Official Report: Minutes of Evidence

Committee for Health, meeting on Thursday, 20 October 2016

Members present for all or part of the proceedings:

Ms Paula Bradley (Chairperson)
Mr Gary Middleton (Deputy Chairperson)
Ms Paula Bradshaw
Mr Robbie Butler
Mr Gerry Carroll
Mr Trevor Clarke
Mrs J Dobson
Mr Mark Durkan
Mr I Milne
Ms C Seeley
Mr Pat Sheehan


Dr Tom Black, British Medical Association
Dr Alan Stout, British Medical Association

General Practice: British Medical Association

The Chairperson (Ms P Bradley): I welcome Dr Tom Black, chair of the British Medical Association (BMA) GP committee, and Dr Alan Stout, deputy chair of the BMA GP committee. You are very welcome, gentlemen. Go ahead when you are ready.

Dr Tom Black (British Medical Association): Good morning. Thank you, Chair and Committee, for giving Alan and me the opportunity to come here today to give evidence to you on the crisis general practice is facing in Northern Ireland.

It might be useful for me to put this into some sort of context and briefly set the scene. There are approximately 349 GP practices in Northern Ireland. That has actually already become inaccurate since I wrote it last week; there are a couple fewer. We have 1,274 GPs and about 950 whole-time-equivalent GPs delivering the service. That figure of 950 whole-time-equivalent GPs is fewer per head of the population than we had in the 1950s. That is an extraordinary assertion. In Northern Ireland we have, as you know, a population of about 1·8 million people, but we have 1·94 million patients. That is because of cross-border workers, and obviously, it is a situation we deal with in the south and west.

We have demand going up, and patients are presenting with numerous illnesses and more complex issues. The reason why they have more illnesses and more complex issues is because we are so successful as a health service in keeping people alive, so they accumulate more diseases. Our success in that creates more demand.

I want to talk today about the three main issues that are connected and underpin the situation we are in at the moment. Those issues are workload, workforce and funding. Growing demand has resulted in a significant increase in GP workloads. Workload is what we are there for. Working hard is what GPs are famous for, and we do not shirk that.

Our secondary care colleagues are working very hard as well, as are all the other professions, particularly nursing and social care. However, at the moment in general practice, our concern is that the workload is unsustainable because there are not enough GPs. The real issue is not so much the workload as the recruitment and retention crisis we have in general practice.

Unfortunately, this has been going on for some time. You have heard us in the media repeatedly warning about this over the last decade. We have gone to the Department and asked for real assistance. We have explained how we are having collapsing practices. Unfortunately, to date we have not been seen as a priority by the Department of Health. That is the key here. It recognises, it understands, we have done the joint working and we have all the statistics, but we are not a priority. I think all of us understand why general practice is not a priority.

I do not want to sit here today and just give you a list of statistics; you are all aware of them and have seen the evidence we submitted. We have had two major BMA reports in the last year outlining all the statistics. All the statistics we use and quote and have presented to you are Department of Health statistics, validated by Department of Health statisticians. So, when we say things, it is not just us making up the numbers; these are from the Department of Health.

As is said, we have won the argument through the data but we have not become a priority for various reasons. Suffice to say, the number of times patients visit their GP, their need for prescriptions, blood tests and referrals to secondary care etc are on the rise. That obviously impacts on the daily workload of GPs, which is fine, because that is what we are there for — to work hard. But for a number of reasons, we are not coping at the moment.

We believe that has been backed up by a number of medical workforce reports done over the last 10 to 15 years by the Department that show we are not training enough GPs. We had a recent increase in the number of trainees from 65 to 85. That was brought in by Simon Hamilton when he was Minister, and it was welcomed by us. All the reports of the last 10 years, of course, suggest that we should have more: we should have 111. So, we are behind the curve on that.

Where retention is concerned, a quarter of our GPs are over 55. Many of them work full-time, so in the next five years — it is actually three or four now — we expect to lose a quarter of our workforce. That quarter of the workforce — those GPs who look like me, with grey hair and long experience — do 30% of the sessions, so they are working much harder than average. We are going to lose nearly a third of our workload capacity in the next few years.

The Department recognises the need to workforce plan, otherwise it would not have spent the resources it has carrying out the numerous workforce planning reviews. But those have been of no use, in that the recommendations have not been implemented.

We are not here today to give you problems. We are also going to present solutions. One solution would be to implement the recommendations of the Department of Health's own workforce plans, which said we should have 111 GP trainees. That was the recommendation from 10 years ago, but if you want the honest truth, you need 143. There is no point in me representing that number to you; that is consistent with the numbers that Scotland are training. Nicola Sturgeon, as you saw last week, made another major announcement in Scotland about £500 million going towards primary care. Nicola Sturgeon is very able and was the Health Minister, and she knows what's what. If we trained the same number as in Scotland, it would be 143. I am not asking for that. Why? Because we are way behind the curve and could not recruit 143. We could recruit 111 and should do that now.

Obviously, even if the Minister announced that next week, we still would not have those GPs working on the ground any time soon. It would take three to four years to bring them through. We have no silver bullet and no panacea, but there are building blocks to help general practice survive. Increasing the training numbers is one of them.

An important thing to note about GP training is that — this is counter-intuitive — when GPs complete their training, they no longer individually cost the Department anything by way of salary. Their salaries are subsumed within the block contract for general practice so that any additional cost of increasing the number of GPs is simply the training period of three years. If I take on a new partner, you would not provide my practice with any more funding. We would all reduce our wages and share it with the new partner. I would love you to provide me with a new partner, because my partner retired last month and I have not found a replacement yet. I am hoping for a replacement to come back from Australia in December. We are working very hard in the meantime until that young doctor returns from Australia. That is the sort of situation most practices in Northern Ireland are in at the moment. They are working with one doctor less.

As I said to you, I do not want to bombard you with statistics, but the evidence shows that, in the last 10 years, consultations have increased by 67%, lab tests by 218% and repeat prescriptions by 41%. The average GP day now involves 43 consultations, 178 prescriptions, 30 lab tests, 95 letters plus all the other stuff. Forget everything and just focus on the 43 consultations. No other professional is asked to perform 43 consultations. No accountant, no lawyer, no fireman would be asked to do 43 things in the one day. It is an extraordinary pressure. Just to home right down on that, the old guys like me are looking for the finishing line and thinking, "I'll stick it out". The young doctors are coming in and being asked to do 43 consultations plus everything else, and they are saying, "Do you know what? Where did my life go? Where did my family go? I can't sustain this", and they step out and take jobs elsewhere. So, everything we are discussing today concerns the workload and the fact that we do not have the workforce any more because we are not training them and the ones who are trained find the situation intolerable. We are here looking for help. What are the solutions? I will hand over to my deputy, Alan Stout, who is much younger than me, obviously, and is looking for innovations in the future.

Dr Alan Stout (British Medical Association): Thanks, Tom. I just add my thanks to Tom's for inviting us here today. As Tom said, this is not just about problems; it is about solutions. We know Tuesday will be a key day, and we are entering a transformational agenda, which we very much welcome. With the problems Tom alluded to, the only thing that can save not only the health service but general practice is a significant transformational agenda. We very much welcome that. Having said that, if general practice collapses, which it is doing at the moment, a transformational agenda becomes extremely difficult, because general practice has to be fundamental and a really significant building block for the transformational agenda. This is not just Northern Ireland or the UK; this is the rest of the world. If you look at some of the plans and projects coming out from the rest of the world, you see they are all very consistent in their shift to primary and community care and taking the pressures off secondary care. So, we are going to be in significant difficulty if general practice collapses.

The opposite of that is that, if general practice is thriving, invested in, strong and transforming itself, the impact that can have on long-term elderly care, long-term social need, elective care, emergency department (ED) attendances and hospital admissions is really significant. We need to reverse the trend of the knee-jerk reaction of simply pumping money into an old and broken system. That can be done through investment in primary and community care. The key point is that general practice has to be the building block and starting point. There has to be the survival and support of general practice before everything collapses around us.

We are all aware of the demanding complexity that is coming through the health service as a whole. That is particularly prominent in general practice, and one thing we have seen very evident — Tom alluded to the number of patients coming through general practice — is that we have very much set up a GP-only model in primary care, and that happened through lack of investment over the years.

One of the priorities that we see is not only the increase in GP numbers but the building of a proper, robust primary care team. As Tom said, there are 43 consultations coming through practices per day. If we had a repertoire of staff, they could see those patients on our behalf because they do not necessarily all need to be seen by a GP. If you have a mental health worker, a pharmacist, a physiotherapist, nursing staff and so on in a practice, that could take a significant pressure off GPs and allow them to see the cases we know we need to see. That provides the continuity, particularly with complex comorbidity and elderly care. Those are the patients we know are putting pressure on the system long-term. It is about other staff and freeing capacity for people to do the right job and for us to do what we are best at.

We have been working extremely hard in primary care with certain solutions. One of those is askmyGP. I think you maybe heard about that last week from the royal college. It has pros and cons. It is about providing rapid and same-day access and getting the appropriate patients seen by the appropriate people at the right time. My and Tom's practices are involved in those pilots, and we see benefits to that, but it is also starting to identify very strongly some of the weaknesses. One of those is the lack of a primary care team and lack of alternative.

We have also created the federations of practices. I suppose they have a very simple description: they are about primary care working at scale across the population to try to increase efficiency and reduce variance across groups of practices in a locality. Those now have full coverage in Northern Ireland. They are covering roughly 100,000 patient populations, and 17 are now set up in Northern Ireland.

We very much welcome the Minister's support with the pharmacist project, and we now see the first wave of that coming into practice. That, hopefully, is a first step to a primary care team, and pharmacists, certainly in practice, can not only significantly improve the safety and quality of prescribing but start to take workload and work pressures off general practice. We have also started to see the product of some elective care working as well and, again, the potential impact of investment in support of primary care on waiting lists. The results of that are astounding so far, and furthering it will certainly have a huge impact on the implications for waiting lists and how the health service is delivered in Northern Ireland.

Funding is very important, and I think the transformational agenda is very important with this. We currently spend 49% of the block grant on health and social care in Northern Ireland. If we do not transform, what does that need to go to? Does it need to go to 55%, 60% or 65%? The only answer is to transform. We are not necessarily saying we need to spend a lot more money, but we need to spend our money differently and in more efficient manners, and we need to start to take the pressures of lots of different parts of the system. It is inescapable. We need a resource shift into primary and community care to achieve that. That will be in the primary care team supporting federations and the ongoing or future work with those. It will also involve the training places. We are seeing evidence of that in Fermanagh already — it is the most obvious example — where 18 practices are going to go to five, probably in the next year. If that happens, it will not help any part of the service.

Finally, we are very grateful for your support, Chair, with the petition we had recently. That is important in the context of patient support for this. Patients hugely value primary care and the continuity they get through general practice and their GP. Our fear is the impact of all the problems we talked about today on patient care and on patients.

The Chairperson (Ms P Bradley): Thank you both. As you know, we had the Royal College of General Practitioners in last week, and we went through a lot of issues with it then. There are some things we did not get to drill down deep enough into. The evidence is there. I think we see evidence that the GP crisis has been going on for the last decade at least. Look at the number of people who turn up at our EDs, the amount of unscheduled care and the amount of elective care that is being cancelled because of that. The evidence is definitely there to say that, if we had more GPs in place, a lot of this would not be happening. I can certainly see that.

You talked about the 111 trainees, and, when I put the petition in, it stated 111 trainees. If we were to, from this year, say, "OK, we are going to do that", how long would it take for GP practices to get back up to a level where they felt they were providing the service for their patients?

I want you to talk a little bit more about the GP federations — we did not discuss that in great detail last week — and the impact they will have. Could you let us know whether all GPs are part of them, or is it a percentage of GPs? I also want to highlight with you the working group on GP-led primary care recommendations. It talks about a mixed economy of service, and that is something we have not discussed in Committee either. It was to do with salaried GPs, independent GPs and academics coming together. Do you think there is room for that in the future as part of some of the solutions to try to help?

Dr Black: I will take the first bit, which is on workforce, and Alan will deal with the federations' multidisciplinary team aspects.

The problem we have is that we are in the middle of the collapse of general practice. You have heard me in the media talking about the crisis and the impending collapse. We are already in the middle of it in some parts of the health service. Within general practice, it is like Humpty Dumpty. I do not mean to trivialise it, but we all know you cannot put it back together again. General practice in Fermanagh is like Humpty Dumpty. We cannot fix it. Why? Because it has been left too long. The 18 practices — sorry, 17 practices — in Fermanagh will coalesce down into five. That is what the GPs in the area tell me. I was taken aback by that, and I said, "Let us focus on eight or 10 practices and try to save them". They said, "No, it is five". One of those five practices, which we regarded as safe, collapsed a couple of weeks ago. So, it is four and is probably going to be three sites. Now, you would say to me, "That is ridiculous. Go in and put more staff in. Money will solve this". Money will not solve it. Increased training numbers will not solve it. People will not go into those small rural practices where the workload is so onerous that there is no life to be had. That might seem strange coming from a GP, because we are supposed to work very hard, which we do. I do not like to talk about individuals, but there are instances of people just collapsing, physically and psychologically, under the pressure of this. We are looking at three sites and, hopefully, at four or five practices in Fermanagh to provide services. We will try to do hub-and-spoke and do our best, but a lot of patients in Fermanagh are going to be travelling 30 and 40 miles to see their GP. That is not satisfactory.

Armagh is collapsing at the moment. Tyrone will be next, and small practices in Belfast will also be next. We have predicted this over the last two or three years. It is not the future any more. We are right in the middle of it, and our concern is that we really cannot stop this from happening. This might sound cataclysmic or apocalyptic — whatever word you want to use — and you think, "This is not going to happen". We are 70 years into the NHS, and this has never happened before. It has already happened in the United States of America, where three quarters of family doctors have disappeared, so there is 25% of the workforce there that there was 20 years ago. They have already done this. They have managed to collapse general practice, so it does not exist, and that is why in America they spend twice as much per head of the population on healthcare with much worse out-turns than we have. We already have a clear example that this can happen. If we increase the numbers to 111 as of next August, we hope we could fill those places for training. They will come out in three years' time, so they will not be a solution. We already know that was the standstill situation from 10 years ago. We really need to be training 143. Will that save us? No. Will it help? Yes.

We have a real problem in the east and west and in the north and south of Northern Ireland. The problems are presenting in the west, and the problems are presenting in the south. The option, which we heard about in the media today, of a medical school in the west that would be graduate entry and GP focused would definitely help the west and the south.

The short-term solution for how we get through the next three, five and 10 years is the multidisciplinary team and bringing the pharmacist into GP practices. We are very grateful for the help, which is starting now. The mental health workers are part of that team, because mental health is as big a problem as general practice. I am not saying we are the only problem; mental health, community nursing and general practice are the three big issues in the health service.

I will let my colleague, Alan, describe the federations and the multidisciplinary team now.

Dr Stout: The multidisciplinary team leads quite neatly into federations, because one role that federations can have is to house those and primary care teams across groups of practices as opposed to each practice employing a raft of people individually, with the same person maybe being employed by two or three different practices.

Federations are interesting because they came around a couple of years ago when we had a meeting to try to identify the weaknesses in primary care from our perspective. One of the strengths in primary care is the individual care and the continuity that is provided by a practice. But that also creates a weakness, in that you have lots of individual practice units, so it is very difficult to get primary care working at scale and starting to take on different agendas.

One of the theories and thoughts behind federations was to get the groups of practices together so that you can start to deliver primary care across a population and a population model. We very quickly identified the population model as being 100,000. That is based on evidence from throughout the world on the change and impact you can make across a population. We were also extremely keen at an early stage to set them up as community interest companies, which are not-for-profit companies. They are there for the community; they are community facing and have a community statement.

One of the words we used at an early stage was "variance". It is about trying to manage variance across primary care. We see lots of variance in lots of different areas, whether it is in prescribing, referrals, ED attendances or access to your own GP. The variance is not necessarily good or bad; it is just different, and there is usually an explanation for it. Working as groups of practices, it is much easier to try to address that variance and maximise the primary care. In primary care as it is currently contracted, there are pockets of practices that, for different reasons, do not provide certain services. The issue is ensuring that other practices can carry out those services on their behalf.

Even more important in the greater scheme of things was GMS-plus, which looked at what you can do above and beyond what would normally be expected of primary care. Elective care is the perfect example of that. Again, if we go back to variance, we see significant variance in what different GPs will refer. That might simply be because they are under pressure or because they were sued over a case this time last year and are practising very defensively. It might be as simple as the fact that their practice nurse is off, hence the rest of the practice is under pressure and they cannot do the things in their own treatment room they previously would do. It might be that they just do not have the experience in that. If you are a one- or two-man practice, that is very difficult to manage. Across a group of practices — in my area, there are 25 practices — it is very easy to identify one or two people who are extremely good at dermatology, one or two who are extremely good at gynaecology and one or two who are extremely good at ENT. If you can get the referrals and the threshold up to their level across a group of practices — work to date has shown that can reduce referrals and demand for secondary care services by anywhere between 30% and 50% — that would be extremely significant.

The other part of it is working together. We talk about a want and a need, and there is a definite need in primary care at the moment for continuity of care for complex comorbidity and chronic disease and for the frail elderly. Those patients are being harmed by a tsunami of demand. We know that demand is going up and up every year, but it is preventing the patients who have the real need and get the real benefit from spending time with their GP from accessing that. That demand is a want, which does not specifically require the patient's GP; it only requires any GP or healthcare professional. If you could take that out of the workload — we are getting into the realms of the 10-minute consultation — it would free time for GPs to spend 20 minutes or half an hour with the patients who really need it. The impact that has on the long-term care of a patient and the risk of them having to attend ED or requiring hospital admission and all the complications that come with that through delayed discharges and long-term social need are significant. We need to move to a much more preventative and proactive model as opposed to what we have at the moment, which is simply a reactive model.

The Chairperson (Ms P Bradley): I see the GP federations as a really positive step forward. I got what you said about dermatology; I know that there are certain GP practices where you will have a GP who is skilled, knowledgeable and confident in undertaking dermatology work, and that saves a referral to a very long waiting list to see a hospital consultant. Part of having the federations, then, is to share skills and knowledge and to identify areas within that federation where people need to be upskilled and given that confidence. I know that the number of GPs within the federations is only finite. Are all GPs part of federations?

Dr Black: Yes. The whole of Northern Ireland is covered by 17 federations, which are not-for-profit community interest companies. It is an extraordinary achievement. Well done to my members for actually funding that themselves. It is something that Simon Stevens in England or Nicola Sturgeon in Scotland would love to have. We have achieved that.

We have seen what Bengoa will say, because it will be what Hayes, Donaldson and TYC said about the push from secondary care into community care. We understand that. That is why we have set these federations up so that, when you invest money in primary care and the community, it will not go anywhere near our wallets, which I think is a major consideration. It will go into these not-for-profit community interest companies so that the work can be done. For instance, we are able to invest in pharmacists at the moment. It is a great way forward.

Dr Stout: It is interesting because I was at a meeting just yesterday morning and there was a group at it from the ICPs in Northern Ireland. It was a meeting on the King's Fund. They were bringing back feedback from that. Obviously, areas of England are ploughing ahead and different funding packages and so on have gone with those, but the feedback that came back from that group, from all the other people attending from England, Scotland and Wales, was that they wished that they had what we had: well-established ICPs, which are good, multidisciplinary networks of clinicians, community groups and patient groups coming together to look at and design how services are delivered, and pathways, but also unified primary care, where you can actually deliver it at scale in populations. Again, the feedback is that they have done it the opposite way.

What we now need is the accountability to move to those local-population-based groups. What has happened in England is that they have passed the budget first without actually having the structure in the organisation, so they are getting lots of difficulties with that. Bizarrely, for us being in so much difficulty, they are actually quite jealous of the set-up that we have and the ability that we have to deliver it. We now just need the next step.

The Chairperson (Ms P Bradley): It is coming across. It came across last week and is coming across today that you want to see change. We know that it needs to happen, even with the likes of multidisciplinary working and triaging. We know that not everybody needs to see their GP. I spoke earlier about self-referral with physio. Now there are over 7,000 people who have self-referred in the South Eastern Trust. I know that that alleviates a lot of the pressures on you. That brings me on to what I asked about the mixed economy of service. Do you see that working? Do you see it helping, where you have the independent and the salaried?

Dr Black: Yes; it will work very well if someone would like to implement one of the wonderful plans that we keep producing. Did we implement Hayes, TYC or Donaldson? No, we did not. Now we have Bengoa. I know that Bengoa will be a good report. I know that the Minister is going to have a vision and we will all say, "That is great." Then, we have the problem of actually implementing it.

I will go back to what I said earlier: we have fewer GPs now than we had in the 1950s, yet we are shifting all the work from secondary care into primary care. We have four doctors in hospital for every one doctor in the community; four behind the brick walls in the hospitals and one in the community. There are 4,300 hospital doctors and 950 whole-time-equivalent GPs. Where did it all go wrong? All the reports say the same thing, yet we keep putting all the doctors in behind the hospital walls and we do not put any into the community. We keep trying to shift work into the community, which is what we keep doing. GPs take on more and more until the young doctors actually turn to us, the old guys, and say, "That is it. I am not interested. I am away."

The Chairperson (Ms P Bradley): We talk about patient-led services, patient experience and clients. We also know from them that they do not want secondary care. They want to be seen by a primary-care provider in a timely fashion and have whatever it is sorted or referred on if it needs to be, and then go back to their work, their lives and whatever they are doing. Nobody wants to be admitted to hospital or end up in an emergency department because they had difficulties in accessing other services. I do not think that anybody here would disagree with what you are saying and would not support that shift. I have a couple of other things, but I am quite conscious that I need to let others speak.

Ms Bradshaw: Thank you very much for the presentation. I am going to talk about allied health professionals linking into GP federations. That is absolutely wonderful. However, when I was at a meeting of the all-party group on multiple sclerosis recently, I heard that there is, for example, a degree of specialisation within physios. I am just wondering how you will get round some of those more complex conditions, because they cannot be all-singing, all-dancing. I have another question after that.

Dr Stout: That is really important. It is the freeing capacity scenario. You are absolutely right that there will always be a need for specialist areas of practice, whatever the area, be it a physio, a doctor or a nurse. The problem at the moment is that we are dominated by sub-specialisation. The key is to have the predominant workforce actually dealing with the predominant problem — the common or "normal" problems. That then frees up capacity for people with a specialist interest to deal with the ones they really need to deal with. At the moment, because the system is set up in the wrong way, and we are dominated by rotas, buildings and sub-specialisation, nobody is getting access to the care that they need. You are absolutely right. That is fundamental to how you set that up to free capacity for the right people to see the right things.

Ms Bradshaw: Thank you. I have a second one, quickly. What you have not mentioned today, although you may have done so in some of your reports, is the role of the community and voluntary sector. I am thinking, for example, of the great work Action Cancer does in screening; I know that it is trying to extend the service. How do you see that sector fitting into the transformational agenda? I know that it is not necessarily within your gift today, but what is their role going forward generally?

Dr Stout: I will take that one again. That is huge; it is absolutely vital to the whole ethos behind population health. The preventative, educational, proactive model rests on engagement with local community groups. Think of something as straightforward as a public health agenda. If you are centralised, with a diktat from above that supposedly covers every part of Northern Ireland or of the UK, it is really difficult to implement. However, the way you can really make a difference to a public health or preventative agenda in a locality is by getting down into the grass roots of community groups. Then you will know where the problems are, what the target areas are and so on. That is vital, and that will be a hugely instrumental part of any population health and future model.

Mr Sheehan: Thank you very much for coming in. I suppose that the way GP practices work is a sort of microcosm of the whole health service. They work in silos; there is very little collaboration or sharing of good practice and so on. I am interested to hear about the federations of GPs and how they work in a multidisciplinary way. Take somewhere like Belfast. I come from west Belfast, where there are loads of GP practices, pharmacists out there in the community and other health service providers, yet there is not a lot of collaboration between them. The watchwords for the future — not just for health provision, but for education and other sectors — are collaboration, cooperation and sharing of good practice. Would you like to comment on that?

Dr Black: That is really important, and I have brought a Belfast person along to tell you what is happening in Belfast. [Laughter.]

Dr Stout: You are right, and that is what I was alluding to when I talked about the evolution of federations. That was one of the things that we identified. There are individual practice units, which we know are all doing extremely good jobs. Some of them are now struggling, as Tom said — possibly not so much in west Belfast as in Fermanagh, but throughout the Province. You are absolutely right about that collaboration and that closer working. I did not run through the whole key principles of the federations, but the fourth one is education and peer review. Again, going back to the King's Fund, there was a recent King's Fund report. The sustainability of a service is not simply about putting in a different service; it is about local clinical leadership, education and peer review, and then, and only third, being a primary care community alternative to referral or to a secondary care service. So the first two are fundamental: there has to be that local leadership in a community and in a population, and there has to be an inbuilt education and peer review where you really are starting to influence and change behaviour down the line.

Mr Sheehan: That is all very good, but we all hear stories — we talk to GPs, pharmacists and so on — and there seems to be a bit of competition there. Do you not agree with that?

Dr Black: No. We work hand in glove with pharmacists. They are great, and they are the only ones who make our numbers look small. Pharmacists work so hard, see so many patients and — I was going to say "protect", but that is not fair — help us so much with the workload, working with patients every day, seeing them across the counter and sorting out their medication. They produce 40 million prescriptions per year. Pharmacists and GPs are the best of pals, and when one of them rings me up, I take the phone call straight through, because I know that they are on the phone to help me. It might be a piece of advice for me.

Mr Sheehan: A pharmacist said to me that one of the reasons why a lot of GPs will not direct their patients to pharmacists for the likes of vaccines or inoculations or whatever is that the pharmacist only charges a tenner, but the GP charges twenty quid. Do you have any experience of that?

Dr Black: That is an English thing. I appreciate that that is an issue in England, and it has been an issue as recently as last week in England. It has never happened in Northern Ireland. If somebody wants to help me with my workload, great. We have discussed before how much GPs are paid, Pat. They are very well paid. I would like to be paid less. I would like you to give me a nice young GP, from Australia if need be, whom I can hand over some of my money to so that I have less work, because this grey hair did not come from me being well paid; it came from working too hard.

Mr Sheehan: I must have the same problem. [Laughter.]

Dr Black: You have exactly the same problem, Pat. The more help that you can give me, and our number-one wish — the first thing that the federations did in Northern was that we wanted pharmacists in to help us because they are so expert at medication. That was our number-one wish, and well done to the Department for helping us with that. It is only starting, but we are the best of pals with pharmacists, Pat, honestly.

Dr Stout: It is a really important point. An overriding principle, and this is really important for any transformation, is that it has to be collaborative and not competitive. There is competition right throughout the health service — or supposed competition; there is not actually any competition. Collaborative working has got to be critical to any transformation.

Ms Seeley: Thanks to both of you for being here today and for your presentation. Before I ask a question, can I seek some assurances around the closure of the surgery in Portadown, which was announced in the news today and yesterday evening?

Dr Black: I was dealing with this yesterday and working with the health board in collaboration, although, earlier in the day, we were not in collaboration, we were having a row. But we worked hard and, by last night, we hopefully got it sorted. This is an extension of the Fermanagh problem. It never occurred to me that Fermanagh would go first. I thought of other places, but I will not name them. You would think that Fermanagh is a lovely place to work, but Fermanagh was caught because of the age profile of its GPs who are retiring. We have been watching the Portadown situation for a number of months, and the situation is that all eight practices in Portadown health centre have very high numbers of patients and very low numbers of GPs, and they all basically needed an extra GP each. So we have been trying very hard to keep it stable.

The eight practices in Portadown became seven a couple of months ago and became six last week, and practice 478 — because we do not like to name people — collapsed. It used to be a four-doctor practice, but it has none now. So there are no GPs there this morning. That is 5,200 patients. The board is turning to the other practices and saying, "You take up the slack and see these patients". No offer of staff or money was made, because obviously we are in a socialist republic, Pat, and you just take up all this extra work. The other practices, needless to say, rang me up and said, "We will collapse". They named one practice and said, "It will go within two weeks if this happens, so we will be down to five". So we worked very hard yesterday, and hopefully it helps in some places. We have doctors from, would you believe, County Antrim sitting on phones today triaging the calls. Why? Because Antrim and Down are still the two places where we have GPs. They are triaging the calls into practice 478 in Portadown. The other practices have taken on the duty of taking any triaged calls today. They are already busy seeing their 43 each per day, but they have undertaken to take on that extra work. We have locums tomorrow and on Monday, and they will be paid at a premium. That creates its own problem because those locums will not be available to other practices that need them for cover.

You can see how hard we are working and how hard we are trying but, at 8.30 pm last night, the doctor representing the other practices was on the phone to me saying, "Yes, that is all right, Tom, but we all have more than 2,000 patients per doctor in each of the other practices. We are not coping as it is, and now you are asking us to take on more". I said the magic words, "But we will have the Bengoa report next week and we will bring you hope". And he said, "But they will not implement it, like the other three reports". I said, "We are going to make them implement it". We are saying, "Guys, hang in there and we will bring you some hope". That is Portadown at the minute. Why is it Portadown? It should not be, should it?

Ms Seeley: I want to place on record my thanks for the work that you have done around that and, indeed, my thanks to those doctors who have stepped in. I want to give assurances that this Minister fully intends to implement this report and that it will not sit on a shelf gathering dust. I also welcome your comments on the questions around community pharmacists, a relationship there and how crucial they are. That is an important message to get out there.

I know that I asked you this outside, but I have a question on how GPs take appointments. I gave you the example of Lurgan, where there is a practice that you phone up and you will maybe get an appointment within a month. There is another practice that takes appointments on the day. The book is open from 8.30 am, and the allocations are for that day. Do you believe that there is a better way to take appointments and schedule appointments? None of this is through any fault of the doctors, because they are extremely hard-working and are taking appointments as they come in, scheduling them for as soon as possible. If we change how we take appointments, it might be better for all.

Dr Black: I have the perfect answer for you, Catherine, because, six months ago, I was that practice with a three-week wait and now I am the practice where everybody gets seen on the day. My practice is in the Bogside in Derry, and it is within a stone's throw of where my father, grandfather and great-grandfather were all born. The resource that you give us to run these GP practices, which the public own, is a community resource. I have always reckoned, and my patients and family members in the practice have always told me, that they own the practice and the resource. They are right. The public pay for this, and we are there to service their needs. We always had the attitude of, "There are the appointments. Book them". Gradually, over the last number of years, the wait has gone out from two or three days to four or five days and, at the beginning of the summer, it went to three weeks. Everybody was telling me, "This is not good enough", and I was working harder and harder and getting nowhere.

As Alan mentioned earlier, we brought in a new system called askmyGP, which is a system that first derived from America and some places in England. I saw it as part of my job in London. I thought that I should bring that back and the board, give it its due, backed it. We had five pilots, and it has been so successful that we are running it out to hopefully 30 practices in the second phase. Essentially, it means that you have to work really hard for about two months and get rid of the three-week backlog. On 9 May, I think it was, we came in on Monday morning and there was nothing booked. We had really sucked up all our backlog. You take the attitude from then on that everything gets dealt with on the day, but the quid pro quo is that you cannot say to patients, "You can book an appointment for next Thursday". They ring in and say, "I would like to see a doctor", and the receptionist says, "The GP will ring you back within the hour". Our average callback time is 18 minutes. We ring them back, and they say to me, "I would like to see you", and I say, "Would you mind telling me what it is?". The receptionist does not take any details; we do that. The guy says, "I was in with you last week. I hurt my back. Do you remember? It's no better with the tablets you gave me". I look at the records and go, "Oh right, I see that. OK. The next step is a physio referral. I will refer you to a physio". He says, "What time do you want me to come in at?". I say, "I don't need to see you. I've seen you last week. We've tried the medication. The next step is physiotherapy. I'll refer you now", and he says, "Oh, great".

So you can see — you made the point earlier, Chair — how you can actually triage out physiotherapy things. Say a guy rings in and wants a vasectomy, I do not actually need to see him if I can see from his records that he is healthy, so I will refer him on for a vasectomy. I do not need to bring him in to do that. So, suddenly, you are freeing up appointments. And who are you freeing them up for? The elderly with complex comorbidities, those with emergency problems, and, in particular — my favourite — sick children, whom you do not want waiting at all.

It is working really well. You can imagine how many times I am on the phone. On Monday, I probably phoned back about 50 patients, and I probably saw 30 or 35. You can see how that is much more effective because I have actually increased my efficiency. It is hard work, particularly on a Monday, but the patients and the staff love it.

Ms Seeley: OK. That is good to hear. Thank you.

Mr Sheehan: Sorry, Tom, what do you call that system?

Dr Black: askmyGP. Pat, if you google askmyGP, you can go on it and run your symptoms through the computer algorithm. What I did not mention is that you do not have to just phone; you can actually go online to me. A lot of patients go online, because they are at work or whatever, and fill out the questionnaire for their particular problem. I then click into their screen and go "Right", and I ring them up, or I could get a staff member to ring them up, and say, "I see you've got the urinary tract infection that you usually get. I'll leave you a prescription". They love it, Pat, because a lot of them actually do not have to leave work; there is all this tension now around how to get out of work to see your GP. So far, so good; I am touching wood here. You know what the health service is like: success in the health service breeds more demand.

The Chairperson (Ms P Bradley): When are we getting that in every GP surgery?

Dr Stout: That is the key. In the spirit of being collaborative and not being competitive, our average callback time is 12 minutes. [Laughter.]

A Member: Lessons to learn there.

Dr Stout: That is right.

There are three weaknesses — I jotted them down here — to this that have become immediately apparent to us. We are obviously doing it in a Belfast practice. First, given that, as Tom mentioned, patients love it, our net patient transfer or patient increase is now 350 new patients. That is since we started it in May time as well, and it is massive for us in an area of diminishing population. We have almost increased our list size by 5%, which is quite frightening. That is simply because patients want same-day access. Until it becomes more widespread across the other practices, that is going to be difficult. It is ultimately going to come down to patient choice. The other weakness that we identified very quickly — Tom mentioned that Mondays are busy. On Monday past, we had 140 calls before lunchtime that we had to phone back. It is very doctor-dependent if you do not have enough doctors there, so it does not get past the need for doctor numbers. You cannot ring back 140 people with two doctors there. You need at least five and, even with five, that is stretching it. The third thing, which we mentioned earlier, is that at least half of the ones that I triage and bring down to see me could have seen somebody else, if I had somebody else there, but we do not have anyone else there, so they all come to see me. That is really key.

As for the evolution of it, I think that it is a good service. It is extremely good for patients and patient access. An interesting follow-on to it is that it is very easy then to identify what the demand is for other services and elective care. Actually, if you extended it into an elective care type of agenda, you would know how many patients in a day need to see a dermatologist, a gynaecologist or an ENT consultant. A phrase that I use an awful lot now is that we have waiting lists for the sake of waiting lists, simply because of how we have set up the system. We have set up a system that favours and benefits doctors, not patients. If we started to change that dynamic — askmyGP is changing that dynamic in primary care — across the whole of the health service, we would see an extremely different health service.

The Chairperson (Ms P Bradley): Sorry Catherine, just to pick up on this again, Last week there were concerns about some patients actually missing out; there was a downside for vulnerable patients. What do you believe about that?

Dr Stout: No. They still are allowed to book appointments. We would give our receptionist discretion. Funny, the folk from England, who set it up initially said, "Do not; you have got to stick hard and fast. You have got to use this". Having done it for a day, we said, "No, no, for certain groups of patients still allow the discretion to book as they would do." So, for example, if an 85-year-old lady, who lives alone, does not want a phone call back, we are perfectly happy for her to be booked in.

Dr Black: Another instance involves Syrian refugees. We have a number of those, and, with the language difficulties, you have to book ahead and get an interpreter. Patients with hearing difficulties, again, have to book ahead. So you accommodate those. You think you have a brilliant, 100% scheme, and then you go, "Oh, right, except for those exceptions."

Mrs Dobson: I thank you for your briefing. You know of my long-term support for the BMA, and I commend you for highlighting this crisis, along with the Royal College of GPs last week.

I have been busy writing down your quotes because you both have been very frank and very honest with us. Tom, we are in the middle of a collapse in general practice, and our concern is that we cannot stop this happening. Briefly, I want to touch on the situation in Portadown as well, which has sent ripples of fear throughout the community. In fact, my husband's uncle, Dr Willie Dobson, was a GP in Portadown for 45 years, and he is 86 now. He rang me last night and said, "Pet, can I do anything to help?". That is the lifelong caring and commitment of a GP that they all have, and I think you have highlighted that very well in your presentation. They do rally together to help when there is a crisis.

I would like to focus on future and succession planning because you said that a third of the workforce are retiring, with 50% being over the age of 50, and much-loved GPs, like uncle Willie and others, will be retiring within the next two to five years. That is as well as what we are experiencing at the minute. It is particularly frightening. You have outlined the longer-term solutions: more training and more GPs, and that is going to take a while to do if we get those additional places. However, focusing on the shorter term, what can we do to help you, what needs to happen now and how do we make it more attractive to female GPs?
I have a superb female GP in Banbridge, and I do not know how she copes with the workload, but she does. But it is not sustainable, and she is telling me that so many of her friends are just getting out; they cannot cope. How do we cope in the shorter term, and what about female GPs?

Dr Black: Joanne, in the short term, we bring help in, and that is the help that we have discussed — the pharmacists, mental health workers and physiotherapists — so that we can share out the workload.

We need a very clear signal next week from the Minister. I have great confidence in this Minister because I have met her and she seems clearly focused on the problems. This Committee is clearly focused on the problems. We need a very clear message next week that we are going to train more GPs and we are going to do something similar to what Nicola Sturgeon has done in Scotland and put confidence into the system. If we put confidence into the system, we will give hope to the GPs who are struggling at the minute.

I take your point about female GPs, and this is not a sexist thing, basically this is just practical issues. The young lady doctors have to spend more time doing portfolio working and part-time working because of family issues, and that is fair enough. How do we make it a more civil environment for them to work in? I will give you an anecdote. In my practice one Friday, my young female partner's baby was brought in by her husband. I always describe our practice as a family and that the 20-odd people who work there are all working together. He brought the child in at lunchtime. It was a baby, about seven or eight months old. I thought that was great. I said to her afterward, "That is lovely and I like to see that sort of thing happening", and she said, "Oh, I had not seen her since Tuesday", and I said, "Why had you not seen the child since Tuesday?", and she said, "Well I am coming in here at 7.30 am, and I am going home at 8.30 pm when she is in bed". I thought, "Oh dear", and that is partly, Pat, why we brought in the askmyGP thing. I looked at that, and I thought, "That's not sustainable. I'm going to lose this young doctor". The young doctor is really delighted with the askmyGP service because we work very hard. We work between 8.30 am and 6.30 pm now. She stays on until about 7.00 pm, but she is now seeing the child.

You are quite right: if we are going to maintain our workforce, which is predominantly female among the younger GPs, we are going to have to create an environment where they can work. This, again, is part of the problem in Fermanagh, because we have a medical school in Belfast, and it depends on who you marry because, if you are a student in Belfast and you marry some guy who works in Belfast, we cannot get that cohort to come and work in Fermanagh because it is 85 miles away. That is partly the thinking behind having a medical school in the west, because if we can get them out there as students, they will marry a farmer from Omagh and stay out there. That is our great hope, and obviously secondary care needs that as well.

It is very difficult, and the next three to four years are going to be a real problem for us to fix this.

Dr Stout: It overlaps a little bit with one of your questions, Chair, about the mixed economy. That is something that we have been working very hard to try to maintain. Sometimes, the mixed economy is seen as a negative, but it is actually really important to try to give that flexibility within the career for family-friendly working and flexibility within the working week and the timings and so on.

It does not only apply to the younger doctors or female doctors but to the doctors who are retiring, whom you referred to. We are putting an awful lot of work in at the moment to see how can we actually retain a little part of them. Rather than having them retire and losing 100% of them, is there something that we can do and some way in which we can keep half of their working week or half of their working commitment or even 20% of their working commitment?

Mrs Dobson: Is that something you are engaging in currently with the female GPs, then?

Dr Stout: Very much so.

Dr Black: We are developing GP chambers. It is not a success yet. We are trying very hard to create GP chambers, where we can hold on to older doctors or those doctors who need portfolio-type working, and create chambers, like the chambers of barristers, where they would work. For instance, in Portadown on Tuesday, the doctor who went down to help was an older colleague who retired five years ago. He got his arm twisted and was sent down, and he said, "That's scary. That's enough of work", and this is the oldest, hardest guy you ever met.

Mrs Dobson: I remember taking Uncle Willie back to Portadown health centre a few years ago, and we saw the difference. He could not believe how it had changed from his time, yet the people coming in and out all knew him. He had delivered their babies and had been there, so the people were still the same Portadown people who he had cared for, but it had changed so much and was so big.

Dr Stout: We might try getting his phone number from you later. [Laughter.]

Mrs Dobson: I will give you his phone number, no problem. He will be all chuffed if he reads the Hansard report of this.

The minor ailment scheme is an excellent scheme and takes considerable pressure off GPs. I am very supportive of it. Would you like to see an expansion of the scheme? I do not think it is well known. Not enough people seem to register that they do not have to go to their GP with minor ailments or colds but can go their pharmacist. Would you like to see more initiatives around that?

Dr Black: There was a problem with the minor ailment scheme. It was much broader. It was very strange about the dynamics, Jo-Anne, in terms of access. We had a lot of patients going to GPs and a lot going to pharmacists, and those patients knew what they were doing. Then we got a minor ailment scheme into pharmacy, where we created a new work stream as it were. Patients went in and got their prescriptions free from the pharmacist, and that work created a validation for that access. Then it was cut back, and those patients who previously did not come to us, then went, "Well, if I can't get it free from the pharmacist, I'm going to the GP", and our workload increased by about 17%. My answer would be complex, which would be, "Yeah, I'd love to see a minor ailment scheme; no, I wouldn't", because you would cut it back again and actually create a bigger workload for us. That is a strange response, isn't it?

Mrs Dobson: It is. Something that is designed to alleviate pressure —

Dr Black: But when you cut it back, it creates another work stream for us. That is when, in my practice, we started losing control of the workload.

Mr Durkan: It has to be more than a scheme.

Mrs Dobson: It does.

Dr Stout: It has to be coupled with education and health promotion. By simply increasing access, we increase demand for things that do not actually need treatment a lot of the time. The knock-on effect is that the demand, irrespective of whether there is a minor ailment scheme or not, just goes up and up, as people contact us earlier and want more instant treatment.

Mr Butler: Thank you. That was really informative. I welcome the fact that you went round some of the statistics, but they are all there for us to look at. That gives us evidence and leverage. I want to make a comment on askmyGP. That was a really good description of it. You talked about innovative solutions. That is really welcome, and I appreciate that.

I was number-crunching and looking at some stuff. You said that there was a need for 111 trainees — you actually said 143, but it says 111 in your briefing paper. Those are very honest statistics taken from a Department of Health publication. However, of 111 trainees, 111 might not finish. In 2014, of 65 trainees only 33 finished and —

Dr Black: I will —

Mr Butler: Sorry, I am going to go just a wee bit further. I know that you will be able to qualify that, or I hope that you can. The other side of that is that, based on another publication, it costs around £500,000 to train a GP. The train of thought is that we train GPs only to lose them to more lucrative contracts in other jurisdictions. Is 111 want you want as a finishing figure, or does 111 take account of the fact that only 50% to 60% might finish? With that in mind, what is your position on roughly £500,000 being given to train somebody who takes a job somewhere else? Should that be recoverable?

Dr Black: You have given a snapshot — you are quite right in your figures — of 65 trainee places and 30-something GPs coming out. Actually, 64 came out, but as many of them are female and are what are called less-than-full-time trainees or take maternity leave, they come out a year or two years later. Out of 65, 64 did come out. I was a GP trainer for 20 years, until I gave it up last year due to other commitments. We have the best GP training scheme in the United Kingdom by a mile. They do not ask what the percentage of pass rates or completions is in Northern Ireland; it is always 100%. If you give us 111, you will get 110 back. There is always one.

Dr Stout: It does not count heads. The outflow is full-time equivalents. If you have 60 people, but those 60 people work half time, that is 30 full-time equivalents. That is why the numbers look slightly different.

You are right to ask that question, because we do not want to spend a lot of public money training people who are not going to work here ultimately. That is a UK-wide problem. One of the Department officials made the comment to us one day — it was an ongoing debate — that it is amazing how much policy in Health is directed by rumour and anecdote. There was a rumour or anecdote that a lot of our trained doctors or trainee doctors were disappearing off to Australia or New Zealand. When we looked at the figures for the last five years, I think that three had gone. It is extremely few. A rumour had started somewhere — we do not know where — that all these doctors were going, but when we tracked them, we found that they were are all working in Northern Ireland.

Mr Butler: Thank you very much. That is a really good answer; it is the type of answer we like to hear.

You mentioned the reports over the years that have not been fully implemented. It is heartening to hear Catherine Seeley say that the Minister will implement Bengoa. I do not share that level of confidence, but I hope that is factual, because, as you outlined when you talked about what has happened in Fermanagh, there has been an implosion within the Ambulance Service. There is almost a two-tier health service. If you live rurally and in social exclusion, you do not even get the emergency services in the same time. The standards are slightly different. Access to acute care is slower, and we all know that, with medical conditions and especially where there are co-morbidities, speed of response and access to treatment is of primary importance. I thank you for painting that robust picture of what is happening.

Mr Carroll: Thanks for the presentation. I have two quick questions. It says in the report that there needs to be a 10% increase in the funding of GP services. Do you have a rough idea of how much extra that will be? Can you paint the scenario of what will happen if that extra 10% is not allocated over the next few years?

Dr Black: Thanks, Gerry. How should I describe this? Mark, Derry in 1957 —

Mr Durkan: Before my time.

Dr Black: It was before my time too. Somebody handed me the Londonderry Services Directory 1957. I thought, "What is interesting about that", so I looked at it. There were 36 GPs, including Dr Fallon, Dr Cavanagh, Dr McCloskey, Dr Milne from the Waterside and Dr Kelly; all the names I recognised from the very beginning of my career. There were 36 of them, which was one GP for every 1,380 patients. There is now one GP for every 2,000 patients in Derry; we have fewer GPs now than we had then. How many consultants were there in the City and County Hospital? Sixteen. Altnagelvin was built a couple of years later. How many consultants are in Altnagelvin now? Two hundred and fifty. We have fewer GPs now than we had in the 1950s, and we have 10 or 20 times as many consultants. Is that because all the reports say that we should take all the resources out of primary care and put them into hospitals? No, all the reports say the opposite.

We always used to say that we did 90% of the work for 10% of the budget, but we are now on 5% of the budget. Representatives of the Royal College of General Practitioners were here last week and said "8%". If you divide 255 million by 4,880 and multiply it by 100, you get 5·46%. That is the proportion of the health and social care budget that we spend on general practice. Is that sustainable? Clearly it is not, and we have described why. Do I want that money for my back pocket? Nope. I would like the amount of money to go from 5% to 11%, which is what Nicola Sturgeon just offered. In England, there is £2·4 billion going towards primary care. So, we are asking you to do what they are already doing in the other three countries.

We have a report: it is from a GP-led review, which we sat down and worked on with the Department. That came out in March, and we are sitting going, "Yeah, the report's there. Could somebody please fund this and implement it?" That is what we are really good at in Northern Ireland: preparing reports. "Paralysis by analysis" is the old phrase for it, before your time, Gerry.

Mr Carroll: So, you are saying the extra 5·4%, or whatever the figure is, needs to go on employing more doctors.

Dr Black: On the basis of Nicola Sturgeon's offer last weekend, you would have to find an extra £200 million for general practice in Northern Ireland. I could not spend that money: I cannot train GPs, because nobody wants to be one. What should we do? We should work over five years, bringing in, in the first instance, the pharmacists, the physios and the mental-health workers to gradually build up the multidisciplinary team.

We have not talked about health visitors and district nurses. There are fewer health visitors than there were 15 years ago, and there are fewer district nurses than there were 15 years ago. Who on earth did that? Whose decision was it to cut health visiting and district nursing and build up more and more staff inside the hospital walls, where you cannot get at them because of waiting lists? Who decided that?

The Chairperson (Ms P Bradley): We only need to look at the likes of perinatal mental health services, with women waiting two or three years to receive a diagnosis for postnatal depression. When I had my children, 25 or 26 years ago, my health visitor and district nurse were invaluable. I did not go near the GP, because they sorted out whatever needed sorted out, and they were fantastic at it. We are seeing the knock-on effects on all of this.

Dr Black: Yes.

Dr Stout: There is a really important point about the 10% figure. That will always be a black-and-white figure, and you need to put something down as an indication of what you need, but you cannot just take a lump of cash and put it somewhere else and say, "We're going to get something for it", because you can be pretty sure you will not. The difficulty is that we have a transactional health service, and we know that it does not work. If we — by "we", I mean all of us, collectively — do things right and move away from a service that is dominated by the interests of doctors to one that is dominated by the interests of patients, and if we design a service that creates the best possible patient experience, which, almost by definition, will be primary care based and led, the funding can follow that. So, if you build the service around providing the best possible patient experience and the best possible patient pathways, just let the funding follow that.

What you will find very quickly is that that will probably not be 10%. If you do it well, it will probably be an awful lot more than 10%. Look at examples from around the world. We are great at bringing in international experts, are we not? There is an Alaska programme, and there are a couple of New Zealand programmes, in Canterbury and Auckland. They are spending over 50% of their budget on primary care. When you go to that sort of level, you are not simply talking about GPs. They have their respiratory specialists employed in the community, going out and doing home visits to patients with chronic chest conditions and so on, so that patients do not need admission to hospital or to spend two or three weeks there. Again, that is if we do it right and have the confidence to allow the funding streams to follow that as opposed to focusing on, effectively, buildings and rotas and trying to spread everything so thinly with the limited budget that we have.

The Chairperson (Ms P Bradley): Just on the back of that; we have had the acute care at home teams. I know from way back when I worked in the health service, on respiratory wards, that a lot of those admissions could have been prevented if we had had the correct teams in place in the various trusts and the confidence to say, "No, you do not need to be admitted".

Dr Stout: Yes. It is worth commenting on acute care at home. It is actually quite successful in that it shifts that focus, assessment and decision-making to a patient's home as opposed to the hospital. By definition, you are talking about elderly patients. With the best will in the world, when an 85-year-old lady in her dressing gown and slippers arrives at hospital by ambulance at 6.00 pm, somebody will admit her — you can be pretty sure of that. However, if you can change that focus to her house, and that is where you make the assessment and decision-making, you have options from there, be that to bring in a multidisciplinary regime, more support, access to diagnostics or an urgent outpatient appointment within the next few days. That has a significant impact. We have already been able to show how it reduces admissions, length of stay and the long-term social need.

Mr Middleton: I welcome you both. I met Tom in the constituency. I had not met Alan until today. From what I am hearing, there is great anticipation and hope that, next Tuesday, the report will provide all the answers. I know that, Tom, you are saying that it will probably just be what we have heard before. I think that the key bit will be what the Minister says and the report that she puts alongside that as to how it will be implemented. Obviously, we want to see resource to go along with it, not just another report. I can speak only for myself, but, in the job that we do, we discover new strategies almost every week as regards what went on previously.

Alan, you mentioned England looking on almost enviously at our situation. I know that we are in difficulties, but you said that they put the budget before the change. Next week, when we get the report, we will say, "There is the change; we now need the budget to go along with it". That is something that we, as a Committee, will of course try to press the Minister on when she comes before the Committee.

My concern is more about the immediate short-term solution. You mentioned that 17 GP surgeries will go down to five in Fermanagh and that there have been issues in Portadown. If money will not solve the issue immediately and additional training places will not solve it immediately because that is longer-term, how can we prevent immediately, in the short-term, the situation that has arisen in Fermanagh and Portadown from happening in County Tyrone, Londonderry or any other area? How do we solve that issue?

Dr Black: That is a very good question, Gary. It gets to the nub of this. I will talk like a union leader, now. My members want to resign from the health service. They feel that general practice is being destroyed by the NHS, and it is. Within five years, we will not have a GP service, except in Belfast, Derry and maybe Ballymena. They are telling me, "Stop this hope-and-change thing" — it sounds like Obama — "We need to get out of the National Health Service and work outside it if we are going to save general practice".

You can imagine the areas that are ringing me up and telling me off for that. I say, "No, we have hope that the Minister will do this", and they say, "We have heard that three times before. It will not happen".

As of next Tuesday, we start our first roadshow for collecting undated resignations. We will start collecting resignation letters from all the GPs in Northern Ireland. You might think that that is a bit radical, and it is. Have we done it before? We have done it twice before: in 1966 and in 2001, when this last happened. I am trying to reassure the members that, if this report is not implemented and we do not see a true shift from secondary to primary care, we as the union will protect the service for patients and move it outside the National Health Service. For 70 years, before the NHS was invented, GPs worked outside the NHS, and, for the last 70 years, we have been inside the NHS. We would rather be in it because we see the fact that it is free at the point of delivery as a key element of our service but, if we are to end up like America, where three quarters of family physicians — GPs as we call them — disappear, we would be remiss in our responsibilities as a union to protect our members but, more importantly, to protect the GP service for patients. There is no confidence among the GP community that the report will be implemented. GPs will simply say, "There is a straight graph. We see where it is going. We are dead".

You will see us taking a parallel twin-track approach, which is about federations, askmyGP and being innovative. To be frank, that does not cheer up any of our members, because they say, "We are drowning, and we have no help". The second part of our twin-track approach is to be a union and say, "OK then, we will start collecting the resignation letters, and, 12 months from now, we will be outside the NHS". That is a very harsh message, yet it will give some hope to our members that we will play a key role in decision-making on the implementation of the report. It is a very difficult time, Gary; it is as bad as we have seen it since 1969. It is much worse than 2001, and it was bad enough then. It is really difficult.

Mr Middleton: It sounds almost like a last attempt, and, hopefully, the Minister will provide some reassurance. I appreciate that you are saying, Tom, that you are trying to reassure your members, but the difficulty for us is trying to reassure the public that they are safe and will get access to their GP when they need it. I appreciate the challenges that you face, but our role is not only to ensure that you get the resources that you need but to try to reassure the public. That is my concern. Members of the public do not like to hear about resignations and threats of resignations. I appreciate that, for you, it is about desperation, but it causes a real concern for us. Maybe the message will go out to the Minister that she really needs to provide reassurance next week that this is not just another report but is something that will be implemented.

The Chairperson (Ms P Bradley): I agree with what Gary and you have said. It is stark and harsh — we need to hear that — but it is up to every member in this room and every political party in the Chamber, because the Minister can advise and direct only so much. We have said in this Committee that we want to do everything within our power to assist with that in this mandate. There is a different feel and a bit more momentum now to say, "Enough is enough. This needs to change now". Trevor, do you want to come in on that point?

Dr Stout: May I make one comment, Chair, to reassure Gary? It is important to say that we have patients' interests at heart, too. We heard about the problems in Portadown, and, through this, we are trying to have a managed transition to protect patient services. Without it, we will have the unmanaged, uncontrollable collapse of general practice, which will be the most detrimental thing to patient care. If no change comes, we see an absolute disaster coming. The only way that we can pre-empt and prevent that without help is to try to manage it ourselves in some way. This is about making it a managed process as opposed to an unmanaged, uncontrollable collapse, which will be hugely destructive to patient care.

Mr Clarke: Chair, I listened to what you and others have said, but I want to turn this question slightly round. We are all possibly the same in pre-empting what is in the report. However, Tom has come up with a suggestion to come outside the NHS — it is probably an anti-union suggestion — but that is by the by. What happens if there is something in Bengoa that you do not like? Does the same resignation letter still come out?

Dr Black: Trevor, I have been doing this for 20-something years; I have not seen Bengoa, but I could tell you what is in it. I have full confidence in the politicians. I think that you are all clued in. You know exactly what needs to be done, and I have full confidence in the Minister coming out with her vision, consistent with Bengoa. I have full confidence in the Assembly and the politicians in getting this right. You then have the problem of implementation. You all know what I am talking about: vested interests. Everybody, everywhere will be for the big plan, but against it in their local area. That goes not just for politicians and the public but for the medical profession. My profession will say, "Great plan, but not here". We have a real problem.

The parallel problem that I have, Trevor, is that, as Alan said and as we have seen in America, if we do not put our foot in the door here, there will not be a GP service. At the moment, the NHS is completely toxic, and you have heard all the stats. It has got so bad that, even if they were to give me the money now, I could not fix it. We must have a proper plan, properly implemented, and a planned shift into primary and community care.

Catherine, I have great confidence in the Minister coming out next week and saying all the right things. I have spoken to her, and she really gets it, just as everybody gets it here today. Chair, you and I know that it will be really tough implementing the report.

Mr Clarke: I agree with how you are putting your point across, Tom, and I agree with everything about all the reports. I have said — people tried to hold me to this last week — that, regardless of what is in the report, we have to implement it. There are others — this is a political statement — who will play politics because they will join those who say, "This is the wrong place. This is the wrong idea" because they think that it is the populist thing to do. However, lots of things in Northern Ireland have to be done, whether it be in health, in housing or in lots of other things. We have to change how we do things — education, schools, closures. It all has to come, but the populists will jump on the bandwagon and say, "Not our wee school because my grandmother went there and she got a wonderful education" or "That's a great practice" or "We've heard about Jo-Anne's uncle, and he's a great doctor". Things were great in the past, but they are not working any more, and we have to change how we do things. I am saying this to members around this table, not to you. The politicians all have to man up and say, "There are brave decisions to be made, and we have to grasp them". We cannot continually get reports from individuals who are supposed to be professionals and then set those aside because we do not like them. We have to run with this.

Dr Black: I agree.

The Chairperson (Ms P Bradley): We have a great job of work ahead of us.

Mr Milne: Thanks for your presentation. I have to say that it has been a very depressing, but probably honest, conversation. I have a few points. One problem that I have is that you say that there has been a decline in GPs since the 1950s and that the eye has really been taken off the ball when you think of fewer GPs, a growing population, people living longer, growing health problems and all that. The reason why I used the word "depressing" is that we expect a service, and we have a vision to move along with all that and not be left in the position that you describe today. This has not happened overnight or on this Minister's watch. This has been happening for decades. I am glad to hear the comments from all of us here today that all the political parties need to work together. I think that there is a willingness to do that because we care, and we should put care at the centre of health. My question is: where did it all go wrong? It has gone wrong somewhere along the line. Somebody has taken their eye off the ball, or somebody has come up with reports and did not implement them for whatever reason. Where did it all go wrong? When did it all go wrong? Are you talking about 40 years ago?

Dr Black: It is the last 10 or 12 years, Ian. It is the obsession in Northern Ireland with the secondary care sector and hospitals. I said that Hayes was not implemented — I was a member of the Hayes review — but a start was actually made. At the beginning of Hayes, we had 17 acute hospitals in Northern Ireland. It is extraordinary to think about it: we now have 10. In England, a similar area would have two or three hospitals. There you go: I am talking hospitals and buildings again when I should be talking about services. We have an obsession in Northern Ireland: everything has to be about hospitals and buildings on the BBC, in the media, for politicians and for everybody else. You can focus on that, because — do you know what? — there are flashing lights on ambulances, and that makes great TV. You can then have people lying on trolleys, and that makes great TV. These hospitals are all in the middle of towns, so the camera crews can get there quickly and identify the problem. Obviously, the solution to the funding crisis in general practice is for me to buy a few ambulances and trolleys and set up the same sort of scene for the cameramen. I do not mean to trivialise it, but people have taken their eye off the ball.

I go back to Nicola Sturgeon, and Simon Stevens in England; I am careful not to say Jeremy Hunt because he is not wild popular in the BMA. Other countries have made the connection. They made the right decisions. They have implemented their plans and are funding them, and we need to do the same. There is now maturity in the system; the Assembly has really matured. All the messages I hear now are much more mature than 10 years ago. We have to take our eyes off the flashing lights and look at health prevention and health promotion. The number of heart attacks in Northern Ireland is half what it was 25 years ago. Why? Because of treatment for high blood pressure and other things, and fewer smokers. It is far better to halve the number of heart attacks than to have a fancy unit that fixes heart attacks. We all know that, but we should apply resources to it.

Mr Milne: You said that the money should be spent differently and more efficiently. We heard last week that 11% of the health budget should go to GP services. Can you tell me where you would find the savings in the Department to go towards GP services?

Dr Stout: OK.

Mr Milne: When we talk about getting more money, we have to understand that there is a block grant. We are allocated so much money, and 49% of that is already going to the Department of Health. We have to be real: where are we going to get the finances from?

Dr Stout: It is about doing things differently. I go back to my previous comment. We have a service that is designed around doctors rather than patients. If you extend the doctors, you can start to say that it is built on management, commissioning and doctors as opposed to patients. We have a very transactional health service, which, as Tom quite rightly says, is dominated by hospitals, buildings and rotas. The more buildings you have, the more rotas you need, hence the more staff you need. If we flipped the entire thing round and said, "Let us build a service that is predominantly designed to benefit patients", you would do things extremely differently. Not only that, you would start to answer questions about what buildings and services you still need in certain areas, safety questions about whether, as a heart attack patient, it is safe to go to a certain unit or to one of the two all-singing, all-dancing units that we can afford and staff. By doing things differently, you would start to free resource and move things into more of a community setting.

We talked about a couple of examples, acute care at home being one. Delivering care in the community — making decisions in people's houses — has a knock-on effect on ED attendance, hospital bed occupancy, long-term social need, length of stay and everything else. There will always be savings there, but you cannot just go straight for the saving. You cannot just say, "Today or on Tuesday we will close 50% of our beds". If you get the service right at the outset, that is when you answer the question of how many beds you need, because only the people who really need to go into hospital will go in and only the people who really need to be there will still be there. Of course there are savings to be made.

The other example was elective care. The amounts that we spend on supposed solutions to the waiting lists never seem to make an awful lot of difference. If the service is designed, first and foremost, from primary and community care to try to maintain and control the level of referrals and how a patient is seen — preferably in the community — that has a significant impact. Again, it is back to the fact that we have designed a system in which everyone needs to go to hospital.

Mental health is a perfect example; Tom mentioned it. By and large, patients in Northern Ireland do not die from mental health. There are suicides, but the numbers are relatively low. Patients with mental health issues die of other illnesses. One of the biggest predictors of chronic ill health and morbidity is having a mental illness at the outset. We know that — all doctors know it — but we are not proactive in managing it. It does not take us by surprise when somebody who has a mental health history becomes unwell physically, yet we have a reactive health service. So what happens? A patient gets referred and sits on a waiting list, as opposed to tackling the problem at the outset, having much more proactive management and preventing that long-term morbidity and the implications at the outset.

Mr Milne: Sorry, Chair; I have one more point. Some of us mentioned working in silos. I am glad to hear you talk about multidisciplinary teams, which makes a lot of sense to me. Do you think that the health system works in silos? If that is the case, where is the problem with the overview of all that?

Dr Stout: There are silos, and there always have been silos. Probably the only way to get around historical silos is to introduce an element of accountability. I think that you might hear some of this on Tuesday as well. By way of a simple explanation or description of that, all clinicians, whatever they do — GPs, surgeons, district nurses on home visits to elderly patients or healthcare workers — are responsible for what they do. I will be held clinically responsible for whatever happens to a patient who leaves my room, but at no stage is anyone accountable for what happens. Until you introduce that accountability, you cannot really change the direction of travel. Hence, if Tom is my patient and I have a bit of doubt about what is wrong with him, I will refer him as opposed to trying an alternative. However, I am not accountable for that, for the cost, for the implications, for the use of the independent sector or any follow-on from it. If you introduce accountability at an early stage in a patient pathway, that will have the biggest influence on behavioural change and the long-term implications for the system.

Mr Durkan: Thank you, Tom and Alan. Generally, I like to go last so that I can pick up on things, on points that have not been made and on the questions that have not been answered. On askmyGP, Tom, I was going to ask your GP how she gets her baby to sleep from 8.30 pm to 7.30 am, because I have not cracked that one, that is for sure. [Laughter.]

You appearing before the Committee so swiftly after the presentation from the royal college just serves to emphasise what a crisis situation we have. You guys said that there is no magic bullet, but the more we have talked and the more I have listened today, it sounds like you think that the Bengoa report and its implementation could be a magic bullet. It is up to all of us to make sure that it is a live round, because there have been magic bullets before that have ended up, to keep the analogy going, firing blanks. I do not doubt that it is the Minister's intention to implement the report, but the road to hell is paved with good intentions, and you named them: Hayes, Donaldson and TYC. I have no doubt that the Ministers, the Committees and the Assemblies at the time wanted to see those implemented. I hope that the Minister can transform healthcare, and I want to play a supportive and constructive role in helping her to do so.

Tom, you touched on the difference between localism and populism, and I think that you hit the nail on the head. Trevor described it as populism, and I think that he was referring to politicians. You said that it is there among healthcare professionals as well. When politicians or local public representatives in certain areas are being approached by medics in their constituency who tell them that they have concerns about proposals in the report, it will be very hard for an MLA or a councillor to say, "You know what? The Chief Whip of the DUP has told me that we should just suck it up". That will be very difficult. It will be grand; I am sure that Altnagelvin will be grand, anyway.

Virtually all the other issues have been touched on, the case being that you need to reduce the workload. That does not rest solely within the health budget. We wonder where we will get the money to move from one system to another. Clearly, most other Departments also have a responsibility to reduce the workload and the number of people who fall into ill health and need the help of you and others.

With respect to increasing the workforce, Tom, you spoke about a medical school in the north-west. I heard a bit about that this morning, and I have to do a wee interview on it at lunchtime. The BMA, maybe at your conference in the spring, expressed an opinion on how that or any medical school should look. Will you expand on that?

Dr Black: Sure. One of my other jobs is deputy chair of the BMA council. The issue of a new medical school has come to council, and we have been supportive of it, as you would expect us to be. The first phase of Magee's application for a medical school has already started. The emphasis is on graduate entry and a GP focus. That is deliberately the case. The Western Trust, for instance, is spending £11·5 million this year on medical locums — not nursing locums — and that would fund a medical school. So we know that, if we put a medical school in the west, we will improve recruitment and retention, and it will virtually pay for itself. We think that graduate entry will be more likely to be successful; you will get a different type of candidate. The GP focus is very important because of the Fermanagh situation and that in Armagh and Tyrone. We see this as a very good idea, and the west and the south will have considerable need of it in the future. It is a good news story, and it looks like it will be a success.

Mr Durkan: That is my interview sorted, anyway. [Laughter.]

Dr Stout: On your first point, Mark, and in terms of the review, its implementation and questions and queries on it, I would be shocked if there were not questions and queries. Of course there will be questions and queries from politicians, the public, doctors and so on. The key for any of us as medical leaders, and you as political leaders and so on, is to have the confidence, courage and commitment to say, "This is the right thing to do". What is the alternative? It is what we said at the very beginning. Do we go from a budget allocation of 49% to 55% or 60%? I would guess that the people who will query little elements of any report will be the same people who will complain about increased public spending, the need for increased taxes, increased revenue or taking revenue from elsewhere. There has to be that leadership, courage and commitment to say, "We are doing the right thing".

Mr Durkan: Is it into the comply or die stage?

Dr Stout: Well, the reality is there. Where do we go?

Mr Durkan: I do not dispute that. We hear it loud and clear every week in evidence sessions here and every day on the air waves. We had a wee bit of a chat about the cost: if we were to do the same as Scotland, it might be £200 million. Where might that money come from? I have no doubt that the savings are there and will be made through the transformation of the care system. In my opinion, TYC came off the rails because the transition was not really funded. It was said that savings would follow changes, but the investment was not put in to make the savings in the first place, and that is where it all went wrong. I know that we cannot pre-empt exactly what is in the report or the Minister's recommendations, but I would certainly hope that there is a substantial transition package this time round.

Dr Stout: Yes, there would have to be. It is an invest-to-save scenario. You do not necessarily need to talk big numbers to begin with, but there needs to be a commitment to investing in new models because you cannot change everything overnight. It will need that time and that transitional period.

The Chairperson (Ms P Bradley): OK, members. Everybody has had a turn. Is there anything else that you would like to add before we wrap up? Do you feel that you have covered everything?

Dr Black: Thank you very much, Chair, and thank you to all the members for their contributions. I have appeared before the Health Committee many times — I am not just saying this — but there is definitely a feeling in the profession that your side of the house is focused on the problem and is willing to work and implement. So that is the medical profession and the politicians sorted; we just need to sort out everybody else now. [Laughter.]

Mr Durkan: The best Chair, you see.

The Chairperson (Ms P Bradley): We will certainly hand that over to you, Tom, if you think that you can sort that out as well. Let me say thank you. I think that this has been very timely today, because it will lead us on to next week, with the publication of the report and the Minister in attendance at the Committee.

As someone who has worked in the service and been a part of politics for the past number of years, I think that this very much needs to be led from within. On a lot of the issues, if staff, from whatever disciplines, the unions and everyone else, can buy into a plan of action, that gives the public the comfort of knowing that this is the best thing to do. You are absolutely right: we hang on to so many buildings rather than giving the best service for people. I look forward to the next few years, and I think that we as a Committee have made a commitment to strive to make a better health service for everyone, whatever it may look like. No doubt, you will be inputting with us in the future. We are certainly very glad to hear the stark truth, because that is what we need to hear in order to get that change made as soon as we can. Thank you so much.

Dr Black: Thank you, Chair.

Mr Durkan: Sorry, Chair. I have one final item. What will it take for you to put the resignation letters into the shredder?

Dr Black: We need to save general practice. I have lost one county; I say "I" because I take it personally. I am starting to lose another county. We need a commitment to a multidisciplinary team. I need my health visitors and district nurses back, a multidisciplinary team and more GPs being trained, otherwise, we cannot stop members leaving, and, if members leave, there is no service, anyway. So, yes, we will watch.

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