Jim Wells
South Down · Democratic Unionist Party · Northern Ireland
“On a point of order, Mr Deputy Speaker. In November 1982, I made my maiden speech in the Chamber, and, here we are, 40 years later, and I am making my last speech in the Chamber as a DUP MLA. I was the last person in the Public Gallery when the Assembly collapsed in 1976.”
“<BR /> <BR />Mr Deputy Speaker, I thank you for your indulgence and for your patience with me over many years. Unfortunately, Mr McGlone has just left the Chamber; I was about to thank him. I have enjoyed my 27 and a half years in this Building.”
“I wish that I could, but I have only five minutes. <BR /> <BR />That was so that a very small number of Irish language zealots could go in and register their marriage or civil partnership in Irish or in dual language: £261,000. Did anybody stop to think about whether there was a more cost-effective way of doing that?”
“We are all perfectly happy with a genuine expression of people's culture. That is fine. However, when the language is so cynically used by militant republicanism, unionism has difficulties. Why, for instance, is there no translation into Irish of the words, "United Kingdom", "Londonderry", "Northern Ireland" or "Her Majesty The Queen"?”
“The Member has made the point for me. The official who came to the Committee made it absolutely clear that £261,000 had been spent already. It was farcical to bring that before either the Finance Committee or the Assembly, because the money had been spent and the processes had been set up.”
“If they want the unionist community to accept the Irish language as a genuine cultural expression, they should get rid of the political baggage and extremism, and stop using the Irish language as a political weapon to try to subjugate unionism.”
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“To date, the Pancreatic Cancer Research Fund has supported 27 research projects in the UK, with grants totalling £4 million. All of that was raised through fundraising and donations. Its mission is to defeat pancreatic cancer by funding and promoting innovative, world-class research into the disease — research that will lead to the development of more effective detection, diagnosis and treatment. <BR /> <BR />A report published recently by the National Cancer Research Institute, which analysed the research funding by UK Health Departments and charities over the 10-year period, 2002-2011, showed that research funding for pancreatic cancer increased significantly over the period from £1·5 million to £5·1 million. However, many Members have said that they do not believe that that is enough.”
“<BR /> <BR />Many Members raised the issue of the paltry amount of money, in the overall scheme of things, that is dedicated to pancreatic cancer, compared with breast cancer, say, which is not to decry the wonderful efforts being made in that field. It is unfortunate that we are not giving a condition, which, in 20 years' time, will, unfortunately, be very high up the fatalities league table, the attention that it deserves. <BR /> <BR />The fundamental discovery research led by academics is funded from a wide variety of sources and is relevant to all cancers and their prevention. In February 2014, the previous Health Minister launched the Northern Ireland fundraising group of the Pancreatic Cancer Research Fund (PCRF).”
“I want to clarify the situation, because he raised a very valid point. I will write to him on that important issue. <BR /> <BR />My Department funds the core staff and facilities of the Northern Ireland Cancer Trials Centre and the Northern Ireland Cancer Network through the regional Health and Social Care research and development fund. That support enables trusts to benefit from research funds provided by cancer charities or industry, for example, but does not specify the types of cancer on which research can be conducted. So, although the predominant cancers studied in Belfast are breast, prostate and colon, which reflects the expertise and experience of Northern Ireland researchers, clinical studies involve many types of cancer.”
“That has not happened, so we expect the final guidance on the drug to be published in January 2015. I will write to him and provide full information about that because it is quite a complex situation. I can tell you that the NICE-approved drugs that are there already are available and are not one of the 40 where there has been considerable debate and which come under the IFR process.”
“Currently, almost one fifth of patients newly diagnosed with cancer in Northern Ireland participate in clinical trials. <BR /> <BR />Since 2000, Belfast has had a successful pancreatic cancer clinical trials portfolio. The completed trials have led to major publications, thereby adding to the global knowledge available to clinicians who are treating pancreatic cancer. At a wider level, a new health and social care research and development strategy for Northern Ireland is nearing its public consultation stage. <BR /> <BR />At this point, I will clarify something that I said to Mr McKinney the Member for South Belfast. At the moment, all NICE-approved drugs for pancreatic cancer are available in Northern Ireland, but we anticipated a NICE decision in October of this year on the particular drug he mentioned.”
“While acknowledging the particular difficulties associated with identifying the early symptoms of pancreatic cancer, which can be non-specific and common to a range of illnesses, I look to researchers and clinicians to advise on how best to improve pancreatic cancer referral guidelines in ways that are practical and evidence-based. <BR /> <BR />Belfast City Hospital is a major research centre for cancer, and there are close links between the Belfast Trust and the universities, including academics and clinicians. The Northern Ireland cancer trials centre and network enables patients and others from across Northern Ireland to participate in clinical trials of potentially beneficial prevention strategies, diagnostics, treatments and care.”
“<BR /> <BR />Most diagnosis of pancreatic cancer occurs in cancer units and in the cancer centre at Belfast City Hospital, and people are then referred to the regional multidisciplinary team as recommended by NICE guidelines. If surgery is deemed appropriate, it is carried out at the Mater Hospital in Belfast. As several Members indicated, only 15% of sufferers actually benefit from surgery because often it is simply too late to do anything at that late stage. Systemic anti-cancer treatments are provided in the Belfast cancer centre, and the decision as to whether surgery is appropriate is entirely clinical. Where surgery is not deemed appropriate and the disease is advanced, the only treatment may be referral to a specialist palliative care nurse.”
“A review of the framework is due to take place in 2015-16, and this will inform the way forward in our fight against cancer. <BR /> <BR />I fully support the efforts that GPs and other health professionals are making in a challenging situation to boost their awareness of early diagnosis, reduce misdiagnosis and ensure that pancreatic cancer survival rates are improved across Northern Ireland. GPs receive training in pancreatic cancer diagnosis in the GP curriculum. This includes interpreting common symptoms, understanding the indications for urgent referral for pancreatic cancer and understanding the risks associated with various symptoms that may indicate pancreatic cancer.”
“No reliable screening test has been developed, and the symptoms are often absent at the early stage of the disease. When symptoms do present, they are usually non-specific. In other words, they are common to many illnesses and often present at a late stage. Consequently, outcomes are poor for this form of cancer. <BR /> <BR />To ensure that the best services exist to meet the needs and preferences of people and are accessible to all regardless of where they live, a service framework for cancer prevention, treatment and care was published in February 2011. The framework sets out 52 standards that are common to all cancers in relation to the prevention, diagnosis, treatment, ongoing care, rehabilitation and palliative/end-of-life care for people who have cancer and those who have a bigger risk of developing cancer.”
“They also highlighted that many people put off going to their doctor because they are afraid of what the doctor may find. That seems to be a particular problem for males in Northern Ireland, who are four times less likely to go to their GP than the ladies. I think that that is something that we, as a gender, will have to address because, unfortunately, we can often present ourselves when it is far too late. There was poor awareness of cancer survival rates in general, and most people had little idea of life expectancy after a diagnosis of cancer. These findings have informed a forthcoming cancer awareness public information campaign, the visible signs of which will commence this month. <BR /> <BR />Most Members who spoke raised the issue that, unfortunately, the diagnosis of pancreatic cancer presents particular difficulties.”
“My mind is not closed on that, but I can certainly see technical difficulties with doing that and doing it in a way that does not cause confusion among the public. <BR /> <BR />A stakeholder engagement session was held on 8 May and was attended by fifty representatives from the community, voluntary and charity sectors, who looked at the evidence and rationale to support the development of a cancer awareness campaign. The PHA was then tasked to complete qualitative research that aimed to establish the public attitudes, knowledge and awareness of cancer signs and symptoms. I am afraid that the key findings are not encouraging. They highlight that the awareness of cancer signs and symptoms is relatively low among our population in Northern Ireland.”
“I was very taken by the comments of the honourable Member for South Antrim Mrs Cameron who mentioned the fact that survivorship is so much better when the diagnosis is made by a GP rather than in a crisis situation during an emergency admission to hospital. By that stage, of course, it is often far too late. The Public Health Agency is working on a new cancer awareness public information campaign, and that work is well advanced. <BR /> <BR />I take the point that was made by the Chair about having a dedicated campaign for pancreatic cancer. The difficulty is that we have 21 main serious cancers in Northern Ireland, and it would be difficult to justify having 21 separate campaigns. I know that Una Crudden is very keen that we have a specific bespoke ovarian cancer campaign.”
“Unfortunately, pancreatic cancer is one of the cancers for which there has been no improvement of any note in the last four decades <BR /> <BR />I hope that Pancreatic Cancer Awareness Month will result in more patients seeking medical advice at an earliest possible stage of the disease. As Members will be aware, the Public Health Agency has an awareness campaign for the signs and symptoms of cancer. We believe that that is a key factor in detecting cancers early and increasing the chances of successful treatment and survival. We are very much where we were with ovarian cancer and exactly the same principles have been established.”
“<BR /> <BR />On my second day in office, I announced in the Assembly that, for the first time ever, Northern Ireland had passed a very important milestone and that there were more people alive with cancer after five years than had passed on. I am delighted to say that I got that wrong. It is not after five years but 10 years that 51% of cancer sufferers are alive. There have been tremendous successes in identifying cures for cancer in many fields. I quoted the example of leukemia. When I was a child, 82% of leukemia sufferers passed on, and now 82% of children with leukemia are alive after 10 years. That is a remarkable achievement.”
“Those are very worrying statistics. One of those who died was Adrian Patterson, a church elder in my church and a family friend. He got the terrible news that he had pancreatic cancer, and it was very quickly established that his condition was terminal. <BR /> <BR />Pancreatic cancer is the fifth most common cause of cancer death, causing 5% of all cancer deaths in the United Kingdom each year. The shocking statistic — there is no other word for it — that has been quoted by almost every Member who has spoken is that, in the 1960s, the rate of those with pancreatic cancer who were alive in five years was 3% and the survival rate now in Northern Ireland is still 3%. That is a truly dreadful statistic.”
“First, I pay tribute to Mrs Kerry Irvine, who, by her perseverance, has ensured that the issue has been raised in the Assembly. It is a fitting tribute to her husband Noel that the issue is receiving such serious attention in the Chamber. <BR /> <BR />I welcome the debate to acknowledge Pancreatic Cancer Awareness Month and highlight issues relating to what is, frankly, a dreadful illness. I was shocked when I heard from Mr Buchanan that 24 people pass on every day in the United Kingdom as a result of pancreatic cancer. That is a truly shocking statistic. Each year, around 8,500 people in the United Kingdom are diagnosed with pancreatic cancer. According to the Northern Ireland Cancer Registry, in 2012, 244 people were diagnosed with pancreatic cancer in Northern Ireland. Frankly, even more shocking is that 243 died.”
“I should point out to the Member that all the drugs available to treat pancreatic cancer in Northern Ireland are available without going through the individual funding request (IFR) mechanism. There is no impediment to their access in the Province.”
“Since I have become Minister, I have received letters from quite a few MLAs, even those who are in the Chamber, on this issue. Members, if that happens, I really do want to hear from you. I find it a matter of great concern if someone is caught in that position not once but twice. Indeed, I have a case before me at the moment where it happened on three occasions. I think that we need to get some assessment of how this is going because it causes enormous distress to patients, and I simply cannot understand at times why it is happening.”
“Nonetheless, it is clear that the Committee is concerned about HSC consultants who practise privately. In view of that, I am content to ask my officials to discuss with the Patient and Client Council the feasibility of undertaking research along the lines suggested by the Committee. I will inform the Committee of any outcomes of that in due course.”
“In addition, the Department’s guidance, 'Management of Private Practice in Health Service Hospitals in Northern Ireland', sets out key principles, including that consultants and their employing organisation — the trusts — should work:”
“for HSC patients, nor should they ask other HSC staff:”
“To avoid conflicts of interest between public and private work, ' A Code of Conduct for Private Practice', was agreed between the BMA Northern Ireland and the DHSSPS. The code is for consultants and includes — this will answer the points made by the honourable lady for Foyle — the requirements that programmed HSC commitments should "take precedence over private work" and that, in the course of their HSC duties and responsibilities, consultants should not:”
“The Committee made this recommendation on the basis of the anecdotal evidence and observations that it received. I have received those as well. However, as Minister, I want to make it clear that my Department has absolutely no evidence that consultants seek to divert patients to private health care or that they underperform in the public sector to maintain long waiting lists. <BR /> <BR />Northern Ireland’s size makes sustaining a private health sector of any significant size that could utilise medical staff from elsewhere more difficult. The Northern Ireland independent sector, therefore, predominately utilises existing medical staff from the health service. <BR /> <BR />The potential for a conflict of interest has long been recognised and was addressed by the introduction of a code in November 2003.”
“The Committee dealt with that issue, and I was just about to answer that point. The Chair must have been using her Londonderry crystal ball to try to pre-empt what I was going to say. The Committee recommends that the Department develop policies to mitigate potential conflicts of interest for doctors who work in both the public sector and the private sector. I agree that there is that perception.”
“<BR /> <BR />We should never overlook the fact that a very substantial amount of our health and social care is already provided by independent contractors. GPs, dentists and community pharmacists, for instance, are all private practices or individuals carrying out work on behalf of the trusts, the board or the PHA. So, let us not get too hung up on how we deliver. Let us ensure, first, that it is free at the point of delivery and, secondly, that it is of a high quality.”
“<BR /> <BR />The report recommends that an action plan be developed to decrease spend on the independent sector over the next three to five years. I am very mindful that the HSC should always have some access to the independent sector to be able to respond to specific demands while ensuring that in-house capacity is well planned and that there are arrangements to access additional in-house work, which is part of the normal planning process. However, I have to say that the figures over recent years from the tenures of Mr McGimpsey and Mr Poots and from my tenure indicate that the only way that we can make substantial inroads into waiting lists is to refer patients to the private sector. I am, therefore, content to ask the Health and Social Care Board to take forward the Committee's recommendation on the issue.”
“That is exactly what the Health and Social Care Board is doing in seeking to develop, in individual specialties across Northern Ireland, long-term strategic approaches so that demand can be managed in-house. However, this will take a considerable time to come to fruition. When money is available, we have to use the private sector. <BR /> <BR />As Members know, I wrote to the private sector on 1 October and said that no money will be forthcoming for the rest of this financial year for private procedures. The vast majority of those procedures in the system are wending their way through. I believe that all those procedures will have been carried out by Christmas. Apart from some diagnostics, there will be no further private sector involvement this year. I have to say that the situation for next year is not that rosy either.”
“I do not think that we should get ourselves into political silos on what we feel about this. This is good news all round. It still represents less than 2% of the entire health budget, excluding social services. We are not getting into an ongoing or rolling programme of privatisation. We use the private sector when required. <BR /> <BR />In order to deliver improvements in waiting times, there remains in Northern Ireland a need to bridge the gap between the capacity available in the health service and the demand for procedures, which continues to rise. To address this gap, we use the independent sector. The Committee is absolutely right to ask what we are doing to find more efficient ways to deal with increases in demand for in-house procedures, but, in the long term, we will still rely somewhat on the independent sector.”
“It is worth saying that the Health and Social Care Board provides funding only for procedures or diagnostic investigations in the private sector beyond that which is contracted by the trusts. There is no double funding here; this is additional. It is money being used in a very cost-effective way to reduce the huge numbers of people who require urgent or long-term orthopaedic interventions. I make no apology for using money that is available, either through monitoring rounds or from within the Department's existing resources, to try to relieve the pressure on waiting lists. <BR /> <BR />I visited these facilities quite recently, and I have to say that all the patients whom I spoke to were very complimentary about the treatment that they had received.”
“That is 26,000 people who had their condition relieved. I have spoken to people who have attended private clinics, and two things are evident. First, they do not care whether they get relief through an operation in a private clinic or a National Health Service hospital. What they want is urgent treatment. Secondly, we know from experience that numerous other outpatient activities are carried out in the private sector and that the treatment outcomes are extremely high. We had 91,000 outpatient activities in 2013-14. I have no great baggage about that. If we can use the private sector to relieve waiting lists and provide a high level of care and provided that that is done at a tariff that is affordable and cost-effective, I think that that is a very good use of public finances.”
“<BR /> <BR />Considerable comment was made by Members about the involvement of the private sector. I noticed that that made up a substantial part of Mrs Cameron's speech. It is important to indicate the level of investment that has occurred in the private sector in recent years. In 2009-2010, it was £57·5 million; in 2010-11, it was £24·7 million; in 2011-12, it was £52·6 million; in 2012-13, it was £66 million; and in 2013-14, it was £66·9 million. It is noticeable that there was a very substantial dip during Mr McGimpsey's tenure, which again indicates the pressures that he was under, as I am under, as far as funding is concerned. In 2013-14, that £66·9 million meant that 26,000 surgical procedures could be carried out. That is hips and knees and all sorts of elective, mostly orthopaedic, operations.”
“The Department is working to develop, strengthen and build the governance framework surrounding the health and social care sector to ensure that, on behalf of the people of Northern Ireland, our service delivery is of the best standard possible for all our patients. I therefore recognise the Committee's recommendations as positive and certainly not at odds with the work being taken forward by the permanent secretary. I fully support the Committee's assertion that strong leadership is required from the Department. The Committee's recommendations relating to strong leadership, clearly defined policies and personal accountability will be considered further by my Department within the ongoing development of stronger performance monitoring structures.”
“As Minister, I am content that the roles and responsibilities of the Department and the Health and Social Care Board in performance management are clearly defined in legislation, and the annual commissioning plan direction sets out formally the key strategic priorities and statutory obligations, together with the associated standards and targets that the sector must meet. Against that framework, I am pleased to report that work was recently commissioned by the permanent secretary to look at how the Department exercises its monitoring of performance management. That is being carried out by the Health and Social Care Board and the Public Health Agency, along with its direct accountability relationship with the arm's-length bodies, and has resulted in significant changes across the range of governance activities in the Department.”
“I have therefore asked the Committee to look at the experience of introducing such targets elsewhere to better understand the scale of investment required, the potential benefits and whether such an investment could be justified in the current financial climate. I will consider that before making any decision on the introduction of a referral-to-treatment target and am extremely grateful to the Committee for the work that it has carried out, providing as it does in its report a substantial contribution to the Department's thinking. <BR /> <BR />Linked to the introduction of RTT targets, the Committee has made recommendations that new arrangements for managing performance and a clearly defined policy on how compliance with the targets will be enforced should be put in place.”
“Instead, efforts were refocused on working to ensure that the HSC met existing targets so that, regardless of the measurement adopted, waiting times were minimised for patients. <BR /> <BR />The Committee's report makes it clear that the introduction of RTT targets in the National Health Service, in conjunction with the necessary investment in services, resources and technology, has delivered further improvements in waiting times for patients in England. However, as the Committee was advised in evidence, changing to an RTT target will not in and of itself deliver improvements in waiting times. The introduction needs to be supported by extra investment, training, technical support and, most critically, positive engagement from clinicians.”
“From the patient's point of view, it lets them know how long they can expect to wait from referral to treatment, rather than how long they will wait for each stage of the patient journey, that is, assessment to diagnosis and treatment. Again, the Chair articulated the point that, really, that is difficult for the patient to understand. <BR /> <BR />Members will be aware that a 25-week referral-to-treatment target was planned for Northern Ireland in the 2008 Programme for Government, but this was not taken forward at the time due to public sector funding pressures that made it unlikely that the investment required to deliver the target would be available to the HSC in the immediate future. I have to say, Members, that little has changed there.”
“It is acknowledged that focusing efforts on waiting time targets has delivered a substantial improvement in waiting times, although in recent years these have had to be scaled back, in line with available resources and increased demand. Nonetheless, targets continue to be viewed as the best way to maintain and deliver improvements in performance. The targets set in Northern Ireland have largely been informed by similar targets in place elsewhere in the United Kingdom, and it is useful to see how well they have worked elsewhere. <BR /> <BR />I welcome the report's recommendation in relation to referral-to-treatment targets, known as RTT. It is clear that such targets provide a more transparent view of the patient experience.”
“The longer they have to wait, the more anxious they become, which can affect their health and well-being. I thought that Mrs Dobson illustrated that very well. In addition, we are aware that delays in diagnosis and treatment can, in some areas, result in poor outcomes for the patient — a situation that we must always seek to avoid. I have to say, as a constituency representative, that this issue crops up time and time again in my inbox, whether by email, post or phone calls. I understand the pressure that Members are under in this situation. <BR /> <BR />Considerable resources and efforts have been used in recent years and have been directed at reducing waiting times, both here and in the rest of the United Kingdom, as they represent a key indicator of the health service's overall performance.”
“I welcome the opportunity to respond to the Committee's report on the review of waiting times for elective care and to the views expressed by Members today. As most Members will know, I was a member of the Committee until very recently, and I was party to the discussion and the drafting of the report. Therefore, I understand clearly the Committee's concerns and the challenges we face. <BR /> <BR />Members will be aware that long waiting lists and the time that patients spend on them are a concern not only in Northern Ireland but in many other countries. While most patients understand that there will be some delays involved in receiving their treatment, their personal concern is about the speed with which the queue moves, rather than the number of people in front of them.”
“I beg to introduce the Food Hygiene Rating Bill, which is a Bill to provide for the operation of a food hygiene rating scheme in Northern Ireland.”
“<BR /> <BR />The trusts were under considerable pressure to act quickly, and I hope that we have tried to be as open and transparent as we can be. My door is open. If she has concerns about this, she can come and see me. Other representatives have asked to do so, and I will speak to them and try to explain the decision. Also if the honourable Member for Londonderry East has an alternative way of saving £600,000 in the Northern Trust, please let me know.”
“My understanding is that in most trusts — I do not know specifically about the Northern Trust — MLAs and MPs were called together for a briefing prior to the decision. Certainly I know that that happened in the South Eastern Trust. Then, there was a written statement, which I issued, providing details of the decision, and there was also a media briefing by the chief executive of the Health and Social Care Board. These decisions came about very suddenly, because we did not know where we stood until the October monitoring round was concluded, where we got the extra £60 million. I say to Mrs Sugden that, if we had not got that extra £60 million, we would be having a very different conversation indeed and the cuts would be much more severe.”
“Well, the Barnett consequential of £8 billion, as the honourable Member knows, is £240 million. If I had £240 million today from the Finance Department, I would be absolutely delighted and could deliver all the services I have promised. This is not unique to my situation. It is UK-wide and, indeed, it affects the Irish Republic as well.”
“As the Member knows, we have experienced a 6% increase in demand for health service provision over this last four years, and a 2% increase in income. Therefore, we should not be surprised that we are in this very difficult situation. Something had to give, and we are at that point. Demand is exceeding resources by a very considerable margin. This was not forced upon me other than for one simple reason: if I did not take action now, we were heading towards a very significant overspend on the budget for 2014-15. I had to take action, and the later we left the decision, the more difficult it was going to become. <BR /> <BR />I am not unique within this Assembly; other Ministers are facing exactly the same pressures. Indeed, in the rest of the United Kingdom, we are told, they need £8 billion to balance the books on health.”
“The staff will be moved elsewhere, but, of course, the costs associated with running the service will cease: the heat, the light, the electricity etc. That will stop for the next five months, and then the decision will be reviewed. I can only go on the information that is given to me by those who should know their facts.”
“I can assure you that that will happen, because they will not have the £600,000 to spend; it will be taken from the budget. Therefore, on that basis, I have to accept that what they are telling me is true.”
“The Member for East Antrim is slightly mistaken. It has been termed the regional centre, but 80% of the patients who go there are from the Northern Trust, with the remainder coming from the Western Trust and only two from Belfast. The South Eastern Trust and the Southern Trust do not provide any patients whatsoever to it. Technically, while it is a centre that provides for a wide part of Northern Ireland, it is not an official regional centre. <BR /> <BR />I can only go by the professional judgement of those who have been at the coalface in the Northern Trust for many years. They tell me that they can save £600,000 through this particular change in service provision.”
“This is simply trying to find out where we can find £7 million in the Northern Trust in five months, nothing more, nothing less, and in a way that does not affect front line acute care. This is what the trust has said to me, and I have to respect its judgement because it is at the coalface. Am I going to question trusts on these proposals? Absolutely.”
“I welcomed the extra £60 million that we achieved in the monitoring round and the £20 million in June, but I do not think that he understands the fundamental difficulty that I am having in making the books balance. The trust faced an almost impossible situation, and it had to go forward with a policy that was the least-worst option in reducing its outgoings from now to the end of March. Therefore, if we had not made a move, we were destined to over-run. <BR /> <BR />As far as privatisation is concerned, I have no difficulty with private provision; it is less than 2% of the entire Health and Social Care budget. I personally prefer the provision that is best for the patient or the client; I am not hung up on where that is provided. However, this is not part of any ongoing privatisation policy.”
“The decisions that I have to take are not long term and strategic; they are firefighting decisions to try to get the books to balance. The one option that I do not have this year is to over-run or overspend; it has been made very clear to me that that cannot happen. <BR /> <BR />I agree with the Member that such decisions make it more difficult to implement Transforming Your Care, but we have very little room in which to manoeuvre in making cutbacks when we are seven months into the financial year.”