Official Report: Minutes of Evidence

The Chairperson (Mr McCrossan): I welcome Dr Frances O'Hagan, chairperson of the British Medical Association NI (BMA NI) General Practitioners Committee (GPC), and Dr Ciaran Mullan, deputy chairperson of the BMA NI GPC. He is also a GP in my local practice, so I declare an interest. I also welcome Dr Ursula Mason, chairperson of the Royal College of General Practitioners (RCGP) NI, and Dr Emma Murtagh, deputy chair of the Royal College of General Practitioners NI. Also with us are Dorinnia Carville, the Comptroller and Auditor General from the Northern Ireland Audit Office (NIAO); Mr Stuart Stevenson, the Treasury Officer of Accounts (TOA) from the Department of Finance; and Julie Sewell from the Department of Finance. You are all welcome. We deeply appreciate your time and presence, because we know how busy you all are.

I refer Committee members to the written submissions that were kindly provided by the BMA NI and the RCGP. As I said, you are all welcome to the Public Accounts Committee (PAC) to give evidence. Time is of the essence, so I would appreciate it if your opening remarks were brief. Members will have questions, and that will allow for further conversation. If any of us interject at particular times, it is so that we can take the most from the session as opposed to anything else. With that said, thanks again for being with us. I welcome you to brief us.

Dr Frances O'Hagan (British Medical Association NI): I will kick off, and Ursula will follow me. Good afternoon, Committee. The opportunity to advise you on access to general practice is welcome. I am the chair of the Northern Ireland General Practitioners Committee. I am a practising GP and a partner in the Friary surgery in Armagh. With me today is my deputy chair. I will let Ciaran introduce himself.

Dr Ciaran Mullan (British Medical Association NI): I have been a practising GP in Strabane for 23 years. I have been Frances's deputy for the past six months.

Dr O'Hagan: You have received our briefings. I will outline our position to the Committee prior to taking members' questions. While Ursula and I will sing from the same hymn sheet, the BMA is distinct from the Royal College of General Practitioners, in that we consider and act on contractual matters. I will start, and then Ursula will then go through her stuff.

As MLAs, you probably receive messages every week about access to general practice. It affects every citizen in Northern Ireland, including all of us; we all are patients as well. We thank the Committee for its interest in the issue.

General practice is in crisis. Contract hand-backs represent the most visible indication of the crisis that we are in. As of March 2024, there were 312 active GP practices. That is a reduction of five practices from the previous year and a reduction of 38 in the past 10 years, which means that 11% of our practices have gone. The situation in 2024 is untenable, and, without a solution, it will get worse. The other thing to remember is that the population has increased by 70,000 in the past 10 years, while we have lost 38 practices.

Access to general practice is something that we continually hear a focus on. The Health Minister also has a focus on it, but there has been no commensurate upturn in funding to enable us to meet the current demand. Despite that and contrary to popular belief, we believe that there is good patient access in place for many patients; in fact, GPs have significantly increased our patient consultations. In 2022, as we emerged from COVID, GP practices saw 9·7 million consultations: last year, that rose to 10·1 million consultations. That is a 5% increase, with a decrease in doctors. Just think about that. Those 10·1 million consultations mean that, each week, general practice in Northern Ireland delivers over 200,000 consultations. That is 10% of the population seeing their GP every week. Think about that. That is a lot. The other thing that we need to mention is that, in 2024, we saw the majority of consultations back to being face-to-face. Well over half are back to being face-to-face. There is an idea that we are closed and doing nothing and that nobody can get a face-to-face appointment, but the figures do not support that.

Access to general practice goes a long way beyond getting the phone answered and seeing a doctor. Included in your briefing pack is the infographic of the iceberg. It is a very important infographic, because everything below the surface is also access that we do. For example, if I look up your blood results and I comment on them and give you a ring to say, "You need folic acid" or something like that, that is access. If my nurse takes you in and does your diabetic review or your smear, that is access. If I read a hospital letter and, on it, the hospital wants me to do something, I have to contact you and get you in: that is access. All those things and all the paperwork that we do are access. If we do a solicitor's letter for you or a life insurance report, that is access. Access is not just answering the phone or getting a face-to-face appointment. It is really important that that be understood.

There remains much to do, but it needs to be enabled by investment from the Department. We believe that the best way to improve access would be for the Department to focus on investing in the general medical services (GMS) contract. That is what we call our "core contract". It is a standard contract to deliver the core services negotiated between us in the NI GPC and the Department of Health. It is the BMA's position that at least 10% of the Health budget should be spent in general practice, considering that we do 95% of the consultations. That is not a big ask. That is what it was when I first started in general practice. It is now 5·4%, so, with 5·4%, we deliver 95% of care. That needs to go up, if you expect us to do more. If the Minister wants to shift left, he needs to shift the resources with it. By the way, that is the lowest investment in general practice of any of the four nations. It is simply not enough to deliver 200,000 consultations a week and keep going.

General practice will always be best placed to be the first point of contact for people. We should aspire to continue that, but, with the desire to shift left, which we wholeheartedly agree with, we need to move the funding. In the first instance, we are asking the Minister to increase our core funding by £40 per patient per year. That is £80 million. Out of a Health budget of £7·8 billion, that is merely 1%. All we ask for is 1% to start to get us back to where we need to be. I am often asked by MLAs what general practice would do with 1%, and I am happy to answer that. I assure the Committee that every penny would be spent. The spend would vary from practice to practice, and we have heard that there is no consistency among practices. There are practices that have very few GPs, very few staff and very few nurses. They would invest in those members of staff. There are also practices that are patchy about multidisciplinary teams (MDTs). There are 10 federations in Northern Ireland that have no MDTs, so we would invest money in that as well. An MDT does not work if you do not have a doctor there to supervise it.

The overall additional funding would begin to progress the stabilising of practices. It would also give GPs confidence that the Minister is listening and that general practice is valued. It places its belief in the Minister understanding that shifting left means reconfiguring how finance is allocated. Costs are increasing rapidly, and the increase in National Insurance contributions will be immense, if we have to shoulder that. That is a significant cost that we just cannot afford. Ideally, we would want the Treasury to ensure that general practice is exempt, but, failing that, we call on the Department of Health to provide additional funding and for it to be a reimbursement on a recurrent basis. If that does not happen, we will lose staff and access will be reduced. April is fast approaching, and we need an urgent solution. Without that, we will, unfortunately, be looking at cost-cutting, because we have no other way of bringing in the income.

I will speak briefly about indemnity. We are currently in a round of constructive negotiations with the Department. Resolving this is key for our members in Northern Ireland, as we are the only GPs across the UK who pay for this ourselves. We believe the Minister has taken our indemnity seriously.

My final point is that the importance of MDTs in providing stability in practices and improving access to equitably meet the needs of our population cannot be overstated. MDT roll-out needs to be prioritised by the Department, and funding of the roll-out needs to be regular and recurrent. At the minute, only seven of the 17 areas have MDTs, but I go back to this point: you cannot bring in an MDT unless you have more doctors.

Before I finish and take questions, I reiterate that, as GPs, we are doing the best we can with what we have, but we need to see a recognition from the Minister to increase our funding. The GMS contract for 2025-26 must include solutions for indemnity and National Insurance and a modest increase in our core funding. Anything else, I am sorry to say, will result in further practice closures and contract hand-backs.

The Chairperson (Mr McCrossan): Thank you, Dr O'Hagan. You have answered my question completely. You have not left out one part of it. I was about to ask whether GP services are in a state of crisis, and the obvious answer, given your opening remarks, is yes. I was going to ask about your current view of the sector, and you have answered that. I was also going to ask what can be done to fix it, and you have answered that. We are on the one page, which is a good starting point in recognition of the serious problem. It is clear to us all that there is a problem, and a lot of this is about how we communicate that problem and how we find a solution to address it in the interests of our patients and, of course, practice generally.

When I looked through the detailed briefing, I was alarmed at the figures. We do not always realise that there has been a significant increase in the population, but a drop of 38 practices is an example of a blunt statistic that alerts our attention to the issue that we have. Equally, there has been a 5% increase in demand for the services, and, further to that, 10% of the population sees a GP every week. That is also alarming. There are also funding issues, and you have talked a lot about funding. The ask is not huge — I think that you said 1%. I was looking at the figures for England, which is looking for 15%: it sits at 10%, and Northern Ireland sits at 5·4%. Is that correct?

Dr O'Hagan: Yes, and 10% is our minimum. We aspire to move to 15%, because, if more work is moving, we need to fund that work.

The Chairperson (Mr McCrossan): OK. If there is no increase in the current rate of funding for GP practices in Northern Ireland, what will be the impact over the next couple of years?

Dr O'Hagan: More practices will close, and access will be reduced, because we just cannot keep going. If we are not funded to keep the doors open, how can we stay open? We have practices that are teetering on the brink. The National Insurance thing is massive. If you employ a lot of your staff, especially if you employ your doctors, which the MDT practices do, they could shut overnight. Ciaran is in an MDT. How many practices are there under the community interest company (CIC)?

Dr Mullan: Emergency measures have kicked in with practice closures, with trusts and federations taking them on. That cannot be sustained. If you do not have the model of funding going into core general medical services to allow people to maintain independent contractor status, you will run out of the emergency provision, which has happened in the last while. Again, the MDT model is so critical, but it has created more inequity across Northern Ireland between practices that have MDTs and those that do not. It creates more issues, and, as Frances said, if you do not have the critical mass of GPs in practices to put an MDT around, it will not work either.

The Chairperson (Mr McCrossan): I got carried away with your briefing and forgot to ask for your opening remarks, Dr Mason, but it was because everything that you said drew my attention. Thank you to Dr Mullan and Dr O'Hagan for that. I now welcome you, Dr Mason, to make some brief opening remarks.

Dr Ursula Mason (Royal College of General Practitioners NI): Thank you very much, Chair. You will not be surprised to hear that we all sing from the same hymn sheet. There is nothing that Frances has said or even that you have made comments on that we will argue about. I will keep my opening remarks brief in the interests of answering questions.

I am the chair of the Royal College of GPs in Northern Ireland, and I have been a GP partner in south Belfast for over 20 years. I will let my colleague Emma Murtagh introduce herself.

Dr Emma Murtagh (Royal College of General Practitioners NI): I am a GP in east Belfast.

Dr Mason: I will touch on a few things that Frances has spoken about, but I will start with what I was going to say last, because GPs want what patients want and what they deserve. What they deserve is good access in a free-at-the-point-of-need NHS general practice, not us firefighting every day with urgent demand with our limited capacity. We are very constrained in our ability to do what we do best because, as Frances said, there is a crisis in general practice. All the signs are there. You know what they all are, including the contract hand-backs and the inability to recruit. A third of practices in Northern Ireland have accessed crisis support in the past three years.

The underinvestment and the inadequate workforce planning mean that we have a smaller number of whole-time equivalent GPs than we had a decade ago, but the population increase is there and the need is there. We have an older and ageing population, with more long-term conditions. We have spiralling waiting lists that are not coming down, and, more often than not, the only people whom those patients can access are GPs. Therefore, the demand is outstripping the capacity and continues to rise. Those 200,000 consultations every week are not enough, yet that is what we are we being funded for. Therefore, we get what is being paid for, and we struggle to maintain an ability to deliver for all of our patients safely and equitably. That pressure is there. It is outstripping capacity, it is adding to GP burnout and it is adding to our recruitment crisis. That shift left keeps pushing and pushing without the investment and without the funding to meet it.

We want to deliver good and timely care to patients. We just need the resource to do it. We are doing more and more with less and less, and we are at crisis point because that cannot continue. Frances asked you about what access would look like for you, but I will compare access to other parts of the system, because every part of our NHS struggles with access. The 8.30 am scramble on the phone each morning that we hear about patients having to endure is our equivalent of crowded emergency departments (EDs). It is also the equivalent of red-flag waiting lists in the hospital sector. The countless people who cannot get through on the phone or are told, "Sorry, no more appointments. Phone back tomorrow. Emergencies only" are our equivalent of the ambulances stacking up outside EDs and our equivalent of those ever-growing routine waiting lists. It is difficult to quantify that demand, let alone film it, but it is there. Many of your colleagues on the Health Committee have seen what it is like on the ground in general practice with us over the past few months, so they know what it is like.

Our problem is not flow but capacity. Sometimes we conflate access with capacity. We do not have capacity to deal with the need that is there. It does not matter how many phone lines we have if we do not have a call navigator at the end to direct that call or, importantly, a GP to see a patient when it is needed. Our GPs work regularly beyond safe limits every day, fitting in the extras, doing another house call on their way home and staying late again and again. Sustaining that compounds the burnout, it compounds the issues that we have with recruitment, and it is not good, safe patient care. It is more and more for less and less again, and we cannot continue to do that.

We really care about our patients, and we are really worried about what we might miss. Where are the additional red flags that we are not picking up? Where is all the ill health that is being contributed to by our not being able to meet today's need today? I know that the Audit Office set out the need for a GP workforce as being vital if we want to start tackling capacity issues — those capacity issues frustrate GPs as much as they frustrate patients — but GP recruitment numbers have stalled. We need to go from about 121 to 161 incrementally over the next few years to get to where we were in 2014. That is not to increase numbers; that is just to get to where we were. There is a decade's worth of lag.

In April last year, the college released a retention strategy with solutions to keep GPs in their jobs, because they are leaving. They are quietly quitting, they are burning out and they are retiring early. They are not even taking up posts after they have qualified because of the situation here. Our 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 a work plan that was fully enacted and resourced. Neither of those has happened

MDTs have been cited as a key element of transformation and, by all means, they are really important in primary care, but they are not happening fast enough or equitably across the region. Though that increase is welcome, it will not solve the crisis in general practice. MDTs will create a degree of short-term stabilisation and a little bit of access in primary care, but they are not a silver bullet, not least because of the inequity that sits at the minute. As Frances said, the funding of MDTs should not and cannot be at the expense of ensuring that core services are adequately resourced and sustained. Without that robust core where medical generalism delivers whole-person, whole-of-life care, a model of MDTs wrapped around it will not deliver for patients.

I turn to contract hand-backs. Most GPs who hear that a contract has gone back hold their heads in their hands and think, "Who is going to be next? Will it be us? Will it be our partners down the road?". That is without even considering what patients think when a contract goes back. They think, "Will I lose services? What will happen to my practice? What will happen to my care?". Contract hand-backs are a signal of chronic underfunding and recruitment challenge. They are not a signal of failure, but they raise a red flag to the system. Something needs to change.

The Chairperson (Mr McCrossan): Dr Mason, the briefing is very detailed and very good. I just worry that you will leave us with no questions. [Laughter.]

Dr Mason: I will make a final comment. We know that there is a well-rehearsed benefit for investment in general practice. For every pound invested in it, there is a £14 return to the economy. That is the biggest return across the whole of the health system. If we think of Frances's ask for £80 million, imagine what will come back to our economy if that is invested in primary care and not somewhere else in the health service. I end with that.

The Chairperson (Mr McCrossan): I am sorry for having cut across, but, genuinely, you had answered my question, and I thought, if you had answered my questions, you would have answered other members' questions. I appreciate that briefing very much, and your honesty in your opening remarks. Before I pass to my colleague Diane Forsythe, I will touch on the funding issue again. Just to be clear, is the 1% request simply to even things up and stand still?

Dr O'Hagan: Yes.

The Chairperson (Mr McCrossan): OK. What would return GP services to where they were in 2014? That was the year that you said was probably the best example.

Dr O'Hagan: Something between 10% and 15%.

The Chairperson (Mr McCrossan): The reason that I ask that question is that England is sitting at 10% and looking for 15%. We are significantly behind that at almost half of it. I have some concern as to what will be required to catch up.

Dr O'Hagan: What happened in Wales this year is easier to read across. We have a population of approximately 2 million; Wales has 3 million. This year, in-year — I am not even talking about what I want for next year — Wales got £51 million as recognition of how defunded general practice is there. Wales is better funded than we are.

Dr Mason: One of the things to consider, though, is that, incrementally, as you increase funding, 1% keeps the doors open and the lights on, and it creates a degree of stability. However, we need to grow services and make sure that that shift left can happen in the most appropriate and safe way for patients. Those additional or incremental percentage points, where you move from 5% to beyond 10%, deliver really good service for patients. They are about making sure that we have a workforce that can do the job and create care for patients when they need it, as well as thinking about aspects like the infrastructure, the wider teams and bringing care into the community. When we talk about moving from 5% to beyond 10%, it is about restructuring the whole service to have a lens that is facing into the community. That is what you would get for the money beyond the 1% that Frances has talked about. This is about creating a much more stable and effective general practice within a wider primary care setting.

The Chairperson (Mr McCrossan): I know that I am holding up time, members, but I am conscious of where things are. If there was an increase to funding that even exceeded the 1% request — say it was 2% —

Dr O'Hagan: Happy days.

The Chairperson (Mr McCrossan): — what would the knock-on effect be on, for instance, the numbers of people headed towards emergency departments because they cannot get access to a GP?

Dr O'Hagan: If you look at last year's figures, you will see that GPs provided 10·1 million consultations and EDs provided 675,000. If we were to get additional funding and more resources and had more GPs, we would get past the status of where GPs are an endangered species. We would start to see more GPs and to provide more care in the community. We could start facing things from hospital back towards us.

Dr Mullan: I will quickly add to that. You pointed out a disparity between us and England, Wales and the rest of the four nations, but there is also a disparity between us and the Republic. That 1% or 2% increase to funding would send a message when it comes to retaining the workforce. If a medical graduate or someone who is going into GP training can see that the Department is taking general practice and primary care seriously, where the Minister has targets around the shift left and where funding follows that, you are much more likely to attract and retain a workforce. Otherwise, they will move to one of the other nations, down South or further afield, as they do at the minute.

The Chairperson (Mr McCrossan): As is happening, I was about to say. One thing that I will carry away from the session is the idea of GPs being an endangered species. That is hugely alarming, but probably accurate.

Which of the four nations has the best practice? I know that there are issues across the board, but which nations do you see as doing it well?

Dr O'Hagan: The issues are different in different areas. Our contract in 2004 was the same across the four nations. The core contract has remained the same, but the bits around the edges have changed in the different areas. In England, they still have some elements of the quality and outcomes (QOF) framework. We have QOF elements in our core contract, but we still do the work. To get quality, patients need time. If you are going to do the preventative work that we currently struggle to do, which saves money down the line, that is where quality comes in and you are then able to say, "I can spend time with this patient", rather than rushing them in and out, taking work home and doing your bloods at night. It is about time and resources. We will be able to feed that back in.

Look at the Republic of Ireland. I live in Armagh. If I were to move 10 miles up the road, statistically speaking, my life expectancy would increase by four years and my husband's would increase by up to six years. On average, a patient here sees a GP nine times a year. That is spread across all the population, allowing for people in the middle of their lives who do not see their GP much at all. In the South, it is three times a year, yet they have better outcomes.

Dr Murtagh: It is really important to look at the new GPs whom we are training. We currently train 121 GPs per year. They are trained excellently. They have a three-year training scheme. I work on it, so, of course, I say that it is excellent. By the end, they are competent GPs who can deliver excellent care. It is really important to say that, during their training, they deliver fabulous care to the population as well. They are the people whom you see when you go to an ED with your child, when you go to the fracture clinic or you have a baby. Those doctors are all working in our hospitals and GP surgeries, so we want to keep them.

In Northern Ireland, this year, 50% of those who come into our scheme are international medical graduates, meaning that they have not qualified in the UK. We need to work really hard to keep them, because there are many reasons why they may wish to go elsewhere. They may wish to go to the Republic of Ireland or to other parts of the UK. We need to be really good at keeping people here. One worry that we have is that people are finding that terms and conditions are better elsewhere. They are voting with their feet, perhaps because they do not have roots here, so they put their roots down somewhere else. It might not be too far away, but it could be here, if we could do better.

The largest proportion of people who are leaving the GP register are the over-55s, but a concerning number of people aged between 25 and 35 are leaving the GP register. That really worries us. Because we are mostly self-employed and we work independently, there is no exit interview. No one comes to you and says, "Why are you leaving?". You just leave. You go and get a job elsewhere. You might move to a position that, you feel, is less stressful.

That is not quantified. We know why people are leaving, but we really need the people who are working to stay.

Ms Forsythe: I thank you all for being here. You have explained things in a way that has given me a lot of food for thought when it comes to understanding some of the wider issues.

I am really concerned about the increase in employers' National Insurance contributions. When it was announced by the Labour Government in October, a lot of people thought about businesses, which are in crisis. I am particularly concerned about the impact on public services. I have done a lot of work over the past four months and identified that, for core Departments and non-departmental public bodies (NDPBs) here, there will be a recurring additional cost of £200 million a year. Treasury has not committed to funding any of that yet, but there is an expectation that, from June, about two thirds of it will be funded. On top of that, the Department of Health estimates that, for independent providers, such as GPs, dentists, community pharmacies and the like, it will cost an extra £35 million a year. That sits outside of the core element for which it is fighting for a Treasury contribution; it sits almost on a separate line. You said that you are already significantly underfunded to deliver the contracts. Will the significant additional cost from April onwards have a huge impact on the ground immediately in terms of access to GPs?

Dr O'Hagan: Yes. It will close some practices.

Dr Mason: Contracts will be handed back, without a doubt. Practices are already very financially precarious. It is important to note that practices cannot go over budget. We cannot do that; nobody can bail out an independent contractor practice. The bailout is that the contract goes back, and either you suffer the financial risk and consequences of that, or the contract gets taken on by someone else. If the cost of the National Insurance increases is not met, it could be catastrophic. It is money in and money out. Even if that money were to come in via the contract, there would be no additional benefit to general practice. No extra services would be provided as a result of that money's going in. It is money in and money out — back to Treasury — but it has the potential to destroy a lot of practices financially.

You will be aware of the mixed model of general practice delivery. Until about four or five years ago, we were wholly independently contracted in Northern Ireland, unlike the rest of the UK, where there were mixed models of health boards, private practices and the like running practices. We now have trust-run practices in Northern Ireland — which is where a contract has gone back, there has been no contractor and a trust has been asked to take it on — as well as federation-based, community interest company contracts, which all involve salaried doctors. I cannot speak to the trust practices, because I do not know whether the trusts are exempt, and whether that will work, but CIC practices are already facing significant overheads and increased costs due to their running a salaried service. If every member of the delivery team is salaried, those practices will not be able to function because of their NI contributions. You are probably looking at somewhere in the region of £130,000 across eight practices. That will put those practices under, financially. That is not talking about independent contractors, such as us. If there is no mitigation, we will have huge figures to meet, which will result in either a contract hand back or a financial restriction on services or access. We will have to stop employing people, which will be either someone on the end of the phone or somebody delivering care to a patient in front of them.

Ms Forsythe: That is important to note at this juncture. Obviously, it has been happening since the report, but that is really important.

Dr O'Hagan: We are the only one of the independent contractors that has no mechanism of earning any additional money outside what we make through the contract. We cannot sell more glasses or cosmetics. We cannot do more private dental work. We are not allowed to charge our patients for anything, other than for things such as HGV services, but nothing else.

Ms Forsythe: I take on board your point, Frances, about access for patients. You listed a lot of different things that I had not thought of regarding access. Is there anything that GPs could do to improve access for patients?

Dr O'Hagan: We would definitely deliver more if we had more GPs, nurses and multidisciplinary team staff, but we cannot deliver more with less. The 10 million consultations — 200,000 a week — demonstrate that we are doing a lot. In fact, statistically, we are doing a lot more, and that is just not sustainable.

Ms Forsythe: I appreciate that; thank you. I have a final question. The Audit Office report pointed to a continued greater reliance in Northern Ireland than in England on non-face-to-face appointments since the COVID pandemic. You mentioned about half of appointments in Northern Ireland being conducted face to face. The report said that, by March 2023, 45% of appointments in Northern Ireland were face to face, whereas, in England at the same juncture, face-to-face appointments represented about 70% of consultations. Why is that?

Dr O'Hagan: We are up to 57%.

Ms Forsythe: That is still behind England. Why is that?

Dr O'Hagan: England has other mechanisms. That is where the mixed model comes in. We do not have access to the walk-in centres and other things that England has. We have the GP-only model in Northern Ireland; there is nothing else. You also have to remember that not every patient wants a face-to-face consultation. Any patient who asks me for a face-to-face consultation will get one, but not every patient wants that. Sometimes, you have a row, almost, that goes, "Actually, I want to sound your chest" — "No, just give me an antibiotic" — "No, I really want to sound your chest. Please come in".

Dr Mason: It is also really important to think about what face-to-face versus Phone First versus whatever means. You may be aware that, before the pandemic, there was a huge push for GP practices to move to Phone First. In 2017, a particular type of Phone First access was pushed on GP practices by saying to them, "This will create more access. Will you move that way?" As a practice, we always had pre-bookable appointments, we thought that we had pretty good access, and we said, "No, we do not want to do that". When the pandemic hit, we had to flip to Phone First, and, having then moved from not seeing too many patients because there was a need to limit contact to where we are now, we would never go back to fully face-to-face appointments, because the way in which we do it now means that I can see more people in a more timely way. My lists are longer because I can deal with a proportion of people by telephone, which is what they want. I can also prioritise so that, if you are on my list in the morning as a telephone call, with something that I see has been care-navigated through to me and is an emergency, I can prioritise your call and phone you at 9.02 am rather than have you be my "extra" at 12.15 pm when I am running an hour late because of all the face-to-face appointments and you have had to take time off work to come and see me.

We have to create a model that fits as many people as possible. Phone first probably helps us to deliver that in a better way by giving patients options. We need to fit those options for the people who need them most so that, when you need a face-to-face, you can get it, and when telephone works best, you can get that. There is also digital. We often text patients with information and have two-way conversations via text. That works for some people too. It is about making sure that we create an environment in which the people who can access services in one way get them that way and people who can do so in another way have that way available to them.

Mr Crawford: Thanks, panel, for your time today. I want to go back to the handing back of contracts. We know that in 2022-23, 13 practices were handed back or gave notice of handing back their contracts, and there were six such practices in 2023-24. I have no doubt that that decision was not easy for any of those practices. Apart from the obvious, what underlying issues or concerns drive GPs to hand back a contract?

Dr O'Hagan: When a GP hands back a contract, it is exceedingly distressing for the GP. Remember that they are also losing contact with their staff. There are GPs who were very conflicted and probably should have handed back sooner, before they got to the point of no choice. There are two big factors. One is funding — do you have enough money to pay your staff and make a living? — and the other is having enough doctors. If you do not have enough doctors, it does not matter how much funding you have, you are not going to survive. One of the hand-backs in our area was of a practice with 5,500 patients and one GP. How the heck does one GP do that? It is not possible. If you have to do that single-handedly, you do not have any holidays and are not guaranteed any days off. You have to be there five days a week, every week. If you get down to the point at which you have very few doctors, stress ramps up. At that stage, it does matter whether you have funding, because you just cannot stick it.

Dr Murtagh: As Frances said, we are all patients, too. That is something to remember. We all have to try to access our GPs, often on a regular basis, for ourselves or family members. We get it; we know. We also hear from our patients. Every day, many patients tell me how many times they have tried to get through on the phone. That affects us, because we are sitting right in the midst of the community; we are beside people's homes; we are the front door for them. Even though, at times, it is hard to get hold of us, we are there and we are visible. It causes us significant anxiety. At least 40% of GPs feel that they cannot cope at least once or twice per week. That is a frightening statistic. In the UK, it is supposed that one nurse dies by suicide every week and a doctor dies by suicide every three weeks. We talk about burnout, and it is real; it happens a lot. People are quietly quitting without us knowing about it, and we need to bear that in mind.

Dr Mason: Absolutely. Frances and Emma talked about the difficult, tough decisions that GPs make when it comes to contract hand-backs. One of the other challenges is that, once that decision has been made, it has the potential to create a ripple effect in other practices. If the contract gets taken on, that is fine, because, hopefully, we will secure a workforce, and a new group of doctors will go in. If that does not happen, however, there is a risk of dispersal or, almost, of a forced allocation of patients, and, if a practice is already struggling — we know that a third of practices have accessed support because they are in crisis — that could have a domino effect in a region.

That is one of the key areas that we need to focus on: helping to support workforces in areas where it is hard to recruit. We do not do that very well. We have a single model for contracting and a single model for training GPs. Once they qualify — get their certificate of completion of training (CCT), as we say — and are spat out the other end, there are few mechanisms to support recruitment and probably not enough to support recruitment in hard-to-recruit areas. It is in the hard-to-recruit areas that we see an increased number of contract hand-backs. Those are border regions and regions of high deprivation. Historically, we would have had trainees going to those regions who may have been international medical graduates or graduates who had come from the Republic of Ireland who had no intention of ever working in Northern Ireland but were going to go back home to work.

We could create novel solutions to support recruitment and retention in areas where it is already hard to recruit. England, Scotland and Wales have done that. There are often rural supplements or remote supplements or other things that you can do to bring GPs to an area. Once you bring someone to an area and they put down roots and see what a nice place it is to work in, they are move likely to stay there. We have a very small GP fellowship scheme in comparison with the rest of the UK. At the moment, a pilot is in place in the Southern Trust area in hard-to-recruit areas and places where a significant number of contracts are going back. That is designed to support recruitment in an area and support career development for early-career GPs. We know that if we are able to support those GPs in their first few years out of training, it is much more likely that they will take up substantive posts. Creative things can be done to support recruitment in areas where it is hard to recruit.

It is also important to note that, in areas of high deprivation and inequality, there are fewer GPs per head of population. Therefore, we need to tweak the funding model to support additional funding in areas where the need is greater. Our current funding model is not fit for that purpose. There are things that could be done to make it a bit easier, but action is needed. We cannot get away from the fact that, if there is no investment, we will not let that happen. Even with the current salaried models — the CIC models — it costs about 30% more to run those practices than it does with an independent contractor model. I do not think that we can afford that in the long term. We have to enhance the bit that works well, which is the independent contractor model. As Lord Darzi said in his report to the NHS, GPs have the greatest financial or fiscal awareness of all the parts of the system. We need to enhance that.

Mr Crawford: That is great. Thank you.

The Chairperson (Mr McCrossan): Thank you very much for that. I will comment briefly, because I am interested in a couple of things. The closure of a GP practice is devastating in any community, but it has a direct effect in rural communities, because it is often difficult to pick them up. In the Western Trust, my constituency of West Tyrone has suffered in the past.

I will follow up on an earlier question, and any of you can answer this. We know the knock-on effect of a practice closing, because you have clearly articulated that, but what is the implication of the trust taking it over?

Dr O'Hagan: There are three models. There is what we call independent contractor status. That is where a practice is run as a business. You then have the situation in which a trust takes over a practice. That is a salaried model. We are struggling to get figures from the trust and the strategic planning and performance group (SPPG) on how much that costs, but, having looked at what doctors are paid as locums, we suspect that the cost is astronomical. The CIC model also costs more. Ciaran is involved with a CIC, so he can tell you better than I can. It is a salaried model as well. It costs more, but you get less.

Dr Mullan: As Ursula mentioned, it costs at least 30% more to run CIC practices. The difference between the trust model and the CIC model is that a CIC has a clear three-year plan to make the practice attractive again in order to recruit independent contractor status. A lot of the early practices are coming to the end of that three-year plan. If core funding is not addressed, the CIC practices will struggle as well.

To answer your question on the trust piece, Chair, essentially, where there are staff in a practice who can continue to work, they will move over into the trust. Ultimately, GPs who may have been partners in that practice may be offered salaried work in the trust, or they may leave, in which case the trust then has to recruit. It is as simple as that.

The Chairperson (Mr McCrossan): This is the critical question: if you are offered a salary, is it at a higher level than you previously received?

Dr Mason: That is hard to know.

The Chairperson (Mr McCrossan): OK. You do not have those figures. My concern is this. Things are clearly tough, as you have outlined. If, when things get tough, after making difficult decisions, practices ultimately have to close, is there a risk that trusts, by taking over the practices, incentivise — I use that word loosely — the closure of those practices?

Dr O'Hagan: The answer is yes.

Dr Mason: Absolutely.

Dr Mullan: It is the domino effect that Ursula talked about earlier.

The Chairperson (Mr McCrossan): We do not only have a locum challenge.

Dr Mason: If a trust or any contractor takes over a contract, it is duty-bound to fulfil the contract, which means that it has to provide services for patients. You have to do that in an open market. One of the struggles for practices in a trust-run contract is that they cannot recruit locums. They cannot stabilise their practice, because there are higher fees for working in a trust-run practice. We do not even know how many salaried doctors work in trust-run practices. We know that there are lots of locums, but we do not know how many. If the practice next door to me closes and is taken over by the trust, and I think, "Gosh. They are doing that kind of work for that kind of money, while I am absolutely knocking it out of the park every day and am two minutes from burn-out", why on earth would I do what I am doing, when they are doing what they are doing? I will just hand my contract back too. We will end up having a service that costs infinitely more.

The Chairperson (Mr McCrossan): That gives me and, I am sure, other members particular concern. I will use the Western Trust as a local example because this happened in the Western Trust: what the trust thinks is a solution is creating a wider problem, which is caused because the Department of Health will not properly fund GP practices. Is that accurate enough?

Dr Mullan: The trusts are being charged by the Department to take on the practice when there is no alternative.

The Chairperson (Mr McCrossan): That potentially creates a larger problem down the road.

Dr O'Hagan: Potentially, yes.

Dr Mason: If you were to ask the trusts, I suspect that they would say, "We would really rather not, thank you very much, but we have been told that we have to". It is no fault of theirs. They have to provide a service. Every citizen in the country needs access to a GP service. That is part of where they are. They are caught between a rock and a hard place.

The Chairperson (Mr McCrossan): It looks like a typical sticking-plaster approach instead of a solution. Ultimately, if we dealt with the problems that we face on those issues, we would not have to have the sticking plaster. I appreciate your honesty. Colm wanted in, briefly, and then we will go to David Honeyford.

Mr Gildernew: I will wait until you come back. The moment has passed, in a sense, so I will come back to it and let David to go ahead.

Mr Honeyford: Thank you for coming in. It is difficult to listen to what is happening. We get it from the other side in the constituency offices. It is difficult for our constituents to get access to healthcare, not just the GP services, whether that is because of waiting lists or whatever. As primary services change — and you touched on hand-backs and that sort of thing — do we need to start again and look at a new model of delivery?

Dr O'Hagan: No. Fund the model that we have.

Dr Mason: The evidence is there: the independent contractor model has the best financial discipline of the entire health service. It delivers more for the money that goes into it, and the returns are there. The other models that are being used are more expensive. I am not sure of any other model anywhere in the world that delivers the same amount of benefit as a well-resourced workforce in an independent contractor setting. We have so much buy-in. GPs live and breathe their practices every day of the week. We create flexibility for patients, and actually, we can deliver in our communities what they need.

There will be a variation across the board. What happens in my practice will be different to what happens in a practice in west Belfast, because the needs of the patients are different. I can make my decisions and they can make their decisions to deliver for their patients within the confines of the contract, but we are able to have a bit of flexibility. Other models would create a degree of inflexibility and would cost more, so I would challenge the question, "Do we need to look for something else?" No. We just need to make sure that we do not break the bits of what we have that are not broken and that we fix the bits that have broken over the last decade.

Dr O'Hagan: It's a bit like:

It is not going to be too long before we are all gone if we keep going at the rate that we are going.

Mr Honeyford: To clarify that — and I am not suggesting; I am just trying to tease it out as you speak — should we be looking at something else? If you were starting from scratch tomorrow, and we did not have GPs today but we will have GPs tomorrow, and you had a blank sheet of paper, is the model that we have now exactly what you would put down on that page as the business plan and design?

Dr Mullan: If it is properly resourced, and you put in a primary care team around core general practice provision, yes, that would be the best model.

Mr Honeyford: OK, that is fairly fully answered. Thank you.

Mr Delargy: Thanks very much for your presentation. You have probably answered a lot of my questions already in your really detailed presentations and responses. Thanks very much for that. Can you provide any additional detail on the Department's commitment to build and retain the existing GP workforce, and what more can be done? I appreciate that, in the context of what you have said, that question is generic, but I have a follow-up point or two as well. Is that OK, Chair?

The Chairperson (Mr McCrossan): Yes.

Dr Mason: On the existing workforce, we released a strategy document, 'A Workforce Fit for the Future: RCGPNI Retention Strategy', last year. It was a series of 17 recommendations that would create short- to medium-term stability. It needed to be read in the context of needing additional investment and a proper workforce plan for the future. That was to keep the folk that we have in place in place now.

We went across the entire country and spoke to GPs from every stage of their career and in every area. We asked them what would keep them in their role and what would make them go. Those 17 recommendations were fixed on, essentially, workforce and workload. There is a huge issue around workforce. We have talked about that significantly. The GP workload is huge.

Emma has talked about the implications of burnout and what is happening, but there are things that could happen in a workload space that would make a difference. We do a lot of work that is not ours and that belongs to another part of the system. However, it comes to us because we are the most accessible part of the system and the part that patients see. There are huge amounts of work that probably need to be done in the secondary care setting but end up on our desks. If that could be taken from us, it would make our day so much easier. We would then have an eight-hour day rather than a 12-hour day.

There are also aspects of digitisation. A huge amount of what we do still sits in the past.

There is this lovely Encompass IT system that is working across secondary care, but it does not really interface with our systems. What we really need, and what we really would like to see, is the introduction of electronic prescribing. That would shave probably 60 minutes off my day and allow me to see six more patients. That is the kind of thing that GPs talked about in respect of workload. Workload, however, is directly related to the number of GPs and practice team members, which is directly related to the amount of funding that comes in. Workforce and workload are inextricably linked, but, to keep people in their job, we need to make sure that the terms and conditions for people who are working here are similar to those elsewhere on these islands. That is hugely important. We also need to make sure that GPs who are in jobs are not burning out.

We are keen to ensure that there are supports in place for GPs and practice team members who are struggling, as Emma talked about. We are the only area in these islands that does not have a practitioner health programme for GPs and clinical members of the team who are struggling with mental health and other problems. We do not have access to a dedicated programme that every other clinician and doctor across these islands has access to. We need to make sure that we keep well the people in our system who are keeping our population well.

That is just a flavour of what we are talking about. We can furnish you with the whole strategy on retention of the GP workforce, if that would be helpful.

Dr O'Hagan: We cannot overstate the benefits of e-prescribing. We spend hours every day pushing and signing scripts — you know the days that you have been in work, because you come home with a green finger. The scripts that we sign are piled high, and we are trying to make sure that they are correct and safe. That bit of green paper gets lifted by a patient or is sent to a chemist and the chemist delivers it. There are bits of green paper going round the system, and all of that could be abolished by having e-prescribing. E-prescribing has been operating in England for years. The technology is there. It was switched on overnight in the South when COVID hit. Now, they are telling us that they hope to have it by 2034 — that was the last estimate.

Dr Mason: Ten years.

Dr Murtagh: Given the way that we work, we really have to have a commitment to sustainability. That is a major issue when it comes to e-prescribing. There are vans driving around, bringing prescriptions from my practice to pharmacies, never mind the paper and all the consumables involved. It is really important that we move e-prescribing forward.

Mr Delargy: Those are practical suggestions. You offered to forward any other reviews or suggestions in writing, and that would be welcome. We need to distil all that information and ask the Department specific, targeted questions about how all of this can be done better.

I am particularly interested in the contracts. You have delved into that issue quite a bit already. Often, when we talk about contracts, it is about contracts being handed back and crisis management and crisis support for contracts. I am really interested in the other end: the access for GPs to take on a contract and the support that is in place for them. Obviously, there are financial implications. Is there any financial support to allow people to take on the management of a practice? Are there any mentorship programmes? What support is there to encourage people to take on the management of a practice?

Dr O'Hagan: If you apply for a practice that has been handed back, for talk's sake, and you are successful in gaining that contract, there is a three-year programme of additional support. It is based on so many pounds per patient per year. However, that is withdrawn after three years. The CIC practices are trying to support partners who are already there or new partners who are coming into their seven practices. They have a three-year programme whereby experienced GPs and practice managers go into those practices to build them up, give support and make sure that the doctors there are transitioned from being salaried into the position of taking over the practice and running with it. It can be daunting. It is not just about seeing patients; it is about all the other stuff that we put on the iceberg in our briefing paper. You have to be a business manager and run a HR department. You have to look after your staff and ensure that they have the correct terms and conditions. It is daunting, but there is some support out there. It can be difficult when an experienced GP, who has been doing all the business management, retires. You sometimes see younger GPs panicking and thinking, "I can't do this", which can also lead to a practice closure.

Dr Mason: An important thing, which we mention in our strategy, is the GP fellowship programme. It could be a two-year programme that supports the career development that you talked about, Pádraig. It is about trying to ensure that GPs are equipped not only to see patients but to be managers, to deliver the service, to support business development, to be the employer and to set the direction. That kind of programme would support that. We know that the vast majority of GP trainees want to stay in Northern Ireland and would be open to the option of a GP partnership within three to five years of qualifying. They do not want to walk into a partnership, and they are not equipped to do that by any means, but we could do things that would enhance their ability and support them to take up those posts. We are just not doing enough of those things.

The Chairperson (Mr McCrossan): To incentivise them.

Dr Mason: Yes.

Mr Delargy: That is what I am getting at. From your responses, it is clear that there is potential to change that and that you have ideas and strategies on how it should be done. There are many strands to that. Would it be fair to say that what is there at the moment does not suffice? You have talked about incentives and strategies that could be put in place: for example, giving better support and mentorship. Is there anything else that would increase the opportunity for people to take on partnerships?

Dr O'Hagan: Funding.

Dr Mason: Funding, yes.

Dr Mullan: It comes back to the core funding issue that we talk about. When we were coming into practice, the model meant that the job was attractive. You had more senior members when you were coming through as a trainee. You may have had locum shifts in a practice and got to know all the different aspects of practice management, alongside the evolution of the practice managers that have come in. If that model starts to deteriorate because of a lack of ability to address core funding, you can incentivise left, right and centre, but, ultimately, it will not be enough. You will just move to a salaried model, which will be trust or federation delivered, and it will be much more inefficient. It comes down to core funding and young GPs coming into a practice and gaining a raft of experience, whether that be clinical, management or business. If that core funding model is not there to support it, the young GPs will not be attracted to it.

Dr Murtagh: We also need to look at the narrative surrounding general practice. It is negative. Whatever you see on social media or mainstream media —

The Chairperson (Mr McCrossan): It is a bit like being a politician. [Laughter.]

Dr Murtagh: We are all in the same boat, so we get it. You can understand how demoralising it is when you open your social media and see those stories about the job that you spend hours per day doing. A GP's day is now accepted as being 12 hours: that is standard. Days are split into sessions, and half a day is a session. It is accepted that a six-session week is full-time. That is 36 hours, which is practically your 37 and a half hours of a standard week. We have to try to address the public narrative, because that is most certainly putting young GPs off coming into substantive posts.

Dr O'Hagan: That is not counting the hours that GPs spend on the computer at night doing bloods, letters and whatever else.

Mr Delargy: There are multiple elements. It would be really interesting to pull all that together into four or five specific asks that we could take back. That is probably on us as a Committee. Chair, maybe we could have further engagement with the witnesses, whether that is a follow-up in writing or something else. The more specific we are, the better it will be for getting actions in place.

Thanks very much. Your answers have been really comprehensive throughout, and you have helped us to get a better understanding.

Dr O'Hagan: Pádraig, to summarise: National Insurance, indemnity and the £80 million, please.

Dr Mason: Plus the 17 asks that we have in the retention strategy. We are not asking for much.

The Chairperson (Mr McCrossan): I would have started with the £80 million, but, as long as it is in there, that is grand. [Laughter.]

One of the key frustrations for me, having been a public representative for almost 10 years, is that, while we are slow to implement change and complain that we cannot afford to do the things that we are doing, we do not effect any change. Government here takes a sticking-plaster approach to most things. However, there is a significant investment happening with Encompass. I do not know whether you have looked at that in any great detail. We talked about electronic prescribing. Have you explored whether there is an option for electronic prescribing, as Colm said in the previous session, to be built in or be like a bolt-on to the Encompass system?

Dr Mason: I sit on a working group that is tasked with making progress towards electronic prescribing. That is not really an option. Electronic prescribing will sit within a primary care setting rather than a secondary care setting. Encompass is largely a secondary care IT system, and what we use in primary care is different. The other challenge with an e-prescribing system is that it needs to work in both general practice and community pharmacy. It potentially needs to work elsewhere across the system, but let us just talk about general practice and community pharmacy because that is where most prescribing happens. There needs to be the same system in both, because it has to go from one to the other. There are lots of different models across the world. The one in England, which Frances talked about, is up and running. It absolutely could be lifted and shifted, although there are challenges around procurement, funding and the timeline, which are the big issues. Other models elsewhere are being explored.

A challenge for us is that it has been on the agenda for the past 10 years, and it now looks like it will be on the agenda for the next 10, so we come back to the whole aspect of demoralisation and what value is placed on general practice within the system. We see all the lovely new IT stuff that is going into secondary care and all the money going elsewhere, and we are sitting with our 5·4% thinking, "Nobody really values us. Nobody really thinks that it is worth investing in general practice". The public and GPs just have that perception. There are fixes, but a big challenge is that most of those fixes require money, and that is the big barrier to e-prescribing being implemented.

The Chairperson (Mr McCrossan): The cost of not doing it is greater.

Dr O'Hagan: Exactly. You got it in one.

Dr Mason: It is huge.

The Chairperson (Mr McCrossan): That is important. In this place, we always have to come back to the cost of not acting. "Invest to save" is a term that is used quite a bit, but it does not happen a lot up here, which is deeply frustrating.

Dr Mason: There is a £14 return for every £1.

The Chairperson (Mr McCrossan): Did someone say earlier that they have said that it will be a decade before electronic prescribing can be brought in?

Dr Mason: It will be about 2034.

The Chairperson (Mr McCrossan): If that is the case, given how technology is advancing by the day, it will be out of date by the time it comes into measure. We will be using AI to order prescriptions. The pace at which things operate here is unacceptable. That is where the wastage is happening, and that is why there is not proper investment in the services that we are talking about. You have articulated the problems clearly.

Mr Boylan: I thank the witnesses for the presentations. They were comprehensive. Frances, I apologise: you have come up from the beautiful constituency of Newry and Armagh and I could not be there in person.

Like my colleague who asked the previous questions, for us to formulate recommendations at the end of this, I want you to be succinct and specific in your answers. I will try to narrow it down. Frances, you mentioned different percentages. We know that funding in the North has traditionally been lower than that anywhere else in the UK. What level of investment is needed to sustain and build general practice?

Dr O'Hagan: As I said, £80 million is what we need in the coming year; that is 1% of the total budget. We will then try to move to a minimum of 10%, which historically it was. In England, Scotland and Wales, they are asking for 15%. The 15% would allow you to bring more care into the community.

Mr Boylan: Is that 1% the £40 per patient increase mentioned in your paper?

Dr O'Hagan: It is the same thing: £40 per patient multiplied by £2 million is still £80 million.

Mr Boylan: One hundred per cent. This is for us to get a better understanding. You gave comprehensive briefings and answered nearly all the questions. I just want to get it into my head for reference once we go to make the recommendations.

There is an increase in the number of private GP practices. What impact is that having on access but, more importantly, on those who cannot afford it?

Dr O'Hagan: Exactly: it is about the people who cannot afford it. It is also a variable service. We provide access to everyone, but some private GPs provide access only in certain areas: for example, family planning or joint injections. We love doing some of that stuff, and it is easy. A complicated mental health patient will not go private; they will come to us. A frail elderly person who has four or five chronic conditions will come to us. Private GPs provide some access, but it is for the low-hanging fruit. We still get all the complicated conditions, and that is how it should be, because private GPs do not have access to any medical records; they just have what the patients tell them.

We have a particular problem with online prescribing by private GPs, particularly those in England. If they prescribe a patient the weight-loss jab, we will get a letter to say, "By the way, your patient got this. We would like you to check that the patient doesn't have a list of 20 things". Where am I going to get the time to do that, and what do I do if I think that it has been prescribed inappropriately? We had an instance where we believed that it had been prescribed inappropriately against the indications and said, "We really need to go back and let the company know", and they refused us consent to go back to let the company know. It can make for difficult relationships with daytime general practice, especially in the area of prescriptions.

Dr Mason: Cathal, it is another symptom of the issues that we have articulated. Our patients would not need to turn to private GPs if there was capacity in the system for us to see them on the NHS. It goes back to the comment that I made at the start about what it is that we, as GPs, want. More and more of those private services are available. The concept of the private GP has only sprung up in the last couple of years. When we all qualified as GPs, no GPs worked privately — hospital consultants absolutely did. You went into general practice in the knowledge that you would only ever be an NHS GP, because that is what we did here. Now we have a shift, and we will struggle to pull back from that, because those early-career GPs — Emma talked about all the challenges and all the negativity — look at it and think, "Actually, I could set up a private service here and see all the really easy stuff. It'll be really easy pickings, and I'll make a really good amount of money out of it. Why would I bother going into an NHS setting where I'm going to work 12 hours on a full-day shift and, then, when I go home, have all those challenges from all the really complex patients swimming about in my head and have to hold all that risk?".

It is really important to remember that NHS GPs carry an inordinate amount of risk. That is because of the volume of patients whom we see, the complexity of the cases and the fact that they are undifferentiated. Every person who comes through my door could have anything and everything, and I need to be able to handle that, so we carry a huge amount of risk. For our colleagues in the private sector, there is a different model of service delivery. The more we underfund NHS general practice, the more our patients put their hand in their pocket. They fund private general practice; they make up the shortfall from their own pocket.

Dr O'Hagan: On the issue of carrying risk, we have not really touched on waiting lists. If I sit in front of somebody and say, "You're 70. I'm referring you for your hip", they will ask, "How long will that take?". It will probably be five years before they are seen and another five to seven years before they get their hip done. When the patient is referred, the risk is with us until they are seen in five years' time. They are not yet a patient of a consultant; they do not get allocated a named consultant until shortly before their appointment. We carry all the risk of that person getting frailer, needing increased medication and being in severe pain. Last week, one of my patients, who was on a waiting list for his hip, joked, "I probably never would have got it. One benefit of falling and breaking my hip was that I got it done".

The Chairperson (Mr McCrossan): I have written about more hips and knees in west Tyrone than I can count.

Mr Boylan: Frances, the report states that GPs are reducing their working days and leaving the profession. Will you give three or four bullet points to explain why that is happening?

Dr O'Hagan: We are not actually reducing our working day. Our working day is 12 hours. Three 12-hour days and the time spent doing paperwork at home equate to working more than full time. It is impossible to do five 12-hour days. It is just not possible. If you add up the hours, it is ordinary full time. In a salaried model, a salaried GP will only work 37 and a half hours at most.

Mr Boylan: The model is there and is working, as long as it is properly funded: is that the gist of what you are saying?

Dr O'Hagan: Yes.

Dr Mullan: Correct.

Mr Boylan: OK. Thank you very much.

The Chairperson (Mr McCrossan): Cathal, to supplement that briefly: to be fair, when you compare it with how other jurisdictions are funded, it clearly points to a disparity and a problem here. Whilst there are problems in other areas, ours seem to be worse.

Mr Boylan: That is why we are doing the inquiry: we are trying to ascertain the problems and challenges. It has been a good session so far. Thank you, Chair, for letting me back in.

Ms Brownlee: This genuinely has been really insightful for all of us, so I really appreciate your time. In response to Cathal's question, you touched on risk and the safety of patients. You talked about the workforce, the extreme pressure on staff and the workload increasing. How do you think that it is all impacting patient safety and risk?

Dr Mason: A patient on a red-flag waiting list who waits months to be seen: that is just one example. We could sit here for the next six hours and give you examples. You might talk to a GP who is almost in tears because they are referring a patient who cannot afford to go privately, and they know that that patient in front of them has cancer, that they are not going to be seen, and that, when they are seen, their cancer will have progressed to the point where what would have been a good outcome will be a bad outcome. That is what we are dealing with every single day. That is not talking about the people for whom you know that, if you could get in there early, it would make such a difference. We are really good at preventive care, we are really good at doing proactive things and we are really good at treating the whole person.

However, we are firefighting every day. If a patient comes in and you know you have 20 more to see, you cannot give them what they need. We are trying to almost ration what we have for the people who need it, knowing that there is a huge amount of need out there that is not being met. That is the thing that plays on all GPs' minds. What contributes to burnout is knowing that you will potentially miss something or, when you do pick it up, that it is not going to be actioned. I talk to GPs who have moved to the South, and they have said, "The reason I've moved to work in the Republic is that, when I refer somebody, they get seen and sorted. I know I'm doing a good job. They come back to me, and we've got the outcome that we needed". That does not happen here. We refer patients, and we know that they are probably never going to be seen if it is a routine thing. We do not have routine care here anymore. I could refer a four-year-old child who needs a tonsillectomy to ENT, and they will be out of primary school before they get surgery. That is what we are dealing with, and that is why our workload is so huge.

We are seeing patients again and again and again and again. If you could take that away from us, we would have a lot more ability to deliver for our patients. That has an impact on patients, and it is soul-destroying. I work in a region where someone can come in to me and say, "I've got a problem — and I've got private health insurance, doctor". Part of me thinks, "Thank goodness for that". The other part of me thinks, "What about all those people out there who do not have that, who cannot put their hand in their pocket or who are going into debt?". When you get that day in, and day out, it really does have an impact on the care that you can deliver for patients.

Dr O'Hagan: If you are referring somebody to get their hip done, there is a way to skip part of the waiting list. You can pay privately for the initial consultation and then get put on the NHS waiting list of the doctor who sees you privately. It is ironic that one of the large private hospitals in Belfast now has a payment plan with the credit union. That is shocking. I only found that out the other day. People are going into debt. People are saying to their families, "I don't want birthday presents or Christmas presents. I want that £200 or £300 so that I am able to go see the consultant. At least I am skipping the first four or five years". It is absolutely soul-destroying for the patients and for us.

The Chairperson (Mr McCrossan): On the ground, I see more and more of that. The continual message in the public domain is, "Look after your health". However, when people cannot access healthcare, they will, if they can afford it, pay whatever they can to access it.

Equally, people who are paying National Insurance and their taxes feel that they are not getting their fair share, and, ultimately, they are going on alternative routes. It is just a symptom of the whole system falling on itself simply because the system is not solution-focused. It is continually sticking-plaster approaches, which is deeply frustrating generally.

On the scenarios that you spoke about earlier about hips and knees, there is not a week in my office that I do not have multiple people of a certain generation coming to me asking me to write to the trust in relation to it. It is very frustrating. The cross-border scheme alleviated some of the pressure —

Dr O'Hagan: Yes, it did.

The Chairperson (Mr McCrossan): — and it gave people a lease of life, but I have seen people's health and well-being worsen because, by the time they get one hip fixed, the other hip is having the same problem because of all the strain. It is affecting the quality of life.

Dr Mullan: The focus of the session is access. Those same patients are asking us to write the letters to expedite their appointments and their surgery. While they wait, they continue to come through our doors. A lot of it could just be anxiety about the wait, but a lot of it will be progression of symptoms. They will become sicker. It is as simple as that. That impacts dramatically on access.

We talk about revolving-door patients. It is because we know what they need. They are not getting what they need, and it has an impact on access and primary care as well.

Dr Murtagh: They develop other conditions because they are not able to move, they are not able to exercise and their physical and mental health suffers. We are sometimes being forced into prescribing pain-relieving drugs or patches that the patient otherwise would not need. There are all sorts of issues with those.

We see patients on multiple medications. The vast bulk of them are sorting out a problem that has been caused by another medication that they are given, and those people are potentially having to go on antidepressants, which is another issue because we do not have the access that we need to counselling and therapies in the community. The ripple effect is massive.

Ms Brownlee: I do not think that a day goes by when MLAs do not get those types of complaints and concerns. It is horrific. When you say that your health is your wealth, at no point should finances and bank balances ever be taken into consideration. You should be able to be seen and get that support at the time of need. We are in a situation where that is clearly not the case any more, and it is horrific.

I want to touch on the long hospital waiting lists, which we spoke about, and how that is impacting on primary care.

Dr Mason: We talked about the impact on our workload. I am going to turn it to be more positive because there has been a lot of negativity. There is a scheme in general practice that deals with very routine things that can be dealt with by using GPs who are upskilled in certain areas. That GP elective care service has been one way to try to reduce waiting lists in secondary care and, in a way, to stop patients getting referred in the first place. It has been a very successful scheme, albeit funding to it has been cut.

As GPs, we would like to see the scheme rolled out more to develop further pathways where we could see patients. Again, it is about bringing care closer to the community. If you have a community hub that can deliver for patients so that they do not need to go to hospital, that is bound to be much better. It is also much more cost-effective.

For example, the vasectomy service in the general practice elective care system delivers vasectomies across the region. Prior to the service being introduced, there were probably only about 50 vasectomies done in a 10-year period. I am not sure that those numbers are true, but it was a very small number. In fact, those vasectomies cost three times more than they cost in primary care. It is a service that has been developed with GPs upskilling and developing special interests. It is an area that our early-career GPs want to do. They want a special interest; they want a portfolio; they want to be able to do something more than general medical services. That service now delivers cost-effective vasectomies in communities for patients.

They also deliver across a range of options such as women's health, musculoskeletal medicine, dermatology and a few others. It is one example of the flexibility and innovation that I talked about that happens in general practice. We want to make sure that the system works, and that is one way that we can deliver for patients. We can do those more straightforward procedures by upskilling GPs, and we can do them more cost-effectively in a community setting. If we can upskill our workforce, it will keep them in their roles here, because they see that as an attractive option. We talked about the negative side of the waiting lists and all those patients coming back, but that is one positive aspect around the waiting lists.

The hubs also reduce health inequalities. We know of the need that is met in communities. A local GP practice is much more easily accessed than travelling miles and miles to a hospital for something for which you do not need to be in hospital. That is just one example.

Dr O'Hagan: This point is a bit ironic. One of the services was for women — women's health. We are the only one of the four nations, including the Republic of Ireland, that does not have a women's health strategy. Some of the great and the good went across to look at the system in England, because England has women's hubs that run really well and take a lot of care out of the hospital. When those people asked, "Where did you get the idea?", they were told, "We got the idea in Northern Ireland". That is what they said, yet we have defunded it here and have no women's strategy. It is ridiculous.

Ms Brownlee: Thank you.

The Chairperson (Mr McCrossan): You would be a good politician. [Laughter.]

Ms Brownlee: I was going to say that.

Thank you very much for that. During the Committee's previous evidence session, one word that struck me was "communication". You have opened my eyes to how you have been affected at the coalface. You deal with this daily, and the figures, statistics and data that you presented have allowed me to look at this in a totally different way. Do you feel that the Department supports you? Do you feel that it tells the story of how you are dealing with the situation at the coalface? Is it educating patients in order to make sure that they have the knowledge and understanding of where to go, how communication happens and what options are available? You listed a number of ways to access GPs that I had not thought of. That is a key point: we are getting a fantastic service, but sometimes we do not realise it.

Dr O'Hagan: The iceberg graphic in our submission is a good way of demonstrating that. The short answer to your question is no, we do not feel supported. We do not feel that our story is being told. That is evidenced by the fact that people are still saying that GP practices are closed and that GPs do not see people face to face. We would like to try to get rid of that myth.

The other way that the Department could support us would be to bid for funding. In last year's June monitoring round, £120 million came to Health. How much of that came to primary care? Not one penny. As individual GPs, we cannot bid for that; we are dependent on the SPPG part of the Department to bid for that funding on our behalf. We did not get even 1p of it.

The Chairperson (Mr McCrossan): You are at the coalface.

Dr Mason: GPs feel devalued by that, and that feeds that narrative. We feel that the system does not value us. Given that everyone describes value in terms of monetary value, the fact that it is 5·4% of the budget speaks volumes. That is the value that the system puts on general practice. If that is the value that is put on us, here is where we are.

Ms Brownlee: I appreciate that.

Mr Gildernew: There was a lot of information there and a lot of issues that I recognise from my previous role as Chair of the Health Committee. I absolutely and fundamentally agree with your comments about the potential for a shift left. Far too often, we talk about transformation only in terms of hospital transformation and secondary care, but there is huge potential for primary care and community care to put more assets out into the community.

You mentioned the population increase, which I also recognise as being an issue. It is not just population increase that is a problem, but the fact that people are getting older and there is more complexity, as well as the waiting list issue that Cheryl touched on. When I left social work in 2017, where I had been with an older persons' team, our workload had been increasing, numerically, by 5% or 6% year on year, with no increase in staffing. There is a similar dynamic in GP practices.

We could also do more on the changing profile of GPs. As you touched on, there are many more younger women who are not prepared or do not want to work all the GP sessions. There is much more work to be done there. That would probably take up a whole other report as well, but I absolutely recognise that issue.

The negative narrative absolutely needs to be challenged. There is also, potentially, a bit of a negative narrative in medical training for GPs, which needs to be challenged. I welcome the Magee medical school model whereby we take in older graduate entries who may be more rooted in GP practices. I hope that that all helps.

Given the time, I will get straight on to my question. How essential to the public is the development of the MDTs — the multidisciplinary teams — with the physios, the OTs, the social workers, who have been mentioned, and all those other professions? How essential is the implementation of MDTs to removing or reducing pressure or for assisting you to deliver your service?

Dr O'Hagan: It is a very important part. At the minute, it contributes to the inequity: the word "patchy" was used earlier. You must remember what is behind that. All our professional colleagues are fantastic and work really well, but they are not used to working autonomously. A level of supervision is required from the GPs, and the members of the MDTs need to come back to GPs to query things. If you do not have enough GPs, you cannot implement the MDT model: it is not possible. You need GPs on the ground to work with those colleagues, and then the model will work.

I want to make the point that it is not just women who work six sessions a week. My male partners do exactly the same.

Mr Gildernew: Absolutely. I understand that. What I am saying is that we should recognise that we have many more younger women who are maybe starting families and simply cannot commit to that level of work. I wonder whether we are providing enough flexibility in the contracts that we are offering. Related to that is the issue that you touched on about them not necessarily wanting to run a business. Is there more that can be done?

Dr Mason: I do not think that it is about what they want: it is about facilitating and supporting them. As I said, when we ask our early-career GPs, they want to be GP partners and to achieve that within a three-to-five-year time frame. It does not matter whether they are male or female. There are three female partners sitting in front of you, and we all have families. We have to make sure that we do not go down the rabbit hole of thinking, "We have an increase in the working population of female GPs, and we must make sure that we do that." We just need to make the playing field a level one for GPs and to make sure that we are resourced enough to support them in their career. That is probably a bigger, wider question for another time.

I will return to the issue of MDTs, if you do not mind. We recognise that having a wider practice team and care in the community is better for patients. There is a stabilising factor there, in the short term, from an MDT perspective. I speak as a GP who will probably be one of the last to get an MDT because, where I work, we are at the bottom of the list. There is great inequity for the patients in my practice compared with the ones who live four miles down the road and are registered in a practice that has had an MDT for the last four or five years. It is hard to fathom that patients suffer huge inequity of access.

Frances talked about core general practice. That is vital. The figures are out there. The Audit Office figure for the funding of GMS across the region in the year 2022-23 was £375 million. A fully rolled out MDT is going to cost somewhere in the region of £116 million. That is to add one whole-time equivalent mental health worker, one whole-time equivalent physiotherapist and one whole-time equivalent social worker for every 10,000 patients. We need to be careful about making sure that there is proportionate funding for the delivery of service in a community setting.

MDTs are really important, and I would welcome a faster and more equitable roll-out, but I need to make the case that we cannot fund them at the expense of general practice.

Mr Gildernew: I have a final, brief question on that. Earlier, the Chair asked, "If you had more money, what would you do with it?". You answered that you would invest in staff. If you had the money right now, do the core GP staff and the MDT staff exist, and is enough being done on workforce planning?

Dr Mason: There are issues around training and staff availability for MDT roles. There has been an announcement. In order to staff an MDT, you need to train those people. However, from a general practice perspective, we need to increase the number of GP trainees that we have: we need to increase that workforce and that pipeline. We are losing GPs, and we need to replace them. We need to make sure that we have more GPs for the ageing population that you talked about.

If I had more money tomorrow, would I put it in MDT or core GP? I would probably put it in core GP, because we are at the risk of hugely destabilising the service. You talked about hospital reconfiguration and where we need to go. We are sitting on and delivering the foundation of the health service. That foundation is really unstable. It has cracks in it that people probably do not comprehend. We need to make sure that we shore that up and stabilise it. MDTs are a way of doing that, but you cannot put an MDT around a practice that does not exist.

Dr O'Hagan: That is why we are asking for the funding incrementally. We are not asking for the 10% all at once; we recognise that we could not spend that all at once. However, if you gave us 1% year-on-year, we would definitely be able to bolster general practice, get more people in, come up with ideas about how to keep our trainees and look at the different schemes that are available. That is what the money will be used to do.

Mr Gildernew: I thought that I had a fairly strong commitment from the previous Health Minister about the indemnity issue, so I am disappointed to hear that more progress has not been made.

The Chairperson (Mr McCrossan): I agree. We will chase that up.

Dr O'Hagan: There is an indemnity offer with us at the minute, but we cannot give that on its own to the profession to decide whether it is enough. We need indemnity, NIC and core. On its own, the offer for indemnity is not enough; we need the others as well.

Mr Gildernew: One brief thing, Chair, to say on the record —.

The Chairperson (Mr McCrossan): You have been very patient with us, Colm, so work away.

Mr Gildernew: We talked about the cross-border scheme. It is worth remembering that, a number of years ago, we lost access to the whole of Europe as a result of Brexit. That was a huge loss.

The Chairperson (Mr McCrossan): You have been great witnesses. You have been with us for two hours or so. We really appreciate your time. The presentations were very hard-hitting. The answers to our questions were very blunt and honest. They have put shape on where things are from our perspective; I think that I speak for the Committee in that regard. Knowledge is power, and we have learned today things that we did not know previously.

You talked about £80 million, which sounds like a lot of money, but, when it comes to fixing something as vital as local GP services, it is very little as a starting point. There was a headline in December that stated:

We do so much so badly. There are things that we could fix and do well. I have heard, for countless years, constituents complaining about access to GPs and everything else. What you have told us today is a very different story, and one in which each of us has a role to play; we have a responsibility to challenge the narrative, to support our GPs as well as our patients, and to challenge the Department of Health to step up and start doing more. Just over 5% of funding is not adequate when you compare it across the board. Your very honest answers to our questions today reflect that.

Cheryl asked whether you feel supported. I knew from the outset of your presentation that you do not. That is very difficult for GPs, who are doing an extremely challenging job. It is often similar to politicians a wee bit: we never hear about the good that we do; we hear about just the bad. It is important that the Assembly and the Department of Health get a handle on the issue. You are not asking for the mountain; you are asking for a bit of help to put things back in the right direction.

I really appreciate your honesty. You have made the session quite straightforward for us. We have got a lot out of it. I am sure that the Comptroller and Auditor General, the Northern Ireland Audit Office team, Stuart and Julie will agree.

Do you have anything further that you would like to say?

Dr O'Hagan: Thank you for giving us this opportunity, for allowing us to speak plainly, and for taking on board what we have said. We want to provide better access for everybody. We can do that if we are funded properly.

The Chairperson (Mr McCrossan): You are saying, "Let us do our job". That is the fairest way in which to put it.

Dr Mason: All of us want what patients want. It is important that, given all the negative narrative, people understand that, even though they think that we are not working or not doing what we are supposed to be doing, that is exactly what we want. We want to be able to deliver a high-quality service, because that will keep us all well and healthy into the future.

The Chairperson (Mr McCrossan): Thank you.

Dorinnia, do you have anything that you would like to add?

Ms Dorinnia Carville (Northern Ireland Audit Office): No.

The Chairperson (Mr McCrossan): Are you happy? We have covered a lot. Stuart?

Mr Stuart Stevenson (Department of Finance): No comments from us, Chair.

The Chairperson (Mr McCrossan): Stuart, you are very quiet today.

Mr Stevenson: Some comments were made about monitoring rounds and so on. It is challenging for public expenditure and for the Department to face up to the realities of some of the things that have been discussed. That is all that I can say about that.

The Chairperson (Mr McCrossan): Change is needed. Invest to save.

I thank the panel on behalf of the Public Accounts Committee for being with us, for travelling some distance and for taking time out of your busy schedules. I can give you a full assurance that we have heard you loud and clear. Thank you.