Annex A

17. The 'Fit for the Future' document on Primary Care (PC) was a distillation of a broad consultation process, and it received widespread support. The current document 'Building the Way Forward in Primary Care' is a reining back from the more radical moves originally envisaged. Is the panel confident that we will eventually get to the position of local PC Groups with devolved budgets for commissioning services?

There is anecdotal evidence that not all GPs and nurses are enthused about taking on the extra responsibilities that will flow from the new PC development to make the changes happen on the ground. What are the panel's views?

How do we ensure that GPs will not automatically seek to take the lead but instead adopt the principle that whoever is most appropriate to lead in the circumstances does so? [Mr McFarland]

1. The 'Fit for the Future' document received a near unanimous welcome, but it could be argued that it was too radical. The new consultation document recognises the need to be more pragmatic. Nonetheless, it could well provide a back door to those more radical proposals over time. This is an evolutionary process that will require a change of mindset if we are to move to a truly equitable PC system where all providers of care feel equally valued. This new document provides a skeleton of the way to move forward.

While it is true that some GPs - and other health professionals - may have their doubts about the proposed changes, we would hope to meet the formidable challenges ahead with determination and enthusiasm. Nurses welcome the empowerment opportunities to deliver services that they are qualified for, but they must have equality as a group. It must be a team effort the relevant professional in the General Practice takes the lead as appropriate. A workforce planning strategy is needed across NI. PC groups will need to be adequately resourced so that staff can develop necessary skills by attending leadership and commissioning courses.

GPs fully accept the principle underpinning the proposed model for PC that it is a multi-disciplinary approach where each team member has something important to contribute. Health is also recognised as multi-sectoral, involving housing, education and the environment. Therefore, the views of the community and voluntary sectors must equally be taken on board. The thrust has to be a bottom-up approach with PC professionals working in partnership together with a strong community input.

17. The concept of equal treatment is very important if effective teamwork is to be developed within the PC Groups. Does the panel envisage any problems with the expanded role of the nurse practitioner within the Group? [Mr Kelly]

1. If there is to be equality in the Groups, team building will clearly have to respect the position of each of the professional partners. The nurse practitioners can provide care directly to patients by taking on some minor work done by GPs in the past, including local health needs assessments. GPs recognise they cannot deliver a quality service without input from Nurse Practitioners, Practice Nurses, and Community Practice Nurses. If GPs take on too much, the system will collapse and the general public will suffer. There are some examples of PC Practices in England where the Chairperson is a nurse.

17. The Acute Hospital Review Group will be reporting in May, which is timely given the interdependency of Acute and PC services. In future, much low-technology hospital work should pass to the PC Groups. This requires an immediate plan for relevant professional training for the PC staff. Is there an action plan to take this forward now? [Ms Hanna]

1. We fully agree that there needs to be effective planning. We await with interest the Hayes Report and envisage building the PC Group to take account of the overlap of issues: treatments formerly prescribed by consultants can be handed to GPs, along with the discharge of patients into the community and quality and type of care.

It is important to note that the Total Purchasing Pilots took some two years to build trust between professionals. There needs to be multi-professional training to start building up working relationships. There will be different educational requirements across the various professions. The sharing of premises and information is important, as well as training requirements for the leaders of the organisations. Effective planning will involve examining the delivery of care, for example, there are not enough nurse practitioners to cope with the extended chronic disease management. And GPs will need training for the work previously done by consultants, such as early discharge from hospital.

17. What size of population is envisaged for a PC Group, because there are clearly differences between urban and rural areas in terms of accessibility? Could a PC Group transcend the Border if there were practical benefits? [Mr Gallagher]

1. There is no definitive answer as to the size of PC Group catchment numbers. Figures mentioned have ranged from 50,000 to 250,000. We would see natural communities coalescing around the PC Practices. But clearly some Groups, particularly in rural areas, will have smaller numbers than others. However, on a cautionary note, having too small a Group could create difficulties in providing effectively the full range of services envisaged. We see the system evolving with discussions with communities and local representatives.

We are not aware of any consideration that has been given to the concept of developing cross-border PC Groups or user catchment areas.

17. The issue of what constitutes a community would need to be strategically thought out. Likewise, the multi-disciplinary training must be planned effectively to take account of the clear demographic changes in society, which is, in effect, a ticking time bomb. The panel has already referred to the fact that the system is failing the elderly, and the immediate need for an extra 10% for community care funds. We therefore need to be proactive in first obtaining funds and then delivering the most effective service.

I am also concerned about optimising user involvement and community participation. How do we engage users and get them continuously involved in the new PC arrangements? [Ms McWilliams]

1. In terms of constructing training courses, we can draw upon the useful experiences and best working practices from the Pilot Groups. Multi-professional training has already started in England, and we will provide the Committee with a copy of the Commissioning Initiative Programme. Also, Prof. M Savage has begun the innovative practice of training nurses with medical students, which is a good start for the future.

There is a clear need for a properly planned health care service for the elderly, where problems can be averted through better monitoring. Voluntary organisations can work effectively with PC Groups to help prevent hospital admissions in the first place, for example, in the provision of respite care. Areas for scrutiny are the lack of planning for nursing home admissions, hospital care and discharges, and the funding problems for community care. The problem in the past has been that areas such as care of the elderly, mental health and learning disability have not been seen as high profile, and they consequently did not attract proper resources.

User involvement is a difficulty that has been exercising us. The community lifestyle in general must change and we recognise that housing and education are part and parcel of better health. We must therefore engage with other agencies to deliver a similar message and promote a community development approach, of which Health Action Zones have been a good working example. The bottom-up approach should help stimulate user involvement, as staff working at the coalface are best placed to empower and influence patients to participate.

17. In the context of the increasing proportion of the population in the older age bracket, are there any plans to build partnerships between the PC Groups and private nursing homes? [Mrs Robinson]

1. We are starting to build bridges by bringing together the managers of nursing homes to address health issues. Some projects are looking at the treatment of chest infections, which plays an important role in the prevention of hospital admissions. This of course creates its own difficulties in terms of further stretching the nursing homes workloads, but it is an important step forward.

17. There is a perception by some that GPs are strong-minded people who may want to take control within the PC Groups. On the other hand, others may wish to opt out. How do we avoid a two-tier system within the new arrangements and ensure that the Groups work effectively as team units? [Rev R Coulter]

1. Quite simply, if the system is going to work, the GPs will need to respect fully the other providers; the price of failure will be the total collapse of the PC Groups. We need to put in place arrangements to deliver better quality of health care, and this will inevitably involve all the professionals in a Group giving up some autonomy and resources to make the system work. There is a difference between domination and leadership, and while GPs may take the lead in some instances, others can equally do so where appropriate. We must devise structures to promote clinical governance that enable all the health professionals to operate at a level with which they are comfortable.

17. The 'Fit for the Future' document was welcomed by the BMA, as it advocated a bottom-up approach with the delegation of budgets to PC Groups. The present plan, however, is to withdraw commissioning to the HSS Boards, and to have powers trickle down to the Groups at a later stage. Is this approach not too cautious? It may take years before the PC Groups get full responsibility for the resources. [Mr McFarland]

1. We hope your fears are not realised. We do have some concerns about the consultation document in relation to the position of the HSS Boards. In order to have a workable structure, a regional strategy is needed to support PC providers. As providers of health care at the coalface, we need empowerment and a measure of control over how the money is spent. However, we need to be careful and responsible in the expenditure of limited public resources. This is why we prefer an evolutionary approach towards ultimately reaching the stage where the PC Groups take on full commissioning powers, as envisaged under Option 4 in the new consultation document. Over the next year shadow local care groups should be set up, which we would be keen to be involved in.

17. Has the panel had the chance to examine any PC Group Trusts in England and to learn form their successes or failures? [The Chairman]

1. There have been variable experiences with the PC Groups in England, usually mirroring where they started off. For example, the Total Purchasing Pilots tended to hit the ground running and have now become PC Trusts. Others that started from scratch took 18 to 24 months just to gel together. The emphasis should be on the need to allow groups to proceed at their own pace, as not all will be able to take on budgets immediately. A Commissioning Leadership Programme in Buckinghamshire Health Authority has helped contribute to effective leadership and team building skills, from which we can learn.

17. I noted that the BMA in one of the recent editions of the Medical Journal discuss Option 5 in the consultation document. Is there scope to bring together Options 4 and 5 to deliver integrated local community health and social care services? [Ms McWilliams]

1. The difficulty lies in our mix of acute, community and mixed HSS Trusts. In England some PC Groups have moved to PC Trusts that subsumed work previously done by community Trusts, which is a vision for the future. We need an all-embracing regional strategy incorporating Primary Care services, acute services, workforce planning, IT and the voluntary and community sector.

Health and Social Services Minutes 14 February 2001