Official Report: Minutes of Evidence

The Chairperson (Mr McCrossan): I welcome to the meeting the following Department of Health officials: Peter May, accounting officer; Gearóid Cassidy, director of primary care; and Dr Margaret O'Brien, head of general medical services (GMS). We also have in attendance Dorinnia Carville, the Comptroller and Auditor General (C&AG) in the Northern Ireland Audit Office (NIAO), and, from the Department of Finance, Stuart Stevenson, the Treasury Officer of Accounts (TOA). Welcome back to the Public Accounts Committee, and thank you for agreeing to give evidence today. It is good to have you here.

You will appreciate that we have a lot of burning questions, so, in order to make the best use of our time, we ask that you keep your opening remarks as brief as possible, because it is very likely that a lot of our questions will touch on some of the points that you will be raising. We have a significant time constraint today, given the number of questions that Committee members have on the back of previous evidence sessions.

Please do not take it personally if I interject at any point, as I will simply be trying to move the evidence session along. I appreciate your understanding. I would like today's evidence session to focus on how we can best use our available resources for GP services, notwithstanding the announcement that the Minister has just made about expanding primary care facilities in general practices. I am sure that you will want to touch on that in your opening remarks.

We heard a lot about funding last week, but I emphasise that the remit of the Committee's inquiry extends beyond funding. We will want to explore a number of areas with you today, including short- and long-term improvements to patient access; workforce and retention issues; contractual issues; and regional disparities in equity of access to GP services, including for multidisciplinary teams (MDTs). Mr May, I now invite you and your colleagues to make some brief opening remarks.

Mr Peter May (Department of Health): Thank you, Chair. It is good to be back with the Committee today. I will keep my remarks brief. Gearóid Cassidy is the Department of Health's director of primary care, so he leads on the policy for primary care. Dr Margaret O'Brien, who is a qualified GP, is the head of general medical services in the Department's strategic planning and performance group (SPPG).

First, let me state how important general practice is and how central it is to the delivery of health and social care, as well as how committed we are to making primary care a success. Secondly, let me welcome the Audit Office's report and signal that we are progressing the implementation of its recommendations — excepting a couple that we have partially accepted — to the time frames that were set out.

Thirdly, you invited me, Chair, to say something briefly about the Minister's announcement this week of the expansion of multidisciplinary teams in primary care. That is the result of a transformation bid that was made and approved by the public-sector transformation board and then by the Northern Ireland Executive. That will see an expansion of the MDT service to two thirds of the population of Northern Ireland from the current one third. I am happy to go into more detail on that in the questions that members may wish to ask about MDTs.

Fourthly, I should highlight the point that the nature of the Audit Office report can take us into the policy space very easily. There may be some things that, I believe, are for Ministers to respond to rather than civil servants. I hope that you will understand that if we get to that place. I will not be looking to hide, but I do want to flag that as an inevitable consequence, given the nature of the inquiry.

The final thing that I want to say is that we are at a very late stage in the negotiation on the GP contract for 2025-26. I hope, again, that the Committee will understand that, although we can explain broadly the areas that are under discussion, because of the nature of the contractual relationship discussion that we are having, we will not want to get into detail about numbers. We hope that that matter will be resolved within a matter of weeks, and obviously before the start of the next financial year.

Those are the only comments that I wish to make by way of introduction, Chair.

The Chairperson (Mr McCrossan): I appreciate your keeping your remarks brief. We have eight or nine different areas on which to touch. Hopefully, you will be able to provide us with some clarification. I will start, after which I will bring in colleagues. What is the Department doing to improve patient access to GPs right now?

Mr May: Thank you for that question. We all know that access to GP services is probably one of the hottest subjects in all your mailbags. We have been taking a number of actions over a number of years to try to enhance GP access, including investing money during the COVID period, when over 90% of practices got a total of £2·3 million to assist with telephony services for GP access.

You asked specifically what we are doing right now. GP access is one of the things that is on the table for inclusion in the contract this year. We are looking at ways in which it may be possible to secure guarantees about access, such as there being online access to online appointments more readily, on the basis that removing non-urgent calls from the queue early in the morning would enable more people to get through more easily.

It is worthwhile my highlighting the point that some practices do access very well, so you will hear far fewer complaints about them. A one-size-fits-all approach is therefore not required. We are looking to develop a best practice guide to encourage all practices to learn from the experience of the best.

Inevitably, some small, single-handed practices have less capacity than some of the larger, multi-partner practices, and that may be part of the feature here and one of the issues on which we need to provide support and guidance in order to try to move towards having minimum standards. We will not get there this year, but we hope at least to set a benchmark in the contract negotiations.

The Chairperson (Mr McCrossan): Thank you very much for that answer. As you will be aware, our inquiry is as a result of the Northern Ireland Audit Office's report, which is fairly detailed. Since it was published, what specific actions have been taken in response to the concerns raised in the report?

Mr May: The report contains eight recommendations. I do not know whether the Committee wants me to go through each recommendation in detail, but I am happy to pick up on some individual ones. Recommendation 1 was on the collection of GP activity data. We introduced a standardised process for collecting GP activity data as part of the 2023-24 contract. It focuses on the way in which general practices record their appointment and non-appointment activity and goes beyond what the GP or the practice nurse does by dealing with all the professional elements that are associated with a practice. We see that as being the first step in the process to creating a consistent approach to in-hours activity across GP practices, and it is based on the standards set in NHS Scotland. We are looking to build on that process. The date by which to have made progress on recommendation 1 is April 2025, and we are on track to deliver against it.

The Chairperson (Mr McCrossan): How many of the eight recommendations have been implemented?

Mr May: I think that they all have future dates for final implementation. As I said, we are on track to deliver on them, but I suspect that none has been completely delivered. Many are in the process of being delivered or have chunks of delivery against them. I am happy to provide a summary to the Committee, if that will be useful.

The Chairperson (Mr McCrossan): OK. Given the concerns raised in the report, is there any way in which you can provide data to demonstrate whether access to GP services has improved since it was published? I know that you gave an example briefly, but are there any other examples?

Mr May: We have found it very difficult to secure the base data, because, when people phone a practice and get an engaged tone, it has not proven possible for us to identify how many find themselves in that situation. Where people are in a queuing system, we can absolutely measure the data, but it is very hard to measure the total number of calls. That, in turn, makes it very difficult to be able to demonstrate the improvement that you are looking for.

We see practices introduce improvements regularly, and we think that that is making some impact, but we know that there remain challenges. We have all heard at least one story of somebody who found it difficult to get a GP appointment. That is a concern not just to the GP but to us in the Department.

The Chairperson (Mr McCrossan): I have a final question before I bring in the Deputy Chair, Cheryl Brownlee. What targets or key performance indicators have been set to track progress that has been made on the recommendations in the report?

Mr May: The recommendations may not always lend themselves to specific targets. You will see that there are recommendations on GP workforce data and the GP workforce plan, and we are making good progress against them. We have a suite of measures on GP recruitment and retention, including a GP retainer scheme, an attract, recruit and retain scheme, a GP mentor scheme, and an induction and refresher scheme. Compared with 2015 levels, we have also increased the number of GP training places by 86%. We are therefore making progress against all the recommendations.

Rather than there being a specific target, the target is to achieve what the recommendations state. In the contract, there are specific things that we look to measure. I will ask Margaret to say something about some of the ways in which we measure the success of the contract. Inevitably, in a contractual relationship, there would be expected to be a healthy tension. We will always push GPs to do a bit more than what they would perhaps like to do. They will say to us, "If you want that, you will need to give us a bit more money". That is the nature of the relationship. Margaret, do you want to say something about the core things that we look to measure in the contract and about how your team goes about doing that?

Dr Margaret O'Brien (Department of Health): Sure. Thank you for the opportunity to address the Committee today. I am head of general medical services. Currently, I contract with 307 general practices across the region. I have a small team of medical advisers, who are based around the region. We visit our practices on a three-yearly basis. Every practice gets a visit every three years, but we also look at those practices about which we have had complaints or about which underperformance issues have been raised. We therefore visit those practices in addition to those on our three-yearly programme.

For that visit, we have a set of indicators, such as looking at the number of patient complaints that there have been about the practice. We look at its performance as it relates to the quality and outcomes framework, which we stood down just this year before introducing a new Northern Ireland contract assurance framework (NICAF), so all our visits this year are in line with the requirements set out in it. There are six domains, one of which is access, and my team of medical advisers will run through the indicators with the whole practice team, by which I mean the GP partners. We use the red, amber and green (RAG) rating system to rate their performance against the indicators. We will then set an action plan, so a plan is sent to the practice following the visit. It will cover issues for remediation or provide feedback on the good work that the team has done.

We also monitor their adverse incidents. GPs come to us for review. In the practice, they have to keep a log of the number of people who are registered and the number of people whom they have removed from the register, because there are strict rules on that in the contract regulations. My team will therefore investigate adverse incidents.

The Chairperson (Mr McCrossan): You referred to 307 practices earlier. To how many practices that have had multiple alerts raised about them have you had to make a special visit?

Dr O'Brien: I do not have the exact numbers to hand, Chair, but, typically, we would have to visit fewer than 10 practices, and about a specific thing, which may be the underperformance of a practitioner or an increase in the number of complaints about the practice.

The Chairperson (Mr McCrossan): What time period are we talking about for those 10, Dr O'Brien?

Dr O'Brien: Within the year.

The Chairperson (Mr McCrossan): OK.

Mr May: There may, however, also be practices that are under stress, either because of challenges with having the right medical professionals available or for financial reasons. There may well be additional visits to provide support, which is a different sort of feature to what Margaret is talking about.

Dr O'Brien: We also fund the practice improvement and crisis response team (PICRT), on which the GP Federations lead. We work very closely with them. They assist those practices that are struggling and produce an action plan. We work with the practices as well. That is in addition to our rolling three-yearly programme to visit the practices that my team identifies and specifically visits.

The Chairperson (Mr McCrossan): OK. Thank you.

Ms Brownlee: Thank you so much for coming today. I will touch on patient access and waiting times. First, what steps are being taken, or, indeed, have been taken, to increase the availability of same-day and urgent appointments? How is the Department ensuring that vulnerable populations, such as the elderly, those on a low income and special needs groups, have adequate access to their GP?

Mr May: I will take the second question first. Access to GPs should be based on patient need first. That should be the governing principle.

We are keen to ensure that everybody can get access to their GP within a reasonable time frame. The first thing to say about same-day appointments is that not everybody needs one. For some people, an appointment could be about a prescription that they wish to discuss, so it is fine for them to wait for longer. In the contract, however, there are clear elements about the times on which a practice should be available. A specific set of times is set aside. I will ask Margaret to go into the detail. We would expect, on five days a week or for nine sessions a week, there to be availability. Margaret, do you want to say something more about that?

Dr O'Brien: The contracted hours for GP practices are from 8.00 am until 6.30 pm, so the practice will have appointments available within that time frame. On the fringes, by which I mean from 8.00 am until perhaps 9.00 am and between, say, 6.00 pm and 6.30 pm, the majority of practices have local arrangements in place with their GP out-of-hours service. Those arrangements will kick in during that time frame. In the course of the normal day, however, by which I mean from 9.00 am to 6.00 pm, practices will operate same-day and urgent appointments. How they do that will differ for each practice.

In the access domain section of the NICAF, which I mentioned previously and which we introduced for 2024-25, in order to try to standardise what that looks and feels like for patients, because we want them all to have similar access, we have stated:

and:

on all those days, apart from bank holidays.

Ms Brownlee: How does the Department monitor that? If a GP is not able to do that, is not offering appointments or is having to turn away patients regularly, how are you made aware? Is it through the complaints process?

Mr May: The complaints process is one way, but data is also produced and provided to us through the general practice intelligence platform (GPIP) that gives us an understanding of GPs' activity. We are therefore likely to catch anything that is systemic in nature. Is that fair to say, Margaret?

Dr O'Brien: Yes. I will explain what the GPIP is. Currently, we are able to extract from it the codified operational data, which is on what general practices are doing about clinical conditions. That data is anonymised before we look at it. It gives us an opportunity to look at outcomes and at the care that our practices are providing. The element that we introduced as part of our response to recommendation 1, which is about standardising how we capture GP activity data, is a new theme that we implemented towards the tail end of 2023. We issued a suite of guidance for our GP practices to code. I will refer to it as the appointment module of the GP clinical system, because the clinical system is there to record consultations, diagnoses and outcomes for patients. We are now using that clinical system by issuing a suite of codes to enable our practices to obtain the activity element. When a patient presents and wants an appointment, we are therefore able to code and determine, for example, how many appointments the practice has given out, how many home visits it has done and how many times the nurse has seen people. That is therefore done not just for the GP but for the whole practice team. We are currently pulling that information out of the clinical system.

At the minute, we are also capturing a weekly return on survey activity, which is coming from the practices, but that is more subjective. We have not been able to turn off that survey yet, because there are a few practices that really need to acknowledge the guidance more robustly. As Peter said, that is one area at which we are looking. We will have a practice dashboard in order to look at practices' activity and outcomes. That information may then trigger us to do a more targeted practice visit.

Ms Brownlee: You mentioned practices operating from 8.00 am until 6.30 pm. Are you aware of how many do that? Do you have the data?

Dr O'Brien: All of them. Those are their contracted hours. I did mention, however, that some of them have local arrangements with their GP out-of-hours service.

The Chairperson (Mr McCrossan): It is an important question, because I am not familiar with the situation locally. I am not sure whether colleagues are aware of any practice that is open until 6.30 pm. That is the reason that the question was asked.

Dr O'Brien: As I said, practices will have local arrangements with their GP out-of-hours service. It tends to pass over after 6.00 pm.

Mr May: Practices are not necessarily seeing patients up until 6.30 pm. It is just that they are open.

Dr O'Brien: Yes, that is right.

Mr May: That is the other point to make.

The Chairperson (Mr McCrossan): Sorry, Cheryl, but I just want to touch on something. You mentioned a practice dashboard. My big concern is about equity of service. We need to ensure that everyone has equal access to GP services across the board. Does the dashboard ensure that that is measured? Does it include information on opening and closing times and appointments?

Dr O'Brien: That is the intention, yes. As I said, the dashboard is not fully operational at this point, because we have a few practices that need to fine-tune things, but, yes, that is absolutely the way forward.

Ms Brownlee: We heard from the British Medical Association witnesses last week that there is an absence of routine care. Are you concerned by that statement? What plans do you have to address that gap in the provision of primary care?

Mr May: Can you say a little bit more about the context in which they described the access to routine care, please?

Ms Brownlee: A number of comments were made about the lack of availability of routine care, the lack of funding for it and the lack of workforce. They also mentioned mental health concerns among GPs.

Mr May: I think that I understand the concerns about the ability to meet the full range of demand that is placed on general practice. I mentioned the multidisciplinary teams, which are the one of the key ways in which we can broaden the range of healthcare professionals available in primary care in order to meet a greater degree of the needs of patients in a timely way. The recent announcement about expanding the number of MDTs will help hugely those areas that will be getting an MDT. We recognise that a number of GP Federations will still not be in receipt of the MDT — five in total — so there will need to be a further roll-out after the four- or five-year period of the current roll-out in order to get MDTs across the whole region. That, however, is the direction of travel for the Department. It is what we would like to be able to do.

You may be wondering why it will take us so long to roll out MDTs. Part of the challenge is that we have a limited number of healthcare professionals, so the risk is that if we were to move too quickly, we would potentially be denuding secondary care — mental health services, physiotherapy and social work — of the skills that it needs to deliver its normal workload. We have to view the roll-out as part of a joined-up system, with a single pool of skilled resource, and be careful to make sure that we do it in a way that is sustainable. We will move quickly this year, and we believe that between 60 and 70 healthcare professionals will be brought into MDTs in the next 12 months, although that is a rough estimate at this stage. That gives the Committee some idea of the scale of the roll-out and explains why, if we were to try to do it much more quickly, we might end up inadvertently creating a problem with service delivery in another part of the system.

Ms Brownlee: We were discussing the appointment system. There was financial investment into that and the like of triage and digital consultations. Do you believe that that has improved patient access? How is that monitored, reported and recorded to analyse whether there has been improvement in access?

Mr May: Undoubtedly, it will have improved the situation, but we are also in a situation in which, I think that GPs would tell us, demand continues to rise. That is a feature of the challenge that we face. I have already explained that some of the measurement of access is extremely difficult because we do not have the raw data in the way that is needed. However, we hope that, through this year's contract, we will make further progress in establishing some core standards and a core approach in relation to separation. A lot of this is about separating out the channels so that fewer people will need to make a phone call first thing in the morning.

Ms Brownlee: You touched on the fact that some practices might be doing fantastic work while others might be struggling slightly, and you mentioned the best practice guide. Has that begun? What stage are you at? How long it will be before it is delegated out to the various practices?

Mr May: I will ask Gearóid to say a little about that. Essentially, we have made good progress. It is fair to say that we have a near-final draft. We have been engaging with GPs in the development of the guide.

Mr Gearóid Cassidy (Department of Health): The development of the guide is at a very advanced stage. It is being developed by GPs who are taking a quality-improvement approach, so there is ownership from the system for what is in it. It is based on local examples of best practice. It covers a wide range of issues and is not just about how to set up a telephone system, for instance, but how to set up workflows behind it and how to optimise processes. The idea is that it will be scalable, so if a practice has an MDT, it will obviously be able to offer a different range of things than a practice that does not. It should be reflective: there should be something for everyone.

On implementation, if you want to think of it in that way, through the contract for the upcoming year, as Peter has touched on, we are looking at making amendments to improve access for patients. Our proposals are based on the content of that guidance. Over the course of next year, we want to establish a programme to work with practices to help them change and optimise. The details have not been worked out, but the idea is that we will not simply have a piece of guidance to sit on a shelf, but a business change programme to sit alongside it to help practices. The idea is that that will be rolled out across the region sequentially. The first step is a contract for next year.

Ms Brownlee: Is there a time frame for that? Has the Patient and Client Council (PCC) been involved in the design of that document at any stage?

Mr Cassidy: A time frame for the roll-out, you mean?

Ms Brownlee: Yes.

Mr Cassidy: The guidance is at a near-final stage. The first step, subject to agreement, obviously, will be getting some of those proposals embedded into the contract. That will be the first step to making them into requirements or expectations for the system. We will be looking to start the business change piece, in a pilot sense, in the spring, but that is still to be confirmed. We will roll it out on an incremental basis, but we have not got a fixed timeline for that. The development of the guidance is being led by a GP, so it is based on the experience of local GPs. It has not had PCC involvement, but we have the GP access working group, which has patient representation. Therefore, we have not had the PCC's involvement, but we have patient representation, and that has been across the development of the guidance.

Ms Brownlee: I have only two questions left. Last week, we were told that, on average, in Northern Ireland, we visit our GP nine times a year. In the Republic of Ireland, it is around three times a year. What can the Department do to assist GPs with that demand?

Mr May: That is a difficult question to answer, because it is essentially a societal issue about the point at which individuals feel the need to seek GP access. We have been looking to expand the range of services offered by our community pharmacies. That is one deliberate way in which we are trying to find alternatives for some of the high-frequency concerns that people may come across. The model in Ireland is slightly different in that at least some people will pay towards appointments. That would be a significant policy shift, probably taking us beyond the space that we are in today.

You are right to highlight the demand for services. We need to work through and think more carefully, working with GPs and primary care more widely, about how to provide alternative access means that do not necessarily involve talking to a general practitioner directly. That is quite a tricky space, because public expectation remains high here.

Ms Brownlee: Lastly from me, you touched on the issue of not being able to get through to a doctor on the phone. You said that it would be difficult to manage the unmet need of somebody who rings 200 or 300 times and gets an engaged tone. Does the Department know how much unmet need there is in getting access to primary care?

Mr May: In the example you just described, if someone phones 200 times, is that 200 people trying to get access or one person? That is the challenge in measuring that. For example, we see practices offering that if you go online at 11.00 am, you can choose when you have your appointment a week hence. That is the sort of thing that makes a big difference to getting access, but we do not have a means of measuring the number of people who cannot access the service on a daily basis for the reasons that you described.

The Chairperson (Mr McCrossan): Thank you, Peter. I want to go back, Dr O'Brien, to the dashboard. You said that it was not yet fully operational. When will it be fully operational? What will that look like for patients, for instance?

Dr O'Brien: The dashboard that I was referring to would be for practices and ourselves.

The Chairperson (Mr McCrossan): OK.

Dr O'Brien: I hope to have it operational in the 2025-26 year.

Ms Forsythe: Thank you all for being here. Access to GPs in Northern Ireland is the front line of our healthcare system. It is the day in, day out experience of patients, and it feels as if we are in absolute crisis. People are coming to constituency offices. We launched a survey, and the attention that it is receiving is huge. When people do not feel confident about getting access to their GP, it gives them a terrible perception of the whole healthcare system, and people are under immense stress. I am really concerned that when we talk about this issue — we had it in last week's evidence session, and we have it today — that we are talking about the likes of dashboarding, which sounds really bureaucratic: managing contracts and managing data. I am concerned that we are losing the patients in this: the patients who are trying to access their GP, people who are sick, people who are vulnerable, people who are genuinely worried about their own health and that of their children or their parents. What is the Department of Health doing to capture the patient experience?

Mr May: Thank you for the question. To be clear, something like the dashboard is a separate issue. That is a management tool to assist the Department in the overall performance of general practice. Whilst access is one of the domains, it is only one of the domains.

Your are absolutely right about the patient experience being really important. We do have means by which we try to gather information about the patient experience. Margaret will say a little more about the detail of that in a second. We measure and monitor that practice by practice. One of the risks is that, because we have all heard at least one bad story about someone getting access to GPs, that then gets conflated to, "Nobody gets access to GPs", and that is just not the reality. Our general practitioners, and the staff who support them, work incredibly hard to ensure that as many people as possible get access in a timely fashion, including through appointments on the same day where that is needed and so on. An awful lot of the demand is met in a very good way. Although I understand the concerns — inevitably, the hard stories are important for us to hear and to address — it is really important that we do not talk down what is being delivered in primary care. There are 200,000 appointments in a standard week, and more than that during the winter, when we invest in additional appointments because of the additional demand. For a population of 2 million, that is a very high number of appointments.

Margaret, will you say something more about the patient experience and how we monitor that?

Dr O'Brien: I will outline what is currently in the contract in relation to GP practices. They are required to provide services and manage their registered patients, including temporary residents, who believe themselves to be ill or who actually are ill. That is what the requirements stipulate. In order to gain true patient feedback and engagement, we are planning to introduce for 2025-26 individual practice engagement with patients. We are currently discussing with the general practitioners' committee (GPC) requirements for practices to engage with their patients, survey their patients, learn from and take on board comments from patients, and introduce some actions as a consequence. Perhaps each individual practice could have a patient participation group to gain true engagement at that practice level.

My team engages with practices on monitoring complaints, any adverse incidents that occur and significant event analysis at individual practice level, which can be positive or negative. It also takes account of patient engagement and outcomes at those individual practices.

Ms Forsythe: Should there be more of a role for the Department of Health in accessing the patient experience? I hear what you are saying, but my experience of dealing with GPs is that they have an awful lot of administrative tasks as it is, and this would be another one for them. If they were to produce that data, would it have to audited by someone? If so, that would result in extra work for everyone. Is there something in that regard for which the Department should be responsible?

Mr May: The answer is in two parts. First, we look very carefully at the administrative burden that we place on general practice. For example, last year, we ended the practice of gathering information under the quality outcomes framework, because GPs said that that was proving too onerous for them. We listened and acted; that was their number-one ask at the time. In relation to our role, I suggest that the way that we do it is the right way. If I were a general practitioner, I would want to know what my patients thought about the service that I was providing, and I would want the Department to act as an oversight mechanism to test that, rather than having everything being drawn to the centre, with the GP practice not having a sense of ownership of that or sight of that. I suggest that ours is a more appropriate way of doing it than centralising it.

Ms Forsythe: There is a difference of opinion. I think that the Department of Health would be concerned about how many patients in Northern Ireland feel that they are accessing their front-line GP care, but —.

Mr May: I am not saying that we are not interested in or concerned about that; I am saying that the means by which we should seek to access that is through reporting from the mechanisms that we have, rather than introducing a different reporting mechanism, which is what I understood you to be suggesting that we were doing.

Ms Forsythe: Thank you. There is ongoing concern that patients are often accessing healthcare services inappropriately, such as attending emergency departments for issues that could be managed by a GP, or visiting a GP when a pharmacist could have provided suitable care. What is the Department doing to educate the public on how to access the most appropriate care?

Mr May: At a general level, we do a lot of messaging, as do our provider trusts, general practitioners and, indeed, pharmacists, about what services are available where and what is appropriate to try to manage that. Inevitably, we need to supplement that with more personalised, one-to-one guidance when people appear at a location that is perhaps not the most suitable for their needs so that they can be given advice and guidance about how it could be done differently and better without their being made to feel bad about it. It may have just have been that they were unaware of the range of things that were available. It is in the nature of the messaging that some people do not pick it up because, until it applies to them, they do not go seeking it. It is not something that you can force everybody to be aware of. We make an ongoing effort to manage that. As I said, there are different ways in which it needs to be done.

Ms Forsythe: Do you monitor and measure the numbers? Is there a survey in an A&E department, for example, that asks, "How many of the people who were here during this shift could or should have been dealt with by a GP?"?

Mr May: I suspect that that data is not available; I would need to check. I suspect that it is not available because a lot of that is about judgement calls. Some cases will be clear-cut, but others will be marginal, and it could be quite bureaucratic and time-consuming to ask people to do that kind of analysis and work out on which side of the line it falls. I do not think that we have that data, but, by all means, I can check.

Ms Forsythe: If you do not capture or gather that, how do you measure the effectiveness of the efforts that you make to educate people on accessing the most appropriate healthcare?

Mr May: It is in the nature of that kind of public information advertising that you can test the extent to which people have read it and understood it, but it is difficult to test the extent to which people apply it when they are in a situation in which they or a family member are unwell, and they then become less certain than they would have been were they not in that slightly stressed situation. It can be hard to measure that in practice, beyond understanding how many people have accessed the information.

Ms Forsythe: Some people try to access a GP when they do not need to but should go to a pharmacist or take another route. With the pressure that there is on the system, do you have no way of measuring that?

Mr May: I do not think that there is a means of measuring that for GPs. You would expect that, often, the receptionists at a practice would be able to provide that advice and guidance to an individual. There is data on all the GP websites that signals the kinds of things that are suitable for contacting a GP about. We make every effort that we can in that way, but we would end up chasing our tails if we tried to put some big bureaucratic mechanism in place to try to measure it.

Ms Forsythe: Absolutely. What is the extent of your engagement with the Patient and Client Council?

Mr May: Gearóid briefly covered that. There is a GP access group that has patient representatives on it. We have met the Patient and Client Council, but it is not formally a member of that, and we are looking at how we will engage with it going forward.

Mr Cassidy: Yes, that is fair. I mentioned the access group. From its inception, it has been equal parts GP representatives and patient representatives. The PCC is not on it but has direct feedback into it. As we look at the future for MDT implementation, we will look at what we can add into our governance structures to make sure that the patient voice is captured in that. That is somewhere where we can strengthen the current arrangements to give the patient voice in all deliberations.

Ms Forsythe: We were told that the number of complaints about GPs received by the Patient and Client Council has increased, while the number of complaints registered with SPPG is declining. What assurance can you give the Committee that it has adequate oversight of the quality of GP services?

Mr May: That who has adequate oversight?

Ms Forsythe: The Department.

Mr May: We can provide you with the sort of information that we have given you about how we oversee the contract on a practice-by-practice basis and the nature of the quite extensive interventions by Margaret's team, both on a generic basis to make sure that everything is OK once every three years and then on a more targeted basis, depending on any evidence that comes to light. Certainly, if the PCC has any information that it wants to share, we are very open to receiving it. I am happy to commit that we will engage with the PCC to make sure that that link is made so that, if it is getting a pattern of complaints, we are aware of that and can take it into account in case we are not being made aware of that.

Ms Forsythe: It all feels quite general, and, as I said, it is your patients that we are talking about. It is the specifics of their access to GP services here, and, while these things are general, there seems to be a real lack of specific data and action to drive straight back through. Is there anything that you can say to me to take back to my constituents in South Down to make them feel that their specific issues are being addressed? There are towns where there are two or three different GP services with completely different service provisions, different levels of complaints and different levels of issues that come to my office. Is there oversight coming from the Department?

Mr May: There is oversight, and we have tried to set out today the nature of the oversight. We have also explained that, through this year's contract arrangements, we are seeking to create a benchmark where the same expectations are placed across all practices to try to reduce any variation. We will be looking to build on that in future years. We are absolutely working hard at this. It is a complex and challenging area, and it is not amenable to simple answers, I am afraid, of the type that perhaps some of your constituents are seeking.

Ms Forsythe: I appreciate that it is the governance. You have the Department of Health, the different trusts and the different practices. That is somewhat the challenge that has been caused by it.

The Chairperson (Mr McCrossan): On data collation and the complaints, this is a bit of a mixture. Have you any data on, for instance, the number of patients being diagnosed with cancer who are being diagnosed at a later stage now compared with pre COVID? Have you seen an increase in the levels, given that they cannot get access to a GP, which is normally the first point from which someone is referred on?

Mr May: There will be data on the stage at which people are diagnosed with cancer. I did hear that, in the immediate aftermath of COVID, there had been some increase in late diagnosis because, perhaps, people had not sought to access health services. I am not sure that I agree, however, with the second half of your point, which is that the reason for late diagnosis is that they could not access a GP. I am not aware of any evidence that suggests that there is a causal linkage between those two aspects, and I am doubtful that there is such a linkage. I do not have the cancer prevalence data available today. It really takes you into the secondary care space rather than the primary care space.

The Chairperson (Mr McCrossan): Yes, it does. The point that I am making is that, if someone has some form of symptoms and cannot get access to their GP at an early stage —.

Mr May: If that were to be the case, obviously that would be a problem. In practice, we have created rapid diagnostic centres, so, where a GP sees a patient and they have concerning but vague symptoms, there is a means by which they can be fast-tracked through to one of two facilities at Whiteabbey and the South Tyrone Hospital to enable the proper checks to be done and for it to be clear whether or not there is a cancer or, indeed, another diagnosis that emerges from the scans that they have as a result of that.

The Chairperson (Mr McCrossan): On the general area that I have just mentioned of the point of diagnosis, I am going off a wee bit slightly. There is a fine line between the primary care element of that early diagnosis and, ultimately, the secondary care treatment that is required for somebody. You said that you monitor the stages of diagnosis. Post COVID, late diagnoses increased slightly. What are they like today? We are now five years after COVID.

Mr May: I am not going to pretend to have the data in front of me. I would rather write to you with details of what we hold on the extent to which there is more late diagnosis of cancer now than there has been previously.

The Chairperson (Mr McCrossan): I would appreciate that. Thank you.

Mr T Buchanan: Thank you for coming before the Committee today. On regional disparities and service inequities, what data does the Department hold on variations in access to GP services across the regions?

Mr May: Essentially, we are coming back to the fact that each practice provides a suite of information to the Department which is looked at on a practice-by-practice basis. There is no presumption or evidence to suggest that there is an overall difference in access by area. We know that, in some areas, the provision of GP services has been more challenging, particularly in some rural areas.

Mr T Buchanan: What help has been offered to those more challenging practices when the data is presented to you?

Mr May: I will ask Margaret to say a little more about the support of the intervention team that sits in the federations but is funded by Margaret. We try hard to ensure that practices can continue. Inevitably, there will be times when individuals are at the end of their natural careers, and it may be challenging to find a successor, or if a partnership breaks down. Do you want to say something more about the work of that intervention, Margaret?

Dr O'Brien: As GPs are independent contractors, we fund them with an overarching amount of money. We do not set the number of GPs or practice nurses or the make-up of the team; that sits with the independent contractor to put in place. The additional resource we give to practices that are struggling is through the crisis improvement and response team. I fund that to the tune of £950,000 per year, and it helps those practices for a variety of reasons, because they struggle for a variety of reasons. It can be that the operational processes are not optimum. It can be a single-handed practice or a two-partner practice and, unfortunately, sickness may have occurred. There is a variety of reasons, but the crisis response and improvement team will go into the practice and offer GP cover. There is an experienced practice manager who works as part of that team to help optimise their flows of patients and administrative work, and they usually set out an action plan with the practice on how it can improve going forward.

Mr T Buchanan: What measures have been taken to address inequalities in access in rural and deprived areas?

Mr May: What are the inequalities in access that you have identified?

Mr T Buchanan: Inequalities in access to GP services, for example, in rural and deprived areas.

Mr May: I suppose I am asking for the evidence base that suggests there is such a difference.

The Chairperson (Mr McCrossan): I share a constituency with Tom. In more rural parts, we have a number of complaints about access to GPs. There are issues in those areas, and that will probably be Tom's follow-up question. The surgeries or practices become at risk, and GPs have handed back contracts, and there has been inequality of access in those areas. There are challenges in rural parts. For example, the Western Trust, not to be parochial —. There are unique challenges in rural areas.

Mr May: The point is that, as a result of the work that Margaret and her team do, a full general practice service is still provided across the region, whether you are in a rural area or not. Of course, in a rural area, you may travel a little bit further to your GP, but the figures are that 88% of the population live within three miles of a GP practice and 95% live within five miles. We are talking about very substantial numbers of people who live very close to a GP.

You are right to highlight the point that, in parts of Fermanagh and south Armagh, there have been challenges in trying to find GPs who wish to step up and become partners in practices. The Western Trust and Southern Trust hold a number of contracts. I want to pay tribute to the work that they have done, particularly the Western Trust. It has taken important leading steps, seeking to recruit salaried GPs to provide continuity of service in its area, and that has demonstrated success through two different rounds of recruitment. I would not want anyone to be left with the impression that, because there have been those challenges, somehow, no service is being delivered, because it absolutely is being delivered.

The Chairperson (Mr McCrossan): Yes, but I think that what Tom was getting at is that, for instance, if you are a single GP in a rural practice with 3,000 patients, it will take someone significant time to get an appointment when compared with a person in another area who has access to three GPs in the same practice. When it comes to equity, how do we ensure that everyone has the same access to their GP regardless of population numbers?

Mr May: There are different practice lists and sizes, but you would not find such a big differential as, perhaps, the question implied: that one GP practice would have a list of 3,000 and another would have three GPs for the same number. There would likely be three GPs for a much larger practice than that. It is true that some of our learning has been that single-handed GP practices will inevitably be a little bit more vulnerable if, as I said, an individual is either looking towards retirement or, perhaps, facing some challenges. Where it is possible to do it, we therefore look to bring practices together in order to have a larger number of GPs, because that adds to the stabilisation of the service. Do you want to add anything to that, Margaret?

Dr O'Brien: Yes, if I may. In order to support those practices and aid them in attracting and recruiting additional GPs, we have introduced an attract, recruit, retain scheme, which can help a practice to obtain either a partner or salaried GP. We offer a £40,000 additionality over a five-year period if a GP goes to that practice to become a partner, and a £20,000 additionality — call it a "golden hello", if you like — to retain a salaried GP as part of that practice for a five-year period. It also helps with relocation costs, advertising for GPs, etc, to those areas. It is not just for rural areas; it is across the region. It has been successful, and 82 practices have availed themselves of it, 52 of which have recruited additional partners and salaried GPs.

Mr T Buchanan: In recent years, we have seen GPs handing back their contracts. Why do you think that has been?

Mr May: You are right: we have seen a substantial increase, in 2022-23 and 2023-24. We were in double figures for both years. We have seen a substantial reduction this year. I think that we had five this year. We hope that the steps that we have taken, working with general practitioners to address some of their concerns, have been helpful in that respect. We certainly believe that the spreading of multidisciplinary teams will be helpful. We have seen far fewer contracts handed back in areas where there is a multidisciplinary team in place, because that provides a broader base for general practice.

I think that the answer to your question as to why we have seen that is, in part, the age profile. We have seen a large number of GPs who are at or beyond retirement age and, perhaps, a greater number chose to take up the retirement option, potentially, in the immediate aftermath of COVID, which was a stressful time for our health and social care system. Added to that are the high demands on primary care. The sad reality is that all parts of our health and social care system are under really significant pressure at the moment. I am sure that that will have played some part in the contracts being handed back as well.

As I said, I believe that the work that we have done has put in place some important building blocks. We are working on some further building blocks in the context of the contract negotiation. We have also expanded the support that is available for general practices so that we can help to get beyond that. We have been helped by not just the trusts but a number of the GP federations, which stood up and helped to take contracts forward where there was no immediate partner, often with a view, ultimately, to creating a partner model. We try to work as part of a wider system, working with all the players to reduce the likelihood of contracts being handed back.

Mr T Buchanan: Not all the contracts that were handed back were from GPs of retiring age. Younger ones handed them back simply because of the pressures that you talked about that are on GPs. Although we welcome the fact that the Department is stepping in to assist GPs, do you think that that is happening a bit late in the day?

Mr May: All that I can say in the short term is that very active work has been done throughout. Of course, we try to learn and to work out what will make the difference. We have to remember that we have been working in extremely financially constrained circumstances that have made it very hard to deliver some of the more obvious steps that could have been taken, given that there is a risk of not being able to live within budget and so on.

I do not agree with that statement, personally; I think that we have absolutely done the best that we can in the circumstances, which have not been easy.

Mr T Buchanan: What is the difference in cost between a practice that the trust takes over and a contractor-run practice?

Mr May: We provided some information to the Committee in the past 24 hours, in response to a request. It is true that some of the costs are higher and that they have been higher. That has often been because it was necessary to put GP locums in place in the short term, and the rate for a locum was substantially in advance of that which would be payable to a normal GP. Similar issues apply in secondary care.

In the past year, we have reduced the amount that is paid to locums per session, and we continue to keep that under review. In an ideal world, we would reduce and phase out the use of locums, but you will understand that our first priority is to ensure that there is the equity of access for patients that you mentioned at the start of your questioning, and we can only do that in circumstances in which we can be sure that we can deliver a suitable primary care service in that way.

Mr T Buchanan: I have one other question. When a GP practice was in difficulty and at the risk of failing, would it not have been better for the Department to have stepped in and helped that practice to stay in place rather than to let it fail and then take it over?

Mr May: Let me assure you that the Department makes every effort to do that through Margaret and her team, often very successfully. There are large numbers of contracts that might have been handed back had it not been for the efforts of Margaret and her team. There are times, however, when that is not possible. In those cases, we need to put in place arrangements to secure a primary care general practice for the population of the area. Again, there has been huge success in ensuring that primary care remains available across the whole region, and we should recognise that success.

Mr T Buchanan: Yes. We welcome the fact that the Department has taken a greater interest in GP practices than, perhaps, it did in the past.

Mr May: I am not sure that I accept that there has been an increase. I think that there has been full-on attention to general practice throughout. Certainly, in my three years in this role, I have spent a lot of time focusing on how we address the challenges that general practices face.

The Chairperson (Mr McCrossan): I think that Tom is talking about the longer term. This is not a new problem; it has been an issue for some years. Often, unfortunately, with some elements of the health service in Northern Ireland, the response often ends up being more costly than a plan, which could have been in place much sooner, would have been. We are seeing, as indicated, that the response to the GP crisis could end up costing us more money in the long run than putting in place proper arrangements that are supporting our GPs and the work that they do. That is the feedback that we had from GPs at last week's session. They do not feel supported and do not feel that they have the resources available to meet the demand.

Mr May: Chair, on the resources point, you will understand that it is the nature of a contract negotiation that contractors will always suggest that they need more money for the service that they are being asked to deliver, just as you would want us to push to make sure that we get the best possible return for every public pound that is spent, including how much service we are able to secure through that contract. This is a natural and important tension and one that I imagine the Committee will want us to maintain while being reasonable about it, because, otherwise, we would end up essentially giving GPs what they ask for, and that would not necessarily guarantee the best use of public money.

The Chairperson (Mr McCrossan): I do not disagree with you on any of that, but there are some elements that I have concern about. The figures on the demand on GP services show that demand has increased and that there are fewer GPs to deal with the demand.

Mr May: There are more GPs than there have been.

The Chairperson (Mr McCrossan): But in practices.

Mr May: There are slightly fewer practices, but there are more GPs. It is true that more of those GPs work less than full time, but, just to be clear: there are more GPs than there have been.

The Chairperson (Mr McCrossan): Is it also fair to say that GP practices — we will get to this later in the evidence session — in Northern Ireland are funded less than their counterparts in other parts of the United Kingdom?

Mr May: We will get to that. I think that it will depend a little bit on what base you use as to whether that is the case or not.

The Chairperson (Mr McCrossan): Yes. There is an issue, which we will get to.

Mr Gildernew: I have a follow-up on that. Permanent secretary, I totally accept the need to apply good housekeeping. I accept that there are more GPs. However, people are living longer and with more complex needs. You have the issue of a lot more people on waiting lists and people with comorbidities. In that context, a crude "more" calculation may not be sufficient. Do you believe that, with all those factors added, GP services have sufficient resource? I will come on to MDTs. I want to put the resource question in the context of an older population and, do not forget, a growing population as well.

Mr May: We have had many conversations over the years about not just GP investment but investment across the full range of health and social care services. I have sympathy with some of the arguments made by GPs, and I also have sympathy with the arguments made by pharmacists, dentists and social care providers and with the arguments about our elective care waiting list problems and our urgent and emergency care problems. The reality is that there are lots of different ways in which we could spend additional money. At the moment, the Assembly, including members of this Committee, sets the budget for the Department of Health. We do not have additional money to spend on those things. The challenge is ultimately — I am not copping out here — a political challenge about prioritisation, and the question is this: where should the money be taken from if we are to give extra money to deserving causes? I am not walking away from the deserving causes across the whole of Health and Social Care (HSC).

The Chairperson (Mr McCrossan): To follow on from what Colm and Tom have pointed out, if there is not a serious recognition of the challenges that GPs are telling us about, as they did last week, and the knock-on effect that those challenges are having on the public, more and more GPs could — could — hand their contracts back, which, in the long term, will cost the Department, and therefore the taxpayer, more money. Is that not the case? That is what I am seeing here in the figures.

Mr May: Of course, there are risks to all parts of our system that, if they do not get more money, it could end up making things more difficult, but we have taken a series of measures over a number of years to stabilise and meet the concerns of general practice. When I came into this role, the quality outcomes framework was the top issue. Money was provided separately at the end of the year in return for GPs demonstrating how they delivered things against a raft of measures. In response to that, we, first, froze that and did not make that a requirement. Then, in 2023-24, we moved the funding up front, and made it no longer conditional on the quality outcomes framework. Instead, we used the new assurance framework that Margaret talked about. Secondly, we made a contribution towards indemnity payments this year and have provided additional in-year funding for each of the years that I have been in post, obviously subject to ministerial agreement.

I reassure you that we do take seriously concerns that are raised. We do act based, usually, on what GPs describe as the main issue for them at any given point. It is true that we are generally not able to address all the concerns that they raise, but that is true for the other parts of our system that I described. I just want to reassure you that this is a Department that has listened and has acted based on what we have heard. As I said, I believe that that has progressed things. I accept that, ideally, we would be doing more, but we are facing hard choices, as I have tried to highlight.

The Chairperson (Mr McCrossan): Yes, I have no doubt. We will talk more about finance later.

Mr Boylan: You are very welcome, and thank you very much for your contribution so far. I want to talk about locums. In trust-funded practices, can the same doctors who hand the contracts back come back into the system as locums?

Mr May: There is nothing in employment law that precludes that from being the case. I do not know whether it has happened in practice.

Dr O'Brien: It has, yes. We have certain practices where they handed back the contract and, in some of those, the outgoing partners are providing locums.

Mr Boylan: Does the Department incentivise hand backs?

Mr May: I do not think so. We try hard to make the model that we have work. As I said, we are looking to introduce, where we can, salaried GPs as a more value-for-money alternative to the use of locums.

Mr Boylan: So, you do not incentivise them. How do you then manage those who you take back?

Mr May: Sorry?

Mr Boylan: How do you manage those who you take back in? Those who hand back, do you just take over? You are saying that you do not incentivise hand backs, yes?

Mr May: No funding is provided to people who hand back their contract, if that is what you mean by incentive.

Mr Boylan: Given the growing reliance on locums to fill gaps, how does the Department assess the cost-effectiveness of using locums compared with long-term solutions such as recruitment or retention?

Mr May: Our preference is to avoid contract hand backs in the first place where it is practicable to do so in order to avoid the need for locum GPs and to use alternative mechanisms, including recruiting salaried GPs or identifying GPs who are willing to become partners in practices. That is our preference. However, we need to make sure that we can provide a service right across the region to all who need access to general practice. Therefore, there are times when locums are, as it were, the least bad solution, if I may put it that way.

Mr Boylan: Does the use of locums impact on the quality of care?

Mr May: I am going to ask Margaret to say something about that. We monitor all practices, and I am not aware that we have evidence to suggest that there is worse care from locums.

Dr O'Brien: Yes, Peter, you are right. It may impact on the continuity of care because patients are introduced to a new doctor. However, as you pointed out, Cathal, in many instances where contracts have been handed back, the outgoing partners are, indeed, providing that locum cover into those practices. There is nothing that we can do about that. They have stepped into a different range of employment and are self-employed. That has an advantage, in that, for the period when the practice is stabilising until we are able to recruit salaried GPs, those patients are still getting access to the GP whom they would have seen previously.

Mr Boylan: That is part of the problem. We should be looking at a longer-term solution and clearing it up. That is why I asked the question in the first place.

Mr May: To be clear, we have increased the number of GP trainees very substantially. That is one of the answers to that. We have a whole range of different ways in which we seek to attract, recruit, induct, mentor and retain GPs, in order to try to maintain practices and make it an attractive career option for the future.

The Chairperson (Mr McCrossan): I have a number of supplementary questions about this because it is the hot potato of the whole session. When it comes to access, do patients at practices have similar access to services available through a standard GMS contract, or what is it? What is available? Reduced to constraints, for instance, on recruitment and locum availability and cost.

Mr May: I am not sure that I quite understand the question, Chair.

The Chairperson (Mr McCrossan): When it comes to access, do patients at various practices have similar access to services available through a standard GMS contract, or what is it?

Mr May: Yes.

The Chairperson (Mr McCrossan): Is it all just the same throughout?

Mr May: Yes.

The Chairperson (Mr McCrossan): Regardless of whether it is a locum, a GP or whatever?

Dr O'Brien: Yes. That is right. If I may just add to that, we have two contracts. We have a GMS contract, which is for general medical services, and we have an alternative provider medical services (APMS) contract, which the trusts contract with us for. The contents of both are exactly the same.

The Chairperson (Mr McCrossan): Back to the locum stuff again. Do GPs who hand back contracts and return as locums then become salaried GPs, or do they remain as locums?

Mr May: That would be an individual decision. It is not something that is determined centrally.

The Chairperson (Mr McCrossan): There is a disparity between salaried GP as against locum costs. It is obviously more cost-effective for the Department to retain salaried GPs.

Mr May: Yes.

The Chairperson (Mr McCrossan): Surely the incentive there is that they remain as locums, because they get more money in their pockets. Is that right?

Mr May: It will depend. It is very much an individual choice. Clearly, a locum may not be offered full-time work. They may be offered sessional work, rather than working every session.

The Chairperson (Mr McCrossan): At £350 a session?

Mr May: Yes.

The Chairperson (Mr McCrossan): And the maximum they do is nine sessions a week? Let us say there is a full-time locum doing nine sessions a week at £350 a session, which is around £160,000 a year, that is a fair incentive over a GP salary at £102,000 or £98,000.

Mr May: Yes, but salaried GPs will have access to holiday entitlement, holiday pay, pension and so on, so the gap is not as large as you might imagine, but, yes, there is of course something of a premium. As I said, some GPs will only be offered locum work on a sessional rather than a full-time basis.

Mr Cassidy: To add to that, we saw from the example in the Western Trust that, whereas it was primarily locum-led, once salaried roles became available that became a very popular option. The Chair is right in that, based purely on the numbers, it might look as though there is an advantage of working as a locum, but experience shows different.

The Chairperson (Mr McCrossan): The devil will be in the detail. How many locums have we employed as GPs?

Mr May: I do not have that information today.

The Chairperson (Mr McCrossan): If we had a breakdown of the costs of the past year, it would probably give a true reflection of the challenge that faces us. The real concern of the Committee is whether there is an incentive to become a locum, effectively. To hand back contracts, for instance, in one state and come in as a locum in another is going to cost the Department more money. It incentivises the closure, it could be said.

Mr May: We can certainly give the Committee information on the scale of use of locum GPs, if that would be helpful.

Mr Gildernew: That information, broken down per trust, would be useful.

Mr May: We have about 1,400 or 1,500 GPs in total, and the number of locums is a small proportion of that.

Dr O'Brien: We have about 2,000 GPs on our Northern Ireland primary medical performers list. About 300 or 400 of them choose to be GP locums. The detail of who employs those GP locums sits with individual practices. Chair, to answer what, I think, you are asking: in the temporary period when trusts hold contracts, in order to ensure that there are GPs on the ground, trusts will employ GPs as locums in the first instance, until they are able to get together an appropriate JD —

Mr May: Job description.

Dr O'Brien: — and advertise as employment law requires, and, indeed, we have found that there has been great uptake of those salaried positions in the Western Trust practices. That means that locums will not be used; the practices will work with salaried GPs.

The Chairperson (Mr McCrossan): Has the number of locums increased over the past number of years? Has the trajectory been upwards?

Dr O'Brien: Slightly.

Mr May: Inevitably, a practice will need to use a locum for a session in order to fill in for a GP who is doing something else. It could be that a GP is representing their practice or the GP community, or that they are attending an event on behalf of the Department, including some of our committees. In those cases, on a sessional basis, a locum comes and fills in, and that is entirely normal. It is exactly the same as the way that it works in secondary care. We need to be careful here. Our objective should not be to say that having locums is bad. Some locum use will be needed —

The Chairperson (Mr McCrossan): Permanent secretary, please do not misinterpret what the Committee is doing. We are not saying that locums are bad; we are asking whether there is a trend of GPs leaving, becoming locums and ending up costing the taxpayer — that is who we are responsible to — more money, because the Department of Health did not put a proper plan in place earlier to support GPs. That is what I am concerned about.

Mr May: I understand the point. The point that I am trying to make is that some GP locum use will be needed in any system. We recognise that the rate that we were paying for GP locums was too high, and we have reduced that rate accordingly. As I said, the Western Trust has done a really good job in seeking to move more of those GP locum roles into salaried roles. That has demonstrated that there is an appetite for it, and, therefore, we will be looking to roll that out more widely as we go.

The Chairperson (Mr McCrossan): Dr O'Brien, did you say that we have 2,000 GPs and you estimate that about 400 of them are locums?

Dr O'Brien: About 300 choose to work in what is termed as a portfolio career.

The Chairperson (Mr McCrossan): Yes, but some of them work sessions. There is no doubt about that and probably —

Mr May: Quite a lot of them are people who have retired from their normal practice and keep their hand in by doing a few sessions a week or whatever. Is that fair?

Dr O'Brien: Yes, and it can even be younger GPs who choose to work as GP locums and do other roles, such as delivering a speciality service in secondary care.

The Chairperson (Mr McCrossan): It is, however, fair to say that some of those locums are working full-time, all year round —

Mr May: I am sure that that is right.

The Chairperson (Mr McCrossan): — at an increased cost to the taxpayer: that is the point that I am getting at.

Mr Gildernew: I fully accept the point that there is an appropriate, necessary and valuable use of locums. You have touched on the rate of pay for locums. What we are trying to get at is whether there is an over-reliance on locums generally in the system.

The Chairperson (Mr McCrossan): There is.

Mr May: We are trying to avoid there being an over-reliance on the use of locums, through the kinds of means that I have described. I would highlight the fact that locums who are working full-time are delivering a service to a part of the community that needs —

Mr Gildernew: Again, that is not in question.

Mr May: No, I am just explaining that it is really important that we recognise that there is a worth and value in what they are delivering for our society. Yes, of course, just as we would like there to be less use of locums in secondary care, we would like to reduce — not eliminate but reduce — their use in primary care. We believe that, through things like the growth in the number of salaried GPs, there is a viable means of building on the successes that we have had in achieving that. However, inevitably, we are talking about choices that individual practitioners get to make. If they choose to end their time as a partner or a full-time practitioner on a normal basis, they can do so. We would not want to stop them being able to provide services in another way, given their skill set.

The Chairperson (Mr McCrossan): Basically, it is a question of value for public money: that is the nub of what the Committee is about. We have concerns that there is an incentive to be a locum, and, unfortunately, the numbers are higher than most of us would like. We appreciate the role of locums in covering sickness, maternity leave and all that. They do an exceptional job — I put it out there firmly that we agree with that — but the numbers are high. I am keen to see what the numbers here are like in comparison with those in other jurisdictions. I would like a breakdown of the costs, if possible, in a greater —
.

Mr May: We will see what information we can provide to you. As was said, some of the information is practice-specific, and practices do not necessarily have to share that with us.

The Chairperson (Mr McCrossan): Your letter indicates that the cost of trust-managed practices has increased to £4·7 million. Is that the correct figure for the cost of trust-run GP practices in 2023-24? It is an increase of £959,000 on 2022-23.

Mr May: That is the total cost to trusts; it is not a comparative cost.

The Chairperson (Mr McCrossan): Why has the cost of trust-run GP practices increased almost fivefold in a year?

Mr May: There were more practices being run by trusts in the second year than in the first year, so, of course, the cost was greater.

The Chairperson (Mr McCrossan): Yes. Do you expect that to increase?

Mr May: This year — 2024-25 — we saw a reduction in the number of contract hand-backs. Therefore, I hope that it will not increase. Trusts are a port of last resort. First, we seek to secure new partners for the service. Then, we work with the GP federation to see if it can take over the contract. It is only failing that that we turn to trusts, because that is not trusts' primary business. It is not ideal, but it is better than there being no provider of primary care in an area.

The Chairperson (Mr McCrossan): There are examples of that in my and Tom's constituency.

Mr T Buchanan: Chair, do trusts use locums in the practices that they take over?

Mr May: They do initially, as Margaret explained, until a job description can be worked up. It then depends on whether they can find someone who is willing to come in on a salaried basis. Returning to a partner model remains the ideal, but that may or may not be possible. It may be that we are seeing a shift in the general practice business model towards one that is more of a mixed economy than what we had previously, where all practices were run on a partner basis.

Mr T Buchanan: That could explain the rising cost —

Mr May: You see a rise because we had to ask trusts, particularly the Western trust, to run more contracts in 2023-24 than we did in 2022-23.

The Chairperson (Mr McCrossan): Yes. We are conscious of that.

Ms Forsythe: We have mentioned quality of care and patient experience. Do you capture data on patients who are treated by a locum rather than their normal GP, are not satisfied and continue to try to access their regular GP?

Mr May: Often, if there is a locum, the patient's regular GP will not be working in that —

Ms Forsythe: Let me rephrase it. Say that I have an appointment and I see a locum, but I did not know until I got there that I would be seeing the locum, and, then, I seek an appointment with my GP, which is what I wanted in the first place: is there any data on that?

Mr May: I suspect not. As Margaret tried to explain, the picture is a bit more complicated. Sometimes, the locum will have been a GP in that practice before. Therefore, it will be an advantage, because you will get to see the GP whom you have always seen, and you are not going to worry about the basis on which they are employed.

Ms Forsythe: It is a wider point about quality of care. I have an excellent GP. On a couple of occasions, I have been fortunate that he knew, when he saw me, that I was not as I usually am. To me, that is a higher quality of GP service. Had I showed up and got my stats taken by a locum, they would not have known my wider —. It is a wider point about quality of care in locum use, and not necessarily just about their use after a contract hand-back. Have you captured any statistics on that?

Mr May: OK. I am not aware of any such statistics. Margaret highlighted the fact that there could be a loss of continuity of care in some situations. That is a challenge that is equally applicable to a maternity leave or a sickness absence. It is, to some extent, unavoidable. However, we track patient outcomes through the work that is done, so, if there were a clear divergence, that would show up. However, we are not able to track patient satisfaction, for example.

Ms Forsythe: I just wondered whether people trying to get through to request to see their regular GP is putting extra pressure on the system. Thank you.

Mr Gildernew: Given the trajectory of where the conversation has taken us, I will ask my second question first. Is the independent contractor model the best solution, or do we need to look at another model?

Mr May: As I said in answer to a previous question, we may have moved beyond there being only one model for general practice. While we will continue to do what we can to enable and promote the partner model, which is in keeping with the way that it has run since the NHS was formed in the late 1940s, it may be that, on the part of some in the GP community, there is less willingness to play that partner role and more willingness to seek different roles as salaried GPs or as locums. Therefore, we may need to accept that there will be a broader range of models going forward. We are open to exploring any models that, we believe, will deliver a good level of service and the value for money that is needed.

Mr Gildernew: Are you actively considering alternative models in that respect?

Mr May: You could say that practices that are being run by GP federations and those that are being run by trusts are already different models from that of a GP partner. Therefore, the honest answer to your question is that it is already happening in some places. We are not proactively promoting alternative models, but, if we were approached by someone —. For example, in England, it is commonplace for one individual to hold a number of practice contracts and then employ salaried GPs. We know that there may be some interest in that. We would certainly talk to people on that basis if they approached us.

Mr Gildernew: Focusing on situations where secondary care trusts have moved in, which has taken place in my constituency and neighbouring constituencies, there is a general acceptance that that is not exactly the best model. Are exit plans in place to put those practices back on a longer-term footing through a traditional or new model?

Mr May: We continue to explore the possibilities. I will ask Margaret if she can add anything specific as to whether any are likely to move to a different model in the near future.

Dr O'Brien: You will be aware, Colm, that the Southern Trust held the Newtownhamilton practice for a period. That contract moved into the federation's hands. We are looking at another practice in that geographical location in the Southern Trust. We are working with a federation to, hopefully, move that into its hands as well. There is active engagement to move practices out of the hands of trusts, which only hold them temporarily for us, and find a longer-term solution.

Mr Gildernew: I will make quick a comment, Chair, before we move on. Some of the reports that have come back showed that patients were happy with those models. Hopefully, the learning about whatever made those patients happier can be worked into the future models.

Mr Boylan: What are your plans to increase the workforce in the medium term? Do you have a workforce strategy to deal with that?

Mr May: We have substantially increased — by 86% since 2015 — the number of GPs in training. This year and last year, 121 places were offered. We filled all the places this year and 119 of them last year. We recognise the importance of making sure that we have the right range of skills. We do not think that we should look at this simply and purely as being a general practice workforce plan; we think that we should take a broader overview of what primary care needs. As I said, we are expanding the multidisciplinary teams into what, I think, will be a helpful space. We have engaged with the Northern Ireland General Practitioners Committee on two planned workforce surveys to include GPs who are working in practices and a full range of other practice staff. Those surveys will be issued before the end of April this year and give us a range of data that we do not currently have on attitudes and so on.

Mr Boylan: Thank you very much for that response. Do you know how many whole-time equivalent GPs we have? If we do not know that, we will not deliver the service that we need to deliver. Can you answer that, please?

Mr May: We know how many we have; the question is whether I can find that information in this large pack.

Mr Boylan: You have that information, though? The premise of the question is that, if we do not know that information, we cannot plan to deliver the service in the first place.

Mr May: We know that 1,449 GPs are registered on the — [Inaudible.]

Mr May: OK. Sorry. I may have been about to mislead you, Cathal, and I had better not.

Dr O'Brien: We know the number of GPs on the performers list. All GPs, in order to practice in GMS and HSC, are required to be on the performers list. That number sits at roughly 2,000 GPs — I can provide you with the exact figures, because the figures vary. That also includes GPs in training: those who are still with the Northern Ireland Medical and Dental Training Agency finalising their training to become a GP. We know the number of people, but it is not broken down by the number of sessions that they provide in a practice, be that as a partner or a locum. We are collecting that detailed workforce information from our GP practices in this contractual year.

The Chairperson (Mr McCrossan): It is whole-time equivalent GPs that we are looking to know about.

Dr O'Brien: Yes, we are collecting a range of information: the number of partners; whether they are partnered or salaried; and the number of sessions that they deliver in their practice. That is what we are collating.

The Chairperson (Mr McCrossan): You do not have that information at the moment? You are collecting it?

Dr O'Brien: Yes, through a detailed workforce survey. In previous contractual years, we knew how many partners worked in a practice, but that was not broken down to how many sessions they provided etc. As a consequence of the work that we did on workforce planning, we knew that we had to collect more detail about the number of sessions that they deliver in their practices. Neither I nor the Department get to set that number. As I said, they are independent contractors. As partners, they can indicate how much time they put in as a partner, be it as a half-time partner or a six-session partner. That is set by the individual practice. We are in the process of obtaining that detailed information.

The Chairperson (Mr McCrossan): It is a wee bit strange that we did not have that information anyway, but that is fine. When will we have it? That is the key question.

Mr May: We will send the survey out before the end of April, so we will have it when we receive the responses and collate the data. It is important to note that that will be a snapshot in time. A GP could decide tomorrow to move from six sessions to three sessions; they do not need anyone's permission to do that. What we need to know is how many sessions are being covered by GPs, and whether that meets the needs of the population. We do not necessarily need to know precisely how full-time or otherwise each individual practitioner is.

The Chairperson (Mr McCrossan): When we have that information, how often will it be monitored?

Dr O'Brien: Part of the contractual discussions that we are having with the GPC is about that data and how frequently we collect it.

The Chairperson (Mr McCrossan): When will we have that information?

Dr O'Brien: We are doing a few surveys, one being on the GP workforce in practices. We are also looking at the practice team as a whole and collecting all that information. Responses to those surveys have to be returned to us before the end of April. We will turn those around and attempt to baseline the practice teams to include GPs.

The Chairperson (Mr McCrossan): Thank you.

Mr Boylan: I need some clarification. To have a workforce model, we need to know the workforce and then develop a strategy to deliver. Are you are saying that you are doing work to obtain that information?

Mr May: Yes. It is fair to say that we —

Mr Boylan: That is fair enough. You have given an explanation; whatever other figures are needed —.

Is it fair to say that we do not yet know how many more GPs we need to train? Do you know, or are you assessing that?

Mr May: We know that we have increased the number that we need to train. In the discussion about this year's training numbers —. There is always a trade-off. It is not just about what we need; it is also about what we can afford. There is a desire to train more doctors, GPs, nurses, social workers and so on, and there is a limited pot of money, and we have to decide where that pot of money goes.

Mr Boylan: What are we doing to try to retain GPs?

Mr May: We have a number of schemes in place, including a GP retainer scheme that offers a flexible and supportive framework for experienced GPs who wish to continue practising without committing to full-time hours. That is one way that we try to retain skilled professionals who might otherwise leave the profession. We have a GP mentor scheme, which is an independent, supportive and safe mechanism for individual GPs as they navigate the pressures of delivering general medical services. That is also designed to improve GP retention. We have the attract, recruit, retain scheme that Margaret mentioned. In addition to providing incentives for people to join, that has retention elements. We have put in place a range of schemes to try to enhance retention.

Dr O'Brien: We have also implemented a GP fellowship scheme. Not all younger GPs who qualify are trained in or au fait with how to run a practice, so they may lack confidence in moving straight from being a qualified GP to taking on a partnership role. We have put in place a regional GP fellowship scheme, which is hosted by one of the Northern Trust federations. We put in place a further GP fellowship scheme in the Southern Trust area. That is to help to recruit and retain GPs in that geographical area, in order to assist us in respect of practices that handed back their contracts.

Mr Boylan: These are not trick questions. This is an important piece of work for the Committee. We need as much information as possible so that, when we formulate our recommendations, it is a proper piece of work. Many MLAs are lobbied on the issue all the time.

The Committee took evidence from the Royal College of General Practitioners last week. The college has stated:

The college warns:

Do you agree with that statement? What are your views on it?

Mr May: I recognise that there are strongly-held views in the GP community about the level of pressure that is on GPs in the delivery of their services. I have tried to set out for the Committee a range of actions — some that we have already taken and others that we will look to take in the context of the current contract negotiations — that are designed to stabilise by retaining people in and attracting people to general practice. We are working hard to make sure that primary care can be successful.

Mr Boylan: Thank you.

Mr Honeyford: What steps is the Department taking to support the implementation of the retention strategy?

Mr May: Do you mean the implementation of the various schemes?

Mr Honeyford: Yes. The GPs have a retention strategy. What are you doing to support them?

Mr May: The schemes that I have just described to Cathal are the interventions that we have put in place. They will all have some level of funding that attracts to them. Those are the specific retention schemes. Then, as I said, we have taken a broader view, which is to listen to what the GP community, through its representatives, tells us to act on: for example, the quality and outcomes framework to begin to address the indemnity issue.

Mr Cassidy: If you have in mind the 'A Workforce Fit for the Future' report of the Royal College of GPs, we have already taken action on a number of the key measures in that, as Peter indicated. One of the key recommendations was implementation of the Doctors' and Dentists' Review Body uplift. That has been done. Key work has been done on pressing forward on the MDT model, as we discussed earlier. The other big ask was on indemnity. We have not gone into that in detail here, but it is on the table as part of the contract discussions. We believe that we have a satisfactory solution to that. Naturally, the Royal College report reflects the wider views of the service, which we have been working on. We have already acted on a lot of the specific measures, or we were already working on them as the report was written.

Mr Honeyford: OK. There are obviously issues across the piece. You have indicated things that you are doing or will do. How will the effectiveness of those things be measured?

Mr May: They will be measured by the extent and nature of the primary care service that general medical services are able to deliver. In global terms, there will of course be specific output measures on the number of GPs leaving the service, the number being attracted to it, availability of the right number of GPs to run the service at specific points, and so on. There will be high-level quality and outcome measures and specific output measures.

Mr Honeyford: In the future, will we be able to look at a document or something that says, "This was done; this was the outcome", or is it just —

The Chairperson (Mr McCrossan): Very broad.

Mr Honeyford: — a case of throwing out all the — ? You have listed several things that you are doing, and I do not dispute any of that. What I am saying is that we see a lot of actions happen, but there is no check to see whether they are effective. That is the bit that we are looking for: if you do these things, what will be the outcome?

The Chairperson (Mr McCrossan): How is it measured?

Mr Honeyford: Yes. How is it measured?

Mr May: In the model that I have just described, it is easier to measure outputs than outcomes. We can tell you how many people took up the fellowship scheme, how many people took up the retainer scheme, and how many people have been attracted using the attract, recruit, retain scheme. We can tell you those things, because they are direct measures that flow. You then join it all up to come to that overarching outcome piece: is primary care doing what it needs to do?

Mr Honeyford: I suppose that the number retained and the number leaving can then be added.

Mr May: Yes.

Mr Honeyford: OK. What has been done to improve recruitment and retention of GPs, particularly in rural and deprived areas? A specific issue about deprived and rural areas came up. What actions are being taken to improve that?

Mr May: Do you want to say more about the scheme that you described, particularly with regard to rural areas?

Dr O'Brien: Yes. I suppose that it is twofold. There is the attract, recruit, retain scheme that we have put in place. I will just pull out some — I am looking at exact numbers. I ran through a few things that it facilitates. One is a "golden hello"; an additionality that you receive if you become a partner or salaried GP. It also facilitates relocation costs. We have more individuals going through our training here who are from various other countries and now require a visa. It would fund that aspect of an approved employer visa, elements of advertising, etc, for the practice. We have reviewed that attract, recruit, retain scheme. We introduced it only around January 2023, so it has been available in 2023-24 and 2024-25. We were taking that forward with the original specification to include all those criteria and outline the funding. We have now taken on board the learning. We have evaluated that, as you mentioned in your previous question, and we will be looking to revise that specification with a focus on an additional amount for rurality to attract even more GPs to those areas. In the Southern Trust and Western Trust areas, which are the rural areas where it is more difficult to recruit, we have recruited 13 and eight GPs respectively through that scheme alone.

Mr Honeyford: OK. What about deprived areas, which include bits of Belfast and areas right across Derry?

Mr May: Is there evidence that suggests that there is a challenge in getting GPs to work in those areas?

Dr O'Brien: Not overly, but the scheme is open across the region, including in the eastern area, which covers Belfast. In the South Eastern Trust area, we have had 16 recruits, and, in the Northern Trust area, we have had 15 recruits.

The Chairperson (Mr McCrossan): What were the targets? I am trying to determine what success looks like or how that is measured. Is there a target in place?

Dr O'Brien: No, it was not a target. We have offered out that funding for practices to avail themselves of it. As I said, 82 practices have applied. There is a set of criteria by which the practice will apply to us. We have given approval in principle to 82 practices, and 52 of those have been able to recruit to the positions that they have advertised.

Mr May: That is one in six of all practices.

Mr Honeyford: OK. What actions are then taken to encourage GPs to remain in the system rather than go into private practice, to the South or abroad?

Mr May: The overall package that is available to GPs through the GMS contract is the principal way in which that is done. I will not rehearse all the additional schemes that we have put in place to try to retain that resource. Those are the measures that we try to take.

Dr O'Brien: There is the fellowship scheme, which encourages and provides additional leadership training, etc, for those younger GPs.

Mr May: The other thing that is available and which we sought to maintain, with some challenge, is some primary care elective services, so that those GPs who want to either retain or build skills in some elective procedures can continue to do that as well. That is another way in which we look to retain them.

Mr Honeyford: Is there no issue here at all with GPs leaving to go to the South, abroad or into private practice?

Mr May: I do not have any available data to suggest that large numbers of people have physically moved to deliver services in Ireland or elsewhere in the world. We have talked extensively in response to previous questions about how we recognise that GPs are feeling under pressure in a range of different ways, and we have explained the sorts of things that we have tried to do to manage that pressure. As I said, all of our health and social care system is under pressure, and primary care is no different, I am afraid. We continually look to see whether there is more and better that we can do. We have set out some of the things that we are looking at in the context of the contract, where we are hoping that some of the measures that we will be able to take, for example, in relation to indemnity, will be acceptable. In return, we will be able to enhance some of the access provisions that we talked about earlier.

Mr Cassidy: The headcount numbers indicate that there is no issue with people leaving the system entirely. We have 23% more GPs than we had in 2014 by headcount numbers.

The Chairperson (Mr McCrossan): In 10 years, it has increased.

Mr Cassidy: That is over 10 years. That does not indicate that people are leaving the system. We have touched on whether they are working full time and capacity for that. Some of what we have talked about here, including the elective work, is, in part, to support people to have those portfolio careers. If the question was around whether people are leaving to go to the South or overseas, the evidence does not support that. They want to work here, but the question is whether they are able to give enough sessions to meet the needs of the service.

The Chairperson (Mr McCrossan): Yes, you have just answered it. The headcount does not give a full picture. There may be more GPs doing less.

Mr Cassidy: But they are not leaving to go to the South.

Mr May: A lot of GPs will say that, practically, it is very difficult to work full time because of the demands that that would place on them, so many are working less than full time.

Mr Honeyford: Of that 23% increase in numbers, what is the percentage rise or fall in the number of sessions being delivered?

Mr Cassidy: We do not have a reliable source of data for the number of FTs being delivered. Broadly speaking, it is pretty consistent over that period, but we do not have any published data on sessions.

Mr Honeyford: How many GP sessions are available at the minute for the public to access? Do we know how many sessions right across Northern Ireland are available this week?

The Chairperson (Mr McCrossan): Or delivered.

Mr May: I will ask Margaret whether she thinks that the GPIP provides that information.

Dr O'Brien: When we get the return on the workforce survey, it will provide that in detail.

The Chairperson (Mr McCrossan): You can understand the concern that we have around that. It shocks me that you cannot provide the information on the number of sessions that are covered by our GPs across Northern Ireland weekly. How do you get a full picture of what is going on if you cannot answer that question?

Mr May: The data that is collected through the GPIP talks about the patient encounter. It does not necessarily talk about the sessions worked. We would be able to tell you how many patient encounters there are.

Mr Honeyford: Let me rephrase it then: how many patient encounters are there in a week?

Mr May: On average, there are around 200,000 patient encounters a week.

Mr Honeyford: OK, and we have 23% more GPs, so what was the 200,000 per week figure in 2014?

Mr Cassidy: It was not calculated then. The 200,000 figure comes from a survey that started through COVID, so we have the data from 2020.

Mr Honeyford: It is from 2020, so we have figures for five years. What we are trying to establish is whether there is a barrier.

Mr Cassidy: I do not have the figures in front of me, but the trend for what has been delivered through GMS is broadly consistent over those five years. We do not have reliable data for the pre-COVID period. It was in the order of between 180,000 and 190,000 when the survey first started to the current levels of 200,000. Obviously, that fluctuates. In winter, there is a higher number, as you touched on, but the trend of the data is that there is a consistent level of patient encounters.

Mr Honeyford: The patient encounters are equal, roughly, over the five years with 23% more GPs.

Mr May: We know that there has been an increase in the number of GPs working less than full time. It may well be that the amount of GP time available is broadly similar to what it was five years ago.

The Chairperson (Mr McCrossan): On accountability, again, I come back to the nub of our Committee's work and value for public money. I find it absolutely shocking — I do not know whether other members feel the same — that you do not record the number of sessions that are covered. How do you ensure value for public money if you are not measuring that? It does not make any sense to me. Why are you only doing that in 2025?

Mr May: We are not measuring activity; we are measuring the outcomes and the patient encounters rather than the number of sessions.

The Chairperson (Mr McCrossan): How do we ensure value for public money on that basis in itself? That is not a proper measure.

Mr May: It is a measure —.

The Chairperson (Mr McCrossan): There is a demand on GP services. If GPs are not meeting that demand and you are not measuring, how do we know where the gap is in service delivery and demand? Are we meeting the demand? How can you measure it properly if you are not measuring sessions?

Mr May: Sessions in themselves will not tell you whether you are meeting demand in any case. They merely indicate how many GPs are available for what period. The risk is that we take this down a pathway that makes sessions more important than they have been in terms of the way in which we run the GMS contract, which is broadly the contract that is run across all of the nations and has been for the past 20 years. I am not sure that that is taking us in the direction that is helpful.

The Chairperson (Mr McCrossan): I am just a bit startled by the lack of data, to be honest. There is a trend emerging in relation to it, and I am concerned that there is just not proper data collection around some of the questions that have been asked. It is alarming.

Mr Honeyford: Surely the number of appointments is absolutely directly related to the outcomes that come out of the practice. If you have not got the appointments, people are not getting access. That is what we are looking at. The fundamental thing that we are looking at is whether our constituents can get in front of a GP, in person or on the phone or in whatever way to get access to a GP. If those slots are not there, or they are not growing in number to meet the demand, the outcomes are not there. I cannot understand how that is not —.

Dr O'Brien: I mentioned this before; it goes back to the understanding of the contract. The GPs are independent contractors who are funded on a four-country basis. The bulk of their moneys are given out under a global sum amount. The general practices — the partners — decide how many GPs, nurses and other allied health professionals they want to employ. That is the contract that was agreed on a four-country basis. That is why, to date, the sessions are worked individually in each practice, whilst we have an overarching number of partners because that is required on an annual basis. The detail behind that is what we are collecting this year.

Mr May: We do collect anonymised patient data about whether or not patients get the treatment that they need and the outcomes, as Margaret described earlier. Be assured that it is not that there is no oversight of what is a very substantial amount of public money going in. That is monitored carefully, through the data that comes through the system and through the regular visits that are made to practices.

Mr Honeyford: I am going to ask you, to get your point of view, the same question that I asked the BMA last week. If you had a blank sheet of paper on which you could dream up a system, is this the system that you would start again with?

Mr May: That is probably taking us into the policy space. If people wanted to change the system that we have at the moment, that would be a political decision.

Mr Honeyford: I am not talking about political decisions. If you had a blank piece of paper on which you were starting from scratch to deliver primary care, is the system that we have now what we would —.

Mr May: In the 1940s, when Nye Bevan was negotiating the creation of the NHS, he tried very hard to secure primary care on the same basis as secondary care, with doctors funded through the national health system. At that time, the BMA opposed that very strongly and wanted the partner model. That is the basis on which we have arrived at where we have got to. I appreciate that you have asked a specific question that I have not answered, but I am giving you that history because there are more partners than government in this who need to decide what future models look like. Government has to be, in part at least, the art of the possible. Clearly, the arrangements that have existed for the past 75 years have come under a lot of strain in the past couple of years. We have seen more contract hand-backs than you would have seen during that period more normally. That suggests that more funding needs to be made available through the Assembly than has been made available and/or that there will need to be a broader range of arrangements. I have set out that we are looking at broadening the arrangements, because I think that the dislocation that would come from making a change to the current system and doing away with it entirely would almost certainly be greater than the benefit you could receive.

Mr Honeyford: Thank you. I have one more question. At last week's meeting, we heard about the introduction of e-prescribing to alleviate a lot of the pressures on the GPs' workload. It is commonplace in England and Wales, and it was described to us that it could be easily implemented here. When will it be introduced to Northern Ireland?

Mr May: There is quite a complex programme of projects that go together and that would help. Some of them are enabling projects that would need to be put in place to implement the e-pharmacy solution. We are funding the project team, and we hope that the project will start in 2027, but it will take four or five years to complete the project. There will be different stages and phases as different bits of the project get delivered.

Mr Honeyford: When you say "the project", is that the delivery of the whole software bit? Are we talking about that being eight years away?

Mr May: We could be talking seven years away, certainly.

The Chairperson (Mr McCrossan): Again, that is quite alarming, to be honest. Thank you for your letter, permanent secretary. We appreciate your providing that to us for today. It was filled with information and is helpful, and it has prompted a lot of our questions for today's session. At the bottom of the letter, it outlines that the Department, dependent on funding, could foresee a system being in place by 2032. That is seven years, as you have said. A lot of people will find that deeply alarming, given that technology is advancing at a rate that none of us can compete with or keep up with. So, we would only be putting a system in place when systems that are in place today will be out of date. Why is this so slow? Surely, it is costing us money by not putting the system in place. Surely, it is a more efficient and effective way of doing business. Surely, our people should be getting the same access to that sort of service as others. It is an arduous process to order a prescription in Northern Ireland. You have to go to submit it physically on a bit of paper to a postbox, in some cases. It is very out of date.

Mr May: It is certainly something that we would like to introduce. There has been a challenge with competing projects and priorities. We have invested in the Encompass scheme, and that has meant that the e-pharmacy scheme has had to wait a bit longer than ideally we would have liked, because we could only afford to deliver so much on IT improvement at the one time. I have had, quite recently, a good engagement with the project team to understand the nature of the programme. They have explained it to me, and, if it is helpful to the Committee, I am happy to explain it in more detail. There are three or four projects that are bound up together, and it is not as simple as just introducing the e-prescriptions without having some of the enabling steps in place. Those take some time to deliver. I am happy to explain in more detail what is in the letter.

The Chairperson (Mr McCrossan): Permanent secretary, most people would look at this and say that seven years is an outrageous timeline for this. Surely, this should be in place. We are lagging behind the rest of the UK on electronic prescribing. There is a shelf-ready model available in other parts that could easily be used here, I am assuming. I just do not understand. It seems that, when it comes to technology and digital transformation, Northern Ireland is just not at the races. Certainly, it seems that the Department of Health is not at the races on digital transformation if we are not going to consider putting this in place until seven years from now. It is clear that the picture will be very different next year, let alone in seven years' time.

Mr May: It is perhaps worth drawing out the bigger IT transformation agenda that the Department of Health and the health system here has been working on. The Encompass system has been introduced and is currently in three of our trusts and will be going live in the two remaining trusts at the beginning of May. It is a major investment. We are the envy of the nations of the UK. All the digital leaders came over at the end of last year, and they looked at Encompass and the fact that we have a single imaging system and a single laboratory results system. They all said, "You are well ahead, and that is where we would like to be". We have the only system that I know of that has introduced an electronic patient record system for both health and social care. Therefore, the wider comments about the Department of Health not being at the races on IT are not correct. I accept that the project has had to be delayed because of the investment made in other projects. There are always choices to be made, and I absolutely understand why others might take a different view as to which project should be prioritised, but I am explaining how we got to where we got to.

The Chairperson (Mr McCrossan): We are talking about GP services, and your letter very kindly confirms that GPs will have a limited read-only view of a person's hospital record. Why were GPs not given full access to patient records in Encompass from the outset? Surely that is an issue? What is the timeline and what funding is in place to fully integrate GP records into Encompass?

Mr May: As I said, the Encompass implementation is massive in scale and nature. The fact that it covered social care as well meant that we had to draw lines around what was and was not achievable. The model put in place for GPs was access only. In an ideal world, of course, we would have a fully integrated system that covers all areas, including the independent sector because there is an interface there with secondary care. Those things need to be considered as future phases of the Encompass programme. Our focus, correctly, has been on securing the proper roll-out of what we committed to, and we will then seek to optimise the use of the system; otherwise, you will have a great system but will not be using it fully. Encompass will have substantial amounts of important data that will help us to manage and run our system better, and we will then look at how we can extend it to other fields, such as primary care. In an ideal world, yes, we would be looking to do that, but there is a limit to how much can be taken on board at any one time. My judgement is that we have sized it appropriately, and, by providing access, we have at least mitigated the worst of the risks.

The Chairperson (Mr McCrossan): OK. You have sort of answered my next question about adding on as we go along. Your letter states that:

Why is the GP out-of-hours service still using an outdated IT system? I suppose that it is the same answer. Will you look at that at a later stage?

Mr May: Yes.

The Chairperson (Mr McCrossan): If so, when? On the three points that I have made, when will they be dealt with under Encompass to come under one system?

Mr May: I do not have a timeline to give you today. We do not have a fully fledged project plan for future phases. There is work that needs to be done on affordability and on the viability of delivery. We are some way away from being able to achieve that.

The Chairperson (Mr McCrossan): Cathal, do you want in?

Mr Boylan: No, Chair. My question has been asked. Thank you.

Mr Gildernew: I start by going back to the 200,000 sessions figure, which was mentioned by the GPs. It is worrying in the sense that, effectively, one in 10 of the population sees a GP every week. Do we know for how many of those sessions the GP was the best person to see?

Mr May: There is no way of measuring that. It is 200,000 interventions with primary care. Therefore, it is GPs plus all the other health professionals who work in GP surgeries. The figure is not just in the GP context.

Mr Gildernew: In general, I am concerned about the number of times during the session that we have heard, "We do not have that data". Data has never been more easily collected and, maybe more importantly, more easily analysed. We are behind the curve in that sense.

I wonder how we will create an appropriate MDT model without data about the best professional to see. I understand that, before I came in, you announced a welcome increase in the expansion of MDTs. What is your assessment of the effectiveness of the MDT roll-out to date in supporting primary care more generally for the population, as well as supporting GPs?

Mr May: An evaluation of the MDT scheme to date is well advanced. It shows the number of patient interactions for the main areas, which are mental health, social care and orthopaedic- or physio-related matters. We hope that the evaluation will be published in the coming weeks or months. The evidence suggests that there has been a 12% reduction in the number of referrals to core trust services by MDT practices compared with non-MDT practices. It also suggests that, for adult mental health services, for example, there has been a 32% reduction in referrals. The 12% is a global figure, so the 32% needs to be read in that context. I think that 300,000 patients were seen by MDTs in 2023-24, an average of 7·5% of whom were referred to secondary care.

Hopefully, that gives you some of the data and evidence. As I said, an evaluation is nearly complete, and we hope to be able to publish that in due course so that everybody can see the data.

Mr Gildernew: OK. I should declare an interest: previously, I was a social worker. The Audit Office report indicates that nursing and social work will be reduced in new MDTs. Is the Department still confident that it will reduce pressures in a similar way to what you are outlining, including the pressure on secondary care, while still representing value for money? Will you give us some understanding of why those professions will be reduced in the new MDTs?

Mr May: There are a number of things. First, with any new model, you need to learn from what works in that model and adjust accordingly. We are also very mindful, as you will be, of pressure on the availability of social workers in secondary care as well. The model had more social work than other professions attached to an MDT. We are looking to make it more similar across the board in its approach. We also need to recognise that MDTs should not be a purely medical model; they should have a connection to the voluntary and community sector for services that can be delivered in that way, because that is a better use of our overall resources. We will look to continue to develop the MDT model. Some of it is about taking account of wider system needs. Some of it is about what works and how we can make it most effective.

Mr Gildernew: Thank you. I note that there seems to be a bit of a mismatch in the percentage of population covered. We are looking at 8% currently as opposed to the third that you are reflecting.

Mr May: Eight per cent get the full MDT service, and a third get some of an MDT service.

Mr Gildernew: The additional money from the Programme for Government will increase that to two thirds. Does that mean that the percentage getting the full service will double from 8% to 16%?

Mr May: No, two thirds is 66%.

Mr Gildernew: Yes, but 8% of the population currently has access to a full MDT. What will that percentage be in the new model?

Mr May: The extra investment will enable the third who get some service to have a full service rolled out and allow that service to then be rolled out for another third of the population.

Mr Gildernew: OK.

Mr May: Does that make sense?

Mr Gildernew: No. [Laughter.]

Not to me.

Mr May: Apologies. Let me try again in that case: the plan is that, broadly speaking, 65% of the population will have access to a full MDT service in five years' time, if that makes sense.

Mr Gildernew: What is the equivalent figure now? I am trying to find —.

Mr May: Eight per cent have access to the full MDT service, and a third have access to some MDT service.

Mr Gildernew: It will go from 8%, which is what it is currently, to 65%.

Mr May: Yes.

Mr Gildernew: I welcome that.

Mr Honeyford: Will the remaining 35% get a part-MDT service?

Mr May: There will not be a part of the population that has part of the service. That 35% will get the full service, along with another 30%.

Mr Honeyford: I am confused.

Mr Boylan: It is like a maths class in here. It is not maths. We are not doing maths.

Mr Honeyford: Will 35% not get any of it?

Mr May: There will still be a third of the population that does not receive an MDT service at all at the end of this. There will need to be a further roll-out phase to do that.

Dr O'Brien: A further phase.

Mr Boylan: That is understandable. We are doing a basic inquiry here.

The Chairperson (Mr McCrossan): For me, it all comes back to this: how many full-time equivalent GPs do you need to meet the required service levels? I do not understand how that question cannot be answered.

Mr Boylan: That is the question. I have been waiting myself —.

The Chairperson (Mr McCrossan): Is that —?

Mr Boylan: The number of GPs has increased by 23%. We are trying to find out why we cannot access GPs, and we now understand that there are a number of reasons: work-life balance, change of hours, people walking out and all of that. We need to get a better understanding of that. That is where we are at. Unless we know what the workforce is, we will never be able to deliver the full programme. That is all that we are saying. Therefore, the more information that we can get in the form of figures and stats, the better. Basically, that is what I want.

Mr May: Let us see whether we can provide any further information to help the Committee with that.

Mr Boylan: I appreciate that there are increasing numbers; you explained all that. I am just trying to get my head around all that.

Mr May: We responded earlier to a question about demand. Multiple factors determine whether you can meet the full range of needs.

Mr Boylan: A hundred per cent.

We are doing an investigation — an inquiry — into access to GP practices. The more information we have, the better able we will be to formulate recommendations. That is the point. There have been some answers already, but that is the point that I am making.

The Chairperson (Mr McCrossan): We are just trying to establish that a 23% increase in GPs does not necessarily mean a 23% increase in service level.

Mr May: We are not suggesting that there is —.

Mr Boylan: We are not saying that either.

Mr May: We are saying that the service level is roughly the same as it was previously, broadly speaking.

Mr Boylan: Exactly. It makes up that percentage.

The Chairperson (Mr McCrossan): In real terms, therefore, it is a reduction in service level, given that there are more GPs.

Mr Boylan: It is not. No, it is not.

Mr May: In real terms, it is a —.

The Chairperson (Mr McCrossan): There are more GPs and less service being delivered. That is what that means, is it not?

Mr Boylan: No. It is not.

Mr Cassidy: The number of sessions being worked by GPs is lower than it was previously, but the level of service that is being provided is consistent. The question was about whether people are leaving the system here to work elsewhere. I do not think that the numbers support that. There is, however, a question over the extent to which the GPs who are here are working full-time, working a portfolio career or working less than full-time.

The Chairperson (Mr McCrossan): I just want to be clear. Am I right to say that you cannot answer the question about the number of full-time equivalent GPs and that, at the moment, you do not know how many full-time equivalents you require in order to service the level of need that is out there right now?

Mr May: The point is that there is not one number to answer that. The introduction of the MDT model will change the demand on general practitioners. You have to see this in a slightly different frame, I think.

Mr Boylan: The way to understand it.

The Chairperson (Mr McCrossan): Different from the traditional sense.

Mr May: You are looking at this purely in the context of doctors.

The Chairperson (Mr McCrossan): Yes, I get that. [Inaudible.]

Mr Boylan: Exactly.

Mr May: We have to look at it in the context of overall primary care provision.

The Chairperson (Mr McCrossan): OK.

Dr O'Brien: We have done modelling for the number of GPs that we need. That modelling has fed into the number of training places and what we may need in the future. As Peter said, however, we need to look at that in the context of the whole practice and what other allied health professionals bring to it. That will have an impact on the number of GPs that we ultimately require, whether it means the number going up or down. We have done modelling, though.

Mr T Buchanan: How many GPs are in training at this time?

Mr May: There are 475.

Mr T Buchanan: Four hundred and seventy-five.

The Chairperson (Mr McCrossan): This is my final question before bringing in Colin, who is waiting patiently online. What will be done to improve services for the third of the population that will have no MDT service for the next five to 10 years? That section of the population will be left with no access to that service.

Mr May: That is correct. There will be an inequality during that period. We very much hope that we will be able to move to rectify that inequality as quickly as possible once the funding becomes available.

As I said, there is also a people resourcing issue that needs to be taken into account.

Mr Cassidy: We are developing plans for MDT implementation everywhere. We have secured funding for the first four years of that, and that is where the attention will be, but we are looking to plan for completion beyond that. Practices in areas that are not getting MDT will be able to see where they are in the queue. It will not be addressed in the next four years, but there will be a plan in place for when it will be addressed.

The Chairperson (Mr McCrossan): That will not satisfy the population that is missing out on that service. It goes back to the question of equity in the service, because people will be left behind.

Dr O'Brien: Whilst it will take longer to implement in those areas, in the meantime, in advance of the next phase of the roll-out of MDTs, we have provided them with opportunities to put in place advanced nurse practitioners. That goes some way towards helping to address the inequity in the intervening period. We have invested £3 million in advanced nurse practitioners across the region. We have about 34·8 whole-time equivalents in place. Areas outside the MDT implementation were specifically targeted for those additional staff.

Mr Gildernew: Will you match the roll-out of the MDTs with where, going by GP profiling, there is most pressure?

Mr May: A programme of areas has already been set out.

Mr Cassidy: In 2022, Minister Swann announced the roll-out sequence for the remaining areas. The development of that sequence was based on a number of factors, one of which was deprivation and need. That featured in the plan that has been announced. As we go forward, detailed plans will be developed by each trust in partnership with the federations: the plans will show which practices will get which staff and in what sequence. We expect local knowledge to inform implementation at local level.

Dr O'Brien: It is important to highlight the investment, in addition to that in multidisciplinary teams, that we have made in all practices through practice-based pharmacists: £20 million of investment has gone into general practice to help our GPs to manage medication reviews. We all know that medications are a high-risk area for general practice. It would be remiss of me not to highlight that significant investment.

Mr Boylan: Margaret, you said that the number of locums was 300-plus-ish, which is roughly 15% of the total of 2,000.

Dr O'Brien: The 2,000 include doctors in training who are in their final year.

Mr Boylan: Let us say that it is 10%, then.

Dr O'Brien: Yes.

Mr Boylan: We should try to incentivise GPs to be salaried in order to get them into the system. The question that we asked earlier was partly about incentivisation, because it could seem as though doctors are incentivised to take locum roles, so we may need the exact figures, if you have them.

Mr May: We have the number of salaried GPs and can provide that.

Dr O'Brien: We do.

Mr Cassidy: It is 314, up from 117 in the past couple of years.

Mr Boylan: OK. In the short-to-medium term, we will have to address that. I know that other people have asked about MDTs and everything else, but we will have these problems for some time. Thank you.

Mr Crawford: I thank the panel for their time and their answers this afternoon. Apologies that I am not there in person for your presentation. My question is about longer-term improvements and investment in general practice. The Chair picked up on the fact that per capita investment in general practice is lower in Northern Ireland than elsewhere in the UK. The Committee has heard concerns that it is also significantly below what is needed to provide safe and effective services. Given that early intervention is widely recognised as the most cost-effective way of treating patients, why is that?

Mr May: OK. As I said in answer to an earlier question, the percentage depends on the base that you take it from. I will make two points. First, taking a percentage is only a proxy measure, because it depends whether the overall budget is adequate. You are taking a percentage of what the total is. Secondly, the data in the Audit Office report took a percentage of the overall health and social care spend. Based on that Audit Office data, if you were to take the health-only spend — in other words, take social care out — the percentage would go up to 6·4%. I highlight those features.

Our numbers are broadly similar to those of Wales but lower than those of England. That is the funding position that we are in . Why is that? As I explained, in recent years, there have been quite substantial increases in funding, in a number of different ways, in the primary care budget and in general medical services in particular. We have rehearsed a whole range of different steps that has been taken to increase that. We are constrained by the pressures that exist on our system more widely, and we absolutely agree that early intervention and prevention are the key. The total of £60 million investment in the next four years in MDTs is squarely in that space and will make a substantive difference, because it is all about intervening before people need an intervention from a primary care doctor or a referral to secondary care. That is the direction of travel, and our Minister, as you heard, is committed to the shift-left approach — the move to more community-based interventions, more early intervention and prevention — and to a greater public health agenda that joins up not just the work of Health but the work of Health with many other Departments. That is common ground and widely agreed across all parties.

Mr Crawford: In England it is 10% per capita. Do you know what it is in England?

Mr May: Sorry, I think that something may have been lost in translation. I am not aware of a 10% figure and do not know where it has come from. If you can give me access to that data, I will look at it.

The Chairperson (Mr McCrossan): In a previous evidence session, we were told that the investment in GP services in England is 10% of the overall budget. There is a campaign to increase that to 15%, given the level of demand on services. We are not sure of the figure in Scotland, which is what Colin meant to ask. Have you any indication of what the figure is there?

Mr May: There are difficulties in comparing data. Our understanding is that England is at about 8·4%, not 10%. If you have a data source that we can look at, I will certainly try to see what we can do by way of comparative data. Not all these figures measure the same things, I am afraid. That is the reality, and we can end up imagining that the situation is rather different from. what it actually is.

Mr Crawford: I have just one more question for the panel, if we have time. It is nearly 10 years since the Department published 'Delivering Together'. The commitment in that was to enhance support for primary care. Do the findings of the Audit Office report demonstrate that the Department has failed, or at least struggled, to implement the Bengoa recommendations?

Mr May: That potentially takes us beyond the narrow confines of this report, but your question raises an important point. A lot of people associate the Bengoa report purely with the reconfiguration of hospital services, whereas it is much wider than that.

It is absolutely about how we develop and build better community-based services, whether that be through primary care or other means. It is true that a succession of major challenges, such as a pandemic and financial austerity, has created real challenges in delivery. However, through things such as the multidisciplinary teams, we are now able to make some further progress, and that is absolutely the kind of thing that Bengoa talked about. We are slower than we would like to be, but we are getting there.

The Chairperson (Mr McCrossan): Permanent secretary, you know the year that Bengoa was published: it was nine years ago. "Slower" is an understatement, many would say, to be honest, when it comes to implementation.

Mr May: It is right to recognise that, for five of those years, there was no ministerial leadership in the Department of Health and that, for two of those years, there was an unprecedented global pandemic. If one glosses over those things and imagines that they did not happen, that is a mistake.

The Chairperson (Mr McCrossan): Believe me, permanent secretary, I am certainly not glossing over the absence of these institutions or the impact that that has had on services for our people and on people's lives. I have no doubt that you are not doing that either.

Mr Gildernew: Chair, on that point, have we slightly overlooked the potential benefits in primary care and allowed transformation to become too much about the hospital sector? You talk about social prescribing and all the potential benefits there. Do we need to refocus in that respect?

Mr May: There is absolutely a need for a different understanding of what health transformation means. It is a much more broadly based transformation that brings in the public health agenda and that whole-community focus, and it recognises that the likes of our digital transformation and workforce transformation are core parts of our transformation and that it is not simply about secondary care and the location of services. Thank you for raising that.

The Chairperson (Mr McCrossan): Do you think that our current system is proactive enough, or is it too reactive? Are we reacting too much to the circumstances that we are presented with instead of planning and saving money in the interests of the taxpayer?

Mr May: Will you give a little more context around that question?

The Chairperson (Mr McCrossan): Yes. For instance, GPs who presented to us last week told us of the pressure that they and services are under daily. The public whom we represent tell us that they cannot get access to those GPs. GPs say that they are not properly resourced to meet the demand out there. They are asking, from my understanding, for a 1% incremental investment in services. Would it not be better, and certainly in the interests of public money in the long term, to invest now to support those services in order to save later? The sticking-plaster approaches, which are all over this in the form of contracts being handed back, taking over practices and locums being put in place, cost more now and will cost more in the long run. Is an investment now not the better solution? Is listening to our GPs and responding to the concerns of our public not the solution?

Mr May: I will probably repeat myself, and I apologise, Chair. I have highlighted all the different areas in our health and social care system where there is a strong case for additional investment, and I have highlighted the fact that, as things stand, the Assembly has not chosen to decide that the Department of Health needs the money that would enable it to make those investments. There are efficiencies that can be made in our system, and it is absolutely right that we should look to make sure that we are making the best use of the resources that we have. This year, we will have made over £200 million of efficiencies, which is unprecedented, and we will put additional pressure on next year for further efficiencies. Ultimately, there are decisions to be taken about prioritisation, and general practice is one of a number of areas with an extremely strong case for additional investment.

The Chairperson (Mr McCrossan): Yes, I am very aware of the pressures overall. My concern is that the situation that we are in, based on the evidence that we have received from those at the coalface, will get worse. In fact, the 1% investment is simply to stand still and keep the lights on. That is what we were told at a previous evidence session. That is extremely worrying and shows that things will get worse. One of the witnesses before us, permanent secretary, told us that GPs faced extinction. That might sound a bit drastic, but maybe that is how GPs feel.

The reality that I see here is that the Department, in my opinion, is not taking the concerns of GPs seriously and is not responding to the concerns of the public, who are directly affected as a result. I appreciate that, to an extent, this is a policy matter, given the need for increased investment, but the role of officials in a Department is to guide the Minister and to place the Minister in the best possible situation to make those decisions. The figure that we have here is that it is 10% in England. Regardless of whether it is 10% or the 8·4% that you said, investment in GP services in England is higher than it is here, and our GPs are very conscious of that. I am very worried that, in the year ahead or in the next few years, we will end up in a situation where all the things that we have discussed today will have worsened, and not dealing with them now will be costing us more. That is the concern that we have, and I do not believe, given what I have heard in this evidence session, that you have the data before you to properly deal with this issue and analyse it effectively to find a solution. It sounds critical, I know, but that is what I am picking up from today's session.

Mr May: I heard what you said. I do not think that you asked me a question, so I do not plan to respond.

The Chairperson (Mr McCrossan): OK. I have made my point. Anyone else?

Members, thanks very much. Permanent secretary, I thank you and your colleagues for being with us. We appreciate your time. You have been with us for quite a number of hours taking a significant number of questions. This is a very important issue for our public, and I am sure that you are very conscious of that. We all, at some point, will require the help and assistance of GPs, and it is vital that we have access to them.

Before I allow you to leave — thank you for your patience — C&AG, do you have any comments to add?

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

The Chairperson (Mr McCrossan): Stuart?

Mr Stuart Stevenson (Department of Finance): Nothing.

The Chairperson (Mr McCrossan): OK. Thank you for being with us and for taking our questions. We hope that the Department will furnish us with the extra information that we require to satisfy the inquiry. Thank you.