Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): There was some confusion about timescales, so we will get straight into it. In the interests of time, I ask members and witnesses to keep the evidence as concise as possible.

With us are Heather Stevens, the director of workforce policy and chair of the regional workforce planning group at the Department of Health, Social Services and Public Safety (DHSSPS); Dr Carolyn Harper, a member of the regional workforce planning group at the Public Health Agency (PHA); and Mr Damian McAlister, a member of the regional workforce planning group at the Belfast Health and Social Care Trust. I hand over to you to make a presentation, and I will then open it up to members.

Ms Heather Stevens (Department of Health, Social Services and Public Safety): Thank you, Chair, and good afternoon. We are grateful for the opportunity to provide evidence to assist your review of workforce planning across Health and Social Care (HSC) in the context of Transforming Your Care (TYC). I propose to highlight very briefly a few issues from the briefing paper that was provided to give you an overview of the approach that has been taken to workforce planning across the HSC.

TYC clearly has to be and, indeed, is a major driver of workforce planning. By the same token, workforce planning is essential to the successful implementation of TYC. In recognition of that, three TYC recommendations — 79, 95 and 97 — specifically relate to workforce planning. They deal with ensuring that critical clinical staff are able to work in a way that supports the new arrangements, the development of new workforce skills and roles to support the shift towards primary care and a more formal integration of workforce planning into the commissioning process to drive the financial transformation.

In 2012, a regional workforce planning group was established, with members drawn from the board, the PHA, the trusts, departmental professional leads and statisticians and others to take that work forward. Initially, the work focused on a diagnostic exercise and the sector skills council, Skills for Health, was commissioned to carry out an assessment of the capacity across the HSC to do workforce planning. That resulted in a training programme being rolled out and a programme to raise awareness of workforce planning issues. The diagnostic report, which was published in November 2013, also recommended the development of an overarching framework that would clearly set out the roles and responsibilities of each of the HSC stakeholders in the workforce planning process. Since taking up my post last year, I have worked with colleagues to achieve a common understanding of what is meant by an integrated approach and to process planning for a future workforce that not only maintains safe staffing but supports the service transformation that is envisaged by TYC as necessary to improving quality of care.

We are finalising the regional workforce planning framework, which sets out the relative roles of the Department, the Health and Social Care Board (HSCB), the PHA and the trusts for the approval of the respective organisations. In short, the draft framework establishes that it is the Department's responsibility to set the vision; to ensure that a regional approach is taken; to provide regional information and trends; to facilitate capacity building; and, crucially, to make decisions on the commissioning of pre- and post-registration education and training as a logical conclusion to the workforce planning process. It is the role of the board and the PHA as commissioners to determine and agree the various models of service delivery, including the outworking of TYC; to challenge the trusts and providers to ensure that they have identified their workforce needs to be able to deliver the commissioned services; and to flag to the Department when intervention is needed on the supply side, recognising, of course, that there is a lead time to making an impact on the workforce through training. It is the role of the trusts to ensure that they have an appropriately skilled workforce in place; to develop operational workforce plans to adapt to what is being required; and to make changes to their workforce as required.

The framework is not just a paper exercise. We are determined that it will drive the practical implementation of workforce planning at all levels across the HSC. We now want to test it. Traditionally, the Department has commissioned or carried out a series of workforce reviews on a uni-professional basis that looked at the dental workforce, the nursing workforce, the medical workforce and so on. Whilst those are still tremendously valuable in informing education commissioning decisions, and will be into the future, they understandably focus on the profession rather than the patient. TYC rightly demands that the needs of patients should be at the centre of our planning process, so we have decided to pilot a workforce review within a programme-of-care approach. The initial focus will be on the domiciliary care service area in the older people programme of care. That will enable us to look right across the range of roles and professions involved in delivering that service and ensure that, on a regional level, we are looking at issues such as skills mix, training needs and the numbers required to cope with a growing demographic. That work is just beginning to be scoped, and an approach as to how it will be taken forward will be discussed at the next meeting of the regional workforce planning group, which is due later this month. In the meantime, a number of uni-professional workforce reviews are well advanced or are under way, some of which have been separately commissioned such as those relating to medical specialties being led by Dr Harper, whilst others are being taken forward as strands of other reviews — for example, the Department's imaging review.

The uni-professional reviews are providing vital information and knowledge on the current size and composition of the workforce, as well as projections to deliver the required services and to further the implementation of TYC. The interim report we recently received on the workforce review of GPs, for example, has given us a real insight into the workforce issues in that area, which is, of course, at the heart of primary care.

My final point is that workforce planning is usually defined as the process of placing the right number of people with the right skills, experiences and competencies in the right job at the right time. For the HSC, with a workforce of approximately 62,500 individuals, that is a challenge, as it is for many organisations, and it is an art as much as a science. Our aim is to match supply with demand closely, but that is technically difficult, given the wide range of factors that can influence forecasting and the complexity of changing the way in which services are delivered. We believe, however, that an approach that provides absolute clarity about our respective roles and that combines uni-professional regional reviews with a programme-of-care approach will help us to do that better, and we are committed to doing that.

Chair, I hope that that is helpful by way of context. My colleagues and I are happy to expand further and answer questions.

The Chairperson (Ms Maeve McLaughlin): Thank you, Heather. By way of context, how many reviews are taking place?

Ms Stevens: We have a number of reviews. We have a general medical workforce review, which is looking at the entirety of the medical workforce — specialisms and general medicine. That has a longer horizon, and it is very much based on scenario planning. It is being taken forward by the Centre for Workforce Intelligence, and its findings are expected later this year. We also have six medical specialty workforce reviews under way, and we have findings from four of them already. We have a nursing and midwifery review, which has reached the stage of being costed and will go to public consultation. There is a workforce strand in unscheduled care, which is looking at a series of issues to improve workforce planning in unscheduled care. Finally, we are about to start domiciliary care and take forward an approach there, but that work has not begun; we are at the initial stages.

The Chairperson (Ms Maeve McLaughlin): So there are 10 reviews.

Ms Stevens: Yes, and a further series is planned on the medical speciality field over the next 12 to 18 months.

The Chairperson (Ms Maeve McLaughlin): So there are 10 reviews. I am trying to be positive about this, but how much do they cost?

Ms Stevens: The general medical review that we commissioned from the Centre for Workforce Intelligence is costing us £35,000, but the rest are being taken forward internally or by using a partnership approach with other organisations.

The Chairperson (Ms Maeve McLaughlin): So there are 10 reviews, and one of them is costing £35,000. Reviews take time, which means money.

Ms Stevens: Absolutely, but it is resource in terms of people's capacity in the organisations that are involved in that process.

The Chairperson (Ms Maeve McLaughlin): With specialisms, are you convinced that that is the correct approach?

Ms Stevens: There is a balance. In making hard decisions about how much we need to provide to the Northern Ireland Medical and Dental Training Agency (NIMDTA) to train, for example, a consultant radiologist, we need to know how many we need to train, because that is an expensive process. Those uni-professional reviews are very valuable in helping us to make such commissioning decisions.

The Chairperson (Ms Maeve McLaughlin): When did the first of the 10 reviews start?

Ms Stevens: Some of them started before I arrived in post. The nursing and midwifery review had certainly started, as had the general medical workforce review. That was the middle of last year.

The Chairperson (Ms Maeve McLaughlin): Did any of them predate Transforming Your Care?

Ms Stevens: In this set of reviews, no. I understand, however, that, previously, from 2001, the Department funded some 29 workforce reviews, and they will have certainly preceded Transforming Your Care. There has been a history of uni-professional reviews from that point. The ones that I just mentioned are all since TYC.

The Chairperson (Ms Maeve McLaughlin): If there were 29 workforce reviews prior to TYC, it would be useful to get a sense of the impact or the recommendations that were taken forward as a result of any of them.

Ms Stevens: They will have influenced decisions at that time, but they will have dated from 2001 and will have needed to be refreshed for an up-to-date picture of the service. If you remember, I said that the initial point is to determine the model for service delivery, and the staffing structure follows that. As service models change, the need for a workforce review changes.

The Chairperson (Ms Maeve McLaughlin): Do you not accept that your biggest service model change was to have been Transforming Your Care?

Ms Stevens: Yes, absolutely.

The Chairperson (Ms Maeve McLaughlin): At that point, your focus, in advance of TYC being implemented, should have been in place.

Ms Stevens: Sorry, I do not understand. We have information on what the workforce was in 2011.

The Chairperson (Ms Maeve McLaughlin): Do you have information about what the workforce should be?

Ms Stevens: We have a series of reviews to tell us, and, as we get the information, we can act on it.

The Chairperson (Ms Maeve McLaughlin): Can you say, three years into the process, that we need x amount of staff in x amount of sectors to implement TYC fully?

Ms Stevens: It is more complex than that because TYC is a very fluid arrangement. As services are being considered and new services are developed that focus more on the community and on care being provided at home, given that demand is growing, we cannot immediately turn off the tap on services that are provided elsewhere. We can see that we have a growing demographic and a growing need, so we have to look at it. You can take a workforce review as a snapshot in time.

The Chairperson (Ms Maeve McLaughlin): I do not accept that TYC is fluid. TYC was the policy context that we all signed up to, as was the shift of the £83 million. I suggest, therefore, that it would not have been rocket science, when TYC was only an idea, to do your workforce planning and ask what we needed to do to shift the £83 million and to shift the focus from acute care to community or primary care and what front-line staff, GPs and consultants we need. We should not be doing it two years into a process.

Ms Stevens: Carolyn wants to come in. The starting point is to determine what your models for service delivery are. That process is under way through the establishment of integrated care partnerships (ICPs) and the work to determine what elements of care can be transferred. The workforce then flows from that. Until you have models of care, you cannot determine what your workforce is.

The Chairperson (Ms Maeve McLaughlin): We had 29 reviews, and you are suggesting that they should have informed that.

Ms Stevens: We had 29 reviews including a workforce review in 2001 and another review of the dental workforce. There will have been one review in 2001, another in 2004 or 2005 and maybe another in 2008. They have to be refreshed. There may have been 29, but they will be outdated. At least one third of them will have been superseded by subsequent workforce reviews.

The Chairperson (Ms Maeve McLaughlin): Are we learning from them?

Ms Stevens: Yes, all the time.

The Chairperson (Ms Maeve McLaughlin): You referred to Skills for Health. What is that?

Ms Stevens: Skills for Health is the sector skills council for the health and social care sector. Its remit is to look at the skills needs of the various occupations and roles that make up the health workforce. It is a UK-wide organisation, so we can approach it to do specific work for us. We have a service level agreement with it and are talking to it about capacity building for workforce planning. It helped us in the initial stages of devising our framework.

The Chairperson (Ms Maeve McLaughlin): So Skills for Health published a diagnostic report in November 2013.

Ms Stevens: Yes; it was on capacity building.

The Chairperson (Ms Maeve McLaughlin): For clarification: where was that report published? Was it circulated? Who was it circulated to? How much did it cost?

Ms Stevens: I would need to get the information on that.

The Chairperson (Ms Maeve McLaughlin): Was it published?

Ms Stevens: It will have been published.

The Chairperson (Ms Maeve McLaughlin): Was it on the Department's website?

Ms Stevens: I would need to check, but the document is certainly available for public scrutiny.

The Chairperson (Ms Maeve McLaughlin): Will you clarify that, Heather, and come back to me?

Ms Stevens: Yes.

The Chairperson (Ms Maeve McLaughlin): The paper also states that the framework is now at its final draft stage. Just so that I am clear, does that mean that it took 16 months from the publication of the report to come up with a framework? Is that a good rate to be progressing at?

Ms Stevens: That work started alongside capacity building work and the roll-out of a training programme that also came from the diagnostic report. In addition, the regional workforce planning group oversaw the commissioning of additional uni-professional reviews. That strand of work was proceeding alongside the other pieces of work. It started before I arrived in post, so that would have been before the summer of last year.

The Chairperson (Ms Maeve McLaughlin): Do we now have a timeline for that framework?

Ms Stevens: It is at final draft stage. We are testing it now.

The Chairperson (Ms Maeve McLaughlin): When will we have an opportunity to feed into it?

Ms Stevens: We will get it approved in the Department, and we can send it to you.

The Chairperson (Ms Maeve McLaughlin): Are we talking months? Are we talking weeks?

Ms Stevens: Weeks.

The Chairperson (Ms Maeve McLaughlin): It will come to the —

Ms Stevens: It needs to be tested. We consider it to be a living document, and we want to test it as we take forward the domiciliary workforce review on a programme-of-care basis. That is a new approach, so it may require the framework to be refined.

The Chairperson (Ms Maeve McLaughlin): So we are talking weeks, and it will be shared with the Committee.

Transforming Your Care very clearly stated that a reduction of 3% of the workforce — 1,620 staff, to be exact — would be required for implementation. How was that 3% figure reached?

Ms Stevens: I cannot give you a clear answer to that. It is not a departmental assumption; the assumption was made by the Health and Social Care Board, which was developing Transforming Your Care. As a best estimate, it will have been developed as a result of looking at the amount of money that was intended to be shifted, and a calculation was then done on the pay bill. That is my estimation of it; I have no information on it.

The Chairperson (Ms Maeve McLaughlin): Can we get that information? It is critical. That was a key objective. I assume that it remains your objective.

Ms Stevens: I asked for that information. It was a working assumption as TYC rolls out. A more nuanced approach is probably needed as opposed to having a blanket figure of 3%. I keep going back to the process that we have all signed up to, which is that you look at the model of service delivery and make your workforce fit that model. We should not be shoehorning ourselves into a particular percentage reduction. The TYC 'Vision to Action' document acknowledges that you might need growth in the workforce in the community setting.

The Chairperson (Ms Maeve McLaughlin): It concerns me, Heather, that, three years into a process, we hear that it was a working assumption.

Ms Stevens: That is what the document says.

The Chairperson (Ms Maeve McLaughlin): You have answered my question: you cannot shoehorn. You look at what you need to provide the service and what policy shift is required, and you analyse the workforce needs accordingly. We are now being told, however, that the 3% reduction in staff to implement TYC was a working assumption.

Ms Stevens: That is what the document says. I am happy to ask the board for further information. I did ask the board, but I am happy to go back again to ask for it.

The Chairperson (Ms Maeve McLaughlin): I suggest that we need absolute clarity on that. Are we still working towards 3%?

Dr Carolyn Harper (Public Health Agency): I will give you our experience in medical workforce planning. The approach that we have taken is what you have suggested: you look at the needs of the patients, the demand and the new standards. TYC is one driver, but there are a number of professional documents, new National Institute for Health and Care Excellence (NICE) guidance or new professional standards that are setting new standards for medical cover, for example. There is a move to seven-day services. We want to move to seven-day services, and we took account of all that in approaching the calculations on how many medical staff are required. While it is primarily focused on medical staff, we have also taken into account opportunities for new roles and a skills mix, particularly roles for advanced nurse practitioners in paediatric and emergency medicine specialties. We involved nursing colleagues, and there are clear opportunities by looking elsewhere to develop that role, so they are not purely uni-professional. It is very much about looking at the needs of patients and clients and at trends and demands and making calculations on that basis.

The Chairperson (Ms Maeve McLaughlin): I will rephrase: as it stands today, to implement Transforming Your Care fully, are we talking about a 3% reduction in staff? What reduction are we talking about?

Dr Harper: I will have a go at that. The overall population is increasing in total numbers, and, in relative terms, it is also ageing. While all the good things such as TYC, better preventative medicine, better self-management and earlier intervention will help — we have already seen increases in the number of years that people live, disease-free and disability-free — as the population ages, there will be continued demand for acute hospital care, acute care in the home and so on. There will be patients with increasingly complex needs. On that first principle that there will be a bigger and older population, we will continue to need more staff, not fewer staff, as the years go by.

The Chairperson (Ms Maeve McLaughlin): So is it not now a reduction of 3%? All I am asking for is a figure. I get the context. I am asking for a figure.

Dr Harper: I do not think that any of us at the table is working to an assumption of a 3% reduction in staff.

The Chairperson (Ms Maeve McLaughlin): So we are not working towards a 3% reduction in staff. Is it less than that? Is it greater than that? Can you give us any indication?

Mr Damian McAlister (Belfast Health and Social Care Trust): From a trust perspective, I can comment and say that demand is growing. We are trying to provide many more services in a community setting rather than having people in hospitals, and, even for those in hospitals, we would rather provide their care on an ambulatory basis so that they do not require to be an inpatient. That still requires a growth in services, both in the acute hospital and community setting, so we are not experiencing the reduction in the demand that TYC predicted.

The Chairperson (Ms Maeve McLaughlin): I am going to labour this point. If you are carrying out workforce planning, there must be a target figure somewhere that you are working towards.

Ms Stevens: It is not a reduction.

The Chairperson (Ms Maeve McLaughlin): Is it an increase?

Ms Stevens: We are working to make sure that there is a workforce that is fit to deliver the service models that are agreed as they are agreed.

The Chairperson (Ms Maeve McLaughlin): So that is likely to be an increase in staff employed to deliver TYC as opposed to a 3% reduction.

Ms Stevens: Undoubtedly. Over the last three years, the number of staff in the whole HSC has increased by over 4%. That is reflective of the growing population and growing demand.

The Chairperson (Ms Maeve McLaughlin): I am labouring this because I think that it is important. Can you share with us, if not today then as soon as possible, what we are talking about in terms of the staff requirement to implement Transforming Your Care? If it is not now a 3% decrease, it is an increase. What type of an increase do we need and in what sectors?

Dr Harper: I am not sure that you could come back with a figure as definitive as that, Chair. You have to look at each specialty area or service area. It is not an exact science. It is based on a number of assumptions and trends over time and so on. It is not as straightforward as saying that it will go from x to y, with y being exactly what you need to implement TYC. Implementing TYC, Making Life Better, the Quality 2020 strategy, the maternity strategy or the paediatric review when it comes out are all factors. It is continuous and fluid, which I think was Heather's point. The situation is fluid in that we have to adjust the plans constantly. It is not about going from one fixed point to another.

The Chairperson (Ms Maeve McLaughlin): I accept that, but are we now saying that the target in the policy direction was wrong?

Dr Harper: I do not think that it was a target that the Department set.

The Chairperson (Ms Maeve McLaughlin): It was clearly in the Transforming Your Care strategy. A 3% staff reduction is clearly there in black and white.

Ms Stevens: It is there as a working assumption, which is how it is described. It is not a target. It does not take into account the fact that, for many of the changes that TYC envisages, it is not about recruiting new staff but changing the role of existing staff. All that has to be factored in, so it is not a straightforward case of x new services equating to y new staff.

The Chairperson (Ms Maeve McLaughlin): I again go back to the point that, if it has now changed from being a 3% reduction, we want to be informed as that figure is being developed.

There were reports and reviews into general practice in 2006, 2010 and 2014. Why were those recommendations not acted on?

Ms Stevens: Is that to do with increasing the number of GPs who are trained? At the time, the decision would have been based on available resources. That is the climate that we still find ourselves in.

The Chairperson (Ms Maeve McLaughlin): So it is to do with available resources. Despite the fact that this goes back to 2006, when the potential crisis in general practice was highlighted, with clear recommendations about the number of training places we needed in the North, nothing was done.

Ms Stevens: As I understand it, the training places that have been commissioned have been 65 a year for some time. There are concerns about the length of time it takes GPs to complete their training. Many are taking longer than the three years that we want to see. We are also conscious that we are losing quite a few GPs who train in Northern Ireland and are paid for to train in Northern Ireland to elsewhere. We want to address those serious issues. An increase in training numbers is one part of a bigger review on how we increase the number of GPs currently practising in Northern Ireland. We know that we are under-supplied with GPs.

The Chairperson (Ms Maeve McLaughlin): Of course we are. There is the final 2010 report, and there was also one in 2006. The 2010 report clearly stated that urgent action was needed to increase the number of training places from 65 to 80. I have a copy of the interim report here, and I think that it is worth quoting. The interim report — the figures are very recent — looked at the period from 1 January 2014 to 24 September. The Department has this report. It looked at the number of occasions on which GPs had to close: Kilkeel, 43 times; Armagh, 86 times.

Ms Stevens: We completely —

The Chairperson (Ms Maeve McLaughlin): No, I am sorry Heather. Two very clear recommendations go back to 2006, stating that GP training places were at crisis point and needed to be shifted. One recommendation is to increase GP training places to 111 annually, phased over four years.

Ms Stevens: I completely accept that that recommendation was made. We have built in a requirement to increase such training places as a pressure in our budget, but, as you are aware, that is competing with other significant budget pressures in the 2015-16 discussion.

The Chairperson (Ms Maeve McLaughlin): Are you saying that you have built an increase for GP training into the 2015-16 budget?

Ms Stevens: It is for consideration as part of the 2015-16 budget. The Minister has not yet approved that.

The Chairperson (Ms Maeve McLaughlin): Is it a fair criticism that, given that this goes back to 2006 and that there is a considerable amount of data on it, the recommendations in three reports were not followed through?

Ms Stevens: I cannot argue: the recommendations were not implemented.

The Chairperson (Ms Maeve McLaughlin): This is at a time when there is the potential for the system to burst in a number of sectors, particularly in primary care.

Ms Stevens: That is why we are keen to make sure that the training places that we fund produce GPs who will work in the Northern Ireland system. It is a very expensive process, and we do not want to train them and have them lost to the system.

The Chairperson (Ms Maeve McLaughlin): I know that Fearghal wants to come in on this. You have the report: it is £90,000 per training place.

Dr Harper: That was one of the medical specialty plans that was agreed through and approved by the regional workforce planning group, which Heather chairs.

For clarification, the 2014 report is still working through the process. Heather mentioned that it is factored into the budget for 2015-16, subject to the overall pressures and position. We do not yet know whether the 2014 recommendations will be fully accepted, but we have certainly made the case. The evidence is there.

The Chairperson (Ms Maeve McLaughlin): Are we likely to see an increase in training places, given the recommendations?

Ms Stevens: It will be for the Minister to decide, Chair. In terms of all the other —

The Chairperson (Ms Maeve McLaughlin): Given the policy direction of the need to refocus on primary.

Ms Stevens: The Minister has that information, and he will make his decision in terms of the 2015-16 budget.

Mr McKinney: There is a big pattern in the figures. Of the roughly £27 million available for Sunday and training etc, £23 million of that, last year, went to the Belfast Trust and hospital provision. Fully cognisant that we are short of GPs, how can you justify that level of budget going into hospital training and not into GPs?

Ms Stevens: That is for undergraduate medical and dental training, so it relates to the placements of the students who are going through Queen's and doing their basic medical degree. At that point, they have not decided what specialty they want to pursue.

Mr McKinney: Yes, but if they are not going to GPs for more than about four weeks in their training, how are we going to encourage them into GP-land?

Ms Stevens: We do not have any difficulty in encouraging GPs. GP placements are oversubscribed. We have roughly double the number of people applying who can be accepted by NIMDTA to train as a GP.

Mr McKinney: They are not getting training in GP surgeries to the extent that they are getting training in consultant or hospital roles.

Ms Stevens: Do you mean as part of their undergraduate experience?

Mr McKinney: Yes.

Ms Stevens: At the minute, that is right. We are perfectly happy to —

Mr McKinney: Is that consistent with trying to get people to be GPs?

Ms Stevens: It has not hampered them; we are still oversubscribed with the number who want to apply. That is not to say that we should not be discussing the composition of the undergraduate degree and the placement programme anyway. What you said is very valid. We need to give more doctors experience of primary care in any case. However, it is not an inhibiting factor in attracting people to train as GPs. We are oversubscribed.

Mr McKinney: Is that consistent with what the BMA found in its report about general practice here, with the shortage of doctors, the number retiring and the gap in the market?

Ms Stevens: The constraining factor is the number of places that we can fund, not the placement. The placement is a good idea anyway, but that is not the constraining factor; it is the number of places that the Department can fund.

Mr McKinney: It is one of the constraining factors.

Ms Stevens: I do not agree. It is a good idea to do it, but it is not a constraining factor in terms of the number of GPs who can go through.

The Chairperson (Ms Maeve McLaughlin): The first recommendation in the interim report is that the training places should be increased to 111 annually. Are you likely to support that? Did that recommendation come from you?

Dr Harper: We are all members of the regional workforce planning group that approved that report. I lead the particular work strand to develop the plan, so I absolutely support it.

Mr McCarthy: Following on from that — correct me if I am wrong — you mentioned the figures for the students who want to go into general practice. You are satisfied with the numbers. Only last week, I think that Dr Tom Black told the community that there was going to be a shortage of GPs; the ones who are there are retiring. You are saying that that is not correct.

Ms Stevens: No, I am not saying that at all. It is correct. We have a number of people — over 100 — who want to apply to be GPs, but we cannot, at the moment, fund the places; we can fund only 65. Tom Black would argue that 65 is not sufficient for us to fund in order to meet the fact that a large number of GPs are going to retire. The lack of funding for the training places is our barrier.

Mr McCarthy: Surely that must be an urgent action or work on somebody's behalf to ensure that the required number of GPs will be available as GPs retire.

Ms Stevens: That is why it is built in for the Minister's consideration, but only he can make the decision as to what his priorities are for 2015-16. The arguments are certainly there. Apologies for repeating this, but he will also want us to make sure that the number of GPs whom we fund are encouraged to stay in Northern Ireland and deliver the service here. We are concerned at the number who come through that process and go elsewhere, because that is a loss to the HSC in Northern Ireland.

Mr McCarthy: I come to the roles and responsibilities set out in the draft framework at paragraph 7 of your paper. One of the roles of the board is to ensure that independent practitioners identify their workforce needs for service delivery. Given that GPs are independent contractors, what power does the board have to make sure that they carry out workforce planning, so that they have enough GPs, treatment room staff, nurses and receptionists to keep their surgeries functional?

Dr Harper: GPs were certainly part of the work that we did to develop the GP workforce plan. Indeed, they were more than a part: they were the main leaders and drivers of the plan. The Royal College of General Practitioners was included in that work as well. Any of the workforce plans involve all those who have a direct stake in the service.

Mr McCarthy: We all know that GPs play and will play a very important role in the implementation of Transforming Your Care and are crucial to workforce planning. However, I understand that the Department does not currently compile data on GP practices, such as the number of treatment room or practice nurses. How can the Department truly understand the GP workforce if no data is collected?

Ms Stevens: The HSCB is working on a business case for a data warehouse facility that will capture exactly that information. Obviously, that will be subject to resources, as is everything in the current climate. We are conscious, however, that it would be extremely helpful, if not essential, to have information on GPs. What we have at the moment is what we can glean from the returns that GPs make to claim their funding under the general medical services (GMS) contract. We are constrained by that.

Mr McCarthy: Do you not think that this work should have been done long ago?

Ms Stevens: The need for it has been identified, and it has taken some time. Obviously, because independent practitioners are just that, it is for them and the BMA working with us to agree it. We do not have the power to require them to do it.

Mr McCarthy: Finally, is the Department carrying out any workforce planning for other independent contractors, such as pharmacists or, indeed, opticians?

Ms Stevens: We are certainly aware of the need to do a pharmacy workforce review. It is on our list, if you like, together with allied health professionals. The immediate priority, however, is domiciliary care, which is of course delivered through a mixed economy, with some statutory sector and some independent sector provision. We will get a good sense of what the workforce needs are in that area to begin with.

Mr McCarthy: The sooner that is done the better, surely.

Ms Stevens: Absolutely.

Mrs Dobson: The paper provides some information on workforce modelling at trust level relating to the Belfast Trust. Have any other trusts undertaken workforce modelling yet?

Mr McAlister: Maybe I should clarify my role. I am here as a representative of the regional workforce planning group. I happen to work for the Belfast Trust, and that is why the figures relate only to it. Yes, all trusts provide and analyse their workforce statistics and carry out modelling based on service demand. Then, when a commissioned need is identified, we work with the HSCB as the lead commissioner to secure the resources to meet that demand as identified.

Mrs Dobson: Trusts are currently facing unprecedented pressures on nursing staff. My trust, the Southern Trust, has told me of unprecedented spikes in activity in acute hospitals across Northern Ireland. I appreciate the need to plan ahead; it is essential for changing roles. Surely, however, the challenges in our hospitals are currently happening. What are you doing now to help the trusts to address those problems?

Mr McAlister: Our trust, like all organisations in the health and social care sector in Northern Ireland, is facing unprecedented demand; it has been that way since just before Christmas and continues. We have been flexing up our nursing workforce insofar as we can, both by offering our existing staff additional hours and looking to bank and agency staff to augment our existing workforce to meet the unprecedented demand. When the current surge abates, we plan to look at the demand over this winter and, indeed, over previous winters with a view to scheduling our workforce in such a way as to meet the demand when it is at its greatest. I know that each organisation is doing the same.

The problem is that, when a nursing workforce is faced with significant demand and that demand outstrips capacity, it creates a workforce gap. That is maybe what some areas are experiencing at present.

Mrs Dobson: I met senior management at the Southern Trust last week, and they are under considerable pressure. I note that you said, Damian, that you are offering existing staff extra hours to alleviate the pressure. I am somewhat concerned that too much pressure is put on staff while the Department is not helping to resolve the issue. Staff are coming off long shifts and are being asked to come in for extra hours. They are so dedicated; but I do not like them being put under pressure, and many have told me that they feel under considerable pressure. How, then, will the regional workforce planning group help trusts, with existing staff, to keep pace with the pressure on the services? We cannot go on like this. Staff can only cover additional hours at weekends or whatever. They cannot continue to do this, and so many are going off sick.

Mr McAlister: Maybe Heather would like to answer that. From the point of view of my organisation, the professionalism of our staff is tremendous; what they do every day is fantastic. I hope that they are not being put under duress or pressured.

Mrs Dobson: They feel that they are. They are outstanding in the work that they do, but —

Mr McAlister: Of course. Certainly, the management team in our organisation is acutely aware of the pressure that our staff are under. We are working, through the management team and with the staff, to alleviate that as much as possible and to make sure that staff are not put in a position where their own health and safety is compromised. The regional workforce planning group —

Mrs Dobson: Certainly, I am concerned based on what I have heard from staff who do not want to be identified for fear of their jobs. They are so dedicated and committed, as we all know. This cannot continue, however. What sort of time frame are we looking at?

Mr McAlister: It cannot, I agree. That is what I mean by taking stock of what has occurred and starting to plan for the future. That is the nub of workforce planning. Looking back, past performance is the best predictor of future performance. The demand over winter 2014-15 will influence our approach in winter 2015-16.

Mrs Dobson: You do need to plan ahead, but these issues are evident now. I am really concerned. They are not being addressed now, when staff are demoralised and at breaking point. How then can you continue to future-proof, when they need the help now?

Ms Stevens: I think so, and if I may, I would like to add that I completely support what Damian has said. Patient safety is an absolute priority, as is the health and well-being of staff. We rely on them to do the job that they do. When it comes to grossing up, if you like, our workforce requirement at regional level, we have to be realistic about what we are asking people to do. Currently, we have 62,500 staff, or 54,000 whole-time equivalents, but does that count the extra time that staff put in, thereby masking the fact that we should actually have a higher number? My concern is that we get a really accurate fix on the workforce requirement; one that does not take into account the goodwill of people who are trying to do a lot because they care.

Mrs Dobson: It is alarming. The staff are tremendous, but when they are under so much pressure, that needs to be addressed as a matter of urgency, before we plan.

Ms Stevens: It does. One of the vehicles that we have to try to capture that is a staff survey, which is usually done biannually. We are working with the trusts now to plan the new survey, and I would like to think that we will capture that sort of information, so that we get a sense from people of where the pressures are and to what extent they are working above and beyond the call.

Mrs Dobson: Certainly, I was very concerned about the pressures following my meeting.

To be clear: you are saying that the Belfast Trust will publish its first workforce plan in March 2015. Is that correct?

Mr McAlister: Since TYC, we have been taking forward workforce planning in our adult social and primary care services, which covers mental health, learning disability and older people services. It is quite a broad area of service delivery in the organisation. We are confident that, by the end of the month, we will have published a workforce plan, which will then in turn inform our commission bid to the HSCB, as the commissioners, for the additional resources to maintain those services. It does take time to develop them, because the first step in any workforce plan is identifying the service need, and we have been considering in mental health, for instance, how we move away from inpatient treatment to treatment at home. So, from that perspective, it is a service reconfiguration, and it might just mean a reskilling of some staff; for example, psychiatric nurses who previously worked on a ward to work as community psychiatric nurses. That is workforce planning at its sharpest edge, and we are confident that, by the end of this month —

Mrs Dobson: It is a ticking clock for time.

Mr McAlister: It is, and the sooner it is published, the sooner we can engage in discussions in the workforce planning cycle with the board as the commissioner and then ultimately with the Department, if there is identification that there are additional training places required, for example.

Mrs Dobson: So it is going to be later than March 2015.

Mr McAlister: No, for adult social and primary care, we will have a workforce plan for the Belfast Trust for those services by the end of this month.

Mrs Dobson: In a couple of weeks' time, you will have that.

Mr McAlister: Yes, that is the intention.

Mrs Dobson: In relation to the workforce planning being carried out at Department, board and trust level, how will you ensure that the plans complement one another other and that people do not end up working in silos? Who has overall responsibility for monitoring workforce planning? Is it you?

Mr McAlister: In the Belfast Trust, I am responsible for the monitoring of workforce planning within our organisation —

Mrs Dobson: But what about over all the trusts?

Mr McAlister: For all the trusts, it would probably be the responsibility of the directors of HR and the directors of planning. That is why we have the regional workforce planning group. It is through it that we organisationally present our programmes of care workforce planning, and it is about marrying those with the uni-professional workforce plans that are being developed, for example, down the medical line, to make sure that we do not end up working in silos, where one profession says that it needs x, y or z nurses and another says that, from a programme of care perspective, it wants to move away from a nursing-led model towards more of a multidisciplinary team model that involves nurses, social workers and allied health professions.

Mrs Dobson: How regularly do you meet the chief executives of the trusts? I can speak only from the example of my Southern Trust. Is it weekly?

Ms Stevens: How often does the regional workforce planning group meet? It has been meeting monthly recently, and it is due to meet again on 30 March.

Mrs Dobson: How often do you talk to the chief executives of the trusts?

Ms Stevens: It would be the HR directors —

Mrs Dobson: If I can spend two hours talking and seeing the problems quite quickly, surely you are doing the same.

Ms Stevens: We work with the HR directors who would obviously communicate the views of the chief executives.

Mrs Dobson: You are not actually meeting with the chief executives.

Mr McAlister: We are there as the representatives of the organisations through the regional workforce planning group. So I represent the views of the Belfast Trust chief executive and interact with the chief executive on workforce planning issues, as I would with other service directors within the organisation.

Mrs Dobson: But are you meeting face-to-face with the chief executive of the Southern Trust, for example?

Mr McAlister: I cannot comment on the Southern Trust, sorry.

Mrs Dobson: You are not meeting directly with the chief executives; it is just HR directors.

Ms Stevens: I meet with HR directors, but the chief executives of all the trusts will meet our permanent secretary on a regular basis. There are other avenues.

Mrs Dobson: How regular is regular, given the crisis now?

Ms Stevens: I think that it is pretty regular, but I am not familiar with the schedule.

Mrs Dobson: It would be useful, Chair, to find out how regular is regular, given the crisis that there is now, and how that is defined.

Dr Harper: I think that it is fair to say that no one within the group — no one on any senior management team across HSC organisations — could be in any doubt as to the pressures, the needs and the strategic direction. It reflects the approach that we have taken to date. Firstly, it is patient/client need. Secondly, what is the service model that we need? That is the integrated teams that Damian and Heather have mentioned. Thirdly, what are the workforce needs to put those in place? The move from five-day services to seven-day services will, undoubtedly, help to remove some of the pressure that staff feel on that Monday to Friday concertinaed effort. Undoubtedly, that means that we need additional workforce, because you are covering an extra two days of the week —

Mrs Dobson: They are telling you that three staff members in a particular area will be off that weekend, and they really need that coverage, and they know that on a Thursday for a Friday.

Dr Harper: Yes. You are absolutely right: it is not sustainable. I echo the comments that others have made about the commitment and the professionalism in nursing, medicine and social work, right across the disciplines, to make sure and provide the service for patients. Specifically on the nursing, there has been extensive work to look at nurse staffing levels; it is called the normative nursing exercise. It has been completed in some aspects of acute care, and there are further phases looking at community nursing, health visiting and so on. Again, the results of the first phase of that are factored into the financial planning for 2015-16, so we have started to put in place the recurrent additional staffing that is required to give us that sustainability and take the pressure off staff.

Mrs Dobson: There is nothing like sitting across the desk with a chief executive —

Dr Harper: Absolutely.

Mrs Dobson: — or the head of a department to find out exactly what pressures there are.

In relation to investment and retraining of staff, for those who have time to do it, to achieve the appropriate skills mix, I note that your paper provides examples from the Belfast Trust. However, the majority of those examples seem to be about simply providing training opportunities for staff rather than retraining. Is this a fair assessment?

Mr McAlister: Are you relating retraining to moving from working in one sector to another to meet a shift in services? I think that it is fair to say that, given the demand that there has been on our hospital services over the last three years, there probably has not been the movement from hospital settings to community settings that would involve a retraining of staff. There has probably been some around individual programmes of care, maybe in respect of how diabetes is treated or respiratory illnesses that have been supported with funding from the Health and Social Care Board. What is presented here is predominantly how we are trying to upskill staff in those settings at present to continue to meet the demand in the way that it is coming through our front door. So, yes, in answer to your question.

Ms Stevens: There are a few other examples. For example, in the Ambulance Service, paramedics are being upskilled at the moment to do more of the see, treat and leave as an alternative pathway to help to divert more people away from emergency departments. Carolyn mentioned that there is a move to upskill nurses into advanced nurse practitioner status so that they can start to take on some of the roles that more traditionally have been done by junior doctors. We, in the Department, have a small budget to support health care support workers. Those are people who are working in the HSC at lower levels, bands 2 and 3, but who are very committed and want to upskill and perhaps want to take advantage of open access through the Open University to do, for example, a nursing degree. We are able to provide some support for that. There is a range of ways in which we are trying to upskill staff.

Mrs Dobson: Is that aspirational, given that we seem to be firefighting to get the cover for a shortage of nurses?

Ms Stevens: Yes, and that is reflected by the number of people who can currently go through. Absolutely.

Mr McAlister: I draw your attention to the generic support worker post that we have created across allied health professions in the community. I think that it is an important one. That is a worker who now works across occupational therapy and physiotherapy. Previously, particularly from a client perspective, clients will have had visits from individual workers representing both programmes, so they will have had an occupational therapy support worker and then a physiotherapy support worker. Now, we have upskilled 95 of our staff to be able to cover both disciplines, and it means that the client is getting one face to see and that it is a better service. In terms of upskilling, that is one example of where we have been able to reskill, because that has an element of reskilling where they have had to learn across what was two separate professions previously.

Mrs Dobson: Finally, can the Department quantify how much has been spent across the trusts on retraining staff to meet the shift left requirements since TYC was published?

Ms Stevens: I cannot give that figure today. We can commission that. We can ask for that information and provide it.

Mrs Dobson: It would be useful, Chair.

I am really concerned about the pressure put on the front-line staff, and I have nothing but admiration for the work that they do, but there is only so much pressure that they can take as well, and it is urgent that you deal with that before you get to tackle future planning.

Mr McAlister: I could not agree more with you.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. Thanks for the presentation. It has been referred to a bit by Jo-Anne, but I want to ask about the £25 million shift out of the £83 million for Transforming Your Care and the actual impact of that. The paper does not talk about the impact of that on staff working in mental health and disability. Why would that not have been referenced in the report?

Ms Stevens: We are still working through what the workforce implication is of the resettlement of the £27 million for mental health and learning disability services, so we need to get that information from the board in terms of TYC. I do have more information in relation to the new services that are being commissioned for primary and community care going forward. By 2015-16, an additional £16 million will have gone in, and that will include some recruitment, for example of reablement teams, additional foster carers, staff in dementia services and 40 additional nurses. I can quantify that more easily for you. I need to go back to the board and get more information on the resettlement.

Ms McCorley: When you say recruitment of staff, is that going to be completely new staff or would it be staff coming from other places?

Ms Stevens: It is recruitment of completely new staff.

Ms McCorley: OK. Have any of the existing staff in institutions dealing with mental health issues and disability been transferred?

Mr McAlister: Yes. Where we have reconfigured services to take people out of what you describe as institutions and into supported living programmes and whatever, staff who previously supported people in those institutions have transferred or been redeployed. No staff in our trust have lost employment as a result of a reconfiguration of services.

Ms McCorley: Are staff who are moving to accommodate, maybe, facilitating or providing services for people in a different setting being retrained?

Mr McAlister: Where retraining is appropriate, there would be an element of that, but it is mostly about the institution as opposed to the direct care that is being provided. The care tends to be quite similar, so it is more about the change in the infrastructure of the institution.

Ms McCorley: When will you have the information about the impacts of that on staff?

Ms Stevens: I will commission that.

Ms McCorley: When will it be available?

Ms Stevens: I can get that information to you in a few weeks.

Mr McCarthy: May I come in on the back of that to ask about Muckamore Abbey Hospital? Your comments worried me a bit. I would have thought that this is about patients and people rather than other resources. What is the up-to-date position in Muckamore? I know that the deadline for the Muckamore patients to be resettled was March 2015.

Mr McAlister: I will need to come back to you on that. I do not have the figures to hand, but I know that the programme is continuing and that we are resettling patients from Muckamore.

Mr McCarthy: Are they being resettled where they want to be? My concern, which is shared by others, is that there was a push on to get people out wherever they go and that is not on.

Mr McAlister: That is not my understanding, but I will provide the figures.

The Chairperson (Ms Maeve McLaughlin): Is there somebody from the board on the regional workforce planning group?

Ms Stevens: Yes.

The Chairperson (Ms Maeve McLaughlin): Who is it?

Ms Stevens: There is membership on the commissioning side and on TYC. They have not attended recently because we have been focusing very much on the framework, but they are core members as the group was originally set up.

Mr G Robinson: The Committee had asked you to provide information on how workforce planning is taking account of recruitment issues in particular geographical areas. However, the briefing paper provides no information. Are the Department and the board looking at that issue? Can you give me an answer on that, please?

Ms Stevens: We are very aware of gender issues and working pattern issues, and they are part and parcel of workforce reviews as they go forward. For example, we know as a result of the GP workforce reviews that that is a predominantly female specialty. We know that lots of female GPs want to work part-time. So we get that information through the workforce reviews. We are looking at seven-day services, and we have asked the two pay review bodies — the NHS pay review body and the doctors and dentists' pay review body — to make recommendations, or rather observations in relation to the enablers for and barriers to seven-day services, because, again, that impacts on flexible working patterns. We are very conscious of it, and it is being dealt with through a number of channels.

Mr G Robinson: Is that seven days for doctors, did you say?

Ms Stevens: It is about seven-day services across the piece, recognising that some parts of the system already work over seven days. Nursing care is provided over seven days already and, increasingly, laboratory services are being provided over seven days. In many areas, physiotherapists are being provided over seven days.

Mr McAlister: I will answer your question about geographical areas. From a workforce planning perspective, it is the responsibility of the local trust to identify any geographical concerns that are prohibiting recruitment. In the workforce planning cycle, that would be through the regional workforce planning group fed back through to commissioners and, ultimately, to the Department to try to address.

Mr G Robinson: Does that take in all trust areas?

Mr McAlister: Yes. All the trusts are represented on the regional workforce planning group; that is our responsibility.

Ms Stevens: If there were shortages in, perhaps, the Western Trust, we would be aware of that in the context of attracting middle-grade doctors into those areas. We are aware of it. There is not always a training solution for that; sometimes it is about recruitment and retention, which is very much an issue for the employers to sort out.

Mr McKinney: In your report, you talk about doing workforce planning on programmes of care or on staff groups. In the end you decided, by and large, on staff groups. Why?

Ms Stevens: Traditionally, that is the approach that has been taken for some time. We are now moving towards a programme-of-care approach, recognising that the patient needs to be at the heart of it. That is very much driven by TYC. We think that that is a better way to allow us to look at the skills mix so that we can start to look at different roles that different professions play.

Mr McKinney: Why did you decide to do it on staff groups?

Ms Stevens: We already had those under way when we reached the conclusion that we wanted to pilot a programme-of-care approach. However, I argue that, in any case, they are very valuable, if not essential, in allowing us to make decisions about how many doctors and nurses we need to train. You get that only by looking across the profession.

Mr McAlister: I think there is a need for a blended approach, whereby both can coexist. The programme of care readily identifies how the demand can be met and by what professional group. I think that there is then a responsibility to take that into a uni-professional workforce plan, because you might commission the education. Nursing education is commissioned through a different provider than medical, AHP and social work education. You almost need to have an overarching programme-of-care workforce plan that you then split into the uni-professional workforce plans.

Mr McKinney: Yes, but which is the most important? I think you are saying that it is the programme-of-care work, which is then to be supplemented by the staff. So, we have not done the programme-of-care work.

Ms Stevens: No, no one has. It has not been done in England either. Traditionally, workforce planning is done on a uni-professional basis. We are working through a process now, and we have decided to focus on domiciliary care as a key area that has not been looked at to date but is an area where we see there might be a need for growth. We want to test the approach in that.

Mr McKinney: I welcome that, but it is four years late, because TYC had at its heart the concept of a growing, ageing population, long-term conditions and, clearly, the need for more care. Why are you coming to look at that only now?

Mr McAlister: Work has been done on older people's services. Re-enablement was a concept that was introduced on the back of TYC.

Mr McKinney: That is a specific programme; it has not taken account of an overall assessment of what older people need.

Mr McAlister: I accept that.

Ms Stevens: I do not have a straightforward answer for you, but it might be that it is very difficult. There were perhaps concerns that it could not be done properly. As we have become more confident about looking at the skills mix, challenging ourselves and considering whether a particular profession has to do a particular job, that has now opened us up to thinking that we just need to look at it differently. It has perhaps taken a while for that thinking to come to fruition, but we are there now. We want to test this.

Mr McKinney: But you are not there yet, because —

Ms Stevens: We want to test —

Mr McKinney: — you are at the point of scoping out. You are not at the point that you say you are.

Ms Stevens: No, we are there by having made the commitment to do it.

Mr McKinney: Sorry, now you are making a commitment to do it?

Ms Stevens: Yes, we have decided that we are going to focus on the domiciliary care.

Mr McKinney: You are beginning to scope this review.

Ms Stevens: What needs to be scoped is the consideration of the services that are provided within that domiciliary care service area, for example. We need to scope it out, look at what different professions are involved and look at the population that we are trying to serve.

Mr McKinney: Do you see how I am asking these questions? My jaw is dropping, because, if the first point of principle of TYC was recognising the growing ageing population, surely the first job in the whole thing was to assess the need for that growing older population. That means not the staff need but the patient need and all the needs of that growing demographic.

Dr Harper: You can cut it both ways. If you look at an older person, you can see they may have needs that their general practitioner or community pharmacist can meet. Some others will have needs that can be met in only a critical care unit or by an interventional radiologist in a tertiary-level centre.

Either way you cut it, you need to understand that from both perspectives. For designing training, you certainly need to know how many radiologists we need to train.

Mr McKinney: I understand that, and I get and welcome that you are now, four years late, coming to this as a concept. Does that mean that what we have in place now is not satisfactory? I am talking about, for example, limited 15-minute domiciliary care packages.

Ms Stevens: We cannot comment on that until we do the review. We need to do the review, look at the services that are provided and at the population needs and then make determinations about what the size, composition and skills of the workforce need to be so that we can deliver the service that we all agree should be delivered.

That is part of that process. Then we need to look at the models to see whether it involves statutory provision or independent sector provision, and we then need to look at the skill levels. That is all part of that work.

Mr McKinney: But in the absence of that considered information, I can reasonably question the value and quality of the care that is provided.

Mr McAlister: Care is provided on an assessed-need and individual case-by-case basis, so not everybody gets 15 minutes. The workforce plan is about trying to identify the resource that is required to provide the growing demand that older people are experiencing. As it stands, each case is assessed on an individual basis.

Mr McKinney: Just to broaden it out a bit, is it right simply to look at the domiciliary care side of this? Consistent with the overall TYC plan, with a view to reducing that demand on the expensive side of the service, a much bigger scoping exercise should surely be done on the overall needs of that growing population, which we all recognise is going to put increased demand on the service.

Ms Stevens: I think that will come, but we were conscious that we did not want to bite off more than we could chew by looking at this in a different way. We want to focus on that one area, and then we can roll it out.

Mr McKinney: Typically, how long does a review like this take?

Ms Stevens: It depends. We have not done one like this before. That will be part of the scoping exercise. That work is going on to see how quickly we can get the information together and where it is. So, I cannot give you an answer to that at the moment. The regional workforce planning group will have an idea at the end of the month when that scoping work has been done.

Mr McKinney: Do you accept that there is a reasonable cause for incredulity, given that this work has not been done, given what TYC set out?

Dr Harper: I think your question, Fearghal, implies that other work is not going on. I mentioned the normative nursing work, and Heather mentioned the 4% increase in staffing overall across the HSC.

Mr McKinney: That is OK, but that is from the staffing point of view; you are now coming to the view that this needs to be done around programmes of care.

Dr Harper: No, I said that the driver of the staffing needs is, first, the patient/client need, then the service model and integrated teams, and —

Mr McKinney: But we have not established the specifics or the generality of that patient/client need.

Dr Harper: The general practice report, for example, is very much based on the trends in demand for general practice from patients and their needs. It is calculating on a straightforward basis the workload trends and, from that, the number of GPs, so it is very much driven by patient needs. That is the approach we have taken. It is the same with the normative nursing levels. They look at —

Mr McKinney: It is my understanding — maybe this point was raised earlier — that you do not keep the data on the staff in the GP services.

Dr Harper: We know the numbers. I am talking about the GPs themselves and the number of training posts you need in general practice to meet the need. The report sets out the expansion that is required. It is based on that style of information.

Mr McKinney: I think we are on record as saying that we are very concerned about how domiciliary care is provided here and how inequalities are provoked by individual trusts taking individual decisions consistent with their financial bottom line. That inequality is increasing. Also, Damian, it is clear that some people are not getting care packages and that only those with higher conditions are getting them. That is also flying in the face of TYC.

The recent story about 14 frozen meals being delivered once a fortnight is a new low in the service for and care of our older people. I urge that this review work be done as quickly and as comprehensively as possible and that we, as a society, start to actually look after older people, rather than seeing them as a cost and a burden.

The Chairperson (Ms Maeve McLaughlin): No other members have indicated that they wish to speak. I thank you for your time today. By way of conclusion, I think that a number of questions remain to be answered. It was quite enlightening to hear today that we are not working towards a 3% reduction in staff to implement TYC. That is certainly news to the Committee. As I said, I stress that we want to get a sense of what the figure will be. Somebody somewhere calculated that initial figure for Transforming Your Care. It is also critical, Heather, that we get a sense of the recommendations for primary care, in particular GPs, and for those in the report that I referred to for the 111 training places that are required and were costed at £1·35 million. That does not seem to be an insurmountable amount of money when you look at the effort that should be made on the front line and to keep people out of hospital. I suggest that you come back to us on how that is being progressed. Generally, you are indicating today that the framework will be available in a few weeks and that it will be shared with us.

Ms Stevens: Yes.

The Chairperson (Ms Maeve McLaughlin): I will go back to the point that a lot of this work has been ongoing. The 29 reviews and the 10 reviews that are in the system should have scoped out the need and the demand. We are three and a half years into a process and only now are we starting to grapple with that concept. That is of concern to us all. Thank you for your time today.