Monday 2 July 2001

Departmental Budget Bid 2002-03

Members present:
Dr Hendron (Chairperson)
Mr Gallagher (Deputy Chairperson)
Ms Armitage
Mr Berry
Rev Robert Coulter
Ms Hanna
Mr McFarland
Ms McWilliams
Ms Ramsey
Mrs I Robinson

Witnesses:
Ms de Brún )
Mr C Gowdy )
Mr A Hamilton ) Department of Health, Social Services and Public Safety
Mr P Simpson )

Good afternoon, Minister, you are very welcome. Perhaps you could give us a statement on the Department's document 'Preparing for 2002-03'.

I am glad of this opportunity, early in the 2001 Budget process, to discuss with the Committee the major issues affecting my Department's spending plans for 2002-03. When we discussed these matters five months ago it was with reference to the current year's plans. My message then was that the resources available to health and personal social services (HPSS) are severely limited. For 2001-02, the Department of Health, Social Services and Public Safety (DHSSPS) baseline got an uplift of 7·6% compared to the 9·4% increase received by the NHS and social services in England. This year, therefore, there was no prospect of our matching the developments promised by the Department of Health there.

I am sorry to say that the outlook for next year presents an even sharper contrast between what we can achieve and what is in train elsewhere. The DHSSPS indicative allocation for 2002-03 gives us an uplift of just 6·7%. In England the uplift will be 10·4%. When allowance is made for £19 million of our increase being essentially a technical adjustment and not, as the position report itself recognises, an increase in spending power, the uplift reduces to 5·9% over this year.

In the health sector an annual increase of that order does not merely mean that service development will be limited. In the present economic climate it is open to very serious doubt whether anything less than an annual increase of 6·5% as opposed to an 5·9% increase will maintain services - and "maintain services" means just that.

It means that all the shortcomings and failures that the Committee has highlighted over the past year cannot be tackled unless we get substantial additional funding.

The paper that we have submitted to the Committee touches on why that should be so. It is a fundamental point to which I shall return. First, I want to sketch the broad budgetary context for our discussion.

As 2002-03 is the middle year of the Treasury's spending review period, its overall expenditure limits are not open to revision. Regarding the Executive's assigned budget, the figures show that a mere £20 million of a total of £6 billion has not been allocated. It was because of this exceptionally restricted room to manoeuvre that Mark Durkan asked all Ministers to limit their 2002-03 bids to a few essential priorities. The consequences for the DHSSPS of complying with that request are described in the Executive position report and amplified in the paper sent to the Committee on 20 June. We have tabled a set of bids that I believe to be critical to the well-being of the HPSS and, in turn, to all HPSS service users.

That is the position today - on the face of it, an intractable position. I have no doubt that there are other public services in need of additional funding, and in advancing the claims of my Department I have no wish to deny their entitlement to a fair hearing. However, let us be very clear: if people here are to judge the Assembly and the Executive by anything it will be by the priority we give to health and personal social services.

There is nothing strange or surprising in that. The South of Ireland is making a huge investment in health - it is a number one priority - and England, Scotland and Wales are doing the same. I hope that the Executive and the Assembly will give a similar, positive response to our people's health and social care needs.

As the Committee will see from the position report, my assessment of the minimum needed next year to deliver acceptable treatment and care is a baseline addition of £122 million. In absolute terms that is a lot of money, although it is worth pointing out that it amounts to an increase of just 5% compared to 8·5% sought in other Departments' position reports.

I would like to explain how our figure was arrived at, and why, big as it is, it remains only the tip of an iceberg of pressures. Obviously our paper has covered this ground, but it may help if I rehearse the main themes of the argument.

This is a period of profound and rapid change in the health and personal social services - technological change, clinical advance, therapeutic development and changes in working practices. It would be shameful if patients, and indeed all service users, did not derive the maximum benefit from this process. There is, naturally, a cost attached. That cost is not for the most part determined by what we do here: almost all the significant drivers - for example, on pay, on pharmaceuticals and clinical standards - are determined elsewhere. In a sense therefore it is relatively easy to measure the adequacy of the HPSS settlement. Even if we had the same health status base as England, which we do not, it is plain that a settlement materially short of England's would leave the HPSS exposed with regard to the service that we can deliver to the public.

A consensus seems to be forming that a real terms increase of 4% - an uplift of 6·5% - is now needed simply to maintain services. This is because the pay bill is increasing by 4% a year; the grade and skill mix of staff is becoming more expensive; demography continually adds to costs; drugs and equipment become more specialised and expensive; and people's expectations of standards and responsiveness to their needs are forever rising. Such is the reality that underlies my Department's position report bids.

I shall be very happy to discuss them in detail with the Committee today and over the coming months. There is, however, one single, all encompassing point that should be made: even if all the bids were to be met, the standards of care and access to services that we could supply would still be adrift of those in England and Scotland.

As I implied at the beginning of my remarks, however, the 2002-03 Budget arithmetic is overwhelmingly against even that relatively modest outcome. All of my Department's indicatively allocated increase to 2002-03 is already spoken for, as is explained in paragraph 28 of our paper. As we know ourselves to be faced with some £30 million of newly identified inescapable pressures, it will be essential for the service to get an equivalent baseline addition to meet the cost. Otherwise, existing services are liable to suffer and, for example, Programme for Government targets and waiting lists will be in jeopardy. It would only be if we got more than the £30 million that we could even contemplate further service development.

The outlook therefore is somewhat bleak. I and, I am sure, Mark Durkan would find it helpful to have the Committee's views on the scope for increasing the Department's allocation.

I can see three ways in which that could be done. First, and most obviously, there could be a redeployment of existing 2002-03 allocations. It has always been stressed that these are indicative, and it is therefore reasonable to assume that some skewing would be in order. The problem is that these resources are substantially committed and that a decision to materially redistribute them would have to be taken within the next few months. It would therefore be important for this point to be covered in the Committee's recommendations to Mr Durkan at the beginning of September, if that were to be the case.

The second avenue is through the Executive programme funds (EPF). I am as keen as any Minister to see money put into the Executive's cross-cutting priorities - the public health agenda, for example, is explicitly a cross-departmental responsibility. So far, my Department - which needs at least its present 40% share of the assigned Budget - has got less than a quarter of the EPF allocations. That does not, I am afraid, represent a good start.

The EPF allocations for 2002-03 amount to £52 million. The difference therefore between getting 24% and getting 40% would be £8 million. Invested in the right services, that would go a little way towards ensuring a decent continuing standard of care. The alternative to that, which I do not favour, is to reduce the sums earmarked for the EPFs and to allocate the freed resources to Departments as part of the normal budgetary process.

The third possibility for increasing 2002-03 funding is to hold back some of this year's unallocated money - derived from last year's underspends - and add it to the 2002-03 resource. Always provided that this year's services are not put at risk, I believe that that would also be a reasonable course of action. The time to decide on it, I suggest, would be in the autumn when everyone is clearer about the pressures facing the range of public services this year and next.

It is of course important that the HPSS does all that it can to help itself by ensuring wherever possible that services are delivered effectively, efficiently and economically. There have already been significant improvements in productivity, as outlined in paragraph 31 of our paper, and savings opportunities amounting to about £12 million have already been identified by trusts. Nevertheless, I accept fully that there is always scope for further efficiencies and, in addition to the current fundamental review of needs and effectiveness, a strategic programme of initiatives and reviews has been identified for 2002-03.

I hope that these contextual remarks are of some use to the Committee. We have a lot of work ahead of us on the Budget. I know that you have been asked to provide the Finance and Personnel Committee with preliminary views before the end of this week. Work will continue over the coming months, and I assure you that I and my officials will do all that we can to assist you in coming to your view on next year's DHSSPS expenditure priorities.

You will of course have your own view, but I feel that the priorities and sub-priorities for the HPSS identified in this year's Programme for Government remain valid. However, without significant additional resources and the priority which is being accorded elsewhere to HPSS needs, we will not be able to identify new actions in 2002-03 to continue the progress made this year.

Thank you very much, Minister. When you came in I made reference to documentation you had sent to the Committee. The document is extremely helpful, and I have good reason to believe that it is probably the best that any Committee has received from Departments or Ministers.

We appreciate the massive constraints. One matter that has caused controversy over the last few days is IVF and the £1·25 million that was taken away from primary care and GPs could not prescribe such drugs. I understood that the money was to go to the RVH, the people who are the specialists in this field, but I am told that £0·75 million is being held back.

The decision was that the money would be used to fund the interim service. At present we are doing the preliminary work towards putting that into place. As it is not going to be available until later this year, some of the money is being given to the boards to do the work they need to do in the interim. When I announced the changes, the consultation I wanted, and the interim service that would be organised, I felt that the work that GPs were doing then should be part of the hospital-led arrangement.

I would like to comment on the announcement made today by Mr Durkan, and then come back on a number of questions later.

Minister, you mentioned a number of things in relation to your bid. First, with regard to pay settlements and the additional allocations of £6 million, why is that higher than was previously forecast?

The pay settlements are not decided on here, but they are presently estimated to be running at around 4%.

Our estimates for the 2001-02 Budget were on a par with elsewhere and set at 3·5%. We immediately moved the assessment to 4% when it became apparent that the ratio of increase was 0·5% higher than expected. There are a number of other pay-associated issues, such as the contract for junior doctors' hours. Again, the actual costs of this are growing, once you start looking at the rotas and the number of hours individual doctors are working. Many are working much more intensely than had been previously anticipated, so there are additional costs to that also.

I am not knocking people getting paid a proper wage, but I am concerned that out of the £18·4 million additional allocation, £6 million is lost right away on the pay bill. I was trying to clear that up.

On the one hand it is lost to other things, but it is not lost to the service. That is the big problem, as people see a rising demand. We have talked about demography and new drugs, but pay accounts for 70% of the costs to the HPSS. The big drivers in increasing costs are pay and conditions. It is also something that we cannot or would not cut back on.

It is also worth adding that it goes to front line people. Nurses form the bulk of those getting the benefit of the pay, so it is going to the coalface workers.

In real terms it is an uplift of 6·5%, and 4% of that is going towards the inescapable costs of pay increases. Is that right?

Yes, but if you look at the £19 million, the technical adjustment, you will see that we do not actually have the full 6·7% uplift. It is not an increase in spending power, and therefore the effective uplift is only 5·9%. We need 6·5% to maintain the status quo.

That means that 4% of the 5·9% has already been allocated, leaving us 1·9%.

Yes, that is broadly correct.

That reflects the argument that demographic trends, et cetera mean that we would need an additional 4% a year in real terms to keep pace with the needs that the service faces.

Are we in trouble?

We are in very serious trouble.

Of that 2% there are other inescapable costs such as implementing directives and legislative obligations.

Those would be rolled into the real terms increase of 4% a year.

Last year I talked about the need for £274 million, and although it was a very large amount it was all needed. However, I recognised that the Executive were in their first term, that they were trying to draft the Budget and the Programme for Government and that it was simply not possible for them to make such an adjustment in one year. However, I knew that this need would have to be addressed in future.

This is now the future, and it is absolutely essential that we deal with this matter. If we take wages and price inflation out of the equation, the total bill that was met last year and the balance that we are left with shows that even were my bid to be fully successful it would only take us to where we wanted to be at the beginning of 2001-02.

Having ascertained that we are in serious trouble, may I ask about matters in the Minister of Finance and Personnel's statement on trusts' deficits. He mentions that we may face another deficit and that you have lodged a bid for £10 million to address the trusts' recovery plans. Is that over and above what we have been discussing or is it an additional sum?

I shall ask Mr Hamilton to answer that, but people must understand the difference between what has already happened and what the timing of the recovery plans can achieve.

The £10 million assistance for which we asked in this financial year is non-recurrent; it is for one year only. We have asked trusts to identify savings in their recovery plans, and we have also asked them to work with the boards. If the boards are satisfied that they are delivering their services efficiently, it becomes a matter of funding. We would meet the £10 million recurrently from the additional money in the 2002-03 baseline. We have covered it recurrently, but we need assistance this year to meet the timing effect of the change. It takes time to put savings plans in place, and costs are still being incurred. They are absorbing much of the 2002-03 baseline.

You have also asked for £18 million to address some of these factors, such as pay settlements at higher levels. There is another factor thrown in there, which is the further transitional costs in relation to the situation at South Tyrone Hospital. Would that not have been known about? Why is that not here in front of us in these bids?

There is a technical issue there in that if we were to make recurrent provision for that it would actually anticipate a ministerial decision in the future. Therefore we have a temporary situation until the permanent decisions are taken on that.

It is very difficult for us to scrutinise what we know will be in front of us and what we have got, and there are other pieces coming through as well. Is there anything else in this category?

There will be. Every year we have to bid against the in-year monitoring moneys. We made the point in the paper that, if we were very prudent, we could set up reserves for all sorts of unexpected issues and set that against moneys in the 2002-03 estimate. But that would have a huge opportunity cost. The in-year monitoring process is designed to deal with the unexpected.

I have a couple of questions on today's document. Could you clarify for me the further transitional cost that has been identified in relation to the situation at the South Tyrone Hospital? There is £3·8 million identified there. What is that going to do for the South Tyrone Hospital or the transition period concerning that hospital?

Secondly, I want to ask you about some of the sectors here that were not identified this year for bids. For example, we have had discussions here about respite care. I and, I am sure, others have attended meetings in our constituencies and heard from families desperate to have better respite care in place. I do not understand why there is not a bid for such care in your document. I cannot see one there.

On your second point, there is £1 million mentioned, part of which will cover respite care. It is not shown as a separate item, but I will look for the particular reference and point it out to you.

Can you tell me where it is?

Yes, I will.

With regard to the South Tyrone Hospital, I will ask Mr Simpson to give details on that. By virtue of the fact that you had a temporary transfer and that I have said that existing services should be maintained until decisions are taken on the long-term future, there is an existing ongoing situation that has to be met simply to maintain existing services in the interim.

I think, Minister, you have made the point. Given the transfer of acute services to Craigavon Hospital, there are now additional costs incurred by that hospital to keep those services and to deliver them on the Craigavon site. That incurs additional costs on that site.

At the same time, we also need to continue to maintain some services - non-acute services and other services - on the South Tyrone Hospital site. Therefore it is not the case that all of the costs currently incurred in the South Tyrone Hospital can be transferred to the Craigavon Hospital site. We have had double running - additional costs at the Craigavon site and the residual costs on the South Tyrone site. As you said, that comes out as a need for £3·8 million. That is being spent on a combination of providing additional staff in Craigavon to run the transferred services and to keep services going in South Tyrone because the staff cannot all be moved. Of course, there is also a fixed cost related to South Tyrone as well. We have to continue to maintain the buildings, and so on, for all of this is in a situation where permanent decisions have not yet been taken.

There is a very difficult situation at Craigavon. Two recent reports have been very critical of the build up there, the pressure on beds and the long waits, particularly for the elderly. When are we likely to see an improvement? In other words, there is almost £4 million here. How long is it going to take? How long will patients have to endure the kind of situation that presently exists? Has anybody any idea?

There are short-term and longer-term measures that can be taken. The longer term measures will be subject to my consideration of the report given to me by the acute hospitals review group, the Executive discussion of that and the consultation that will arise from the Executive's proposals, which will include an equality impact assessment. There are, of course, points that we can and are already undertaking in the short term to deal with the specific difficulties that you have mentioned.

Craigavon is currently working urgently on a business case for additional temporary beds on the Craigavon site. They are looking at developing accommodation similar to that which was recently put in at Altnagelvin, while they were recladding and moving significant services around it. That is quite high quality, although it is temporary accommodation. There is a business case being worked up on that now for about 40 beds, which should help to relieve some of the bed pressures on the Craigavon site.

On Mr Gallagher's specific question about respite care, I will point to paragraph 2.14 of annex 2 of the submission paper that we sent to you. In the last sentence, though it is badly printed, it says

"Further costs in this Programme of Care are anticipated for respite care".

The bid is for £1 million in 2002-03 and £2 million in 2003-04.

Mr Simpson mentioned Craigavon hospital and the lack of beds. However, there is also a need for extra nurses as well. I would like to know where the Budget might help. I know that the lack of nurses is a Province-wide problem, but at present nurses are being moved from Craigavon over to Lurgan hospital from the medical ward, which I visited last week. That is causing extreme pressure on the nurses that are there at present. How is that going to help? How is the number of beds going to help if you have not got the nurses to provide for the care as well? I am not criticising the nurses, because they are under extreme pressure. How can you have extra beds and not extra nurses? How is that going to tackle the problem?

Any decision on increasing beds also requires people to look at the overall staffing level in more general terms, in terms of nurses. I have already said that there are 100 extra training places over three years to bring up to 640 the number of places available. We managed last year over the winter months to have 130 extra nurses brought in for that period through the return to practice. The Department hopes to continue doing that.

Each trust has been making strenuous efforts to ensure that recruitment is ongoing. As well as the practical steps that we have taken regarding workforce planning, we will be looking at how recruitment and retention can be improved.

What position will the Department be in if it does not receive the necessary money to follow through from the final recommendations of the consultation exercise on acute services? Can you outline to the Committee the possible consequences of the Department receiving this budget, which is less than what was bid?

The Committee should be very aware of the possible consequences, because throughout this year it has issued statements and asked questions of my officials regarding the existing problems. The implications are that not only will benefits that exist elsewhere not come, but those problems that you have highlighted strongly during the year will remain, if not be exacerbated.

I have issued the acute hospital review group's report, along with a letter, to the Health Service to get its initial views on the consultation exercise. I made it clear that those views will be used to put together proposals which I will discuss with Executive colleagues and which will go to the Executive before going out to consultation. The Executive requires that something of this nature is not an issue for one Minister alone. Due to the amount of money to be spent and the significant resource implications of the review group's report and recommendations, the Department of Finance and Personnel will want to contribute to the discussions before we go to consultation. That Department will also want to look at the points that arise during the consultation.

The Committee visited Musgrave Park Hospital. We are aware of the ever escalating costs of drugs, and you are familiar with the drugs that I am talking about - drugs for rheumatoid arthritis and allied conditions such as anklyosing spondylitis. Some of the Committee members met patients and rheumatologists. The Committee does understand the financial constraints.

The National Institute of Clinical Excellence made comments that cannot be ignored even though they are mainly concerned with England and Wales. Rheumatologists say that certain people will fulfil certain criteria laid down by their profession, but there can be a risk with these drugs. However, people in Northern Ireland with this condition would be helped by the drugs. Providing that they accept that there is a risk - and they would have to formally sign something to accept that there is - and providing that they fulfil the criteria laid down by the rheumatologist, is there any way that that money can be found?

You mentioned that some money was not spent this year - I cannot remember exactly what you said. These people are suffering terribly; it is a horrific condition, especially for young people who cannot work and whose lives are destroyed. I know that if you could wave a wand you would help them.

I am not very worried about the comments of the National Institute of Clinical Excellence. I am more concerned with the fact that rheumatologists, who are very able professional people, say that particular people would benefit. I do not expect a precise answer now but, bearing all that in mind, is there any way in which you could at least look at this and see if these people could be helped?

There are a number of different issues there, some to do with finance and long-term finance, and others to do with being assured, as a Minister, of the question of the safety and the effectiveness of drugs. Clearly because of my specific responsibility, I have to take into account the standing knowledge that we have. These are new drugs, and it is not possible for me to pass on that responsibility to others. I absolutely understand, because I have talked to people suffering in this way and I know what that suffering entails. I know that people would throw caution to the wind - they have stated that they would sign anything, do anything and disregard anything, simply to get help. Having seen their condition, I am not surprised by that.

However, I cannot overlook the aspects of my responsibility, which means that I have to take expert advice and take a range of matters into account. With regards to the gradual introduction, we have to constantly keep this under review; I know that the boards are also doing this. The other aspect is that even here we also have a bid for the possibility of covering us beyond that period. We would have the advice we need on these and a number of other new and more expensive drugs, and we could move on to the stage where it is purely a question of finance. I would not hesitate, and have not done so, to seek with bids the kind of money that is needed both to maintain the gradual introduction - which we have begun at present - and to move beyond that in the future.

This would not be throwing caution to the wind. As I said earlier, the NICE organisation applies to England and Wales, and I accept it would be foolish to ignore what they say. However, we have our own experts in Northern Ireland. Bear in mind that the drug is already used - I am not sure how extensively - and that anyone in the South who needs it can get it. It is used fairly widely in other countries.

The comments I have heard regarding the South suggest that the situation there is not as clear-cut as your comments would suggest.

I do not want to keep on about this point, but all drugs can have side effects - all drugs can kill, some more than others. Patients suffering like this are prepared to take a risk and sign a form. We must remember that we have first class professional rheumatologists who would only be giving the drugs if they thought that there was a very good chance of them helping. Of course there would be a risk, but some risks are worth taking. I appreciate your responsibility on this, but rheumatologists are saying that in many cases we should be prescribing this drug. I am not answering the financial part of it; I am merely talking about patients being helped. I am sure the people we both saw would be delighted to sign a form accepting the danger that any drug may do to them. Could you look at this again, bearing these points in mind?

First, I am keeping this constantly under review. I assure you that this is not something that ever goes off my agenda - it is looked at constantly. However, the very point of people signing forms shows that you know that there is a question there. I could not decide the future of services dependent on what legal action might or might not be taken or what indemnity there is or is not. I have a broad range of factors that I must take into consideration, but I can assure you that this is constantly under appraisal and reappraisal.

In relation to cancer services, bearing in mind that it is the number one killer in Northern Ireland - far surpassing heart disease - why is there no specific bid for cancer services for 2002-03?

What proportion of the £10 million HPSS estates and equipment bid for 2002-03 will be allocated to cancer services, and what will be the consequences for cancer services if the outcome of the bid is less than £10 million? When will we see the commencement of the new cancer hospital on the Belfast City Hospital site?

With regards her last point, the Member will be aware of the revised cost estimates that the trust has indicated for the new regional cancer centre. The original business case was approved at a cost of £32 million. However, the latest estimate is £48 million, and my Department has asked the City Hospital to prepare a revised business case to incorporate the new estimate for my consideration when it becomes available. As this has an impact on timing, I cannot be more specific until I have seen the revised business case and have been able to act on that.

The £6 million additional resources in this financial year will enable further development of services of the cancer units. For example, the bid to which you refer is outlined in paragraph 2.6 of Annex 2 to the report: "Regional Medical Services". That bid includes cancer, nephrology, spinal surgery, cardiac surgery and cardiology. The report states that

"Additional resources of £8 million would support initial steps in the development and necessary enhancement of these services. The alternative is stark".

The report talks about each of the services, but the particular difficulty with cancer services is that we will not be able to continue with the improvements that we have been making in order to bring forward the Campbell report and implement it. We have made significant progress in the cancer units at the Ulster Hospital, Antrim, Altnagelvin and Craigavon. However, we will not be able to continue at the same rate of progress, much less increase the rate of progress, if we do not receive the necessary resources.

I have received a letter from a constituent indicating that there are no intensive care unit beds for cancer patients who require urgent surgery in order to effect a longer lifespan.

The Member should write to me about that point.

Is that OK?

Yes.

Why is the "Best Practice - Best Care" bid line so expensive? The £4 million bid for 2002-04 seems to be very high, compared to the items that we do not have money for. Are things so bad that we need to spend so much money on that?

I am pleased that you are keeping the rheumatoid arthritis drugs under appraisal. Please inform the Committee of the outcome as soon as possible, because we might be able to get a more detailed response to what we perceive to be different payment systems. During a visit to a hospital I saw four patients, each under a different system.

It seemed to be more a question of funding than of NICE. If not, there has been a very poor information system in place to alert those who have enormous concerns. We are getting a lot of mail from those people and you have talked to them yourself.

I am pleased to see the £9·5 million for community care packages. Is that all for community care packages for the elderly? There is £2·4 million for free nursing care. What do you mean by "free nursing care", and how much of it can that money buy?

Are you satisfied that there is funding to introduce the new primary care proposals? What will be the implications if you do not see your full bid? What will be done about primary care? There has obviously been a hiccup in your own plans around GP fundholding. I am trying to see where the bid line is and how funding will be put in place around that.

With regards to the primary care proposals, I hope to be able to make an announcement shortly on the consultation to start putting new structures in place in the autumn. With the end of GP fundholding, the new arrangements will come into effect in April 2002, and some things cannot be done until then. When I had planned to end GP fundholding by 1 April 2001, I outlined that there would be a gradual winding down of fundholding accounts and that money would become available at that point. Fundholding accounts cannot be wound down until fundholding legally ends, so that money will all be tied there until at least April 2002. There will be some difficulties in the interim, but we can move towards having structures agreed and arrangements made.

There is also the question of developments in primary care, which would happen regardless of the particular structures, and they would perhaps be addressed in terms of the consequences of bids not being made. Concerning the structures, there will be no additional costs in moving money out of fundholding to new structures. But doing anything in the interim is held up because the fundholding accounts cannot be wound down until fundholding ends.

We have sought additional funding, and it is clear that without that some other developments that we would wish to see in primary care will not in fact be able to be brought forward. We have made allocations. We need to invest, for example, in the capacity of primary care to manage a range of conditions such as diabetes and asthma - otherwise the pressure on hospital services will increase. There is a need to develop the role of the nurse practitioner and to spread the primary care workload. That is in line with work that is being taken forward in GB.

We need to match investment in modern standards of quality and out-of-hours provision in dental services. There is also a need to support the continuing development in primary care on a multi-professional basis, which is at the foundation of the new working that we are discussing. That is also part of your question, and I will come to that in more detail on best practice. This is to meet requirements of new quality standards in clinical and social care governance and the requirement to support the continuing professional development.

We are asking for an additional £3 million to help primary care develop the capacity to deliver better quality services in local communities, to match the standards and programmes being put in place at present in GB, outlining some of the points that I have raised. The boards' ability to develop primary care services, which are designed to meet local needs, has been constrained by a lack of resources and that will continue if these bids are not met.

In relation to best practice, there are recurrent and additional costs for the commission for care services that we said we would set up, and there is over £1 million for that. There is £0·5 million for the improvement authority and £0·4 million for standards setting. We talked earlier about the Institute of Clinical Excellence. No matter what option is decided for standard setting - whether or not we set up an equivalent here, or have a contractual obligation - we will have to make payments to the Institute of Clinical Excellence. These questions need to be addressed.

The bid for this is £2 million. In presenting this, we have also to say what the cost will be in 2003-04, but it is not an extra £2 million; it is that same £2 million uplifted.

I want to follow on what Ms McWilliams has been saying about primary care and about research and development. I appreciate that there have been changes, and I understand that Professor Sean Fulton is coming in as chair.

We have mentioned primary care before; it is a small department with limited finances. Bearing in mind that over 90% of illness goes through primary care, and the whole future of medicine is tied up with primary care, there has been virtually no research in it coming through that department. As a Committee, we have been told that many times, both collectively and individually. It is right across every aspect of primary care - the various organisations from BMA to Royal Colleges and the Royal College of Nursing. I am not only talking about GPs; it is right across. There is great annoyance among primary care professionals that no meaningful research has been done. We can learn lessons from England, Scotland, Wales and elsewhere, but in Northern Ireland there has been virtually no research done. Perhaps that is something that you and your colleagues could take on board?

I will look at that. The ability of primary care, the increasing workloads in primary care, and the trends we see of moving from secondary to primary care, will depend on the capacity in primary care. It is recognised by us that to have the quality practice staff, primary care will have to be funded if the trends that we see developing are to be successfully carried through.

Minister, we thank you and your colleagues and wish you well in the bids that you have made, You have our support, and we appreciate the massive financial constraints. Thank you also for the documentation.

I just wanted to add something as a gloss to this, because the Committee will be considering how to respond to the Finance and Personnel Committee on this. There is an issue here that the Committee will want to look at. It concerns what sort of health and social services we want to have. This is the opportunity to make a bold statement about what we need to address demands. If we receive only what is in the figure work before us, certain areas will suffer. We will not be able to do as much as we would like in the community: dealing with the elderly; children's services; mental health; learning disability; and moving people from institutional care back into the community at a desirable pace. We will not be able to undertake the construction of the health estate, yet many buildings need to be brought up to modern standards.

There are a lot of areas that need money put into them in order to raise them up to the desired standard, and this is an opportunity for us to raise these issues.

Thank you; I appreciate that. We will consider these matters at our meeting on Wednesday.

Thank you for the opportunity to speak and for your kind words about our submission.

Menu / 12 October 2001