Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): I welcome Dr Ursula Mason, the chairperson of the Royal College of General Practitioners (RCGP); Dr John Goodrich, deputy chairperson; Dr Frances O'Hagan, the chairperson of the British Medical Association NI (BMA NI) general practitioners committee (GPC); and Dr Ciaran Mullan, deputy chairperson of the GPC. Thank you for your time. We appreciate your being here. We have about an hour for the evidence session. I ask you to make your opening remarks, after which we will open up the session to questions.

Dr Frances O'Hagan (British Medical Association NI): Good afternoon, Committee. Thank you for the kind invitation to attend today. As the Chair said, I am the chair of the general practitioners committee. I am a practising GP and a senior partner in the Friary surgery in Armagh. With me is my deputy. I will let Ciaran introduce himself.

Dr Ciaran Mullan (British Medical Association NI): I am a GP in Strabane and have been a GP partner there for 23-odd years. Thanks for the opportunity to speak to the Committee.

Dr O'Hagan: You have received a briefing paper from us. I will outline our committee's position, prior to taking some questions.

The BMA NI GPC is distinct from the Royal College of General Practitioners, which is represented here today by our colleagues. We consider and act on all contractual matters, which are what Ciaran and I will specifically address. We were most recently before the Committee in the summer. Then, we said that general practice was in crisis. Unfortunately, the situation remains unchanged. It was untenable then, and, without any urgent action being taken on the issues that I will identify today, it will get worse. There is no question about that.

I will speak first about indemnity, because it is a hot topic. It is an issue that has been of interest to the Committee. We remain the only health service GPs in the UK who are responsible for their own high-cost indemnity. Resolving that issue is key for all our members. The Minister has taken our concerns about indemnity seriously and has committed to the Department's finding a solution. He is on record as saying that he would bring forward a proposal by the end of December 2024. We received a paper on 10 January, which our committee is considering in detail. At this stage, however, we have some problems with the proposal. We do not believe that the proposed funding is enough. We do not know what methodology the Department used to work out the figure, and only one proposal has been presented to us. We have been told that other proposals have been ruled out by the Department, but the detail has not been shared with us to enable us to respond appropriately. Although we appreciate that there are commercial sensitivities involved, having the overarching detail would have helped us come to a proper conclusion.

A second problem is that we believe that funding should be given out based on the number of GPs, because it is the GPs' own indemnity. The Department proposes to give it out per practice numbers. We will continue to discuss that concern with it. We are glad that an uplift mechanism has been built into the offer, but we are not sure that the mechanism that the Department is proposing to use — the Review Body on Doctors' and Dentists' Remuneration (DDRB) — is necessarily the right one, in that we feel that there needs to be some link to the future real-time costs that we envisage. Another concern is that locum and sessional GPs are not included in the offer.

Our next area of concern is the increase in employers' National Insurance contributions, which, I am sure, will come as no surprise to you. That is of immense concern to GPs. Every practice employs a large number of staff: admin staff, nurses, salaried doctors, cleaning staff and so on. That is a significant cost, and we simply cannot afford it. Our ideal solution would be for the Treasury to ensure that general practice is exempt. Failing that, we would call on the Department to provide additional funding for reimbursement on a recurrent basis that matches actual costs. That is not our preferred way, because we do want that to be seen as a possible increase in funding when it would not be, because it would be going straight back out the other way.

April is fast approaching, and we need an urgent solution. If nothing is forthcoming, one obvious solution is to look at staffing, and if people are to be made redundant or staffing is to be reduced, we need to give our staff enough notice. We therefore need to have word of what is going to happen. Without a solution, there is no doubt that we will see a reduction in services. There is just no other way in which we can do this. We have no other method of charging patients. In fact, we are specifically not allowed to charge our own patients.

Our other risk is that some practices will be so badly affected that we will see closures. In some practices that are run by community interest companies (CICs), all medical staff are employed in a salaried role, and they are at huge risk. Of course, if staffing is reduced, that will have a negative impact on access.

The BMA's position on funding is that an absolute minimum of 10% of the health budget — that is a minimum — should be spent on general practice. Members will be aware that the Northern Ireland Audit Office (NIAO) stated, two years ago, that it stood at 5·4%. We suspect that that percentage has dropped in relative terms. It is the lowest investment in general practice of any of the nations in percentage terms. Scotland made an announcement about additional funding on Monday, and Wales is to make an announcement this afternoon. We know for sure that Scotland said that it wants to move more into the community and support GPs — we absolutely believe that — and we believe that Wales will say the same.

General practice has always been best placed to be the first point of contact for people. As I said, we wholeheartedly agree with the Minister's desire to shift left, but we simply cannot do that unless resources are invested in general practice for us to do the additional work. We asked the Department last year for the resources, and we continue to have the same ask. We know that if we were to get 10% in one go, we would not be able to manage that, but we are looking for a 1% increase year-on-year to get us to that point.

Access to general practice is continuously in focus, and you hear about that issue all the time. The problem is, however, that there has been no commensurate upturn in funding to enable us to meet the current demand, let alone any increased demand. Despite that, and contrary to popular belief, we have significantly increased the number of patient consultations. In 2022, when we emerged from COVID, practices had 9·7 million patient consultations. Last year, that figure rose to10·1 million consultations, which represents a 5% increase. Last year as well, 57% of consultations were back being face to face, which was an increase on the previous year's 43%. Each week, general practice in Northern Ireland delivers 200,000 consultations. I want you to think about that: that is 10% of the population every week. That is powerful.

There is still much to do, however. Investment is key. The best way in which to improve access would be for the Department to focus on increasing investment in core general practice, as well as through the roll-out of multidisciplinary teams (MDTs). Moreover, introducing e-prescribing is a big ask from us. That would free up a lot of time and allow us to have more access.

We welcome the Minister's announcement before Christmas about restarting the roll-out of multidisciplinary teams following the bid for transformational funds. The importance of MDTs in providing stability for practices and equality across practices to meet our population needs cannot be overstated. Remember, however, that if there are no GPs, there is nobody to have oversight of the skilled professionals whom we want to come and work with us. The action needs to be prioritised, and funding for the roll-out must be recurrent. As far as we are aware, it is being bid for through transformational funding, which is not recurrent.

Before I finish and hand over to Ursula, I reiterate that MDT expansion and the general medical services (GMS) contract for 2025-26 must include solutions for indemnity and employers' National Insurance. As important as all that is an increase in core funding so that we can be enabled to do more. Anything else, I am sorry to say, will result in further practice closures.

Thank you very much.

The Chairperson (Ms Kimmins): Thank you, Frances.

Dr Ursula Mason (Royal College of General Practitioners NI): Thank you, members, for the opportunity to give evidence today. I am the chair of the Northern Ireland Council (NIC) of the Royal College of General Practitioners. I will let my colleague John introduce himself.

Dr John Goodrich (Royal College of General Practitioners NI): I am a GP partner in Ahoghill since 2010 and vice chair of the college.

Dr Mason: You will not be surprised that Frances and I will sing largely from the same hymn sheet. She mentioned much of what I will talk about, but I will try to give our view from a college perspective and perhaps a bit of a different slant.

Nine months ago, when we came here, we outlined the crisis in general practice and spoke about the underfunding, the lack of a workforce plan, the lack of access for patients, the burnout and the moral injury that GPs and their teams were suffering daily. I spoke about the stark health inequalities across our population and the resulting poor health outcomes associated with deprivation. I outlined what "good" looks like for a well-resourced general practice that delivers timely, effective care built on relationships with patients and continuity of care. If that were a drug, it would be licensed to treat absolutely everybody, given the health benefits for patients of having that kind of good general practice.

The workforce challenges remain as stark as ever. We have fewer whole time-equivalent GPs than we did a decade ago, and those GPs work at a greater intensity and see more complexity and more morbidity than ever before. Workload has already shifted left and is creeping away over that time, but it is underfunded and under-resourced, and it remains so. GP recruitment numbers remain stalled, despite evidence to the contrary of needing an incremental increase. Getting from the current 121 to beyond 161 over the next few years would still return us only to the whole time-equivalent numbers that we had in 2014, yet there is no plan to move in that direction. Early-career GPs are still voting with their feet and leaving to work where terms and conditions are better and where they can reliably do more for their patients than they can here. Mid-career GPs are burning out and leaving early, while late-career GPs are still making the decision to go.

Nine months ago, we were on the cusp of releasing our retention strategy, with short- to medium-term solutions aimed at keeping hard-working GPs in our workforce and making staying in Northern Ireland an attractive option for GPs from elsewhere and, importantly, our GPs of the future. Our retention strategy came with a health warning: it would not be worth the paper that it was written on without significant additional investment in general practice and without a workforce plan that was fully resourced and enacted. To my knowledge, such a plan or, indeed, an overarching strategy for general practice is yet to be initiated. In fact, although our system appears to be awash with strategies, there remains an absence of one relating to general practice, which is the very place where most of patients' health needs are met during their lifetime.

Of our 17 recommendations, the vast majority have not been implemented. As Frances mentioned, we are yet to secure a region-wide indemnity solution. GPs and other clinicians here have no access to a dedicated practitioner health programme when their health is failing. We await further announcements about MDTs, and our waiting lists remain such a huge burden when it comes to our day-to-day work. Digital progression across other parts of the system has been prioritised over that in general practice, and, in 2025, we are still printing paper prescriptions that are collected by patients and pharmacies travelling back and forth in vehicles. Apart from the safety implications for prescribing, the irony is that those thousands of green bits of paper issued every day are anything but green.

There have been some positives. We have seen a modest increase in fellowship scheme numbers, and, in the realms of primary and secondary care interface work, we have seen engagement and a commitment to work to improve it. When it comes to funding, however, the evidence is clear. The well-rehearsed benefits of a resourced general practice that is beyond our current 5·4% of the health budget are clear. The current health budget is simply not sufficient to keep the doors open and the lights on, as Frances said, let alone to give us the ability to increase capacity, concentrate on continuity and deal with complexity.

In his report to NHS England last year, Lord Darzi noted:

Despite that, as Frances said, practices increasingly find themselves unable to meet the rising costs of basic service delivery through core GMS funding. For some practices, the current funding makes the prospect of recruiting staff — GPs, nursing staff and admin staff — simply unaffordable. That will be more difficult come April, when the increase in employers' National Insurance contributions will come to bear. As Frances said, to move incrementally to beyond 10% will require the shift left to happen effectively for us to realise the potential of general practice. We can provide robust primary care to improve long-term outcomes, if we are adequately resourced, and an incremental 1% increase would create enough stability over the next couple of years for us to start to turn the corner. This cannot wait for a multi-year budget. It needs to be acted on now.

Nine months on from when we were last here, are we in a better place? If you were to ask your constituents up and down the country, I am afraid that they would agree with me when I say, "I don't think so". We all know that "access" is the number-one word in our communities when it comes to general practice, but that can mean different things to different people. Does access mean just getting through on the phone? Does it mean being signposted to self-help, self-care or self-referral? Does it mean securing a GP appointment?

Frances mentioned the 200,000 patients who are seen each week. That is almost half our population getting some type of appointment every month. We have greater access and capacity than we did pre-pandemic, but the real challenge is that the demand has risen and is outstripping our capacity. The 8.30 am scramble on the phone that our patients endure every morning is our equivalent of the overcrowded emergency department (ED). The countless people sitting at home who are unable to get through on the phone or get through only to be told, "Sorry, there are no more appointments today: emergencies only. Please phone back tomorrow" are our equivalent of ambulances stacking up outside EDs. The difficulty is that we cannot even reliably count the demand, let alone film it and put it out in the media. It is there, however, and some of you will have witnessed it recently when you visited a local practice with us. Our problem is not flow but capacity. That relates directly to the number of GPs and the size of our wider practice team. It does not matter how many phone lines I have if I do not have a call navigator to answer them or a GP at the end to see patients when they need to be seen.

GPs regularly work beyond safe limits. Sustaining the service compounds our burnout and is not good for patient care in the long term. We are worried about what we might be missing, what additional red flags are out there and what ill health we are contributing to by not being able to meet the need, yet the march of the mismatch between demand and capacity goes on. Our ageing population needs more and more healthcare, but we do not have the capacity to deal appropriately with that need. We cannot focus on routine. We cannot focus on long-term conditions. We are unable to take steps on preventative care that could make a huge difference, improve our patients' lives and lessen our workload. There is no denying that endless capacity is not the answer, but it is clear from what we see every day and from what you hear about every day that we need to move the dial to increase capacity somewhat and that we need to increase the workforce. To do that, however, more investment is needed.

Finally, I will highlight some red flags. It is important that they be recognised. Contract hand-backs are a red flag to the system. With 29 hand-backs in the past few years, the signals are clear: underfunding is a major factor in destabilisation, while recruitment is a major challenge. Until recently, unlike England, Scotland and Wales, we were operating across the region only with independent contractors. Bearing in mind what Lord Darzi said, those growing contract hand-backs have resulted in a growing mixed model for GP care delivery in the form of trust-run and CIC practices. I do not have access to the data on running a trust-run practice, but I know that the cost of running a salaried service is at least 30% more than that of an independent contractor model. That comes from evidence from Wales, and early data from the CIC practices backs that up. Can we really afford to do that? Do we want to prioritise that model ahead of an effective independent contractor model?

Another red flag is the increasing evidence of a two-tier system of care. Patients are paying for consultant-led care as a result of waiting lists, even when they can ill afford to do so. They are, however, now increasingly paying for private general practice care, because our NHS capacity does not meet the need.

Those patients are making up that funding gap out of their own pocket. What about those in your constituencies who cannot afford to do that? The gap in health inequalities is widening.

If the goal is to strengthen and support primary care, as set out in the three-year plan, the action that must be taken is to ensure that general practice is fit for purpose and adequately resourced to meet population needs, with equity and with a focus on proportionate universalism. There is no doubt that competing demands exist. That having been said, the system needs not only to recognise the value of robust general practice but to pivot resource and focus on investing in preventative care to save more in the long term.

Last October, Professor Bengoa highlighted the fact that difficult decisions needed to be made, not least on prioritising community investment. We can no longer ask the question of how long general practice can wait. The red flags are signalling the need for action now. We cannot ignore evidence that investment in general practice is a key driver for creating a healthier population, and, importantly, others across these islands, as Frances mentioned, are already taking steps to address historical underfunding, with plans to shift resource to community-based care that is digitally enabled, with a focus on prevention. We cannot be left behind.

GPs want what patients want and deserve, which is good access to a free-at-the-point-of-need general practice, not having us firefighting urgent demand with limited capacity and with constraints on our ability to do what we do best. Thank you

The Chairperson (Ms Kimmins): Thank you, Ursula and Frances, for those introductions. They were helpful, but it is sad to think that we were talking about a lot of the same issues the previous time that you were here, although they have probably worsened since then. The employers' National Insurance contribution issue has now been thrown into the mix as well, and that definitely makes things even more challenging. The Executive have strongly highlighted that fact to the British Government. We have had nothing back from them at this stage to see what, if any, solutions are coming forward. We are certainly hearing at all levels what you have told us. Some of us met representatives from Community Pharmacy this week, and they also highlighted their concerns and their impact. It goes back to the piece about how crucial primary care is. The primary care sector has obviously been the worst hit.

My first point is about funding. Ursula, I have visited GP practices and met staff there. To be perfectly honest, it has been a real eye-opener. I always thought that I knew what GP practices did, but, let me tell you, my visits gave me real insight into the huge amount of work that goes on, which includes not only the number of consultations but the admin role of a GP, the job of managing, as an employer, a practice's staffing and everything else in between. In many cases, those jobs are left to a small number of people or, in some cases, only one person. It was definitely a real eye-opener for me, not just as an elected rep or as the Health Committee Chair but as an ordinary citizen.

I understand why we see recruitment and retention issues: the job is a thankless one in many ways. People do not see the huge volume of work involved. If people get through to their practice and get an appointment, they see your GP for eight minutes, and GPs are trying to do as much as they can in that time and write up their notes. People go out and get their prescription or whatever way it ends up, but there is a hell of a lot more going on behind the scenes. You mentioned in your opening remarks that inability to do blood tests and other routine things that should be done regularly to manage long-term chronic illnesses because of capacity. It is very much like firefighting.

There is also an inequity. There may be a practice with more GPs who have a bit more capacity, and people get a different experience there compared with the experience of those at practices that are really struggling, with perhaps one or two GPs running a practice for thousands and thousands of patients. It is just constant crisis management. I want that message to come out of today's session clearly, because I know how challenging the situation is. I understand the public's frustrations, but we have heard in previous sessions about moral injury and how GPs can feel so demoralised by some of the commentary. Something that really struck me — I am probably digressing a wee bit — is that one of the GPs whom I spoke to told me that she does not like to tell anybody that she is a GP any more. It is because of the constant negativity. GPs are told, "Sure, you don't see anyone", "You don't answer the phone" and, "We can't get through". That must be difficult for you when you are doing your best. The workload does not end at 3.00 pm or 4.00 pm that day, nor, for many, does it end when they go home. It is important to acknowledge that from the outset.

Funding is the issue. Ursula, when you launched the strategy report 'A Workforce Fit for the Future' last year, we were all very optimistic, because we saw what was needed. The solutions were in there, but we are still no further on. What has engagement with the Department been like? Your proposed 1% year-on-year increase is a reasonable ask, Frances. What feedback have you been getting on that? Is it something that the Department is considering, or are there any positive soundings being made on the potential for there to be increased funding?

Dr Mason: I will start, and then Frances can talk about the contractual side of things.

We all recognise that this is a challenging financial environment. When we talk about increasing funding, we often get the response, "There is no money". We know that there is no money. I suppose that the question is this: is there money that can be shifted from elsewhere? In a constrained financial environment, either the decision is made to keep to the status quo and keep the funding envelopes in the separate places in which they currently reside or there is an appetite to say, "We need to shift our focus into the community". We cannot wait for extra money, so we have to use what we have now in a different way.

The challenge when we are having conversations is that that has not necessarily been on the cards. The response is, "Perhaps if we get a bit more money, we will be able to focus a bit more on community care and general practice", or whatever else. My concern is that we do not have the time to wait for that. In a constrained financial situation, there has to be a decision made about where that money can be best spent. The difficulty is that if it is spent in one place, it cannot be spent in another. I know that you probably hear lots of different people in these chairs make their case for additional funding. The difficult decisions are made by those who have to apportion that funding.

The argument that we are trying to make is that, by investing in general practice, money will potentially be saved in the future. I will give you an example. Would you rather, in 15 years, be taken with chest pains quickly in an ambulance to a hospital, be told that you have had a heart attack, have state-of-the-art angiography and a stent, be put on five medications and think, "What a wonderful health service I have. It is hugely responsive. It did what I needed at the time and it gave me the treatment that I needed" or would you rather get to 15 years from now and not have had a heart attack in the first place and have every other part of your community have lower levels of heart attacks or whatever other disease? Where prevention makes a difference is that it stops people needing the shiny hospital and the responsive ambulance. If we can prevent more people having, say, heart attacks, we will need less money for the shiny hospital and the ambulance.

The difficulty is that, within current, constrained budgets, people are having heart attacks at the moment who need help, and we need to make sure that we can prioritise effectively. I am not saying that we do not treat people in the hospital; I am saying that perhaps we need to think about how we can shift a little bit of that money into prevention. How can we shift a little of the available resource into the community to get upstream and save money in the future? That is a huge challenge, and it is the challenge in the conversations that we try to have all the time. Frances will probably talk about the contract from a funding perspective.

Dr O'Hagan: We are in active negotiations with the Department, so we are not at liberty to divulge details. We can talk about the principles, however.

You know what we are looking for, which is a 1% increase within the total budget. We are not asking for the budget to increase. Rather, we are asking that our percentage of it increase. That goes along with what Ursula has said. A colleague of mine frequently says that the cars are parked in the wrong direction in the hospital car park: they should be pointing towards the community. There is therefore an element involved of moving stuff out to the community, and that encompasses things such as acute care at home and more services being delivered closer to home, as well as the MDTs. The thing to remember is that we still have to bolster core GP services.

If we are going to deal with more people in the community, including elderly people and people with more comorbidities, we need more GPs as well as MDTs. Ciaran has an MDT service, so I will defer to him to tell you what is needed to get an MDT up and running.

Dr Mullan: Fortunately, I was in one of the parts of Northern Ireland that got an early, fully functional MDT. It is up and running, it gives us extra capacity, and it works well. It is not without its challenges. As Frances said, you need the core GP numbers to provide the clinical leadership and the practices in which you are setting up your MDT members, but it works. The problem is that the service has not been rolled out across Northern Ireland as quickly as we need it to be. We need to develop it further. I am sitting here with Frances and Ursula, who do not have an MDT, so light is frequently shone on that inequity. Ultimately, where we see that something is working and effective, we will highlight that too.

You asked how we attract and retain staff. If you have a practice with a well-established MDT, a core number of GPs who are working together and all the other staff that you need in a practice, and that is working well, how do you look after the practices that are starting to struggle and are getting into a bit of difficulty? It comes down to not only the MDT roll-out being faster and more widespread but the core funding, which needs to happen so that you have the core number of GPs working well in each surgery.

Dr O'Hagan: To answer your question on the 1% increase in resources, whilst that has been a very public ask of ours since last year, the Department has not yet brought it into negotiations.

Dr Mason: John will probably talk a bit about MDTs and what it is like to not have one. Ciaran mentioned the impact on recruitment and retention, but John will talk about access in the day job.

Dr Goodrich: Yes. As you are aware, there are 17 federation areas in Northern Ireland. Just one has a full MDT, six have had a partial roll-out and 10 have none. My practice is just outside Ballymena. We are in an area with no MDT.

The three main areas that MDTs are anticipated to cover are physiotherapy, to deal with the very common musculoskeletal stuff that appears in every list that you do; mental health services; and social work services. The number of contacts for the latter two services is not large, but they are very time-consuming. A couple of mental health contacts in a day can throw your list off quite badly. It is difficult and, at times, emotionally draining work. We do not have an MDT, so the GPs in my practice have to absorb that work and deal with it. It would be so helpful to be able to pass a proportion of that work to an appropriate practitioner in the same building. We have expanded in readiness for that: we are MDT-ready in Ahoghill. That would free our time to deal with other things.

As Frances shared and the Chair mentioned, a lot of our work does not involve the patient-facing consulting role. So much of it is about practice management and dealing with reports, results and referrals. At the moment, that work is done in the margins of the day. You come in early, work through lunch and take some work home. With remote access, you can do it on a Saturday morning from your study, but that is not sustainable. An inequity is developing across Northern Ireland whereby some practices have an MDT and some do not. For young GPs, locums and those who aspire to partnership, there is a pull towards the MDT areas, where they will have a better standard of working life and a better balance in their working life.

The Chairperson (Ms Kimmins): Thank you for that, John. I have met with the Southern GP Federation Support Unit, and I have spoken to GPs in different practices and compared the difference. You mentioned mental health practitioners, which is a valid point. Having someone who specialises in dealing with mental health issues is so important and can make a huge difference not just to capacity but to the patients, because they are able to get access there and then.

Likewise, we, as a Committee, recently met with Versus Arthritis and talked about musculoskeletal conditions. How do you view the progress of the physio role being rolled out? What is the comparison between a surgery that does not have an MDT with a physio, or one that has a partial MDT with a physio, and others? What about the impact on stabilising practices? A lot of people go to GP surgeries with chronic musculoskeletal issues, so I assume that having a physio on-site makes a huge difference.

Dr Mason: Some evidence has been gathered on consultation and referral rates, particularly around physiotherapy because it is see, support and go. Mental health is a little bit different, as is social work, but the evidence that is emerging around physiotherapy is that it reduces the number of appointments that patients need to deal with their musculoskeletal condition, and reduces the prescription of analgesics. It is important to hold on to that when we are thinking about how we make it better for patients. John talked about the impact on GPs, and Ciaran talked about the impact of the supervisory aspect and having the core general practice, but, ultimately, it is better for patients: they get better care in a more timely fashion. Across Northern Ireland, there is a huge inequity in people's ability to access MDT services. Patients in my practice cannot get any access to those services. We will probably be the last federation area to get an MDT. My practice is in Carryduff. The practice five miles down the road in Saintfield has a full MDT. One of my patients could live on the same road as, or even be a neighbour to, someone who is registered in a different practice because our areas cross over. If they both get back pain, one of them will get a completely different service to the other. We cannot afford to continue with that postcode lottery.

Dr O'Hagan: As well as that, it is about the patient journey. If you have a mental health problem and get an early intervention, it is much more likely that your long-term outcome will be much better, and it is less likely that your condition will become chronic. It is the same for patients who require physio, but the mental health example is stark. Getting early intervention for a mental health problem, rather than going on a waiting list to see a counsellor or whatever, can very much turn the journey around, in conjunction, obviously, with the GP if you need medication. It is about where that patient ends up and their outcome. Although the current outcome for some conditions is medication and a place on the waiting list for physiotherapy, it is about the patient's productivity and their being able to get back into work and be a person who gives back to society, as opposed to being somebody who is off and whose condition is deteriorating while they wait on the services of somebody who could be in my surgery. I do not have an MDT either.

The Chairperson (Ms Kimmins): It goes to the bigger point about investing in primary care and investing to save. If people who needed to see a physio, a mental health practitioner or a social worker were able to do so at an early stage, instead of being seen by their GP, who would not be the appropriate person to deal with their condition, that would be investing to save. However, if someone is on a waiting list to see a physio, during that period they will be in a lot of pain and will be going back to their GP to seek appointments and prescriptions. Ursula, you made the analogy of avoiding a heart attack or heart issue 15 years down the line. If we continue as we are, all of the money will end up having to be directed to acute services because everybody will be in crisis. Those are really important points.

I have other questions, but we have covered a lot, so I will move to other members. Thank you all for that.

Miss McAllister: Thank you very much for your presentation and for coming to the Committee again. I know that we have had opportunities to engage over the past few months too.

I will focus on indemnity in the first instance. I fully appreciate that there are ongoing negotiations. I will propose to the Chair that we, as a Committee, write to the Health Minister to ask whether he can give us more information. There is one option. Was there any back-and-forth discussion about why none of the other options would work?

Dr O'Hagan: No, we were presented with one option, which was a figure. There was information about how it would be given out and how it would be uplifted in the future, but we were not given information on how we got to that figure or why other options were discounted.

Miss McAllister: In your feedback to the Department, did you say what you would like to see?

Dr O'Hagan: Yes.

Miss McAllister: Did you receive any comments back on any of that?

Dr O'Hagan: The last meeting of our team with the Department was just a few days after we got the letter of offer. Since then, we have taken it away, discussed it with the GPC and come back with these concerns. Our next meeting is due in about two weeks and we intend to take the concerns to that. There has been some informal contact back, but we need to take it formally into the negotiations to see if we can get more information and a better offer.

Miss McAllister: It does not really scream "co-design" or "negotiation" — however that word is defined — if it is just a one-way system. That is really disappointing but not at all surprising. Hopefully, we, too, can get more information.

Dr O'Hagan: I have to say that after nearly 10 years, I am delighted to have something to start with. I really am.

Miss McAllister: That is good.

Dr Mullan: We accept that there are other models of indemnity in the other UK nations, so we have an opportunity to pull from their experience and from those other models. We recognise that a certain amount of work went into the offer, but we need to develop it, and that is what we are driving at.

Miss McAllister: We, of course, also appreciate the funding issues but, like you say, it is about shifting the funding as well. Unfortunately, the Department seems to be very afraid of doing anything different, which is disappointing. If the current offer is accepted, how much of a disparity will there be among GPs, locums and anyone who is not covered? I understand that locums are not included. Is that correct?

Dr O'Hagan: At this moment in time, locums are not included in the offer, and we represent all GPs.

Miss McAllister: Do you think that that was done purposely by the Department to entice more doctors into taking up permanent places as opposed to locum work?

Dr O'Hagan: Yes, that is exactly what they tell us.

Miss McAllister: What could work to entice more locum GPs into permanent positions?

Dr O'Hagan: I am going to harp back to this the whole way through the session: increase our core funding. Yes, of course, increase the funding for the community work as well but do not forget the core funding. Unless we have better terms and conditions and more money to employ more doctors and give them independent contractor status, we are never going to get to where we need to be. We will not even keep pace with our current demand let alone be able to do the other things that people want to move out to us. We believe that those things are done better in the community — there is no question about it, and MDTs are a good example — but we still need the core reinforced so that we have the doctors there to be the overarching people. That will also mean that we can get more doctors in so that we can do what everybody wants us to do, which is to provide more access.

We mentioned access, and you mentioned the other issues. I extend an invitation to any member of the Committee to see what my practice is like. In our briefing papers, we included a diagram of an iceberg, which clearly demonstrates the amount of work that is involved in lifting the phone and getting an answer and/or getting an appointment versus all the other work that goes on, and that other work is access. If I am looking at your blood results, commenting on them and giving you a treatment plan, that is access. My looking at your hospital letters, acting on them and calling you in for something else is access. My bringing you in to our nurse and getting your diabetes bloods and annual check done is access. All of the things in that iceberg diagram are access. The way in which "access" is batted back to us is couched in phrases like, "Answer the phone and get an appointment". Access involves so much more, and that diagram is good at demonstrating what we want to say.

Miss McAllister: I can attest to that. I visited practices in north Belfast on a particularly busy day, and one thing that I noticed, which should be highlighted, was that GPs have to prioritise the very sick patients who call in and, often, the frail and elderly who may not be as able as others to contact them. I saw that on the ground, and it was great work. It is worth exploring whether there is any capacity to campaign on a wider issue.

Dr O'Hagan: That is why triage works. It is not fastest finger first. Just because you are first on the list does not mean that you will be phoned back first. You will be phoned back depending on what you tell the receptionist about your condition that day. It is not that receptionists are being nosey. If you go to A&E, you tell the receptionist what is wrong with you. If you want a dental appointment, you tell the dentist's receptionist what is wrong with you. You need to tell us the truth. You do not have to give a huge amount of detail, but we need to know some information so that we can prioritise when we are skimming up and down the list. For example, if we see "chest pain" or "very short of breath", that will be a priority. If we see, "I want to talk about my report last week from a consultant", that will wait a wee while. If we see, "I want to talk about my cholesterol result", we will get there, but we need to get those other people in first.

Dr Mason: We appreciate that each individual's health is private. When you are in a big faceless hospital, talking to someone who you will probably never see again, it is so much easier to impart that information. We are very much at the heart of the communities that we serve. The reception team, the nursing team and even the GPs live and work in those communities, so it becomes a much more personal thing. We need to get the message across to the public that the system is there to get them better care in a more timely fashion. Our care navigators and reception teams are highly trained and the information they receive is regarded as being completely confidential. That is something that people forget. They think that, because they meet someone in the schoolyard or know their granny, that person will impart their medical information to others. That is not the case. We all work under very strict confidentiality codes. That is something that we need to get out to the public: giving that information so that we can enact a degree of clinical triage or a telephone consultation allows us to be more flexible and to see more patients. I probably see at least 30% more patients every session than I did 10 years ago because the information that I get helps me to prioritise. We are getting more from the system by doing that, but it feels like it is a retrograde step for our society. Unfortunately, in our capacity-constrained system, it is the only way that we can operate and see as many patients as we can with the people that we have. To do more, we need more.

Miss McAllister: Thank you. That is key, going back to the contract negotiations and the core funding issue. I suspect that the situation is similar to that with the indemnity negotiations. There needs to be a step change in how we negotiate, to be honest. We understand, as do both sides, that not everyone will get everything that they have asked for, but there needs to be a bit of a change because the public are very much watching.

Dr O'Hagan: We cannot be left behind. We are watching very carefully to see what Wales announces today. We are led to believe that it may well be significant. Scotland has put additionality in, and England is looking at doing so. We cannot be the only one left behind with no additionality in our core funding because we are already the worst funded among our counterparts.

Miss McAllister: I have a final question. I do not expect you to answer it today; perhaps, we can have further engagement on it. It is about the change in how we spend the overall Health budget and how decisions are taken. It would be interesting to hear from experts and people who carry out the work of the health service on what they think could and should be done to ensure that the shift left is into the community. I do not expect you to answer that in a public session of the Committee, but it will be worth liaising with you on that in the future.

The Chairperson (Ms Kimmins): Yes. As we are talking about budgets and things like that, I want to very quickly raise something that was brought to my attention in the last couple of weeks. It was from a nurse in a treatment room, and it blew my mind. She said that because the consumables budget is £516, they are in a position where they cannot afford to buy butterfly needles. I am not a nurse, a phlebotomist or anything like that, but the impact of that is huge. I contacted the Department about that and the response was that the practice is over budget and there is nothing that it can do.

Dr O'Hagan: People do not understand. This is not about GP pay; it is about the budget that goes to a practice. People do not understand that, out of that budget, we have to pay for our heating, lighting and staff costs, including, where appropriate, any increase in the number of staff. Then you have the cost of paper, cleaning the building, the stock in the nurses' treatment room and everything else. All of that has to be bought. If I want to do minor surgery, I have to buy the pack and the instruments to do it. If I want to fit a coil or a Nexplanon for a lady, I have to buy the necessary pack to do so. The issue is the budget that comes to us that enables us to do our work. Salaried GPs know what they are getting at the end of every month, but the GPs who are independent contractors, including the four of us, have no clue. We get what is left.

Dr Mullan: You made the point earlier about health provision and budgets. As an independent contractor, you cannot go into deficit. If you spend all your money, you just do not provide the service. It is as simple as that. Therefore, you get what you pay for. That is basically how it works. As Ursula said, you are getting 30% efficiency with the independent contractor model, but the reality of that model is that if you do not have the money, you cannot provide the service, get the equipment or employ the staff. It is as stark as that.

The Chairperson (Ms Kimmins): Then there is an impact on the patients.

Dr Mason: That is one of the reasons why a lot of the contracts are going back: it is financially unviable. From talking to a lot of colleagues, we know that GP partners are often taking home less money at the end of the month than their salaried employees. If their bottom lines drop, the GP partners still have to buy the butterfly needles, because you cannot take blood from a child without one, and if a child needs their blood taken, you ought to take it

There are so many aspects to this. The funding is being supported by the GP partners through the time and effort that is going into running the business. A lot of GP partners are voting with their feet and saying, "I cannot do this anymore. I cannot prop this up or take that financial risk any more". We hold clinical risk, but we also hold a huge financial risk that other parts of the system do not. The big issue is that it would not take a huge amount of additional funding, in the grand scheme of things, to create that degree of stability. One percent is about £80 million, and 0·5% is £40 million. The Health budget goes beyond £7 billion, so it is not a huge amount of money, but that is what we need to find, this year and next, to create some degree of stability in the system.

We are all jobbing GPs. I really like my job. I would like to be able to do it a wee bit better and to give a wee bit more, but until we get some degree of stability, all we are going to find is people thinking, "I don't know if I can do this any more". We have a very small window of opportunity to keep things on track, and we need to be very careful about making the best use of that time so that we can move forward and know that we are on the right track and that GPs will stay the course.

The Chairperson (Ms Kimmins): Absolutely.

Mr Donnelly: Thank you so much for your presentations. Sadly, it was all very familiar. We heard this from you when you first came to us, and we have heard it in subsequent meetings. I am sorry that things have not improved, and that we sit in the same situation, or probably, given the impact of the UK Budget, a worse one. It has been raised time and again in the Assembly. We have had debates on various aspects of the health service and it has been mentioned that general practice is not funded enough. The 5·4% has been raised time and again. We tend to get "irony klaxons", which is a term used by the Minister about his financial pressures, and I absolutely understand that.

In the community, access is the main issue that is raised with us. Everybody talks about access, so it is encouraging to read in the report about the increase in consultations. Certainly, that is something that I will take away. Having visited the GPs in my local area, I know how hard they work and that they do more consultations than they should. The report says that 200,000 consultations take place a week in Northern Ireland, which, as you outlined, is 10% of the population. It is phenomenal that each week that number of people are being seen and are getting a consultation. It also suggests that 85% of GPs are working beyond their contracted hours. That is also phenomenal and screams to me that the funding is too low. There is an alleged 30% extra cost to the salaried service. If a trust is running a GP service, its costs may well be running at 30% more than those of a normal GP service. Again, that screams that the funding is too low.

Even the shocking number of contracts that have been handed back — 29 — screams that the funding is too low. I have two quick questions. What can be done within the current political and financial context to improve working conditions for GPs? You mentioned a health service for GPs, as you did at a previous meeting. Has that been progressed?

Dr Mason: To my knowledge, it has not been progressed. It is a practitioner health programme, and we are the only area of the entire British Isles that does not have access to a practitioner health programme. We know that burnout and ill health among doctors and other allied health professionals is a significant issue. It is often very difficult for a doctor to approach another doctor, particularly in a small place like Northern Ireland and even more so if it is about issues related to mental health or addiction, which have become increasingly common among clinicians. A dedicated programme that supports doctors and gets them back on their feet and into work has been shown to be hugely effective, and it will prevent catastrophes like suicide.

We know that suicide rates among doctors are much higher than those in the general population. By enabling our clinicians to access such support, we will be going some way to support their staying in the working environment and to prevent it happening in the first place. It would be hugely beneficial if we could get that over the line here. There is a lot of work going on behind the scenes by a group of GPs, dentists, hospital clinicians and pharmacists, which is spearheading the campaign. It would be a very welcome step if that programme was afforded the small amount of funding that it would take to get it off the ground. There are models across England, Scotland, Wales and the Republic of Ireland, which all offer services for doctors and clinicians who are in difficulty. We remain behind that curve.

Dr Mullan: The primary care infrastructure — the buildings that GPs work out of — is quite important. While there is a development programme, year-on-year, to try enhance that, the finances need to be bolstered more quickly. Some new builds have happened in primary care, and more are planned. In essence, it does not only come down to attracting staff into the functional teams: if the buildings are not fit for purpose and do not have the proper facilities, there will be an impact on recruitment. Therefore, the primary care infrastructure in Northern Ireland is another live issue for us.

Mr Donnelly: Going back to the practitioner health programme, is funding the main barrier to it progressing or are there other barriers?

Dr Mason: Funding is the main barrier. There is a draft business case, although I do not know whether it has gone as far up the chain as it needs to to enact a decision. It is my understanding that securing funding is the most significant barrier.

Mr Donnelly: It is clearly important, given the long-running and intense pressures that GPs have been working under. We should look at how the practitioner health programme can be progressed. Certainly, that is something that we should raise with the Minister.

How do we encourage trainee GPs to come to Northern Ireland? What are the main barriers to attracting GPs? Except for everything you have mentioned.

Dr Mason: There is a lot of information in our retention strategy on what our trainees have said. Even though we are nine months since that was published, it still holds fairly true. A significant amount of work needs to be done to attract people to Northern Ireland to work, be they GP trainees or established GPs who are coming home or coming here because they feel that it is a good place to live and work. We have different terms and conditions; it is not as attractive a place to work. Across the UK, we have seen an increase in the number of international medical graduates coming to join all the training programmes, and GP training is no different.

We need to make Northern Ireland a welcoming place to train, live and work, and also a place where, if you have come here from elsewhere, you feel that you can stay and that it is a good place to stay.

All our trainees, particularly international medical graduates, are much more mobile. Their certificate of completion of training (CCT) is a ticket to travel. If terms and conditions are better elsewhere, be that across the UK and Ireland or beyond — Australia, New Zealand, Canada or wherever — the certificate is essentially a ticket to a better life and a better work-life balance. Those people will move. We need to make here a much more attractive place. While we can potentially attract more people in to train, the bigger job is to retain them. That involves things like workforce and workload. If your workload is inordinately much more difficult and will cause you to burn out within five years here, why on earth would you not go to Australia? That is where you will have a better work-life balance, actually feel as though you are really doing something with your qualifications and career, and fulfil that need to be able to effect change and help people.

We have a huge amount of work to do, but we are battling against really difficult headwinds. As Frances said, if funding and investment go into general practice elsewhere across the UK — we know what is happening in the Republic of Ireland, where terms and conditions are much better — we need to ensure that we can actually compete with the rest. I am not even suggesting that we compete with the best; we just need to compete with the rest locally so that we can keep the doctors that we bring here in the first place. Again, it is about ensuring that the environment within which we work is an effective one and one that is not making us sicker and making our patients sicker.

Dr O'Hagan: I will just highlight that, in retention, we have been successful at recruiting into trainees one particular group of people. Ciaran and I feel it because we are in the south and the west. Anybody who comes up from the Republic of Ireland is also classed as an international medical graduate. In my practice alone, this year, I have two trainees. One is from Laytown and one is from Bettystown. Both of them are living there and travelling to me. Will they stay once they are trained? Not a chance. They are two very good GPs. Last year, I had a girl from Dublin. The year before that, I had a guy who was originally from Pakistan but had come up through Limerick. The only one of them who might stay is the guy who came up through Limerick. He brought his wife and children with him, and his children are now in school. I believe that he will stay. We have that challenge that they do not have in other parts of the UK because of our land border and our ability. I do not blame those trainees, if they have been unable to get a training place in the Republic of Ireland, for coming up here to get a training place with every intention of going straight back again because the terms and conditions are better down there. That is something that we need to keep in mind, as well as the general retention.

Mr Donnelly: OK. No problem. Thank you very much for everything that you are doing. Thanks for that presentation.

Ms Flynn: Thanks very much. Sorry: I came in slightly late and missed some of your remarks at the beginning of the meeting, Frances.

First of all, I will ask a question about the GP elective care service. I saw in the briefing paper some detail explaining that the capacity and scalability would be there if additional funding became available. The example was used of the success of the transfer of vasectomy from secondary care to primary care. The buzzwords there are "cost-effective" and "gold standard". Given the financial burden and pressures that we are under, all the conversations that we are having with the Department, trusts and everyone who is involved in the healthcare system at present are about how we can make things more cost-effective, become more efficient and take more pressure off emergency departments and hospital waiting lists. This seems like a perfect example of how something like that can be done. Are you having any conversations, and at what level are they, with the Department and senior managers of the trusts to see whether it is possible that any additional surgeries could be transferred to GP practices? There is definitely something there.

Dr Mason: Part of the answer to your question is, yes, there are conversations. Going back to what GP elective care was, it was initially started to try to level the playing field for patients in general practice and provide access to services that some but not all GPs could provide, because every practice's skill mix is different. A small GP practice maybe did not have the ability to manage women's health or do minor surgery. It is about being able to say that, locally, we can get that done in a hub that is close to home. The upside to that is that not only does that create additional capacity in general practice for things that can be done in general practice but it takes pressure off the hospital system because, before the GP elective service, the practice will have referred the patient into hospital for that service. Those conditions were born out of —. Initially, we looked at the biggest referral rates into certain specialties such as gynaecology, dermatology, musculoskeletal and orthopaedics. Those were the low-hanging fruit. They were the things that GPs could do, and the service was born out of that.

Vasectomy was a bit different because it was a new service and it was developed. The gold standard was that it was done the way that it was done and that GPs across the rest of the UK were doing it, so we sent some GPs over to train and do it and set the service up. What was provided was a more level playing field so that, if you are a patient in Cullybackey, you get the same service as in Castlewellan or Cookstown. We created an environment, and what we have been able to show with elective care is that not only is it transforming care for patients and bringing it closer to home and all of those buzzwords that we all talk about, but it is reducing health inequalities. Referral rates into GP elective care in the likes of north Belfast, where there are higher levels of deprivation, are much higher, but their needs are being met. They are being seen in their local communities closer to home.

The difficulty is that the funding was cut, so the capacity that was there pre COVID is not there now, with the exception of vasectomy. The decision that the then Health Minister, Robin Swann, made to move money from secondary care to primary is, to my mind, the first and only time that I have known it to happen that funding that has been in secondary care has been moved to primary care. One of the core reasons behind that was that it was more cost-effective. First, the gold standard procedure that was being done in primary care was not being met in hospitals, and, secondly, a vasectomy in hospital was costing about £1,200. It costs about £400 in primary care. It is a no-brainer, and we have been having conversations with individuals in the Department about the fact that, where there is something that is being done in a hospital setting that could be done in a community setting, those hubs are now in place right across Northern Ireland. They are in every federation area, and, if we can deliver services in those hubs safely and effectively and more cost-effectively, which is really important, we will of course have those conversations and try to facilitate that. If that means that that is a GP with a special interest or an enhanced skill, we will work towards that. If that means bringing other expertise from a wider multidisciplinary team into a community hub, absolutely let us look that, because that infrastructure is there. Notwithstanding Ciaran's discussion around the wider infrastructure piece, those hubs are there. That good governance and accountability is there, and that cost-effectiveness has the potential to be harnessed even more.

Ms Flynn: That is exactly the type of stuff we need to be moving towards in terms of, as you said, cost-effectiveness. You were using language around the hubs, models and infrastructure that is already in place, including the work that is being undertaken for a women's health action plan. You mentioned gynaecology; we know that we have the worst waiting lists across all of these islands, and not just for gynaecology. I am using that as an example in terms of women's health. If the Minister and the Department are going to be launching a women's action plan, hopefully, soon, following consultation, where does general practice fit into that? Is there scope to tie in some of the waiting lists from gynaecology?

Dr Mason: , particularly when it comes to common gynaecological conditions. Our women's health hubs were basically for long-acting contraception, menopause and hormone replacement therapy (HRT) care and urogynaecology. They were the main things. Ironically, when the hubs were set up and we were delivering the service, some of the colleagues from hubs had a conversation with folk from NHS England about how we were delivering women's health hubs. They have taken that model and run with it. They are providing it in greater and greater quantities, and we are taking steps backwards. It is so disheartening to think about something that was designed, delivered and initiated here and which is such a good idea but has almost been stagnated in its ability to continue to deliver. One aspect of the elective care hubs was to not only deliver services for people but train GPs, so that, if you did not have a skill in dermatology, you could come to a hub to train up and then deliver it in your own practice, almost putting yourself out of business. The funding for the demand management side of things and the training was cut alongside the service delivery funding. If we could get the go-ahead to move that forward, there would be the option to not only deliver for patients but increase the skills mix in general practice and create more capacity in it.

Dr O'Hagan: There is a word of warning in there, because you will say to me, "On one hand, you are telling me that you do not have enough GPs, yet you are going to do that other work". We need to be cognisant of the fact that, yes, we can and should do that work, but we need —

Ms Flynn: Core funding.

Dr O'Hagan: — the core funding so that we can produce GPs. Many GPs now have what they call a "portfolio role", where they want to do life in general practice and life doing other things so that they bring that skill back. Bringing money into the cohort is not just about money. An example is minor surgery. When I go to do a knee injection for somebody, by the time that I have paid for the nurse who comes with me and the pack to do it, I get around £49 for that. It is nearly ten times that to get it in the hospital. The elective hubs are very efficient, absolutely, but we are damn efficient as well. We are really efficient. If you put in money to allow GPs to grow, we will be able to provide more things at practice and hub level. If we are to staff the hubs, we need more GPs back here to train in order to allow them to take time out to go and do that other work.

Ms Flynn: Of course. Thanks very much for that. It was really interesting feedback on those hubs and that model. Ursula, there was an event — I think it was the launch of the women's health action plan survey — where we had a presentation on the NHS England model. Everyone was blown away by it, and there was a discussion in the room about how we should be working towards a model like that and learning from the NHS model, and we are hearing today that —

Dr O'Hagan: It was developed here.

Ms Flynn: — the model originated here. It is about recognising and celebrating that and using it as your argument, because, as Frances said, if you can stabilise the core funding, you can hopefully start to build and work towards those other really important projects.

Dr O'Hagan: There are other things. We are focused at the minute on providing procedures and stuff. There are other things that would neatly fit into and could be housed in general practice, such as, for example, diabetes services. You could bring your dietician and your diabetic expert nurse in under the community services, so that they are properly facing primary care. At the minute, if somebody needs podiatry or something like that, their cars are parked at the hospital. They are not parked in the community. We have a huge problem with diabetes. It is one of the fastest-growing diseases that we have, which is going eat up a huge percentage of the budget. We should be looking at shifting that.

We have a respiratory hub that, I think, Liz saw at Moy Health Centre. We are trying to get people diagnosed who are difficult clients where we are not sure whether they have COPD or asthma, because that all overlaps, or whether they have pulmonary fibrosis. We are trying to bring that service into the GP surgeries and get those patients diagnosed earlier and only send the cases to hospital that are complicated and need hospital care, rather than having people sitting on hospital waiting lists to get a diagnosis in the first place. An awful lot more than just procedures could come into primary care, but — you will be sick of hearing me saying this — we need the funding to do that.

Ms Flynn: Core funding, yes. You all have mentioned different issues about health inequalities that underpin everything that you are talking about around the preventative work that you could be doing to address them. That is clear to see. Again, I make the point that addressing health inequalities was one of the Health Minister's priorities that he set out from day one. It is about how we use that as part of the argument to support the calls from GPs to lift the core funding up. If doing that ticks the boxes for the Minister's targets on reducing health inequalities, it would be a sensible thing to do, were money to become available or were you able to move around money that you currently have, as Ursula said. I am not saying that that is an easy thing to do, but it is important to make the case about health inequalities. It is a priority for the Health Minister, and you are clearly able to help support him in his endeavours to deal with it.

Finally, Frances, you mentioned in your opening remarks —. It says in the briefing paper that over half — 51% — of GPs indicated that they:

That is huge. What also stood out is the fact that 45% — nearly half — of GPs get so stressed at least once or twice a week that they feel that they cannot cope. That is shocking. If that data were to be fed back to the public for any other profession, it would not be seen as acceptable. Do you know what I mean? If GPs crumble, the overall system will crumble. The impact is on the GP, of course, but also on the patient. You spoke about, should things not change and core funding increase, a reduction in services, additional closures and, essentially, a reduction in people accessing general practice care. Will you give me a sense of what those statements mean and what you foresee that looking like? Would it be a case of practices starting to close on certain days, opening for only a half day or reducing some of the services that they currently deliver? What do you think that means as we face into the rabbit hole of a reduction to services and additional closures? What does that look like?

Dr O'Hagan: I will take you back to the first point that you made about the figures. That was not our survey; it was a survey that was conducted by the Department of Health. The Department conducted a survey that was open to all GPs on the performers register. It got close to 600 responses, which is well over half of the profession. That is really good for any survey. I agree that the statistics that came out of it were frightening, and it was not the older GPs who were thinking about leaving; it was a lot of the younger ones. I am an old fogey now and am at the stage where I could retire, but I do not want to, because I still love my job — I am one of those ones. Our job is a huge privilege. We get to walk with patients from the cradle to the grave. They let us into their innermost troubles and secrets, and they celebrate with us at joyous times. It is the best job in the world, but we have to allow it to flourish by having enough of us to do the job in the way that we want to do it. It was nowhere near as pressurised when I started out as it is now. I have been in general practice for nearly 30 years. I am a grandmother now, so I can see my grandchild coming through, as well as my children.

That is our aspiration. That is what we want to do. If we do not get funding, however, we will, unfortunately, do exactly the opposite. If I am looking at a bill and I have a bill for staffing —. We looked at the bill for our practice, and we are not too bad compared with some. Some are way up at over £50,000. We are at a magnitude of £10,000. What is that, in reality? Is it a receptionist? Is it part of a doctor? Part of a nurse? What is it? Those are the only costs that we can cut. We cannot cut the cost of heating the building or the fact that we need paper and all the rest of it, so that is our only magnitude of cuts. Do we cut GPs? At the end of the day, GPs are the most expensive part of the workforce, so do we cut them? A cut to GPs is a cut in access. If we were to cut the number of girls on the desk, that would cut the number of people who could answer the phone. That is absolutely not what we want to do; it is the polar opposite of what we want to do. That is why we are here today. We are here to try to explain how important it is that we do not do that. It is counter-intuitive and counterproductive. I strongly suspect that it is not what the public wants and am sure that it is not what you want for your families.

Mrs Dodds: First of all, I offer my apologies for missing most of the presentation. I did, however, have a good conversation with Ursula a few weeks ago. Around the Committee, there is huge support for the work that GPs do. There is general agreement that we are better to have services delivered closer to people, closer to communities and so on. It is about trying to make the brave decisions that make that happen. Nuala mentioned that. If you are looking at a 1% increase in the overall amount that goes to GPs, in the overall context of the budget — this year, if I have read my papers correctly, over £8 billion is allocated to health — is not a huge amount of money.

Dr O'Hagan: A pittance.

Mrs Dodds: I do not know why that transfer cannot take place. As Nuala said, it will take braver decisions to make that happen. That is my statement of intent. It is important to say that, and I do not think that there is anybody here who is not with you on that. That is important.

I want to ask about a couple of things that have been on my mind, having talked to some GPs. One is about what patients perceive as the service that they get from GPs. I think that it was you, Frances, who mentioned it. In a constituency office, one of the most common complaints that I will get is, "They never answer the phone", "I cannot get an appointment with my GP", etc. I am not saying that you are not all working very hard, but that is one element. I spent a morning with the GP surgery in Banbridge. I spent a whole afternoon — hours — with the southern federation. I talk to GPs: this week, it was GPs without electricity who could not connect with patients. I talk to GPs quite a lot, because I see their importance in people's lives and in the lives of our community. It is important that we try to change that perception.

The other element of that is that what I see across my constituency is almost an inequitable service from GPs. We have GPs who are now administered through the federation or through the trust, where it is basically a phone-answering emergency service. I was at the GP surgery in Banbridge at 8.30 am, and it was a hive of activity. People were coming and going, talking to GPs, talking to receptionists, listening to the phones going and so on. It is important for people like me to do that. There is that perception, and, in some people's reality of that, there is unequal access to services. That is a problem. I would really like to have a further conversation about how we tackle that. That is important.

Waiting lists: in Northern Ireland, we have the largest waiting lists. Sorry, I am just going to throw it all at you. I am sure that you will be able to deal with it. In Northern Ireland, our waiting lists are the largest ever. Sometimes, when I talk to GPs, I get an impression of people who struggle almost with moral harm, because they know that their patient needs an investigation, but the waiting list for neurologists, or whatever the condition is, is very long. I would like you to comment on that. How can we try to improve that in a practical sense? I understand that some kind of forum or service to GPs themselves is quite important, but I also think that something needs to be done between the trust and GPs. I hear from GPs that they spend hours trying to chase results and all sorts of things, so why is that so inefficient?

Dr O'Hagan: I will start.

Mrs Dodds: Sorry, that is a lot of stuff to unpack.

Dr O'Hagan: There is a lot in there. I am glad that you went to the GP surgery, and I encourage as many Committee members as possible to come along. I will have any of you any day, especially on a Monday morning. You are more than welcome. 'Good Morning Ulster' came out to my surgery last year and interviewed people before we all got up and going and as the girls were coming in.

An interview with Mary, one of my receptionists, really struck me. It was just before the 8.30 am rat race started. Mary was honest, and I was a bit taken aback. The interviewer asked her, "What are your feelings, now that it is 8.25?", and Mary said, "My heart is in my mouth, and I get anxiety because I worry so much that I will not find the patients who need us, we will not get to them or the appointments will be gone before we do". That was telling. Our staff are as anxious about that as we are. Ursula regularly refers to the people who do not get through as our equivalent of the ambulances waiting outside hospital. The people who are scrambling are in the equivalent of the ED waiting room.

I frequently hear patients say, "There are not too many in your waiting room today". I say, "Hold on a second, we have four doctors on. How many people did you see out there? You saw four. In the treatment room, we have two treatment room nurses, so you saw two people who were there for them. We have two nurses on, so you saw another two people". Those people will all be taken in and treated and will come back out, and, when they come back out, another eight people will be in the waiting room. Multiply that every 10 minutes. If we kept everybody in our waiting room, all day, for eight hours, you would not get in the front door. They are not all there at the same time, so people think, "There are not very many here", but that is because we are making appointments, and, by and large, taking people at the appointed time. If we know that someone is coming with a mental health problem or something that will take longer, we afford ourselves more time so that we do not keep people waiting in the waiting room. I totally agree with you that there is a perception that we are doing nothing and that we are not answering the phone.

Mrs Dodds: I do not think that anybody thinks that you are doing nothing, Frances. That is not the case. None of us on the Committee thinks that.

Dr O'Hagan: It is about the public perception, as you said.

Mrs Dodds: We need to help you to change public perceptions.

Dr O'Hagan: Absolutely.

Mrs Dodds: I am just being honest about what I hear.

Dr O'Hagan: We accept that.

Dr Mason: Alterations are definitely being made. John's practice will manage access differently from my practice, which will be different from Frances's practice. That is often in order to meet the needs of the population, but it also depends on the staffing level. If you run a practice that has been finding it really difficult to recruit, being two doctors down and with somebody off sick, you will change access arrangements to meet the needs of the population in the best way that you can.

There is inequity. We know that the number of GPs per head of population in areas of high deprivation is lower than it is in areas with less deprivation. It is harder to recruit in such areas. Ironically, it is the patients in those areas who need more access and service, but we do not have the ability to give that, or the funding model does not fit that purpose or allow it to happen.

The other aspect of access is that, often, as Frances said, it is about trying to meet needs where they are in the best way that we can, but, again, it is about what our public want and need from us. We do not have the capacity for that, so, unfortunately, people get turned away. We would love everybody to be able to be seen when they need to be, all the time, but the simple fact is that we cannot do that, so each practice does the best that it can. Sometimes, a practice has capacity because it has IT infrastructure or a telephony system that another practice does not have or because the practice manager or the team knows how to work and navigate the system in a better way.

I talked about counting people. On an average Monday morning in our practice, about 900 phone calls come in. There is absolutely no way that we would have enough reception staff to deal with 900 phone calls. Some of the people who call will not be seen; that is our dropped demand. Some people will get through on the phone and get an appointment, and others will get through and be told, "I am sorry. We do not have any more routine capacity". That is, perhaps, different from what happens in other practices. To some extent, it is about being able to afford everyone a baseline expectation for their experience of general practice, but, ultimately, access will depend on the number of bodies on the ground, whether they are GPs or MDT members, and on how teams are structured. There cannot be a one-size-fits-all approach.

There is an argument that the way in which GP practices are funded, which is dictated by the Carr-Hill formula, is, at the moment, inherently not fit for purpose. We need to look at how better to fund the services that need to go into general practice. For example, for every four patients whom we register in our practice, we get paid for three of them because we are not in an area of high deprivation. In Ciaran's practice, however, for every six patients he probably gets paid for eight because he works in an area of high deprivation.

Dr Mullan: That is right.

Dr Mason: We need to make that funding model more fit for purpose so that we are meeting the deprivation and the inequality where they need to be met. Lots of things need to change, but it is important to say that every GP practice across the country is doing the best that it can with the resources that it currently has, and each will do it ever so slightly differently.

Dr O'Hagan: You mentioned about the electricity being off for some GPs. I want to thank publicly many of the people around this table who helped us this week to try to get the electricity supply back on. Practices ran right through this week with no electricity, and even if they did get electricity, they had no internet, which meant that they had no phones or computers. Speaking for the southern area, we have had practices house people. A treatment room of a local practice up the road was housing the doctor, and, in Portadown, a practice was housing the receptionist. I want to say publicly how grateful we are, how hard everybody worked and how doctors came together. I also thank anybody around this table who helped us. I ask that we look to the future and learn how, in such a situation, we can prioritise a GP practice to get it back up and running again and get us up the priority list with Northern Ireland Electricity and Openreach. However, that is something for the future.

Mrs Dodds: That is a huge piece of learning. I had people say to me, "I really need to contact my GP but I can't", and it was not their fault. They just had no way of doing it.

Dr Mullan: You mentioned waiting lists, and it is well versed how patients are having to wait longer. They are then getting into difficulty, and will come through our door, so that has an impact on access, full stop. I may sit across from a patient, and decide, "You are going to need hospital intervention of some kind", whether that is routine or urgent. When they have something as simple as an arthritic hip, and I say, "You need a new hip. How long you are going to have to wait for it is a different matter". That impacts on your working day. You know that those patients have a need, and it is not likely to be met any time soon.

Another thing has crept in that was never the case. When you have been looking after somebody and they are becoming more acutely unwell, and you decide that they need hospital treatment now — as in urgent or emergency care — we will get the reply, "You're not sending me to the hospital, are you?". That is the case with all our colleagues in secondary care who are doing their absolute best under pressure, and with our Northern Ireland Ambulance Service (NIAS) colleagues as well. However, for a patient who is getting more acutely unwell to say, "You're not sending me to the hospital, are you?", that is the reality of some of the acute access difficulties that we are now facing, where somebody is frightened to go to the hospital.

Mrs Dodds: What about ambulance access? Is that a huge issue?

Dr Mullan: Terrible.

Dr O'Hagan: The only patients we would recommend that to might be from nursing homes or those who have a possible fracture. I live in Armagh, and the closest hospitals are Craigavon or Daisy Hill. If they are elderly and have chest problems, we are saying to people, "Bundle them into the car. You will get there quicker." The perception used to be that if you got an ambulance, you would be prioritised. That is not the case now. You will spend your time outside in the ambulance. That is through no fault of the ambulance or ED staff; they are working really hard, but if you want to get your person seen quicker, it is better to get them, however you can, to the hospital under your own steam.

Dr Goodrich: There was an email recently about a 24-hour wait for an urgent ambulance.

Mrs Dodds: In the Northern Trust?

Dr O'Hagan: No. It was across the whole of Northern Ireland.

Dr Mullan: Everybody got that email.

Dr Goodrich: Just yesterday morning, I was in clinic, and I had a woman in her early 40s come in with bad chest pains. She was quite distressed by it, so I put her on the couch, did an ECG and a few other things, and there was clearly a problem. I said, "We're going to have to send you to A&E". She said, "Yes, I woke at 3.00 am with this. I phoned an ambulance. I have been waiting for six hours." She came to me when our doors opened at 9.00 am. I said, "I can phone an ambulance, too, but it will probably be six hours for me as well. Have you anyone who could take you up?" She had nobody. She was over from England and was isolated. We decided that the least worst situation was that I would write her a letter and put it in an envelope with her ECG and she would drive herself up to Antrim Hospital. I phoned the hospital later just to check that she had made it. That is not in any way a good situation to be in. That is just one example. We frequently have that difficult conversation with patients who do not even want to go. Those who can get there know that they will face hours of waiting on a plastic chair.

Dr O'Hagan: The email also said that, for somebody in a healthcare setting, it could take over 30 hours. Does that mean that I am meant to sit on a Friday afternoon with the patient in my surgery until Sunday morning?

Dr Goodrich: You would be better putting them in your own car and driving them up.

Dr Mason: I think that many of us have done that.

Dr Goodrich: It also pushes the GP into taking more risks, handling stuff in the community that we would not have done 10 years ago, simply because the patient does not want to go, or will not go, and we are doing our very best to facilitate that. Sometimes, we act outside of protocol to do that. It is difficult and stressful.

Mrs Dodds: Thank you for being so open with us. We, as a Committee, are seeing in this most recent exchange the real pressures that GPs are under and the toll that it takes on you, as a person who is providing care in almost impossible circumstances.

Dr Mason: Sometimes we are not even providing care. It is really important to hear your thanks. We are really grateful for it. I think that any GP who is watching this, either live or in the future, will be really grateful for that as well.

You talked about moral injury. That is what we see every day, right up and down the country. I think that we have all had conversations with colleagues about being in situations that we have found very difficult. The ambulance is one thing, but when you are trying to make a red-flag referral for a patient whom you know has cancer, you know that they are not going to be seen any time soon because red-flag waits are beyond six weeks, eight weeks and 10 weeks. That is before they see someone; before they get the investigation. As part and parcel of what we do, we see lots of patients who are not that sick but are sick enough to see us, and, sometimes, we see people whom we know are really sick. When you know that you are making a red-flag referral, and you know that that patient has cancer, and that their outcome will be much worse because of the waiting list and the delay, that really takes its toll.

Sometimes, I am fortunate enough, because of where I practice, to be able to say to the patient, "Can you go private?", or they will say to me, "I'll go private". However, if you are working in a community in which that is just not an option, those patients get a non-service; they get a service that makes them sicker. If you are doing that day in and day out in your practice, and that is all that you see, it is no wonder that people are saying —

Mrs Dodds: I talked to GPs who told me that they have almost "re-red flagged" red-flag referrals, if that makes any sense to you.

Dr Mason: Yes. You say to patients, "If you haven't heard, let me know". Invariably, they let you know, and you then get back on the phone or try to put another letter in, but that often gets bounced back because the patient is already in the system. It could be really urgent. A red flag creates that degree of difficulty for us, but think about those patients, sitting at home, knowing that I have referred them with a red flag. They think, "OK, the doctor thinks I've got cancer or needs to rule out cancer". That is what a red flag means. If a patient has been told that they have been referred with a red flag, they have to just go home and wait for weeks and weeks. It is bad for us, but think about the patients. My goodness.

Dr O'Hagan: It is terrible. As well as that, a red flag is one thing, but they are more routine. I am now saying to patients in my surgery, "OK, you're now 70. I think you need a knee replacement." The patient could say, "Well, how long, doctor, will it be before I see the doctor?". I will say, "Well, to actually see the doctor, it'll be between three and four years", after which they will be put on the surgery waiting list. If the patient then asks, "And how long could it be, then?", I have to tell them that it could be another six or seven years. They would then be 80; are they ever going to get it?

Patients say to me, "Is there anything that I can do quicker?". I will say to them, "Well, you can go private". They might ask, "Do we have to do it all privately?", to which I might say, "Well, you can skip the first part of the waiting list by seeing the consultant privately, and then revert to NHS". Even patients whom I know cannot afford it are asking me to do that for them, especially for the specialities that have huge waiting lists.
We are now getting to the stage where patients ring up and make the appointments themselves and you do the letter. They come back to me and say, "It is three months even to be seen privately."

Mrs Dodds: OK. Thank you.

Mr Robinson: Thank you for your presentation. It is very powerful: probably one of the most powerful and convincing presentations that we have had at the Committee for a long time.

I see your frustration and members share it, I assure you. We see the ideas that you present and models of care, such as MDTs, which evidence has shown makes a change. We also see how the Department seems resistant to rolling out those MDTs, and it is a deep source of frustration for the Committee.

I want to ask about indemnity. We were very excited last time, to hear Robin Swann tell us that £5 million was going to be made available. It ended up being repurposed, repackaged money, within the existing envelope. One prominent member of the Committee called it "a sleight of hand". I do not use that term —

Mr McGrath: Go on, do it. [Laughter.]

That is exactly what it was.

Mr Robinson: I will not put the witnesses under that kind of pressure by asking them whether they believe that.

Dr O'Hagan: We have been promised this time that the offer will be additional, new and outside the current envelope. We want to ensure that the repurposed money from last year is all still there to start with. That is one thing, and we will seek reassurances on that. We have been told that the amount that we have been offered is new, and I hope it is.

Mr Robinson: Good. You answered the question before I even asked it, Frances. I was going to ask whether it will be new money.

Dr Mullan: It has been stated as new.

Dr O'Hagan: It has been stated that it is new money, yes.

Mr Robinson: That is good to hear. I ask this before we conclude. You do not work in mandates, but we do. In the worst-case scenario, where will general practice be? It is about those asks: National Insurance contributions, core funding and indemnity. If they are not delivered, where will general practice be? Tell the country today.

Dr O'Hagan: In one word, closed.

Dr Mullan: There will be closure. Parts of the population will not have access to GP services. That is the reality.

Dr O'Hagan: Think of our 200,000 consultations a week, which is 10% of the population, versus the 750,000 consultations in ED every year. ED will not be able to cope with 200,000 more a week. It just will not.

Mr Robinson: I hope that the Department is listening.

Mr McGrath: If the Department does not listen to you, there is no point our giving you false hope. There will be no major, massive improvements in the health service in the next 18 months to two years. If there were, the Committee would see the plans, hear about them and be consulted on them. It is an absolute flipping disgrace that you are back here again, after six months, telling us that things are just the same, or marginally worse, than they were six months ago and marginally worse than the time we met before that. Ursula, we have been talking for years about the health service with others as well. There is just no pathway that I can see to the situation getting better for primary care. It just is not. It is extra pressure, extra workload and less money. Something has to give.

There are just does not seem to be any response from the Minister. We hear about a "shift left". It seems to be that the work shifts left, but the money does not shift with it to help you do that work, and that is just not possible. I lay it down here: it is over to the Minister. Come back and tell us that things are going to be different for primary care. Tell us, because we will get warm words from the Minister. About two thirds of the words he gives us will be telling us the problem that we have already told him. We need to hear what the solutions are.

Dr O'Hagan: If you look back at the history, we were here last May, and that was when we were relatively optimistic, before we realised how this year's contract would pan out. I will not go into any more detail. We are in a more depressed situation now. In last June's monitoring round, £110 million was allocated to Health. I asked the Department why none of that had come to general practice. Why not? Because they did not bid for it.

Mr McGrath: You know where you are in the priority stakes. Let us put it publicly to the Department: it is over to it to come back and convince us that it will do things differently to help primary care, especially if it is looking for GPs to do more, considering your current workload. Take, for example, something like e-prescriptions. It might be a small thing, but it would probably take 1% or 2% of your time off the table, which would allow you to focus on everything else. It is a computer system. I remember asking the question and getting the ridiculous answer that it would take about 10 years to get the IT systems in place.

Dr O'Hagan: We were told 2032.

Mr McGrath: You were told 2032. If that is how long it takes our Government and Executive to help you to get a bit of paper from one building to another —

Dr O'Hagan: In a safer manner.

Mr McGrath: — we have to think about the way that we conduct business. Every bank and high-street organisation can do it. Schools can do it. I can send an email from here to my team members at my office. One is in an office in the Building, and one is in an office in Newcastle, and I can communicate with them. I am sure that it is not rocket science. We do not need people to come over from NASA to sort it out. I am sure that the system is already in place in other places. Again, it shows the value that the Department puts on you, if it will not even sort that out.

Dr O'Hagan: The lack of value.

Mr McGrath: I met GPs and visited GP practices last summer. I went into three meetings, and, on all three occasions, at least one of the doctors apologised and said, "Do you mind if I sign these while we are talking?". They were doing their prescriptions, because it was something that they could do at that stage. It is a disgrace that we cannot even get that sorted.

I want to ask another question. We have had this debate before. We have talked about wanting to retain the staff and GP and about pay and conditions. We are having conversations about a duty of candour. Is that being discussed by your members, and, in short, what is their view on it? We need to have the conversations and to find solutions for it, because it is needed. From what I hear anecdotally, people seem to be a bit frightened and scared of it. I do not think that it will help us any further to deposit another thing on you that makes people say, "Do you know what? I am out of here. You can get on with it".

Dr Mason: First, it is really important that we frame the conversations with the history of why we are having them and acknowledge that harms, some of them serious and significant, have been inflicted on people and that people have suffered. It is important also to point out that in moving towards creating a framework where a duty of candour can be a positive and important part of what we do, we must also recognise that there already is a professional duty of candour, which for clinicians is there every day that we practice as part of our duty and professionalism. That is an important frame within which to set any conversation around the duty of candour, as we are currently debating it in this country.

Our members are considering the current Being Open framework. We considered it as a college. Colleagues from the BMA and beyond are doing so as well. In itself, the framework sets out perhaps even more than a duty of candour, from an organisational perspective, which would, to some degree, sit side by side with our professional duty of candour. Organisationally, the Being Open framework sets out candour — openness — in routine day-to-day practice. It sets out how you can learn from mistakes and errors and what you do when something goes wrong, which is the duty of candour bit of it. In and of itself, the framework is a positive move and step.


It would bring us in line with other countries across the UK. England, Scotland and Wales all have a statutory duty of candour. To some degree, there are nuances in how that is applied in general practice. The current Being Open framework does not reference general practice in Northern Ireland, which seems a bit strange. It talks about the larger organisations, but, as a smaller organisation, we have challenges because of the size of general practice and how we interact with larger organisations. There needs to be some degree of nuance in how you would enact an organisational duty of candour in the realms of that document.

As a whole, however, a lot of really positive things can be taken from that, because we really want to encourage and enact a no-blame culture and the ability to learn from mistakes. If we could put that in place, it would go a long way towards reassuring the public about what the system does when something goes wrong. The big challenge is if you attach individual criminal sanctions to a duty of candour, what would that do? Our members and a large proportion of the medical body believe that it would actually do the exact opposite: it would create a culture of fear and blame and an inability to continue to be open and seek ways to make things better. From a general practice perspective, there are some very significant concerns about what would criminal sanctions do. John, perhaps, has some examples of what that might look like in our practice and what we do on a day-to-day basis.

Dr Goodrich: Yes. We are constantly trying to improve the service because excellence is not a destination but a journey. As part of that, you are doing quality improvement projects in your practice. You go in and look at your work, measure it against the standard and see whether it needs to change. Let us say that a practice is looking at the management of cholesterol issues in its patients. Cholesterol, as you will know, is one of the main risk factors for vascular disease in all its forms. You follow a data trail and find that there are lots of patients whose cholesterol is registered as high; they are on statins and well looked after, but a few are not. There are 10 patients, so you go into those notes — you are going to contract them and offer them a statin — but you find one who had a stroke a few months ago. You look at the notes and see that the high cholesterol was documented three years ago and they have had a stroke in the interim. You look a bit further and perhaps they have had a visit to the hospital with a diabetic issue or a vascular issue, where it was also noted but not acted on. Where is the duty of candour in that? Was the statin omission itself the chief reason when risks are often multifactorial? The fact is that I am only one of several clinicians who had a hand in this chart. How much time do I spend digging into that? Where do I find the time? Then, do I bring the patient in for a conversation? There are a lot of practical considerations here.

I am open to the duty of candour for continuous learning in an open environment, and we do that. Like Ursula, I am just not convinced that attaching criminal sanctions to that is the best way to achieve it. First, it would disincline a doctor to do a quality improvement search. Secondly, there are issues with interfaces, where we share care with a multidisciplinary team in our clinic or with colleagues in secondary care. If you find a deficiency in care and it is between the two of you, that does not foster good working relationships. Who reports and who carries the can? The criminal sanctions element needs to be very carefully thought through for unintended consequences.

Dr Mason: Those unintended consequences are obviously about workload, as John has discussed, and the interactions that we have with patients. Defensive medicine is probably one of the unintended consequences of attaching criminal sanctions to a duty of candour. We can ill afford defensive medicine in this country with regard to over-investigation, over-referral and those things. I think that, through a framework such as the Being Open framework, we can foster that openness, honesty and learning in a way that does not point blame and does not attach that degree of, "Well, if I do not speak up then I might get criminally investigated". There are lots of challenges here, and I appreciate that there is a real difficulty about why we are having this conversation and the things that have gone on before, but I think we need to be careful about those unintended consequences.

Colin, you asked specifically about the workforce. If we are trying to recruit, retain and attract people into a clinical workforce across the health service, and we have a situation where our framework differs from those in other regions because of this additionality around criminal sanctions, it becomes inordinately difficult to attract people into working in the health service at any level because of that.

I suppose that it would be hanging over you. As organisations, we need to foster a culture of openness without that. Is there a risk that we would see a decimation of our workforce? Absolutely. Is there a risk that people would retire early? Absolutely.

I know that that does not sound good or like reasons not to bring the duty in. Actually, we should think about the benefits that we can get from an organisational duty of candour and not necessarily about having a stick to beat people with. There is a real risk of those unintended workforce challenges compounding the difficulties that we already face when we know that those organisational duties of candour are in place across the rest of the UK and are being effected. If we could take that initial step and perhaps reassure some people that that framework is there and is working without initially attaching those criminal sanctions, that would be a very positive move.

Mr McGrath: Thank you. I know that the conversations on the matter will continue, and it is important to get them all out there. We will have more of them. We have to progress the measure, but it is about trying to find something that works for everybody. We do not want to frighten people off, but we need to address some other priorities and pressing things as well.

Dr O'Hagan: Can I quickly mention e-prescribing? It is ridiculous that e-prescribing is taking so long. The system is there in England, Scotland and Wales for it, but it is just a matter of bringing it over. They switched it on overnight in the Republic of Ireland when COVID came in — overnight.

The Chairperson (Ms Kimmins): I am conscious that we have another briefing, and we are probably nearly an hour over time, but this has been a very important and useful discussion, particularly for us. We have been very vocal about the duty of candour. We said in the debate that we want it to be properly co-designed to ensure that a lot of those fears are addressed. There is a lot of misinformation out there about what exactly we are trying to do. For me and, I think, the Committee, it is fair to say that it is about protecting not only patients but staff and ensuring that there is no cover-up, because that is what has led to the issues. Doing that would mean that people feel safe to be able to be open and honest.

Just last week, we had a briefing on the cervical smear review. If ever I saw a reason for a duty of candour, it was that. That involved 14 years of nobody speaking up about anything, and look where we are. We could rhyme off all the examples, but that is not to say that everyone is bad and everybody is telling lies. I worked in the health service. I can see it from both sides. That is why we have to find a position that everyone can be comfortable with, but it is about getting to the crux, because we are all dealing with families and individuals who have been impacted. That is where it is coming from. However, it is a broader discussion, and I hope that that will be opened up further in the time ahead.

Dr Mason: As clinicians, we would welcome the opportunity to have those conversations about what things might look like. You are absolutely right. Speaking up and talking about error and what needs to be done is where we need to get to. There are lots of really good lessons to be learned from elsewhere. The huge challenge for us is the attachment of the criminal sanctions. I do not think that anybody here is in any way against an organisational duty of candour, and that is hugely important, but it is about making sure that, in enacting it, we create the best opportunity to grow that culture of openness and of being able to do the right thing and to effect the change that is made as a result of learning. The worry is that criminal sanctions would do the exact opposite. However, I would really welcome the opportunity for clinicians to get involved in further conversations.

Dr O'Hagan: I will take everything back to basics. In any discussions that we have today or going forward, we have to remember that we are all patients — that means every one of us in this room — as are all our families. We just want the best for them.

The Chairperson (Ms Kimmins): Absolutely. That is clear from the discussion today. Thank you all for your time and for everything.