northern Ireland as “deeply unsatisfactory”. Would you agree with that assessment?
Dr McBride: In answer to previous questions, the working group that I chaired, when asked to consider whether there should be a change in the law in relation to fatal foetal abnormality, very clearly made a recommendation that the law in Northern Ireland needed to change.
Q243 Lady Hermon: Is that because it was deeply unsatisfactory?
Dr McBride: During that process, in the evidence gathering for that report, I met many women who had experienced termination of pregnancy. Along with the Chief Nursing Officer, I met women who had travelled to other parts of the United Kingdom, who had had experiences that were far from satisfactory, sometimes horrendous, in terms of their stories and accounts. Very courageously, they shared those stories with us and, indeed, some of them have shared those stories very publicly. I also met with obstetricians, who said that they felt they could not fulfil their duty of care to their patients. For a doctor to say that they cannot fulfil their duty of care to an individual woman as a consequence of the law, in any jurisdiction, is an indictment of all of us. That is why we, clearly, as a working group, recommended to the then Justice Minister and the Health Minister a change in the law. Unfortunately, as I said earlier, the Executive fell before that could be considered.
Q244 Lady Hermon: Yes. There was a report and you chaired the group. It was across two Departments, the Department of Health and the Department of Justice in Northern Ireland. When did your report complete?
Dr McBride: I can check the exact timing, but as I recall it was 2016.
Q245 Lady Hermon: Yes. Was it published?
Dr McBride: No, because it was a report to Ministers.
Q246 Lady Hermon: Why was it not published in 2016, which was well before the Assembly collapsed, in 2017?
Dr McBride: Again, there is a convention that advice to Ministers is that; it is advice to Ministers. I find myself in the very unusual position of discussing a report, which is now in the public domain, that was basically advice to Ministers, which would have informed discussion at the Executive. That is not the normal way that things work, but it is now in the public domain. The decision to put the report into the public domain was made due to the importance of the report, recommending a change in the law for reasons that were based on what we heard from women about their experience and from professionals saying they could not fulfil their duty of care. It was determined that it was in the wider public interest to put that report into the public domain because there did not, at that time, seem to be any realistic prospect of an Executive returning anytime soon to consider that.
Q247 Lady Hermon: Has progress been made on drafting legislation, even in the absence of the Assembly?
Dr McBride: There can be no progress made by the Department of Justice in the absence of a Minister to draft legislation in this respect.
Q248 Lady Hermon: You have a Supreme Court ruling, which has indicated that there was going to have to be change because the law is deeply unsatisfactory.
Dr McBride: We do not have a Supreme Court ruling. What we have is a non‑binding judgment by a majority, and you are quite correct.
Q249 Lady Hermon: It was dismissed on a technicality.
Dr McBride: Yes, the court determined that the Northern Ireland Human Rights Commission did not have the standing to bring the application in relation to article 3 and article 8 of the human rights legislation. But it was a very significant step that the judges determined to make public their judgment and I think they did so very deliberately.
Q250 Lady Hermon: In order to do what?
Dr McBride: To signal the fact that they had significant concerns, I think. I cannot interpret that, but I understand it was a highly irregular move by the judges who sat on the Supreme Court. I suspect it reflected a strength of feeling in relation to the matters that they were considering, but again that would be pure speculation on my part and probably inappropriate for me to say.
Q251 Lady Hermon: In the absence of an Assembly, any draft legislation and any change whatsoever, what support is currently being given to mothers who have had the dreadful diagnosis that the baby they are carrying has a fatal foetal abnormality? What support do they and their families have in this interim time?
Dr McBride: That support is available through their local obstetrics services, from their midwives, from their obstetrician and, in due course, from the bereavement support that we have in place across the health and social care trusts in Northern Ireland. Is it sufficient? No, I do not believe it is. I did task the Public Health Agency to develop information and leaflets to support women with a diagnosis of a fatal foetal abnormality. We are currently awaiting legal advice as to whether, in that guidance, support and information to mums and dads, we can include information about the services that are currently available in England.
Q252 Lady Hermon: This would be legal advice from whom?
Dr McBride: It would be from the Departmental Solicitor’s Office.
Q253 Lady Hermon: The Attorney-General, I thought, perhaps.
Dr McBride: It is complicated. I am not competent in matters of law, but it has never been tested in courts in Northern Ireland whether it is lawful to promote or be seen to be procuring services in other jurisdictions that may be lawful in that jurisdiction but unlawful in Northern Ireland. It is important that we do not expose those preparing such literature to risk of legal challenge. But the Public Health Agency also has plans to provide a co‑ordinated, central service, to support women and their partners going through these very difficult circumstances.
We can do better in Northern Ireland for women in these very difficult situations. Our doctors and midwives are telling us we need to do better. Women have told us we must do better. The current law, as it stands in Northern Ireland, in the context of fatal foetal abnormality, from work that I was asked to do by the then Justice and Health Ministers and what I have heard from doctors, does not permit them to fulfil adequately their duty of care to the women. There are strong views in Northern Ireland in the medical profession, in the legal profession and in the public. These are, probably rightly, matters that, in due course, need to be considered by Ministers in Northern Ireland.
Lady Hermon: Thank you very much indeed.
Q254 Chair: Can I just, finally, press you a little bit on the suicide prevention strategy? You said it is your judgment that lives are not being lost for the want of a suicide prevention strategy. Can I then ask you what the point of a suicide prevention strategy is?
Dr McBride: Basically, the strategy contains a number of new elements. For instance, it sets specific targets in relation to a reduction in deaths by suicide. It sets a more prominent role for individuals bereaved by suicide, both in the design of services in terms of their lived experience, but also increased bereavement support. We have bereavement support in place. It includes the recommendation of adopting zero suicide within our mental health services, which I have already indicated we are progressing. It makes recommendations for increased multisector training around suicide prevention, which would be not only for health and social care professionals, which we are doing, but broader training for community gatekeepers, who are those in youth clubs, sports, clergy, et cetera. We are doing much in that space, working very closely with our churches in Northern Ireland, with work around Flourish, but it was basically about putting more resource—
Q255 Chair: I accept all that, but they are intermediate outcomes, are they not? Their aim is, surely, in this particular circumstance—that is to say, suicide—the prevention of suicide. Given the points you made about support for families and what have you, the main purpose of the preventing suicide strategy is to prevent suicide.
Dr McBride: Yes, to do so as effectively as we can, and to make sure that the services that are in place are fully evidence based and are providing value for money. For instance, we have £8.7 million, ring‑fenced, that we provide into the implementation of Protect Life. It will require us to look at our community and voluntary sector providers of those services to ask, “Are we getting value for money? Is there a better way of providing those services?” That will take us into the arena of procurement. When you are in the arena of procurement of services and issuing contracts for services, it exposes the risk of potential challenge if, indeed, it is deemed that the process by which—
Q256 Chair: I am not putting you, professionally, on the spot. I accept that officials are trying to do everything they possibly can in the absence of Ministers and this Committee has been at pains to make that absolutely clear, but I put it to you that the absence of a suicide prevention strategy is costing lives.
Dr McBride: I do not accept that.
Q257 Chair: Then what is the point of a suicide prevention strategy?
Dr McBride: Any strategy is about how we best co‑ordinate our efforts and deploy our resources to most effectively achieve an intervention. I have absolute confidence in the work we are doing under the current strategy. I have absolute confidence in the governance arrangements that we have in place. As I said earlier, it might be hugely beneficial, were we to—and, indeed, in due course, we may—make a judgment that it is in the wider public interest to launch that strategy. If that is the case, that would be beneficial. But it would be wrong, misleading and potentially dangerous to communicate a message publicly or, indeed, from this Committee that lives were being lost as a consequence of not having a strategy in place.
Q258 Chair: Thank you for that. That is loud and clear, although it is, of course, not a problem for a committee such as this to broadcast messages, however uncomfortable they may be.
Can I press you on cancer screening again? We have established that there is a need for FIT, and for screening for human papilloma virus, HPV. The purpose of that is, clearly, to save lives. Would it be reasonable to say that, given such a strategy, decisions on those things are not being made for want of Ministers?
Dr McBride: Had we had Ministers in place, decisions of that nature would probably have been made more expeditiously. Undoubtedly, the absence of Ministers creates some challenges.
Q259 Chair: Thank you for that. Would it also, therefore, be true to say that the sole purpose of screening is to save lives and to reduce morbidity?
Dr McBride: That is a reasonable summary.
Q260 Chair: We can deduce, then, for want of Ministers, lives are being lost in Northern Ireland.
Dr McBride: No, with due respect, Chair, that is a significant extrapolation from one statement to another statement. It is a matter for you, however.
Q261 Chair: That is logic.
Dr McBride: Well, it sounds like contrived logic, with due respect, Chair. I do not wish to sound disrespectful, but it sounds very much like a public utterance as opposed to a logical conclusion from two statements that are connected but not necessarily related by cause and effect.
Q262 Chair: I see no point in doing screening unless you are going to save lives and reduce morbidity. You have said that, because we do not have a Minister who can make decisions on this matter, those things are not being done.
Dr McBride: Let us be clear. At this moment in time, we have differences in bowel cancer screening right across the United Kingdom. I have made that point in an earlier statement. In Scotland, from 2007, we have had bowel cancer screening for all those over the age of 50 up to 74 years of age. From 2007, we have had FIT testing. We already have variability in Departments’ prioritisation and commitment of resource to take the new FIT test forward and, indeed, to consider the JCVI recommendations on when to screen.
Wales, as I have indicated, will be introducing FIT testing from January of next year. They have, again, made a commitment to increase screening from 50 when it is practically possible to do so. It differs from Scotland. England has made a commitment, from the autumn, to move to FIT testing and to extend the age of screening when it is practically possible to do so.
There are already phased differences of implementation of JCVI recommendations. The JCVI provides advice to Ministers and Ministers make determinations on priority, subject to the resources available. As Chief Medical Officer, do I want the most effective screening test that is based on evidence for the population of Northern Ireland? Yes, I do. As Chief Medical Officer, do I want to ensure that we are maximising the effectiveness of our screening programmes? Of course I do. Is HPV testing a more effective screening tool? Yes, it is. It will probably reduce the frequency of screening and, in the longer term, may have reduced cost, but it will increase the pressure on colposcopy by some 60%, because that is what the sentinel sites in England have demonstrated.
I have said that the Department has not made a decision not to do things on either of those. The Department has directed the Public Health Agency to do all the necessary preparatory work in advance of the Department, in due course, because we keep these under review, or an incoming Minister making that decision. If there comes a point where we feel the public interest is not being served by not making a decision, we will make the right decision for the public of Northern Ireland and I will provide that advice unequivocally to our Permanent Secretary, who is equally committed to ensuring that we do the right thing for the population of Northern Ireland.
Q263 Lady Hermon: Even in the absence of a Minister.
Dr McBride: Even in the absence of a Minister.
Q264 Chair: That is the important thing. We will have to examine the logic of the record when it is printed but, for me, personally, the absence of suicide prevention and cancer screening strategies, in the way we have discussed, inevitably has consequences. Those consequences need to be dealt with in some way or another, ideally by decisions made by Ministers or, failing that, in accordance with guidance issued from the Secretary of State to officials in Northern Ireland, but those decisions do need to be made.
Chief Medical Officer, we have put you through it today. That is two hours, which is quite enough. Can I thank you very much indeed for being here? We are really most grateful.
Dr McBride: Chair, thank you and all the Members. I was going to say I enjoyed the experience; maybe I will when I reflect on it. It has been a good interaction and it has been useful. It is useful to have the opportunity to have our approaches, our logic and our thinking tested in this manner, so thank you for your time.
Chair: Thank you.