Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): I welcome Dr John O'Kelly, who is chair of the college of GPs; Shauna Fannin, who is deputy chair; Dr John Woods, who is the BMA council's chair; and Dr Tom Black, who is the council's deputy chair and chair of the BMA NI GP committee. I ask each of the representatives to make an opening presentation, after which I will open the meeting to comments and questions.

Dr John O'Kelly (Royal College of General Practitioners): On behalf of the college, I thank you for the invitation to address and give evidence to the Committee this afternoon. We have met several members of the Health Committee on an individual basis on a number of occasions and have very much appreciated the time given by you to listen to our concerns and discuss various issues.

Most of you will be well aware of the issues facing general practice in Northern Ireland. The college is the professional organisation for GPs in the United Kingdom and has approximately 1,300 members in Northern Ireland, which is over 80% of the GP workforce. We have 50,000 members in total in England, Scotland, Wales and Northern Ireland, and we have over 600 members in the Republic of Ireland. General practice faces similar urgent concerns in all these countries, and the Health Departments in England, Scotland and Wales have begun to take action on some of them.

Chair, we have provided you and your colleagues with a briefing document, which, I hope, together with our previous conversations, will offer an insight into the serious crisis that is emerging in general practice.

The college has traditionally focused on the key issues of setting and developing the standards for general practice to deliver the highest possible quality of care for our patients, the training of young GPs, the further education of established GPs and research in general practice. In November 2013, the college launched an unprecedented campaign — Put Patients First: Back General Practice — in response to concerns for the future of general practice and the delivery of care to our patients. The campaign calls for an increase in the percentage of the NHS budget allocated to general practice to 11% to reverse the trend of disinvestment and to allow GPs to continue to deliver high-quality care. That is in the context of the increasing needs of our population, significant rises in consultation numbers, the movement of care to the community and the increasing complexity and number of medical conditions that our ageing population will develop.

As you are aware, we have a serious crisis emerging in the GP workforce that can no longer be ignored. Morale is at an all-time low. In Northern Ireland, we have the lowest number of GPs per head of the population in the United Kingdom at 6·4 per 10,000; the oldest GP workforce, with 24% of our GPs over the age of 55; and an ageing practice nurse population. Insufficient numbers of young doctors are being trained as general practitioners, and, in addition, we have real problems in the retention of GPs.

There have been three workforce reviews since 2006, with each highlighting the need to increase the number of GPs. It is with dismay that the college notes that there has been no action taken on the recommendation in these reviews. Each one has highlighted the urgent need to increase the number of general practitioners in the workforce. The 2014 interim report on the GP medical workforce said:

It recommended that the number of GP training places in Northern Ireland should be increased to 111 annually, phased over four years, with an initial target to increase the number by 15 for commencement by August 2015 but implemented no later than August 2016. The Department of Health has pursued a policy over the last decade akin to the ostrich's head in the sand. It is time to get the head out of the sand and start dealing with the situation. Our concern is that the recommendations of the 2014 report will not be acted on, as happened with the previous reports. If that occurs, be in no doubt that general practice in Northern Ireland will face meltdown in the next few years, with dire consequences for our patients, especially our most vulnerable patients. We already see problems with shifts in GP out-of-hours not being covered, with outlying centres not staffed. This will continue to deteriorate and will have knock-on effects on in-hours care in emergency departments.

As GPs, we want to deliver the best possible care to our patients. Our job is complex, demanding, interesting and professionally rewarding, and we get great enjoyment from it. I know I can speak for Shauna and Tom by saying that we do not want to do anything else, but it is incredibly frustrating when you find that you are being constrained by circumstances outside your control. If we do not address the working environment for GPs in Northern Ireland, we will end up having a brain drain, with our young, brightest doctors emigrating or taking up positions in other parts of the United Kingdom.

The college is calling for a new deal for general practice, with increased investment in infrastructure, support staff, secretarial staff, practice nurses, pharmacists, physical therapists and other allied professionals. We need investment in training, increasing the numbers of GPs in training and extension of GP training to four years. We need retention and returner schemes and a greater emphasis on general practice at the Queen's University undergraduate medical course. With these measures, we believe that we can turn the tide and have a profession that can continue to deliver the highest quality of care to our patients.

Dr John Woods (British Medical Association): Good afternoon. Thank you, Chair, for the opportunity to come from BMA Northern Ireland and give evidence to the Committee about workforce planning in the context of Transforming Your Care (TYC).

Committee members will have received a copy of our briefing paper, and I will address some of the main issues in that. The BMA represents all doctors delivering care to patients in primary and secondary care in Northern Ireland, and we believe that effective medical workforce planning is essential to allow those clinicians to deliver high-quality care and safe care to patients. That is why the BMA has been advocating so actively and contributing to a whole series of medical workforce reviews. Those were done and published in 2004, 2006 and 2010, and we are involved in the current round. We advocated very strongly for the current round of reviews, and we are involved in those. To date, they have been in paediatrics and in general practice.

Northern Ireland really has a first-class medical workforce, and I think that patients rightly expect to be able to continue to access high-quality care and safe care. We believe that ineffective workforce planning is seriously undermining that goal, and we see the consequences of a lack of effective workforce planning. Crucially, this is increasingly impacting on patient care. Despite work done by the Department to date, we are very concerned and frustrated at the lack of progress that has been made to date.

Implementation of TYC began four years ago, but we have not yet seen the changes that are needed in the workforce to make the TYC vision a reality, being planned and being resourced. We have not seen any work on that to date.

I know you are well aware that there is a major workforce crisis in general practice. Although this is the most obvious example, there are similar gaps in secondary care specialties as well, in emergency medicine and radiology for example.

It is easy to see the consequences of ineffective workforce planning. Members will be well aware of, and have commented on, the resources that have been spent on locums in secondary care to fill gaps. The BMA believes that an over-reliance on locums is a very clear consequence of the failures of planning and implementation to date. That money could and should be more effectively spent on training a sufficient number of doctors in necessary specialties.

There is a pattern of continued failure to recognise and adjust to the changing health needs of the population in Northern Ireland. There are a couple of factors here. First, we have an increasingly ageing population and they have more complicated health needs. I see that in my practice as a hospital consultant. Patients are older, sicker, and their needs are more complex in general. That has led to significant increases in demands for diagnostic imaging, scanning and x-rays, so we now have insufficient radiologists to do those tests, and we have been hearing earlier this afternoon about the problems that that causes. Secondly, as Dr O'Kelly alluded to, with TYC, there is a planned shift of service delivery from being predominantly hospital-based to community-based. That has implications for primary and secondary care. Appropriate workforce planning is integral to this. It must be properly planned, managed and resourced, and we are really concerned that that is not happening currently.

A final factor leading to change is that the composition of the medical workforce is changing. Again, there has been failure to act in response to these changes. Our information about the changing demographics of the medical workforce is on page 8 in our briefing paper, but one clear trend is that there is an increasing proportion of female doctors. The medical workforce is a dynamic situation and there is a range of changing factors, which means that it has to be a continuous, ongoing process.

General practice, as Dr O'Kelly suggested, really stands out as an example of a specialty demonstrating the hazards of failing to respond to those changing circumstances. Due to increasing workload, GPs are increasingly choosing to retire or leave. I think you will have seen the results of our survey, which have been published today, showing that one third of GPs will retire in the next five years.

For general practice, the problems have been recognised but the necessary action has not been taken. There is a whole series of reviews showing what the problem is. The crisis affecting this specialty could have been averted if the recommendations in those reviews had been implemented. One of those is the increase in the number of GP training places.

It is important that action is taken soon because, as I am sure you will appreciate, the lead time for training for these people is very long. From entry to medical school to qualification as a GP, it takes 10 years, and it takes 14 years to train a consultant. If we do not address the problems in workforce planning as a matter of urgency, we think that a similar problem will emerge in secondary care in the very near future. This is something that we care about very strongly. We have been very committed to assisting the Department in that and have contributed actively to the reviews to date, but we really are frustrated at the lack of progress that has been made to date.

We now understand from the evidence given to you in your session on 11 March that the Department is looking at a programme of care perspective for workforce planning, beginning with a pilot programme in domiciliary care. We are concerned about that, because we think that it risks further delays in resolving that issue. This has been the problem: things have just been pushed back and back and have not been implemented.

Our recommendations are on page 15 in our briefing paper. We really think it is crucial that the current workforce reviews are completed on a speciality by speciality basis as a matter of urgency and that the recommendations made are properly resourced and implemented. Otherwise, the quality of care to patients will be compromised, and that is a situation that none of us want.

Thank you, once again, for the opportunity to give our views to the Committee. Dr Black and I are happy to take questions.

The Chairperson (Ms Maeve McLaughlin): Thank you both. The Committee obviously shares the view that we need to, if you like, refocus our health agenda in relation to primary community care. That does require a refocusing, rebalancing and reprioritisation of the services that are provided by primary community care.

I have a couple of questions. I have met both organisations over a period of time. The issue is much bigger than simply saying that we need an allocation of funding. There are issues of training and retention. I want to ask about the training aspect first. Both reports have a number of figures, and I think that Dr O'Kelly said that 111 places were needed over a four-year period. Was it 80 places by August —

Dr O'Kelly: 2015, or 2016 at the absolute latest.

The Chairperson (Ms Maeve McLaughlin): Is there consensus on that number with the BMA? Is that correct?

Dr Tom Black (British Medical Association): We need 111 in order to stand still, Chair. We thought that, as a first step, it should be increased to 80. We have heard that there will be no increase. This is the third report that has suggested this; nothing about this is new.

It is about priorities. There is limited funding; this is the health service and we deal with priorities. General practice is clearly not a priority for the Department of Health. Why? That is its decision. It has chosen to keep us as the lowest funded and lowest staffed group with the highest workload and the lowest training numbers. This is a perfect storm. The result of this perfect storm is — and we have already seen it — that out-of-hours has collapsed in real time. If you talk to your constituents, they will tell you that they were suffering nine-hour waits for phone backs at the weekend. That is not a service, it is a disservice. The worst thing you can do in the health service is to pretend to have service.

We have a huge recruitment and retention problem. We have a workforce that is inadequate for the needs of patients, and the canary in the mine is the out-of-hours service. That has already collapsed in real time. With the failure to retain older GPs and those we are training over the next couple of years, we will probably lose another 100 GPs. We have 950 whole-time equivalent GPs. There are more than 2,000 patients per whole-time equivalent GP in Northern Ireland now. When I joined my practice, there were 1,500 patents per doctor. We now have more than 2,000. We have had 67% more workload during that time, as you have seen from our strategy document.

We have a perfect storm. The least you would expect is that the Department would prioritise the training of GPs, and it has not done so. That is extraordinary.

The Chairperson (Ms Maeve McLaughlin): I want to refer specifically to page 13 of the BMA briefing paper. NIMDTA is obviously the responsible body, and it made 65 training places available for general practice. Of that number, 33 completed training, which only equated to a whole-time equivalent of 18 GPs.

Dr Black: We have not lost any of those trainees; they are still in the system. They may have reverted to less than full-time training, which is part-time training in our parlance, or they may have taken maternity leave; but, they will come out in time. Two thirds of our young workforce in general practice are female, and it is reasonable if they need maternity leave because they are that age — you cannot defer that time in your life. We should be taking that into account in our workforce planning, but we are not doing so.

This year, we will lose 80 GPs through retirement. We have a survey out today that shows that 35% of GPs will retire in the next five years, and that 79% of those are aged between 55 and 59. So, we will lose 80 this year. If we are bringing in 30, that is a net loss of 50; so, we have gone from 950 to 900. Next year, it will be down to 850. That is collapse time. Within the next two years, we will not be able to maintain daytime general practice.

You sit back and think, "Wow!". Everybody at this table, and Mr McGimpsey referred to it earlier, knows that the crisis in Northern Ireland is the GP workforce. Everybody knows that this is where most of the work goes. It is the foundation of the health service, yet is not a priority. We saw the Minister announce an extra £15 million for general practice; and I smiled, because £10 million was for premises, Michael, which is not current account investment. It is £10 million that we GPs are allowed to borrow now from the Bank of Ireland to build premises, so that leaves £5 million. Of that, £3·1 million is going into out-of-hours. That is excellent; out-of-hours needs that because they are spending less on out-of-hours now than in 2003. We are spending £22 million on out-of-hours now and it was £25 million in 2003.

We are now down to £1·9 million for general medical services, and that is for enhanced services, which will require extra work. The last thing GPs need is a bigger workload. In this very tight financial settlement, not a single penny has been devoted to general practice, despite the fact that we have suffered cuts for eight years in a row.

Chair, it comes down to the basic question, which you asked the previous witnesses, "What are your priorities?" The priorities are clearly not what they said, which is community care, because district nursing has been decimated. The word "decimated" means that you lose 10%, but it is actually about 20% in most areas. Mental health care in the community has been decimated, as has general practice. Three key areas in the community have been disinvested. Not a priority. Extraordinary.

The Chairperson (Ms Maeve McLaughlin): I think in general, yes. That is why the Committee has looked at workforce planning. When you have such a huge policy shift, it would seem logical and sensible that your first key area of work would be to plan your workforce. What are you workforce requirements? That has been a key issue for us.

I want to drill down a wee bit more on cost. Are the 111 places over four years — 80 by August or, at the latest, by August 2016 — still costed at £90,000 per training place?

Dr O'Kelly: That would be £90,000 extra per place, yes; so that would cost, I think, £1·3 million.

The Chairperson (Ms Maeve McLaughlin): Yes, £1·35 million; so, that is what we are talking about in terms of the training ask.

Dr O'Kelly: The other thing is that not all the young GPs we train are necessarily going into general practice. They are not going abroad, but a lot of them are being employed at staff grades by the trusts and we are losing them to general practice. We have to fix the environment in which general practitioners are working. That is absolutely key. We have got to make it a safe environment and one that you would want to work in.

The Chairperson (Ms Maeve McLaughlin): Going back to Dr Black's point; are you saying that the 33 who completed the training are lost to the system?

Dr Black: They are still in the system; they will come out.

The Chairperson (Ms Maeve McLaughlin): OK.

Dr Black: We are not losing them but, as Dr O'Kelly says, they come out and look at the workload. The workload for a GP now is 47 consultations. You all do surgeries when you go back to your constituencies. Would you like to do 47 this Friday, plus 172 prescriptions, 35 lab tests, and all the other stuff we do? That is the standard day's work.

It takes us about 12 hours to get through that, and then you go in at the weekend and catch up on your paperwork. This is the environment that we are trying to entice young doctors into. To be frank, they come into general practice, stay a year or two, and say, "I have no life. I haven't seen my children for three days." They then go back into hospital, and the most extraordinary compliment they are paying us is that they are going back to A&E posts because they think it is easier. If A&E is easier, we are in trouble.

The Chairperson (Ms Maeve McLaughlin): If my maths are correct, were the other 32 trained and then left?

Dr Black: No, they are still in the system.

The Chairperson (Ms Maeve McLaughlin): The whole 65 are still in the system.

Dr Black: I spoke to the director of the training programme and she is very clear that our attrition rate is only one or two per year. Thirty-three came out and 32 are still in the system and will come out.

The Chairperson (Ms Maeve McLaughlin): Contracts are an issue. I am seeking your views on how, within appropriate processes, you can ensure that we get the maximum number of GPs being able to stay and deliver for constituents in the North of Ireland. Is that feasible? Is it doable? Can something be written into GP contracts? Are we just training GPs up and then they will leave?

Dr O'Kelly: One of the concerns is that you cannot legally stop them working anywhere in the EU. If a young doctor is trained in general practice in Northern Ireland, and England, Scotland and Wales are producing a better environment, then they are going to work there. I talked about the brain drain. We need to fix the environment in which general practitioners are working. I feel confident that, if we can do that, there is enough to keep people here.

The Chairperson (Ms Maeve McLaughlin): A number of members have indicated that they wish to ask a question. Both of your briefing papers are, obviously, very frank and strong, and correctly so, in my view. I noted in the BMA's briefing paper on page 11

That is quite a strong statement.

Dr Black: We have had three reports, and there has been no action from any. You have already had departmental officials in front of you. I was told that the video was better, but I read the transcripts. You were testing them, quite rightly. It comes back to my previous statement. It is extraordinary that this has not been actioned.

I will give you a history lesson, Chair. This happened in 1966, and they had to bring in a new deal for general practice; it happened in 1990, and they brought in a new deal; it happened in 2004, and they brought in a new deal. Simon Stevens, the chief executive of NHS England, is explicit in saying, "We have underfunded general practice for 10 years; there will be a new deal". He needs a new Government in, and he will present a new deal for general practice. He will save general practice in England. Scotland is much better funded because they like their GPs. Northern Ireland would be very grateful if its Department copied what they are going to do in England and Scotland. Wales is in trouble too, admittedly.

Ms P Bradley: Thank you. Like the Chair, I have met both organisations over a period of time. It is sad that we have reached this stage and that no resolution has been found. You said that out-of-hours has all but collapsed. If we do not have this increase, and we see one third of GPs retiring within, I think you said, the next five years, what is ready to collapse next? What is going to happen?

Dr O'Kelly: Out-of-hours will go first. That will have a knock-on effect on in-hours general practice. The pressure on that, with GPs going, is that list sizes will increase, which means that patients will find it difficult to get appointments. We will probably be firefighting. You will find that practices may have to close their lists and, as is already happening, as Tom knows, practices will collapse and close. We have already had a practice in Craigavon. Others are under threat; that will have a domino effect. Everybody will then end up in the emergency department.

Ms P Bradley: That is the knock-on effect. We look at our hospitals and at what is going to happen there. That is going to be catastrophic.

Dr Black: The A&E departments in Northern Ireland, in total, see about 600,000 or 650,000 attendances per year; GPs do 12·7 million consultations. You would need something like another 90 A&E departments. It just cannot happen. The Department is very well sighted on this problem but has failed to make it a priority. When it is just about to collapse, the Department will make it a priority, because it has to, as there is no alternative.

Ms P Bradley: The information you have given us is that there has to be this upload and increase in training because of the length of time that the training takes. It should have been started some time ago, as you say. It is firefighting now, and it has got to the stage where this is the limit. We cannot go any further. This has to happen, and that is exactly where we are now.

I want to follow up on a few points that the Chair made. We know about the brain drain across lots of different professions, and I listened to that again on the radio this morning. Lots of our young people are being trained, and they are leaving. My daughter works in China. Our children are leaving and are taking their expertise to other countries.

With regard to training our GPs and doctors in general — and I know what happens within other disciplines where we invest a large amount of money — should we look at having something written in the contracts to say that they should remain in Northern Ireland? I am being controversial, but what are your views on that?

Dr Woods: I do not think so. As John said, we have to look at the environment here and find out why people are not choosing to stay. I think that people are often very reluctant to leave Northern Ireland, and they would like to work here if it were possible. However, when they look at the opportunities elsewhere, those appear so much better, and that is why they leave. It is much better to try to incentivise people to stay, rather than attempt to put handcuffs or restraints on them. That will not work. People will find a way round it. It has to be that the working environment improves so that it is attractive to work.

Ms P Bradley: So, that is definitely not an option in your opinion. I know that it happens in other disciplines within health and social care, and I know that it happens in social work. If you are investing that money, you expect a return.

Dr Woods: Yes; not a pure restraint, but there are things you can look at. Medical students now come out of university with very substantial loans — £60,000 plus — and if there were some measure of debt forgiveness then, to me, that would seem to be a very positive thing. There are things you could do that are not restraints but are positive and would help the situation. However, a pure restraint will not work.

Dr O'Kelly: If incentives were to be used — golden handshakes, handcuffs or whatever — we should look at areas that are under-doctored and where there are real problems. One of the areas to highlight is rural general practice. That is true throughout the United Kingdom and Ireland where rural areas tend to be undoctored, and there are other areas where there are high levels of health inequality. I think that incentivising young doctors into areas where there is a lack of doctors or where there is a high degree of need may be of benefit.

Mr G Robinson: Thank you for coming today. In my opinion, it has been very useful and helpful to hear your views. Are GPs doing any work to carry out their own workforce planning to ensure that they have enough nurses and receptionists to keep their surgeries functioning?

Dr Black: Mr Robinson, the funding for general practice has decreased every year for the last eight years. When I hire an extra receptionist, as I did a couple of weeks ago, it comes out of my bottom line. When I hire an extra nurse, it comes out of my bottom line. If you keep cutting the funding, as they have done every year for eight years, it becomes difficult. The problem then is that if I advertise a job, which is so badly paid that people would have to take a pay cut to take it, that creates another problem for me in terms of recruitment. I advertised a job in my nice practice in the Bogside in Derry before Christmas, and I got zero applicants. There are 40,000-odd GPs in the United Kingdom. I offered a full share of profits etc, and I got zero applicants. Why did I get zero applicants? It was not so much the money, to be frank, although any locum who might have taken the job would have had to take a pay cut of probably 25% or 30%; I did not get any applicants because they knew what the workload is like, and they will not take a job as a partner because they will not see their children. Everything comes back to workload.

Dr O'Kelly: As I said, we need the increased support of the practice team. We need pharmacists working with us, we need physiotherapists working with us and we need our practice nurses. We need them. When we talk about investment, it is not just purely with GPs; it is investment in the GP workforce and the wider community workforce.

Tom talked about the destruction of district nursing and health visiting.

Mr G Robinson: From a personal point of view, we are now starting to see effects on the out-of-hours practice where I live in the Limavady area. It should be there from about 6.00 pm until 11.00 pm. Recently, that has been cut back. On some nights, from about 10.00 pm onwards, there is no doctor because they have to be railroaded to Altnagelvin for the out-of-hours service there. It leaves wee rural areas like Limavady without an out-of-hours practice.

Dr Black: I asked the four local medical committees to do a survey of the empty shifts in the out-of-hours services. Limavady, as you say, Mr Robinson, is showing up as an area. The whole southern area has shown up, as has the south-east and Belfast. Pretty much all the out-of-hours services in Northern Ireland have huge gaps in their rotas. I have asked for commentary on that from the LMCs, and tomorrow I will submit the evidence to the Department and the health board. GP out-of-hours services in Northern Ireland are now broken, and I want to ask the Department and the board what they are going to do. They have promised an increase in funding of £3·1 million on top of the £22 million that they spend, but we spent £25 million on GP out-of-hours services in 2003. Health inflation, as you know, is 6%. That means that they should be spending £50 million now. If they were to spend the same as Scotland, they would be spending £50 million. Is a general practice out-of-hours service a priority? Not for the Department.

Mr G Robinson: To be fair to the trust, in my area, you just cannot get the doctors.

Dr Black: It is Western Urgent Care. John will remember that I was one of the founding members of Western Urgent Care back in 1995. We set that company up. It was the best out-of-hours service, as you will remember. In Limavady in particular, it was a great service from the local GPs. That work is now so high-risk and so demanding that, if you walk into one of those out-of-hours shifts, you will be told, "There are 100 phone calls behind time, a queue of people 35 or 40 long and 10 house calls. What would you like to start on, Dr Robinson?". The young doctors are saying, "I am not doing that".

Mr G Robinson: Exactly. The trust suggested to us that we could write to the local doctors to ask whether anyone would volunteer. We did not get one reply, and that was understandable.

Dr Shauna Fannin (Royal College of General Practitioners): Of course, the same doctors often work in hours and out of hours, and, if your workload is unmanageable during the day, you are very glad to be able to get home at night and spend some time with your family. The likelihood of that doctor wanting to work in the evening and overnight is very slim.

Mr G Robinson: To be fair, I am not knocking those doctors. They do a tremendous job.

Dr Black: The day job now finishes at about 7.30 pm or 8.00 pm, plus you go in at the weekend and catch up. The out-of-hours shift starts at 6.00 pm. So, I cannot commit to a 6.00 pm out-of-hours shift when I am not finishing until 7.30 pm or 8.00 pm; it cannot be done.

Mr G Robinson: It might be seven days a week.

Dr Black: Yes.

Mr McCarthy: Thank you very much, gentlemen and lady, for your presentation and briefing. I must say I have been sitting in this room for two and a half hours, and it is the most depressing two and a half hours that I have ever spent in this room. You people were sitting at the back, and I am sure you must be disgusted also. I do not know how long it will take us to complete this, but I want to say that I support 100% your campaign to put patients first and back general practice. I am sure that all the members in the room are the same.

I have two or three questions. Dr Black, I listened to what you said and have heard you on the airwaves on many occasions, and I agree entirely with what you are saying. You have criticised the Department, and rightly so. There have been changes in the Department in recent times. You said that there were, I think, three reviews that came up with recommendations and that there were four recommendations from the last review. What do you think your chances are of having those recommendations implemented, given the changes in the Department now?

Dr Black: The Minister and the permanent secretary have a very difficult job. I would not want that job. The criticism that I have of them is not that they do not understand or do not have the knowledge; they clearly do. I have spoken to both, and I think they are both well able, yet my criticism is that they have chosen not to make general practice a priority; they have chosen other areas. That is where my criticism is because if this is the foundation of the health service and the service cannot work without GPs, we are in the worst crisis in my 25-odd years in general practice. This is much worse than 1990 or 2004. This is the back to the worst that we have ever seen in general practice. So, my criticism, Mr McCarthy, is that they have failed to make it a priority.

Mr McCarthy: Given what you said, Transforming Your Care, in my opinion, was based solely on the GP and primary level care, and it is not going to happen. Again, in my opinion, I think that Transforming Your Care is dead in the water. Given what you are saying, you are convincing me more that that is the case, unfortunately, because we supported Transforming Your Care as a vision for the future, but it is gone.

Dr O'Kelly: What has been a failure with Transforming Your Care is setting the key priorities and performance indicators. Nobody could argue with the vision of Transforming Your Care. We were very supportive of it, and I am sure that the BMA has been as well, but there has been no outline of how we get to where we want to be, where we are going to be in two years, where we are going to be in four years and where we are going to be in six years. It has been muddling along. You say that it is dead in the water; I think that it is in neutral.

Mr McCarthy: That is not very encouraging either, given the aspects of where we thought it was going.

I have three questions briefly. I have the letter here. The Health Minister recently announced a £15 million investment in GP services, and Dr Black spoke about it. Within that, £300,000 is to recruit and retain GPs. Your recommendation is for 80 young doctors to be trained. Is that £300,000 going to do that?

Dr Black: No, they are looking to use the £300,000 for innovative schemes to retain and recruit, so, as Dr O'Kelly described, it will be to bring doctors into under-doctored areas, to bring doctors back from foreign parts or to retain older GPs who are about to retire. What they are suggesting is not the wrong thing. I think that success will be very difficult to achieve though, given the environment of the workload.

Mr McCarthy: So, it is not going to happen, really.

Dr Black: If you were 59 and three quarters and you were about to retire on what is a good pension in the health service, could I persuade you to stay on and do 47 consultations and 172 scripts?

Mr McCarthy: I do not think so.

Dr Black: I do not think that you are going to stay on; you are going to go.

Mr McCarthy: Anyway, let us stick to the £15 million. You mentioned £10 million to extend your premises if that is what you wanted, but it says that there will be up to £3·1 million of investment in out-of-hours service. You said that it is up the tubes now, too. Is the £15 million going to be blown away like other millions and we are not going to see the benefit of it?

Dr Black: Well, the £15 million is really £5 million because £10 million is for premises; it is a capital sum. The £3·1 million is recognition from the Department that out of hours is in severe bother. Despite the fact that we have such a constrained budget, they are taking £3·1 million and giving it to GP out of hours. However, to reiterate the point, in 2003, when GPs were running out- of-hours services, we spent £25 million on it. It is £22 million this year, plus £3·1 million, which is £25 million. It should be about £50 million if they had maintained the 6% increase every year that they should have done, but they did not. You cannot get doctors to work because there is one doctor on instead of three. There should be three doctors to run the phone, see the patients and deal with the house calls, but one goes in and says, "Where do I start?".

Mr McCarthy: Again on that £15 million, £1·2 million of investment is to help GPs meet demand for blood tests and other diagnostic work. Do you welcome that?

Dr Black: Yes, that is the enhanced service. It will obviously mean that we will take on work to earn that money, so what we are hoping to do is bring in phlebotomists to do that. Again, it is part of TYC. We are doing an awful lot of hospital bloods at the minute. My treatment room is bunged. I do not have capacity to take on more hospital bloods, but it is obviously better for patients, when they are going in before their cancer treatment, to get their bloods done locally in their GP practice. Getting phlebotomists or nurses to provide that service would be a good idea; not extra money.

Dr O'Kelly: The move to recognise pharmacists in general practice is to be welcomed and will be extremely useful. Certainly, the college strongly supports the pharmacists working closely with GPs in practice — actually embedded into practice — because they can offer an awful lot of support and take an awful lot workload off us. We would strongly support any further developments in that regard, and I think the BMA would be —

Dr Black: Yes, there is a good story there, Mr McCarthy. The Health and Social Care Board is working with us on a pilot to bring forward pharmacists in GP practices. There are 39 million prescriptions. Two hours of my working day in which I should be seeing patients is instead spent producing scripts. A pharmacist placed in a practice could do that work. The board is going to invest in that this year with a rolling programme to increase up to, hopefully, a pharmacist in every practice; about 300 pharmacists in total. That is still fewer than the 400 pharmacists in the trusts, but I would have to make that point, would I not?

Mr McCarthy: Yes, of course you would. In your paper, you state that the percentage of GPs working part-time is not known. Why is that data not available?

Dr Black: What is full-time? Some practices tell me that it is nine sessions a week in face-to-face consultations, some say it is eight, and then the rest of the time is audit, paperwork, education etc. That is a much higher proportion of face-to-face clinical time than you will find in any other health environment. Every practice does its own thing, so you would have to go in and interrogate and check. I have a part-time partner who seems to work every day of the week now. Why? Because we have strong-armed her into coming into the practice more. So, is she part-time or full-time? She works full-time but would like to be part-time.

Mr McCarthy: Your paper also states that they are:

Somebody already mentioned learning disability. Can you give us any more detail on that issue?

Dr Black: My memory of TYC was that there was £86 million going to community, of which £23 million would go to general practice; I do not think I have seen a penny. I will hone it right down to the investment per patient. In 2009 in Northern Ireland, we spent £124 per patient per year. That is what general practice costs. We spend something like £2,300 on health care per patient per year. So, £125 — 6% of the budget — goes on general practice: £124 in 2009, and this year it will be £125. That is a 0·8% increase in six years. During that time, the total health-care budget has increased by 35%. So, that is a 35% increase in the health-care budget, and in general practice the increase is 0·8%. That is a cut of 34% in real terms. That is the sort of thing we are dealing with.

Mr McCarthy: Finally, it is a concern that professional bodies are not represented on the regional workforce planning group. How is that group engaging with the professional bodies?

Dr O'Kelly: We had input to the interim report that I alluded to earlier, and we had representation on the interim GP workforce group, but not on the overall group.

Mr McCarthy: That must be very disappointing.

Dr Woods: It is, and there is a pattern to this. We are involved in each of the individual specialty streams. We are asked to be part of that, but we are not part of the overarching group. It was the same thing in the group that looked at unscheduled care recently. Tom and I advocated for positions on the central group. I think there is a pattern of the Health Department operating in this manner.

Mr McCarthy: So, in fact, they do not appreciate the experience of you people and your input to such a very important aspect of the health service.

Dr Woods: I am not sure why. Clearly, the professionals have an important role to play to bring their experience and their patients' experience to that forum.

Mr McCarthy: Finally, finally, can you give us any encouragement that there is light at the end of the tunnel? We are all affected. We all have to see the GP at some stage or another and —

Dr Black: The light at the end of the tunnel is GP federations. In England, we have Simon Stevens, who is a very bright person with a clear idea. His plan is outlined in the 'Five Year Forward View'. If you want really good reading on health care, read that by NHS England.

We actually moved ahead of him. We anticipated this problem and set up GP federations, with 13 out of the 17 already incorporated as not-for-profit community interest corporations. Through the federations, we will hopefully be able to implement changes: TYC; the transforming of the system; and the shift left into the community. We have persuaded the board to invest in federations through these pharmacists, and the big advantage — this is why we set them up as not-for-profits — is that when they invest in a GP federation they are not paying GPs any more money. They seem to have a real problem with that, which is fine. There is now a forum in the community where they can invest and develop services. You have seen the strategy document. We sent you a copy — you have got it under your pillow, I am sure — and there is a whole section on the federations in that. It is hope for the future.

Mr McCarthy: That is hope for the future.

Dr O'Kelly: The federation model is one that the college has been putting forward from a document in 2007, and we are strongly supportive of it. It is basically collections of GPs and practices getting together, pooling resources and delivering. I remain optimistic. I am one of the two thirds that will not be retiring within the next five years, I assure you. If we are given the tools to do the job, I have confidence in my colleagues delivering. We can deliver. It is not a total solution, but federations offer us a real way forward.

Mr McCarthy: So, you are not as despondent as the people who sat in those chairs previously. They were totally of the mind that, unless millions of pounds come from heaven, we are going to be stuck in zero land.

Dr Black: They have to fix general practice, and they will fix it. It is inevitable. It happened four times before in the National Health Service. Which is more important: the National Health Service or general practice? The NHS does not exist without general practice.

Dr Fannin: In general practice, if you are doing 90% of contracts as a whole in the NHS, you have to take seriously the problems we have with workforce recruitment, retention and returners. All those things are extremely important in order to beef up the clinical workforce. There has been the ostrich, head-in-the-sand approach, not appreciating that we are going to have a major demand/supply imbalance in the workforce, compounded by the things we have talked about.

Mr McCarthy: Thank you very much. I wish you all well.

Mrs Cameron: Thank you very much for your time today, and apologies I did not hear the presentation from the start. I have to say from the outset that I have had the privilege a couple of times of going to a local GP surgery to see the work that they do. I was blown away on the first visit and equally so on the second visit, apart from my own experience as an ordinary punter going to my own doctor's elsewhere. I have much respect and appreciation for the work that you do. It is a challenging role for you and, given that we talk daily about early diagnosis, there is much pressure on you, as doctors, to do the best for us. I just want to say from the outset that I really appreciate the work that you do.

Dr O'Kelly, the BMA paper states that demands on GPs mean that young doctors are choosing not to enter general practice. However, the Committee heard that the GP training places are oversubscribed and that we do not have a problem getting young people to choose general practice. Can you clarify which is the accurate scenario?

Dr O'Kelly: What we have is an incredibly low number of GPs being trained in Northern Ireland: 65. There is no doubt that, if we increase to the 111, we will have problems filling all those. In England, about one in eight training places are not being filled, and they have had to go through two, three or four recruitment exercises to try to fill those. At the minute, it is false in that we are training so few, 65, when we need to be up at 111. Health Education England and the Department of Health in London have stated that we need approximately half of all undergraduates in medicine to be training in general practice in order to deliver the doctors we need for 2020 and 2030.

Queen's has in the order of 230 or 240 graduates every year, so the maths are obvious there. We get 65 because the numbers are quite low. One of the other problems, then, if we train them, was illustrated when I was talking to a young, trained GP recently who told me that he is working in orthopaedics as a sessional doctor on a hospital ward. Again, it was for the reasons that it provided regular hours and because he could not take the stresses and strains of working long hours in general practice. So, one problem when we get them trained is about how we keep them in general practice. I come back to the working environment.

Dr Fannin: We need undergraduates to have much more experience in general practice. A lot of undergraduates make up their mind as to whether they want to be GPs even before they qualify. In Northern Ireland, undergraduate medical students are spending only around 5% of their entire curriculum in general practice, so they are getting very limited exposure. As John said earlier, we are the third lowest in terms of time spent in general practice in the whole of the UK. Students in universities like Keele in England spend over 30% of the time in general practice and, not surprisingly, a very high percentage of Keele's students want to become GPs.

As a college, we are also calling for the overhaul of the supplement for undergraduate medical and dental education (SUMDE) funding so that more time can be spent by our undergraduates out in general practice getting first-hand experience. Of course, they have to be able to see a workload that is manageable, but we feel very strongly and we are all passionate about general practice. We want young doctors to come into our profession, so that is something that we would want as well.

Mrs Cameron: That was raised with me locally on my visit, so I am aware of that. I know that part-time working is an issue as well. We always talk about women going off to have babies, and that is grand, but I noticed in the practice that I went to that there was an awful lot of part-time male doctors of all ages.

Dr Fannin: Yes. As a college, we, of course, are very glad that the gender imbalance that there was in previous decades is now being rectified. We think that it makes for a much more balanced GP population if we have 50:50 in terms of the doctors in general practice. We are moving from a very male-dominated profession two decades ago to a point where more than 50% of trainees in general practice are women. In England, I think that around 65% of GP trainees are women. Currently, around 47% of the workforce of GPs are women. These women are, of course, taking longer to train, often because they are taking time off to have babies and have maternity leave. They are sometimes having part-time training, which is taking longer, but we are not losing those individuals; they are getting their full qualification in general practice. The problem is, then, about creating a flexible working life for them. Most female GPs will not want to work full-time for all their working life; they will want some flexibility with that. Increasingly, however, our male colleagues want that flexibility, too, because they are finding that, in general, the stress of general practice every day, full-time, is just too much.

Dr O'Kelly: A lot of the time, they are doing almost like a portfolio; their basic job is in the general practice, which they do part time, but they are working in other areas. You may find a GP who has a special interest in ophthalmology is working in genito-urinary clinics or is maybe doing some work for commissioning or the trusts. You get that. One of my partners who was full time has gone down to two days a week, but he is working for the Northern Trust in dermatology, doing minor surgery. He made a conscious decision that he needed to do that to keep himself sane. That is probably a trend that we cannot reverse. That has to be taken into account. The models for how we work as general practitioners and how we relate to our hospital colleagues will be changing over the next 10 or 15 years. That has great challenges for us as general practitioners, but I think that we are adaptable and that we can do that and still deliver.

Dr Woods: The BMA is equally positive about women in medicine; they bring very positive things. Part-time working by female doctors seems to be largely unique to general practice. Participation by women in hospital medicine is much greater. Although I suspect that they probably work fewer hours, the majority of them work full time. In fact, one of our members had a grievance case about four or five years ago against the Belfast Trust, the basis of which was that more women work part time. In fact, the converse proved to be the case: men, among consultants, were more likely to work part time. It is a characteristic of doctors who choose to enter general practice.

Mrs Cameron: The whole subject of part-time working is very interesting. It is a very good thing. I understand that it costs a lot of money to train up doctors, but you are still human. If you go off to have children, whether you are male or female, there is no point in having them if you never see them. There is a balance to be struck. Thank you.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. Thanks very much. It has been really interesting to listen to what everybody has said. Are you aware of whether the Department is seriously addressing the issue of workforce composition in terms of gender mix? How does that impact on the workforce?

Dr Woods: We do not think that it has been to date. That is one of the reasons why this crisis has developed in general practice. As we said, there is much greater participation by women doctors in general practice, but that really has not been taken into account. I think that the evidence that we presented referred to 33 people coming out of the programme at the end. That is one cohort that has travelled through. I suspect that 65 went in, but 33 came out. Effectively, that is because many female doctors are choosing to train on a part-time basis, and, ultimately, when they go into the workforce, they are more likely to work part time. That has been clear. The trend did not develop overnight; this has been happening for a decade or more. I suspect that it is outlined in the prior reviews that were done, and it should have been acted on.

Dr Fannin: It has been clear for some time that women are choosing to become GPs. The fact is that more women are applying to become doctors and joining medical courses. This has not just happened suddenly; it has been a rolling progress, but there should have been the foresight that it would be an issue and that you would have to have more training places to keep the workforce demand/supply balance.

Ms McCorley: Taking all of that on board, you do not really think that they are seriously looking at this as an issue.

Dr Fannin: They cannot be if they are not increasing the number of training places.

Dr O'Kelly: It also has had a knock-on effect on NIMDTA. If you do not have the numbers that you are expecting coming out and the students are still in the system, they have to find practices for them to train in. The expense goes up as well, and NIMDTA's GP budget certainly has not increased to allow for that. The blunt answer to you is that I totally agree with you: no, they have not taken it into account.

Ms McCorley: That is another depressing aspect to add to the list that we have heard today. Do you have any views on how to encourage female doctors to work full time?

Dr Fannin: I started off as a full-time GP. Like so many, I now work more part-time hours, but I have a portfolio career, like John, where we do other things. I am a Macmillan GP facilitator involved in the education of GPs in cancer and palliative care. I find that very useful for my own work and I also enjoy it greatly. I think that it is difficult to encourage people to be full-time GPs for the whole of their careers. Some may wish to work part time while their children are small, and some may wish to remain part time all of their working lives. I think that it is difficult to be prescriptive about that.

Dr Black: John Humphrys of Radio 4 visited his GP, Sarah Jarvis, who is quite famous in our community as a high-profile GP. She is leaving general practice because she cannot cope with the workload. He went and spent the day with her, just as you were saying, Mrs Cameron. She was going home at 4.00 pm, and he said, "What kind of a job is this? I thought you said that you worked hard". She said, "I am on a half day today. I am part time". You get to go at 4.00 pm if you are part time.

Young female doctors tell me that they bring their children in to see them at lunchtime because they have not seen them for two or three days. I know of one who brought her child in to see her on Friday at lunchtime because she had not seen the child since Tuesday. You will look at me and ask why anyone would put up with a job like that. You then have to ask yourself why the spouse would put up with someone working those hours. It keeps coming back to workload. Young female doctors work part time because part time is nearly like full time. If you want to make the job more attractive, we have to manage the workload, and the best way to do that is to have more doctors there to do it. It is a circular argument. It is so obvious, yet it clearly is not obvious in certain quarters.

Ms McCorley: I want to echo what everybody is saying about the importance and the central foundational place of GPs in the health system. It is the first port of call, and your GP is part of your life. Given all of the stresses and pressures that you have outlined, it is hard to believe how people function like that. A burning question that I have is this: how are GPs meant to find the time to stay ahead of medical advances? Where do you get the time to do that?

Dr O'Kelly: That is a good question. We are all appraised annually. We have to do audits, and we have to attend education and demonstrate that every year. Like all doctors, we now have revalidation every five years. We are doing that in the wee hours. Sometimes, if we can catch a lunchtime, we do lunchtime meetings. Each practice does it slightly differently. We do evening sessions where we work until 6.00 pm or 6.30 pm and then get a pizza or Chinese takeaway or something and work through that. That is what you do. You have to stay ahead of it.

Mr G Robinson: Healthy eating.

Dr O'Kelly: I know, I know. Do as I say, not as I do.

Ms McCorley: It is hardly conducive to effective learning. It is not the best way to be doing it. I have a couple of other questions. Do you feel that the trusts have made available adequate training or retraining programmes for the medical workforce to meet the shift of the TYC requirements?

Dr Woods: That is a difficult question. Part of the problem is that it is not really clear yet what that will look like, so I think the managers are somewhat in the dark about what will be required, but I think that it will be a gradual process. Work in the community will be done both in general practice and by secondary care doctors. I think that home intravenous antibiotics are a good example of the kind of thing that secondary care doctors are doing. There is a cohort of people who, in the past, have been in hospital because they have some condition like a bone infection, which means that they need a very long, prolonged course of antibiotics. It is now possible to deliver that at home using the district nurses service, supervised by a consultant infectious disease physician. That is an example of the kind of innovative programme that fits entirely with TYC, but I think that those types of projects need to be developed organically, and it will differ from specialty to specialty.

I am a consultant in kidney disease. We have a day-case unit where we have patients come and, increasingly, we try to do as much for them as an outpatient using the facilities in the ward that would historically have been used as inpatient beds. We have converted inpatient beds to day-case facilities. I think it really will differ from specialty to specialty, and that is the kind of organic development coming from the front-line clinical staff that will lead to a shift of care into the community.

Dr O'Kelly: Communication between general practitioners and our hospital colleagues is so important in that. I chaired the western region's multidisciplinary respiratory group for very many years. On that, we had our hospital respiratory colleagues, physiotherapists and the nurses, and we were trying to come up with a strategy for how to improve respiratory care in the west. We did manage to put in pulmonary rehabilitation. We also worked with the British Lung Foundation and the Old Library Trust. Chair, you are probably aware of it and the work that it does up in the Gasyard. We did make progress.

Where you have health professionals interacting, coming up with and sharing ideas, it does work. Unfortunately, there were barriers put in place by — how can I put it — the organisation, and following the rules of the organisation. I would say to all politicians, yes, we have to show our outcomes and how we spend the money, but allow us to innovate. Do not be afraid of letting us innovate. The chair of the college's quality committee is working with some renal specialists to look at a care flow for acute kidney injury, so there is work that can be done. We as GPs may see our hospital specialists coming a little bit more into the community. We could think of paediatrics, for instance, or dermatology. Why does dermatology need to be a hospital-based specialty? That is where we can work together.

Ms McCorley: Finally, both of your organisations addressed the issue of the health service's reliance on locum doctors. Are the proposals to reduce the need for locum doctors coming from either the regional workforce planning group or the trusts?

Dr Black: What is a locum? There are none in the west and none in the south. There are a few GP locums in Belfast. The locums have all gone to Canada, New Zealand and Australia. They Snapchat me: "Bondi Beach, 5.15 pm. Day's work done". That cheers me up. There are locums for hospitals, I am sure.

The Chairperson (Ms Maeve McLaughlin): There are hospital locum doctors.

Dr Black: Yes, but not in general practice.

Dr Woods: There will always be a need for some locums, because people fall sick unexpectedly and there are shifts that have to be filled. We are seeking to work with the Department to do that on a regional basis. We are having some difficulty with that for junior doctors, but we are seeking to make it cost-effective for them. As you correctly identified, locum payments are where there are long-term gaps, often for junior doctors or when a consultant retires, for example. When those posts are not filled immediately, a locum is put in place, which is often a much more expensive proposition than had there been proper succession planning and proper workforce planning to make sure that there were enough people in that specialty.

Mr McGimpsey: Thanks for the presentation. I have been listening carefully. You heard the previous presentation and the issues raised, and we cannot bury our heads in the sand about them: they have to be addressed. I am, basically, asking you the same question, because I am hearing things about primary care collapse, inadequate workforce, workforce retention, retirements, a perfect storm and out-of-hours services being broken. So, it is fair to say that we are in an emergency situation here. The issue is stabilising the situation; how do we stabilise the situation here and now?

In terms of the workforce, we increased the throughput of the medical school from 170 to roughly 250 in 2008. That cohort started to reach the workplace in the last couple of years, yet we discover that 50 young doctors went off to Australia and Canada last year. Clearly, if we are increasing the workforce throughput in training by 80 or 100 and losing half of them to Australia and Canada, using the simple maths that you talked about, that is just not sustainable. That urgently needs to be addressed.

You talked about golden handcuffs and what is meant by that. You also talked about persuading retired doctors back and so on. There has to be some sort of emergency plan. We are in an emergency situation and we need an emergency response. What are the steps, and what is the budget? Have you guys done that? The issue of the budget keeps coming up. A pharmacist in every practice is another proposal. As you know, there has been investment in pharmacists in hospitals, which is a good idea. We cannot go on, as you say, Tom, until primary care collapses. This has got to be fixed. We have got ourselves in an emergency situation, emergency steps have to be taken now and, after that, or at the same time, we need to work on the medium term.

Dr Black: Mr McGimpsey brings us to the big picture and how to solve it. Thank you, Michael. The first short step is getting pharmacists in practice, because if the board, bless them, can find the funding to put a pharmacist in every practice, it saves each GP two hours and suddenly underpins the workload issue.

The five-year forward view in England is very clear that the shift left needs to take place because hospitals are expensive, hospital doctors are really busy and we should retain them for the most acutely ill. The five-year forward view talks about more than half of all outpatient appointments taking place outside trusts with providers in the community. Those providers will be made up of GPs, hospital specialists, nurse specialists etc. That is where the five-year forward view is moving: they call them multi-specialty community providers; we are calling them GP federations.

You and I know that the really big picture in Northern Ireland is our obsession with buildings and maintaining them. You are most sensitive to this, because you are the people who have to put yourselves forward and ask voters to vote for you. That is a local thing, and all politics is local. Who is going to close the 10 acute hospitals that we have? Do we need 10 acute hospitals? If we maintain 10 acute hospitals and the rotas within them that my hospital colleagues have to maintain, we are spreading our resources too thinly across buildings. We have had the Hayes review. Do you remember that? We have also had the Donaldson review and, in between, we had TYC. They are all very clear that, if we take our limited resource, spread it across too many buildings, call each one an acute hospital and then try to establish rotas within them, we will not have enough resource to do the job right, and that is where we are.

I know that Donaldson said — it is a great compliment to the politicians of Northern Ireland — that he wanted an external international group brought in to say: "This is what you have to do, sign there and do as you are told." I have been doing this job for 20 years and I appreciate how difficult it is. When we went into the Hayes review, we had 17 hospitals; we now have 10. How many should we have? Five or six hospitals and three or four networks, probably. That is the big-picture solution.

Mr McGimpsey: That is the big picture, but it is the here and now that I am interested in: today, tomorrow, this year and next. If you are heading for collapse, by the time you get a consensus to start dealing with the issues that you are talking about, it will be too late. Hayes talked about the "golden six", plus three. It began as the golden six, then it became the golden six, plus three, plus, and they are all still sitting there in some shape or form.

It is the here and now that matters. If you are talking about things like primary care collapse and out-of-hours collapse, it is emergency stuff. It is about this year and next. It is the same as the issue we talked about earlier: the waits and all those patients, thousands and thousands of them, sitting in pain and distress. They have to be dealt with and we have to stabilise the situation now. I think that everybody understands what needs to be done. I have to say that, as the Health Minister in those days, there is no way that I would have been able to do that next stage. I was able to do the reorganisation and got, as you know, huge abuse all round. The next stage needs a different type of approach, and it certainly ain't me, thank goodness, and I am not sitting there now, thank goodness.

We need to do something about the emergency now. We are training an extra 80 doctors a year so that we are now putting 250 through the medical school, but you are getting such a low number into GP practice. We are losing so many to overseas. Yes, you can say that that is the environment, but it is just catastrophic for us.

Dr Woods: I think that, in terms of the workforce, we know what to do. The reviews have told us what is required for general practice and we just need to implement that. As my colleagues were saying, we need increased numbers. There are shortages in specialties in secondary care. We are beginning workforce reviews for them, but we need to do those rapidly. That is paediatrics, radiology and emergency medicine — subjects like that. We need to look at the workforce, and that is clearly a substantial issue for general practice. Why is the workload so high and what can we do to reduce it? And we need to look at the working environment and incentives for people to stay. How can we make these jobs attractive?

Mr McGimpsey: It is the bit about young doctors going into training. When they come out, they do not want to do general practice. How do you fix that? That is the wee bit that I am just not catching at the minute. You say that you need more people but you are getting very few, as I understand it, actually signing on for general practice. Yes, there is an argument about Queen's getting more experience for the students as they go through, getting them out to GP practices and all that. That would be an important step, no doubt, but how are you going to get to that?

Dr Fannin: The RCGP UK is promoting general practice. It is doing a big professional marketing campaign to encourage young doctors to become GPs. There is a variety of different moves. Obviously, if you want to increase your workforce, it is going to take some years before you are going to get those extra doctors trained. Even if they decided to start increasing the numbers this year, which is really not going to happen —

Mr McGimpsey: Well, we did that in 2008. We increased the numbers and it has not worked out, you tell me, because 50 went off last year to Canada and —

Dr Fannin: Well, 50 left the performers list. I am not sure whether we know the exact statistics for who left for Bondi Beach or how many, as John says, are working in hospitals because they find the working conditions better. There is the issue of retention and of refresher and induction training for getting people back who may have left general practice for whatever reason. Maybe they have gone to have a child and then are outside of general practice for more than two years.

Are you going to them and saying, "Look, we could refresh and induct you back into general practice"? Are you offering retainer schemes to keep doctors who may want to work only four or fewer sessions a week in the system and keep their professional standards and education going? Those are things that you can do immediately to start to build the workforce.

You have to increase attractiveness, possibly by bringing other support workers into general practice. We talked about increasing the numbers of practice nurses. We have an ageing practice nurse workforce, so we could possibly skill up people as advanced nurse practitioners in general practice, use pharmacists, as John said, increase the number of support staff, and have community navigators. We have patients coming to us who do not need medical care. Patients come to general practice as the first port of call with everything. They need a letter to get a postal vote. They need a letter because they were sick and could not go for an exam. Whatever it is, everything comes to general practice. A lot of what we do is not actually in our remit. A community navigator post of some sort would help that. There is a variety of things that we could be doing that would —

Mr McGimpsey: Sorry, just finally, how many practices do you see being in each GP federation?

Dr Black: There are 20 practices in each federation, looking after a population of about 100,000. There will be 17 in Northern Ireland and 13 are already incorporated as not-for-profit community interest corporations. The last four will come in over the next couple of months. We have managed to —

Mr McGimpsey: Are all your GPs signing up to this?

Dr Black: Every single one — except this one guy, but I will talk to him. Every practice has signed up, to be clear. What they will hopefully do in the first instance, Michael, is start providing the phlebotomy service so that people do not have to go to hospitals. The key short-term solution to the workload issue is to get the pharmacists in. We spend literally about two hours a day on acute and repeat prescriptions. If my four doctors had a pharmacist doing that, we would suddenly have two hours a day of extra time to see patients and maybe get home, making the job more attractive.

Medical students are staying away from general practice for one very clear reason: they are the most highly informed; they go everywhere and see everything. They say to themselves, "I am not doing that. I wouldn't get to go home." You have to create a narrative so that people hear that the system has recognised that general practice is in trouble and is starting to apply resource and staff. Once you create that narrative, you have solved it. We have done this three times before, in 1966, 1990 and 2004. To be frank, I thought that 2015 was the year. I went up to the Department and they went, "Nah. Not yet, son." But it will be soon.

Dr O'Kelly: General practitioners are resourceful. That is the nature of the business. You deal with the unexpected and you have to adapt. I mentioned in my presentation that morale is at an all-time low, and it is. It is at rock bottom. However, if we as GPs can see that people accept that there is a problem and, more than that, are starting to do something about it, we will work as hard as we can to make it right, and you may just stop that flow of GPs out of Northern Ireland and out of the profession.

Mr McGimpsey: We may even get some of them to come back with their experience.

Mr G Robinson: You mentioned the help that pharmacists could provide. Would prescription charges deter pharmacists from giving you that type of help?

Dr Black: No. The pharmacists will come in as employees of the federation, working in the practice. They will work for patients, dealing with acute prescriptions, repeat prescriptions, chronic disease management, diabetes, chronic lung disease, yellow and amber drugs — that type of thing. I do not think that the prescription charge will impinge on that. We, as the BMA, will naturally respond that we want to see everything free at the point of need, universal and funded by taxation, but you have heard that one before; I think that it was Aneurin Bevan who first said that. I do not think that prescription charges would affect the help that we are bringing in.

Ms P Bradley: I want to go back to a point that Rosie made earlier about the medical workforce and the shift left to meet the requirements of TYC. Both Johns used the word "innovation". I have said many times in the Committee and the Chamber that, even for someone in my own household, we had an innovative consultant in infectious diseases in the Royal who showed great forward thinking and planning. She looked at not only the needs of the patient but the needs of the service and saved the trust very many pounds through home treatment. I know that that happens in lots of disciplines in our hospital services. That is the way forward, and it all fits in beautifully with TYC. How are those innovative consultants being supported? Are they being supported by the trusts, the boards and the Department? Is that being brushed away, or is the support there for it?

Dr Woods: Consultants say to us that they often feel that they have very innovative ideas but it is difficult to get trusts to take those forward. Trust managers often have competing priorities, and that is part of the problem. People definitely feel that they have innovative ideas but have difficulty in getting those recognised. I think that trusts are getting better, but we clearly have a significant way to go.

Ms P Bradley: I know from personal experience and you all know of the savings that can be made, whether it is in bed days etc. It is all moving in line with TYC and the patient experience. We all see how important that is. You see that. At the end of the day, if we are all going to be quite clinical about it and look at the financial savings that we so desperately need to make in our health service, we need to look at that a bit more closely.

The Chairperson (Ms Maeve McLaughlin): OK. I have a final point in relation to workforce planning in general. The original target suggested a 3% reduction in staff. When the departmental officials were in front of us a number of weeks ago, they indicated that that was just a working assumption. Do you have views on the reduction or increase in our medical workforce that is required to implement TYC?

Dr Black: In the next decade, the number of over-85s will increase by 84% and the number of over-65s by 46%. Those are rough figures, but we are in deep trouble. The last thing that we need is fewer health-care workers. Forget about consumerism, convenience and all of that, if we are just to look after our old people with complex comorbidities, we are going to need more health care.

The Chairperson (Ms Maeve McLaughlin): It is certainly not a 3% reduction that is required.

Dr Black: In the next 10 years, history will give us a real lesson in terms of the ageing population and their needs.

The Chairperson (Ms Maeve McLaughlin): OK. Thank you all. This has been very frank, open, honest and informative. We are conducting this work because we feel strongly that TYC is the right vision and policy direction. However, it feels as if the system has not responded accordingly by redirecting the focus towards primary community care. I could say that for any number of sectors. It is a conversation that we have continually across health generally. We will be looking closely at the four recommendations that you have made. We will take them forward and look for responses from the Minister and the Department. Thank you very much for your time. Please continue to have this communication with us.