Mike Nesbitt
Strangford · Ulster Unionist Party · Northern Ireland
“Think public service, wisdom, generosity and courtesy. Think integrity, insight and curiosity, the lack of which is a key criticism of the two public inquiry reports of recent days.”
“I spoke during Members' statements earlier about the untimely passing of the Western Trust's chair, Dr Tom Frawley CBE. I repeat my condolences to his family, his friends and his many admirers.”
“I absolutely share the Member's ambition to see people living in the community. The trusts provide a range of evidence-informed programmes for individuals who are awaiting assessment. For children and young people, early intervention teams deliver proactive needs-led programmes that are neurodiversity-affirming and trauma-informed.”
“Thank you, Mr Speaker. The Western Trust has assured me that it has undertaken a comprehensive early engagement exercise with stakeholders, involving all political parties, local businesses, service users, community groups, the Patient and Client Council (PCC), local media, community planning partners and Departments, including mine and D…”
“The role played by social workers in delivering safeguarding and family support interventions is complex and challenging. The work frequently pivots on multidisciplinary collaboration, with parents and carers positioned as partners in the formulation and delivery of safeguarding and support plans.”
“I fully recognise the impact of the current delays on individuals and families. The situation has arisen due to a combination of factors, including funding that falls short of objectively assessed need and previously missed opportunities to reform health and social care delivery.”
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“I thank the Member. I can offer that guarantee; we need every square inch of our hospital estate. The next challenge, having put hospitals into four tiers, is to determine exactly what services are offered by which hospital. That is a fairly significant piece of work, but, if it is approached with logic, it should not take that long to get to where we want to be. I assure the Member that I want every hospital to do whatever it is doing to the best of its ability, and to be recognised as such by the community that uses that facility.”
“There is so much that local hospitals can do; they should be in no doubt about their short- and medium-term future.”
“I thank the Member for her question. If I understood her correctly, she is talking about local hospitals. As I said, I think that, by and large — 80% at least — people are willing to travel for a procedure if they feel that they are going to a centre of excellence. I have said before that, if your local hospital does the procedure that you need once a week but that, by travelling a bit further, you can get to somewhere that does it 10 times a day, five days a week, you are more likely to want to go to that centre of excellence. The local hospitals will deliver the aftercare. I want aftercare to be delivered as close to the home as possible. That, primarily, is where I see a role. It is about delivering day-to-day, non-acute services.”
“<BR /> <BR />Ultimately, as, I think, I said in my very first remarks in the Chamber as Health Minister, everybody wants reform, but everybody has a different idea of what reform should look like. As we go forward, I know that people will object to this proposal or that proposal, but that is the value of the consultation. I am certainly happy to discuss offline with the Member some more detail, if he is interested in the specifics of the feedback.”
“If you talk to the clinicians, they will tell you about the barriers that prevent them being more efficient and more productive, and then, when you speak to the management, you maybe get a better sense of what management perceives to be the barriers to delivering that efficiency and productivity. <BR /> <BR />The one thing about healthcare that I discovered very early in my tenure is that there are so many moving parts. You can see one moving part and say, "Well, if we do something here, that will be really productive and positive", but there will be three or four other moving parts that might say, "Well, if you do that, you will have a negative impact on me". Those are the sorts of conversations that we have been having.”
“I thank the Member for his question. All the royal colleges were involved, and all the chief executives and the trusts were involved. Indeed, a couple of weeks ago, I was at the headquarters of the South Eastern Trust and met the chairs of all the arm's-length bodies that are involved in delivering healthcare. Therefore, extensive consideration has been given to this plan. <BR /> <BR />The big challenge that has been faced by, for example, the people who represent the five geographic trusts is, "What does it mean for me and my service?". One of the most important exchanges in the feedback has been my sense that they need to collaborate and cooperate more deeply and that they have to address the issue of productivity.”
“I think that they have been increasingly showing an ability to cooperate and collaborate rather than compete, but that is a work in progress, and I will certainly try to keep the pressure on to get further collaboration and cooperation. The big issue for me across those trusts is productivity, and I assure the Member that there have been some frosty enough conversations on that issue.”
“There will be consultations — I can guarantee the Member that — on all the changes, but I said that they will either be trust-led or led regionally by the Department. I note that the Member said that the trusts are struggling to cooperate. I have to say that that is not my sense of things. I know that they were set up under the Thatcherite idea of, if you have competition, you drive down price and get a better bang for your buck, to use that expression. I suppose that there was a temptation, when going into the role, to say, "Why do we need five geographic trusts, and why can we not just have one Northern Ireland-wide body?". I do not think that that is worth the effort, but I said to the chairs, chief executives and financial directors of the trusts that I expect them to cooperate and that, in my mind, they are one trust.”
“First of all, I get it. You have waited a long time for the document, and, to a certain extent, perhaps, it is a little frustrating that it has only high-level principles. However, that is the logical sequence by which to roll out the nitty-gritty of reform. It is not just reform of hospitals; it is reform of how we deliver health and social care more generally.”
“Once we can do that, we can have a good, mature debate about who does what.”
“I was there a couple of weeks ago, and the last area that I visited was the emergency department. It was not edifying to see so many people in the corridors outside the emergency department being fed. When you want to access healthcare, dignity is really important. Far too many patients feel that they lose their dignity because of overcrowding, particularly in emergency departments. That was late August, by the way. One of the emergency department consultants said, "I think this is the start of the winter pressures". We have to box clever and use the whole of the estate. <BR /> <BR />I am not the expert, I am not a clinician, and I am not a medical professional who can say how we should do that, but we need to look at the network. It is important to get people thinking of networks. People tend to think of the local hospital as being "it".”
“I do not want to be prescriptive or overly prescriptive at this point in the process. I will stick with what I have said. There is huge logic in trying to separate emergency surgery from elective surgery, because, if you are on a waiting list for planned or elective surgery, the length of the list does not really matter. If you have been given the appointment, it is frustrating to get a phone call early that morning to say, "I am sorry. The theatre is in use for an emergency procedure. The anaesthetist, the surgeon and the theatre nurses have all been taken up, and your surgery is cancelled". Those are the sorts of things that I am talking about. We need a logical redistribution that means that we are more productive and more efficient in what we do. <BR /> <BR />You asked about Craigavon Area Hospital. My goodness.”
“<BR /> <BR />As the Member suggests and as Mrs Erskine made clear, there needs to be accessible and reliable public transport for patients who do not have access to private vehicles, particularly the elderly and the vulnerable. In that regard, flexible appointments, especially for those who are travelling a greater distance, would also be important.”
“An increased focus on centres of excellence for elective care will mean that some patients will be asked to travel further for non-emergency procedures. I refer to the 2023-24 health survey for Northern Ireland, in which approximately 80% of respondents indicated that they would be prepared to travel within Northern Ireland for a routine procedure or operation, if that meant that the waiting time would be reduced. Similar questions were asked by the Age Sector Platform, and over 80% said that they would be willing to travel further if there were benefits such as reduced waiting or procedure times and a lower risk of cancellation.”
“There will be a series of announcements, and, while they might not please the Member, they will certainly give her the opportunity to respond.”
“That is why it will not be possible to do it in a year or in the remainder of the mandate, and that is why I am talking about a five-year plan. We have to bring people with us, and I do not mean just the clinicians and everybody who works in healthcare, important as they are. We also want the community to come with us. Sometimes, when we say that we will change services, people think that they are losing a service from their local facility without being reassured that something better will come in its place. For example, you may separate emergency and elective surgery in one hospital in order to make that hospital a centre for excellence in elective surgery, which would be a bit better for securing its future. <BR /> <BR />Sorry, I wandered off topic a bit.”
“In headline terms, that sequence starts with the announcement in the Chamber today. Professor Bengoa will be at a half-day conference in Belfast next Wednesday afternoon. I will be interested to hear the detail of his remarks on whether he feels that his report from 2016 is still valid — I believe that it is. He will also reference some developments that have taken place globally over the past eight years and perhaps encourage us to take the next steps. After that, as I said, I will publish the three-year plan that will cover the rest of the mandate. <BR /> <BR />Out of that, we will have to get down into the weeds of what we mean when we talk about which hospitals deliver which services. I assure Members that we will go out to public consultation on every one of the potential moves, because that is the right thing to do.”
“I have been working with other Ministers — the Minister for Infrastructure and the Minister of Agriculture, Environment and Rural Affairs — to look at community transport arrangements and how to provide transport for those who do not have ready access to it. I am also thinking about the Northern Ireland Ambulance Service (NIAS), which has a voluntary driver scheme. That scheme took a bad hit to its numbers because of COVID. The NIAS is working hard to get the pool of drivers back up. We need to be imaginative. For example, I think of church networks: it strikes me that people who regularly go to church may be the sort of people who have the kind of community interest that might lead them to think about becoming community drivers. <BR /> <BR />The issues that the Member raised are very much on my radar.”
“There was a variety of answers. Those who came from big cities in India tended to say that they preferred Altnagelvin because it is in the city of Derry/Londonderry, whereas others whose origins were, perhaps, more rural preferred Enniskillen. It is possible to think about imaginative ways in which to tackle those workforce challenges and not just simply buy into a narrative that a rural hospital will not attract a workforce. It may be more challenging, but I accept and rise to that challenge. <BR /> <BR />The Member made a very important point about transport. It is all very well for me to say that I am prepared to travel to Antrim, Londonderry or Enniskillen for my procedure when I have many family members with cars who would be more than willing to take me there and bring me back.”
“I thank the Member for her comments. No acute hospital is, in any way, in danger; in fact, some of the proposals, such as the one to separate emergency from elective surgery, will secure their future. <BR /> <BR />On the first point about attracting workforce, interestingly — well, you will be the judge of that, but I found it interesting — I went up to Altnagelvin a few weeks ago to visit some of our international colleagues who have come here. They go into the centre at Altnagelvin to learn about the processes and procedures that we use in hospitals that may be different from what they are used to in India, Afghanistan or wherever their country of origin is. The interesting thing for me was asking them whether they preferred to be at Altnagelvin in Derry/Londonderry or at the South West Acute Hospital in Enniskillen.”
“That is the principle underlying my thinking.”
“So, yes, I will be guided by clinicians, surgeons, allied health professionals (AHPs) and nurses. <BR /> <BR />There is also a need to consult the local community, because all healthcare is not just personal but local. For example, for most of my adult life, my nearest hospital has been the Ulster Hospital. Of course, I feel an affinity for the Ulster more than I would for the South West Acute Hospital (SWAH), Altnagelvin Area Hospital or Daisy Hill Hospital. I have to get over that affinity and wishing for every service that I need to be delivered at Dundonald and recognise that it is in my best interests, once we have the areas of specialty, to travel a little further for a procedure. Having said that, I know that people who are prepared to travel for a procedure want the aftercare as close to home as possible.”
“I thank the Chair of the Committee for her welcome and her comments. I am, of course, not a clinician; I have no medical or clinical qualifications. As Minister, I see myself as an enabler of change. Recently, I was in both the Causeway Hospital and the Antrim Area Hospital. As the Member knows, the Northern Health and Social Care Trust is consulting on the future of general emergency surgery provision and the potential that it may move from the Causeway Hospital down to Antrim. In its consultation document, the trust has made clear its preferred option, which is the one that I have just articulated. However, when I met the clinicians at Antrim Area Hospital, they made it clear that it was an imperative for patient safety and delivering better outcomes.”
“<BR /> <BR />I say to the Member that a lot is happening. I cannot give you a step-by-step time frame, but I am moving at pace to deliver better outcomes for patients, service users and the staff who deliver healthcare.”
“<BR />I intend to publish in the forthcoming weeks a three-year plan that will cover the rest of my time as Health Minister, if I am spared to work through to May 2027. I have made it clear that I want to see a regional attitude towards breast screening services. We will continue to deliver that at pace. I have talked about my initiative, which I am calling "Live Better", to tackle health inequalities. That is due to be launched in the forthcoming weeks. In association with that, I will look at some of the social determinants of health inequalities. I think of, for example, tobacco and vaping. We will be hand in glove with the UK legislation on that front. I am considering minimum unit pricing for alcohol, because it is clear that, if you go into the most deprived areas, you see the worst impacts of alcohol abuse.”
“I thank the Member of the Opposition for his comments and his question. I can say to him that this will not lie on the shelf and gather dust. Indeed, some Members have suggested that the Bengoa report from 2016 has, over the past eight years, sat on the shelf gathering dust, and that is not the case. There have been some movements on foot of that Bengoa report. I think of day procedures and elective care and how we are trying to separate elective care from emergency operations. That is a sensible way forward. In my closing remark, I asked Members to think about this as one of a series of statements that are coming. Professor Bengoa will be back next week to, as I put it, reboot that report, not to write a new one, because the challenges remain as they were in 2016.”
“It is underpinned by a number of existing service reviews and strategies, which were clinician-led and developed in partnership with those who use the services. Future reconfiguration decisions will continue either to come from regional service reviews or to be trust-led. I am committed to ensuring that such decisions include appropriate engagement with, for example, staff, service users and the local community. <BR /> <BR />In closing, I encourage Members to take the time to respond to the consultation and make their views known. As I encourage Members to look on our hospitals as a network, in the same way I encourage them to regard this statement as one of a series about reform of healthcare delivery that will come in the coming weeks. I commend the statement to the House.”
“Research shows that the vast majority of people — in fact, in the region of 80% — say that they are willing to travel for elective care in order to receive treatment from the best and most skilled experts as quickly as possible. However, I recognise, of course, that there are some for whom any additional travel will be a cause for concern. That is why a section on patient travel is included in the draft framework, setting out the supports available for the public. <BR /> <BR />It is important to note that 'Hospitals — Creating a Network for Better Outcomes' will not itself reconfigure any specific services; instead, it provides a strategic context and structure for future reconfiguration decisions.”
“When hospitals have lower patient numbers, that can create significant issues for professionals working in key specialties. They include the rota and on-call pressures inherent in smaller clinical teams, as well as an insufficient case mix to support specialisation, training and skills development. Those issues inevitably have consequences for recruitment and retention, adding to the challenges of maintaining services. That, then, potentially compromises patient safety and often leads to poorer patient outcomes. <BR /> <BR />We have seen in recent years a number of examples where changes have been made as a direct result of service collapse rather than planned improvement.”
“It is about showing everyone how each hospital fits into the network, determining what the most valuable role for each one to play is and delivering the best outcomes for patients. <BR /> <BR />To embed sustainability and resilience, taking account of our workforce, safety considerations and advances in modern medicine, it is simply not possible to deliver all services in every hospital. It is already the case that different hospitals have different services available. The network approach will ensure that people can still get the right treatment in the right place by the right person, even if it is not necessarily in the hospital closest to their home. I recognise that there are difficult judgement calls to make around that. My view is that patient safety must always come first.”
“The draft framework aims to describe our acute hospital system. Its underlying principle of local provision where possible and central where necessary is key to the document. A fundamental concept is that of an integrated Northern Ireland hospital network. Within that network, each hospital has been identified as part of a particular tier, combining to form an interdependent network. The types of hospitals described in the framework are local, general, area and regional. That network approach will ensure a brighter and more secure future for all our hospitals. <BR /> <BR />I want to be clear in the message that this is not about cutting costs or closing hospitals but about managing change in a controlled way and demonstrating the benefits, which have to be better outcomes. We will continue to need every square inch of our hospital estate.”
“'Hospitals — Creating A Network For Better Outcomes' has been co-produced with the trusts and the Public Health Agency (PHA), which have involved a wide range of clinicians in the process, as well as senior managers and chief executives. Furthermore, during July and August of this year, my officials carried out an extensive pre-consultation exercise that involved engagement with all the royal colleges, as well as with trade unions and service users. The feedback from that very useful pre-engagement exercise has been incorporated into the final draft of the document, which is presented to the House today. <BR /> <BR />At its heart, the work is about how we can improve the sustainability of hospital services and, ultimately, provide an assurance that none of our acute hospitals will close.”
“Thank you, Mr Deputy Speaker. I am making a statement on the launch of the public consultation on the hospital reconfiguration framework document, which is entitled 'Hospitals — Creating a Network for Better Outcomes'. I am pleased to have the opportunity to share the framework document with Members today in advance of the imminent launch of a 16-week consultation period. That will commence tomorrow and will run until 21 January 2025. <BR /> <BR />I am aware that some people tend to promote the belief that there has been no clinical involvement or engagement with health service front-line staff on the development of the framework. That is simply not the case, and I want to set the record straight. It is not something that civil servants have simply cooked up with no outside input.”
“I do not have that detail to hand. What is very clear, however, is that any promises from the UK Government that they would make up that shortfall were not delivered on to any significant degree, and the community and voluntary sector suffers as a consequence.”
“That affirms the value of undertaking the review of the core grant scheme to try to do something better and, importantly to me, to make sure that it is opened up. Over the past 20 years, obviously, the landscape of community and voluntary sector groups has changed in some ways rather significantly, and it is not fair that some groups have access and others do not. I look forward to the fruits of that consultation and the advice that NICVA finally brings to me.”
“To signal my commitment, I have asked NICVA to facilitate a co-design process through which my officials are working with representatives from the sector to redesign the core grant scheme, and, hopefully, that will be for implementation at the beginning of the next financial year. Again, I must add, that is budget permitting. <BR /> <BR />I am running out of time, so I just want to say that I have had a brief on how discussions are going between the Department and NICVA and NICVA's member organisations. Without going into fine detail, I will say that some of the discussions and conclusions have been very surprising. Some of the groups are proposing a way forward that would not have been our first guess, if I may put it that way.”
“To offer a few examples: current recipients provide treatment and support services to people with drug and alcohol addictions, children who are in the care system, older people, victims of domestic and sexual abuse, adults and children with disabilities and those living with life-limiting and life-threatening conditions. <BR /> <BR />The scheme needs to change. In 2010, the Northern Ireland Council for Voluntary Action (NICVA) and Chief Officers Third Sector (CO3) indicated that it was no longer fit for purpose. Furthermore, the Department of Health is operating in a much-different policy and strategy environment and the sector itself has evolved and continues to do so.”
“The scheme has been mostly closed for the best part of two decades, with no route for an unfunded organisation to access financial support. Through no fault of their own, the same organisations — there are around 60 of them, as has been said — have been receiving core grant funding in all that time. Attempts were made to redesign the scheme between 2015 and 2017 and, again, as recently as 2022, but we kept coming back to the old closed scheme. The latest attempt, in 2022, failed because of design flaws, which my Department now accepts were its responsibility. <BR /> <BR />Do not get me wrong: the organisations currently supported under the current scheme work with and alongside some of the most vulnerable children and adults in Northern Ireland.”
“I thank the Member for her intervention. It speaks to a belief that I have formed rather quickly in my time as Minister of Health, which is that, as a generalisation, we have grossly overcomplicated healthcare delivery. That goes right across health and social care. Asking people to jump through hoops because we have a process and leaving a community and voluntary group believing that the process is more important than meeting its needs is something that we need to be aware of. Being aware of it, we need to address it. Even if it is a perception, it is potentially debilitating. <BR /> <BR />In the time remaining, I want to address another aspect of the issue. In addition to inheriting a grant scheme that is extremely challenging in financial terms, I have inherited a scheme that I consider to be inherently unfair.”
“Core grant funding is not their only source of HSC income. Indeed, in the financial year 2023-24, 52 of the 61 recipients held service delivery contracts, and the total value of those contracts was £53 million. I am fully committed to supporting the sector financially going forward, but that commitment will take me only so far. I need a budget allocation that permits me to do so, and I welcome my party colleagues' amendment. The reality is that the budget for the past two years has fallen significantly short.”
“<BR /> <BR />There could have been an outcome whereby, in order to ease the huge financial pressures that to this day weigh down my Department, nothing at all was invested in the core grant scheme, but, to me, that was unacceptable. I was clear that, despite the difficulties that it created elsewhere, I wanted to maintain at least the same level of funding as last year. I hope that that has made a positive contribution towards the financial sustainability of the 61 organisations in receipt of the grant. While I was able to reinstate it in part, I was able to protect the investment in the front-line services that the sector provides. <BR /> <BR />It is important to note that the majority of organisations in receipt of core grant funding also hold service delivery contracts. Those are with my Department's arm's-length bodies.”
“If we can find the funds for those transformative issues, we will release money at the other end or, as they say, on the right-hand side. <BR /> <BR />Despite the financial challenges, I decided in July to maintain my Department's core grant scheme in 2024-25. Much as I would have liked to restore the full grant, that was simply not possible in the circumstances. I understand that Members will say, "But look at your budget of £7·9 billion. How can you not find another £1·8 million?". That is a measure of how constrained the budget is. Yes, I am looking for efficiencies. For example, I have sat down with the trust chairs, and we have had some uncomfortable conversations about the need to be more productive and efficient, but will that yield significant financial savings in the rest of the financial year? It is very unlikely.”
“I thank the Member for her intervention. Many times a week, if not daily, I am given a presentation that says, "If you invest in preventative measures or put some money into transformation here, that relatively small amount of money will release a comparatively large amount of money down the line". Where is that transformational money to come from? It does not exist, and the Members who voted for the Budget must take their element of responsibility for that. I say this to the Member: yes, one thing that I want to do is move from care in hospitals to care in the community. That would be a cost-effective way of doing business. I also want to move from a health service that is primarily about curing the sick to one that keeps the healthy healthy.”
“<BR /> <BR />The sector faces an incredibly challenging financial landscape at the minute, but, let us be honest, so do all Departments. We all know what has been going on. Permanent secretaries and senior leadership teams have been looking at everything that their Department does that costs money and putting those actions into one of two columns: statutory responsibility and non-statutory. If you are in the second column, you are struggling.”
“<BR /> <BR />While I recognise the valuable role that the sector has to play and the importance of investing in it, all Members will be aware of the funding position that the Department of Health found itself in last year and again this year. I am nearly deafened by the irony klaxon coming from my right in particular. The budget position has made it necessary to take incredibly difficult funding decisions and choose between the things that need to be funded to save life and limb and the things that we would like to fund. Having to choose between funding critical statutory services and supporting the voluntary and community sector because it is a good, productive and proper thing to do is a very unpleasant place in which to find yourself.”
“In some cases, the sector provides services under contract to Health and Social Care (HSC) bodies, including the trusts. The Department of Health has also supported the sector through the core grant scheme. That system is intended to be an enabler by covering core organisational costs. It is not intended to cover the full cost of service delivery; rather, it makes it possible for organisations to function and, potentially, to bid for other funding. I have had it described to me as a lever or a way to demonstrate to other funders that the organisation is worth investing in because we, as a devolved Government, believe in it and back it financially. It is important to the organisations that receive it, to the Department of Health and to government in the round that we continue the core grant.”
“That expert would get a one-year contract, and, after six or nine months, they would ask, "Is my contract being renewed?". The answer was, "Well, we're waiting to hear from government". In the meantime, that person would see a safe, permanent job in the statutory sector, and off they would go, leaving the service users in a worse position than the one in which they had begun. In the game of snakes and ladders, they had gone up a lovely ladder to a better place but had then hit a snake and gone back down again, so they knew that there was better to be had. <BR /> <BR />I believe that I understand and appreciate the work of the community and voluntary sector. My Department has supported and relied on the sector for many years.”
“Suddenly, they were in charge of a voluntary and community group looking after victims and survivors. Suddenly, they became chief executives, human resource managers or financial directors, and, because they never started out to become such, they needed help. That, to a large extent, was the genesis of the core grant scheme. As the mover of the motion said, they are among the very best of our society. <BR /> <BR />As a commissioner, I became very aware of the impact of cuts and changes to budgets; the impact of a single-year budget; and, in particular, the impact of constant delays in confirming state funding. If, for example, a group thought of a new service for its service users, it would advertise for an expert to deliver that service.”
“I did not hear a particularly robust evidence base for that claim, but I became closely involved with aspects of the community and voluntary sector as a commissioner at the Commission for Victims and Survivors, where the task was to be a champion for the most vulnerable: those who had suffered most during the 30 years in which we inflicted such terrible pain on one another. Dozens of community and voluntary sector groups are involved in supporting victims and survivors. By and large, they emerged because somebody saw a loved one, a neighbour or a friend get hurt and tried to help. Their doing so resulted in other people saying to them, "Well, you're helping your cousin", or, "You're helping your neighbour" and, "I have a cousin who was hurt", or, "I have a neighbour who was hurt. Can you help them too?".”
“Thank you very much, Mr Deputy Speaker. <BR /> <BR />For Members who put a premium on accuracy, let it go into the record that the decision to cut the core grant by 50% was taken not by Robin Swann but by the permanent secretary at the Department of Health. The reason that it was not taken by Robin Swann or a Member of the House is that the Democratic Unionist Party refused to practise devolution. I ask the Member for South Down to reflect on that. In doing so, she may also care to reflect on the fact that the biggest financial blow to the voluntary and community sector in recent years has been the loss of the European social fund; lost because of Brexit, a policy supported by her party. <BR /> <BR />Ms Forsythe claims that I do not understand or appreciate the community and voluntary sector.”