Official Report: Minutes of Evidence

The Chairperson (Mr McCrossan): I welcome Mr Mike Farrar, the permanent secretary in the Department of Health, and Mr Gearóid Cassidy, the Department's director of primary care. We are also joined by Stuart Stevenson, the Treasury Officer of Accounts (TOA) in the Department of Finance, Dorinnia Carville, the Comptroller and Auditor General (C&AG) from the Northern Ireland Audit Office (NIAO), and other staff members.

Welcome back to the Public Accounts Committee, Mr Farrar. Thank you for agreeing to attend the Committee today, along with your colleague, and for providing the information that was requested at short notice yesterday in advance of the session. You will appreciate the nature of the request, and we appreciate the response, your having received it at short notice.

The Committee has recalled you, as accounting officer, because the Department’s recent response to our report on access to general practice, we believe, fell significantly short of what is required or expected by the Committee. Beyond the lack of urgency, which has been well reported, the Committee is deeply concerned about what appears to be a lack of respect for the people who rely on those services daily. The public are not seeing improvements. If anything, they are facing increasing difficulty in simply getting through the door of their GP practice. That is amounting not only to significant and serious frustration on the ground but to detrimental circumstances for those who are affected and cannot get access to that vital health service.

While the Department may have accepted or partially accepted our recommendations, the implementation timelines stretch for years into the future without credible justification, meaningful interim actions or any indication that the scale of the challenge is fully understood by your Department. Meanwhile, patients remain unable to access the most basic point of entry into the health system. Moreover, the Committee cannot ignore the "sticking plaster" approach that appears to characterise the Department’s response, which is about managing symptoms rather than delivering the fundamental reforms that are urgently required in order to stabilise and sustain GP services across Northern Ireland. That perception is reinforced by the absence of a coherent, long-term strategy, a realistic workforce plan and clear evidence of decisive action taken by your Department.

I remind you both that more than 15,000 members of the public engaged with the Committee's inquiry, and the weekly contact that we receive across our constituencies confirms that little has improved at all. The scale of the crisis is not being matched by the scale or pace of the Department’s response.

Today is therefore an opportunity for you, as accounting officer, to explain the Department’s position, address the gaps and uncertainties in your response and provide assurance that urgent, tangible steps are being taken now — not postponed to the distant future — to deliver real improvements for our public and for patients who are directly affected.

Before we move to questions from members, I invite you, as accounting officer, to make your opening remarks.

Mr Mike Farrar (Department of Health): Thank you. I welcome the opportunity to address the Committee this afternoon. I completely recognise the Committee's criticism, and I know that you were disappointed with the response, so this is a real chance to assure the Committee of the importance that we place on GP access and the priority that it is given in our work going forward and of my commitment on the issue. I acknowledge that the weakness of the original response did not reflect accurately our policy intention, our actions and the fact that this is a strategic direction as well as it could and should have, and I take responsibility for that.

I will say a few things in order to defend those statements. GP access can be seen as a narrow issue, but it is not. It is fundamental to our approach to resetting health and care in Northern Ireland and, indeed, our contribution to fiscal sustainability. That is one of the other big issues that we face in health and care spending, which we are trying incredibly hard to manage in the context of Northern Ireland's overall finances. In defence of that, our reset plan is all about managing demand. Managing demand relies on early intervention and earlier diagnosis, as well as secondary prevention for those people with chronic problems who are potentially manageable in primary care, if they can get better access, but will otherwise end up in hospital environments or independent care homes etc. When you look at our strategy for the future, you see that access to general practice is at the heart of our strategic direction and what we need to do.

During the session, I hope to demonstrate that the weakness was in the written response, not the policy action. It is important to differentiate between those two things. I will try to make sure that you understand why I am confident that I can deliver that. I want the Committee to understand that it is a major strategic objective for us. We know that stabilising and reforming general practice is crucial to our ability to deliver our neighbourhood model of health and to prevent people from deteriorating etc. That is a key priority for us. We will be able to update the Committee on a number of areas in which actions have been taken or are being taken at a speed that, in some cases, is faster than that in the Committee's recommendations. I am very happy to elaborate on that as we go through each recommendation, if that is how you want to handle it.

There is a lot more to say. It is unfortunate that we are in this position; it is not one that I want to be in. My only point on that is that there are three mitigations. First, at the time of our response, we did not have a budget. Five days out from the beginning of the financial year, I still do not have a budget or know what the expenditure will be. There are some areas in which we want to increase expenditure, but, until I have a budget — as you know, I have to live within my means — it is more difficult to commit to doing that for you.

Secondly, it predated something that we have in draft form, because we do not yet have a budget: our operational planning guidance, which commits to our priorities for next year. I will refer to a couple of things from that document during the session. That will tell you exactly what we are saying to Health and Social Care (HSC) about our priorities for action.

Thirdly, at the time of our response, we were in a delicate position when it came to renegotiating with the Northern Ireland General Practitioners Committee (GPC) about returning to the negotiating table to open negotiations for a new contract. One of the things that was in dispute was about some access indicators that we had put into last year's contract, which the GPC felt were not appropriate. Therefore, we were in a position where it was harder to do that. I am pleased to say that we have navigated that, and, as I will go on to say this afternoon, we are now in negotiations with GPs about a new contract, of which access is one of the key criteria.

This afternoon, I hope that we will be able to reassure the Committee that the actions that you saw as fundamental, which I also believe to be fundamental, are being taken forward and that we can address most of the recommendations and give updates as to where we are on them. If we have the chance, we might also discuss some of our further thoughts about how we might move those things forward.

I am pleased that I have Gearóid Cassidy, my head of primary care, with me. If we get into some areas of detail, I am sure that he will be able to help.

I am grateful that the Committee invited me back this afternoon. I am still resting because of a kidney infection. I may put my hand up to ask for a comfort break. If you are able to give me one, should I need it, that would be helpful. I mean no disrespect to you.

The Chairperson (Mr McCrossan): Thank you for those opening remarks. We are conscious that you have had a recent spell of ill health, and we wish you all the best in your recovery. Of course, there will be no question if you require a break at an appropriate time.

You will understand why the Committee felt so strongly that it requested that you were brought back before it for a number of questions. The memorandum of reply (MOR) that the Committee considered was weak, as confirmed by your own words. It does not indicate any sense of urgency or seriousness about the very serious crisis that we hear about daily that affects all our people across Northern Ireland. It needs to be dealt with.

First, before I go into some formal questions, I want to ask this: do you appreciate the magnitude of the crisis that the service faces and the fact that people are suffering as a result of it?

Mr Farrar: Absolutely. Yes, I do, and I know that what we are delivering at the moment is not acceptable. It is not where we want to be, and we commit to improving that.

The Chairperson (Mr McCrossan): Do you also accept that the formal response that we have received in the form of an MOR did not live up to our expectations or the commitments that you gave at our previous session? When I looked through it, whilst many recommendations were accepted or partially accepted, which is to be welcomed, I saw that the timescales were entirely unrealistic. It did not give a sense of urgency that indicates that the issue is a priority for your Department.

Mr Farrar: When we get into the questions, Chair, I want to give you strong assurance that there is indeed a sense of urgency. We have already committed to implementing a number of the recommendations that you made in advance of the time frame that you set, but we were not able to reflect that in our written response.

The Chairperson (Mr McCrossan): OK. Can the Committee have an assurance that future MORs will be more detailed and will be satisfactory in quantity and quality?

Mr Farrar: I very much hope so.

The Chairperson (Mr McCrossan): Thank you.

Mr Farrar, will you set out in clear terms the Department's delivery plan for improving access to GP services over the next 12 to 18 months, including key milestones and how progress will be measured?

Mr Farrar: When you look at the range of recommendations, you see that a number of the actions in the areas of activity that came out of your consultation with 15,000 people are key to improving access, so, if you want to go through the eight recommendations, that is fine. The first one was on our ability to talk to the public about the use of general practice and where they could access alternative services. We certainly have that ability. We have a programme, which I am happy to talk about in future — I will keep it high-level, and you can further probe if you wish — called This is our health. Through that, we have talked to 900 people across Northern Ireland about their priorities. Our approach is to use a something-for-something deal. People want us to guarantee GP access, so we say, "What do you need us to guarantee, and what would you do to help us?". One thing that emerges in that something-for-something deal is our saying to people that, if they can use community pharmacy for minor ailments, that will help us to guarantee access to general practice when they need it. That is the first area that, again, I am happy to describe.

We continue to look at the areas in which there is inappropriate access so that we understand why that happens. We will introduce clinical decision-making tools for access to secondary care, and we will work with the general practice community when it comes to people who come through its doors who could be managed elsewhere. That is the second area in which we will inform ourselves as to the strategy that we need to pursue.

The third thing — this is probably really important to what the strategy will look like — is that we are in active dialogue with the general practitioners about how we might change the nature of their contract in order to support improved access. That matters because, as you know, general practitioners are contractors, so, when you want to influence the way in which general practice works, you have to align that with their contractual incentives, and access being at the heart of that is important.

The fourth area is a vision for general practice. We started our conversation about that on 4 March, in advance of the Committee's recommendation. It is about asking what the priority is and how we work with our GP community. Continuing to expand the range of services around general practice is critical even if the issue is getting more general practice time, because that takes time. As you rightly point out, our workforce planning has not been good, and our workforce strategy needs to kick in, but there is a time lag to that, so we need to look at what modern primary care looks like. It is about supporting our GP community and what works around it, including community pharmacy and multidisciplinary teams (MDTs), with social workers, physiotherapists and mental health workers supporting that wider primary care team.

GP access is multifactorial, and we continue to invest in multidisciplinary teams. We are also looking at, for example, freeing up GP time by accelerating the approach to e-prescribing, which is another of your recommendations. I cannot announce it yet, but we are hopeful about our transformation fund bid on that. We have been have told that it has been successful, but not all the bids have been cleared through the Northern Ireland Office yet. We do not see any tricks in that; it is just a delay. We know, on the basis of evidence from where it has been introduced, that e-prescribing reduces the burden on GPs and the primary healthcare team: we would be releasing their time all the time.

In discussions with the BMA and the Royal College of General Practitioners (RCGP), we continue to look at the introduction of digital and online support for general practice. There is a roughly 50:50 split on digital access at the moment. I will give the Committee one example. I mentioned that I have a battle with a kidney disease. About four weeks ago, I was in England for one day with my own general practice, so I put in, at 8.00 am, an e-consult form, which is an online form. At 8.20 am, that had been triaged by a GP, who rang me to say that I needed to come in and see them. I went in at 9.20 am and was seen by an advanced nurse practitioner. By 10.00 am, I had my prescription picked up through e-prescribing and was out the door. I only had one day in England. The question on that is about how you optimise the value of your individuals alongside the opportunity of technology. We will, undoubtedly, be looking at technological innovation to try to help our GPs. Our GPs do incredibly well to manage the demand that they face, but we need to think about how we channel that demand to make sure that they see only the people whom they need to see and how we use the wider primary care team to ensure that, when you need a practitioner, you see one.

My last point is that I am huge believer in the idea of a specialist generalist. People with complex problems such as frailty are ending up in our hospitals because we are not managing them well enough in our community, hence our focus on neighbourhood. Every time that you refer them to secondary care, effectively, you are splitting a part of that individual's anatomy and going to one particular place. Most of those people have multi-morbidity, social problems and so on, so the role of general practice in the future is huge, and we need to stabilise that and work with our colleagues to reform that. That is why those strategic bits of contracting and vision, which you highlight in your report, are so crucial to getting buy-in from our GP colleagues to what the solution is around access. We had the first meeting yesterday, and one of the issues raised was that of listening to GPs about their view on what will help them by listening to their experience from the coalface. Those are the areas to look at.

On measuring progress, we will talk, if you want, this afternoon about some of the arrangements that we have in place to take public opinion through the course of the next 18 months. We will continue to use access standards as one of the areas that we want to specifically understand and make sure that we are getting better public satisfaction. We will be able to see in the resource use that we have for some people whether or not they are getting that access, because we will see that we are deflecting people away from unnecessary hospital admissions. I certainly hope to be able to update the Committee as we go through the year on the progress that we are making, and I know that you will not be shy about asking me back.

The Chairperson (Mr McCrossan): Thank you for that oversight and indicative timeline for the next 12 to 18 months.

The MOR responses place significant emphasis on the neighbourhood model of care as a key solution to improving access to GP services. With that having been said, can you outline what your vision of the neighbourhood model will look like in practice? What is the Department's timeline for introducing the neighbourhood model of care? How does the Department intend to implement a new model of care effectively when there is no overarching primary care strategy to guide it and, as you have acknowledged, no satisfactory workforce plan to ensure that the staffing that is required is there to deliver it?

Mr Farrar: The neighbourhood plan is pretty simple in a sense, and you see it across the world. People are having to focus on demand because they cannot meet the demand for health and care through increasing supply. The amount of money that we spend in Northern Ireland per head of population is probably aligned with England but is more than in Scotland and Wales, and we are getting poorer outcomes. Why is that happening? It is because too many people are being treated in our hospitals. It is not that our hospitals are bad; they are very good when you get there, and they do their best. However, they are seeing people who could have been managed elsewhere. Moving the focus to neighbourhood is really about asking whether we can make an earlier diagnosis, whether we can get to people earlier and whether we can proactively manage people at risk better.

The idea of the neighbourhood approach is to take 17 areas based on GP federations, because we need GPs, at scale, to be able to engage with this. Fundamentally, they are at the heart of this. Supporting them on access is so important because it releases some of their time to effectively lead neighbourhood working.

Our view is that the individuals who command the resources in that neighbourhood out of hospital — our trusts spend money on, for example, district nursing, midwives etc — will sit around the table. That will include general practitioners, who are funded through our contracts; community pharmacists, who are funded through our contracts; the voluntary sector, which is funded through grants; and our local authorities. Those are the groups that actually spend the money in a community setting, and we are asking them to work together as a management board. It is not a committee. The integrated neighbourhood team (INT) is a board that will look at the amount of resource that it is currently spending and say, "Could we spend that better?". It will be doing casework, and, effectively, alongside that, we will be putting in new money.

For example, Macmillan is in a final agreement with us about how we can support people in the last hours and days of their life and, effectively, is giving us potentially £10 million to £12 million of social funding for that. Companies such as AstraZeneca and Eli Lilly are prepared to put resources into doing weight management and respiratory services in a different way, and we are, auditably, seeing the trusts, because we have a lot of services that are trust-provided in hospitals that should be provided in the neighbourhood. We have looked at the idea that they will be asked to make a 2% shift of resources from hospital to community. That matters because, if you do not put that in, we will just carry on, and we do not have double running. To take palliative care as an example, a lot of people who are currently getting care in hospital do not want to be in hospital for the last days of their life. As you know, hospitals are not a great place to be; regardless of the strength of the staff, people want to be in their own home. The idea is that, by moving palliative care away from hospitals, where it currently is, into community settings, that would count as a way of shifting resource into communities. The neighbourhood model will oversee that. I was with a cardiologist in the Southern Health and Social Care Trust. In some parts of the world, cardiology is a community service that has in-reach into hospital beds. In Northern Ireland, we have a hospital-based service that outreaches. Therefore, if we move our cardiology services into a community setting, as the southern group would like to do, that would count for that.

The idea is about shifting the resource so that the group of people who manage services in the community are collectively able to provide better services. I will give the Committee an understanding of what that could mean very quickly. During the second week of the new year, we had a higher level of excess bed days and of people who were fit to be managed in community settings but were occupying hospital beds. That data will be available to the neighbourhood teams so that they can say, "What packages need to be in place?". Crucially, if you can do it for people on discharge, the way I envisage this, as it goes forward, is that those people will be saying, "How do we prevent the people whom we know are at risk in our communities ending up in hospital settings?".

In the first year of the neighbourhoods approach, the priority will be older people. They will all go live on 1 April — I know that you want to come back at me — and we have three development programmes into which they will all sit. They will be a mixed-ability class, but they will be getting development support. I think that we will start to see real value from putting the focus on a neighbourhood model. With financial flow and a bit of new money, we will be able to do much better with the resource that we have. GPs are at the heart of that, which is why access to general practice needs to figure in the way that the neighbourhood model works.

The Chairperson (Mr McCrossan): I have a number of supplementary questions in that regard, because you provided a lot of information. There is a burning question for a lot of people. You mentioned one of the timelines — 1 April — but what is a timeline for the implementation or the introduction of the neighbourhood model of care?

Mr Farrar: We will publish our guidance on what we want early next week. In west Belfast and parts of Londonderry/Derry, a lot of the key players are already working in that type of way. The guidance will make it clearer what enhanced arrangements need to be in place and will also talk about funding to support the development of what we currently have. In essence, from the point when we issue that guidance, a neighbourhood approach will go live, and, when they start to go through their development programme, they will understand how we can help them to be better in that role. It is not completely prescriptive, but it has some clear guidance about what we are expecting and the accountability. In essence, we go live because every player will be working towards that, but we need the alliances to come together, and, once they are together, we need to support them. I am very confident that, over the first three months of 2026-27, the formation of those groups will be in place. We will have started the development programme, and we will complete that by, I think, late summer/early autumn, so you will see the neighbourhood teams starting to work.

I want to be clear that, in the past in Northern Ireland, we set up something that looked highly statutory with a series of requirements, which did not meet local need or get the buy-in from people. We now have a balance of direction of what we need and some flexibility about meeting local needs. For example, it is very different in Belfast compared with County Fermanagh. We will be helping and supporting them to be effective in managing the transition that we want to see.

The Chairperson (Mr McCrossan): That leads me on to this very important question: what engagement has there been with GPs on the neighbourhood model to ensure that it is effective if the guidance is being published in the next week?

Mr Farrar: Gearóid can answer because he has been part of that. There has been a considerable number of engagement exercises that started in September. We had a call for evidence, and many responses came from general practice and primary care in communities, so you can see that level of engagement. On a number of occasions, I have been involved with conversations with general practice about the ideas in the neighbourhood model. We are looking potentially to work with a GP leader to help us as a champion for it. This evening, I will be giving my second presentation in the past four months to the royal college council. That is part of discussions on the general medical services (GMS) contract with the Northern Ireland GPC. There has been considerable engagement, but you will appreciate that the more that people start to understand what it is, the more questions they have, so it is iterative.

The Chairperson (Mr McCrossan): The Deputy Chair and I, along with the Committee Clerk and Assistant Committee Clerk, met representatives of the RCGP yesterday, and that is not what they are telling us is the case. They said that there has been little to no engagement on the neighbourhood model. What do you say to that?

Mr Farrar: I do not think that that is fair. I will be with them this evening; with Ursula, whom I know and rate highly, and the committee council people. There have been a number of exercises that we can point to where we had GPs in the room. It might not always have been done through the college, but —.

Mr Gearóid Cassidy (Department of Health): As Mike said, we started a fairly wide-ranging process of engagement with workshops from September forward. Some were broad-based and had multiple stakeholders. One was specifically GP-focused to address their issues in detail. There have been any number of other briefings aside from those.

One thing that we want to communicate to all stakeholders — our Minister has said the same — is that, when publish the guidance, it is like getting to the start line, and we have an ambitious plan for how we move beyond that. The guidance that we will publish will set out the rules of engagement. There are areas that are already working in that way, and it will be familiar to them. GP leaders would have been well versed in and well exposed to this. It is possible that maybe individual GPs would have been less well exposed. The point is that we are at the start, and there is a process to follow. We have GP representation on the programme board. GPs are involved in the design of the INTs. As Mike said, we are looking at having GP leadership at a high level as a figurehead for the programme. There is a journey to go on, but that is in common with all stakeholders.

The Chairperson (Mr McCrossan): For the sake of accuracy and to put it on the public record, in the view of the RCGP at our meeting yesterday, the Department is trying to roll out a neighbourhood model of care without first establishing the baseline: what workforce currently exists, where the pressures are and what capacity is needed. The RCGP described that as being the wrong way round.

Mr Farrar: I will be with them tonight. I will pick that up with them and try to understand why they feel like that and to address that problem. I believe that part of the fundamental concern is that they feel that we are effectively launching a fait accompli. What we are launching is the beginning of an approach where we are putting development support into people. The stakeholder conversations led to the guidance that we will produce next week, and that will give a lot more clarity about the model and what we are hoping to do, and more comfort with regard to the time frame to work with in developing and delivering that effectively.

The Chairperson (Mr McCrossan): Mike, I am taking more time than I had planned to, but these are important areas to seek clarification on.

How will you ensure, as the accounting officer, that the workforce is available to deliver home or community-based care?

Mr Farrar: We have to do that in stages. As I said, a lot of our workforce has been focused on hospitals, and had we had them in community settings, we could have been able to do things differently. There will be a transition of resource, and we will support that. One of the reasons why the MDT roll-out has taken a while, as you probably appreciated when you looked at that previously, is that the commitment to increase the numbers of staff in those areas can only be done at the rate at which those individuals come out. That is another reason why we have to look at retention of staff and incentives for them to work in that area. The first thing that GPs will want to see is whether the resources are available for them in order to participate in that model. I believe that when GPs see what we are aiming to do and understand that, they will be very positive about it. The commitment to move and allow them to direct more resources in our system than they currently do will allow them to think about how to bring the workforce away from hospital settings into community settings and grow new arrangements, which is a workforce planning issue, which you quite rightly signalled, so that we can start to bring people into community jobs.

The Chairperson (Mr McCrossan): OK. Will you ensure that that is communicated clearly to GPs?

Mr Farrar: As I said, I have a meeting with the Royal College of General Practitioners this evening. As you know, I am very open to criticism and comment. I feel that there will be a great opportunity this evening to address those concerns.

The Chairperson (Mr McCrossan): OK, thank you. I am going to focus on recommendation 1 before I go to other members. For the record, recommendation 1 is about targeted public education and monitoring:

You have partially accepted that recommendation, citing the range of information that is already available to the public and the future roll-out of the This Is Our Health programme. You referenced that in some of your earlier comments. How is your Department assessing whether those existing channels are effective in practice, particularly given the continuing inappropriate demand on GP practices and emergency departments?

Mr Farrar: First, if we were writing our response today, we would fully accept that recommendation.

The Chairperson (Mr McCrossan): OK, that is positive.

Mr Farrar: I want to sound a note of caution to the Committee. One of the things about directing people to particular parts of the health service is that there is not a great deal of evidence of public campaigns doing that, so we are trying to do things differently. I mentioned the This Is Our Health programme, which will involve working with behavioural science to engage people in what it is that they need us to deliver and, if we can deliver that, what we would need to do to meet that and what they would need to do to help us. One of the things that is coming back strongly is that, given that GP access is really important to people, there needs to be communication as to whether people are aware that there are other areas. The "something for something" deal could be that if you have a minor ailment, you can go to a community pharmacy, which will help us. To date, we have spoken to 1,000 people about 'This Is Our Health', and we will be speaking to 120,000 people in order to get the basis for that deal. That vehicle will help us to understand how better to engage with the public.

Alongside that, we are developing ideas about My Care, which is an app that can show you your records and waiting times for particular specialties. We intend to put a front end on that app that allows us to have a direct conversation with people about their use of healthcare and some of those controversial issues such as the reconfiguration of services. Where we have seen that elsewhere in the world — Kaiser Permanente uses it a lot — it allows for a clear conversation with people about the best place to come. It is not just a hit-and-miss poster in Grand Central Station; it is, effectively, a dialogue with individual people, using the My Care app to do that.

The other thing that we obviously want to do is think about whether there is an approach like the 111 service where, effectively, we could have contact areas where, if people were unsure where to go, we could direct them quickly and navigate them. Where we have seen triage systems in some general practices in England, which I am talking about to the NIGPC, we have seen people use their general practice as the first port of call but be triaged immediately to the right service; sometimes, I add, not into a lesser service but directly into a hospital service. People will use ED because it is an open access service. One example of what we are doing, where Marie Curie is involved, is working with people in ED to spot patients who need palliative care who really could be cared for very quickly to try to avoid those people being admitted.

Therefore, there is the public education piece and then, where you hit the service, the service can direct you immediately to the right place. I would argue that both those things are needed. That is what we will introduce over the coming year.

The Chairperson (Mr McCrossan): You have picked up on an issue that is quite topical and is one that I was going to touch on. We have seen undeliverable commitments in strategies across Departments. Given that there are no available resources, how deliverable is that 111 service specifically?

Mr Farrar: At the moment, it is very hard to say because I do not have a budget at all. In that context, we will make assessments about that service at the point where I know what money I have and whether I can afford to do that quickly. We are trying to do all that we can to prepare for that. We are looking at how we might do that. We are also trying to learn lessons. Other digital triage systems like 111 in different countries have got different aspects, so we might be able to shortcut some of the learning and development of that. That is why I said that the mitigation for some of the hesitancy was around the budget constraints that I might have to live within.

The Chairperson (Mr McCrossan): Given what you have said, what sort of timeline are you saying there is to work out whether that is a viable option?

Mr Farrar: With regard to viability, we will be doing that as quickly as we can in the next year to look at whether that is feasible. I would imagine that a lot will come out of that when we start to talk to the NIGPC about its access questions. One issue is whether there are better ideas than 111. I know that some GPs are hesitant about 111 and Phone First-types of service. However, if we get agreement, we may well be in a position to identify funding to support that.

The Chairperson (Mr McCrossan): You mentioned My Care, but I want to focus on This is our health. As you appreciate, it is not an access-focusd education campaign, and appears to place the onus on the public rather than addressing what is very easily understood as a systemic access issue. What immediate steps will be taken to guide patients to the right care setting? You have touched on that a number of times, and, as a Committee, we have recommended it, but I am not entirely clear on that.

Mr Farrar: What I am trying to say is that we will try to have two points in the approach. One is to have public discourse and dialogue, which would allow us to raise the issue of appropriate access. If you go round Northern Ireland at the moment — I know that you would do that — you will find lots of evidence that, at a local level, that happens now. For example, before a bank holiday, people are signposted to get repeat prescriptions and are told, because we promote it, that community pharmacy can do things. However, there also needs to be a reference point so that, when people contact the wrong bit of the system, we help them to navigate quickly to the right bit. Therefore, there need to be some triaging facilities as well.

I would love to tell you that we would do a big public campaign over the first six months of the year, and that that would be sufficient to deal with the access problems, but I do not believe that it would be. We have to be more sophisticated. The work that we are doing on This is our health helps us to understand why people go to the places that they think that they need. There is a big discussion to be had. In other countries, there is a greater acceptance of going in for healthcare and not seeing a GP. Northern Ireland has a particularly ingrained view of, "I want to see the GP". Ursula and I were talking about that the other day. In effect, she was saying that there is not the same acceptance of going to see other professionals. We have to keep working at that. A lot of it is about getting to a position where people who are in a service are told, by the people who they are seeing in that service, that there are different ways, such as, "You could have gone to a community pharmacy for that problem". If we get e-prescribing in, there will be an opportunity to do things such as repeat prescriptions in a way that means that people do not need to go back through GP practices.

The Chairperson (Mr McCrossan): It is difficult. All circumstances are unique, and everyone's health issues are unique. The messaging could be said to be contradictory for someone who has mental health issues who cannot get access to a GP and who therefore considers going to an emergency department, which, depending on what day of the week it is, could be chaotic. Often trusts, particularly the Western Trust, will say, on their social media accounts, "Do not come here unless it is an absolute emergency, and do not bring anyone with you, because we have no capacity or space". You can understand that the messaging does not exactly solve the problem. Nine times out of 10, the person does not follow on from that care.

Mr Farrar: You are almost saying what I was saying, which is that we need to accept that, if people cannot get to a GP or are not confident that that is the right place for them to go, they will go to ED, because ED is an open service. That is particularly the case while we try to fix GP access. We have a range of services — the minor injuries unit and things like that — to which other people go.

We are saying that it will happen through a gradual process of education, rather than through a big bang. You have asked us to do something over the course of the year, however, and it is quite a specific recommendation in which you refer to an education programme. I am saying that the work that we are doing through This is our health will address that issue, but it will not address it by running a big campaign, if that is what you had in mind.

The Chairperson (Mr McCrossan): Other services or service professionals who are watching this meeting will be saying, "We do not have the capacity in our services" and that the professional services are not available to do exactly what you just described. Would you say that there is capacity? What is your concern in that regard?

Mr Farrar: Do we have enough capacity to deal with the existing demand? I do not think that we do. We therefore have to manage the demand differently. I think that we can help to better manage the capacity that we have, and I believe that there are examples, about which we will be talking to the royal college and the BMA, of where we have increased capacity by managing demand in a different way. We value the time that a general medical specialist has available to deal with the people who only they can deal with by sometimes moving people into secondary care faster, because there is advice and guidance or whatever from a consultant to say that they should be an immediate admission, or by moving some more minor problems away from that and into community pharmacy and community services. Social prescribing is a good example. Alongside the neighbourhood model, we intend to roll out social prescribing. That will move some of the people who really do not need a medical intervention to instead get support from peer groups in the community, through the voluntary sector. We have a very good voluntary sector, but we do not contract as well as we should.

There are things that we can do to increase capacity, but, as we start to do that, we will start to have a clearer view of what capacity we require and the right places to have it. At the moment, it is hard to do, because, sadly, we have people who are not getting care in the right place and at the right time.

The Chairperson (Mr McCrossan): Yes, OK. I will allow Colm to come in, and then Cathal will focus on the second recommendation.

Before doing that, it is important, since you mentioned the community and voluntary sector, that I put on record that the Committee has witnessed the great work that goes on in the community and voluntary sector, and it is fair to say that that sector is the scaffolding that has kept the health service going during very difficult circumstances, particularly within mental health services and other services that are failing to meet the expectations or the needs of people on the ground. On behalf of the Committee, I state our deep appreciation of the exceptional work that is done by the community and voluntary sector in our communities in Northern Ireland.

Mr Gildernew: I was a bit surprised, Mike, to hear you say that people want to see a GP rather than a more appropriate professional. That feels a wee bit new to me. I am not saying that it is not true, and certainly, if GPs are saying it, it has to be taken into account. I would have thought, however, that the greater part of the problem is that people have to see GPs because they are on a waiting list for the other profession that they need to see, and that drives more demand for GPs on that side of the system, rather than the way that you described it.

Mr Farrar: There is a chicken-and-egg situation here. Where we have MDTs and advanced nurse practitioners who are part of the primary care team, there is an opportunity to access them. We would like to get comprehensive coverage to make that service available to everyone and allow the GPs to move in that direction. However, at a meeting with the RCGP, like the chair and vice chair, we talked about the idea of triage through an immediate response to people about where they need to go. One of the points raised with me, which I found surprising, was the view that a lot of people in Northern Ireland are not as happy about being referred to other people. I have not carried out a survey, and maybe we will come to that to find out about the experiences that people want. Certainly, some people are not seeing their GP quickly enough, and there are other people who are taking up general practice time who could be dealt with elsewhere. We have not got it right yet.

The Chairperson (Mr McCrossan): Before I move to Cathal Boylan for the next recommendation, I am concerned that the neighbourhood model is a done deal, and I know that you are meeting the RCGP later. I sincerely hope it is not a done deal, because to get it right, there is a need for partnership working with GPs and the Department, coordination, clear communication and absolute consultation. Is the neighbourhood model a done deal?

Mr Farrar: We are publishing guidance next week about the model being a starting point and how to build on it. We have to give some tramlines because otherwise we are accused of "What do you mean by that?", and we have also had very frequent episodes of trying to do that. At one point, we had the area integrated partnership boards (AIPBs), and we previously had local commissioning groups, and the neighbourhood model is another version of that. There is a real movement about how we start to learn as we go, and the development programmes are about putting some of our neighbourhood groups into action and having learning sets that learn as they go. We already have some very good examples in the call for evidence about the things that have worked that people can adopt. It is not a done deal in that sense, but there are some tramlines to give rigour, discipline and standardisation to the neighbourhood model. We have a shared ambition that they will deal with older people's care as a priority, and we expect the neighbourhood groups to initially focus on the area.

The Chairperson (Mr McCrossan): OK. We will likely keep an interest in that going forward.

Mr Farrar: I am very happy to come back when we get going.

The Chairperson (Mr McCrossan): Thank you.

Mr Boylan: Mike, you are very welcome. Thank you for your comments so far. How does the Department ensure that patient experience data, particularly for formal complaints and concerns raised via the Patient and Client Council (PCC), is captured comprehensively and reflects the true level of public dissatisfaction?

Mr Farrar: If you do not mind, Gearóid will comment on that. We have just introduced a model complaints handling procedure, and there is a process to manage the complaints through our system.

Mr Cassidy: The new model complaints handling procedure was implemented in January this year, and it goes across the HSC. Organisations have six months to implement the procedure in full. In November 2025, we issued guidance to all GP practices about how to comply with the procedure. It is a two-stage process, and the first stage is for front-line resolution, and stage 2 is investigation. At stage one, there is a five-day timeline for the investigation of a complaint, and stage 2 is the more detailed, behind-the-scenes investigation. Practices will provide monthly reports to the Department on any incidents and complaints received. It is important to say that we have widened the net for what counts as a complaint. In the older complaints model, it was just about formal written complaints, and now it is any complaint, whether verbal, electronic, a telephone call or written. When the reports start to come in, we expect to see an increase in the number of complaints received because we have widened the cast of what has been captured.

Under the new model, there is a central analysis of the complaints that have been received. The majority of complaints are for a local resolution, but where there is regional learning, or the specific issues need to be addressed or communicated more widely, that can be done in one of two ways: either through communicating directly with all practices to highlight certain issues or by practice visits. If the issue is specific to a particular practice and there are concerns about that, it can be the subject of or included in the regulatory regime of a practice visit. There will be an intense focus on getting that feedback.

Just to add, there is a publication scheme, and those returns are captured in the departmentally published HSC statistics, which cover HSC and primary care. It is a fairly comprehensive system but, as it is quite new, it is still bedding in.

Mr Boylan: I appreciate that. I know that it is early. That is why I mentioned the PCC. It is early days, and I know that it started in January, but there is no indication —.

Mr Cassidy: Well, it is not really due to be implemented fully until six months from January. We will keep the Committee apprised of progress.

Mr Boylan: OK.

Mr Farrar: To speak proactively on that, we are talking, in the GP contract negotiations, about how patient experience informs appraisal of practices etc. The final thing is that we are working with the PCC on the idea that the whole of our system has people as partners, and Ruth Sutherland and the PCC are strongly influencing all our policies, so we have taken a real step in the patient voice influencing our policies beyond what we have had before.

Mr Cassidy: If I can just open that point out. The PCC is on the programme board for the neighbourhood development. It is leading one of the work streams on that public and patient engagement, which is a really important strand of neighbourhood.

Mr Boylan: I appreciate that. I asked because the Chair is right: people will be listening in today — that is why we did the inquiry — who will be keeping an eye on this.

My second question is this: the Committee recommended systematic region-wide gathering of patient experience data. Why has a region-wide patient survey not moved beyond consideration? When will it be implemented?

Mr Farrar: Sorry, which survey are you talking about. There are a number of surveys.

Mr Boylan: Our survey of over 15,000 people.

Mr Farrar: We are continuing to look at surveying our population. We have a number of surveys that give us information on the staffing levels or whatever. We have to look at all our areas where information from patient experience really helps to drive change and improvements. I am not specifically aware of the survey that you referred to, but gathering patient information is critical to the vision for primary care. I am not certain on what that survey is about. Apologies.

Mr Cassidy: Is it recommendation six, which refers to ONS?

Mr Boylan: Recommendation two. We received 15,000 responses to our NI-wide survey.

The Chairperson (Mr McCrossan): Yes.

Mr Cassidy: Does the recommendation capture a specific action?

The Chairperson (Mr McCrossan): The recommendation response says:

Mr Farrar: Right. If that is what we said, that is clearly what we will do.

Mr Boylan: That is the question that we are asking.

The Chairperson (Mr McCrossan): It is partially implemented.

Mr Cassidy: We touched on it with the GMS contract and the issue that we had last year with some of the access indicators. One of the things that we were looking to include last year with GPs was patient-level surveying. That is something that, ultimately, we did not introduce, but we have just reentered negotiations with GPs, and meaningful measures for patient experience are part of that.

The Chairperson (Mr McCrossan): Will this move beyond consideration?

Mr Cassidy: Yes. I was getting it confused with recommendation six.

The Chairperson (Mr McCrossan): You might have given us a new MOR after this. [Laughter.]

Mr Farrar: Apologies for that. I now know what you are talking about. That is in discussion with the GPs through the negotiations. If we are after information from our GPs, we would have to effectively build that into contractual arrangements with them.

Mr Boylan: OK. Thank you.

The Committee heard that complaints data held by PCC and the strategic planning and performance group (SPPG) presented conflicting trends. What steps have you taken to ensure that complaints information is reconciled, shared appropriately and used to identify regional access problems?

Mr Farrar: When we aggregate that information, we see that a lot of the concerns in complaints are local, and they are fixed locally. That process allows us to see whether there is a consistent view. In that sense, if a lot of the complaints are about GP access, they would be picked up, and we would do what we are doing now, which is to say, "How can we build that in so that we improve our policy and delivery?". To that extent, they will inform and reinforce the view that the Committee got from its survey of 15,000 people that we need to do something about that. I am trying to say that we are.

Mr Cassidy: We have touched on this already, but there was a similar concern at the original hearing about the higher level of reporting from the PCC about complaints compared with us. Through the new process that we described, we expect to capture more complaints, because we have widened it out. That should bring it more into alignment with what you see from the PCC.

Mr T Buchanan: Some of my points have been touched on, but I will go over them again anyway. In recommendation 3, the Committee recommended that the Department produce a primary care strategy within a year that embedded the voice of patients. Where is the Department in developing that strategy, given the fact that no timeline has been provided and that the Committee expects its completion within a year of the report?

Mr Farrar: When it comes to that area, I am confident that we will do it in advance of the Committee's time frame. The first meeting was hosted by the Northern Ireland Confederation for Health and Social Care (NICON) primary care lead on our behalf, and the Minister spoke at that. It took place on 4 March. We have already had that. The output was a variety of steers as to what that vision needs to include.

There is further work, such as the working group that Gearóid referred to, which has cross-general practice input. That work is now in full swing, and we are starting to process its output. As for the time frame, I am very clear that it will be finished well within this year. It will be a vision for general practice and will sit at the heart of the neighbourhood model, because those have to be aligned.

Some of the immediate issues for general practice are about capacity, which we need to address. I will quickly run through the outputs from the first meeting: The gap between expectation and resource is a system-central fault line; innovation is present but uneven, fragile and dependent on short-term support; the realistic vision exists but cannot be achieved without stabilising the core; practice

well-being is a structural issue, not an individual challenge; confidence-enabled working depends on clarity; the themes are not new, but alignment is, and we need to align, and; the system is ready for action, and action now matters more than discussion. Immediately, you can see that we are starting to get at the heart of what the vision needs to deliver. Those were the principles that came out of the first meeting, and we will start to produce that vision. I am very confident that we can exceed the Committee's request to do that within a year. My belief is that we will have it within the next six months.

Mr T Buchanan: Will the strategy be in place before the neighbourhood model is rolled out?

Mr Farrar: They have to work together. We want GPs to participate in neighbourhood working, but if they are to do so, we need to find a way to incentivise them to do that through their contract. If we ask them to do it in a way that goes against how the contract works, that clearly will not work. We have deliberately designed the process so that the strategy for general practice works alongside the neighbourhood model.

Had we taken a different view and said that we need to get the neighbourhood model in, the risk is that it would not deal with a vision for general practice. Had we said that we wanted a vision for general practice and that we would do the neighbourhood model after that, Northern Ireland would struggle, because we would be a further year down the line before we got into demand management. The sequencing means that we will run those alongside each other. Some of the players are involved with both the vision and helping us to develop the neighbourhood model. We have crossover.

Mr T Buchanan: Minimum access standards were a core part of the Committee's recommendations. Why has no date been set yet for agreeing those standards with the GP representatives?

Mr Farrar: While we are in negotiations, putting them into the public domain is not easy, but we are corresponding with the GPs about their view on re-engaging with us about the new contract and agreeing next year's contract.

As you know, there has been collective action, and GPs — I am stating this as fact, not criticising them — were not particularly happy with the new access standards that we put into last year's contract. They did not think that they would achieve what they wanted to achieve. We therefore agreed, as part of getting GPs back around the table, that we would suspend the introduction of the access standards and make access standards a core issue in the new contract negotiations.

The first contract meeting happened yesterday, so the negotiations are something that will happen in the dim and distant future. I have brought in a new person to lead the contract negotiations. She is a very experienced individual who has worked with the BMA before and is trusted by it, and she was clear that access is a key issue for us in the negotiations. It is therefore now being dealt with.

Mr Honeyford: Thank you for coming to the Committee today. I want to look at the workforce strategy for primary care and the associated data. How can the Department credibly proceed with transformation and major service redesign without there being a primary care workforce in place?

Mr Farrar: That is a question that we have asked ourselves. I do not think that we can have a credible strategy for developing services unless we have a workforce strategy to accompany it.

Workforce strategies for healthcare tend to be very difficult, because when workforce planning is being done, there is always a time lag. We know that it takes time for new staff to qualify and that staff leave employment and so on. At the moment, we are doing the best that we can with the information that we have. I have therefore taken the decision to enhance the Department's ability to do workforce planning. Someone whom the Committee will know well is coming in as a new grade 3, and part of her portfolio will be to head up a team taking a more strategic view on workforce by looking at our data sources and then delivering a much more enhanced approach to workforce planning.

The truth is that the work that we are doing at the moment is not as informed as it should be in its understanding of the workforce. We are therefore having to work really hard and fast to put that right.

Mr Honeyford: It is common for the Committee to be told that something is going to happen. I am asking why we have not seen change yet. People still cannot access their GP. Last year, I asked this question, and I will quote what I was told so that I do not misquote what the Department said in response:

I asked the Department how many GPs there were, and officials could not tell me. They did not even know how many people were working in the health service. We now have a paper today that contains GP numbers, but it addresses neither demand nor capacity. How can you ever plan for something when you do not know what is going on?

Mr Farrar: We possibly know more than we said that we did at the time.

Mr Honeyford: Why did you not tell us that at the time, then?

Mr Farrar: I cannot tell you why we answered questions differently in the past, but we do have an understanding of our activity data, because we know what goes through our hospitals and what goes through primary care. The questions are these: is that capacity in the right place? Does it meet the need? At what level does that need exists?

One of your points in recommendation 1 was on the need for the public to be able to understand the data behind why people end up in hospital who could have been managed elsewhere. I am therefore introducing something called a clinical decision-making tool that will mean that, when they are looking to admit a patient to hospital, clinicians will go through a process using the data to determine whether a person warrants hospital admission. They can override that determination, because if there is not an alternative to hospital admission, they will want to make sure that people are safe, but the truth is that that data will be available to tell us the number of people who could have been managed in a community setting had we had something different in place.

Interestingly, what we do not have is data on all the people going to see their GP who could instead have been managed by community pharmacies or through a social prescribing model. The Committee made no reference to that, so you may want to think about it. We will have to work with GPs to collect that data. We therefore have some data but not enough. The truth is that what happens, David, is that we do what we have always done, which is to assume what the activity level has to be and then plan on the basis of meeting the level of activity that comes through the door. If we want to see change, we need to accept that.

I do not believe that, in the past, the Department of Health had a strategy for change. It therefore muddled through on the basis of the information that it had. I cannot deliver a reset for Northern Ireland without having better data to understand where people are in the wrong place in the system so that resource can then be moved to the right place. I therefore feel quite exposed on that point. We cannot just accept that the data that we have about activity tells us where people should be, as opposed to where they are now. That is the issue. You are highlighting that, and I have to be very honest with you and say that that is a vulnerability. We have to move forward, however, on the basis that we start to collect that data, and that will inform us. We have to make some intelligent assumptions, and we do that based on research such as the Nuffield Trust report from 2022, which looked at excess costs from delivering the standards of care that we have. We look at examples of best practice from elsewhere about who can be managed in what settings. We look at countries that take stratified approaches to population that can show that perhaps 5% of people coming to GP surgeries should immediately have gone to secondary care and that perhaps 30% of people could be managed by community pharmacy. We use such examples to make some assumptions.

What I really want, however, is to create a system whereby Northern Ireland has the most intelligent underpinning of its policy in evidence. Encompass and the general practice intelligence platform (GPIP) should give us that, but we have not really used them as yet.

Mr Honeyford: I will go down the rabbit hole that is Encompass. We have a population that cannot access their GP. That is not always true, as there are some really brilliant GP practices. In my area, several are outstanding, but I hear repeatedly about problems accessing others. We want to see change, but you are asking us questions. We need to see change delivered, not to be asked more questions about it. The public need to be able to access GPs. We are looking at data. You have given us information today on the workforce survey. That is great, as it is a start. You have provided us just with a headcount of GPs. One of the questions that I asked the previous time that you were before the Committee — I refer back to Hansard — was how many GP appointments there were, and you could not tell me. You did not know the answer, but I was told that there were 23% more GPs. That may be the case, but there is the same number of appointments, so it obviously does not matter how many GPs there are. How do we ever get to a place of being able to deliver for people so that they can access their GP?

Mr Farrar: We do that by improving our ability to analyse the data that we have, David. The only answer is that we have to do that. The roll-out of Encompass was completed only in the summer of last year, so [Inaudible.]

I often say to people that it is a bit like changing your mobile phone. For a week afterwards, you ask yourself, "Why did I change it? I do not know what certain buttons do". Your functionality therefore drops, but, eventually, you get used to the enhanced functionality and start using it. Encompass is a bit like that. We have this fantastic vehicle that can generate lots of data, but is that data able to inform our practice and policy? Not at the moment. Does it help us think about where people should be? It helps individuals get better care, but, at the moment, we are not using it in a planning way in order to improve the quality of our services. One of the things that I want to do therefore is to help Northern Ireland use the best data system in the world, which is generating fantastic data, to really underpin practice and policy. I do not want to be in a position in which I am saying to you that we have not got that data, when we do have it, or that we are not using it.

I am afraid that I will have to take what you say on the chin, because it is a fair criticism, but I am determined to change that.

The Chairperson (Mr McCrossan): It seems that we are straying into recommendation 6. That is for Colm to ask about.

Mr Honeyford: OK, Chair. I will go back to asking about training places and the workforce. I am flipping between recommendations 4 and 5. You stated in response to recommendation 5:

Is that report going to come out?

Mr Farrar: I think that Gearóid knows more about this than I do. This is our training places task group, and, yes, that is due to report shortly. I think that we are analysing the report —.

Mr Honeyford: It says February 2026. Next week is April.

Mr Cassidy: That group has presented a report on its recommendations for training numbers over the next number of years. We received that in February, so we are currently looking at that. It is being considered alongside wider training needs. It is subject to go to the Minister in the coming weeks. The report is on training places more widely, and GPs are one of the areas considered. We have the report, as indicated in the response.

Mr Honeyford: OK, so that report has been delivered.

Mr Cassidy: Yes.

Mr Honeyford: On time. OK. That is at least something.

Mr Cassidy: To add to the previous conversation, it is worth noting that, when we were last here, we said that the survey response, from which you saw some of the outputs in the letter that came in today, was not yet complete at that point, so that is new information. I fully agree with Mike that we need to get better at analysing data, but this is new data to us. We will have more new data coming in next year for the second year of the return.

Mr Gildernew: In response to our original report, we heard from the Department that it remains very difficult to secure reliable data on patient access to services. I am a bit concerned, Mike, I have to say, about the fact that, with Encompass, we have a vehicle and are trying to find out what all the buttons do. That is a vehicle that we built. It is bespoke and was built here, so it is very important that we get the full usability out of it. You have indicated to us in your MOR that you accept the recommendation that the Department secure reliable data to assess demand within six months. You accepted the recommendation but stated that the time frame was not deliverable, yet you have not given us a new time frame. What is the Department's revised timeline for capturing reliable patient access and demand data?

Mr Farrar: Some of that falls back to the information that we can get from the contract negotiations: what GPs will be providing for us and what we will be looking for. Over the next 12 months, we will be improving our ability to analyse the data that we have, and, obviously, we will put that into planning. To give you some comfort, for the past 11 years — I think that it is 11 years, but I need to be careful about that — in the document that we have produced, we have just given out resources to Health and Social Care without setting any sets of priorities or actions that we require of it. This year, for the first time, we have been able to say what our areas of priority are. The use of Encompass as a vehicle to assist us to understand our system, to drive our process change and to understand things such as variability is in there as a key priority for us.

Mr Gildernew: Encompass will not pick up on the missed phone calls, I take it.

Mr Farrar: Again, that comes back to what we are asking specifically of general practice as part of the contractual obligations.

Mr Cassidy: On that point — sorry to cut across you — three years ago, we did some work to try to assess unmet demand, and the systems could not capture it. There are systems that can provide more lines and can capture some such calls, but, if you are getting an engaged tone, fundamentally, that is not being captured anywhere in any system. Absolute demand is really hard to measure.

Mr Gildernew: That is what I am asking. I am seeking a clear pathway to improvement on that issue. First, I take it that it is in GPs' interests to assess demand, given that they are swamped and overwhelmed with demand and that everybody has to know what the demand is to have any hope of planning or moving towards making it better. It is in everyone's interests, and surely it cannot be that hard to find a way to record the missed calls plus the volume of calls that do go through. That all has to be captured. How much longer will it take to have that information?

Mr Farrar: I am not sure that I can give you a specific commitment on where we will be on that. What I will commit to the Committee on is that, in our discussions with GPs on how we collect information about demand, we will make that a priority in the conversations about what, contractually, they are happy to supply to us and what we, as their commissioner, will need from the taxpayers' money that we spend to try to understand that better. Again, Chair, I might have to is send you a note on that as we progress it. I do not want to commit to a date and then disappoint you again. I assure you that we understand that, if we can understand demand for general practice better, we will have a fighting chance of improving access, because we will know who is trying to get to general practice who could be dealt with elsewhere.

Mr Gildernew: Given that it is in everybody's interest, I hope that there will be good cooperation.

The other thing is that, given that significant public money has gone into assisting GPs with phone lines, surely it is possible to put in place an electronic counter of the missed calls and things like that. Surely that would not be overly onerous for GPs. The last thing that GPs need is to have to fill out more forms. Surely that can be done electronically.

Mr Farrar: I will take that away and examine it. I do not know whether that is possible. You would think that it must be possible to record the number of people who phone and do not get through. There must be other systems. I will use my networks to look for people who can capture that data so that we can give it to you, and we can see whether we could adopt it in Northern Ireland.

Mr Gildernew: I am not saying that that is the only piece that we need to capture, but it should be a basic one.

The Chairperson (Mr McCrossan): On that point, Colm, the conversation that Tom and I had with the RCGP confirmed that there are examples of that data being collated in Northern Ireland. It is possible, therefore. It would do no harm to continue that conversation.

Mr Farrar: If you are happy to pass that information on to us through the Clerk, I will look at it.

The Chairperson (Mr McCrossan): Ursula will give you that information.

Mr Farrar: I will speak to her this afternoon.

Mr Gildernew: What gets measured gets done.

Mr Farrar: Yes, exactly.

Mr Gildernew: It is vital that we get the measurement right.

Mr Dunne: Thank you, folks, for your presentation and for coming back to see us.

Recommendation 7 is on the contract hand-backs, which is a topical issue. I appreciate that the numbers have receded slightly, which is welcome, but they are still a matter of concern. The statistics, going back over the past five years, are alarming. There was a hand-back in my constituency in the past two weeks, which will impact on 2,000 people. That highlights the topicality and timeliness of the issue.

The Committee recommended an immediate review of contract hand-backs, including incentives around locum rates and the capability of trusts to deliver primary care services. That has been partially accepted by the Department, which stated that the reasons for past hand-backs were not captured. We are keen to know what mechanisms will be introduced to ensure that the reasons for future contract hand-backs are recorded systematically, given the Committee's instruction on the need for an immediate review.

Mr Farrar: That is a great question. As our response states, the truth is that, at the moment, we do not have a lever by which we can oblige someone to tell us the reason. We know that it is multifactorial, and we know some reasons why people hand back contracts. If we were to introduce something, we would be required to change some contractual relationships as a consequence. It is pleasing that the pattern of hand-backs seems to be reducing. In particular, we know that we have not had a single contract hand-back in an area where we have rolled out an MDT. Is that fair to say?

Mr Cassidy: Not where there has been a full team.

Mr Farrar: We are starting to understand what might be a factor in avoiding hand-back. It might be interesting to see whether we can build in exit interviews as part of that. I would be interested to know whether hand-back is something that we can address.

The Committee may not be aware that I negotiated the 2002 GMS contract that we currently have. Obviously, it has been amended several times since then. One thing that I wanted in that contract was to give GPs a statutory right to a sabbatical after seven years. We had the resource for that, but, at the last minute, the BMA decided that it wanted that money to be paid in salary rather than used to cover sabbaticals. However, some of those ideas to deal with the workload pressure and stress that some of our GPs are under would be worth looking at again.

That does not really answer your question about understanding the reasons for contract hand-back, but could we have some answers to dealing with that and looking at GPs' well-being? I think that we could. By talking to the royal college and the BMA about their insights, specifically on hand-backs, I would be keen to see whether we could find a solution so that we could negotiate that in.

Mr Dunne: Thank you. As you say, there is a range of genuine reasons, including retirement, but they need to be looked at further. Where that happens — it occurred a number of years ago in my constituency, which is not too far from here — it causes considerable distress, alarm and uncertainty for thousands of patients and calls into question the future of the GP practice. The local knowledge that has been accrued between patients and professionals over many years is lost. It is a huge issue.

Finally, I want to ask you about your evidence base. I am keen to know on what evidence your Department bases its assertion that locum rates are not a factor in contract hand-backs. Going forward, how will the Department assess the capability and capacity of trusts to manage practices and the reporting around those?

Mr Farrar: We know the number of locums whom we have. We do not know what they are all being paid, because that is a matter for them. Interestingly, yesterday, as I understand it, one of the topics that came up was about how to remunerate locums without that remuneration being a greater incentive to move into operating as a locum rather than operating as a GP principal, a salaried GP or whatever. That is a live issue for us, and we need to get the balance right. We need a cohort of locums because we cannot always populate all practices and their partners and salaried positions overnight. We need to work through what would be the appropriate level for the size of our system. How do we recognise and value people who work substantively in practices as opposed to on a locum basis? That was an issue of discussion yesterday between the NIGPC and our negotiators.

Mr Dunne: OK, thank you. Finally, I concur with the Chair's remarks that GP access continues to be a major issue. Constituents contact me every week to express their frustration. We hear regularly that people make 90-plus phone calls before 8.30 am trying to get through to their GP. I echo the need for an action plan. We will certainly keep a close eye on that, and we look forward to having you back again soon on that topic.

Mr Farrar: I can say only that I agree. When we spoke to people about "This Is Our Health" — we have already spoken to just under 1,000 people and intend to speak to 120,000 over the next six months — the number-one priority that came up in those conversations was access to GPs.

Mr Dunne: The fact that 15,000-plus people spoke to us echoes that and is included in our report.

The Chairperson (Mr McCrossan): It was one of the biggest responses to any Committee inquiry in the Assembly, which shows the magnitude of concern.

I will go to Jon Burrows, who is joining us online, and then, if everyone is agreed, we will have a five-minute comfort break.

Mr Burrows: Recommendation 8 is about alternatives to the current GP model. You have stressed the neighbourhood model as the solution. Have you identified specific risks that could delay the April 2026 start date or the March 2027 establishment of the integrated neighbourhood teams? If so, have those risks been mitigated?

Mr Farrar: Thanks, Jon. In essence, they all go live as of 1 April 2026, but some will be very ethereal; some will be clearly in place. As we go through the development programme, we have a date at the end of April on which we will bring together representatives of the existing 17 areas and start the formal process of working with them to get established. Quite rightly, the Committee has warned about people's understanding and perception of those arrangements, despite a lot of stakeholder engagement. The biggest barrier will be people believing that this is another thing that Northern Ireland is doing that will last for two years and then no longer exist. For example, we are not piloting it, as such, because we know the history of piloting. We are not rolling anything out in a slow, staged process. We are saying that we learn by doing, but we will support the teams to do that. We are committed to that resource shift, and we will audit that over the course of the year. At the moment, my answer is very positive. I think that the biggest barrier will be securing the belief and commitment of staff: we need them to see that this model is a fantastic opportunity for people to get care in the right place.

I have spoken to a number of GPs in particular and told them that I see general practice being able to lead on this on behalf of Northern Ireland. Other groups are involved, and it has to be an equal partnership, but the idea of the model is that it puts the focal point into those communities in order to keep people who do not need to be in hospital out of hospital and in their own homes. If I were to be totally frank with the Committee, I would say that this is our best hope that Northern Ireland can get the outcomes that we want within the resources that we have available, and that is a real challenge at the moment, as you know. I am on record as saying that I do not want to come back saying that we need more and more of Northern Ireland's money spent on health and care at the expense of communities, education, skills, jobs, leisure etc. We have to manage the money that we have better, and the neighbourhood model is absolutely the way to do that.

Mr Burrows: Yes. I agree with that broad sentiment. In fact, the entire Northern Ireland Budget, which is £18 billion for two million people, should, if we were to steward it correctly, be manageable. How will the Department ensure consistent delivery across all areas, given that issues such as workforce shortages and unresolved contractual issues could pose a problem? You highlighted those issues in your initial response.

Mr Farrar: I have done a lot of work on variability, and the key starting point with variability is to reveal it. Very often, people are not aware that they are not providing the range of services that others are. That is one of the things on which the Committee could focus, perhaps putting us under a bit more pressure, and talk to the college and BMA about. For example, we might have two practices next door to each other: practice A manages a whole group of people very well; people are flooding through practice B and into secondary care because the practice is not managing. Sometimes that is because the practice is under-resourced, and sometimes it is because the practice is not doing as well as everyone would hope in managing those conditions. Variability starts with revealing the data, which goes back to the questions that David and Colm asked about how we use the data.

With Encompass, we can understand the pattern of utilisation of secondary care that originates in primary care, and we can say how many people come from certain practices. We can work with GPs — not in a blaming way but supportively — on how we tackle the unwarranted variability in general practice. There are some very positive examples of that having been done elsewhere, and those would be very helpful. In my experience, no clinician wants to be poor at their job; they want to be the best clinician that they can be. It is only when they see the difference in what they are doing compared with other people that they understand, and then the moral obligation is to help them to learn and to improve their performance. Variability is a big issue out of hospital in the same way as it is in hospital, and tacking that is mission critical. We have a particular programme that the Chief Medical Officer, Michael McBride is leading: called "sensible care", it looks at the variability of clinical service offers.

Mr Burrows: Thanks. I spoke to GPs recently — just yesterday, in fact — and one of them mentioned that Northern Ireland is the only place in the UK that has GP federations. Do you agree that the federations offer an opportunity?

Mr Farrar: Completely. It is an amazing strength that all our practices belong to a GP federation. In fact, the 17 federation boundaries are the boundaries on which we will have our 17 neighbourhood approaches, so we are capitalising on that. The great thing about federations, as you know, is that they are owned by GPs, which means that they are for GPs. However, they also give us the ability to connect GPs at scale to the business of managing resources. Otherwise, we would have to work with 20 separate practices. The federations will have a huge role in the future, and having them is a great asset.

Mr Burrows: Thanks.

Mr Gildernew: I am so interested in the discussion, Mike, that I forgot to check whether you gave me a revised timeline for the data.

Mr Farrar: I think that I said that I could not do that, Colm. Sorry.

Mr Gildernew: I am very disappointed.

Mr Farrar: I said, I think, that it would be over the course of the year and asked that you please have me back to give you an update on our progress. We will work on that as a matter of priority over the year. I am happy to give you an update, but I did not want to commit to one specific date and then find that I could not deliver on it.

Mr Gildernew: Will the neighbourhood model be an MDT?

Mr Farrar: MDTs will be part of the model, but they work together. They are not an alternative.

Mr Gildernew: That is what I am saying. Will MDTs be embedded as part of the neighbourhood model, and will all areas have that roll-out of MDTs?

Mr Farrar: We are committed to moving as fast we can, as resources allow, towards all parts of Northern Ireland getting MDTs. Evaluation is part of this, but all the early evidence on how MDTs are working shows that they are incredibly helpful in supporting the out-of-hospital offer.

Mr Gildernew: So "neighbourhood" is not "instead of"; it is "complementary to".

Mr Farrar: It is not "instead of". The people in the neighbourhood around the table managing those resources will have those MDTs as part of their construct in terms of the assets they have got.

Mr Gildernew: That is important. Thank you.

The Chairperson (Mr McCrossan): OK.

Mr T Buchanan: I have one question on that. When do you foresee MDTs being rolled out across Northern Ireland? We could end up in a situation in which people in some areas will benefit from them while a lot of people in other areas do not because MDTs are not in place in their area.

Mr Farrar: Because this has been funded through transformation funding, we are dependent on continuing to get support. We are working to identify the resource, because the transformation funding runs for only a certain time. The intention is to roll them out by —.

Mr Cassidy: For all of Northern Ireland, it is 2033.

Mr Farrar: That is quite a while off. If we can get the resources, we will try to accelerate that. One of the constraints is workforce. It is not just about the money; it is about getting the workforce without robbing other bits of the system. We have to grow some of those workers, but the intention is to do that as quickly as possible.

The Chairperson (Mr McCrossan): OK. We will pause for five minutes for a comfort break.

The Chairperson (Mr McCrossan): We will move on to recommendation 9. Thank you for your patience, Mike and Gearóid. The Committee recommended that e-prescribing be introduced with urgency and that a business case be completed within six months. You accepted that recommendation, but the MOR indicates that implementation will not be completed until 2030. I know that you touched on the e-prescribing elements earlier, but can you give us a formal update, on the record, on where that is at?

Mr Farrar: The case has effectively gone into the transformation fund process. All the Northern Ireland stage of the process has been gone through and we are just waiting on the Northern Ireland Office bit to confirm, so we are hopeful that the £42 million that we bid for will be available to us. That will allow us to start the process the minute we get that resource. It is not an easy implementation, because you are talking about independent pharmacists etc, so that takes a bit —. The roll-out should be completed by 2030, but, effectively, it will start as soon as we get approval of the £43 million. That is much faster than was originally envisaged in the Encompass programme, and that is good news. We will think about where we can tie it to the neighbourhood model and MDTs to make sure we get a degree of fairness in where we start some of the process.

The Chairperson (Mr McCrossan): As we have continually heard throughout this inquiry, there are a number of practices that are ahead of the curve on a variety of things, whether it is monitoring the number of missed calls or the use of e-prescribing. Do we know how many practices across Northern Ireland are availing themselves of the system?

Mr Farrar: I actually do not. It would be useful to know that. This evening, I will talk to the RCGP about this issue of fairness, because it is worried about particularly the time frame for rolling out MDTs due to our financial position. We will all try to go together with the neighbourhood model, and there will be three development programmes, but effectively everybody will be starting to do this. We can perhaps be more helpful in thinking about e-prescribing and where you might want to link some practices. It might be practices that are struggling, but we have not set any priorities for the roll-out, and we do not have the money yet.

The Chairperson (Mr McCrossan): Jemma Dolan will cover recommendation 10.

Miss Dolan: Thank you for coming in. I am new to the Committee, and I was not here when the inquiry was carried out. Obviously, access to GPs is a huge issue right across the North, particularly in my rural area of Fermanagh and South Tyrone. For example, my office is in Enniskillen, but my GP practice is in Belleek, which is 25 miles away. Enniskillen has an MDT, but Belleek does not. You accepted our recommendation that the MDT roll-out needs to happen more quickly, but the MOR outlines an eight-year roll-out to 2033. Yesterday, the Chair and the Deputy Chair met the RCGP. They stressed that the roll-out is too slow and creates a postcode lottery, and I can see that in my constituency. They argued that the current approach risks widening the inequality between practices and may further undermine recruitment and retention, particularly in rural areas like mine. What immediate support is being provided to non-MDT practices to ensure fairer access before the completion of the roll-out?

Mr Farrar: It is a good question. The pace of the roll-out depends on money, and the level of funding that is needed is at a scale that is highly dependent on the budget that I have available and what can be done quickly. We are committed to trying to complete the roll-out. We are learning lessons, and one of the things that was suggested was about making sure that the model is evaluated to understand how to get the best value out of the MDTs. Speaking where we are today, I do not have an answer to your question about what practices could do to support other practices that do not have MDTs. However, when we get the neighbourhood model in place, if we have resources in a neighbourhood and a management board for a bigger population — I suspect that in your part of the world there is one federation that covers quite a wide area — it would be possible for that group of people sitting around that management table to decide how to help the practices that do not have access to MDTs and whether there is a way to release more secondary care functions to support general practice in those areas whilst we build up the capacity. The neighbourhood model could be the answer to how we might organise to support practices that will not have the MDTs for a while.

Miss Dolan: You have touched on this, but what annual, publicly reported milestones will demonstrate credible progress on the roll-out of the MDTs?

Mr Farrar: The transformation board holds us to account quite strictly about how those are put in place. There is a benefit realisation process for the benefits we expected to achieve that were put in the business case that was put forward to the transformation board. The transformation board holds us to account, and we report to it on a regular basis about the roll-out and its impact.

Mr Cassidy: For information, we have nine key indicators for the programme that we report on to the transformation board. The Minister published a plan for recruitment. Underneath that are detailed sets of the number of people to be recruited within a certain timescale. We are monitored on our delivery of both spend and recruitment against those things. There is another thing about differential impact, looking at the impact on referrals into secondary care. Part of our business case was that we can see a measurable impact: where we have MDTs, there are fewer referrals from those services into trusts than from areas where we do have those. There are a range of indicators, and they are monitored pretty tightly. I chair the steering board that oversees the programme implementation at the highest level. In turn, we report to the transformation board. We had the head of the Civil Service (HOCS) at our last board meeting to give her assurance on how we are progressing and monitoring delivery. There has been a high level of interest from the board itself and from HOCS personally in how we are going on that.

You will know that the south-west is in the current tranche of MDT implementation. The Minister was in Belleek a few weeks back, and I was with him. They are taking an innovative way, recognising the geography and making sure that the benefit is spread as widely as possible across practices. There is room for flexibility in how it is implemented locally. We are trying to make sure that we sequence it so that everyone gets in a fair way, and in line with the plans that we have built.

Mr Boylan: I am slightly concerned. I appreciate that budgets are not set yet, but some good ideas arose from our inquiry, and you accepted some of the recommendations. I am listening to you, and you are saying that you want to go forward but, by the way, the budget is not there. Surely this is the way forward —.

Mr Farrar: MDTs?

Mr Boylan: Yes. We have outlined what we have investigated and what was found. You are saying that you have to wait to see the budget, but at some point we are going to have to prioritise if we believe that this is the way to go. I am not saying that it is a negative. We all understand about the budget. But from the piece of work that we did, and having listened to all the questions and answers given so far, we have to nail this down as much as possible.

Mr Farrar: That is a good point. I will read from the priority guidance. It is in draft form at the moment until we have a budget. It is just to give trusts a heads-up on what they have to plan for. One of the key priorities is:

At this point, all I can say is that we are committed — as I said when I came about mental health — to this rebalancing. Too much of the resource we have goes on acute physical care and hospital settings. Over the three years — ideally, we will have a three-year Budget — we will be spending more of the money in primary care and general practice. That is a commitment that we are making now. At the moment, I can do it as only a percentage of the resource. I cannot give a quantum but, as a percentage of our expenditure, the balance of priority will be primary care, community services and general practice. Those are the areas where we need to spend more money, and MDTs will be part of that.

The Chairperson (Mr McCrossan): OK, thank you. Just a brief comment from me, because we have covered a lot of ground. Actually, before I do that, has anyone else any other questions?

Mr Wilson: The glitch in my computer feed meant that I did not get to hear the e-prescribing element. Like Jemma, I have come onto the Committee in the past few weeks, so I missed the initial deliberation phase. I am just getting to grips with it now, particularly with regard to my own work. From helping a lot of people to get through the welfare application process, I know that people rely heavily on an up-to-date list of their medications and prescriptions. Whilst we are moving away, clearly, from that paper-based system towards e-prescribing, what does that look like for people who wish to have an accurate reflection or representation of their medication that is readily available without having to go through an electronic process to access it? I help a lot of people, particularly those who are vulnerable or elderly, who are not too well versed in technology, so that could give them some issues. How do you see that playing out? It may have been considered, but I want to know.

Mr Farrar: At its simplest, you have the transaction benefits where you take a lot of the costs out of somebody's having to produce a prescription, someone's receiving a prescription that has to be taken to them, and someone's having to dispense it and dispose of it. At its core, e-prescribing simplifies and improves that process for people who might have difficulty. They might lose their prescription, need repeat prescriptions etc. It takes a whole bunch of cost out of the system. That is one of its benefits, but it also allows you to have the ability to track your own medication etc. That will come down to the detail of the roll-out, but if we go down the route of e-prescribing in the way that it has been done elsewhere, it can connect to your own app to tell you something about your record so that you have that ability to understand.

Mr Wilson: You talk about apps. I think that that is difficult. I help a lot of people to go through online systems, and they are just not able to do it. Their perspective is not that they do not want to do it; they are physically not able to do it. They do not understand, and they resist that type of interaction with technology. What will be the case for them?

Mr Farrar: Talking more speculatively about the benefits that people who have done this are getting and how they are applying it, one thing that it allows for is better and easier access to medication reviews for people. Coming back again to the way in which we spend money in Northern Ireland, there is quite a high level of what is described as polypharmacy, Gareth, where you can have multiple prescriptions for different conditions, and, over the years, GPs have carried on prescribing those, and very often older people or anyone with dementia get confused about what they take and when. The medication review process is much more straightforward when you have electronic prescribing and a more detailed assessment of what people get when. It allows for a lot of contraindications to be seen. This is not widely known, but GPs occasionally make prescribing errors. Pharmacists are good about understanding that and supporting GPs with getting dosages right and things like that. Again, there are a lot of quality benefits in having e-prescribing.

Your point was about access. We have to work hard on that to ensure that, if an individual does not have that ability, maybe a carer can support them in that, or people within the practice who may be part of patient groups may be able to advise and support those individuals. We constantly have to guard against that technological inequality problem.

Mr Wilson: I see the benefits of going to that system. I had a case recently where a constituent's high-strength epilepsy medication was stolen. That had to be replaced within a short time, but it was a lengthy process. I had to physically take him to the GP practice, because he could not drive. Assurance was given that the prescription was sent to the pharmacy, but it had not been, and we had to go back to the GP. It was a very elongated process for that gentleman, and it distressed him. Anything that simplifies or accelerates that will ultimately be a good thing.

Mr Farrar: We will do our best for them.

The Chairperson (Mr McCrossan): Thank you, Gareth. Stuart, is there anything that you want to add?

Mr Stuart Stevenson (Department of Finance): Nothing from me, Chair.

The Chairperson (Mr McCrossan): OK. Thank you. I am conscious that there has been progress, Mike. More has happened than the MOR, as it was laid before the Committee, indicated. Can you provide us with a written update, not on the MOR but on what has changed since the MOR was issued? That would be helpful in making sure that we are clear. That can be done through correspondence.

Mr Farrar: We will do that. As I said, this is live and ongoing, and we are talking to people. We will give you the most up-to-date progress.

The Chairperson (Mr McCrossan): Is there anything that you would like to add?

Mr Farrar: I would like to end on this. GP access really matters, and we need to help our GPs. They are fundamental to the reset and we need to work with them. They talk a lot about stabilising reform and stabilising work with them first. We are really trying to do that. Whilst there are issues for some practices, the vast majority of GPs want to improve this, and we need to give them the context so that they can do it. We are very positive about support for our GPs to improve access, because it is not great for them. They do not like the fact that they cannot get people in when they need them. We will work really hard with them to understand what they believe is the right thing to do. I am very happy to come back to the Committee and explain how we are getting on with it.

The Chairperson (Mr McCrossan): We appreciate that as well. I thank you both, on behalf of the Committee, for coming back to us today and for the clarification of a wide range of points and questions that have been raised. This is a huge issue for the public in Northern Ireland at every part and corner of our constituencies. It is an issue that unites all parties and politicians across the Assembly in the frustration that we hear from people on the ground. The truth is that, when a health service fails, there are serious, life-altering consequences for so many people if they cannot get access to those basic, necessary and essential services. That is why the Committee unanimously decided to take forward an inquiry into access to GP services: because we hear about it on a day-and-daily basis. We all appreciate that there are huge financial restraints and challenges that face all our Departments and absolutely face the Department of Health, but this is a key issue and should be an absolute priority. We know that the scale of the task is substantial, but the Committee is clear that the Department's response must at all times on this matter demonstrate greater urgency, clearer planning and credible delivery timelines. I know that you have made every effort today to reassure the Committee, and those listening in, that it is your priority to do so. The gravity of the situation demands progress that is both tangible and timely, and prolonged delays in this area, or high-level plans without meaningful interim action, will not deliver the improvements that patients, GPs and many others in the wider health system urgently require.

We will consider the evidence that has been very kindly provided. We appreciate the update. We know that you have kindly extended an invitation as well, which I will ask the Committee Clerk to follow up with you. We will continue to engage with the Department constructively and hold the Department's feet to the fire when it is necessary to do so in the interests of the public. Thank you for being here, taking our questions for quite a lengthy time and for being open and transparent with the information that is there and realistic as to where we are at. We appreciate it, but we demand urgency. The public expects it and I know that you are keen to see that happen.

Thank you both very much for being with us, and we look forward to speaking with you soon.