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Northern Ireland Assembly

Tuesday 30 January 2001 (continued)

Mr Speaker:

Order. While there is no guillotine on such stages of legislation, or on the length of time a Member may speak, the Member has now been speaking for substantially longer than any of the other Members - including Dr Hendron, who moved the amendment. In fairness, I ask all Members to try to make their points as concisely as they can. That would allow everyone to join in the debate and prevent our postponing to the evening the rest of the day's business.

Ms McWilliams:

I am aware that there is no guillotine, and with that in mind I am trying to present as much information as I can so that an informed decision can be made. However, I will take on board your views and draw my remarks to a close.

Having asked the Minister to address a number of anxieties and fears, we should make a decision on how we are going to vote on this serious issue. In the end, the focus on improving services for those in the community is what should drive us forward. This decision will lead us to that decision. The sooner we consult and decide on the models, rather than endure uncertainty for another year, the better for all of us.

It is time to promote equality of access and service across all our communities. We know the inequities and the deficits that exist when we do not do that. It is time to build on partnership and get clear and simple lines of accountability.

Rev Robert Coulter:

I support the amendment. The Health Service has been subjected to a multitude of changes over the past number of years. The past 10 to 15 years has been an era of almost constant change that has proved most unsettling for all involved - administrators, employees and the patients themselves. Insecurity and uncertainty have been the main characteristics of the Health Service for too long. The many reviews and recommendations have been an enormous waste of time, finance and resources, especially when so many of those recommendations have not been implemented. People today expect the Health Service to be professional in every respect, and that includes those who make decisions.

Society wants a service that delivers the appropriate care at the right time, in the right place and by the right people. As the Chairperson of the Committee for Health, Social Services and Public Safety has said, there must be a seamless service for a patient from his first contact with his GP through to primary care and on to whatever treatment is required afterwards. Many points have been made, which I will not repeat. Questions, however, must be asked. One question that has been raised concerns the level of deficit in certain GP fundholding practices. The amount quoted was approximately £5 million. Why is this being raised as a problem when groups such as the Royal Group of Hospitals Trust are over £13 million in debt? The use of this kind of argument indicates a lack of consistency.

Prof McWilliams said that best practice should not be lost. Is there any guarantee that it will not be lost, particularly as specialists have been brought in and expertise has been gathered in the fundholding system? Is there any guarantee that, if fundholding is cut off and there is staff disruption - and we have been told that staff will be reintegrated - these people will be prepared to change again and come back to the co-operatives or whatever system replaces fundholding?

We agree that fundholding must go. It is inequitable. The question before the House is when will it go. Why proceed now when a consultation process is taking place? As has already been asked, what is the hurry? It is regrettable that the Ms Ramsey said that opposition to fundholding is a Sinn Féin prerogative. It is not - we are all against fundholding. Why introduce sectarianism to the debate when we should be concerned with getting the best for all patients in our country?

As has been mentioned, the cutting of fundholding now would be a regrettable step. We are going backwards. John Simpson is right when he says that

"to give back the whole of the fundholding control to the boards is a backward step".

We are supposed to be making progress, but we are going back 10 years. The Assembly is here to progress every aspect of life in this community, but in one step our attitude is regressing at least 10 years. If the Health Service is to be restructured, we must question the need for a Department, four boards, four health councils, five agencies, 19 trusts and five health co-operatives. These are the questions we should be considering. It would be unprofessional to cut off fundholding now without waiting for the results of the consultation. I ask Members to stop and think about what we are doing, and I ask them to give the consultation an opportunity to succeed.

Ms Hanna:

This debate would not have taken place if it were not for the attitude of the Minister and her Department. I want to place it on record that the SDLP is opposed to the principle of fundholding. I want that on record in order to avoid anyone making political capital of it. The issue is too important for that.

Fundholding introduced differences in the treatment of patients. It discriminated between patient categories. The SDLP believes in a National Health Service in which services are free at the point of delivery. The Minister and her Department refused to extend the consultation period to develop more radical options for primary care. That short-sighted approach will waste money in the long term. The Minister and her Department want to go backwards to the failed system that was recognised as such in documents such as 'Fit for the Future' and 'Fit for the Future - A New Approach'. The same Department wrote those documents. 'Fit for the Future - A New Approach' was presented to Assembly Members almost two years ago by the then Minister for Health and Social Services, John McFall. We are now being presented with a far more conservative option than that of two years ago.

11.30 am

I want to see real partnerships on the ground, involving GPs, nurses, social workers, physiotherapists, occupational therapists, pharmacists and podiatrists commissioning services for their patients. It is the professionals and the practitioners working on the ground who best know the needs of their patients. I have talked to many practitioners. I can assure Members who are worried that the nurses have not been consulted that I have talked to many nurses. They have deep concerns that the Department and the Minister are going backwards.

We need to see the results of the review of acute hospital services in place if we are ever to make the fundamental changes required. We talk about an integrated, interdependent health care system. How can we create that without all the pieces of the jigsaw? I want to see fundholding ended, but I want real primary-care partnership at the heart of whatever replaces it. We need to build on the innovative practices and pilot schemes that have evolved in the past few years.

The main urgency for ending fundholding now appears to be a monetary one - an overspend of approximately £5 million by fundholding practices. Of course, much primary care has been under-resourced, and it is essential that money be spent where it is needed. I need to know the real cost of going back to where we were before fundholding. Surely it would be more cost-effective to make some radical decisions at this stage, rather than taking retrograde steps that will move us further away from the ideal of an integrated and interdependent health care system. Ironically, we will now need additional resources for primary care to go backwards. I urge the Minister to listen and to take a more radical approach to the future of our health care.

Mr J Kelly:

Go raibh maith agat, a Cheann Comhairle. I oppose the amendment because it is divisive and unnecessary. It is predicated on the view developing here that those of us who oppose the amendment are uncaring about primary care, the health of our constituents or ensuring that we make provisions for a health service that is delivered at the point of need.

I have listened to everyone arguing for the ending of fundholding. No Members have said that they are for the continuation of fundholding. All that they say is "We want fundholding ended, but why the hurry?" Why then the hurry on this amendment? Why bring to the Floor of the Chamber an amendment that is divisive in our attempts to create a proper, caring Health Service, particularly in the area of primary care? It puts people such as Sue Ramsey and myself in a position where, by opposing the amendment - and opposing it in Committee for four and a half hours or more - we are somehow seen as backward-looking people who are not in favour of a Health Service that is socialist in its content and direction. That is why this amendment is unnecessary and divisive.

There is a suggestion that fundholding will end completely on 1 April. In fact, the statement from the Minister says that there will be a six-month, or perhaps longer, winding down of fundholding. To suggest that ending fundholding in this way is somehow detrimental -

Mr Ervine:

If the Member would give us some understanding of what it would wind down to, perhaps those who support the amendment might have a totally different attitude.

Mr J Kelly:

I can only speak from my understanding as to what it would wind down to. It is winding down to the wind-up of a primary health care. That is why I am opposing the amendment. If I thought that the winding down of fundholding was not going to be in line with arrangements ensuring that we were making the beginnings of a primary care service that is radical and will deliver care to those who need it, I would not be opposing the amendment.

I oppose the amendment because it is divisive and unnecessary. I received a letter from members of the mid-Ulster commissioning pilot scheme this morning. It went through all the various things that we have already discussed. While they are not in favour of ending fundholding in what they call a transitional period, they are saying that the scenario whereby GP fundholding is extended for another year would be worse. Even they are aware of the fact that fundholding has not delivered an equitable health service. It has delivered a two-tier system of health.

Mr McFarland:

The Member will recall that we had extensive discussions about how we might find some way through this. It is fair to say that the Committee did not wish to extend it for a year, but the Committee had no option because there would be no system in place if it went through. We are interested in having something to replace the present system. If the Minister could produce something to replace it, and find a way of altering the timescale, I am quite sure that we would all be happy enough with that. The problem is about the replacement.

Mr J Kelly:

Let us hear what the Minister has to say about that. I am confident that this Minister will attempt to deliver - and will deliver - a primary health service that will be worthy of her own political and social philosophies. I will look forward to that.

I agree that there are difficulties in the interim and in the transition. However, those difficulties are exacerbated by the amendment. They could have been better overcome had we adopted a more consultative approach. I do not take on board that the winding down of fundholding will hinder the beginnings of the delivery of a proper primary care service.

On the question of costs, there is no doubt about it. We talked to the boards in relation to the present position. Who will pay for the deficit of the fundholders, except the boards? Who will pay for the deficit of fundholders, except the Department? If fundholders get an extension for a year, they will surely say at the end of that year that they will not be paying the deficit - whatever it might be. It will then be open season as regards what happens within fundholding.

I oppose the amendment because it is divisive and unnecessary. I would not oppose it if I thought for one minute that we were not all saying the same thing. We are singing from the same hymn sheet - for a change. We all want a proper primary care service and a proper health service for the people we serve. The only dispute is about how and when it should be delivered. This hiatus that we talk about might not be as big a chasm as some are making it out to be.

I listened to Dr Hendron's list of doom as to what might happen. I would not oppose him if I thought that the things he suggested would come to pass. I have just been handed 'Building the Way Forward in Primary Care', in which the Minister states:

"I am pleased to present this consultation paper. It sets out proposals for new arrangements in primary care to be put in place following the end of the GP fundholding scheme. It also puts forward a future policy agenda for the delivery of primary care services."

The Minister and the Department have given a commitment. I hope that the Assembly will drive that commitment forward, not in a divisive way, but in a united way, so that we, as Ms de Brún said, might deliver the best possible health service to our constituents and the people we serve, a Cheann Comhairle.

Mrs I Robinson:

It is obvious that the Minister's stance has more to do with politics than the good practice of providing the best care to the public. Sixty-five per cent of GPs chose the fundholding alternative, and 35% opted to stay with the boards. The so-called inequality of the present system is down to a matter of choice, not direct or indirect discrimination against those GPs who decided of their own volition not to become GP fundholders. That is a matter of fact. The "them and us" scenario that has been painted is due to choice alone.

The relevant facts were well put by the Chairperson of the Health Committee, Dr Hendron, Mr McFarland, Mr Berry and Billy Hutchinson. We wish to see an end to GP fundholding. However, during the Health Committee's deliberations, it accepted that there would be a void if fundholding ceased by 1 April 2001. The Health Committee's vote on this issue last Wednesday reflected these concerns - it was six to two in support of this amendment.

We need to take account of the expected reviews of primary care and the future of acute hospitals. Sensible and informed decisions can be taken with all of that information to hand. The bogeyman of the £5 million deficit run up by several GP fundholders was held up as a good reason to end the practice. That seems strange to me, bearing in mind that it costs an additional £90 million a year to run the 11 Government Departments, whereas only six were required before the Assembly was established - there was no concern about that. An extra £20 million is required to service the North/South bodies - again, no concern.

We will get only one chance to make the Health Service work for all of Northern Ireland's people. I urge caution and ask the SDLP to remove its three-line whip so that it can join the Health Committee's Chairperson and the majority of its members in support of the amendment.

Ms Gildernew:

Go raibh maith agat, a Cheann Comhairle. I welcome the Minister's decision to end GP fundholding. I welcomed that decision before I listened to this morning's debate. After listening to everyone else say that fundholding is wrong, I want to put that point across strongly.

Before the establishment of the Assembly and the Executive, all the political parties were clearly calling for the end of GP fundholding. I cannot understand the argument behind this morning's debate. In my opinion, the amendment is madness. GP fundholding has created an unequal, two-tier health system at primary care level. Delaying the end of GP fundholding will result in the waste of millions of pounds in propping up a system instead of developing new arrangements.

Given that primary care is so important, and given that the delivery of primary care services has major ramifications for every other aspect of the Health Service, it is critical that the Assembly get this issue right. The inequalities created by the GP fundholding system cannot be perpetuated because we do not have the bottle to change it. GPs lobbied me before the Executive was set up and during the suspension period because of uncertainty in the Health Service. That fact illustrates how demoralising this issue was.

We need to use resources wisely to put a credible system in place that treats everybody equally. Health should not be used as a political football. The Assembly should use this opportunity to create a fair and equitable system. I oppose the amendment. Go raibh maith agat.

11.45 am

The Minister of Health, Social Services and Public Safety (Ms de Brún):

Go raibh maith agat, a Cheann Comhairle. Cuirim i gcoinne an leasaithe seo go tréan. Chiallódh sé go leanfadh an scéim chisteshealbhaíochta liachleachtóirí ar aghaidh go ceann bliana eile. Creidim go bhfuil cúiseanna láidre ann le deireadh a chur leis an scéim seo ar 1 Aibreán 2001, mar a d'fhógair mé é bheith de rún agam a dhéanamh.

Bhuanódh leanstan ar aghaidh le cisteshealbhaíocht éagothromaíochtaí aitheanta na scéime, chomh maith leis an mhaorlathas agus na costais arda riaracháin a bhaineann léi. Dhéanfadh sí dochar do fhorbairt socruithe úra sa chúram phríomhúil agus d'fhéadfadh sí cur leis an róchaiteachas sa bhuiséad sláinte agus seirbhísí sóisialta, rud a rachadh go dona do sheirbhísí.

Is sainmharc í an chisteshealbhaíocht den seanmhargadh inmheánach sa chúram sláinte agus sóisialta a chaithfear a ligean chun dearmaid. Is mian liom gluaiseacht chun tosaigh a fhorbairt socruithe sa chúram sláinte agus sóisialta a bheas bunaithe ar an pháirtíocht agus ar an chomhoibriú chan ar an choimhlint agus ar an bhristeachas. Beidh mo mholtaí do shocruithe úra sa chúram phríomhúil níos cuimsithí ná an chisteshealbhaíocht, ag cur réimse níos leithne de ghairmithe cúraim phríomhúil san áireamh agus ag coimisiniú réimse níos leithne seirbhísí.

Tá roinnt fáthanna praiticiúla ann a gcreidim gur gá deireadh a chur le cisteshealbhaíocht ag deireadh na bliana airgeadais seo. Ag deireadh na bliana is dóiche go mbeidh róchaiteachas cisteshealbhóirí níos airde ná mar a bhí anuraidh - agus seo nuair atáimid ag iarraidh an ceann is fearr a fháil ar fhadhbanna easnamh agus róchaiteachais sa bhuiséad SSSP go ginearálta. Má leantar de chisteshealbhaíocht go ceann bliana eile, tá gach seans go mbeidh an róchaiteachas níos airde arís ag an am seo ar an bhliain seo chugainn. Cuireann róchaiteachas cisteshealbhóirí brúnna ar áiteanna eile i mbuiséad na seirbhísí sláinte agus sóisialta. Díolann na boird sláinte agus seirbhísí sóisialta astu agus caithfidh siad acmhainní a chur i leataobh chun na críche seo - acmhainní a b'fhearr a chaithfí ar sheirbhísí eile.

Ceanglaítear ar mo Roinn, de réir na reachtaíochta cisteshealbhaíochta, bheith sásta go bfhuil cisteshealbhóirí ag riar a mbuiséad go héifeachtach. Má leantar den chisteshealbhaíocht, tá seans go mbeidh ar an Roinn líon suntasach chleachtais an róchaiteachais a bhaint den scéim, rud a dheifreodh an scéim titim as a chéile in aimhréidh. Cuireann riar éifeachtach cisteshealbhaíochta éilimh nach beag ar chisteshealbhóirí, ar bhoird agus ar iontaobhais. Dá mbeifí an saothar mór seo le cur le scéim sheanchaite a choinneáil ag dul go ceann bliana eile bhainfeadh sin saothar agus acmhainní ón chlár suntasach oibre a bheas riachtanach i bhforbairt socruithe úra sa chúram phríomhúil.

Lena chois sin, dá leanfaí den scéim go ceann bliana eile ní dhéanfadh sin ach fad a chur leis an éiginnteacht faoina bhfuil cisteshealbhaíocht ag feidhmiú. Chuirfeadh sé leis na fadhbanna atá ag cuid cisteshealbhóirí foireann chisteshealbhaíochta a choinneáil. Ó Aibreán 1998, d'fhág 28 gcleachtas cisteshealbhaíocht. I mórán cásanna tharla seo de bharr fadhbanna le foireann a choinneáil nó a earcú agus de bharr fadhbanna a bhí acu ag riar de réir buiséad. Dá gcuirfí fad leis an scéim ní dhéanfadh sin ach cur le fadhbanna oilteacht a choinneáil agus bhainfeadh sé faoin chumas cisteshealbhóirí an scéim a riar go héifeachtach i rith a bliana deiridh.

Tá cuid mhór den airgead atá de dhíth orm le hinfheistiú i socruithe úra sa chúram phríomhúil ceangailte sna costais riaracháin a bhaineann le cisteshealbhaíocht. Má leantar den chisteshealbhaíocht go ceann bliana eile, b'éigean domh na hacmhainní atá riachtanach le socruithe úra sa chúram phríomhúil a fhorbairt a chuardach in áit éigin eile. B'fhéidir go mbeadh orm cuid den airgead a úsáid a bhí de rún agam cur le seirbhísí cúraim phríomhúil na líne tosaigh sa bhliain seo chugainn.

Tá sé de chuspóir ag mo chuid moltaí úsáid a bhaint as cuid den airgead atá ceangailte faoi láthair i gcostais riaracháin cisteshealbhaíochta le hinfheistíocht £2·5 milliún i seirbhísí cúraim phríomhúil na líne tosaigh. Dá mbuanófaí cisteshealbhaíocht chuirfí moill le scaoileadh an airgid seo.

Is maith is feasach domh an gá leis an tréimhse aistrithe idir deireadh chisteshealbhaíocht liachleachtóirí agus tús na socruithe úra a riar go cúramach agus go tuisceanach.

Ón 1 Aibreán 2001, an dáta a ceapadh do dheireadh a chur le cisteshealbhaíocht, ghlacfadh na boird sláinte agus seirbhísí sóisialta freagracht, go ceann tamaill ar scor ar bith, as réimse iomlán na seirbhísí sláinte agus sóisialta dona ndaonraí uilig a choimisiniú chomh maith le freagracht as acmhainní atá á riar ag cisteshealbhóirí faoi láthair. Coimisiúnaíonn boird bunús na seirbhísí do chisteshealbhóirí cheana féin chomh maith le hiomlán na seirbhísí do neamhchisteshealbhóirí. Toiseoidh siad ar iomlán na seirbhísí a choimisiúnú arís nuair a bheas deireadh le cisteshealbhaíocht. Leanfadh na socruithe seo ar aghaidh go dtí go raibh na grúpaí áitiúla sláinte agus cúraim shóisialta, ag brath ar thoradh an phróisis chomhairliúcháin, ábalta cuid de fhreagrachtaí coimisiúnaithe na mbord a ghlacadh orthu féin. Leanfadh liachleachtóirí ar aghaidh ag cur seirbhísí ar fáil mar a dhéanann siad faoi láthair.

I strongly oppose the amendment, the effect of which would be to continue the GP fundholding scheme for at least a further year. There are strong grounds for ending the scheme on 1 April 2001, as I have announced it is my intention to do. Continuing fundholding would perpetuate the acknowledged inequities of the scheme, and the bureaucracy and high administrative costs associated with its operation. It would be damaging to the development of new arrangements in primary care and could contribute to overspends in health and social services budgets which would affect services adversely.

Fundholding is the mark of the old internal market in health and social care, and it must now be consigned to the past. I want to move forward to develop arrangements in health and social care that will be based on partnership and co-operation, not confrontation and fragmentation. My proposals for new arrangements in primary care will be more inclusive than fundholding is. They will involve a wider range of primary care professionals and commission a broader range of services.

For a number of practical reasons it is necessary to end fundholding at the end of the financial year. At the end of the year, fundholders' overspends will probably be higher than last year. That should not be the case at a time when we are actively trying to get to grips with the problem of deficits and overspends in the health and social services budget. If fundholding continues for a further year, the overspends may be even higher next year.

Fundholders' overspends create budget pressures elsewhere in the health and social services. The overspends are paid for by the health and social services boards. They have to set aside resources for that purpose, resources that might have been better spent on other services. The Department of Health, Social Services and Public Safety is required, under fundholding legislation, to be satisfied that fundholders manage their budgets effectively. If fundholding continues, the Department may therefore be obliged to remove a significant number of overspending practices from the scheme, thereby hastening the disorderly disintegration of the scheme.

Mention has been made in the debate of the differences that exist between legislation for trusts and legislation for fundholding. The legislation is different, and that is why the approach is different.

Managing fundholding places considerable demands on fundholders, boards and trusts. Investing all that effort in sustaining an obsolete scheme for another year would divert effort and resources from the formidable agenda involved in developing new arrangements in primary care. Moreover, continuing the scheme for a further year would prolong the uncertainty under which fundholding has been operating. It would exacerbate the problems that fundholders have had in retaining fundholding staff.

Since April 1998, 28 GP practices have left the fundholding scheme. In many cases, that was because there were problems with retaining or recruiting fundholding staff and with managing within the budgets. Prolonging the scheme would simply increase the problems of retaining expertise and undermine fundholders' ability to manage the scheme effectively during its final year.

Much of the money that I need to invest in new primary care arrangements is currently tied up in the administrative costs associated with fundholding. If fundholding continues for a further year, I will have to look elsewhere for the resources needed to develop new arrangements in primary care in order to bring them forward. That could mean having to use some of the money that I intend putting into front-line primary care services next year. My proposals envisage using some of the money currently tied up in the administrative costs of fundholding to invest an extra £2·5 million in front-line primary care services. Extending fundholding would delay the release of that money.

I am very aware of the need to manage the transition period between the end of GP fundholding and the start of new arrangements carefully and sensitively. On 1 April 2001 - the intended date for the ending of fundholding - the health and social services boards will assume responsibility, at least on an interim basis, for commissioning the full range of health and social services for all their populations and for the resources currently managed by fundholders. Boards already commission the majority of services for fundholders as well as all the services for non-fundholders. They will resume the commissioning of all services once fundholding ends.

These arrangements would continue under my proposals until such time as the proposed new local health and social care groups, subject to the outcome of the consultation process, are in a position to take over some of the boards' commissioning responsibilities. GPs would continue to provide services, as they do at present.

Guidance issued by my Department has instructed boards to urgently consider, with fundholders and trusts, the impact of ending fundholding on services put in place locally by fundholders, and to ensure that these are maintained where possible. In order to provide boards with greater flexibility in managing the transition from fundholding, I have proposed that they should get additional resources for primary care in the next financial year. As a result, there will be no vacuum in the delivery of services when fundholding ends. Services will continue to be provided, and only the commissioner will change during the interim period.

I am aware of concerns raised in some quarters - and I have heard them in this debate - about the transition to new arrangements. I believe that these problems can be managed. As elsewhere, it will not be necessary to create new statutory bodies, and this, as I have said, has not happened. In developing new arrangements in primary care, health and social services boards will be given an explicit remit by the Department to support the new groups actively and positively. They will be held accountable for their performance in this regard, and will be expected to work in close partnership with primary care professionals so that all involved have real ownership of the process.

If we are to move forward, as we envisage, to a primary-care-led service, everyone in the health and social services at all levels will be expected to facilitate and support whatever emerges from the consultation process. The consultation period on the new arrangements will end on 2 March 2001. There has been a suggestion that I was asked to extend that period. I have not been asked to do that. After that date, I will take decisions quickly on the way forward in order to enable the service to turn its attention to putting in place the new arrangements early in the new financial year. The intention is to build up as quickly as possible to the implementation of the new arrangements.

During the six-month period that will be required after the end of fundholding to wind down and close fundholders' accounts, the new arrangements will be built up. The resources needed to invest in new arrangements are currently tied up in fundholding, and investments in the new arrangements will be able to be made only as those resources are released.


There was also the issue of pilot schemes. This is a separate question and is not tied to this legislation. I want to look at how the services put in place by the pilots can be maintained during the transitional phase. However, maintaining the work of pilots is a different issue to the matter of ending fundholding.

A number of other issues have been raised, principally by Committee members, about the health and social services boards. As I said, everyone throughout the service will be expected to facilitate and support whatever emerges from the consultation exercise. I believe, therefore, that the transition from fundholding to the establishment of new arrangements can take place without disruption to services or detriment to primary care, provided that fundholding ends on 1 April 2001.

Resources for primary care will be addressed as part of my announcement about next year's financial allocations for health and personal social services. The boards have been explicitly instructed to examine how services put in place by fundholders will be maintained. It is true, as Prof McWilliams said, that non-fundholding GPs have made savings in prescribing costs - and some of these have been substantial - through the prescribing incentive scheme which will be open to all GPs after fundholding ends.

Information technology systems and a new information and communications technology strategy for health and personal social services - which will embrace primary care - are being developed. Following the repeal of existing legislation, new regulations will be introduced outlining how any fundholder savings remaining at the end of the scheme will be used. Guidance on this will be issued with clear ideas of how savings will be used. The key issue here, however, is that fundholding savings are currently used, and will be used after the scheme ends, for the benefit of service users. In fact, fundholders who are permitted to use savings for a variety of purposes set out in the legislation have used them to improve premises, and in some cases there have been complaints that this represents a personal asset to the GP.

The proposal for change, as I have said, will not increase the power of boards. They will have to include all primary care professionals in the new arrangements that are up for consultation. They will also all be tasked with improving primary care for their populations and with the work of commissioning services for them. I can therefore give an assurance that the position of boards will not be copperfastened by arrangements whereby new groups would operate as board committees, nor will this have a bearing on the outcome of the forthcoming review of public administration. Members would not want me, at any stage, to bring forward proposals that would pre-empt that review. I am only one member of a larger Executive, and my proposals need to fit in with the wider arrangements being made by that Executive.

The establishment of the proposed new local health and social care groups as committees of the boards is to provide a legal and accountability framework within which to operate. My proposals are designed to be accommodated within existing health and social care services structures in order to not prejudice the outcome of the Executive's planned review of public administration. However, they will be sufficiently flexible to be able to be adapted to any changes to health and social services structures that emerge from that review. My proposals in no way rule out radical changes to health and social services structures in the future, depending on the outcome of the public administration review.

I can give an assurance that staffing issues associated with the ending of fundholding will be dealt with sympathetically. Action is currently being pursued on a number of fronts to ensure that redundancies can be avoided and that the skills and expertise of fund management staff are not lost to the service.

Health and social services boards will consider sympathetically bids from practices to retain former fund management staff permanently in other posts. In making financial allocations to the health and personal social services bodies for 2001-02, I propose to provide additional resources for primary care to allow boards more flexibility in considering the staffing requirements of practices.

I hope that this will also extend to a redeployment facility, which currently exists in health and personal social services for staff who are employed in fundholding. This will enable those staff members to be matched with suitable vacancies arising elsewhere in the health and personal social services field as well as with vacancies in any new primary care arrangements set up after the consultation exercise. Some fund management staff will continue to be employed for several months following the end of the scheme to close fundholding accounts, by which time I expect fresh employment opportunities to be available within the new primary care arrangements.

This amendment, if accepted, will extend the life of a scheme that already experiences difficulties and is inherently inequitable. Depending on the outcome of the current consultation on the 'Building the Way Forward in Primary Care' document, I hope to press ahead quickly with developing new arrangements in primary care that will end the uncertainty that has existed in this area for a number of years. To extend fundholding for a further year is unnecessary. It will damage all progress that has been made towards the new arrangements and create greater problems for the service than it is designed to resolve. I urge that this amendment not be accepted.

Dr Hendron:

I would like to thank the Minister and my Colleagues who have spoken in the debate. The Minister has mentioned the matter of one year. I told the Minister on behalf of the Committee for Health, Social Services and Public Safety that a period of six months had been suggested but that the Committee had decided that a six-month period would not work because it would end in the middle of the financial year.

I want to refer to a few of the points raised by my Colleagues. Alan McFarland spoke about the GP staff and about how we are losing expertise in these professions. That is the burning point of the debate. Paul Berry said that there is nothing in place to deal with the need for a unified service, but something credible must be in place. That is the key to the debate, and it has not been dealt with, in my opinion. Sue Ramsey said that it is the policy of Sinn Féin to oppose fundholding. That has also been the policy of the SDLP from the very beginning, as well as the policy of most Members. However, the debate is concerned with what will replace the arrangements that the Minister has proposed.

Mr McCarthy said simply that we should get this right because it concerns the future of primary care. That is it in a nutshell - we must get it right. Mr Billy Hutchinson pointed out that the money would go to the boards rather than into primary care. He made a valid point regarding these funds being taken away from occupational therapists and physiotherapists. The boards will use the money in whatever way they deem necessary, but there is a lot to be desired of it by the community.

Monica McWilliams spoke at great length on many issues. First, she talked about a period of opportunity to move forward and said that in all of this the nurses' voices are not being heard. I have not said that the nurses' voices are not being heard - I have spoken to many community nurses. Although I mentioned the Royal College of Nursing and the fact that I have spoken to its leadership, I have spoken with ordinary nurses as well. We will not move forward if this amendment is not accepted; we will move backwards. On behalf of the Health, Social Services and Public Safety Committee and given my wealth of experience in primary care, I can safely say that that would be a backwards move.

Monica McWilliams also talked about building. Building on what? If the fundholding and the primary care arrangements disappear - and the Minister has not indicated that the pilots will stay - what is there to build on? That will be a backward move. Most doctors - certainly the younger ones - use generic prescribing and therefore save on prescriptions.

I have nothing but the most profound respect for community nurses. Most health visitors are employed by trusts, but some are employed by fundholders, and they are worth their weight in gold.

Rev Robert Coulter said that we needed a seamless service. That point has been made over and over again by many people in the last few months. As we move along, we should remember that John McFall's 'Fit for the Future' document has been around for a couple of years. That was addressed to the Assembly and to the people of Northern Ireland, and it seems that its findings are being pushed aside. The Minister's suggestions bear some very vague similarities to that document.

Carmel Hanna made the point about being against fundholding - which we all are - but she highlighted the problems of going back to a failed system. That is exactly what would happen on 1 April - we would go back to the 1993 situation.

We all want a first-class primary care service. I accept that the Minister wants that - way down the line. However, I have already made the point that we have every reason to be concerned about the whole transition period. That point was certainly not answered.

John Kelly said that Members were all against fundholding, and he also mentioned the deficits. He asked what we would be winding down to. I have already made the point that we would be going backwards, and I will come to the deficits in fundholding shortly.

Iris Robinson talked about inequalities and the fact that doctors have a choice. That is true, although some practices in Northern Ireland might have wanted to go to fundholding but were not allowed to. She is quite right, however, that others chose not to. The review of acute hospitals is coming up shortly, and there is an ongoing review of primary care. Those reviews should be interwoven.

Michelle Gildernew said that she wondered why the amendment was put forward. That was explained over and over again. She asked why fundholding should be propped up. I think that she was missing the point there, and she did not suggest what might take the place of fundholding.

The Minister's key point, made again and again, concerned the financial aspects of the issue, and the perpetuating of inequalities. What she is doing, however, is going back. I accept that non-fundholder patients were at a disadvantage, and that the majority of patients under fundholders - generally speaking - were advantaged. It is now being suggested that we move a step backwards to where the boards were in control of non-fundholders. Surely we should be taking a step forward for everybody in Northern Ireland. I spoke of that earlier, as did my Assembly Colleagues who are supporting the amendment. That is what it is all about - for everyone to move forward. We have heard nice, but vague, aspirations for the future, but we have not been told specifically what will happen in the transition.

The Minister greatly emphasised the matter of overspending, and some Colleagues mentioned it. One should understand how fundholding works. When it was first introduced, amounts of funding were given to run the practices. If savings could be made of, say, £50,000 or £60,000 - not for personal gain, but from a practice's point of view - the board would permit the savings to be used to develop that practice. That was good - perhaps another clinic could be run, or an extra nurse employed. That is fair enough. However, the following year, that money is taken off. Each year they are given a smaller budget. Any savings gained are taken from them. So, you can see how they would get in trouble.


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