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Northern Ireland Assembly

Tuesday 30 January 2001


Dogs (Amendment) Act: Royal Assent

Health and Personal Social Services Bill:
Further Consideration Stage

North/South Ministerial Council: Ministers’ Attendance

Maternity Services

Garda Síochána

Children’s Commissioner

Traffic Congestion (Ballynahinch)



The Assembly met at 10.30 am (Mr Speaker in the Chair).

Members observed two minutes’ silence.

Dogs (Amendment) Act: Royal Assent

Mr Speaker:

I wish to inform Members that Royal Assent to the Dogs (Amendment) Act has been signified. This Act became law on 29 January 2001.


Health and Personal Social Services Bill:
Further Consideration Stage

Clauses 1 to 60 ordered to stand part of the Bill.

Clause 61 (Short title and commencement)

The Chairperson of the Committee for Health, Social Services and Public Safety (Dr Hendron):

I beg to move amendment 1: In page 39, line 5, at end add

"; but section 39 shall not be brought into operation by such an order before 1 April 2002".

I have always been opposed to fundholding because of the inequalities associated with it in respect of patient care. As I have already said to the Health Committee, I have been in general practice for many years. I retired not very long ago, but nevertheless I still have a slight link with a practice in west Belfast that in turn is linked with a multifund — a large conglomerate of over 200 doctors. The link is very slight; I am paid for what I do, but I do not receive any pecuniary gain as a result of the fundholding aspect of that practice.

Nominally, this debate is about GP fundholding, but it is really about the future of primary care services in Northern Ireland. The Prime Minister, Tony Blair, told us not all that long ago that the National Health Service should be primary-care-led. That is what all senior health personnel were saying. What we wanted in these islands was a primary-care-led Health Service starting at the coalface from the bottom up, not from the top down. The former direct rule Health Minister, John McFall, produced the document ‘Fit for the Future — A New Approach’. It was addressed not only to the people of Northern Ireland but to the Northern Ireland Assembly. It emphasised a primary care service but left it to the Executive and Members of the Assembly to progress.

My Committee was familiar with that document. It certainly had a vision for the future of primary care. It expressed a vision of health and personal social services as a single integrated service centred around primary care, directed by and accountable to the Assembly, where the needs of the people came first and the needs of organisations came second — and I want to emphasise that.

We must build on the present strengths of the Health Service. There are many things wrong with it, but there are some strengths, and we should build on them. The structures should be simplified, and the number of separate organisations should be reduced. Dr Maurice Hayes’s acute hospitals review is due to report in the spring, and I hope that it suggests a rethink of management principles and how the health and personal social services can be restructured to make a deal with patients in a meaningful way. Dr Brian Patterson, who is on the GP committee of the British Medical Association, states that

"the establishment and maintenance of ego-building empires must give way to patient-centred service. Primary care relies on a vibrant and effective hospital sector to facilitate the delivery of safe and quality care for patients. This is another reason why any hiatus in the delivery of primary care would be counter-productive. The future of primary care services is much more complex than simply abolishing GP fundholding and pilot commissioning schemes. To abolish fundholding and pilot schemes before new arrangements are in place is wrong and counter-productive."

Mr John Simpson, former chairperson of the Eastern Health and Social Services Board, was reported in the ‘Belfast Telegraph’ of 23 January as saying that to transfer responsibilities for delegated decision making back to health boards would be equivalent to putting the clock back.

I have always been opposed to fundholding because of the inequities it caused. Patients of fundholding doctors did better than those of non-fundholding doctors in accessing secondary care. If fundholding were to cease on 31 March without specific and appropriate primary care arrangements being in place, there would be a massive hiatus. Furthermore, the considerable expertise gained by commissioning pilot schemes would be lost.

There have been many such schemes in Northern Ireland, and they have all been successful. The Minister would accept that point. Let me give one example. The Lisburn primary care commissioning group was able to develop an integrated care pathway across primary and secondary care for terminally ill patients. It was also able to develop a model of community consultation that brings health and social care professionals and statutory and voluntary agencies together with service users to identify local needs and the action required to address them. It also improved the quality and standard of care that patients received through an agreed programme of clinical governance at practice level, where information and good practice is shared between GPs in respect of, for example, patients with diabetes. I emphasise this, because this involves many people — doctors, nurses and various people at community level. Primary and secondary care professionals have developed jointly prescribing guidelines for ulcer-healing drugs, antibiotics and analgesics and hormone replacement therapy.

The Armagh primary care commissioning pilot scheme developed a significant range of patient-centred services through a partnership of professionals, users, the local community and other statutory and voluntary sector organisations. It delivered the first community-based cardiac rehabilitation programme in Northern Ireland. It is important for Members to appreciate that point. Since that programme was launched in April 2000, more than 70 people have benefited from that vital service, compared with only six in the previous year. Its nurse-led Heart Wise clinics are in all local GP practices and provide a high quality of evidence-based secondary prevention service for cardiac patients. The pilot scheme has also provided a primary-care-based counselling service for people who are depressed or have suffered a bereavement and a fall prevention programme for the elderly.

I could also go on about pilot schemes commissioned in mid-Ulster, Ballyclare, north Down, Antrim, Ballymena and north, south, east and west Belfast, all of which have been substantial achievements. I saw those schemes as the nuclei of a future primary-care-led health service. It is important, therefore, to build on the benefits. What are they? A higher quality of patient care; greater access with improved local service; a better response from hospitals; a reduction in waiting times and lists; greater choice for patients; highly motivated primary care staff; patient involvement; computerised, easily accessible clinical information systems; and the development of nurse practitioners. I am sure that the Minister would not want to be responsible for withdrawing the following: cardiac rehabilitation services based in leisure centres in Armagh; enhanced delivery of diabetes care in Newcastle, Whiteabbey and Magherafelt; screening of people with learning difficulties in Antrim, Ballymena and north and west Belfast; and community development initiatives in the Hillhall estate in Lisburn and in south Down. Nor, I am sure, would she want to be responsible for the closure of primary-care-led hospital beds in Whiteabbey and Castlewellan, which will further increase pressure on our hospitals.

It is vital that the achievements of the present arrangements be preserved and carried into a new framework. A top-down approach will not work. Effective and efficient management of new primary care structures cannot be enhanced by increasing the power and influence of health boards.

The Assembly is unlikely to have another chance to create major initiatives in primary care in the foreseeable future. That is why this debate is so important. Giving more power to health boards makes any future review of such a structure much more difficult. The Minister has said on a number of occasions that the Executive will carry out a major review of public administration. I accept and support that, but the Health Service cannot wait for it. A review of the Health Service, which examines looking at boards and trusts, is needed within the next year and a half.

The draft Programme for Government states that we must

"refine existing policies and programmes and create new ones, tailored to the specific needs of Northern Ireland."

It says that

"our joint aim must be to improve our policies and programmes and create the best legislative framework for the future."

That is what this debate is about.

"A vision of a modern, successful society must include major improvements in the health of our people."

Former President Bill Clinton said recently that to stand still is to go back. What the Minister is proposing for primary care is, de facto, a return to the days before fundholding, with the inevitable loss of expertise gained by staff involved in pilot commissioning schemes and fundholders in general. In the draft Programme for Government, one of the actions to be taken is to

"finalise a strategy which will replace the GP Fundholding Scheme with fairer, less bureaucratic arrangements in primary care designed to strengthen structures for delivering high quality primary care services in local communities".

Giving more power to health boards will not strengthen those structures. After all, they are the ones who are looking after GPs in Northern Ireland who are not fundholders. It is ludicrous, therefore, to put everyone in the charge of the boards. In the past it has been a failure.

Dr Brian Patterson said that going back eight years to health board management would undo much of what has been achieved. What we have always asked for is a seamless transition. It is not just fundholding; the commissioning pilots are also being told to down tools. The Royal College of Nursing has said that it welcomes the primary health care document, especially the abolition of GP fundholding in Northern Ireland. However, if GP fundholding is abolished in April, with no infrastructure in the interim, many problems will emerge for nurses and nursing.

10.45 am

Royal colleges have been inundated by primary care people, both doctors and nurses, expressing their deep concerns about job losses. General practitioners have been funding nurse-prescribing roles from fundholding savings. They have already informed nurses that their employment will be terminated in the future due to a lack of funding. We are deeply concerned about this latest development and would like to express our support for the amendment proposed by the Health, Social Services and Public Safety Committee on Wednesday 24 January 2001.

The mere mention of the words "royal colleges" results in some Members becoming annoyed. While surgeons and physicians may have played some role in the downgrading of Dungannon, Magherafelt and Downe Hospitals, one cannot have a blanket condemnation of all the royal colleges. Mr Speaker, you will appreciate the point. We are talking about the Royal College of General Practitioners and the Royal College of Nursing. Dr Peter Colvin, Chair of the Northern Ireland faculty of the Royal College of General Practitioners, as said:

"I think the hiatus in the organisational structures is very detrimental to primary care. It is demoralising for health care staff and frustrating for those trying to deliver a quality service to their patients."

He added that the resource implications for the overhaul of primary care structures must be addressed.

The Minister’s document contains a list of aspirations for the development of primary care services. There is no commitment to resources and no timetable to put these aspirations in place. Dr Colvin further declared that he was concerned that the quality of patient care would be affected gravely by the hiatus.

We must give the people of Northern Ireland the best primary care service possible. Our people deserve that. It is what this debate is about. We are not likely to have another chance for some time. The future of primary care will affect every family in Northern Ireland. It will affect every man, woman and child. It will affect the elderly, children, the mentally ill, the disabled and the socially deprived. Therefore, we must get it right. We all know about the poor health of people in this part of the world. Life expectancy in Northern Ireland is among the worst in Europe. We have the third-highest death rate in Europe from coronary artery disease. Female lung cancer rates are the highest in Europe, as are those for breast cancer and teenage pregnancy. Young male death rates from accidents and suicide are the highest in the EU.

With regard to health inequalities, sickness and death hit the poorest worst and first. The death rate for the unskilled is three times greater, and the poorest are twice as likely to die prematurely. The Health Service in Northern Ireland, as in the rest of the United Kingdom, is in a poor state, with huge hospital waiting lists and delays in the treatment of cancer and cardiac surgery. These factors all add to the great confusion. Our patients deserve better.

Given the will, there is more than enough talent in primary care in Northern Ireland to enable us to develop a primary care service that is fit for the twenty-first century. Before Members vote, I ask them all to consider the positive proposals in John McFall’s document ‘Fit for the Future — A New Approach’. Members should consider this and then look at the main section of the document, titled ‘Building the Way Forward In Primary Care’, and ask themselves whether, if fundholding and, above all, the GP commissioning groups, finish on 31 March, structures will be in place not only for the smooth development of primary care but also for the provision of the best possible service for the people.

Mr McFarland:

GP fundholding is wrong in principle, and it must be changed. It is an inequitable system. Members will be aware that some 90% of medical care is carried out at primary care level. Sixty per cent of GPs — 600 — in Northern Ireland are fundholders. They cover 65% of the population. Two thirds of the Northern Ireland population come under GP fundholding. It is fair to say that fundholding has been, by and large, a success. There have been some failures. Some doctors have not handled it well. However, those doctors who are in fundholding believe that it has been a success. Their patients are happy that they get a better service. This is where the problem arises, because that situation is inequitable for patients who are not in fundholding practices and whose commissioning is done by the boards. They do not get as good a deal. That is unfair, and that is why there has to be change.

Over the past few years, a substantial expertise has been built up in fundholding. Professionals deal with the money and commissioning matters. There is a great danger that, if fundholding is ended precipitously on 31 March, many people who are not NHS staff but who are contracted to GPs will be lost. They will find jobs elsewhere. The future plan for primary care, as you are aware, is to bring GP commissioning into being at a slightly higher level, not with individual doctors but with groups of doctors. Those organisations will need the expertise which currently exists in fundholding, but by the time we get round to it — in a year, perhaps — and we are then looking for such people, they will have obtained work elsewhere.

What is the hurry about all this? We are being asked to end fundholding on 31 March and to give commissioning back to the least successful commissioners in the current system — the boards.

Members will be aware that a primary care review is taking place. Dr Maurice Hayes is carrying out an acute hospitals review. The object of the exercise is to produce a new system, a seamless robe of medical care that is the best we can design for our patients. The primary care review does not report until 2 March. It seems that, regardless of its findings, we will chop fundholding by 31 March. We have had no opportunity to look at what the proposals might be, nor to devise an equitable and suitable system that we all like. Regardless of our choice, fundholding is to be chopped. That is not right.

The Committee has spoken to the British Medical Association, the Royal College of General Practitioners and the Royal College of Nursing. Those organisations are happy that GP fundholding should go but are very unhappy at the speed with which it is taking place. This morning I received a letter from my north Down primary care organisation that said, "Please do not do this until you have something to put in its place." My point is that I do not understand why this is being rushed, why a decision to chop this is being taken before there is something better — which we hope will come out of the reviews — to put in its place. It makes no sense. We will lose the expertise, and how will we get it back? What is the hurry? We need time to put the new system in place.

The professionals are against stopping GP fundholding on 31 March. Patients will lose out until there is a better system. I urge Members to think carefully, because we are in serious danger of throwing the baby out with the bath water. We need time to allow these studies to take place, and to allow the Department to bring forward something sensible with which Members and professionals are happy. I urge Members to support the amendment and buy us that time.

Mr Berry:

I support the amendment. Many discussions have taken place in the past few weeks in relation to the repeal of GP fundholding. It was expressed time and time again — Mr McFarland and Dr Hendron have covered it very well — that many professionals argued before the Committee that they had no problem with the ending of GP fundholding. The problem they found was that there was nothing to replace it, and they asked why we should rush through the whole process. We should give it a year and then go for the ending of GP fundholding. If this measure goes through as it is, our Health Service will become nothing more than a joke.

Like many others, I find it hard to understand how anyone could come up with such a measure without first asking a few simple, common-sense questions. What have others done about this issue? What will replace the present system? What will be the immediate effect of abolishing that system? Most importantly, what vital services will close as a result of ending GP fundholding? If the Minister had been briefed properly she would have asked herself these questions. Are there any excellent things we ought to keep? Should this matter be phased in along a set timetable? These and other simple questions were never asked, and perhaps never answered.

The English model says that whatever is good will be retained. As Mr McFarland said, we are throwing the baby out with the bath water. Many would say that we are not even keeping the bath. GP fundholding was not in itself a disaster, which is why it is being retained in England. Rather, the fault lay in the fact that not every GP was a fundholder. That is why so many have come to oppose it: it brought division to a once-unified service.

The Assembly is faced with a choice of whether to act like vandals or like responsible politicians. The vandal will abolish without replacement; the responsible politician will replace and abolish as a unitary act. Since we have nothing to replace GP fundholding, we cannot abolish it. Discarding the system is the work of a philistine with no comprehension of the effect and impact on patients, services and GP morale. If a person were to fix a vehicle in the way that the Minister proposes to fix the Health Service, it would be akin to abolishing the petrol engine and going back to steam, while waiting for an inventor to come up with a replacement.

Many people and professionals in the community do not want to see the continuation of GP fundholding, but they want something credible in its place before action is taken. I support the amendment, and I trust that Members will stand behind the Chairperson and Deputy Chairperson of the Health Committee in support of it.

Ms Ramsey:

Go raibh maith agat. I oppose the amendment. I am a member of the Health Committee, and we had a number of frank discussions in the Committee. In fact, some Members have said more today than they said at the Committee meetings. Perhaps it has something to do with having speech-writers.

My colleague on the Committee, John Kelly, and I felt that we could not support the amendment. Our views were placed firmly on the record. Sinn Féin is on record as saying that GP fundholding has been wrong from its inception. Every party in the Assembly has said, at one time or another, that GP fundholding is wrong and that it welcomes the ending of that system.

The Chairperson of the Committee, Dr Hendron, said that pilot schemes will be lost. It is my understanding that pilot schemes will not be lost. Extending GP fundholding for another year would not give us time to put in place a proper replacement. The expertise and staffing mentioned will not be lost; they will just be reintegrated into another part of the service. Keeping GP fundholding would send out the wrong message, because for years it has created uncertainty, not only among staff but in the service as a whole. This amendment would just add to that.

GP fundholding is wrong. It created inequalities and a two-tier system in the Health Service, and it must go. Mr McFarland said that GP fundholding is wrong but that it has been a success. I do not know where he got that from. If something is wrong, how can it be a success? He also mentioned expertise. As I have said, that expertise will not be lost.

11.00 am

The professionals are against change. They do not want to lose control of GP fundholding. We need to point out that the overspending within fundholding has led to large deficits that have had to be met by the boards. Those deficits are taking money away from front-line care. The Minister told the Committee last week that, because of this overspending, some 45 GP fundholders will be legally required to leave the scheme this year. That adds to the uncertainty.

GP fundholding is unfair. It has created a two-tier system. Continuing it for another year will tie up much-needed resources and will only add to the delay in delivery of primary care. The Committee Chairperson was also told that GP fundholding will not end right away; there will be a phased rundown over six months, while at the same time implementing primary care. Members need to take that on board. If we delay it for another year, and there is then another phased rundown, where will we be going? We will be two years down the road.

The services provided by GP fundholders will not end. The delivery of the service will continue. The only difference will be in who commissions that service. This fightback by fundholders be stopped. The sectarian, anti-Sinn Féin politics of the DUP must not be allowed to dictate this amendment. I find it worrying that some members of the SDLP are prepared to support maintaining fundholding, even though —

Mr Beggs:

Does the Member accept that this is a matter of judgement on health issues? It is totally false to introduce sectarianism. This is a matter of looking after patients in all Northern Ireland.

Ms Ramsey:

I accept what the Member says. What I am clearly saying is that anti-Sinn Féin sectarian attitudes should not be allowed to dictate this amendment.

Some members of the SDLP are prepared to support maintaining fundholding, even though the Chairperson of the Health Committee, Joe Hendron, has said time and time again that fundholding is wrong. Fundholding created inequality in the Health Service. For the first time, this Bill gives us the opportunity to tackle the inequalities in the Health Service and the inequalities created by GP fundholding.

I cannot support the amendment.

Mr McCarthy:

I support the amendment. I ask the same question that Alan McFarland asked: what is the rush? We must get it right this time. Many important points have been raised this morning, particularly by the Chairperson of the Health Committee, Dr Joe Hendron, whom I consider to be more expert on the subject than many Members.

Fundholding was interesting and, perhaps, useful in certain circumstances. However, a decision has been made to leave fundholding behind, and we in the Alliance Party and many other parties in the Assembly support that. The extra time outlined in the amendment will give all concerned the opportunity to put in place something that will benefit both the patient and the GP. Using the experience of fundholding and other practices during recent times can only help us all to provide a more equitable way forward for the Health Service.

The Alliance Party supports the amendment.

Mr B Hutchinson:

I support the amendment, as a member of a party that has been totally opposed to GP fundholding and recognises that it creates a two-tier system. We believe that it should be taken out of commission. Our big difficulty is that nobody has convinced us that this money will not go back to the boards when the time for doing away with GP fundholding arrives at the end of March.

We all talk about how we will spend this money on primary care. In my view, if the money goes back to the boards it will not be spent on primary care. It will be spent where it is always spent — in acute hospitals, particularly the Royal Victoria Hospital. That is where the inequality is. We allow the Health Service to take money from primary care and put it into acute services. We continually must ensure that whatever we have in place is primary care, and that it recognises the nurses and the health visitors in the areas where we live and work. That is what we need to do. To date, nobody has convinced me that primary care will be a winner when GP fundholding is removed. We want fundholders to remain for another year, until such care is in place.

We could argue about where the money will be spent, but when GP fundholding goes, the boards will be left in control of their money. In recent years, I have watched my area’s board spend that money as it pleased. It spent it on the deficits for which it, rather than the GP fundholders, was responsible. It has done away with the people we need, such as physiotherapists and occupational therapists, who have been taken out of my area and not replaced. Despite this, there are still elderly people in my community, some aged 84, who have to wait at least two years before they can even get a consultation.

Let us make sure that we get this right. Let us hold on to the GP fundholding for one more year until we have an alternative primary care service in place. Let us not leave it to the boards, because they will put the money into acute hospitals and not into primary care.

Ms McWilliams:

This is a time of uncertainty, but it is also one of major change. The ongoing reviews of acute hospitals, acute care and primary care and investing for health signal a period of hope. That should be seen as a period of opportunity and not as a period of threat.

The extent of people’s concern that we may move backwards rather than forwards is disappointing. In my opinion, the reverse is taking place, and the announcement that GP fundholding is to end marks an opportunity for us to move on to something different.

I am very concerned, and I have a number of questions for the Minister about the closure of fundholding and the role of the boards. It is also important for us to remember the members of other multidisciplinary teams in primary care. "The Invisible Army" was the title of a conference held last week by community nurses, district nurses and health visitors, who believe that their voices have not been heard in this debate. We must remember that it is not just GPs who should have a major vote in deciding the way forward.

The removal of fundholding has been presented in a very negative light, even though many GPs and other health care and social care professionals welcome such a move in the light of the inequities and the perverse incentives it created. We should be made accountable for deficits. In the Eastern Health and Social Services Board alone, fundholding has created a deficit of £4·1 million. According to empirical evidence, five fundholding practices in the North Belfast and West Belfast constituencies had £2·7 million savings, of which £1·47 million went back into the practices for structural improvement. Only £117,000 was spent on services to the community. This is taking place not just in South Belfast but also in extremely deprived communities, of which there are also many in South Belfast.

We who hold others accountable for how they spend their money should be making decisions on such inequity and deficits. Is that what we want to continue over the next year?

Fundholders have also expressed concern to Members of the Assembly and Health Committee members that innovative practices will not be protected or continued. I ask the Minister to address that point.

According to the departmental officials who addressed the Committee, it seems that they will build on good practice and incorporate its various elements rather than just end them. I pay tribute to the excellent practice that has emerged from the commissioning pilot schemes, including the pilot scheme on the care of the elderly which took place outside my constituency in the Down Lisburn Trust area. And if we can build on the innovative practices now in place and mainstream them, we will relieve some of the alarm, anxiety and fear of those working on that pilot scheme.

Savings on prescriptions have been made, and that is probably the area flagged up most by GP fundholders. However, it is unfair to suggest that non-fundholders have not saved on prescriptions also in the past years. On some future occasion we may debate the distribution of generic rather than specialist types of drugs to some people. Nonetheless, whether or not patients’ needs are best served by the way in which doctors have had to address themselves to the prescription charge debate, it remains laudable that both fundholders and non-fundholders have made substantial savings on prescriptions. The main worry for GP fundholders is that any savings they have made to date may be dispersed after 31 March. That will obviously be an anxiety for people who have gone out of their way to make savings. If these economies are taken from doctors and given to the boards, the doctors may feel that all their hard work has been to no avail. On the contrary, I believe that where savings were made, they were benefited from. Perhaps the Minister could address that issue in her response.

There is also the matter of redeployment. What is to happen to the staff who were part of the pilot schemes and those who work in fundholders’ practices? We are not heartless individuals. The boards have been asked to address that task. The debate must continue about whether or not those staff can be redeployed elsewhere and whether some of the best practices can be mainstreamed. Otherwise, we will wake up on 1 April and suddenly discover that everything has changed and all the best has been thrown out.

Even if we had gone down the road of ‘Fit for the Future’, as opposed to the road of the current consultation document, we would still be going through a period of transition. Transition is something that we know about. As we are often told, we are in a period of transition with devolution. Clearly, there is going to be a massive public administration review, and we are heading towards that in this period of transition. In the end, we will be focused and fixed on agreed best services for primary and community care, and all Assembly Members will have been part of that decision-making process. We do not want to move away from providing services to the community. Those models are the options we must consider.

I would also like to mention data systems. GP fundholders tell us that they have the best data systems and that those who are not in fundholding practices have poor systems. This is not an issue of GP fundholders versus non-fundholders; it is an issue for the whole country. We should have a regional strategy on accurate data systems. We need a database across the country that records waiting lists and tells us accurately when patients went into hospitals, how long they were there and when they came out. To date, it has been possible for patients to fall through the system, and they have neither been tracked nor traced. We should now attempt to redress this problem as part of our strategy on the way forward rather than leave efficient data equipment a premium available only to GPs who benefited from the fundholding system.

We need to focus on clinical practice. The best clinical practice should not be lost. Concerns have been voiced that the innovations implemented there did not show the best way forward. Dr Hendron said in his introduction that he is concerned about expertise. I have experience of restructuring and major change in universities. We built on the best expertise and made progress. The last thing anyone wants to do is marginalise good expertise; rather we must continue to centralise it and thus dispel fears.

11.15 am

That is why we need to move forward quickly from a system based on those GPs who showed an interest in change and a pilot system toward mainstream organisation in primary care with a view to raising standards everywhere. It is time to end that uncertainty and move forward.

I am concerned about this issue in relation to the boards. Clearly, there is great unease about the role of the boards and a worry that if local health and social care groups are established as subcommittees of boards it will be more difficult to review and change their role following a review of public administration. Members have already said that it will be difficult to take that power away. I am also concerned that not everyone takes an interest in this issue and that Members attack boards unnecessarily. Different parts of the administration have different roles to play.

The community service is an excellent public service. The Minister and I saw it last week when the South and East Belfast Trust was handing out awards for home-care packages, which are delivered by a multidisciplinary team working together in the interests of individual patients to ensure that the patients remain at home, or are discharged earlier from hospital, or never have to go to hospital in the first place.

Members have voiced fears that boards want to give themselves even more power. That may happen in the transitional stage, but my understanding is that the opposite will happen once a decision has been made on the best strategic model, which is currently out for consultation.

There should be no special pleading for boards, but they are a key building block in the current system. In the transition period they may be the glue that holds the different elements together. When the jigsaw pieces are eventually put together the glue will no longer be needed. My understanding is that the boards do not want to be in that position any longer than is necessary.

A central thrust of the proposed new arrangements is not about adding to bureaucracy. However, it is when Members think that an additional tier is being added that we get the longest speeches. The arrangements are about creating opportunities for integration and partnership with the health and personal social services. In Northern Ireland we have been commended for our integrated family that encompasses the social services on the one hand and the Health Service on the other. We aim to drive forward the different components of that service.

Primary care professionals and trusts have important roles to play in working with boards to develop the new plans. I am very heartened by the action, health, well-being and implementation plans in ‘Investing for Health’, and the contents of that document need to be incorporated.

Let me also give voice to those least heard — community nurses, district nurses, school nurses and health visitors. More than 150 of these health care workers have written to me. Their conference was held on Friday 26 January 2001, and I have tried to circulate a letter I have received to as many Members as possible. The letter states:

"GP fundholding has curtailed innovative practice and staff development in the community. One example is that many GPs have been very reluctant to support the development and extension of practice of community nurses and health visitors, even though such developments are beneficial both to patients and to staff.

I am appalled by the injustice of this two-tier system which allows inequity of service provision within the communities.

Limitations have been placed (both financial and professional) on community nurses and health visitors. The latter especially have lost a large part of their public health role that they are trained and skilled to deliver.

If GP fundholding is extended, health visitors will be unable to effectively deliver the public health agenda which has been proposed in the ‘Investing for Health’ consultation document. Because of the payment system to GPs" —

many Members may not realise this —

"health visitors are commissioned by them to meet their targets in relation to immunisation programmes and development surveillance of pre-school children. Community nurses and health visitors are trained to work using a holistic approach to patient/client care. GP fundholding has served to disempower nurses by focusing on a medical model of intervention and a task orientated model of practice. This scenario exists largely because GPs are trained to treat disease rather than to prevent it."

Those are pretty harsh words. However, community nurses and health visitors are concerned that, if this remains in place for another year, they will continue to be treated as people who simply carry out immunisation and surveillance programmes because of the payments given for that work. Rather, they should be viewed in a holistic way, given that they have been trained to carry out the public health role of preventative care.

Community nurses and health visitors say that they feel —


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