COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Comprehensive Spending Review Priorities

Thursday 21 June 2007

Members present for all or part of the proceedings:

Mrs Iris Robinson (Chairperson)

Rev Dr Robert Coulter

Dr Kieran Deeny

Mr Alex Easton

Mr Tommy Gallagher

Mr John McCallister

Ms Carál Ní Chuilín

Witnesses:

Mrs Linda Brown }

Mr Andrew Hamilton }Department of Health, Social Services and Public Safety

Dr Andrew McCormick }

Ms Julie Thompson }

The Chairperson (Mrs I Robinson):

You are very welcome again, Andrew and Andrew, Julie and Linda — we have got to know each other so well that I am not going to use surnames. I invite you to give a short presentation, which will be followed by questions from Members. I hope that Members will work to a deadline of about an hour. I now hand over to you, Andrew, and your colleagues to speak on the subject of the comprehensive spending review (CSR).

Dr Andrew McCormick (Department of Health, Social Services and Public Safety):

Thank you for the opportunity to be here this afternoon. The comprehensive spending review is an important topic. When completed, it will set the direction and the resource allocations for three years to come. A great deal hinges on our getting this highly complex process right and ensuring that the outcome is the best that it can be, given all the different considerations.

We have all been before the Committee before. Julie Thompson, our director of finance, will pick up from me after my introduction. We have given the Committee a briefing paper, but the material is complex, so we will have to maintain an ongoing dialogue. At this stage, the Department is putting proposals to the Department of Finance and Personnel, and those will be fed into an Executive process, but quite a few steps must be taken before a final decision will be made.

The Executive will need to examine the proposals from all the Departments, take account of views from all the Committees, and collate the resultant information. By September, a draft Programme for Government and a Budget must be out for consultation. The Department of Health, Social Services and Public Safety is conscious that, in order to have an orderly decision-making process, it is necessary and normal for final decisions to have been made by December, thus allowing for the proper planning of detailed finance in health and social care organisations.

The Chairperson:

In the interests of reassurance and clarity, will the efficiency savings of 3%, which all Departments have been asked to make, go back to Northern Ireland’s Department of Finance and Personnel, to be bid for by Departments, rather than to HM Treasury?

Dr McCormick:

Yes. That process began under direct rule as part of Gordon Brown’s approach to the comprehensive spending review. The Executive, under the influence of the Minister of Finance and Personnel, are insisting that we continue to produce efficiency savings at or above that level. The process of efficiency savings provides more choice and flexibility for the Executive to consider a range of issues across all Departments.

The Chairperson:

It is nice to know that the money is not going back to Gordy.

Dr McCormick:

I will say a little bit about the way in which the total is determined. The Minister of Health, Social Services and Public Safety, Michael McGimpsey, is keen that the Department has strong engagement with the Committee. We will be glad to hear your views, because it is a complex prioritisation process, and we are asking that comments be returned to Mr McGimpsey by early July 2007. That will allow the Minister to speak knowledgably in his engagement with the Executive during the summer and at the crucial decision-making time. During the process, HM Treasury sets a fixed departmental expenditure limit that does exactly what it says on the tin.

The Chairperson:

I have used that line.

Dr McCormick:

Yes. The limit outlines what each Department can spend over a three-year period. As the departmental expenditure limit is determined by the Barnett formula, Northern Ireland receives a pro rata share. Whether that share is increased, or decreased, is determined by Whitehall. The Chancellor has already announced figures for education in England and Wales. My hope is that he is keeping his powder dry on health and has that funding as a rabbit to take out of the hat later. However, that is only speculation.

We do not know what the full outcome will be. HM Treasury has said that this year’s outcome will not be known until the autumn. That is a bit later than usual and will complicate our process. Although the Chancellor has indicated the total resources in broad terms, it leaves us still a bit in the dark.

The Chairperson:

When we debate the Barnett formula at Westminster, we can use all the necessary clout that we may or may not have with a new Prime Minster to try to extract more moneys.

Dr McCormick:

Yes. The Barnett formula is partly designed to provide a systematic basis and avoid the need for negotiations. Joel Barnett devised the formula so that a three-yearly negotiation process would be unnecessary. However, it is well known that there are always negotiations. The outcome is not yet certain, and will not be for some time.

The indications are that, through the Barnett formula, Northern Ireland will receive approximately 3·5% growth a year. In real terms, if inflation is taken to be 2·5%, that amounts to 1%. That is a small level of real growth. It is a much lower rate of growth than we have been used to over the past few years. Therefore there is very significant change. Seven fat years followed by seven lean years is the way in which to look at it. The past few years have been very positive and have included the major boost that health spending got in England in 2002, along with the 1% increase in National Insurance. Therefore we have had a major injection of funding into all services over the past number of years. That rate of growth will be much lower in future.

In Northern Ireland, we must look for efficiencies through internally generated resources. The efficiencies that have been mentioned are there to allow the Executive to channel their resources. Being modest individuals, we have constrained our proposals and have asked only for a little more than £1 billion by 2010-11. Our expectation is that the £340 million of efficiencies that we have been obliged to identify and generate will be returned — and some more on top of that — in order to address health and social care priorities. However, that will be entirely subject to the Executive’s prioritisation process.

Within a three-year planning cycle, there is practically no limit on what we could ask for — or what could be spent — on social care. There are needs and opportunities that would make a real difference in people’s lives and make a valid and demonstrable improvement in health and well-being. There is much that we could do. However, we live in the real world, and in the context in which taxpayers are not prepared to hand over unlimited resources. Therefore, we must be thoughtful and prudent about prioritisation and about coping with a much tighter financial environment.

On average, there has been 7% growth in the Health Service in Northern Ireland over the past three years. If the rate of the growth in the Northern Ireland total is going to rise by only 3·5% a year over the coming period, and we have already had 7% growth, that serves to emphasise the comparison between the fat years and lean years. The Health Service in England had growth of nearly 9% a year over the past three years, so we have fallen a bit behind during that period. There is a significant risk that we might fall further behind.

However, resources have been used in significant ways over the past few years, such as in major efforts to tackle waiting lists, which is an important priority. The modernisation of pay structures, although controversial, was urgently required, and new contracts that were drawn up under those structures were costly and consumed much of the new money available.

Major reform and modernisation programmes made good use of available resources during the fat years. Now, we must examine how we can draw on the efficiency gains and on whatever can be secured in the CSR through negotiation with DFP and the other Departments. Our proposals will require an uplift of 6% a year. That is the horizon for which we are aiming; how far we progress towards it will depend on the upcoming prioritisation process.

The figures in the papers that we have submitted to the Committee would take us to that level of growth. The level of bidding is high, but it can be justified in its own terms and is not unreasonable compared with the past few years, in which we had faster growth. In the present context, we know that what we have requested will be difficult to secure because of the wider limits.

I shall put it this way: if Northern Ireland as a whole is to expect a growth rate of 3·5% a year, and we are asking for 6%, which is getting on for half of the total allocation, we will only receive that sum if all the other Departments are granted a great deal less. It would only work, in fact, if all the other Departments were subject to reductions in real terms. Our bids are justifiable, but even as I say that, it is unlikely that they will be secured; it is unlikely that the Executive would agree that every other programme should be reduced in real terms.

To put the entire matter into context; our bids are highly justifiable, although they do not go as far as we would like, because there are many other aspects that could be provided for. We also have a moral obligation to secure real efficiencies and rigorously prioritise our activities. That is a big challenge.

We must get our house in order, maximise value for money and secure good outcomes. We must negotiate effectively in the prioritisation process; work with other Departments, and find opportunities to provide joined-up Government and to work together successfully. It is important to note that many aspects of upstream health and social care depend fundamentally on the activities of other services such as education, employment and housing to address the core long-term issues of health inequality.

We must ensure that our systems are working well; that we have good information, and that there is good interaction between various groups in health and social care. Having a well-organised system is part of achieving that.

Michael McGimpsey has already mentioned that there is a gap of around £400 million a year when spending here is compared with that in England. That amount would cover the difference between our budget for 200/-08 and what we require to provide a level of service that is comparable to that across the water. The difference is genuine, and that adds to the challenge. The deficit is large, and is unlikely to come our way easily, but that is a measure of the issues that we are facing.

That provides a broad context for the challenges that we will face. Ms Thompson will now outline in more detail the approach that we have taken in constructing our proposals.

Ms Julie Thompson (Department of Health, Social Services and Public Safety):

We have taken the approach that is currently being adopted by all Departments. The first stage is to identify what one has no choice but to do. For the Department, those items amount to approximately £700 million. Approximately £575 million of that amount relates to routine uplifts for drugs, pay, inflation, and other payroll expenditure for the Agenda for Change programme. The costs are inescapable, and they have to come out first from any resources.

The balance — £125 million — is for ongoing contractual commitments such as the capital programme or training commitments whereby students who are going through the system need extra years paid for. A large portion of the money will bring improvements to service provision by the Department.

After analysing the inescapable costs, we then have to look at service development. The Programme for Government will be based on a small number of strategic PSAs or overall priorities. At the end of May, Michael McGimpsey took the Committee through the top six priorities he proposes for health and social services, and they are outlined in the briefing material that we have provided. They include: better life chances and protection for children; provision for people with mental-health illness or disability; high quality primary community care services; access to high quality, safe, secondary care services, and improving health outcomes for patients with life-threatening conditions. Those six priorities are not in any rank order. They will be fed into the overall Executive Committee process.

Presumably, the Committee will wish to engage most keenly on those areas, as they are the areas in which there will be service developments and an element of choice for strategic direction.

The strategic direction of the proposals places a greater emphasis on improving health and well-being than there has been in the past. That change of emphasis includes looking at health problems before they reach the hospital system and taking preventable action. Therefore, there are proposals for investment in screening and health-protection areas. As Michael McGimpsey outlined, there is also a range of investments for mental health, disability and children.

That is an overview of the general process through which every Department is working. We all have to feed proposals to the Executive so that Ministers can determine the overall priorities and then start to work them through the system.

Dr McCormick:

We are glad to be having this engagement with the Committee, as we have reached a crucial stage. There is a long way to go before September, December, and the final decisions. We must think about what matters most and target resources as effectively as we can. There is a range of issues that we need to face up to.

DFP will be asking DHSSPS what it really wants — what matters most, and where the line must be drawn. At that stage, the temptation would be to include a little of everything and, perhaps, not deal with anything effectively, therefore the Committee’s views and challenges on the issues that matter most will be fundamental.

The Chairperson:

I shall don my Chairperson’s hat and start the discussion. I am concerned about mental health, and in particular the provisions for people with dementia, eating disorders or who have suicidal tendencies. We are all aware of the dreadful number of young people who have ended their lives. There are so many different areas of mental health, yet there are so few units and beds. In particular, there is a shortage of units for children and adolescents. Recently, that shortage has been voiced strongly through various media.

There is no breakdown of mental-health provision in the synopsis I have received from the Department. However, it is probably in the other paper. I have not had a chance to study both in detail, as my diary has been crazy lately. How much money will be ring-fenced for mental-health services, provision of capital investment for new builds and resources for attracting new staff? Psychiatric nurses are needed. However, that area of the profession seems to be dwindling, and the career path does not seem to be attractive for nurses simply because of the pressures and the distinct lack of investment over the years. Can you respond to that?

The Minister is considering recommending the introduction of the human papilloma virus (HPV) vaccine to reduce the rate of cervical cancer. Has the cost for that been included in the CSR, and has the operational cost of providing the vaccine been determined? I have a moral difficulty with the vaccine. As someone said on the radio this morning, there is a tendency to believe that if 12-year-old girls are given the vaccine, that might encourage sexual activity from an early age. The vaccine is intended to reduce the incidence of cervical cancer, which can be attributed to frequent sexual activity from a young age. Would you respond to those points before I hand over to my colleagues?

Dr McCormick:

The Department and the Committee must mobilise on the mental-health and learning disability agenda. The Bamford Review is almost finished, and an action plan is needed, which will, in many ways, be determined by what is available through the CSR.

The Minister is about to announce the establishment of a panel, or board, of experts to challenge the Department and others on delivery in order to ensure that that is seen through and that the facilities and, in particular, the workforce are there to deliver on this vital agenda. It is a challenging area, and it is important that it be examined in the fullest sense and that the root causes of issues are tackled through long-term care.

It is difficult to tackle suicide, because when someone has reached the point where they are close to suicide it is difficult to intervene. Intervention is much more effective at the earlier stages. Suicide is a deep problem for society as a whole and any strategy must be effective on a long-term basis.

Mrs Brown can give more details on the breakdown of the Department’s bids and what we are trying to secure.

Mrs Linda Brown (Department of Health, Social Services and Public Safety):

The Bamford Review is very broad, comprising 10 reports. In order to tackle the issues for which the Department is making bids under Bamford (1) and Bamford (2), activities have been grouped under four headings: keeping people out of hospital; resettling people from hospital; new services, such as eating disorders and non-drug therapies such as physiotherapies, etc; and respite care. It is not possible to drop one of those. They must be progressed together otherwise there will not be progress.

I urge the Committee to consider the four sets of activities alongside the remodelling of the entire mental-health service. It is important that more people are treated in the community and less by psychiatrists. Patients with urgent and complex needs must be differentiated from those with routine problems, and that has not been the case in the past.

Within that strategic approach, the Department has also included a number of activities in the mental-health spectrum. We have made a bid for money for the introduction of psychotherapies and non-drug therapies, and so forth. Bids have also been made for funding the development of community mental-health services, new services to deal with eating disorders, and drug and alcohol addiction services. Furthermore, funding is required for the development of new services that will treat people with personality disorders and for a range of respite-care services. Those bids have been split into Bamford (1) and (2). That split illustrates what the Department believes is achievable in the first stage of reforming mental-health services and what can be achieved later.

One important element in the reform of mental-health services and in moving things forward is the workforce. More work is required on workforce planning but, in addition to implementing changes on the ground, much is dependent on the recruitment of staff. Changes cannot therefore be made overnight; there must be a lead-in time.

An example of the positive results is to be found in the area of child and adolescent mental health, and the difficulties around that. In the past two years, the number of child and adolescent psychiatrists has increased from 15 to 21. There are now more consultants working in that field. Although progress has been made, the Committee will appreciate that that recruitment took some time. There is also a new strategy on suicide prevention, which I believe was mentioned at a previous evidence session. There is also a bid in the CSR for more money to extend the ongoing work in the area of suicide prevention.

Funding for the child and adolescent mental-health services has been made available through the children and young person’s fund. From the Department’s CSR bid, the Committee can see that we are trying to mainstream the total funding under that package. We are happy to answer detailed questions on the breakdown of that, but it is available for the Committee’s scrutiny.

The Chairperson:

On 5 July, the Committee will receive presentations from families who have endured the dreadful trauma of suicide. We will also hear from a psychiatrist, who will give a direct overview of the shortcomings in service provision. I am looking forward to that, because it will be important to hear from the people who are suffering due to the lack of provision and from those who are trying to deliver the service but who do not have the wherewithal to do the job in the way that they would like.

Dr McCormick:

The HPV vaccine is part of the bid on cancer control under the first PSA. There is a clear and demonstrable need for that vaccine, and it is believed that it offers a chance to prevent a number of deaths from cervical cancer.

I understand the issues raised, Madam Chairperson, but my understanding is that for the vaccine to be effective, it must be administered at age 11 or 12. That is the clinical reason. If we proceed with the programme and it is effective, we will have availed of an opportunity to make a considerable impact on the incidence of a disease that causes 30 to 40 deaths a year in Northern Ireland. In clinical terms, it is the right thing to do. The moral issues must be resolved and handled in a different way by society.

Ms Ní Chuilín:

The CSR is a large piece of work to scrutinise, and I hope that this is not the only opportunity that the Committee will have to consider it. I would like to put that on the record.

We have discussed mental health in previous meetings. As regards bids in respect of the CSR, the Bamford Review and the Investing for Health strategy cut across several Departments, for example, the Office of the First Minister and the Deputy First Minister and the Department of Education, which would be involved with preventative work in schools. I assume that other Departments have taken that into account when submitting bids and that DHSSPS will not be expected to carry the full weight of the cost. I would like more money to be ring-fenced for mental-health services. I did not really understand what was meant by Bamford (1) and Bamford (2), but now I do. I suppose that everybody’s view is that prevention is better than cure.

The second issue jumped out at me when I read the document: when items such as infrastructural investment and capital requirements are mentioned, does that mean PFI? Is that Civil Servicespeak for a way of pushing through PFIs? I have read the material again and again, but perhaps I am just too cynical — if it means PFI, just say so.

Dr McCormick:

On the first point, there must be more engagement with other Departments. The DHSSPS has given the matter a great deal of thought and made it a priority. We have had contact with other Departments to ensure that they give the issue some attention in their submissions and presentations to DFP and their respective Committees. That is our hope.

When the board of experts is appointed, one of its functions will be to provide stronger links with the other Departments, and it will be an important function. The board will comprise representatives with a range of expertise, including those from a user/carer perspective, and it can show all concerned the parts that they can play — for example, the housing sector, the Department of Education and the Department for Employment and Learning. That should be, and must be, part of the CSR process, and we will encourage our colleagues in the other Departments to take that on board.

Infrastructure investment means just that, and without prejudice as to how it is procured. When deciding on the procurement process to be adopted, each project will be looked at on merit, and the Minister will want to have his view on policy direction and whether or not, or to what extent, PFI should be used as a procurement tool. There is no prejudice implied, and a genuine process lies ahead. We will, of course, take full account of the Committee’s views, and the Minister will want to engage on that issue.

I am aware that the Committee had a long discussion on PFIs with our colleagues last week. Mr McGimpsey will have his views, and the Executive will have to make some policy decisions about PFI — the extent to which it should be used and the kinds of projects that might or might not be suitable. As officials, we will offer advice on how best to secure value for money through the process. However, even if PFIs were pursued as vigorously as possible, it is still likely that a large proportion of procurement would be carried out by conventional means. There is no prejudice or presumption at all.

Ms Ní Chuilín:

When I looked at the budget, I read figures on the costs of hospitals. Around £200 million has been suggested for one hospital and several hundreds of millions for another. Those figures seemed too low. Do they represent the PFI sum or the actual cost? Could we return to that matter? I will find those figures and read them to you. That does not seem right.

Ms Thompson:

That was discussed during last week’s briefing on PPPs and PFIs. I do not believe that there were figures of that order in this paper, but we will certainly provide you with whatever clarification you need.

The Chairperson:

Rather than waiting for you to find that, you can write to us.

Dr McCormick:

We will provide the information.

Dr Deeny:

I am new to the game of huge budgets, but regardless of securing the health budget from the Exchequer, I wish to ask whether there will be an out-and-out fight among the Departments over who gets what.

Like the Chairperson, I am deeply interested in mental health and in the terrible epidemic of suicide hitting this country. Speaking as an experienced doctor, no matter how many nurses and psychiatrists we have, there will still be people who will take their own lives. Although many people are mentally ill, a number of them show no signs of illness whatsoever. That is the problem facing our society, as has been said in the media and by the Minister;

We have heard about Japan, and it is very worrying that the more affluent a society becomes, the more suicides occur. In my own practice, I have seen people who have given no indications of having mental ill health and yet have taken their lives. Other Departments, such as the Department of Education, must be involved in combating the problem. We must get the message into the schools that suicide is wrong and that it leaves families in devastation. Also, as we mentioned last week, our churches ought to get actively involved.

Are there plans to transfer budgets among Departments? For example, are the DHSSPS and the Department of Education to have joint budgets?

I wish to support Carál Ní Chuilín’s comments on the importance of prevention. Dealing with illnesses early saves money. They become more costly to treat later. The same applies in all areas of life, including finance, and I am deeply concerned about going down the road of PFI. If we do, we shall have problems in 10 years time. How many PFI projects does the DHSSPS currently have, and how many does it plan to have over the next five years? Is there competition among Departments? Will there be a transfer of funding among the Departments in areas such as mental health and suicide prevention?

Dr McCormick:

The first two points are related. We need a clear process, and, given that we are all working for the collective interest and looking for the best possible outcomes for society as a whole, there should be joined-up working, with joint budgets, where appropriate.

During the previous period of devolution, funds were set up to provide for the work that cut across departmental boundaries. That was one technique that was employed; there may be others on which the current ministerial team will decide. The Executive have shown signs during their discussions of the Budget and the Programme for Government of looking for cross-cutting priorities and people-focused priorities that centre on various aspects of society; for example, mental health and learning disability — which we have discussed today. One way in which to have a priority for mental health would be to build contributions from a range of services.

Dr Deeny’s first question hinted at competition among Departments. There is a risk, or a tendency, for Departments to engage in an arm-wrestling match, where the only symbol of success worth having is a big budget. Departments must rise above that and be able to see that the outcomes for society are what matters. In the end, that is how the process will be judged.

Ms Thompson:

Cross-governmental working has been a key part of this year’s CSR. Departments must inform the centre of the engagement that they have had with each other. They must be up front and clear about that so that linkages can be made more easily than in the past. That will ensure that the cross-governmental system works better.

Dr McCormick:

Dr Deeny enquired about the number of ongoing PFI projects. The Enniskillen hospital project is a major initiative that was put out to procurement last year as a PFI, and the project is progressing on that basis. The Omagh hospital project was initiated as a PFI project by the direct rule Administration in March 2007. Subject to further consideration, that project will follow the PFI route. However, the Department needs to examine that and evaluate the value-for-money aspects at every stage.

Several other projects have been planned so far on the basis that they will proceed under PFI. That was the plan during direct rule, but whether those projects will proceed in that way will be a matter for decision. As I said to Carál Ní Chuilín earlier, there is genuine decision to be made on each of those proposed projects. The relevant Minister will make such decisions in the context of any policy that the Executive set. There is no prejudice.

The Chairperson:

I am afraid that one or two people still have their mobile phones switched on. I ask people to switch them off completely, because they interfere with the recording system.

Mr Andrew Hamilton (Department of Health, Social Services and Public Safety):

There are also several examples of smaller-scale PFI projects: for the provision of renal dialysis stations and equipment leasing, for example. We often forget that, in many instances, the independent sector is our partner. One such area in which healthcare relies heavily on the independent sector is in care of the elderly. With residential care and nursing-home care, the independent provider goes to the market, secures funding for the premises and provides the facilities in which people live. The Department then pays for that.

Another notable point is that almost all family-practitioner services are in the independent sector. Practices provide the facilities, and the Department reimburses them through the remuneration arrangements.

Mrs Brown:

I will respond to Dr Deeny’s questions on some of the mental-health issues.

You mentioned the difficulty for society in coping with suicide, and the need for education. Much work has been done to educate people, to promote the issues and to work with GPs as part of the Protect Life strategy that has been developed. To date, 161 GPs and 71 practice managers have undergone awareness training, but there has also been a big push from sections of the community to undertake that work.

The Chairperson:

That is very heartening to hear.

Mr Easton:

The combined proposals will cost about £1 billion, according to the document that you have provided. It says that there is a requirement to skew significant additional funds from the Northern Ireland block grant. From where will the funds be skewed in the health budget?

Dr McCormick:

As I said in my presentation, for DHSSPS to secure resources at that level would require the Executive to give substantial priority to health and social care at the expense of other Departments. The funding would be skewed from other Departments. That will be difficult to do, but it is a question of the extent to which the Executive choose to set strong priorities. It is a decision for the Executive to make. The money can only come from other services in Northern Ireland. To give health and social care a substantial priority would mean that other services would have a lower rate of growth or, in some cases, reductions in real terms. That option is there, but it would not be an easy decision to take, and I cannot pretend otherwise.

The Chairperson:

You always seem to be last, Tommy — but not least. I do not want you to develop a complex.

Mr Gallagher:

You are making me paranoid.

I wish to make a general comment. It is worrying to hear that the Department faces tighter budgetary controls at a time when the demands being made of it are continually increasing. The Minister, departmental officials and the Committee face huge challenges. I support the points that have been made about the Bamford Review. No matter how the available money is allocated, there will be gaps, and there is so much unmet need that it is difficult to know what to do. I have no big ideas on what to do about that.

Alcohol and drugs are huge problems. The drugs and alcohol strategy, which places responsibility for dealing with young people on the education sector, is not being well delivered. That means that the health sector must deal with problems as they arise. Although the intentions behind that strategy may have been good, the problem has merely been moved around, and nothing is being done to tackle that problem. The schools are too busy; they do not have the necessary number of trained people, and the message is not getting across. The health sector must examine how it can enable people with expertise to get in touch with young people about alcohol and drugs. The best time to deliver that information is during the formative years of people’s lives.

Some of my good friends are GPs, so I make the following point with the greatest respect to doctors. I live in a rural area, and I do not understand why out-of-hours cover operates as it does. The local boards pay for out-of-hours cover, and I would like to know how much that costs the Health Service. There must be a better way in which to organise out-of-hours cover. If my hunch is correct, a great deal of money is used up by providing GP cover from Friday evening to Monday morning and during the week from 5.00 pm to 9.00 pm.

Dr McCormick:

Next week, there will be a meeting of the new strategic direction for alcohol and drugs steering group (NSDSG), which will involve the other Departments. That will present an opportunity to involve the Departments and the voluntary-sector players who are developing the drugs and alcohol strategy in order to consider what is going wrong and how it can be made more effective. Your points will be raised at that discussion.

Mr Hamilton:

Under the new contract, GPs were given the option to continue to provide an out-of-hours service or to cease doing so. Across the UK, GPs have stopped providing that service as part of their normal terms. The health authorities — the local boards — have had to take responsibility for providing an out-of-hours service.

As Kieran Deeny will know better than I do, the ordinary GP service is delivered from 8.00 am to 6.00 pm, at which point the out-of-hours arrangements kick in and operate through the night, and over weekends and bank holidays. From memory, to provide that service costs about £18 million to £19 million a year in Northern Ireland.

We are working with the boards to consider ways in which to organise a more effective service, with greater co-operation and more integration with out-of-hours hospital services. Those enquiries are at an early stage, but we recognise that there is scope for utilising a range of skills other than those that are primarily delivered by doctors.

The Chairperson:

I know that this question is mischievous, but how are you getting on with the Executive and the Minister of Finance and Personnel in your attempts to extract £1 billion over three years?

Dr McCormick:

It is early days.

The Chairperson:

You should have been a politician. [Laughter.] Well sidestepped.

Mr Hamilton:

We need whatever help we can get.

The Chairperson:

Yes, we do. Perhaps I should not have asked that question.

Mr Hamilton:

May I mention early-intervention strategies? They are a theme in all the bids that we make, and their time has come. In the past few years, much has been done to reform hospital services, but we may be on to something really exciting. We may be able to change how people access the Health Service. To put services in the community would enable earlier access and avoid hospital admissions.

Considering the big picture, I think that the main demographic trend shows an increase of 50% in the population aged over 85. That, added to the state of health of the population, which is the worst in these islands, suggests that the Health Service will be overwhelmed if we do not change the way in which we deliver services. It is not only an imperative; we want to do it because it will result in a much better service.

Too many people go into hospital because services in the community have not been available to prevent them reaching a point of acute crisis. If we can get early intervention right, we can promote better health and maintain independent living for longer. As much as anything else, this is a plea from the heart for the Committee to use its influence to support that type of strategic approach.

The Chairperson:

The hand of history is on our shoulders.

Ms Ní Chuilín:

Hospitals are for sick people, as I keep saying.

Dr Deeny:

Dr Brian Dunn from the general practitioners’ committee of the British Medical Association Northern Ireland also said that not only more doctors but more health professionals are required for primary care in order to prevent unnecessary hospital admissions.

A current cause for concern, which I am experiencing, is the problem with recruiting health professionals to rural areas throughout Northern Ireland. The Department must address that issue. Proposals to improve primary care services are all well and good, but if rural areas cannot attract doctors and nurses, plans for the future will be scuppered.

Mr Hamilton:

I agree. It is a question of having a vision. We must demonstrate that a new system will work and provide a worthwhile career for professionals in which the workload is manageable. As you indicated, that system will be based on teamwork and not on individual practitioners working on their own.

The Chairperson:

Community care and community-care packages were heralded as the new way in which to deal with the elderly, and, indeed, several statutory nursing homes were closed. Unfortunately, that plan was not followed up, and the money was not available to allow people to bypass A&E. Bed blocking resulted from the fact that those people were then put in hospital beds. The unavailability of packages means that some women have been in hospital for six months or nine months, unable to get home. Given that people are living longer, that type of situation must be addressed. There could be a massive explosion if we do not get it right now.

Has the panel to look at mental-health issues been established yet?

Dr McCormick:

Not yet. We are in contact with some individuals about that; we are nearly ready.

The Chairperson:

I assume, and I hope, that psychiatrists who are at the higher end of their profession, who know their way around the whole system and who know what is lacking, will have an input to that panel. I will be talking to the Minister on Monday about several matters, so I will be keen to pick his brains on that issue.

Thank you all for coming, and no doubt we will be in touch fairly soon.

Dr McCormick:

We will be in touch again.

The Chairperson:

Thank you.