Official Report: Minutes of Evidence

The Chairperson (Mr McCrossan): I welcome to the meeting from the Patient and Client Council (PCC) Meadhbha Monaghan, chief executive officer; Peter Hutchinson, senior policy impact and influence manager; and Katherine McElroy, principal practitioner for advocacy. Dorinnia Carville, the Comptroller and Auditor General, is present, as is Stuart Stevenson, the Treasury Officer of Accounts. You are all very welcome to the Public Accounts Committee. We are deeply appreciative of your time. Thank you for agreeing to give evidence to us today on this very important issue. I kindly ask that you keep your answers brief and to the point so that we might make the best use of our time this afternoon. If, at any time, we interject, it is just to keep to time, not for any other reason. I invite you to lead the way. Thank you.

Ms Meadhbha Monaghan (Patient and Client Council): Thank you very much for the opportunity to meet the Committee today to discuss access to general practice. We have provided the Committee with a written submission on the topic, which we hope has been of assistance. To build on our submission, I will share with you a bit more information about the Patient and Client Council and our role, along with some reflections on our evidence in the context of current primary care provision in Health and Social Care (HSC) in general. The PCC is the second-smallest arm's-length body in the Department of Health in budgetary terms, but we have a significant mandate from the Northern Ireland Assembly through the Health and Social Care (Reform) Act (Northern Ireland) 2009 to represent the interests of the public in health and social care and to seek to influence the system from within. As such, we have a very wide brief but a budget of only £1·8 million to undertake that task, with 34 staff working regionally. Out of our budget, we seek to provide advocacy services for people who have health and social care issues right across the breadth of those services, as well as to engage the public and to seek to influence policy and systems change. Our budget equates to less than £1 per head of the population that we seek to serve. Annually, the PCC supports about 800 cases and about 4,000 calls from the public.

Under the 2009 Act, we have five statutory functions. We also play an important independent assurance role, which the Minister of Health has set out in the framework document. We are one of only two organisations that has that role, the other being the Regulation and Quality Improvement Authority (RQIA). Our independence is something that we take very seriously. We understand it in structural, financial and psychological terms. That independence is critical in order to support and encourage public trust and confidence in the health service. As is set out in the framework document, we are funded directly by the Department in order to maintain that independence from HSC service providers. Structurally, we are governed by the PCC council, which is unique in contrast to other HSC boards, in that its membership is prescribed, but our independence is most fundamentally supported by the psychological independence of our staff. We acknowledge the challenge in that regard. There is an explicit constructive tension in how the PCC is set up. On the one hand, it represents the interests of the public, while, on the other hand, it works within the system to influence change on behalf of the public.

As is stated in our written evidence, we understand our role in the system of governance and assurance as providing the wider public, HSC trusts, other service providers and the Department with information, insights and evidence gathered as part of discharging our statutory functions. That includes our role in providing advocacy support and advice on the best methods by which to engage the public, and that is primarily based on direct engagement with service users. It is within those parameters, and in that context, that we offer our evidence today.

In reflecting on access to general practice, the PCC acknowledges the wide-ranging, dedicated and compassionate care carried out every day by committed GPs, multidisciplinary teams (MDTs) and general practice staff right across Northern Ireland. We also acknowledge the significant pressure that GPs and the general practice system is under and that addressing access issues will take a significant medium- to long-term investment approach. Many of the factors that influence that are outwith the PCC's mandate to comment on, but we can reflect what we have heard from the public. Our aim in the written submission was to give the Committee a flavour of the experience that the public have shared with the PCC about GP and primary care services in Northern Ireland, including the issues and challenges that they have faced, the positive experiences that they have had and areas for improvement.

In contrast, the Northern Ireland Statistics and Research Agency (NISRA) data on GP complaints shows a downward trend. PCC cases and contacts about GPs annually have, however, remained relatively constant, showing an increase of 70% from 2022 to 2023. Issues of concern to the public have also remained relatively consistent. The PCC engaged directly with the Royal College of General Practitioners Northern Ireland (RCGP NI), the British Medical Association Northern Ireland (BMA NI) and representatives from the community and voluntary sector on those issues throughout 2022. We spoke about the issues at the all-party group (APG) on ageing and older people in 2024 and, most recently, sought to inform the departmental GP access working group. From the information in our written submission and from what the public have shared about their experience of accessing GP services, what emerges is a patchwork of experience: a lack of consistency in patient experience, a lack of consistency in what the public can expect and a lack of patient experience data with which to analyse what is working well and what could be improved.

We note and welcome recommendation 8 in the Northern Ireland Audit Office (NIAO) report 'Access to General Practice in Northern Ireland', which was published in March 2024. The recommendation encouraged the Department:

At the PCC, we believe that patient feedback and experience is a tool for intervention. In considering improvements in the short to medium term, the key questions are these: how do we know about patient experience of GPs and primary care, how do we collate that information across practices and regionally for intervention, and how do we encourage a more active partnership with the public to support dialogue about service experience and delivery? A number of systemic changes would help. They apply to the issue as much as they do to the broader health and social care system, and they would not only benefit the public's experience of and outcomes from the health and social care system but improve the system itself and the experience of those who work in it. Those improvements are, first, consistent and accessible mechanisms for gathering information on patient experience across GP and primary care services, along with the better use and triangulation of data and insights across Health and Social Care in order to learn early and drive improvement. The second is to promote open and honest dialogue with the public as partners in their care, including harnessing the potential of digital and the need to take a more strategic approach to public participation across the health and social care service, including having GP and primary care services as a critical partner. The final one is to develop a regionalised approach to advocacy services to ensure that people who need support in order to access health and social care or to resolve issues get the support that they need, because, fundamentally, advocacy support is particularly important to helping address health inequalities.

In closing, I acknowledge and thank members of the public who have shared their experience of GP services with us to enable us to give evidence today. We are happy to expand on how we think, practically and strategically, that those systemic changes might help and to take questions on our opening statement and written submission. Thank you.

The Chairperson (Mr McCrossan): Thank you very much for your presentation and for the honesty that came across on some of the issues that we, as public representatives, hear about daily. I also thank you and your colleagues for the work that you do in difficult circumstances. I should declare an interest as someone in public life who has referred a number of constituents in your direction for assistance. I thank you on behalf of my constituents for the work that you do and for the important role that you play.

I will start with a question, after which I will being in my Committee colleagues. How does the Patient and Client Council gather evidence on patient experience in general practice, and what are the main issues with general practice about which patients contact you?

Ms Monaghan: I will answer the first part of your question and then refer you to my colleague, who will answer the second part. People can contact the PCC in a range of ways. Ordinarily, that happens directly through our Freephone line, which operates from Monday to Friday. We deal with about 4,000 calls, and the data that reflects the number of calls that we have received about GP services is included in our paper. People can also walk into PCC offices, of which we have a number across the region. There is also access via social media and the contact forms on our website. Other people are referred to us directly via trusts. We also undertake a range of awareness-raising campaigns across the region. Would you like to speak about the main concerns, Peter?

Mr Peter Hutchinson (Patient and Client Council): Yes. The main evidence that we provided in our written submission comes from our case management system, which our practitioners use when they are supporting members of the public. We divide the system into two main elements. One is contacts, who are people to whom we have been able to provide advice and information in a straightforward way, while the other is cases, which we use when people need more support, including advocacy support. Some cases can go on for a number of months, or even for years.

The top area for cases on which members of the public have provided us with feedback is communication, which relates to the type of information that they have received. That information includes some issues with the callback system and the telephony system; changes to people's medication, or their feeling that they have not been given the right medication; treatment and care diagnosis; treatment and care quality; and staff attitude. As you will understand, we have slightly less information about contacts, but, having done a scoping exercise, we know that the top three key issues are access to appointments, advice and information relating to complaints, and issues relating to medication. You can see from the written evidence that a lot of the issues with access to appointments are to do with people calling numerous times, their having difficulty accessing or gaining an appointment and the difference in booking systems.

That is what people have told us, so it is not necessarily an objective assessment of the quality of care or service that has been provided. We also have a focus on early resolution of people's issues with general practice and other HSC organisations with which we work.

The Chairperson (Mr McCrossan): That is very helpful, Peter. Is it fair to say that the complaints that you hear about daily are consistent in nature across the board?

Ms Katherine McElroy (Patient and Client Council): I am inclined to agree. In 2024, 1,800 members of the public — citizens of Northern Ireland — contacted the PCC with concerns about their primary care and GP services. As Peter pointed out, there was a whole range of reasons for that, but access is definitely one of the most frequent issues about which we are contacted, particularly by people who complain about trying to contact their GP via the phone. We hear particular concerns from older people who may not have the technology that is required to engage with the telephony system. People who are concerned contact us about that, and if we assess a person to be particularly vulnerable, such as an older person who lives alone, we have a safeguarding concern, so we will try to engage directly with their general practice. We cannot contact a GP every time that a member of the public makes contact with us, because, first, we would be blocking up the phone line for that GP as well, and, secondly, the practice manager would not take that too well, but we would definitely make contact if we had concerns about vulnerability.

Another access issue is geographical access to GP surgeries. I am based in Omagh. The number of single-handed or dual-handed GP services in the west in particular has decreased significantly over the past 10 years. Although people in the west live, on average, 3·1 miles away from a GP surgery, there are pockets of the west where people may have to travel 10 miles, 15 miles or upwards of 20 miles to access a GP. A number of years ago, the PCC worked directly with a community group in Rosslea whose single-handed GP had retired. A genuine effort was made to try to recruit to that position, but it was not successful. The area was therefore amalgamated with Lisnaskea, which could mean travelling 10 miles or 12 miles on rural roads without good public transport infrastructure.

People for whom English is not their first language also encounter access issues. Although they may be proficient in conversational English, they may not fully understand medical jargon. Unless you are a medical practitioner, you would not. We have therefore been assisting a number of migrant support organisations to help their clients with accessibility, particularly by ensuring that translators or interpreters can help families in that situation.

The Chairperson (Mr McCrossan): Thank you for that. It is good to hear from Omagh. I have a brief follow-up question. Given the work that you have been doing over the past number of years, have you found the number of complaints to be trending upward?

Ms McElroy: The trajectory is definitely upward. Even in 2022, which we would probably consider to be the first year out of the pandemic, we had about 1,100 calls. In 2024, we had 1,800 calls.

Ms Monaghan: In the cases that were coming to us, PCC statistics showed a 70% increase in complaints about GP services and primary care in that year. That reflects the overall upward trajectory of complaints made to the PCC generally. We saw a 42% increase in our cases across the board, but issues of concern with GP services and primary care that have come to the PCC year-on-year have consistently represented about 25% of our overall caseload.

The Chairperson (Mr McCrossan): Thank you. Peter, did you want to add to that?

Mr Hutchinson: I was just going to say that that shows that our number of cases and contacts is increasing. As Meadhbha said in her opening statement, however, the number of complaints being reported to the strategic planning and performance group (SPPG) about GP services has shown a downward trend, so there is a bit of incongruity there.

Ms Monaghan: That is why we emphasised the point about consistency of patient experience and regional mechanisms for gathering information. We have certainly noticed a difference in the data.

Mr Gildernew: Thank you, Meadhbha and your team, for your presentation. You receive a budget of £1·8 million. It is sobering to hear how small a body you are. I declare the same interest as the Chair, in that I have also referred people to the PCC. I have had some individual cases work out really well.

An expanded form of advocacy would greatly assist not only patients but, perhaps more critically, the system. How will the system learn if it cannot glean those real experiences? It needs to get massively better at doing that. Some of the difficulties that people face are multifactorial and can include bureaucracy, a lack of understanding of what is being asked and, let us be honest, resistance. That is why the system would benefit from having a duty of candour. That would empower healthcare workers in the system by giving them learning. That is probably for a whole other Public Accounts Committee report, however, so I will return to the subject. I thank you for the work that you do.

What is your assessment of the current quality of access to GP services? You have partially answered the second part of my question, which was this: what are the main areas for improvement? I noted the four areas that you set out, but do you have anything else to add?

Ms Monaghan: I agree with you about advocacy services. The PCC's model, particularly in the past two to three years, has been targeted more at early resolution, which means working alongside service providers to try to resolve issues early. We are working with innovation and consultancy services (ICS) in the Department of Finance on quantifying the benefits of that to the system and potentially to the public purse. I mention that briefly, because it may be of interest to the Committee.

To get back to your question, Peter outlined how we work on the information that comes to us from the public. We are not saying that it is an objective assessment, but it is no less valid, because it is the public's experience of quality of access. In our submission, we included patient experience from the regional patient client experience (PCE) programme. We see some really positive experiences from that programme. I note, however, that there are only 68 stories about GP services across the region on the Care Opinion platform. The majority of them are positive about people's quality of experience, but the stories that have been shared reflect the issue with access. It is therefore fair to say that, once people get through the doors to see their GP, multidisciplinary team or whichever professional best meets their need at that point, their experience of the quality of care provided is positive. It is the access issues and the lack of measuring against demand for the service that are particularly problematic. There is a question around how we can drive improvement across the system and monitor performance arrangements in GP services if we do not have the appropriate magnitude of reliable and consistent patient experience data to inform us. I want to highlight that point.

For us, one of the core issues at the minute is that there is a paucity of data on patient experience regionally. It may be that individual GP practices are gathering that data. They may be doing really good public engagement work in their local area, but if we want to make regional improvements to how we gather and analyse that information and then feed it into the system at a regional level, there is a challenge involved in our doing so.

Mr Gildernew: Could we apply a bolt-on to Encompass to capture some of the data?

Ms Monaghan: I referred earlier to the potential of digital in certain apps that sit alongside some of the digital systems. The potential that Encompass offers is really interesting, and not only for how data on patient experience is gathered but for how there might be two-way dialogue. As a health and social care system, we are often very good at doing one-way communication, but we are not always listening. Through Encompass and some of the My Care apps, for example, there is the potential to inform and educate the public about the changes that are happening, about the pressures in the system and about the challenges that GP services and primary care face. There is also an opportunity to listen to the public's experiences and make more rapid improvements as a result. In the shorter term, there is a lot of potential.

Mr Crawford: I thank the members of the panel for their time and for their presentation. I will touch on access as well. I appreciate that you mentioned it in your opening remarks and in some of your answers. What level of access are patients looking for or expecting from their GP? What does an acceptable level of access look like?

Ms McElroy: Colin, the majority of people are interested in being able to make contact with their GP via the Phone First system that is now in place and not have to rush to the phone at 8.30 am only for all possible appointments to be gone by 8.50 am. They also expect consistency across the board. People say, "My next-door neighbour's GP does a, b and c, but mine does not. My next-door neighbour can make contact with their GP via text and receive something back". There is therefore that inconsistency across practices, and there is a public information piece for the public to understand as well. Unless they work in the system, people probably do not understand that GPs are contractors and provide a core business. Beyond that, GPs have no further obligation.

Initial access is therefore the issue. Moreover, people still perceive GPs not to be doing face-to-face consultations. We appreciate that that is not the case, but the public perception is that face-to-face consultation will be offered only if it is deemed to be required.

The other issue with accessibility concerns multidisciplinary teams. Only 8% of the population have access to an MDT. There was an initial roll-out of MDTs, but that has stopped, so vast swathes of the region do not have access to one. If it were possible to have an MDT in every GP practice across the region, people would have direct access to a physiotherapist, a social worker, a speech and language therapist or whatever other specialist they require, and that, in turn, would probably free up more appointments.

Ms Monaghan: How we change the nature of the relationship between health services and the public in Northern Ireland is a fundamental question. You asked what it is that the public need. We should ask them. We need to switch the relationship from being one that is less about their being passive recipients of care to being one that is more about an active partnership. In our experience of engaging with the public, we find that they often hold very innovative solutions that may not necessarily cost more but that answer the question of what they are seeking and how they might be serviced. That would be interesting to explore.

That comes back to the patient experience piece and to Katherine's point about just being able to get through to the practice. You can see from some of the evidence that we have shared about people's experience that they are anxious about putting more pressure on services, about reaching the wrong professional or about becoming an irritant. We need to take the bull by the horns and look at how we shift the dialogue. We need to educate people about the real pressures on the service, because those pressures are here for the long term.

Mr Hutchinson: I will add to a point that was made earlier. There is growing evidence that, when practitioners and professionals engage with members of the public, and they receive positive feedback and learn from instances of less satisfactory care, it has a positive effect on their morale and on that of the place in which they work. It has a positive effect on their desire to do their work and to learn how to improve services. It is therefore a double win.

Mr Crawford: That is really helpful. Thank you.

Ms Brownlee: Thank you so much for your presentation. It was very good. I have used your services before. Doing so was fantastic and really helped my constituent at the time.

You mentioned there being inconsistencies across the board. In your work, do you see any examples of best practice? If you see something that is very positive, how is that communicated and then replicated elsewhere? Indeed, if you see something that is very negative, how is that addressed?

Ms Monaghan: The reason that we wanted to include some of the evidence from the regional patient client experience programme initiative Care Opinion, which sits within the Public Health Agency (PHA), is because the bulk of the stories on the platform are positive. Unfortunately, by nature, a lot of the people who come to the PCC have issues, and that is one of the challenges.

We produce information annually on the consistency of patient experience. It goes through our sponsor branch in the Department of Health. We actively try to feed the information back to the Department. The inconsistency that is the patchwork experience of people's reality of GP services also speaks to your question about the ability to share best practice at a regional level. If we were to have the ability to collect the experiences of people regionally, that would allow us to address some of the issues for improvement and also identify good practice. I am not sure that we could say any more than that about identifying areas of best practice at this stage, unfortunately.

Ms Brownlee: I appreciate that.

Ms McElroy: I will add to that. Communication goes a long way to addressing a lot of the issues with which people come to us. For example, they may not understand that GPs no longer do travel vaccinations. That is a very small example, but communication does go a long way. That was particularly the case during the pandemic, when, for all good reasons, there was a rollback of opioid prescriptions. People had been provided with information, but the level of communication proved to be very difficult. People did not understand. They believed that they were being taken off their medication or that their level of pain was being disbelieved, when that was not the case. Opening up of lines of communication helped. From making contact with GPs regularly, my view is that, once communication is established, issues get ironed out relatively quickly.

Ms Brownlee: Communication is absolutely key. When I was researching for this evidence session, I found that, in 2014, the Patient and Client Council had conducted its own survey about access to GPs and produced a report. Can you provide any more detail? Have you conducted any more surveys? Have any of the recommendations from your report been implemented? How was your communication with the Department of Health? Did it react to the recommendations?

Ms Monaghan: What is interesting about our 2014 report, the follow-up work that we did in 2022 in 'People's Priorities' and the evidence that we are providing today is that some of the recommendations in them are very consistent. They are about patient experience. They are about listening to patients, about how we connect regionally and about the role of advocacy services. They are about identifying burnout, which is a very real issue among GPs, and addressing it.

To answer your question, a lot of the recommendations were identified as action that the SPPG and others could take. We find that we are still consistently highlighting the same issues about what we feel is needed.

Mr Honeyford: Thanks for coming in. You talked about the numbers, and the increase of 70% in the number of complaints is frightening. I will pick up on the issues themselves. Are the issues with which people are coming to you different or new, or is the number of complaints just increasing?

Ms McElroy: The issues are much the same. The system requires us to categorise them, David, and there is definitely an increase in the number of complaints across the board. The issues with communication, medication, access and so on have remained constant. Complaints have increased just in number.

Mr Honeyford: Has the change since COVID been in the scale? Is it the case that the issues that people are coming to you with are not different — they are the same as they were before COVID — but that the numbers are different?

Ms Monaghan: As far as we understand it, the top issues of concern have remained consistent. Those tend to be about communication. Issues with medication have increased as a theme but, broadly, it is about treatment through care diagnosis and care quality. There are many examples for each of those categories, and we have tried to give a bit of the flavour of that. Across each of those themes, access is a consistent issue. We might look at primary concerns that are raised by people who feel that they did not get the right quality of care or feel that the attitude of staff was not right, but access — actually getting to speak to someone — is a consistent theme in each of the issues of concern.

Mr Honeyford: If were to go back five or six years — before COVID — access was issue then. Are you saying that it is still an issue but on a greater scale?

Ms Monaghan: Yes.

The Chairperson (Mr McCrossan): Before I let Cathal in, I refer to the paragraph in your briefing paper headed, "Staff Attitude":

Are you picking up a sense of fear among patients that they may be asked to go elsewhere if they complain about their GP or the service that they receive?

Ms Monaghan: I am not sure that we can be as conclusive as that. Our evidence shows that there are issues with access to GP services, being deregistered, trying to access other GP services or moving between services. Those, potentially, point anecdotally to some issues there. When I reflect on it, what is interesting to me is that the data that the PCC holds on the number of complaints relative to the regional data is very mismatched. When you look at what people are asking us about, at times it is, "How do I make a complaint?", or "How do I access that information?". There is definitely an issue there with how the public feel they can raise issues and how that, potentially, might have an impact on service provision.

The Chairperson (Mr McCrossan): OK, thank you. Cathal Boylan is joining us remotely.

Mr Boylan: Thank you very much, Chair. I apologise for not being there in person. I recognise the good work of the PCC and thank the panel for their presentation and their answers thus far. I want to talk a wee bit about multidisciplinary teams. Has the panel had any insight from patients as to whether MDTs are operating successfully and providing greater access to primary care, or are they merely a signposting service?

Ms McElroy: It would be difficult for us to know, because if people are successfully treated by an MDT they will not come to us. Looking at the data, however, and at the fact that there is only 8% coverage across the region, that would suggest that those 8% of people are getting access to various levels of professionals in the NHS without having to sit on waiting lists or wait for long periods to access treatment such as physiotherapy. Therefore, you would imagine that people would have a better and more positive experience in being able to directly access the professionals to whom they need access. The premise of the MDT was exactly that: allow members of the public to have that direct access rather than sit on waiting lists for long periods.

Ms Monaghan: When we prepared for this session, we did not look specifically at MDTs in the PCC data. However, I draw to your attention to the Care Opinion platform on patient experience, which has had some regional traction through its 10,000 More Voices work on multidisciplinary teams. That is where the Committee may find more information to answer that question, Cathal.

Mr Boylan: Thank you very much.

Ms Forsythe: Thank you all very much. It is really important to the Committee to get the voice of patients in the room as part of the inquiry. You mentioned that people come to you when they have complaints. It is important to understand how you are capturing what is going well and what patients feel is going well with their GP services. The Committee will be making recommendations to the Department of Health. How do you feel that, overall, the voice of patients is being heard by the Department of Health? Have you any ideas on how to improve that?

Ms Monaghan: To achieve balance with some of our evidence, we have sought to include experience from the Care Opinion platform. Care Opinion is the regional patient experience programme that is run through the PHA. Anyone can go onto the Care Opinion platform about any service in Northern Ireland and talk about their story. You will note a number of examples in the paper of positive GP stories from patients. As I mentioned, there are a small number of stories about GP services on the Care Opinion platform: it was not rolled out to GP and primary care services, so it is not in wide usage within them.

There have been about 68 stories over the last year, the majority of which are wholly positive. That is one mechanism through which the patient experience is heard across the region. It is one part of the overall public engagement and patient experience landscape in Northern Ireland, which includes targeted interventions around personal and public involvement; the programmes that the PCC runs on its engagement platforms that influence policy at a regional level; and information from advocacy and complaints both from the PCC at a regional level and from the HSC trusts.

One of the main points that we wish to highlight is that more could be done with GP and primary care services to understand the patient experience at a regional level. When you look at the data that we hold, or reference the GP access working group at the Department of Health, whose report referenced 42 individuals, much more could be done to either harness the patient experiences in GP practices that we are hearing about and elevate them to a regional level or embrace the patient experience, more broadly, to recognise good practice and understand what is working well and try to replicate it.

On public engagement in general, the PCC sees a need for, and the benefit of, broader strategic cohesion in public engagement for health services. That is a strategic priority of the PCC: it is the thing that we are trying to drive. In Northern Ireland, we are very fortunate that we have a statutory duty for personal and public involvement. That has been in place since 2009, but we are now in a different health context. A lot of good work goes on regionally, but quite a lot of it is in local pockets. There is a need for us to pull that together at a more strategic regional level to more positively influence service transformation and design. A critical component of that is the changing relationship because it works both ways. People are more invested in what they help to create. With the challenge that we face in health in respect of the transformation of services, it has never been more important to engage people in those conversations at an early stage. We need to inform and educate people on what the changes need to look like. We also need to engage people in those conversations at an early stage because the changes that are coming down the line are more acceptable when you understand what they mean and when you experience them at the regional level. A more strategic regional approach to that, generally, would be welcome.

Ms Forsythe: Thank you very much.

Mr Honeyford: I go back to paragraph 28 of your submission on staff attitude. A lot of issues related to that are brought to my office. I should have said in my first contribution that my GP practice won "GP Practice of the Year" and is absolutely fabulous.

Mr Gildernew: Was it you?

Mr Honeyford: It was nothing to do with me. A lot of the complaints that I get to my office are about the barrier that goes up when making the first call to reception. Are the front-line staff a hindrance or a help to accessing GP services? Do you have any opinion on that?

Ms McElroy: People identify that as being a particular barrier. When we spoke to the all-party group on ageing and older people, the GP representative referred to the receptionists as being "care navigators", which was a new term to me. The public are not fully aware that receptionists have the ability to, for want of a better word, triage cases. However, when you live in a local community and the person taking your call is your next-door neighbour or someone that you know, there can be reticence about sharing personal information.

It is something that needs to be communicated more effectively to help people understand that the receptionist's role is not just to take a call but to be a care navigator. There can be a conflict there.

Mr Honeyford: How do you address that barrier? You have nailed the issue that we hear about, which is the receptionist being a neighbour or known to the caller. That is particularly the case in rural villages, including those in my constituency. If the patient knows the receptionist and does not want to share personal information with them, how do you remove that barrier?

Ms McElroy: It is about open communication between the GP practice and its patients to help them understand the way in which their information has to be received into the practice and how that will help expedite matters for them. Communication is key to all of that.

Ms Monaghan: There is another aspect, which is about providing multiple options. Speaking to someone directly might be the preferable option for some people, based on accessibility issues, additional needs or age. Others may wish to be able to provide their information through digital means, such as an app or a call-answering service. It is about looking at different pathways for access. The other component, which follows on from communication but is often lost, is building trust. Trust is built through people understanding why the nature of access has changed, what is going to happen to their information and why the role of the person who is taking that information has changed from receptionist to care navigator. An emphasis on building trust, so that people feel comfortable accessing the practice in that way, is really important.

Mr Hutchinson: Communicating and engaging with the public to assess and address those issues involves a different type of communication and engagement by a GP practice. Engaging with the public and having them participate requires commitment and, often, investment, which means that you will need to know your goals and be able to see the potential gains, which, we suggest, are better patient experience, better quality of outcomes and a better place to work because there is a more collegiate approach to how you are delivering services. It is a different way of doing things, which links back to the need to be strategic and to look at the service in the round.

Mr Honeyford: Thank you.

The Chairperson (Mr McCrossan): We appreciate your time with us and your answers. You mentioned earlier that there needs to be a shift from passive recipients of core services to a partnership approach with health providers. Will you expand on that? How can that be achieved?

Ms Monaghan: First, it is a continuum because there are situations in which being a passive recipient of care is appropriate. For example, if you have cancer and are in receipt of treatment, you are more likely to want to be a passive recipient, where you will be achieving good-quality care from professionals in your best interests. The continuum, and where you fall on it right through to active partnership, is very much dependent on circumstances. Someone who is an active partner in their care is well informed; is able to make informed choices; is aware of the services that are available to them; and feels that they share a level of power to make choices about their life that enables them to live a healthier life, which potentially avoids needing to access services as much. That is a fundamental change in how a person partners with care providers, with their contribution to the patient experience being welcomed and valued.

One of the challenges in making that shift is the reality of how people experience health services in Northern Ireland because it is a system that is under strain. People vote and pay their National Insurance contributions, and they have certain expectations about the care that they should receive. However, if that is not developed or delivered in the way that professionals would wish because of all the challenges that we are aware of, people will either accept the situation or avoid accessing services. Some may be able and willing to buy services, which is where the drive to private healthcare comes from, and others may fight for their expectations of the services. There is another choice, which is about looking to shift towards a more active partnership approach to delivering care.

The Chairperson (Mr McCrossan): It is interesting to explore the other approach, but do you find that, due to the nature of the situation that we face in accessing care, people just avoid accessing it? Some people can go private, but, as we know, that option is not available to everybody. That raises serious problems and questions. Do people who find it difficult to access care just avoid going through the process entirely? In my experience, people say, "It's not worth the hassle. I'm not doing it", and ultimately are not diagnosed in time.

Ms Monaghan: There is a lack of information on patient experience. We are not currently able to assess the experience of the people who do not access care at all. The information that we have provided to you is based on those who have come forward or tried to access services. The most concerning thing is about those individuals who are already more marginalised or are outside of the access conversations: we simply do not know about their experiences. That is a potential problem.

The Chairperson (Mr McCrossan): What more can be done by your organisation generally to reach the people who are not sharing those experiences? Not everybody will understand what the Patient and Client Council is or does; in fact, most people are educated on the work of your organisation only when they approach an elected representative who says, "Well, this is the avenue that you could go down". How do we ensure that there is greater awareness of the good work that you do in raising those concerns, which applies pressure and, hopefully, produces solutions for people? How can we best support that?

Ms Monaghan: In the past year, we have embarked on an awareness-raising campaign that is about trying to explain the breadth of the work of the PCC. Historically, it has been known as a complaints organisation, but four of our five statutory functions are about engaging the public and advising the system on best methods. We have new promotional materials, animated videos and testimonials from members of the public who have used our services. We have sent out those materials right across all of the trusts. All of the general practices recently received those as well. We really encourage our elected representatives and anyone who has access to the public to raise awareness of the PCC's services.

When it comes to reaching those who perhaps are left out of those conversations, our concept of a more strategic approach to public engagement is that it takes place through a network of networks. The voluntary and community sector is a touch point every day for people who are coming into services and are being supported in certain ways. We partner with the voluntary and community sector, and with health service providers, to try to access individuals at their point of need. An example of how we have been doing that in the past year is our positive passporting initiative. That is about ensuring that there is a clear pathway to PCC services and access to support through charitable and voluntary and community sector organisations that work with those who might have a health access need but also have other needs being met in different ways. We partner with them and work in collaboration to make sure that people do not fall through cracks. When you look at some of the findings from inquiries and other reports, you see that people very much felt that there was a revolving door when it came to being signposted to other services.

A second initiative involves our siting of PCC support in the community. We host clinics in existing spaces where people come to access need, such as food banks or voluntary and community sector or support organisations. If people have an issue, they can access PCC support at that point of need. That is instead of there being an expectation that people will seek out the PCC, because, as you said, it is very much the case that you do not access or know about our services until you critically need them, at which point it can be too late.

The Chairperson (Mr McCrossan): Sometimes, local surgeries are points of information about a lot of things. I am one of those people who reads everything that is on the wall. Have there been any barriers to promoting your service in local GP practices?

Ms Monaghan: We sent out the information only recently. Our feeling is that most services are very receptive to partnering with the PCC and making people aware of our services. Infection prevention and control and the move to digital mean that people are not as open to putting up posters as they used to be. That creates issues with people's accessibility. However, the My Care app provides a different way in which to reach people and point out PCC services and those of other organisations. I hope that we will be able to explore that.

The Chairperson (Mr McCrossan): Dorinnia, do you want to add anything?

Ms Carville: No.

The Chairperson (Mr McCrossan): You are happy enough. Stuart?

Mr Stevenson: I am happy, Chair.

The Chairperson (Mr McCrossan): You are all well behaved today. Is there anything further that the witnesses would like to add?

Ms McElroy: There is one thing that I would like to add regarding the shared care arrangements between GPs and private practice. As private practice increases in volume across Northern Ireland, patients may not understand that if they access private care there is no obligation on their GP to continue that care, particularly around prescriptions. We have found a rapid increase in the number of people contacting us about adult ADHD services. Those people have accessed private care and private prescriptions, but their GPs have not been obliged to continue with them. There is definitely an education piece to be conducted on the implications for patients of continuing down a private pathway. The fact that there is no diagnostic and treatment pathway in Northern Ireland for ADHD has created a huge difficulty for a lot of people.

The Chairperson (Mr McCrossan): I am experiencing that at the minute with a number of people. Thank you for raising that, Katherine. That is very helpful.

I thank each of you for being with us, for your presentation, for taking our questions and for answering them and sharing the experiences of your organisation. I say again, very firmly, that we are appreciative of the work that you and your team do. I am one of the signposts that directs people to you where necessary, and I know that many others do the same. This is an important inquiry, and your evidence session is key to it. Thank you very much for being with us. We appreciate your time.

Ms McElroy: Thank you.

Ms Monaghan: Thank you.

Mr Hutchinson: Thank you.