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Northern Ireland Assembly

Monday 11 March 2002

Contents

Assembly Business

Public Petition: Transfer of Omagh Permit Office

Assembly: Committee of the Centre

Assembly: Committee for Health, Social Services and Public Safety

Assembly: Committee of the Centre

Primary Care

Agriculture Industry

Oral Answers to Questions

Department of Education

Department of Health, Social Services and Public Safety

Department of Finance and Personnel

Agriculture Industry

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

Members observed two minutes’ silence.

Assembly Business

 

Mr Speaker:

Following last Monday’s Question Time, Mr Derek Hussey raised a point of order seeking clarification on the convention adopted by the Speaker or Deputy Speaker in choosing supplementary questioners.

The choice of supplementary questions is at the discretion of the Speaker or Deputy Speaker, and there are many matters to be taken into account. I have discussed the matter on several occasions with the Business Committee. There is the need to balance satisfactory exploration of the issue with the need for Ministers to answer as many tabled questions as possible in the time available.

Aside from the question from the Member who tabled the question, I shall ordinarily call a maximum of two further supplementary questions. I do that to ensure that Members who take the trouble to table questions are not excessively disadvantaged by other Members who request to ask supplementary questions. I shall not generally call more than one Member from any party to pose a question or supplementaries to it. In addition, I shall not call a Member to pose a supplementary question who already has a listed question on the Notice Paper that may be reasonably expected to be reached by the Minister during Question Time.

There are many other matters to be taken into account, such as the preference accorded to Chairpersons and Deputy Chairpersons of Committees whose Minister is answering the particular questions, the preference accorded to other Members in a constituency, when a constituency is the subject of a question, and the recognition of Members who have a standing interest in the issue to hand.

With only two supplementary questions and at least five major sections of the House, if not more, it is clear that on many occasions there will not be a balance within a question. However, the Speaker or Deputy Speaker does try, as far as possible, to maintain a balance over time. I have studied Hansard in respect of this period of questions, and I am content that, as far as was reasonably possible, the proper conventions were followed in questions to the Minister. I hope that this assists in clarifying the matter for the Member and the House.

Mr Hussey:

On a point of order, Mr Speaker. The Minister mentioned people who had a relevant interest in the issue. However, two members of the Committee for Regional Development were not called to speak. In spite of the cross-community nature of the Assembly, no one was called to speak from this side of the House.

Mr Speaker:

I have to say that I think the Member is picking and choosing; he needs to be careful that he is not challenging the Chair. The question of the occupant of the Chair at any time is not a matter of issue. The conventions are clear, and Members will see that the matter was properly attended to. I hope that the Member will read all of what I have said, not just the bits of it that happen to suit that particular question for himself.

Public Petition: Transfer of Omagh Permit Office

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Mr Speaker:

Mr Hussey has begged leave to present a public petition in accordance with Standing Order 22.

Mr Hussey:

I beg leave to present a petition on behalf of 91 farmers from West Tyrone under Standing Order 22. I acknowledge the work of Omagh district councillor, Bert Wilson, who is a farmer and a signatory of the petition. The petition is in support of the transfer of the Department of Agriculture and Rural Development permit office from Sperrin House, Omagh, to the agricultural mart at Drumquin Road, Omagh. The concern of the petition is further heightened by the closure of parking facilities at the former Omagh Showgrounds site, thus increasing the difficult access problems at the current location of the Department’s permit office and the problems associated with parking in Omagh generally.

Mr Hussey moved forward and laid the petition on the Table.

Mr Speaker:

I will forward the petition to the Minister of Agriculture and Rural Development and a copy to the Chairperson of the Committee for Agriculture and Rural Development.

Assembly: Committee of the Centre

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Resolved:

That Mr Duncan Shipley Dalton shall replace Mr Fred Cobain as a member of the Committee of the Centre. — [Mr Davis.]

Assembly:
Committee for Health, Social Services and Public Safety

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Resolved:

That Mr Tom Hamilton shall replace Mr Alan McFarland as a member of the Committee for Health, Social Services and Public Safety. — [Mr Davis.]

Assembly: Committee of the Centre

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Resolved:

That Mr Danny Kennedy shall replace Mr James Leslie as a member of the Committee of the Centre. — [Mr Davis.]

Primary Care

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

I beg to move

That this Assembly expresses its grave concern about the future of primary care services in Northern Ireland and calls on the Minister of Health, Social Services and Public Safety to take prompt action to allay the serious concerns of the professionals and staff working in health and social services about the arrangements for local health and social care groups.

The debate is about the future of primary care services in Northern Ireland. The Prime Minister, Tony Blair, and successive Secretaries of State have told us that the Health Service should be primary care led — it should be led from the coalface: from the bottom up; not from the top down. The former direct rule Minister, John McFall, produced a document some time ago called ‘Fit for the Future — a New Approach.’ It was addressed to the New Northern Ireland Assembly, and it expressed a vision of health and personal social services as a single integrated service centred around primary care.

The needs of people were to come first, and the needs of organisations were to come second. The proposed new groups are to be committees of the health boards. I welcome the end of fundholding because of the inequities in the system. However, the four health boards have been around for years, carrying out the commissioning for non- fundholding practices, and they have not succeeded. We are moving backwards rather than forwards.

I unequivocally support the setting up of new primary care groups, with multidisciplinary teams working together. However, the guidelines should have been issued a year ago — certainly, at least 10 months ago. Our vision for primary care should be similar to that in England — empowering front-line staff to use their skills and knowledge to develop innovative services, with more say in how services are delivered, and empowering patients to become informed and active partners in their care.

We understand the massive financial constraints on the Minister and the Department of Health, Social Services and Public Safety and I am aware of the recent report by the Northern Ireland Confederation for Health and Social Services (NICON), which covers the four boards. One of the points that it made was that an extra 100 million per year is needed, in real terms, over the next 10 years to bring the service up to an acceptable level. I accept that there has been a legacy of underfunding over many years. However, a 72% increase for the health budget was announced in October 2000; 17 million was allocated in November 2000; 145 million was allocated in January; and a further 185 million was allocated in February. In total, the budget available for 2002-03 will be over one third — 37% — larger than the budget when the Minister took office. That is an increase of 687 million.

There are huge pressures on primary care professionals. I must refer to the waiting lists, which everyone is currently talking about. I accept that there have been 20 years of underfunding, and I appreciate the efforts that the Minister has already made. We have the problem of the cancellation of outpatient clinics. We have so-called bed blocking — I do not like that term, but we all know what it means. I am aware of the Minister’s framework for action on waiting lists announced in September 2001 and the boards’ comprehensive waiting list plans and quarterly monitoring reports. Indeed, I think that there are also bimonthly meetings. However, if there were one board instead of four it might be easier, and we might get more uniformity of services across the North.

On 20 February, the Minister announced the establishment of 15 new local health and social care groups, and I will quote from her press release at that time. Commenting on the high degree of consensus among stakeholders in establishing the new groups, the Minister said

"I hope this will point the way to a continuing focus on partnership, co-operation and shared objectives, which will be crucial for the new Groups to fulfil their full potential."

I accept that, but there was not consensus among stakeholders on the option that the Minister chose. In the same press release the Minister said

"The experience of the five Commissioning Pilot Groups has shown that GPs and other primary care professionals working together in groups have improved the provision and quality of local services."

I agree with that statement, and I would have thought that the new primary care groups would be based on such pilot groups. However, Dr Harold Jefferson, chairperson of the successful Lisburn commissioning pilot, said in a recent letter to all MLAs

"I am deeply distressed and disgusted at the present plans for the local health and social care groups. What is to be their function?"

Dr Jefferson goes on to make the point that although we are told that the groups are developing from the commissioning pilots, they bear scant resemblance to these organisations.

On 1 March, the director of primary care in the Department of Health, Social Services and Public Safety replied to Dr Jefferson. In his letter the director blames the Assembly, because it voted last year to delay the ending of GP fundholding. However, Mr Speaker, you and Members know that the purpose of the amendment was to facilitate, and ensure that the Department brought about, a seamless transition into new primary care structures. Over a year has passed, and we do not have any such transition. The director also said

"We have always believed that a timescale for setting up the new groups is achievable, provided that there is appropriate commitment, co-operation and goodwill from all concerned."

However, there is total commitment and goodwill from all the professionals in primary care.

The problem lies with the Department, which seems to have wasted almost a year. It is inexcusable that the guidelines for new primary care arrangements have not been introduced in the last nine or 10 months. I have heard explanations from the Department about finance and personnel. It can juggle the figures in whatever way it likes, but the fact is that at least 10 months have been wasted. The guidelines must have been ready a year ago, and I do not see why they were not announced long before they were.

12.15 pm

Mrs Hilary Herron of the Royal College of Nursing (RCN) sent a submission to the Assembly’s Health Committee, expressing the disappointment of RCN members. The RCN referred to the amendment tabled a year ago and the fact that seamless transition is now impossible. The RCN also stated

"Frontline primary care nurses have not had an opportunity to voice their opinions regarding the guidance on the constitution, governance and accountability arrangements."

Front-line nurses who work at the heart of the community should be represented in the group.

In its letter of 19 February 2002, the Northern Ireland Board of the Royal College of Midwives made various points, one or two of which I will quote

"We were profoundly dismayed therefore to find that the midwifery profession is not even mentioned in the recent Guidance Circulars, there is no recognition of midwives as primary care professionals, there is no provision to have midwifery representation on the Management Boards of the proposed new Local Health and Social Care Groups."

The Royal College of Midwives also stated

"Although the Minister in her announcement of 12 October 2001 indicated that there had been ‘broad support’ for the preferred model proposed in ‘Building the Way Forward in Primary Care’, the Royal College of Midwives, in common with most other professional organisations in Northern Ireland, including the Royal College of Nursing and the British Medical Association, did not support the proposal to establish LHSCGs as committees of the existing Health and Social Services Boards, seeing this as adding another layer of bureaucracy to an already ‘top-heavy’ structure for health care provision".

Dr Brian Patterson of the General Practitioners Committee (Northern Ireland) of the British Medical Association Northern Ireland also wrote on 1 February 2002 and made many points. I will not repeat all that group’s concerns except for two, which I will quote:

"lack of detailed guidance across the board bearing in mind LHSCGs are due to go live in 8 weeks’ time";

and

"no details of timescale as to when LHSCGs will be empowered".

All Members will have seen that letter, so I will not quote anything more from it.

The Northern Ireland Multi-Disciplinary Primary Care Forum stated

"We see proposals that still have no clear vision or commitment. They create, in the words of one civil servant, a set of new bureaucratic quangos."

It goes on. The Northern Ireland Public Service Alliance (NIPSA) quoted two aspects of deep concern:

"fair protection for GP fundholding staff.";

and

"inadequate public consultations about the Department’s guidance on the composition and operation of the proposed Local Health and Social Care Groups."

In relation to the first point, I am aware of the redeployment centre in the Central Services Agency. I have had telephone discussions with the relevant person there. I hope it works out, but I have doubts about it.

The bodies that wrote in totally supported the new groups, as we all do. They do not, however, make any reference to delays. Correspondence was also received from Prof Salmon, Chairperson of the Northern Ireland Trust Nurses Association, from the Directors of Nursing in the boards and from the Association of Directors of Social Services, whom we met last week. There were also a couple of other groups. We all support the local health and social care groups, but it is a question of how the groups are set up and why the guidance was not given long ago.

The Minister appeared before the Health Committee on Wednesday 6 March to discuss the health budget and primary care. We were pleased that she did, and it took several hours to cover both subjects. At the meeting, reference was made to the Committee meeting on Wednesday 27 February, when representatives of the Royal College of Nursing, the British Medical Association GPs’ Committee and the Royal College of Midwives attended. Those bodies requested a meeting with the Minister. Members will have a copy of a letter dated 19 February, signed by Dr Brian Patterson, Mrs Hilary Herron of the Royal College of Nursing and Mrs Breedagh Hughes of the Royal College of Midwives, in which they expressed extreme worries about the situation. Those three groups represent many front-line staff, and, therefore, the Health Committee advised them that they should seek a meeting with the Minister. At the Committee’s meeting last Wednesday, we were told that no such request had been received. I subsequently found out that a letter, signed by all three representatives, was handed in at Castle Buildings on Tuesday afternoon. I am not suggesting that the Minister knew about that, but the letter was handed in.

I strongly support the primary care groups. We will be in big trouble if we do not get primary care right, because it is the basis of the whole Health Service. Everyone concerned must be involved in meaningful dialogue.

I welcome the end of fundholding, and I sincerely want the new primary care groups to succeed. We have had a golden opportunity for change. Perhaps it is not too late. The people of Northern Ireland deserve the best; it is now up to the Minister and her Department to achieve that.

Mr Speaker:

The time limit for this debate is two hours. As one might imagine, many Members wish to participate. Therefore, in order to facilitate as many Members as possible, I am imposing a limit of six minutes on all contributions, except those of the Minister and the mover of the motion.

Dr Adamson:

My background is in community child health, although I trained as a general practitioner. I am acutely aware that early diagnosis has become increasingly important, due to recent advances in drug therapy and the potential gains from the modification of risk factors. In most areas of medicine early diagnosis assists the GP, as it permits the formulation of a management plan, which obviates much of the later crisis intervention. Family practitioners remain the central core of the provision of support and co-ordination in medicine, which benefits both patients and carers.

I am not a member of the Committee for Health, Social Services and Public Safety, but I keep in close contact with my Colleagues on it. The Department’s consultation paper, ‘Building the Way Forward in Primary Care’, had many positive features that can be readily supported. The proposals were outlined in section 6 of the document, following an analysis of five models or options in the previous section. This is the model described as option 3, evolving into the option 4 model. Both models involve the creation of multidisciplinary care groups to serve populations of between 50,000 and 150,000. Option 3 proposes groups that would be mainly advisory, while option 4 proposes groups having devolved commissioning budgets.

If any approach is to be successful in developing the agenda for change in health and social care and developing the full potential of primary care, we must clarify the concept of primary care to include health, social and community care. It is inevitable, and highly desirable, that closer working relationships with community trusts will develop, and, eventually, integration can take place between the new local health and social care groups as equal partners.

Adequate resources will need to be prioritised to allow the new groups to flourish. Important areas include training and managing support and resources for infrastructure and programme development. The costs involved in information and communications technology (ICT) development are considerable, but essential if desirable quality improvements are to be realised.

Much will depend on the overall resource allocation to health and social care. If the allocation is inadequate, no amount of innovation or efficiency will be able to deliver the required outcome. Northern Ireland should aim to have at least the same resource per capita as any other region in the United Kingdom — preferably a sum that fully reflects the additional needs of our population.

Option 4 might not be an end in itself, but it is a firm foundation for further developments in integrated health and social care delivery. The Department has said that it must ensure that the right structures are in place and that the right policies are pursued in order to achieve the Executive’s strategic priority of working for a healthier population. However, we must not become bogged down in bureaucratic wrangling when the real war is against disease, social injustice and the inequalities in health and well-being for a large section of the population.

Mr Berry:

The motion does not argue for the retention of GP fundholding. Indeed, the argument is not about the merits or demerits of GP fundholding, which, as it is currently constituted, is dead in the water. Those who wish to rehash arguments over that issue have lost the plot, or at best they want to deflect attention away from the real issue that the motion is concerned with.

A recent newspaper report about the discontent over the circumstances surrounding the ending of GP fundholding exemplifies all that is wrong about the way in which the Health Service is run in Northern Ireland. It is one thing to remove GP fundholding, but it is quite another to turn back the clock by 10 years without any understanding of what will replace it, or without the implementation of a replacement that will fit in with the improvement of the Health Service. That is not only sheer incompetence but official ignorance under the guise of skill.

(Mr Deputy Speaker [Mr Wilson] in the Chair)

In its wisdom the Assembly gave the Minister and the Department a year to come up with clear plans that were properly resourced and carefully set out, and which could be supported fully by the Committee for Health, Social Services and Public Safety and the primary care sector. Instead, the Minister was aggrieved when the Assembly delayed the ending of GP fundholding for another year. That was a wise decision. There was no replacement on the table, under the table or outside the door. There were not even mirrors. It is now one year later and — surprise, surprise — the issue is not much further forward. It is little wonder that professionals are distraught and angry. The seamless transition is non-existent. The Minister has angered just about everyone who is involved in the delivery of services. Doctors, nurses, midwives and a host of other professionals are extremely angry at the latest botch-up by the Department.

What has been happening? Since the issue was last debated in January 2001, little has happened. In the past few weeks, however, there has been some activity. The Department issued a press statement on 16 October 2001. Impressively, it took from January 2001 to October 2001 to come up with that. The statement was followed by a circular on 14 December 2001. There was no consultation or negotiation before, during or after those events. It is an attempt at change by uninformed, incompetent diktat. It is clear that if the Minister had spoken to professionals, she would simply have exposed her own ignorance.

The Minister promised the Assembly that when GP fundholding was replaced, all would be well. All is not well, and worse still, there will now be a gaping hole where once was there were clinicians in operation. That is hardly the most brilliant piece of leadership. There is chaos, uncertainty and, at best, mere cant. It is unacceptable that just a few weeks before the changeover nothing concrete is in place. Perhaps everything is supposed to happen over the next couple of weeks, as if by magic. Furthermore, there is no blueprint. Neither the Health Committee nor the Assembly has been presented with the finalised blueprint for primary care, a blueprint that should have been debated and voted on by the Assembly. That would show professionals where things are going. How the Minister can continue to make piecemeal changes without a plan is beyond the comprehension of any rational individual.

The Minister, the Department and those who work in the primary care sector do not know where things are going. Not once has there been a simple outline of how the removal of GP fundholding, in the absence of any specific transitional scheme to finalised agreed arrangements, will improve either the quality or quantity of care. There has not been one piece of hard, factual data. The Assembly is entitled to hear how the removal of GP fundholding will improve the quality and quantity of care to patients in the absence of a transition to finalised arrangements. Where are the hard, real, factual data?

On 17 January 2001 it was recorded that the Chairperson of the Health Committee expressed the strong view of the Committee that GP fundholding should cease only when the Department could make the planned seamless transition to an agreed alternative.

Amazingly, we are no further on today. Those who argued against our motion last year said that it was wrong. One Member had the nerve to suggest that an extension would not allow for a proper replacement for GP fundholding to be put in place and that it ought to go immediately.

12.30 pm

We must listen to the British Medical Association (BMA), which wrote to the Committee for Health, Social Services and Public Safety about the end of GP fundholding and said that there had been no detailed guidance, no details about timescales, no proper resources, no meaningful consultations, no primary care development funding and no details about the redeployment of GP fundholding staff. That is a clear vote of no confidence on the part of the professionals. I support the motion.

Mr J Kelly:

Go raibh maith agat, a LeasCheann Comhairle. This motion does not come before the House with the full consent of the Health Committee. The vote was 4:3 in favour. My Colleague, Sue Ramsey, and I opposed its tabling because of the same misinformation that we have heard from Mr Berry. We believed that the motion would be divisive and would not be concerned with primary care or with the delivery of healthcare to those who need it.

At the Committee’s meeting last Wednesday, Sue Ramsey and I asked for the motion to be postponed for a week or a fortnight to allow people working in primary care piloting commissions to address the Committee. The Committee has only heard from groups opposed to the transition from GP fundholding to primary care. Even within those groups, there has been marked disagreement over the way forward.

I thought that the Committee’s function was to bring the Minister before it to address its concerns about primary care and to ask people working in that sector to give the Committee their views on the transition from GP fundholding to primary care. That did not happen. There was no consensual discussion from those representative bodies in favour of primary care. Their point of view was not heard. The only point of view that the Committee heard came from those who were ostensibly opposed to the introduction of primary care. The Royal College of Nursing, the Royal College of Midwives and the BMA disagreed among themselves over the way forward.

It was inappropriate for the Chairperson of the Committee, as a GP, to bring the motion to the House without declaring his interest in the transition from fundholding to primary care.

Dr Hendron:

On a point of order, Mr Deputy Speaker. If Mr John Kelly looks at the record of the debate last January he will see that I clearly and unequivocally stated my slight link with primary care at that time. My position has not changed since then.

Mr McCartney:

On a point of order, Mr Deputy Speaker. The Assembly is entitled to note that the Chairperson of the Health Committee, Dr Joe Hendron, is a GP — the world and his wife know that. Any suggestion in these circumstances that he has any axe to grind or that he has misled the Assembly or the Committee in any way is quite wrong, and that should be stated.

Mr J Kelly:

The Chairperson’s vested interest in GP fundholding was not on the record of this debate.

The House of Commons Select Committee on Health said of the transition from GP fundholding that it would improve patient care and the health of the population by

"putting doctors and nurses into the driving seat and by ensuring co-operation rather than competition within the NHS".

We support that.

The Committee’s second report also recognised that

"there have been some problems with implementation in areas where there have, historically, been tensions between fundholders and non-fundholders and that changes are going ahead more smoothly in areas where general practice has traditionally enjoyed a good relationship with the health authority."

It went on to say that all health professionals in primary care, whether in general practice or community trusts, were finding the pace of change quite threatening, so there have been difficulties in England, Scotland and Wales with the transition from fundholding to primary care. Such expressions of doubt and concern have not just come from this Assembly, its Committee for Health, Social Services and Public Safety and its Health Service.

My colleague and I oppose this motion, because ample opportunity was not given to practitioners in primary care to express their views to the Health Committee. There are difficulties, but the best way to address them is for the Minister, the Committee and all the groups involved in the transition to meet and discuss how those difficulties could be solved. A more orderly method of teasing them out is by discussion and debate. There is no doubt that primary care is the care of the future — by all objective standards of critical analysis it can ease tensions in the Health Service. Go raibh maith agat.

Mr McCarthy:

I thank Dr Joe Hendron, the Chairperson of the Committee for Health, Social Services and Public Safety, for bringing a vital subject to the Floor of the Assembly. I also welcome the Minister and hope that she can help us to overcome our concerns.

We must not forget that the one-year extension to GP fundholding brought benefits to local communities. However, we are a few weeks away from the introduction of an entirely new system, and I am deeply disappointed that very little is known about how things are expected to work out. I hope we are not experimenting with the health, and possibly the lives, of people. Ordinary people want and expect a good local GP service, and in general they are not interested in how it is administered.

All Assembly Members have received correspondence from anxious people, one organisation noting that

"A year of development time has been squandered, Assembly wishes ignored.."

This is not the first time that Assembly wishes have been ignored, and we must act to ensure that the will of the Assembly counts and is acted upon by the Executive and its Ministers. The same organisation concluded that

"the opportunity to change the HPSS to work better for the population has also been ignored.

We see proposals that still have no clear vision or commitment. They create a set of new bureaucratic quangos. They have no obvious purpose or goals, certainly none that could not be achieved by existing arrangements."

In addition, the Hayes Report identifies the need for a strong, well-organised primary care system. That does not seem to be the aim of current policy guidance, and it certainly will not be its outcome.

I support local primary care groups that can and must make a difference to the health of our constituents. I appeal to the Minister to heed the advice of medical professionals who have years of experience and are willing to see change succeed. There is no reason to change the system unless we are confident that it will bring early benefits to health provision for everyone. That must be a priority for all. I support the motion.

Ms Morrice:

Health and social care groups will improve prospects for better services if they are developed through meaningful engagement between professionals and service users. The experience drawn from successive primary care pilot schemes has shown that family doctors, community nurses, social workers and other professionals can work together successfully to redesign and develop services for the community. For the benefit of all, we must grasp and exploit the opportunity to extend this concept to people throughout Northern Ireland.

The purpose of local health and social care groups is to give the people who work in primary care, and the communities that they serve, more influence over the way in which services are arranged and developed. At present, planning and development of the services is organised through what is called "commissioning", and responsibility rests with the four boards. It is important that, under the new arrangements, the next few years will see local health and social care groups gradually taking on more responsibility for commissioning services. Most importantly, the process must be undertaken through effective, collective working between professional staff and community representatives. We hope that the boards will be fully committed to actively supporting the growth and development of these groups.

We have stressed on several occasions the importance of how the 18 members of each group will be chosen. When the groups become fully operational, five of the members will be GPs, and the remainder will be made up of a range of grass-roots health and social care professionals, including those allied to medicine, nursing, pharmacy and social work. It is significant that two members will be community representatives who will promote the interests of patients and other service users.

Scotland, England and Wales are already moving in this direction, and it is time for Northern Ireland to develop such community groups. A balance must be struck between representation and the obvious need to not make the groups cumbersome. Initially, not everyone will be able to achieve representation. We are glad that there is a mechanism to review the situation within 18 months. Groups will be able to be flexible, but I stress that midwives should be represented on them — they must not be left out.

Ms Ramsey:

I understand the Member’s concern about midwives. The Royal College of Midwives expressed that concern, so I raised the matter with the Minister in the Health Committee meeting on Wednesday. The Minister said that, in the guidance, "nurses" is used as a generic term and does not exclude midwives.

12.45 pm

Ms Morrice:

I thank the Member for that information. That is good news, and I hope that midwives will be included.

Real opportunities to improve services and build community confidence and the confidence of professional staff do not come often and must be quickly and properly grasped. It is clear from letters that we receive that there are concerns about the Health Service, but they can, and should, be addressed through the normal channels. My Colleague, Monica McWilliams, as a member of the Health Committee, will be working to allay those concerns.

Making changes to health and social services is rarely risk free. However, it is a hugely important task that is often wrongly perceived as presenting a threat to the stability of existing services and to the jobs of much- valued health and social care staff. Health and social care groups can strengthen services — they pose no threat to the roles and jobs of front-line staff. If anything, they maximise opportunities for staff and provide a basis for professionals from many backgrounds to interact more readily with patients and to tailor successfully services to meet their specific needs.

Although we accept that the Minister should work hard to allay existing concerns, we do not support the motion. This is a real chance to make meaningful and constructive change to primary care services in Northern Ireland, and we should take that chance when we can.

Mr McCartney:

I support the motion. It is public knowledge that the Health Service as administered in Northern Ireland is dysfunctional. The waiting lists are not only the worst in the United Kingdom, they are the worst in Europe, and it is plain that organisational reform of the delivery of primary healthcare is nothing short of chaotic. What are the reasons for that? The first reason is how resources are used, and the second is the delay in this much-needed reform.

As Dr Hendron rightly pointed out, capital investment in the basic infrastructure of health was underemployed for many years under direct rule. However, that merely underlines the failure of those who agreed the terms of devolved Government to ensure that the underspend on capital infrastructure funding was made good.

Having said that, resources are also being massively reduced by a welter of bureaucratic expense under devolved Government. Several weeks ago, I pointed out that 12 billion will be spent on the administrative costs of running the 11 Departments and the Assembly. Almost 14% of the block grant is being spent on feeding the Assembly and its administrative processes, which are a dripping roast for those who benefit from them.

I have been recently informed that the cost of ministerial cars, which are provided by the Assembly and by the Administration, amounts to 12 million per annum. Something must be done about resources. We shall not receive more resources through any increase in the Barnett formula, so they must be obtained in other ways — and not by petty efforts such as raising the rates by 12 million to screw many small businesses and put them out of business when that 12 million will cover only one third of the 36 million needed to meet the Office of the First Minister and Deputy First Minister’s administrative costs alone, Mr Trimble’s Department. Therefore, something must be done about resources.

There is also the issue of organisational reform. It is plain from correspondence to Members from the professional organisations affected by these reforms — GPs, midwives, nurses and other care professionals — that the transitional arrangements for going from fundholding to the provision of primary healthcare through local health and social care groups is nothing short of a disaster. The Minister has provided no guidance on the core issues. Local groups cannot influence either the commissioning of secondary care services or primary care development, and we have no details of the timescale within which the groups will be able to do that other than a bare statement in a circular.

The Minister’s statement of 16 October 2001 about groups progressing to delegated budgets as quickly as they can demonstrate their capacity to deal with them entirely ignored the fact that a broad spectrum of fundholders and other groups have experience of controlling their budgets and could do that efficiently. There are no guarantees with regard to service provision to patients after 1 April. However, the Minister has done something about that belatedly. The funding arrangements are totally inadequate. In Northern Ireland the funding will be 3 per patient; on the mainland the funding is between 7 and 8 per patient. How can any form of comparable primary healthcare service be delivered when the cost of providing that is being cut from 7 or 8 to 3? There is also a lack of meaningful involvement of all stakeholders in the process, and there has been no meaningful consultation on the constitution of the groups, the management boards or the remuneration arrangements.

In response to John Kelly, I will close by stating that most groups are totally opposed to what is happening. The South and East Belfast Primary Care Group had this to say:

"In February 2001, the Assembly rejected the timetable then proposed to develop new Primary Care structures issued by the DHSSPS. The Assembly accepted the argument that the gap between the ending of existing arrangements on 1 April 2001 and the earliest operational date of any new proposals would be detrimental to the provision of Primary Care services."

The Minister and her Department have wasted an entire year and have failed to put in position any guidance, instruction or constitutional arrangements whereby primary care can be developed. I have great pleasure in supporting the motion.

Mr McGrady:

I approach the motion and its expression of concern for the new structural arrangements based on information that I have received from people on the streets and in constituency offices, including people from the medical fraternity, and their experiences. There is enormous and grave concern that the new structure is not even designed to deliver better primary care and will constitute yet another bureaucratic structure laid over an already overstructured delivery of medical facilities.

There is concern about the levels of bureaucracy and the levels of resources that were supposed to be available for the new development. I hoped, as did all laypersons, that the new structure would speed up access to primary care and contribute to shortening the much-quoted waiting lists, which are causing increasing daily concern to people on both elective and non-elective waiting lists. An increase over the past year of 145 % and a failure by the Department to achieve its set targets and explain why those targets are not being met against a backcloth of increasing funding are shortcomings, not least in clarity.

We must try to achieve that clarity so that we can redress what appears to be happening, which seems to be — and I cannot substantiate this with facts and figures — more money chasing less effective delivery. If that is the case, it requires an urgent and extreme remedy.

I come to the debate not from the point of view of statistics or finance but from my experience and knowledge of the unnecessary pain and suffering being placed on families, the communities and the country. The relief of pain and suffering is the objective of all medical services.

Mr J Kelly:

Will the Member give way?

Mr McGrady:

No, I have just started. I will give way when I come to something substantial that the Member might wish to query, but I have not dealt with the generics yet.

It is correct to look at how efficiently and effectively the Heath Service is administered, but that must be done with the objective of achieving better relief of pain and suffering. We cannot include in a motion such as this the provision of care for cancer patients, because that is not primary care - although initially everything is primary care. People are literally dying against a backcloth of a lack of medicines and treatments that are available elsewhere, and that is never acceptable in a society such as ours.

Alongside that, medical professionals - GPs, midwives and district nurses - do not know how the proposal can work, and they do not know why it has been made. In fact, GPs have asked the Department to explain the objective, purpose and facilities that will drive the new structure, which will start in two weeks, but they have not had a meaningful answer.

We have heard Members talking about a variety of bodies - the Royal College of Nurses and the Royal College of Midwives - who say that there has been no meaningful consultation on their participation. However, district nurses and midwives are primary carers. If they do not know what is going on, what, in the name of God, are the patients going to do?

GPs are not sure about what is happening and what will be expected from them. The new body to be set up - and I stand to be corrected on this - will consist of GPs, who will get an extra 17,000 a year for administration. All of the others, midwives, district nurses and lay people, if there are any, will get nothing. This is not an even-handed scheme that will encourage co-operation and a better development of resources.

The BMA finds the process incredible. It says that there is no long-term vision, no medium-term plan and no short-term direction. It criticises the lack of information it is receiving from the Department, information that is necessary to achieve what, it is hoped, will be an improved system of delivery.

Mr Deputy Speaker:

Time is up.

Mr McGrady:

My goodness - time passes when you are enjoying yourself.

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