Primary Care -
Implementation of Local Health and Social Care Groups

Wednesday 27 February 2002

Members present:
Dr Hendron (Chairperson)
Mr Gallagher (Deputy Chairperson)
Ms Armitage
Mr Berry

Rev Robert Coulter
Mr J Kelly
Mr McFarland
Ms McWilliams
Ms Ramsey
Mrs I Robinson

Ms C McIlrath ) Royal College of Nursing (NI)
Mr D Gowdy ) Multi-disciplinary Primary Care Forum
Ms B Hughes ) Royal College of Midwives

Dr B Dunn ) British Medical Association (NI) GPs' Committee

I welcome Ms Carole McIlrath from the Royal College of Nursing (NI), Mr David Gowdy from the Multi-disciplinary Primary Care Forum, Ms Breedagh Hughes from the Royal College of Midwives and Dr Brian Dunn from the British Medical Association (NI) GPs' Committee. This discussion is very important; we thank you all for coming.

I shall ask each of you to present your case in turn. Committee members will ask questions after they have heard the four presentations.

The Royal College of Nursing represents 12,000 nurses in Northern Ireland. In the entire UK, it represents one third of a million nurses. I do not represent the board nurses in this instance, because they have a different perspective on the changes. Rather, I represent community nurses - the front-line, grass-roots nurses.

How many community nurses do you represent?

I am not sure how many nurses work in primary care, so I cannot give the Committee an exact figure.

The Royal College of Nursing responded to the 'Building the Way Forward in Primary Care' consultation paper last March. It feels that its recommendations have been ignored and not addressed in the new arrangements. It agrees with the principles of 'Building the Way Forward in Primary Care', which are to reduce bureaucracy, improve service delivery, have groups of multi-professional people and encourage grass-roots input into commissioning. However, it feels that the new arrangements will not support those principles. The Royal College of Nursing welcomes the reforms, but thinks that they should be more radical.

The Royal College of Nursing feels that the current arrangements will have a detrimental effect, not only on primary care, but also on secondary care. If the plans go ahead, primary care services and developments would be reduced and some would be eliminated. That would place pressure on the acute sector. We all know that that sector already has an overwhelming capacity and is at crisis point.

The Committee for Health, Social Services and Public Safety tabled a motion a year ago to ensure that any new arrangements for primary care would result in a seamless transition. That seamless transition is now impossible, and a year has been wasted. We do not know what has been done in the past year to develop primary care to ensure that seamless transition.

The timescale for setting up those arrangements has been imposed on primary care. It is five weeks until implementation; we have an issue with that. The groundwork has neither been done nor have preparations been completed to prepare for implementation.

The Royal College of Nursing also has an issue with the consultation on the guidance. The guidance has come out and we have not had a chance to consult on it - it has simply been enforced.

Front-line, community primary care nurses have not had an opportunity to voice their opinions on the guidance on the constitution, governance and accountability arrangements. That is due to the short timescale. Many of our members who work in primary care have come forward to say that the guidance has not even been issued to them.

We want to ensure that the nurses who are on those groups will be front-line nurses who work at the heart of the community and know the issues on the ground. There is concern about the strategic input from nurses at board and trust levels. Nurses who see patients at clinics and visit them at home know the areas of deprivation and other problems. At a more strategic level of nurse management, the focus is on numbers rather than on the quality of care and the health outcomes. District nurses tell us that they have been instructed by their nurse managers to see 15 patients per day, regardless of quality or health outcomes. That is what happens at a strategic level, and we would be happier for grass-roots community nurses to be involved on the management boards. Senior grass-roots nurses have the skills and capabilities required for involvement. The current arrangements do not reflect a bottom-up approach and that is to the detriment of primary care services.

Some primary care nurses view the groups as bureaucratic quangos. They seek an assurance that boards will not dominate committees, an assurance on timescales for devolved budgets, and an assurance that primary care services will not suffer as a result of there being no devolved budget until April 2003. They also seek an assurance that the level of bureaucracy will be reduced and that local primary care initiatives, many of which are nurse-led, will continue and develop.

We see no function or vision for those groups from 1 April 2002 until 31 March 2003. Without a devolved budget they will exist with no funding to support development in primary care. Moreover, strong local management of those groups is crucial.

A further issue is the proposed £3 funding per head of population. As part of the Royal College of Nursing, our response was that it was inadequate. What is it for? What does it include? Is it for management and administrative support only, or is it for primary care development or infrastructure development? That is not clear.

Primary care development funding is also necessary to sustain ongoing and innovative projects, many of which are delivered, or have been set up, by nursing. We also need to link up with community groups to ensure high quality care.

Resourcing the new arrangements must be a priority target, together with the development of primary care infrastructure. The amount of funding available is uncertain, but such issues as workforce planning, recruiting the correct levels and grades of staff, and developing the information and communication technology systems in primary care are crucial. Another priority is primary care research, so that the highest quality of care can be provided for patients, based on good health outcomes demonstrated by completed projects.

We chose option 2 proposed in the 'Building The Way Forward In Primary Care' document. Change must be more radical. We support the Hayes Report, which advocates implementing a true primary care-led service with a bottom-up approach. The current arrangements do not support that. If current plans go ahead it will be impossible to implement that Hayes Report recommendation.

Training and development programmes are essential and we highlighted those as a priority for that year that we now feel has been wasted. We do not know what training and development has taken place, but it is crucial to the development of the new primary care infrastructure.

The current role of primary care is merely to contribute, and the commissioning function must strengthen that. The added layer of bureaucracy will lead to inequalities in healthcare.

The enforced structures will maximise bureaucracy rather than minimise it. There will be some conflict among the primary care professionals, the trusts and the boards. The nurses who work at the very heart of the community must be supported and included in the process.

Nurses contact us because they are concerned about their jobs. They were told a year ago that they would lose their jobs, but when fundholding was extended, they were able to keep their positions. However, some nurses have said that they will lose their jobs. Some of them are willing to give their names, and we shall forward those to the Committee.

That would be a great help.

Others do not want to be mentioned for obvious reasons.

Morale among the nurses who have contacted us is rather low at present. The Royal College of Nursing needs to retain the nurses that we have. We must retain the experience, skills and expertise that many nurses have developed. Grass-roots nurses have been involved in commissioning pilot schemes, so we must secure their employment. Some have been told that they will be moved and that they will not be doing the same job, and some are worried that they will have to leave community nursing and enter the acute sector. If they do that, they might have to go down three grades. We want some assurances that that the services that nurses provide, and their jobs, will be protected.

We wish to have a clear vision for primary care and a function for those groups. They should be true primary care-led groups. The boards and the trusts should be there to empower primary care professionals, but they should have non-voting rights on the management boards. The boards and the trusts are crucial to getting the groups off the ground. However, the groups should be primary care-led and the grass-roots primary care professionals should have the voting rights.

We also want adequate funding for primary care development. We want to know what that funding will be and to be provided with a breakdown of what it is for. We want to see timescales for the devolved budget allocation that have a clear vision for a primary care-led service.

From April 2003, the budgets will be devolved. We want to see timescales beyond that date, and we want to know when the majority of budget will be devolved, as well as how much will be devolved. There must be a robust infrastructure.

I have already mentioned funding, the development of primary care, and an investment in training and development. However, we were recently disappointed to learn that funding for the target initiative, which was established to take doctors, nurses and receptionists in a practice for half a day per month to train, has been withdrawn. That had fantastic outcomes, and we feel that it urgently needs to be reintroduced.

More time is needed to ensure a seamless transition. A year has been wasted, and 1 April 2003 is not a realistic target. We want written assurances about the services that will be maintained, as well as a guarantee that nurses will not lose their jobs and that a bottom-up approach to community nursing will be implemented in all the new arrangements.

Thank you.

The Multi-disciplinary Forum for Primary Care has met the Committee before. It covers all professions in Northern Ireland. It is not a representative group in any elected sense, although it is one in which people from most professions and parts of Northern Ireland participate. It is a voluntary grouping that, to all intents and purposes, is a think tank that focuses on some of the primary care development that we strongly believe should be urgently advanced in Northern Ireland.

My background is as a manager inside and outside of the Health Service. I have worked in the Eastern Health and Social Services Board, and in the Department of Health and Social Service's primary care directorate when this policy first came out in 1995-96. Most recently, I have worked in the North Down Primary Care Organisation - one of the eight pilots in Northern Ireland.

Interestingly, I am sitting between a nurse and a midwife. We have been nursing this policy for six or seven years in the hope of a safe delivery. We are ready to cut the cord, and I hope that the baby will be in a fit state to survive. That is a genuine concern - we shall have done a great deal damage if this baby is not fit to survive.

The Committee has read the paper from the Multi-disciplinary Forum for Primary Care. I wish to highlight four key points in that report. I speak as a manager, and I hope that I reflect the concerns of the professionals that I work with daily, and that I have worked with in the past four or five years, in various guises, across the Province. The four points are: the level of commitment to the policy; clarity of what is expected of the policy and of the groups; the composition of the groups; whether they are designed to be effective and whether they will be effective as key partners in the care process; and some confidence-building measures that will ensure that we do not find ourselves back here again. It is nothing personal - I simply do not think that, so late in the game, this is the way that we should take the policy forward. The problem may be with the perception of others rather than with reality. Primary care professionals are concerned that they will be left holding a rather sickly baby if they do not make the effort now to put things right and give this child the best possible start.

The first issue is commitment. From my experience in the past few years, this policy will work only if it has the active support of everybody - politicians, the Department and all the health and personal social services. We have asked for guidance that affirms that commitment, but, so far, we have been left with the same set of words. Nothing seems to change on paper. People will say things in speeches and across the table at meetings, but the written word does not change. That is always slightly unnerving. A departmental official told our pilot group that we were there to see whether we could survive. I still remember the sense of shock when we heard that. I know what that lack of commitment meant for us as a group in the following two or three years. We must get past that tentative stage of wondering whether it will work or not. There must be commitment. After all, this will be the only game in town, and we have not been given the necessary commitment.

The next issue is clarity. We have no vision of how those new groups are expected to develop. At this stage, our colleagues in GB have been presented with a four-stage staircase from advisory group level to primary care trust level. They have a clear sense that they will be given help. They are expected to climb that staircase quickly and on a measured and controlled basis. We have no sense that that is how we are positioned. We do not feel that we have a staircase or a future development pathway. We have asked for those issues to be addressed, but that does not seem to be happening. It is disappointing, especially as we understood the policy was ready to be implemented in January 2001. Uncertainty, more than anything else, will kill those groups at birth. As a group, we have observed that if one is not sure what it is that one wants to do, not much will happen.

There has been much agonising over the composition of the groups and how we can get a board that is effective, energetic and representative. A small number of activists are generally required for a board to be effective and energetic, whereas much larger numbers are needed for it to be representative.

I do not intend to labour those issues, as I am sure that others will further develop them. However, on behalf of my colleagues and management, I say that the proposed position for the lead manager seems to leave the group in a rather weak position. In fact, some of the advertisements for that job give the impression that the post is for a meetings' secretary, rather than one that involves significant management skills.

In my experience of pilot studies the energy of our staff at the coalface drives change. They know what is wrong, and they want it to be put right. That energy is being eroded as we speak. I have been taken aback by the draining of our group's energy in the past few months.

Finally, the Committee is perhaps more familiar with confidence-building than I am, but we need some sense that this vision, or lack of vision, will be managed and taken forward in a constructive way rather than be left to chance. A Northern Ireland-wide steering committee involving groups is essential, but it does not seem to be a prospect. I also wish to see a robust training programme that ensures that those groups get support and move forward with common purpose. That would be an immense help if those mechanisms were in place.

However, that is all still ahead of us, which is part of the problem. I am not saying that those mechanisms will not happen, but at present we have no guidance that states that they will. The Committee has an opportunity to help - I shall not say to rescue this policy before we get much further, because that is a bit too strong - but the people with whom I work are despondent that this will not work as well as they would like it to work, and as well as Members and their constituents need it to work.

The Royal College of Midwives is a professional organisation and a trade union. We represent 98% of midwives in Northern Ireland so we have a mandate to speak on behalf of all midwives. The board of the Royal College of Midwives has discussed the proposals in depth. The board encompasses members from all our branches, which cover all of Northern Ireland. Local activists and shop stewards also discussed it in depth last Thursday on the shop floor, and there is no more grass roots than that. They articulated their concerns and their colleagues' concerns about the proposals contained in the guidance that has been issued to date.

The Royal College of Midwives supports an end to GP fundholding. We never supported its introduction, and we are glad to see the end of it. We also support the entire concept of multidisciplinary working, working across agencies, communicating and working with members of voluntary and community organisations - especially those that have women as the focus - and working with women in rural areas, as they tend to be disadvantaged at times.

There is a concept that midwives work in hospitals delivering babies. Those who are familiar with the way in which maternity services are provided will realise that most women, if their pregnancy is normal, spend one or two days in hospital in what is a nine-month gestation period and a six week post-natal period. During those nine months before the birth and the six weeks afterwards, community midwives provide most of the care. They work in partnership with their obstetric colleagues in hospital and general practitioners in the community.

However, the situation that has evolved in Northern Ireland since trusts were developed has meant that many midwives who practice and work in the community are employed by acute trusts. We know from our colleagues in England's experiences that that was a potential difficulty. When we were asked a year ago to provide a response to 'Building the Way Forward in Primary Care', we highlighted that as a potential area of concern, but it was not taken on board. To our dismay we now find that the word "midwife" does not appear in any of the guidance; midwives are not recognised as primary care professionals. Midwives work in the community as part of Sure Start projects, leading breastfeeding support groups, leading and working with post-natal depression support groups, working with women who are on the receiving end of domestic violence. That work is ongoing at grass-roots level in the community. There is no recognition anywhere in the guidance from the Department of the existence of midwives, let alone recognition of the work that they do in the community. Our members in Northern Ireland have viewed that with great concern.

The Royal College of Midwives has concerns about the seamless transition from one system of primary care commissioning to another. Midwives provide a seamless service as well. They work flexibly across hospital and community boundaries. A woman can book for her confinement in the community. Her midwife will deliver her baby in the hospital and care for both mother and child at home afterwards. Hospital midwives rotate out into the community regularly in order to keep their skills updated. Midwifery is one of the few professional groups in which there is such a degree of flexibility and rotation. The way that the proposals have been presented makes clear distinctions between hospital midwives and community midwives, which is a concern.

The Royal College of Midwives was generally supportive of Dr Maurice Hayes's proposals. It agreed that primary care could not be looked at in isolation from acute services. However, it is disappointed that that is not embodied in the guidance that has been issued to date. It also has a problem with the term "nurse". I shall not labour the point; suffice to say that legislation is currently going through Westminster that will establish a new council of nurses and midwives. That will come into being on 1 April 2002 and will mean that nurses will be required to notify of their intention to practice as nurses. They must also sign the live register. Midwives will be required to notify of their intention to practice as midwives and maintain their clinical practice in the area of midwifery. Nursing and midwifery, therefore, are increasingly becoming separate professions. Nobody confuses doctors with dentists. It is about time that people realised that nurses are not midwives and vice versa.

I have a nursing qualification. However, it has been a long time since I nursed anybody. I would never advise anyone on a nursing matter. Midwives do not take kindly to nurses advising them on midwifery matters. Midwives have difficulty with the requirement in the guidance circular No 2 that nurses - that being the generic term - who wish to apply to serve on the management boards of local health and social care groups must be employed by a community trust or a GP. That effectively excludes most of the midwives who work in Northern Ireland, especially those in the urban areas where there are high numbers of child-bearing women - places like the South and East Belfast Trust area, the North and West Belfast Trust area and the Foyle Trust area.

The midwives who work in those areas are employed by acute services trusts. The community trusts in those areas do not have any midwives in employment, not even to advise the nurse who is appointed to the management board. The North and West Belfast Trust does not employ any practising midwives. Therefore, I do not know where its midwifery advice comes from or who advises its board members who are nurses. The Royal College of Midwives has major concerns about that.

There have been discussions between the Royal College of Midwives and the acting director of primary care about which services are likely to be commissioned in the future. Maternity services are currently not commissioned by the pilots. Indeed, they are not commissioned by GPs at all. It is not clear whether those bodies will ever commission maternity services or whether that will be a reserved activity of the current health and social services boards. Those groups appear to have no strategic direction or clear plan, with respect to the current situation and where it should be in three or four years' time. That causes concern. There is almost an element of the groups being established in order to establish the groups. As Mr Gowdy has said, if the groups do not have a clear purpose they will not develop and they will not do anything that will be helpful.

There are major concerns that, because maternity services have not been commissioned in the past in the primary care sector, midwives, in particular, have no experience of participating in primary care pilots. No training has been provided in the past year for those people for whom commissioning is a new experience. The Royal College of Midwives would have liked to have seen the past year used as an opportunity to avail itself of the experiences of colleagues in Wales, Scotland and England, in order to provide better understanding and insight, and to enable those people who are supposed to be active on the new bodies "to hit the ground running" from 1 April.

We are concerned about the mechanism for ensuring effective community and user representation on the boards of the proposed new groups. For many years, midwives have worked in partnership with women to develop maternity services that are responsive to their needs. Women having babies are not ill; for most it is a normal physiological life event. They are not patients, so they do not have the imbalance in the relationship. They tend to be equal partners in their care, and we work closely with them to see how we can meet their needs.

However, we are concerned with the way in which the boards will be structured. Women who are not known for putting themselves forward for public positions may not apply to sit on the boards. Given the lack of clarity on expenses that will be available for user and community representatives, who will pay for their childcare, and who will pay for their transport, if they live in rural areas?

I am on the steering group of the Women's Regional Consultative Forum, which is an umbrella body that has been set up in Northern Ireland to establish our equivalent of a National Women's Council of Ireland. The guidance has been circulated to that group for discussion next week, and there are already major indications of concern from the women of Northern Ireland about how their voice will be heard. It appears that it will be difficult in getting midwives on to those groups. We are concerned that women will be doubly disadvantaged in that neither they nor the healthcare professional, with whom they work most closely, will have a voice on the decision-making bodies.

I apologise for the absence of Dr Brian Patterson. He wanted to be here, but he is attending negotiations in London for a new contract for GPs.

I speak on behalf of the British Medical Association (BMA) GPs' Committee. The committee is a statutory body and represents all GPs, not only BMA members. The views that I shall put forward are the unanimous opinion of the GPs' committee from our most recent meeting. However, GPs give different view, as they are individuals. There used to be a saying that six GPs in one room would give seven different opinions.

We are trying to articulate what GPs want to say. We are concerned, but we have no wish to be obstructive; indeed, we want to be constructive. We want to see new structures emerge that will deliver better care for all our patients. Our concerns are shared equally with other professional groups in primary care. It is not a matter of GPs empire-building or wishing to dominate.

Our concerns were summed up in a letter sent from the Royal College of Nursing and the GPs' committee to the Minister, and it was also copied to MLAs. It says that our concerns are not those of self-interest, rather they are based upon what we believe to be reasonably held professional opinions. Our concerns go directly to the heart of the provision of primary care services to the population. We cannot lend ourselves to a system that we believe is incapable of delivering services to patients effectively.

The BMA (NI) GPs' Committee is supportive of the development of local multidisciplinary groupings, with the potential of employing people at a grass-roots level to determine the delivery of local services. This solves some of the problems currently experienced by communities in accessing healthcare. Local health and social care groups as structured from 1 April will not achieve that. The Department has not adhered to its own timetable for issuing guidance on core issues, and guidance on the constitution and the remuneration arrangements was issued in mid-February, with the groups expected to go live less than seven weeks later.

A seamless transfer to the new arrangements is highly unlikely. We are in exactly the same situation as this time last year, when the Assembly gave the Department a year to establish the new institutions. Little has been done in that year and circulars are still being issued. Any hope of having functioning groups in place - and I emphasise that they must be functioning -is a pie-in-the-sky idea. It is unlikely that the groups will be functioning until well into the new year.

Local health and social care groups have not been empowered to influence either the commissioning of secondary care or the development of primary care. The groups will act only in an advisory capacity in the commissioning process. Given the composition of the group management boards, which are dominated by representatives of boards and trusts, there will not be much that primary care teams can do to exert their influence effectively. That makes a nonsense of the bottom-up approach that we have always advocated. The groups are likely to entrench the position of the boards and make rationalisation impossible.

No details of the timescale for empowering the groups has been provided, other than a statement, in the circular HSS (PCD) 12/01, that local health and social care groups will be expected to develop the capacity to manage a delegated budget for commissioning some services in April 2003. Primary care needs a detailed, clear-cut timetable of what will be commissioned, by whom and when. Changes to the timetable should be exceptions to the rule. The proposed system relies on convincing boards to devolve such roles to the groups. Historically, boards have been extremely reluctant to do that.

Patients have received no guarantees on service provision after 1 April. Boards have been tasked with attempting to preserve services, some of which are extra nursing services. However, some practices have yet to be approached by boards. GPs would have preferred a guarantee that no service would be discontinued, and that an attempt would be made to increase rather than decrease the number of services. At least under fundholding, 65% of patients received a better service. We fear that from 1 April, 100% of patients will receive a worse service.

We also have concerns about the treatment of staff in fundholding practices and commissioning pilot schemes. No meaningful discussions have been held and no practical assistance has been given to retain the good quality staff in primary care. Guidance has been issued on how to close fundholding. We have been told how to make staff redundant, and we have been promised a staff redeployment unit. However, most of these groups have already issued redundancy notices to their staff. What message does that send to the staff about the value that we have put on their work over the years?

We must emphasise that fundholding was not the fault of GPs or fundholding staff; it was Government policy at the time. The staff that we are discussing have families, mortgages and other commitments. They are being punished because there has been a change in the political ideology.

We have other concerns, and I am sure that we shall make those known during the discussion. The funding level of £3 per head is inadequate. There has been no meaningful involvement of stakeholders. To date, only the senior management on the nursing side has been involved. In our board area at least, there has been little GP involvement, and workers on the ground do not know much about what is happening. There has been no meaningful consultation on the constitution of management boards or on the levels of remuneration, and there has been no identification of new primary care development funding, which is essential.

I apologise if I sound negative. The GPs' committee has no intention of actively opposing or campaigning against the proposals, if they are implemented, but we have told GPs that we cannot commend them. Each GP is free to decide whether to participate. The debate is ongoing in primary care - it is ongoing in many practices. Many GPs want nothing to do with the groups. Some feel that, although they are opposed to them, they should fight their corner, and there are a small number of GPs who are prepared to work in the groups.

We are concerned that the groups cannot succeed without enthusiastic participation and commitment from GPs. It would be easy to fill seats with people who might go to a meeting once a month, but who do not have any great commitment to the body. People must be committed to, and believe in, the bodies to make them work.

We make this presentation with sadness. We have lost an opportunity to help to deliver a better service to our patients. I shall quote from the letter that was sent to the Minister from the Royal College of Nursing, the Royal College of Midwives and the BMA (NI)) GPs' Committee. The penultimate paragraph says that

"We implore you to think again! Resume constructive dialogue with all concerned. Together we can work towards the establishment of a Primary Care Service which enjoys universal support and which will deliver tangible benefits to our patients. The present conflict is unedifying, unnecessary and can only cause harm. We believe the crisis which looms can be avoided by further consultation and the abandonment of those features of your proposals which we believe are irrational and ill considered."

Thank you, Dr Dunn, and I thank Ms Hughes, Mr Gowdy and Ms McIlrath for the helpful documentation that they gave to the Committee. Every member of the Committee wants the best Health Service that it can get for Northern Ireland. That applies to primary care as well as other areas. Some members may place different emphasis on different aspects, but overall we want the best Health Service.

I shall hand over to my Colleagues, and, so that we have the most orderly debate, they should ask one question each initially, which may be followed by a supplementary question. I would prefer one witness to answer each question, if possible, because of the limited time available.

Thank you for your presentations. There are serious issues about the new arrangements for primary care. Dr Dunn, you mentioned the staff redeployment unit. What do you understand that unit to be, and what is its function?

I have no idea what it is; it was mentioned in a circular. When it was first mentioned, questions were raised about it. The Health Service unions were not keen for GPs' staff to be offered that service. Apparently, they will be offered it, but we know nothing more about it. Beyond the mention in a circular, there was no further guidance.

Can anyone else throw light on the concept of a staff redeployment unit? Is it well grounded?

Before the development of health and social services trusts, there were four boards. Everybody was employed through the boards in units of management in each board's departments. It is my understanding that a staff redeployment unit was based in the Central Services Agency (CSA). That service was not offered to the staff of, for example, South Tyrone Hospital in Dungannon when it closed. Staff were not notified that the mechanism was still in existence, nor were they offered an opportunity to avail themselves of it. It is my understanding that the unit was resurrected when an end to GP fundholding was proposed. I do not know where it sits, or who staffs it, or what the mechanism for running it is.

I want to attempt to answer that question. Yesterday I phoned the chief executive of the CSA to ask about that body, because I knew nothing about it. He told me that it has been in place for around eight years. It has not been used much. It currently looks as if it may be fairly busy. [Laughter].

I was not trying to be funny. If an individual is to be made redundant, it is the employer's responsibility to contact the CSA. People do not simply turn up at the CSA, say that they are redundant and are seeking a job. The body that employed the individual is obliged to contact the CSA and to feed it the information, which goes on computer. A trawl through the Health Service system is undertaken. Something may or may not come up. If something does come up, the individual is interviewed for whatever that post may be.

That could mean that someone in Belfast must go to Newry, or that someone in Newry must go to Coleraine. Those problems exist. It is a body that has not been used much. However, I am not saying at all that it will be useless. The chief executive was up front and said that the staff redeployment unit had not had the experience in the past of hearing from many people. I am not saying that that will to happen; we are just fearful.

Someone told me yesterday that that body has not been operational for some time. A few days ago, someone dialled the telephone number for that body, and it was out of action. I understand that the Department has rushed to re-establish a telephone line and the body in the past few days.

It is a rusty body.

That is my understanding of the level of activity.

I have found this session to be enlightening. It comforts me to know that we extended the deadline for a year. Sadly, we have not made the most of that year. It has been obvious from the presentations given that the management boards of the local health and social care groups are criticised as being top-heavy, and that not enough doctors and nurses are represented. What would your idea of an appropriate local health and social care group management board make-up be? I throw that question open.

We do not have a big problem with the composition, excluding the trust and board staff. Trusts and boards should be there but in fewer numbers. People who work on the ground should be there in greater numbers.

However, you would like midwives to be represented on it?

Absolutely.

Do you agree that, as a Committee, we should be asking for an extension of the deadline?

We would like to see that. We have a worry about the interim period.

Would you like more time to liaise and consult?

Yes.

The Royal College of Nursing agrees totally with what Dr Brian Dunn was saying about the group's composition. We also agree about midwifery. We wish to see the consultation period extended so that the transition will be seamless.

The discussions that we as a board have had have recognised absolutely the value of having trusts and boards sitting around a table. They are there as mentors. They are there to instruct, advise and support the new groups, to nurture them through their infancy until they are ready to be weaned. We have some difficulty with them having voting rights on what will be a decision-making body. Although we appreciate that they should be included, the fact that they now have voting rights gives them a position that is perhaps not compatible with a bottom-up approach to primary care. We obviously want the midwives represented.

I was reading the second report of the Select Committee on Health at the House of Commons. Speaking about primary care in England, it states that

"We note that there have been some problems with implementation in areas where there have, historically, been tensions between fundholders and non-fundholders".

Are we getting into that? That is only one element coming from that side.

I honestly do not think so.

That is what that Committee said.

Fundholding GPs accept that fundholding has come to an end.

I do not want to get into that argument. I am simply making a point that came from a different Committee. I presume that we are discussing the detail, and not the principle, of primary care. We are discussing why there was a 10-month delay and a lack of information. We broadly agree with that approach, but the question is how we go on from here and how we approach it in that context. We are not against the principle of primary care. We support the notion of primary care services, which, of course, includes the nurses and the midwives.

Dr Dunn mentioned political ideology. I question whether it is being driven by political ideology rather than -

Are you going to ask a question, Mr Kelly?

I just want to make our view clear on that. What have you done in the past year to prepare for primary care?

It is very hard to prepare if you have no guidance.

If you knew that fundholding was coming to an end, what did you do to prepare for that? I am not being critical.

We have held meetings and we have been lobbying. We cannot understand why the guidance has been so late in arriving. We are either being told that it was not yet prepared, in which case one has to ask what the Department has been doing, or that it is being issued in dribs and drabs so that no one can oppose it. It is difficult to oppose what we do not know about. We still do not have the full guidance for the groups.

There is no issue between fundholders and non-fundholders. As far as I know, GPs are fairly united in what they want. We want a system that allows us to provide services for our patients. We are not interested in dominating or manipulating or having political agendas. We want to work together. Social workers have not been engaged in this discussion. I feel that they should be represented here today.

It is regrettable that we are discussing this serious matter when the Department should have got it right last year. I have one main question that Ms McIlrath has referred to. The Royal College of Nursing documents and letters, which all members of the Committee have seen, state that the groups will have no function from April 2002 until March 2003, and will exist with no funding to support the development in primary care. That is a great concern for the whole Health Service. The Committee understood that the groups would be given budgets for primary care development. Can anyone at the top table clarify that situation?

We have had to fight to have GMS moneys ring-fenced. Those moneys are basically for our staff, for IT equipment and for premises. I am afraid to mention it but it is a bit like the Assembly office allowances. It is money that we pay out and are reimbursed for. If that money is not ring-fenced, it means that the group could take a decision to spend it on something else. That means that we would spend the money and not be reimbursed. That is why we were keen for that, and eventually we got that. The GMS moneys will be ring-fenced, but we have no idea about primary care development. There is no mention of it.

We are going to have the opportunity to question the Minister next week. You have an opportunity to advise us of your concerns. There are two issues here. One is the matter of workforce security, which was mentioned earlier. I see that NIPSA has suggested a personnel management process that would have the direct involvement of the Department. The guidance has been published, and 1 April is the deadline. You have said that that is too tight. How would you respond to a proposal to review that and some of the arrangements? Mr Berry mentioned the strategic vision: where will it go and what will it do? Is it a priority for you to know when commissioning will start and how soon you can allocate budgets? The Minister may have been concerned that too much was being put onto those new groups, especially since a great deal of development is necessary. Are you looking for deadlines?

We would like a timetable of what is devolved, the exception being that if something happens we can choose not to do that rather than work and try to persuade the board that we can manage. The timetable for devolving the budgets should be in place, and if a group proves that it cannot manage, the process should be reviewed and put back. However, that should be the exception.

Several of us met the permanent secretary three or four weeks ago, and we put that to him. Targets should be set to pin down the level of commitment from the boards and from the Department to make things happen, rather than to drive people into a corner, making life impossible. At the minute it is very loose - we are told that if we behave ourselves we might get a budget in 2003. I would expect the system to move towards, say, a 20% drawdown by 2003, and we should be enabled, trained and supported to manage that. I am not saying that every group will want to do that, or even be capable of doing that, but the system needs that impetus, otherwise it will stand still.

When primary care groups in particular were established, it was almost an iterative process. They developed at their own speed, but they also had a clear aim of where they were heading, and they could begin to commission services as and when they felt able. We do not have that clear direction. Just as the national health plan in England is overarching, those groups also had a clear vision of what would happen in the acute sector, with which they could align themselves. The progress has been co-ordinated in both sectors. We have no idea what developments there will be in the acute sector here. We are also aware that the public administration review is lurking in the background, and we are expected to develop primary care almost in a vacuum. That makes it difficult because you cannot see how those developments will relate to others. It would be a good start for us to have a clear vision of where primary care is going. We do not know whether local healthcare and social care groups will commission maternity services; we do not know what level of input midwives could and should have. It is vague - there does not appear to be an end goal.

Can Ms McIlrath answer the question on workforce planning?

I would need to consult on that and get back to you.

That is fine. I was responding to the point in your presentation about the lack of security, which is affecting morale, about what will happen after 1 April. My question was about the personnel/management process.

You can write to us about that.

We will. We must look at the numbers of people and also at some of the issues in more detail - we went through this very quickly today. We are trying to look at local needs for the different boards and to identify staff levels. However, there is no clear guidance that says at what level those nurses will be. The guidance talks about strategic level, and nurses must look at what they are developing towards with regard to career pathways. Do they want to go into that area? Further guidance on precise nurse levels and community front line nurses is therefore necessary.

I thank the panel for its submission. Although my question is directed at Ms McIlrath, all of you touched on the elimination of some services and developments in primary and secondary care by the introduction of social care groups. I would, therefore, appreciate your responses. I am pleased to see Dr Paula Kilbane in the gallery, because we received assurances from the Eastern Board last week that all services provided under the fundholding scheme would be maintained. Which services are disappearing?

One service which will go is nurse-led clinics. Nurses have been told that they will lose their jobs or will be redeployed. Where will the nurses involved in such programmes as diabetes, mental health, health promotion, screening and preventive medicine - and full-time practice jobs - go? They all have caseloads, so those services will disappear. Moreover, the input of nurses who are involved in projects or who sit on advisory panels will be withdrawn. I will come back to you with further information on relevant issues.

That would be helpful, in the light of what Monica McWilliams said.

What does David Gowdy, with his background experience, think the Department is doing? It is in the most appalling mess about the issue and has managed to alienate almost every primary care practitioner. Where has it all gone wrong?

You may have the wrong Mr Gowdy.

The Department is in a difficult position, and I do not envy that. It is coping with uncertainty and is attempting to make sense of all the different voices in the fields of primary and secondary care, and in the boards and trusts. That is a difficult circle to square.

I am disappointed that progress has been slow. I do not know the reason for that, but it is not because of a lack of effort or application on the part of the people I deal with. They are as frustrated by the process as I am. I have no insight as to why it is so difficult and confused. In GB, south of the border and even in other parts of the world, the process is moving forward, albeit with stops and starts. We seem unable to take the next step, and I am at a loss as to why we cannot move ahead surefootedly. It has been one of the most frustrating matters I have had to deal with in the last two to three months, particularly since we were told almost a year ago that the policy was ready to run.

Ms McIlrath mentioned that she represented community nurses, but not board nurses, who are manager nurses. However, they are all nurses. For clarification, could she explain why board nurses seem to be comfortable with the situation, whereas community nurses are not?

I cannot answer that. The board nurses made it clear to us just before we came here that we do not represent them on the matter.

But there was no explanation.

They are happy with the way things are.

That is quite an interesting area. The board nurses, or a percentage of them, presumably will sit on the board groups.

That is why.

I do not want to put you in a corner, but that seems strange, given the level of discussion on the subject.

They feel that the Department has consulted them. Therefore they feel that they have been included in all the arrangements.

And community nurses feel that they have not been included.

The ones that are coming forward to us, and certainly the ones that we have met through our focus groups, not just recently but during the last year, or through the programmes that we roll out - I roll out the primary care leadership and commissioning programme - are not saying that they are happy.

I have just come from a meeting with the board nurses, and they made it clear that they wanted it known that we are not representing their views here today. We represent hospital nurses too, and there will be an impact on them as well. It is not fair to say that we just represent community nurses.

This meeting has been very helpful. The Department, while exercising its moral conscience, has seen the need, from the patients' point of view, to introduce a layer of administration with 270 members, 15 managers and possibly as many deputy managers and support staff, costing in excess of £4·8 million per year. How will patients be advantaged by the implementation of the Department's marvellous vision, or how will they be disadvantaged?

Our worry is that there will merely be talking shops with no actual commissioning. One of the reasons that GPs took up fundholding was that they had been taking part in talking shops for years, and nothing ever happened. With fundholding we could influence things, but we feel that we are going back to sitting around a table once a month to talk and talk, and nothing happens.

The service is in a dire state. I have been a GP for 22 years, but I have ever seen it so bad, and there is nothing in the proposals that will improve the situation. Somebody said that we are going from four boards to 15 boards. That is our feeling. There will be an increase in administration with no gain to patients.

We have argued for years that maternity services should have an overarching strategic regional planning body at departmental level and smaller groups at local level to implement that overarching policy.

The four boards have not served women in Northern Ireland well. In the past each board has made decisions independently about the rationalisation of services. The Western Board, for example, closed the maternity unit in Omagh and did not consider the impact that would have on women living in the neighbouring board areas. Then the Southern Board closed the maternity unit in Dungannon. The maternity unit in Magherafelt, under the Northern Board, is hanging on by a thread. That leaves women all over the middle of Northern Ireland with no access to in-patient maternity services.

Our experience of the four boards has not been very edifying. Maternity services policy should be decided centrally with regard to the number of consultant obstetric units, the development of midwife-led units and the development of a Northern Ireland-wide maternity service. The creation of local health and social care groups that were bottom-up and involved the users of the service provided the potential for the development of a service that would meet the needs of the women in a local natural community. The two should work in tandem, which is more or less in line with what Maurice Hayes said.

I would like to pick up on that point. If it is not done well, £4·8 million will be wasted. If it is done well, it will attract the energy of the primary care staff to drive the system and improve it. I do not mean to be facetious, but we could ask the Committee a similar question about why 108 MLAs are better than 18 MPs. The answer to that would focus on the MLAs' knowledge of what happens on the ground and their ability to use that knowledge to solve problems, which is advantageous. There is an advantage in that.

The same applies to primary care. If we get the grass-roots people attached to the process to drive it forward, we will achieve the sort of change that has not happened so far. There is an opportunity for change, but it must occur at the grass-roots level.

Most of my questions have been answered. I found the presentation interesting, but it was also disappointing because you have many concerns about the way forward in this situation. We have to get it right this time. We are moving from GP fundholding to some other system, and there is no point in examining it again in three or four years. Perhaps it is important to extend the time limit, but by how much? What would all of you do if the limit were to be extended for a year? Do you have a plan, and how would you start and finish it?

You have genuine concerns, and I know from my many contacts and the amount of letters that I receive that the medical profession is not happy with the situation. We cannot fudge this; we must get it right. How much time would you need, and what would you do? Would you just sit around for another year? I am not saying that that is what you did, but there is no point in putting off the change if you are going to come back this time next year to tell the Committee the same thing.

I am glad that I have found out what the difference is between a nurse and a midwife.

I would like to pick up on the issue of the timescale. We have already laboured over that. The policy has been visible since 1994 in one form or another. We cannot take another year, except as a last resort. Although it may be difficult, we should be trying to move quickly into some sort of discussions where the key players on all sides try to resolve some of the sticking points that are causing the difficulties.

In some cases, making relatively minor changes to wording may be a solution. Confidence should be built up, so that the details that are set out and the things that we are asked to do will be exactly the same. We do not want some detail that we have overlooked to derail the process six months down the road. Keeping the process going is like riding a bicycle - it needs momentum or else it will fall over, and someone will get hurt. We do not want to see the process stop, or fall over, after six months, because of some hidden problem.

We presume that the delay and the hesitancy has been caused by issues which may be of genuine concern to other people but which have not been presented to us in a way that we can understand at present. That may be a partial answer to Mr McFarland's question about the reason for the delay. There may be some detail of concern that we have not seen, but which we should take account of.

We are all saying the same thing about the need for GP fundholding to end and the need for multi-professional working and consumer representation. Given that we agree on those issues, we do not need to do much work on them. It would have been much more beneficial had we, as the professional representatives of the people who are providing care at grass-roots level, worked with the Department to develop the guidance. The guidance was handed down to us. We were not consulted on its content, except when we were asked for our responses to the document entitled 'Building the Way Forward in Primary Care'. We made a robust response, but everything that we said seems to have vanished into a black hole. My board is asking why we should bother to respond to consultation documents, if our response is going to be ignored.

It would be more helpful for us to sit around a table with the departmental officials, put on our collective thinking cap - I presume that there is a great deal of intellect between us and the Department - and work in tandem to produce something that we could all live with. That has not happened.

You seem to be talking about an extension of a few months, rather than a long-term extension.

The other issue is the non-voting rights of the board people and the senior management of the trusts. We should try to get those people to build a front-line staff.

I am happy with your response that the extension would be for a matter of months. I assume that you can identify sticking points even at this stage and that you could sort those out quite quickly. In view of that, a three- or four-month extension would be reasonable.

Ms McIlrath mentioned non-voting rights for board members, and I can see her point. However, I am concerned because Dr Dunn said earlier that we do not want this to become a talking shop. If senior managers are appointed at that level the groups will not become talking shops because it will be possible to make decisions without going back to the boards or trusts. Can you clarify your remarks, because you seem to be contradicting Dr Dunn?

Nurses appointed to the board will represent a wide discipline of nurses. The infrastructure that they have to enable them to pass the information on is also important. The senior management can support them.

The other way to stop the groups becoming talking shops is to devolve the budget so that they can make decisions.

The sooner that happens, the better it will be.

Was the BMA not given an assurance about that several weeks ago?

The date given was 2003.

In one of its responses to 'Building the Way Forward in Primary Care', the Royal College of Nursing said that nurse representatives should be elected to the groups by their peers. That would ensure that they have the confidence that comes from the support of the nurses. The representatives would be able to go back to the senior management to say what they need, knowing that they spoke for all nurses. That suggestion was not taken on board.

The first guidance is dated November. Were you called on to give your views at that stage? Was a round-table meeting held?

No.

The second guidance was issued in January. Were you called to a round-table meeting to give your views at that point?

No.

The Department had an opportunity to hear your views. Apart from that, is it correct to say that this is the only chance that you have had to express your views? Is it correct to say that you have not been consulted since the guidance began?

That is correct.

The General Practitioners' Committee (GPC) met the Minister to explain all of its concerns.

Was that meeting held at the request of the GPC or the Minister?

The GPC requested the meeting in October, and we met the Minister in January.

We saw the press statement that the Minister released following that meeting.

I want to put this on record because, in a devolved Administration, it is important that we keep holding these round-table meetings with the people who are implementing the new policies. If there is guidance available, we should take advantage of that. There probably was an opportunity to do that after November. We would all argue that November's guidance was vague. However, there may have been an opportunity for you to respond. I understand your point, Dr Dunn, but the request came from you. Was there an opportunity for the Department to call you? As each one of you represent an organisation and meet at inter-agency through the local health and social care groups, then it might be useful to so it at this level too.

On that point, the Department responded to requests for meetings from two groups I am part of, and in January the two groups met with the permanent secretary or the acting director to consider what the guidance should contain. I am not saying that those meetings were particularly successful with regard to their outcomes, but they were held.

There is no doubt that we would all like to see the end of fundholding. All four of you asked why 10 or 11 months have passed without guidance having been issued. The purpose of the amendment put down in January was to get that seamless transition. I do not know why guidelines have not been issued earlier, although I have tried to find out. I would prefer a totally bottom-up approach to the matter, and the Committee has stated that many times before, particularly in January last year. The situation is not the fault of the boards. The proposal that these new groups are to be committees of the boards has come from the Department.

Ms Hughes, I take your point that nursing and midwifery, like medicine and dentistry, are distinct and separate professions. One hopes that midwives and nurses on the front line will be represented.

Senior representatives from the three organisations, the General Practitioners' Committee of the BMA, the Royal College of Nursing and the Royal College of Midwives met and then each representative signed that letter, and it was issued to the Minister. We have seen copies of that letter in which it was stated by the signatories that

"We the undersigned write this letter to you as officials of the organisations we serve and with the authority of those organisations."

While I accept that the signatories speak for their organisations, what is the significance of that representation and to what extent do they speak for those organisations?

We have 98% of midwives in our membership in Northern Ireland. We have an active interface with members at grass-roots level. I cannot make such a statement without the authority of my board. The board has representatives from every branch in Northern Ireland, and it was a unanimous decision that I should raise the concerns of the board. We also have the grass-roots activists, the stewards, working throughout Northern Ireland, and, again, there was a unanimous endorsement from them. The only other significant group is the midwife managers' advisory group, but owing to the timescale attached to the guidance, we did not have time to meet with that group. However, our letter to the Health Committee and to MLAs and also to the Minister was drawn from our response to the 'Building the Way Forward in Primary Care' document. That encompassed views and opinions from every single one of our groups of activists across Northern Ireland. I can say, because ours is a close-knit profession, that I speak on their behalf.

I am sure that the same principle applies to the Royal College of Nursing and to the GPC.

There is a whole spectrum of GP opinion. The chairperson of the GPC's opinion reflects the feelings of the majority of GPs. However, GPs are thinking hard about the issue; they do not want to oppose something that could help. It is not merely a matter of saying that they oppose it and that they do not want to do it. GPs want to work something out. They are doing that on all levels, and they want to come to an arrangement.

Dr Dunn, I am glad that you raised the last point. The function of primary care is to commission the Health Service to assist in the integration of primary and community healthcare, to work closely with social services on planning issues and to improve public health. That is the aim.

Exactly.

The difficulties that we are discussing today seem to be mostly in the detail: Ms McIlrath has problems with nursing; Ms Hughes has problems with midwives; and Dr Dunn has problems with GP fundholding.

There are no problems with GP fundholding.

I meant problems with the transition. Are feelings among primary care professionals so strong that they are not prepared to let the new proposals get off the ground? As a group, have you sought a meeting with the Minister?

No.

Was there a reason for that, or was a meeting not considered?

It would be difficult to co-ordinate such a meeting.

The timescale was short.

We requested a meeting with the Minister in October, and it took place in the middle of January. The Minister's diary is obviously full.

Given the urgency of what we are discussing today, as a group, will you request a meeting with the Minister? Is there too much tension between you to allow for a collective meeting with the Minister?

No.

They requested a meeting in November but did not get to see the Minister.

That is a separate issue. I am referring to this group's having a meeting.

I beg your pardon.

Does the fact that there is so much opposition to the idea mean that you are not prepared to give it a go?

It is not so much opposition as concern. It is not a matter of boycotting and opposing. The groups will not work unless the members are committed and prepared to put in hours of hard work. Unless members are committed, they will turn up, go through the motions, take their pay and go home, and nothing will change. We want a system whereby people are committed and will work to change and improve the situation.

As a group, will you seek a meeting with the Minister?

There needs to be more than a meeting. A process needs to be developed.

I am referring to a meeting that will begin a process.

In that case, yes, we will request a meeting.

I am deeply disturbed by the arrogance of the Department of Health, Social Services and Public Safety. It has shown complete disrespect for healthcare professionals. The Committee has been discussing that matter for at least a year. The Department has been operating in a similar way to the old-style Soviet politburo. Edicts come out of the ether without there having been any consultation. The Committee must send out the message that departmental officials must meet with you and agree on a solution to the problem. The situation is crazy. There was an opportunity a year ago. All Committee members agreed that there was a year in which to sort the issue out into a seamless robe that would knit the reports together. That opportunity has been squandered. It is disgraceful that with a few weeks to go we are still shambling along, and no one has spoken to you. We must resolve the issue. It is crazy.

What commitment did you get from the Minister for the GMS budget?

We got a commitment that it would be ring-fenced.

Was that a definite commitment?

As far as I am aware, we received a written commitment.

I have written to Dr Patterson expressing my concerns about that, and I will raise them with the Minister.

Much of this is to answer questions in my head because I have relevant concerns to those that you are bringing. We are told that the new social care groups are top-heavy and bureaucratic. We are going from 150 commissioning groups - that is, GP fundholders - down to 15. According to the Department's press release, that would free up £2·5 million from administration to be spent in front-line patient care. Why are we are being told that it is too top-heavy when you are going from 150 to 15 groups?

From a nursing point of view, it clearly states in the documentation that we are talking on a strategic level here and that the boards and trusts will be able to nominate their people onto those groups, albeit that one will be a nurse. We want those people to be community nurses who see patients and know the issues on the ground, rather than someone at a strategic level looking at numbers.

There is no difficulty with the configuration that there will be 15 local health and social care groups. That is reasonable, given our population. The concerns are that it is not clear what will be devolved to the groups, when it will be devolved and what services they will commission.

I take that on board, and I share some of those concerns. There is much confusion - or perhaps I am confused. I was led to believe that only £3 a head would be spent on administration. The BMA said it would be approximately £7 or £8. I could not argue for £7 or £8 to be spent on administration when the rest could go into front-line care.

In England, there were step-by-step stages. You are well aware of the stages. You must get them up and running, and then when they are set in their ways, you talk about giving them budgets. Then they start commissioning services. We need to walk through where we are going. I take on board what you are saying. The Department must be asked hard questions about that. We, as a Committee, know that sometimes we have asked for papers from the Department, and have not received them. You can be assured that we will be asking those questions.

It must be made clear what exactly the money is for and what money is going to be put into infrastructure development, and into training and development. It is unclear how much money there is going to be for all that. Are we talking about £3 a head for administration only? We do not know what else is included. We need some clarification on that.

All members of the Committee have been invited to an event on 20 March in the Stormont Hotel. One of the primary care trusts in England, Bradford City Primary Care Trust, will be giving a short presentation. It is probably one of the best examples of a primary care trust in England. You will see the results that can be delivered when a trust is properly resourced.

Recently I attended an event in the Stormont Hotel on the primary health forum, at which we had some input from those operating in England. It was interesting to hear from them. They went through some of what you, and we, are going through - the pain of change, organisational change, and trying to see where things go next. Would you say that there was a big difference in what they were told at this stage and what you are being told?

I am also concerned that there is a voice missing in our discussions today - that of the service users. Have you had an opportunity to talk to your service users? The organisational structure says that there shall be two among the rest of you. Perhaps they might have had some views. The difficulties lie in whom we get, how we go about getting them and whether there are enough of them.

As I said, I have sent the guidance out through the women's regional consultative forum to over 400 women's groups in Northern Ireland. There will be a meeting of the steering group of the forum next week. It is hoped that by then it will have picked up some of the concerns of women users across Northern Ireland and it can relay it through that mechanism. The other mechanisms that we will use are the local maternity services liaison groups, where professionals and women work in partnership. I imagine that the councils might also have something to say. The timescale is so short that it is difficult to have meaningful consultation.

Mr Gowdy, will you be inviting some of the public representatives to the conference that you mentioned?

There is a separate exercise to bring that to the table. However, the conference was set up to literally fly people in for a couple of hours to learn from their experience. We set it up from a North Down perspective, as the Bradford model, working with a number of trusts collaborating to provide a communal service, was similar to what we needed in North Down with the Ards group and the south-east Belfast group. We started out wanting to learn from these people rather than us sharing our learning, although that will happen later on in the year.

On the issue of public representation, we have a lay member on our board who is the chairperson of the health committee in the local council, and that person is as confused and frustrated as we are. There is nothing we can do to help the lay member make any more sense of it than we can.

Thank you all very much, on behalf of the Committee. You came at short notice. We have your documentation. It has been outstandingly helpful, and we appreciate it.

20 February 2002 / Menu / 6 March 2002