Primary Care: Extreme Pressures

Private Members' Business – in the Northern Ireland Assembly at 3:45 pm on 14 May 2024.

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Photo of Alan Robinson Alan Robinson DUP 3:45, 14 May 2024

I beg to move

That this Assembly values the enormous contribution of those working in primary care across Northern Ireland; notes that this includes GPs, nurses, health visitors, physiotherapists, social workers and mental health practitioners; recognises that primary care is generally the first point of contact within the health service for those who become unwell; further notes the recent Northern Ireland Audit Office report on access to general practice, which found that almost one in three local practices has sought crisis support in the past four years; regrets the absence of a specific workforce strategy for general practice; believes the failure to train, recruit, retain and reward staff has limited progress toward the roll-out of multidisciplinary teams in local primary care settings; calls on the Minister of Health to provide an indemnity scheme for GPs in Northern Ireland in line with arrangements in other parts of the United Kingdom; and further calls on the Minister to increase the number of GP training places and invest in an enhanced fellowship programme for newly qualified GPs as part of an ambitious, costed and time-bound plan to grow the primary care workforce.

Photo of Edwin Poots Edwin Poots DUP

The Business Committee has agreed to allow up to one hour and 30 minutes for the debate. The proposer of the motion will have 10 minutes to propose and 10 minutes to make a winding-up speech. As one amendment has been selected and is published on the Marshalled List, the Business Committee has agreed that 15 minutes will be added to the total time for the debate. Please open the debate on the motion, Mr Robinson.

Photo of Alan Robinson Alan Robinson DUP

Thank you, Mr Speaker. How many Members can say that they have never fielded a call to their office from patients struggling to get through to a GP surgery? I would safely say that not one of us can. I could tell you of multiple complaints to my office. I have struggled to access GP services, my staff have struggled and my family has struggled. It is a common complaint, and it is not getting any better.

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

Forgive me, Mr Deputy Speaker, for starting off my contribution on what some may see as a negative, but it is an issue that dominates my office and one that my constituents will expect and demand that I highlight on the Floor of the House. It is vital to state from the outset that we need to fix it on behalf of patients and GPs.

I will follow up my somewhat negative comment by thanking those who work in that vital sector for their tireless efforts. We must always acknowledge their commitment to the well-being of the people of the Province. Primary care is often the first point of contact in our health service, and it plays a key role in maintaining the health and resilience of our population. Professionals such as GPs, nurses, health visitors, physiotherapists, social workers and mental health practitioners form the backbone of our healthcare system. They are the spine of the health and social care team.

To put that into some context, 2,041,000 patients were registered with GP practices in Northern Ireland as of 31 March 2023, with around 200,000 general practice consultations undertaken each week in 2022-23. However, recent findings from the NI Audit Office reveal concerning trends. Almost one in three local GP practices has sought crisis support in the past four years. That alarming statistic underscores the urgent need for action. We cannot afford to overlook the challenges faced by our primary care workforce.

The report said that 1,448 GPs were registered on the Northern Ireland primary care medical performers list as of 31 March 2023 but that more than a tenth of GPs on that list left during 2022-23, with 318 GP practices in the Province as of 31 March 2023. However, of those, 39 were assessed as being at risk in the same period. On top of that, 13 contracts were handed back during 2022-23. The report detailed how general practice accounts for 5·4% of all health and social care spend in the Province, with £375 million spent on GP practices in 2022-23.

Whilst multidisciplinary teams (MDTs) are seen as a key element of transforming primary care and helping the wider healthcare system, only 8% of registered patients had access to the full range of MDTs as of March 2023. Progress on MDTs simply has not met the ambitions. MDTs are key to reversing the fortunes in general practice and wider healthcare. Working as part of a much larger team is attractive to many doctors. It means, in simple examples, such as arranging annual leave or covering for a colleague who is off sick, that there is a much broader group to carry the burden, rather than just one or two colleagues. The Department of Health has cited financial pressures as the key issue in not improving primary care. However, the Comptroller and Auditor General was clear in his March report that, even with a lack of sufficient funding, the Department needs to explore alternative and credible options for the implementation of the MDT model over the coming years. I trust that the Minister will answer the following questions today: has he taken this recommendation on board, and will he expedite the review of the MDT project and bring a revised business case?

Other findings in the report were that pressures on general practice are driven by a growing and ageing population and that a significant number of GP practices are under severe pressure. It also found that data on activity in general practice is limited and that it is unclear whether activity is above pre-COVID levels. Published workforce data does not provide a picture of the working patterns of GPs. Nobody is questioning the commitment and integrity of our GPs or allied health professionals and the staff who support them. There are, however, legitimate unanswered questions facing the Department of Health on the current levels of accountability for activity in GP surgeries. Is the Minister confident that throughput has returned to pre-COVID levels? Has face-to-face contact increased in recent months? How many appointments are made available each day, and how does that vary from practice to practice? Are there plans for targets to be set in contracts for GP services? There is scant detail on these areas, and there is an apparent dearth of any robust or strategic approach to capturing such data for the purposes of informing future general medical services (GMS) contracts for service delivery.

A workforce strategy is a cornerstone of any successful healthcare system. Regrettably, the Province lacks a specific strategy tailored to general practice. Without a clear road map, we risk stagnation and missed opportunities for improvement. Recruitment, training, retention and reward mechanisms are crucial components of workforce development. The Department of Health needs to do more to incentivise newly trained GPs and, indeed, to incentivise to stay those with experience who are considering walking away from the profession. This means ensuring that they have the space and opportunity to pursue professional aspirations. It means fair remuneration for the work that they do, and it requires a workforce strategy that practically acknowledges the need for flexibility when it comes to longer-term fostering and guaranteed leave.

The recent Royal College of General Practitioners Northern Ireland (RCGPNI) strategy to tackle GP workforce retention and 'A Workforce Fit for the Future' had similar concerning findings. The average number of registered patients per practice has increased by around 17% from 5,500 to 6,439 since 2014. This increasing demand suggests the need for a further expansion in GP training places into the future. Whilst training more GPs is important, so is ensuring that those who qualify remain here and forge a career in primary care across Northern Ireland. The drain of expertise to other jurisdictions needs to be stemmed. An increasing number of early-career GPs who have trained in the Province are not taking up posts here, and, according to the recent RCGPNI survey, 29% of GPs stated that they would be fairly or very unlikely to be working in general practice in the Province in five years' time.

Some 60% said that they had found it fairly or very difficult to recruit GPs to their practice in the past year.

The report went further and said that fellowships were not available for young GPs working in substantive posts unlike in other parts of the UK, where weekly opportunities exist to further develop clinical aspirations. Many of the GPs surveyed reported practice infrastructure that was not fit for purpose, which led to poor working conditions, and the lack of a functioning secondary care service was highlighted as exacerbating GP workloads and patient demand. Also, there was a perception among many GPs that little help was available for practices until they reached the verge of collapse. Notably, only one of the practice contract hand-backs was in an area where an MDT model was in place.

It is welcome that £5 million has been made available to help cover the cost of insuring GPs against claims, hopefully aligning with arrangements in other parts of the UK. That will, in the short term, provide much-needed support and security for our front-line healthcare providers, and we can only hope that it will help to persuade graduates to work in the Province rather than being lost to across the border. It is certainly a welcome start, and it is one that we hope will provide a longer-term solution.

Added to the many other problems, the primary care estate is not in good shape. Technology needs to be embraced and better utilised, whilst being mindful of the quality impacts on certain protected groups. The morning rush to obtain an appointment by phoning the practice is utterly unacceptable for a modern service, and new ways need to be provided. That could include the ability to seek assistance and obtain an appointment online via mobile phone. Surely, there is no reason why primary care and other areas of public services, such as MOT booking, should be in any way less equipped for the modern world than business and retail.

It is clear from the two reports that primary care in Northern Ireland has reached crisis point. We have fewer GP practices than 10 years ago, GP contracts are being handed back and a large cohort of trained GPs are choosing not to work in primary care or are working very limited hours because of the stress involved and a lack of support. All of that points to a model of general practice that is on its knees, and without concerted action —

Photo of John Blair John Blair Alliance 4:00, 14 May 2024

Will the Member bring his remarks to a close?

Photo of Alan Robinson Alan Robinson DUP

— the situation will inevitably worsen as our ageing population grows.

Photo of Colin McGrath Colin McGrath Social Democratic and Labour Party

I beg to move

Leave out all after "primary care settings;" and insert: "calls on the Minister of Health to publish a timescale for the full implementation of multidisciplinary teams across the North; and further calls on the Minister of Health to provide an indemnity scheme for GPs in Northern Ireland in line with arrangements in other parts of the United Kingdom; and calls on the Minister to increase the number of GP training places and invest in an enhanced fellowship programme for newly qualified GPs as part of an ambitious, costed and time-bound plan to grow the primary care workforce."

Photo of John Blair John Blair Alliance

Thank you. The proposer of the amendment has 10 minutes to speak, and five minutes to make a winding-up speech. All other Members who wish to speak will have five minutes.

Photo of Colin McGrath Colin McGrath Social Democratic and Labour Party

Thank you very much, Mr Deputy Speaker.

"The stark options facing the HSC system are either to resist change and see services deteriorate to the point of collapse over time, or to embrace transformation and work to create a modern, sustainable service that is properly equipped to help people stay as healthy as possible and to provide them with the right type of care when they need it."

Those words formed part of Professor Bengoa's report eight years ago, and, prophetically, I believe that they have come to pass. We are seeing the collapse of multiple services and increasing waiting lists across the health sector. It is a deeply worrying time. The extreme pressures that we face are evidenced most clearly in primary care. The motion is an important opportunity for us to discuss these issues. The amendment that the SDLP is proposing is a minor one that we believe complements and strengthens the DUP motion. The focus of our amendment is to shine a spotlight on the importance of the multidisciplinary teams. The provision of MDTs was an outworking of the Bengoa report in 2016 and was first piloted in Down and Derry in 2018.

Primary care in the North has undergone significant operational change in a short time. On top of the operational change, we have witnessed an incredibly turbulent time for those working in primary care, which only intensified with the emergence of COVID-19. As a result, over time, we have seen a fresh focus, though perhaps not enough of a focus, on prevention and health promotion, and a reorientation of the health system away from treatment solely in hospitals towards the delivery of care in the right place for the patient. That can often be in the community or, as we are seeing even more now, at home.

Multidisciplinary teams have emerged out of that focus. This new way of delivering primary care brings together GPs, pharmacists, district nurses, health visitors, allied health professionals, social workers, advanced nurse practitioners, physician associates and others. There is no doubt that, where multidisciplinary teams have been implemented fully, successful health outcomes have followed. I see it in the Down area in practices where MDTs have been fully implemented. I have been lucky to visit some of the MDT practices in my community to see the benefits not just for the patients who go to them but for the staff who work in those units.

MDTs establish a truly holistic way of delivering primary care. With the development of modern technology, the ideal is that members of the public will find it easier to book an appointment with their local practice and get the right care at the right time. That is the ideal, but the present reality is different. Partial implementation of MDTs across the North has resulted in unintended consequences by creating new health inequalities. Of the 17 GP federations across Northern Ireland, only one — the Down federation — has had a full complement of MDTs since the inception of this new way of delivering care. That is not because it is my local area, I promise, but we have supported the moves to deliver MDTs. I have been proud to host in the Down area the pilot for across the North. It is distinctly worrying that 10 of the 17 GP federation areas in the North have no MDTs at all. That creates the unintended consequences that I mentioned: the creation of health inequalities.

Photo of Deborah Erskine Deborah Erskine DUP

I thank the Member for giving way. I agree with him about MDTs. As a representative of a rural constituency, the Member knows the importance of having access to the full complement of healthcare staff in a primary care setting. It is disappointing that we have not had the full roll-out, despite some previous announcements about MDT allocations.

Photo of Colin McGrath Colin McGrath Social Democratic and Labour Party

I thank the Member for her intervention. It strengthens the argument about how we need to see that roll-out across all areas so that everybody can access the full range of services on an equal basis. The people of Fermanagh are just as entitled to that as the people of Down.

It leaves us in a situation in which our health is affected by where we are born, where we live and work, and our age. When there is an imbalance in the distribution of resources and services, we see that imbalance in health outcomes. As a result, those living in areas of greater deprivation are often at risk of suffering from poor health outcomes. General practice is ideally placed to help to counter that and address the imbalance.

Be under no illusion: contrary to what some said yesterday, the SDLP is not criticising for the sake of it. This is not about apportioning blame. Rather, we must recognise the reality of where we find ourselves and seek the right solution. That is the purpose of the amendment. I say that because nobody could be in any doubt as to the Health Minister's commitment to the important issue of reducing the pressures on primary care and to the roll-out of multidisciplinary teams specifically. I know that his commitment has been unwavering, and I am not just bigging him up so that he compliments me in his remarks.


I know that the Minister offers that support to MDTs. We must, however, be cognisant of those working in our healthcare sector, because, for them, the reality is that they are suffering from burnout or are not far from it.

With more contracts being handed back by GPs, and health trusts then having to take over control, it is clear that that a paradigm shift is required, both operationally and culturally, in our delivery of primary care. Multidisciplinary teams are ideally placed to deliver that change. Operationally, the process of triage by reception staff is important for placing the patient with the most appropriate mental health, physical or social care needs within the MDT profession at the right time. We know that, culturally, some members of the public are still reluctant to speak to GP reception staff and want only to speak to their GP. That is understandable, but it places another operational layer on our GPs, who are already struggling.

We are living in a post-pandemic world, and that presents new opportunities and new challenges. Today, more than ever, we need to unlock the potential of the health service to meet the needs of patients. Today, more than ever, we need to support our general practitioners to ensure that not only do we retain staff but we make the career path attractive for future generations, which the proposer of the motion referenced.

The Royal College of General Practitioners Northern Ireland recently published 'A Workforce Fit for the Future', In that document, we hear doctors express the factors that are most important to them, the top six of which are work-life balance; income; workload; practice stability; the ability to pursue a GP role with special interests; and a practice with MDTs. It is important to note that the implementation of MDTs can lead to enhanced practice stability, so much so that, in practices that have a full complement of MDTs, only one contract has been handed back. When that happened, the trust was able to put in place the necessary structures to reduce patient disruption. Access to MDTs was also factored into GPs' decisions to remain working. The evidence could not be clearer: MDTs are essential for the present and future of our health service, and they must be fully rolled out.

I appeal to the Minister to provide an assessment of the impact that the Finance Minister's proposed Budget settlement will have on our ability to roll out multidisciplinary teams. We know that their roll-out is needed for the future stability of primary care here and that we must get the right finance delivered to the Department of Health in order to be able to deliver the transformation that will strengthen our health service and make sure that it is indeed fit for the future.

Photo of Liz Kimmins Liz Kimmins Sinn Féin

I thank the proposer and his colleague for tabling the motion. It is fair, and not an exaggeration, to say that our health service is on its knees. Every corner of the system is under severe pressure, and staff are working in the most challenging and, too often, unsafe circumstances. Every day that that situation continues, patients get sicker and need more care, and there is less capacity to provide what is required. Something has to give.

We hail the benefits of early intervention and prevention in healthcare, as they undoubtedly promote better patient outcomes and ensure that people live well for longer. Although we know that people across the North are living longer, many live with a range of health conditions and languish, with a very poor quality of life, on waiting lists. Sadly, many even die while on waiting lists.

We are in crisis management mode, trying to put money into our health service at the latter stages of a patient's journey — in some cases, when it is already far too late — when more care is needed, which costs more and adds to the already colossal pressure that is on our health service. To turn the ship around, we need to focus our efforts upstream on the first point of contact for patients, which is primary care. A properly resourced primary care service is critical if we want to transform our health service and improve the health of our communities. There is not one Member in the Chamber who has not had constituents come to them for help because they have been unable to get an appointment with their GP. That situation is worsening by the day. Just last week, another GP practice in my constituency announced that it will not renew its contract, owing to the huge pressure that it faces to deliver that important service. That is a very difficult decision for any GP to have to make. We heard very clearly at the recent Royal College of General Practitioners event that that is not a decision that any GP wants to take.

At the Health Committee, we heard just how stark that picture is from the royal college and the British Medical Association (BMA). GPs are experiencing unprecedented pressures as demand for their services grows but the capacity to meet that demand declines because many GPs are leaving the profession prematurely.

There is a real difficulty in attracting new doctors to choose general practice as a career that they want to come to, with much more attractive opportunities in the South, in Britain and overseas with much better pay and conditions. Without a GP workforce, we simply do not have a fit-for-purpose GP service. The impact of that on patients, staff and the health and social care system as a whole is far-reaching. General practice is often referred to as the "front door" of the health service, and every person in our communities will rely on their care at some stage in their life. That is why it is vital that they are supported.

The rolling-out of multidisciplinary teams and addressing indemnity are two of the most important issues, and a permanent solution to both would take enormous strain off the entire healthcare system. A GP practice with a full complement MDT, working with nurses, social workers, Community Pharmacy and mental health practitioners, can bring care back into the community and, crucially, will be able to treat a variety of health, mental health and social issues, which will improve patients' health outcomes while alleviating the pressures on the health system overall and utilising the broad range of skills, knowledge and expertise that we have in spades across our statutory services and, equally importantly, in the community and voluntary sector. Across the North, we have a skilled, experienced and agile community and voluntary sector that already provides invaluable support and services to some of the most vulnerable people in our communities who, without that sector, would have none of the services or facilities that are critical for their needs. It is absolutely essential that the community and voluntary sector is an integral part of any future roll-out of MDTs.

To conclude, it is fair to say that there is no doubt that the financial picture for the incoming Budget is challenging, but we cannot afford to stand still or do nothing. We need to see a plan for the Budget and a workforce plan, because that will support primary care and it will support staff in the jobs that they have set out to do — they are vocations — but it will also meet the growing needs of patients and the people we represent.

Photo of Nuala McAllister Nuala McAllister Alliance 4:15, 14 May 2024

I thank the proposer of the motion for tabling it. We are happy to support the motion and the SDLP amendment. Like many Members in the Chamber, my constituency office is inundated with requests from constituents about access to their GP. That is no surprise, because the Royal College of General Practitioners has said that, in the last month, at least 128,000 patients have been impacted by practices handing contracts back or closing.

We all know that access to GP services is the number-one issue that our constituents raise with us, but we also know that there are many reasons why they struggle to get access. I want to explore a couple of those reasons. Primary care encompasses general practice, community care, mental health and dental care and a large number of other services that represent people's first point of contact with the health service. I understand that the motion focuses on GP services, but I want to touch on the others a little, and my colleague will focus on the workforce challenges.

I want to focus specifically on the funding issues that cause the instability, because we hear about that every day in our capacity as health spokespeople for our parties. There is a significant disparity between the level of service provided by primary care and general practice and the funding that they receive from the Department of Health. The Royal College of General Practitioners has highlighted that primary care represents 95% of the care provided to the population across a lifetime, but, despite that, primary care received only 5·4% of the Health budget in 2022-23.

We have all met numerous representatives from across the primary care sector, and they all report that the current level of funding is unsustainable. Unfortunately, the consequences of that are clear. Since March 2022, as many Members have mentioned, 25 practices have handed their contracts back to the Department. Ninety-eight practices have sought crisis support in the last four years, which is one in three practices in Northern Ireland. With existing issues around recruitment, training, conditions and pay, it is no surprise that the general practice workforce is choosing to practise elsewhere.

It is not just limited to general practice: I am sure that other Members will agree that they hear from constituents that NHS dentistry is also a problem. I note that there was an announcement of support for general dental services (GDS) at the beginning of the month. While the asks of the motion are about general practice, I ask the Minister whether he considers that announcement premature, given that some business cases are not approved and may not be approved until as late as August. Hopefully, the Minister will address that, but I recognise that the motion focuses on general practice.

The contract agreement announced last week was undoubtedly a positive step. The BMA committee achieved a significant win, and I congratulate it on all the work that it has done over the past few years. The £5 million to cover indemnity costs for one year must be welcomed; indeed, we have all lobbied the Minister in our Committee capacity and as party representatives. As the BMA stated, however, the progress that has been made needs to continue past the first year. We need a long-term indemnity solution. It is crucial that we get that right and that support is forthcoming.

Primary care often represents a person's first point of contact with the health service. It is no secret that the Health Minister has many competing requests for funding. However, funding for primary care is an investment in the health service as a whole. GPs can and do provide more relief for A&E services, They can help to enable early intervention, which will inevitably ease pressures on waiting lists and lead to better outcomes for patients. Dental care is crucial for oral health and can play a significant role in the detection of some cancers. Health visitors and social workers provide important support for vulnerable members of our community. As the roll-out of multidisciplinary teams continues across Northern Ireland, we will see even more benefits to the overall primary care sector in identifying any early health interventions that are required.

A multidisciplinary team will soon come to north Belfast, and I welcome that, but I want to raise the issue of capacity in general practice for those MDTs. Capacity in space and location is another issue that the Minister must consider.

Photo of John Blair John Blair Alliance

Will the Member bring her remarks to a close?

Photo of Nuala McAllister Nuala McAllister Alliance

I am happy to support the amendment and the motion. I hope that the Minister will answer the questions about primary dental care.

Photo of Alan Chambers Alan Chambers UUP

Every opportunity to talk about the challenges facing our health service is welcome, even if, occasionally, as today, a number of the points raised are out of date. I do not make that comment to point-score, but it is a fact that the motion and some of what it refers to may be coming a month too late. The recent agreement on the general medical services (GMS) contract and, especially, the announcements on interim payments for GP indemnity have been warmly welcomed by many of the GPs to whom I have spoken over recent weeks. Similarly, the direction of travel of shifting some services back into primary care rather than out of it, such as the recent announcement on vasectomy services, has reinforced confidence and has served as a useful illustration of what can be done with the right mindset.

It is fair to describe primary care as the cornerstone of our health service, especially given that 90% of all contacts with the health system locally take place at that level. There is no doubt that it is the most cost-effective means of delivering high-quality care while being the one that is most valued by the patient. It also remains the most accessible element of the health service, with many patients remaining under the care of GPs and other general practice staff whom they have come to know over many years. Of course, there are undoubted challenges with GP access. While it is a mixed bag, with some patients seeing little, if any, diminution of access, there is no denying that, for too many others, it is becoming increasingly difficult even to get through to practices to make an appointment.

Before the latest collapse of the Executive in late 2022, seeking to improve access and remove the unnecessary bureaucratic burden on GP practices was being given significant focus. Unfortunately, as with so many other services, patients really lost out during the subsequent political and budgetary impasse. Nevertheless, it is probably fair to say that there is now greater cross-party recognition of the contribution made by the various staff who work across primary care.

Unfortunately, the rhetoric of supporting and investing in primary care was not always demonstrated previously. For instance, the proposers of the motion rightly talk about GP training places, believing that:

"the failure to train, recruit, retain and reward staff has limited progress toward the roll-out of multidisciplinary teams in local primary care settings".

That is absolutely right, but those Members show no regard for their party's culpability in the matter. Theirs is the party that held the Health portfolio for five years from 2011 until 2016, when, instead of investing in staff training places, it implemented swingeing cuts. It is a fact that the root cause of the problems in the health service can be traced back to decisions that were made a decade ago.

Ideally, I would not be standing here today making such points, but, ultimately we should not allow MLAs from whatever party to try to present an alternative version of the truth. I see no reference in the motion to the fact that, a number of years ago, Robin Swann decided to proceed at risk, in the context of no budgetary cover, to increase the number of local GP training places to 121. Whilst that might be an inconvenient fact for the proposers of the motion, it is an increase of 86% since 2015-16. Of course, several other points were raised in the motion that are equally distorted.

The largest elephant in the room, however, has to be what the motion calls for and how that compares with the decision that was made on the Budget barely a few weeks ago. The Minister and his officials have been clear with the Health Committee over recent weeks and months that further MDT roll-out is their top priority and that, when it comes to transformation, some additional investment is needed in staff and buildings. Just over two years ago, the Minister announced the next planned expansion for the three proposed GP federations for the MDT programme in north Belfast, south-west Fermanagh and Omagh, and east Antrim.

In supporting the motion, I recognise that my party will be acknowledging achievements that Minister Swann has already made and that it will seek uplifts in the health budget to fully fund any of the motion's outstanding aspirations.

Photo of Linda Dillon Linda Dillon Sinn Féin

The motion rightly emphasises the invaluable contributions of those working in primary care across the North, but attention also needs to be drawn to the interconnectedness of primary and social care services, both of which are essential pillars of our healthcare system. Primary care providers, including our GPs, nurses, mental health practitioners and our community pharmacy, play a crucial role in addressing our communities' healthcare needs. However, it is vital to recognise that many individuals who require primary care services also have complex social care needs, and that must be addressed in order to ensure holistic well-being.

The challenges that primary care services face, including the strain on local practices that seek crisis support, must not be underestimated. Those challenges are often exacerbated by social determinants of health, such as poverty, homelessness and social isolation, which can impact on an individual's ability to access and engage with healthcare services effectively. I made that point at a meeting today with the strategic planning and performance group (SPPG). It is not a case that people are hard to reach; it is that services are difficult to access for some people. We need to ensure that we deliver services in the places where people need them, and that is in their communities, where they can easily access them.

The broader social care landscape must be addressed, and that includes investing in community-based support services, such as social work, physiotherapy and health visiting, which are essential components of a comprehensive primary care system. In order to truly enhance primary care provision, it is vital that we see an increase in social prescribing and, crucially, the ability of health and social care professionals to develop links with early support services — again, it is about the early intervention and prevention services — to protect our people and keep them well, rather than keep them sick. Social prescribers can help to reach more marginalised and vulnerable groups in our communities, and that could have a transformative impact on health inequalities and improve outcomes for the health of our people.

I appreciate that the Minister has worked with GPs in recent times to deal with the indemnity issue, and he has come to some interim solutions for that, but we need a long-term solution.

Likewise, it is vital that the Department works closely with our community pharmacists and invests in a sustainable funding model to protect that service.

We must not forget the importance of integrating social care into our primary care strategies, recognising that health and well-being are intrinsically linked to social factors. It is only by doing that that we will genuinely improve health outcomes for all, particularly those in our marginalised and deprived communities.

Photo of Deborah Erskine Deborah Erskine DUP 4:30, 14 May 2024

Hardly a week goes by in which someone does not get in touch with me or my constituency office to talk about GP services. The common refrain is that it is difficult to get through on the phone to get an appointment. That is perhaps symptomatic of the pressure and problems behind the scenes, which are the cause and what we need to deal with.

It is important that we pay tribute to the vast contribution made by our GP and primary care staff across Northern Ireland. I pay tribute to my GP practice and thank it for all the work that it does alongside the excellent community pharmacy provision in my area. My practice, Brookeborough and Tempo Primary Care Services, was one of 13 practices that had to hand back its contract in 2022-23. The Western Trust stepped in to provide a service for the some 8,000 patients on the books. We have already seen practices in my constituency close their doors. Rosslea surgery, for example, closed a number of years ago.

How is that sustainable? In Northern Ireland, as of March 2023, there were 317 active GP practices — a reduction of 33, equating to 9%, since 2014. Yet, the average number of registered patients per practice has increased by around 17% since 2014. It is clear that primary care in Northern Ireland has reached crisis point. We now have fewer GP practices than we did 10 years ago. The practices that are operating are not evenly distributed across the Province. GP contracts are being handed back with increasing frequency. The roll-out of multidisciplinary teams has stalled. Many patients are frustrated with the phone triage service and have been unable to secure timely access to care. Contracts for GP services still do not contain performance targets. A large cohort of trained GPs are choosing not to work in primary care, because of the stress involved and a lack of support. The list goes on.

Those problems will not be addressed overnight. However, the importance of delivering real change cannot be overstated. Previous evidence shows that over 90% of NHS contracts are with GPs, yet they account for only 5·4% of the health and social care spend in Northern Ireland. Training more GPs is a key pillar of the DUP's five-point plan, but so too is ensuring that those who qualify remain here and forge a career in primary care across Northern Ireland. The drain of expertise to other jurisdictions needs to be stemmed. Recruitment and retention are two sides of the same coin. The Department of Health needs to do more to incentivise newly trained GPs, and, indeed, those with experience who are considering walking away from the profession, to stay. That is particularly true when you look at rural areas and the need to incentivise young trainees and GPs to stay in the likes of Fermanagh and South Tyrone.

I welcome the Department of Health's announcement of an agreement on the general medical services contract with GPs for 2024-25. However, I heard more detail on that through the media, as I travelled to Stormont, than I did from the Minister, either through a written ministerial statement or in the Chamber.

Photo of David Brooks David Brooks DUP

Will the Member give way?

Photo of David Brooks David Brooks DUP

Does the Member agree with me that, given the broad range of ministerial statements on a number of important issues, it is regrettable that the Minister did not bring this issue to the Assembly via a written or oral ministerial statement?

Photo of John Blair John Blair Alliance

The Member has an extra minute.

Photo of Deborah Erskine Deborah Erskine DUP

I thank the Member for his intervention. I agree. This is a huge issue that all our constituency offices deal with. It is regrettable that it was not brought to the Chamber in order for us to look at it fully.

Progress towards addressing the long-standing lack of indemnity provision for GPs is welcome. However, the uplift in funding between practices is linked to annual contractual arrangements, and there is still a need to pursue and agree a long-term solution. Furthermore, we understand the desire for GP practices to have certainty on cash flow. Equally, that needs to be balanced with ensuring that GPs are accountable for their performance against clinical indicators for the various illnesses and conditions that they manage. Cutting ties with the equality and outcomes framework in the current GMS contract has raised concern in that regard, particularly given that the new Northern Ireland assurance framework does not seem to have been finalised ahead of agreement being reached between the BMA and the Department on this year's settlement. Can the public be confident that all practices are operating services at the same standard when those outcomes are not being recorded?

For too long, "Budget issues" and "Pressures" have been the cry and the reason behind not moving to a sustainable solution. "Stabilisation should come first", is what I have heard, but waiting around for stabilisation is clearly not working, and failure to act will see the complete collapse of our primary care, with a domino effect across the health service. Therefore, I thank my colleagues for tabling the motion. We will support it and the amendment.

Photo of Danny Donnelly Danny Donnelly Alliance

I thank my DUP Health Committee colleagues, Mrs Dodds and Mr Robinson, for tabling the motion and my SDLP Health Committee colleague, Colin McGrath, for his amendment. Alliance will support the motion and the amendment, as mentioned. Some of the context has already been described. Certainly, Alan pointed out the many practices that have sought crisis support over the past couple of years. In our areas, as we heard from across the Chamber today, we all know of practices in crisis that have been struggling or have closed.

The motion presents an opportunity to acknowledge the valuable role that is played by primary care workers in Northern Ireland. As it rightly states, primary care is normally the first point of contact in the wider health service for people who are unwell, and it encompasses many areas including pharmacy, social work, mental health and physiotherapy, to name a few. One of the issues that the Health Committee picked up on was the impact that waiting lists have had on general practice, as was mentioned. We heard that up to 20% of the workload of GPs is affected by people who are on our extremely long waiting lists here in Northern Ireland.

I want to focus on a couple of issues, one of which is the importance of our workforce and, especially, the need for a workforce strategy. It is welcome that the Minister is retaining the additional number of GP training places at 121, which was agreed two years ago, but the Minister and the Department need to go further. A commitment to a workforce plan for general practice would be an important step forward, particularly one that includes an intervention to make general practice positions in Northern Ireland more attractive to boost recruitment and an intervention to provide support to our existing workforce at all stages of their careers. We have heard from GPs — time and time again — that we need more GPs in general practice in Northern Ireland. Urgent action needs to be taken to retain the GP training cohort that finishes in August. That will require a commitment to funding a fellowship scheme across Northern Ireland, but it is also necessary for us to compete better with other parts of the UK, as well as the Republic of Ireland, which is particularly important since the South currently provides more favourable conditions for GPs due to the higher salaries and more favourable work-life balance. Until we address specific conditions here, which are very different from those in GB — due to circumstances already mentioned — we will not have the necessary conditions for a stable primary care workforce.

I also want to discuss MDTs, which have been well mentioned in the debate. They are a central aspect of the 'Health and Wellbeing 2026: Delivering Together' report, which envisaged a 10-year approach to transforming health and social care, but progress in implementing MDTs has been delayed by budgetary and staffing constraints and, of course, political instability. Of the 17 GP federation areas, only one has introduced a full MDT in the four years since the launch of the aforementioned report. The evidence in support of MDTs is clear, as we heard from Members who have spoken already. According to data from the Department, 62% of MDT patients are treated entirely within primary care, meaning that there is no need for onward referral.

MDTs provide a key stabilising factor for practices in crisis. That is evidenced by the fact that, in a presentation to the strategic planning and performance group (SPPG), 83% of the 18 practice contract hand-backs that occurred from March 2022 to November 2023 were in areas with no MDT allocation. The remaining 17 were in areas where only a partial MDT was in place. It is for those reasons that we need an urgent timescale for the full implementation of MDTs across Northern Ireland. I welcome the planned roll-out, particularly in East Antrim. The call for that is strengthened in the amendment.

It has never been more important to see vital changes to how primary care operates in Northern Ireland to support our workforce and deliver for patients, including through the implementation of the MDTs, in line with previous recommendations and commitments. When I speak to GPs, they mention to me that core funding needs to increase for general practice. The recent GMS contract agreed for this year is a good starting point. However, more is needed to prevent GP practices from failing. That would mean that we would have more GPs, which would make general practice more viable for GPs to commit to.

The expansion of MDTs is vital. Although it will not be a magic bullet, it will maintain the level playing field between practices that have MDTs and those that do not, which will equalise the delivery of healthcare across Northern Ireland.

Photo of Órlaithí Flynn Órlaithí Flynn Sinn Féin

I welcome the opportunity to speak on the motion. I am happy to support the motion and the SDLP's amendment. It is important to acknowledge at the outset that, as mentioned by other Members, primary care includes community pharmacists as well as our GPs, nurses, mental health practitioners, social workers and health visitors, who all play such a crucial part in providing healthcare for the public in our local communities.

I cannot complain about the care that I have received from my local GP surgery in west Belfast, Ballyowen, or my local pharmacy, Coopers. They have been dealing with me and my family for years, and I do not have any complaints. I had my wee son Torin a year-and-a-half ago, so the health visitor has been coming and going to visit us, and I cannot fault any of the care that I have received. However, I am conscious that not everyone has had the same experience. Given the pressures outlined in the motion and the amendment, different GP practices, pharmacies, health visitors and all the rest will feel different types of pressure. That will have an impact in that not everyone will have the same experience when it comes to how many phone calls it takes to get through to the local surgery or how long they have to wait to see a GP or a health professional. It is important to note the positive experiences that people are having. It has been said by all the Members who have spoken that no one is taking away from all the brilliant work that GPs and health professionals in primary care carry out. However, no one is in denial over the massive pressure that they are under. Hopefully, we can help to support them.

Over the past number of weeks, we have received briefings at the Health Committee, and MLAs have been receiving emails from GP surgeries and practices from right across the North. To be fair, from the emails that we are getting, we can sense the stress and exhaustion that exists: they have highlighted the different pressures that they are genuinely under. The Minister will be aware of all that. Some of the emails tell us, in their own words, that primary care and general practice are at the point of failure and are failing because of the strain that they are under. They talk about widespread destabilisation and, as we have heard, the increasing number of practices that have had to hand back their contracts, which is linked to there not being enough investment in the workforce. Those are the same issues that cut right across all the problems that we have across the health system at the moment.

There is no point in listing the Members, but Alan, Colin, Danny and most of the Members who have spoken mentioned the number of practices that have closed. There is the really stark statistic that one third of practices are in receipt of additional support and intervention from the crisis team. That is a really high number.

It is really worrying that a third of all of the practices that we have in the small place that we live in are getting crisis support from that specialised team.

There is also the problem of all of the GPs who are leaving. As we know, a lot of them are going South for better pay and conditions. The arguments that have been made in the debate are ones that we receive directly from the general practices and GPs. I am sure that the Minister is across all of the detail already. It is about what we can do to help the situation.

Everyone has touched on the MDTs issue. It is a really worrying postcode lottery. The fact is that, of the 17 federations, only one has the full complement of staff. The intention is there to expand on that, but it is not good enough to expand it from one GP federation to three: it needs to be across all 17. I know that, in an ideal world, with an ideal budget, the Minister would do that, but it is so unfair to leave certain people —

Photo of John Blair John Blair Alliance 4:45, 14 May 2024

Will the Member bring her remarks to a close?

Photo of Órlaithí Flynn Órlaithí Flynn Sinn Féin

— in a postcode lottery, where one GP surgery has an MDT and the other does not. Hopefully, with today's motion and the amendment, we will see some progress on those issues.

Photo of Gerry Carroll Gerry Carroll People Before Profit Alliance

Our primary carers face an unacceptable amount of pressure without the resources to address it. While demand continues to escalate and the workforce is becoming more and more depleted, the real-terms funding cuts in general practice have created an unmanageable burden. To neglect and abandon the people who are holding up the foundation of our health service is cruel and unacceptable. The crisis has, unfortunately, been building for many years, and the necessary action to address the scenario has not been taken. It should not be surprising that the pressure has contributed to such poor retention in GP health services, with over one in 10 doctors leaving the sector in the past year.

Privatisation and austerity measures have eroded the capacity of our healthcare system to function more generally. We need to look at erasing the market principles that have been forced on health services. We should stop treating GPs as business owners and let them be doctors. It would be beneficial for the Assembly to consider the Cuban healthcare model, which has the highest doctor density in the world. It focuses on the needs-based allocation of carers to communities and has a comprehensive state-backed system that does not allow an extreme financial and workload burden to be placed on its workers. It has already eradicated polio, malaria and tetanus, and I believe that it is the only country in the world that has eliminated the mother-to-child transmission of HIV. Dr Clare Wenham of the London School of Economics and Political Science asked why it is not promoted as a great case study. I suggest that, as with most things, it is probably down to politics.

In a reversal of trends across the world, Cuba tends to send its doctors across the world when crises emerge, be they natural, viral or whatever. To serve a population of 11 million people, the country has 90,000 doctors. That is eight for every 1,000 citizens, which is more than double the rates in the USA and in the UK, which are 2·5 doctors per 1,000 people and 2·7 doctors per 1,000 people respectively. Cuba also has a preventative model that stops people getting ill, rather than treating them when they are unwell. We need to adopt more of that approach to stop the car at the top of the hill, rather than intervening when it has crashed at the bottom. Too often, our health system tries to play catch-up with people's health when it should intervene at a much earlier stage.

We also need to talk about barriers to studying medicine and, thus, to people becoming doctors. The applicant pool for medical degrees is far too small. In 2017, the BMA reported that more than nine in every 10 medical students in the North were ex-grammar-school pupils. There is nothing wrong with that generally — I am a former grammar-school pupil — but the issue of class needs to be added into the question. The medical profession generally needs to represent the society that it serves. It cannot be the sole preserve of middle-class and upper-class kids. When university fees amount to almost £5,000 a year for four years, that basically sends a message to working-class kids that they need not apply to study medicine, and that is completely unacceptable.

Recognition of our healthcare practitioners is not enough. It does not recruit and improve the retention of GPs. Our system needs complete transformation in order for them to do more than just survive the pressures of their day-to-day work. We need our Executive to supply a health budget that will mend our health service. It needs at least a 6% increase each year just to stand still, and that is completely unacceptable.

GP contracts need to be addressed. We need to start to treat them as GPs and public-sector workers rather than private-sector businesses. That would take the pressure off them when it comes to insurance and other costs and would also allow care, rather than making money in some cases, to be the main factor.

It would be remiss of me not to mention junior doctors as well. I believe that a motion on that is coming up next week. If we are to have a sustainable GP and healthcare sector in the months and years to come, we need to pay them what they are demanding and what they are owed.

Photo of Justin McNulty Justin McNulty Social Democratic and Labour Party

I support the motion, as well as the amendment from my party, the SDLP. I welcome the opportunity to speak to the motion today. I regularly visit Daisy Hill Hospital to speak with staff and patients in the hospital corridors. I also visit Craigavon Area Hospital, and there the outworkings of the crisis in primary care can be seen plainly at first hand. Far too many people present at accident and emergency departments because they cannot get appointments with their GP, because their GP appointments are delayed, as a consequence of which there are health impacts, or because they have just given up and do not go to see their GP. The health impacts are then exacerbated. Far too many people are lined up head to toe on trolleys and chairs in hospital corridors, waiting for prescriptions to be dispensed. They are often waiting to receive what is essentially primary care because they cannot get an appointment with their GP.

I do not for a second blame general practitioners for the crisis in primary care: far from it. GPs and their staff are doing what they can with the resources available to them. Unfortunately, they suffer from poor management and a lack of ambition from the health establishment. Take, for example, the long overdue health hub in my constituency. The development of the hub in Newry was announced in 2013. It was recommended for fast-tracking and was expected to be operational by 2016. Eight years on from that expected opening date, not a single sod has been turned on the site.

I have lobbied extensively on the issue, and although there are always unforeseen project issues, I neither understand nor accept that it is reasonable for people in my constituency to wait any longer for a health hub that was promised over 10 years ago. Is it any wonder that the people of Newry, south Armagh and south Down believe that they are always the last to get and the first to lose? I welcome the opportunity to speak to the motion today, but we need to get the basics right. Access to health services is a critical issue for the people whom I represent, and they have a right to expect that promises made will be promises kept.

For the Mullaghbawn GP surgery in south Armagh, I particularly welcome the component of the motion that calls for the extension of GP indemnity insurance to the North, in line with arrangements in Britain. The heart of the motion is correct, in that it identifies and seeks to remove the burdens and barriers faced by primary care practitioners. My family's local GP surgery in Mullaghbawn has experienced tremendous difficulty recruiting a managing GP after the departure of the long-standing local doctors in the practice. Dr Deane and Dr Maguire left a lasting legacy of care and compassion for their patients, and they are missed by all, as is their predecessor, Dr Smyth.

In my efforts to secure a replacement GP in Mullaghbawn, I advocated special incentives to entice an appropriate managing GP to the surgery, but those calls largely fell on deaf ears, with the health authorities seemingly preferring to stick to established policy rather than act innovatively. If we are serious about confronting the challenges in primary care, it is imperative that we recognise that doing the same thing over and over again and expecting a different result is the essence of insanity. I add my voice to the calls on the Minister of Health to provide an ambitious vision for growing the primary care workforce.

I will finish by paying tribute to the staff and clinicians in GP surgeries who are overwhelmed by the demand. I know from my own doctors in Newry, Dr McVerry, Dr McGee and Dr Farnon in the Cornmarket surgery. When I visit, the phones are ringing incessantly, machine gun-style. I wonder how on earth they cope with the relentless, incessant pressure. I thank those clinicians and their staff: well done, and keep going.

Photo of John Blair John Blair Alliance

I call the Minister of Health to respond to the debate. Minister, you have up to 15 minutes.

Photo of Robin Swann Robin Swann UUP

I welcome the debate today and the opportunity to recognise and pay tribute once again to the vital role played by primary care as part of our health and social care system. We have heard from many Members about matters such as community provision, community pharmacy and waiting lists, and that is recognition that no part of our health and social care system stands alone in regard to how we want to support all our patients or where pressures are felt.

Many Members who spoke today acknowledged the enormous contribution made by GPs, their practice teams and, indeed, the other health and social care professionals who, together, make up the primary care workforce. I therefore understand the ongoing challenges that patients and GPs, along with their teams, face, not least the impact of increasing demand and the resultant burgeoning workloads.

The fact that 26 general practice contracts were handed back between 2022-23 and the end of April this year has been mentioned a number of times. That is a testament to the pressures that GPs and their teams have to deal with daily, but it is right to recognise that officials in my Department have worked hard to ensure that, where contracts have been handed back, no practice has closed and patients have continued to access GP services in their area. That achievement is a testament to the work of my departmental officials.

Mrs Erskine mentioned the closure of Roslea. I checked that, and I think that it happened in 2017, somewhat before my tenure, but I will get back to the Member when I have checked who held the Ministry around that time.

Photo of Liz Kimmins Liz Kimmins Sinn Féin

I thank the Minister for giving way. Mullaghbawn surgery is an example of where the Department and the trust have stepped in, which is welcome, but he will know from our recent correspondence about some of the challenges that are faced there because we do not have a retained workforce but are operating the service with locums. Does the Minister agree that tackling that workforce issue and ensuring that we can retain GPs who consistently provide the continuity of care that is needed for patients is more important?

Photo of Robin Swann Robin Swann UUP

Absolutely. I will come back to the Health Committee Chair's point later in my contribution.

It was interesting that Mr Carroll referred to the healthcare model in Cuba. I looked around the Chamber to see how many Members were, like me, here in 2012 and remember that Health Committee members — Jim Wells and Sue Ramsey, I think it was — visited Cuba then to see how that healthcare model worked and whether they could bring back recommendations. I am not sure how far that has progressed since then.

A Member:

He is still there.

Photo of Robin Swann Robin Swann UUP

That may be uncalled for.

On a serious point, we cannot continue with a situation where, in some instances, GPs face such sustained pressure that they feel that the only course of action left to them is to hand back their contract. I am firmly of the view that it is not enough for primary care or general practice simply to survive. That is why I said that it was important to stabilise it before we move on to what is my ambition as Health Minister, which is for it to thrive. I want to build the resilience and capacity of the service so that it is sustainable for the long term and is better supported to deliver improved outcomes for patients.

As Mr Chambers mentioned, some of the points in today's motion have been superseded by discussions and engagements that have long been under way. For instance, only last week, I was pleased to announce that agreement had been reached on the 2024-25 general medical services contract. In the past, that was never the subject of debate or a ministerial statement, but I will take forward the concerns that have been raised, and maybe future Health Ministers will make that the subject of a statement. I appreciate the constructive and positive approach to those negotiations that was taken by the leadership of the Northern Ireland General Practitioners Committee to get us to that position. Whilst the budget provided to me by the Executive does not allow me to make a substantial increase in the overall value of the contract, I am pleased that the agreement makes significant progress against one of the key aims identified by GPs, which is the inclusion of provision for dedicated funding for indemnity costs.

Importantly, the new contract arrangements will provide GPs with greater certainty about their income throughout this year, as well as reducing administrative burdens and associated costs to practices.

The 2024-25 contract replaces the quality and outcomes framework (QOF) with a clinical care domain, which itself is part of a wider Northern Ireland contract assurance framework, and the funding that was previously associated with QOF, as well as a number of specified enhanced services, will now be incorporated, for the first time, into the core GMS contract. It is important to stress that, in bringing QOF and enhanced services into the core contract and under the new contract assurance framework, GPs will still be required to deliver these services to their patients as is clinically appropriate.

I know that GPs have previously raised concerns about indemnity. I am pleased, therefore, that this year's contract, for the first time, provides dedicated funding of £5 million to practices to support the costs of indemnity. That is an interim measure, as has been identified, pending the identification of a long-term model for future provision. That was a promise that I made to general practitioners before I left office the last time, and it is a promise that I have kept. My Department is committed to identifying solutions to address this issue, and work is continuing on options appraisals through the business case process, which will result in the identification of a proposed way forward for GP indemnity here. However, I am under no illusion that the new 2024-25 contract will resolve all the challenges faced by general practice: given the limits on the funding available to me, to put it quite simply, it will not do that and I do not believe that it can.

The motion refers to the Northern Ireland Audit Office's recently published report on access to general practice, and I have welcomed the publication of that report because it holds up a mirror to the current state of general practice. Its findings reflect my and my Department's assessment of the challenges facing our service. However, I want to be clear on this: the issues impacting on general practice are complex and require a sustained, long-term response. There is simply no short-term fix, and it will take time as well as resources, but we are committed and determined to deliver for primary care, for its workforce and for patients.

Central to that is exploring how we can make primary care and general practice more resilient; improve demand management and access to GP-led services; and strengthen the GP workforce. On demand management and access to GP services, we have already started to do that. A set of principles has been developed that will support more coordinated and streamlined management of the interface between primary and secondary care, clarifying the appropriate responsibility for patient management right across those two sectors.

I am asked regularly, including by Members of this place, when general practice will be back to normal or back to how it used to be. As Minister, I need to be honest and say that we have a growing and ageing population that is living with more complex chronic conditions, and, over time, that is leading to increased demands on our GP services. In a standard week, as has been mentioned, our general medical services clinical teams carry out over 200,000 consultations, of which half are currently done face to face. I fully understand that there will be times when people are frustrated that they cannot get through to their GP practice without numerous redials, and, again, that is why my Department has been actively looking at practical ways in which we can best respond to and deal with increasing demand.

Our GP access working group is working to continuously improve the management of patient demand and to optimise workflow within practices.

Photo of Robin Swann Robin Swann UUP

That group is also exploring how technologies can further develop improvements in accessing services for practices and patients alike.

I will give way to the Member.

Photo of David Brooks David Brooks DUP

Does the Minister agree that a way has to be found to prioritise those patients who are trying to reach their GP? I recently had contact from a constituent who found a lump. She complained to me that when she finally got through, she was told that she should go and talk to her local councillors and politicians about the frustration she faced rather than being given a face-to-face appointment. Surely that is unacceptable and surely a way has to be found to prioritise people who have very serious needs.

Photo of Robin Swann Robin Swann UUP

I will not deal with a case about a specific patient on the Floor, but if the Member wants to write to me with specific details, we can follow up on that.

It is important to recognise that primary care is changing and that it offers a range of services that previously have been outside its scope and have been provided in secondary care. As an example of that, in April, I announced that regional vasectomy services in Northern Ireland will be fully transferred from secondary care to primary care to be provided by GPs, with the required funding moving from trust budgets into primary care. Innovative initiatives to extend the range of services that are provided in primary care are also happening at a local level. Earlier this month, I visited Moy health centre to see a new GP-led service in the Armagh and Dungannon GP Federation to improve lung health. That early respiratory diagnostic hub will provide advanced lung-function testing, meaning quicker diagnosis, which will reduce respiratory admissions and help deliver better management of respiratory diseases. Those are just a couple of examples of how primary care is evolving, providing a broader range of services closer to people's home and improving the patient experience, as Ms Dillon referenced.

In order to help primary care to deliver and grow, it is critical that we train, develop, support and retain the GP workforce. In my previous term as Minister, I increased the number of GP training places to 121 by direction. As referenced, that was an increase of 86% since 2015-16. The number of places will be retained at that level even with the challenging budget position that I have. My Department has worked with GP representatives and other stakeholders in the Northern Ireland Medical and Dental Training Agency (NIMDTA) and our universities to increase the exposure of undergraduates to general practice as part of the curriculum to not only, hopefully, encourage more GP trainees but ensure that there are sufficient GP training practices to meet the demand for and support of GPs in training.

The GP fellowship scheme is also supporting recently qualified GPs to transition from the training environment to independent practice, with opportunities for personal and professional development. My Department very much values the fellowship scheme and the chance that it provides for recently qualified GPs to have access to an attractive portfolio of opportunities. Looking to the future, my Department is considering how the scheme might be further developed, subject to available funding, to extend the range and scope of fellowship placement opportunities and to provide for educational bursaries to be available for all fellows.

Other steps that my Department is taking to support the GP workforce include the introduction of the attract, recruit, retain scheme in order to support the recruitment of GPs in areas where it is hard to recruit. That scheme is already in place. Since its establishment in January 2023, 46 GP practices have applied and received approval in principle for funding under that scheme, and some 25 practices that have applied have received final approval and payment for a recruited GP.

We have continued to boost capacity in the wider primary care workforce by investing £25 million per year in the primary care MDT programme, £90 million annually in the general practice pharmacy programme and £3·1 million to recruit advanced nurse practitioners. Members have discussed, and I know, how valuable MDTs are in areas where they have been established and the difference that MDT roles have made. That model remains key to stabilising vital primary care services in our communities, providing a continuum of high-quality services right through from prevention to treatment, management and care of patients with more complex needs.

I am committed to the further implementation of the MDT model across Northern Ireland. My Department has long since developed the plan for the implementation of MDTs. Unfortunately, as with other initiatives, the pace and roll-out of MDTs has been seriously and repeatedly constrained by the ability of the necessary recurrent funding to support it. I will point out that, in the transformation pot that the Finance Minister identified, funding for MDTs will be one of the bids that I will make from that, so I look forward to support from across the House in whatever way possible for that bid.

The bottom line is that I cannot deliver what I do not have the money to fund. The 2024-25 Budget, which the Executive recently approved, was deeply disappointing. As a direct consequence, Health will face significant budgetary pressures this year. I have no doubt that, despite the best efforts of my Department and the wider health and social care system, we will deal with the fallout and consequences of that financial shortfall not only in primary care but across health and social care. Sadly and, unfortunately, the fallout from that will impact directly on the lives of people across Northern Ireland. Therefore, I continue to press my case to get the funding that we need for health and social care. That is what I believe our population deserves and what our workforce deserves.

Photo of John Blair John Blair Alliance

Will the Minister bring his remarks to a close?

Photo of Robin Swann Robin Swann UUP

I urge all Members to stand alongside me on this, and, more importantly, to stand alongside health and social care in Northern Ireland because, to reduce waiting lists and to deliver transformation, our health service —

Photo of Robin Swann Robin Swann UUP

— needs the quality services that our people deserve, and it needs commitment from across the Assembly Chamber.

Photo of John Blair John Blair Alliance

I call Cara Hunter to wind on the amendment. You have up to five minutes.

Photo of Cara Hunter Cara Hunter Social Democratic and Labour Party

Thank you, Mr Deputy Speaker. I will start by thanking our GPs for their hard work and commitment to the health of our communities. I know quite a few GPs in my constituency, from Portrush to Limavady and beyond, and I note how much more accessible mental health support, in particular, has been thanks to the advancement of multidisciplinary teams.

I welcome today as an opportunity to talk through some of the most difficult challenges facing general practice and how we must see changes made urgently. The healthcare system in Northern Ireland is overstretched, underfunded and utterly overwhelmed. Primary care, being the bedrock of our health service, provides 95% of the care that people need throughout their lifetime. In March 2024, the NI Audit Office, in a report into GP access, revealed that GPs received just 5·4% of the total health and social care spend in 2022-23. That lack of investment reveals itself most dramatically in the closure of surgeries, emigrating doctors and low morale. So many GPs have been left to make the difficult decision to exit a professional career that has, historically, been both attractive and somewhat rewarding in many ways. GPs have continued to take on fewer hours, and, therefore, fewer patients have been seen. Liz Kimmins touched on the really important issue of there being more attractive options in the South. We are losing talent who choose to practise elsewhere.

Alan Robinson touched on the fact that, last year, 13 GP practices decided to hand back contracts, causing the loss of around 70 doctors, which, undoubtedly, negatively impacted on the thousands of patients who were on their books. That was an inevitable consequence of such decisions, and it will only worsen. The shameful situation is that one quarter of our population is on a health waiting list. With one third of GP practices having sought crisis support in the past four years, it is little wonder that faith in our crumbling health system has been shattered. To underline what we already know, a recent survey found that 72% of people were dissatisfied with their local GP waiting times. Perhaps most worryingly, 32% of patients in need of an emergency appointment reported having to ring more than 30 times, on average, to get through to a receptionist. Having spoken to male constituents in particular, I note that, when they ring GPs, they often get a female receptionist and feel really uncomfortable about talking through more sensitive or private health matters and do not convey how serious something actually is because of embarrassment or hesitation.

Is it any wonder that 85% of people have said that it is more difficult to get access to a GP post-pandemic than it was before. The Assembly must resolve that issue, reverse the crisis in the health system, protect the health and well-being of our population and ensure that our wider health services are not further overwhelmed by patients who may avoid them if they do not receive a timely GP appointment. Many constituents who are overwhelmed and frustrated, having tried and tried and still not had contact, give up and do not ring back. Today is an opportunity to have the conversation about how we can promote the working conditions that enable our GPs to serve the public in a manner that preserves the dignity of their patients and the profession.

I will move quickly to Members' comments. Deborah Erskine touched on the importance of MDTs in rural areas such as Fermanagh, and I share her concerns and thoughts as I, too, represent a rural constituency. Colin McGrath said that this is a time to unlock opportunities for our health service by investing in primary care. Nuala McAllister said that she is inundated with messages from her constituents about their inability to access a GP. I am sure that none of us is a stranger to that. Alan Chambers acknowledged the work of the Minister so far, and Gerry Carroll included international examples of what we can do in looking to resolve the matter here.

We have seen our GPs shoulder the burden in having to deal with escalating demand alongside a declining workforce, while facing real-terms funding cuts that we have never seen before. Huge challenges lie ahead, but, in having these types of conversations, we are taking all the right steps to ensure that we see changes.

A huge "Thank you" as well to the wider community pharmacy, which also faces significant challenges but has really stepped up to the plate and provided support for communities. The more we invest in primary care and community pharmacies, the smaller the number of people showing up at A&E waiting rooms in utter distress and pain. Now is the time to invest in GPs and community pharmacies.

I thank the Minister for being here to hear our concerns.

Photo of John Blair John Blair Alliance 5:15, 14 May 2024

I call Diane Dodds to conclude and make a winding-up speech. The Member has up to 10 minutes.

Photo of Diane Dodds Diane Dodds DUP

Thank you, Mr Deputy Speaker, and thank you to colleagues for what has been a thoughtful debate. More importantly, however, thank you to our GPs, allied health professionals, health and social care workers and all who do a sterling job in that front-line service of primary care.

Every person in Northern Ireland is registered with a GP, and we all expect an enormous amount from those GPs. The debate has never been about bashing anyone, the Minister or GPs; rather, it has been an opportunity to discuss the problems in a rational, thoughtful way, and I thank colleagues for that today.

There has been much talk in Northern Ireland recently about the Covid-19 inquiry — the Minister has borne the brunt of that, as have I — but the best thing that we can do coming out of that is to give our GPs, constituents and community a health service that is fit for purpose. Minister, you have the support of the Health Committee in doing that. It is important to remember that when we have these debates.

The challenges in primary care and general practice are enormous. The service that the public receive and the environment in which GPs and some public servants work have fundamentally changed over the past 10 or 20 years. Minister, I absolutely accept your assertion that we are not going back. We need to plan for the future and have a proactive vision of what a really good primary healthcare system can look like. As things stand, however, we know that patients are not being assessed in a timely manner. The workload for GPs is continually expanding, and there really are not sufficient staff to run the service at its optimum.

When thinking about the debate, I thought about the general point that I wanted to make. We have talked a lot about transforming our health service. I think that it was Colin McGrath who quoted Bengoa. There is no doubt that there are big, fundamental issues that we need to work at in transforming services for the community, whether for cancer patients, stroke patients or whomever. However, if we do not transform primary care, we will not achieve a knock-on effect in secondary care in elective and other procedures. On that basis, it is good for the House to talk about the challenges that face primary care and those involved in providing it.

Sometimes, we think of this being an almost monumental challenge that we cannot overcome, but there are simple things that we can do that will help us to get to that transformation position. Many Members from across the Chamber mentioned funding. I am sure that some might take exception to this, but two million of us are registered with GPs, yet they receive 5·4% of the healthcare budget. We will have to rebalance that and look at it for the future. That is important in transforming the service.

While the motion focuses on GPs and GP practices, primary care is about so much more. It is about community pharmacies and mental health support services. It is about the community and voluntary sector, which does sterling work. Many of those organisations work quietly, bit by bit, with the most vulnerable people in our society. That is also very important to remember.

I turn to some of the contributions to the debate, because an important theme runs through them. When proposing the motion, my colleague Mr Robinson described and emphasised the importance of primary care, adequate funding and multidisciplinary teams and of having a workforce strategy so that we can have a plan and measure against targets along the way to see how we are doing. He talked about the retention of GPs in the system and training for GPs.

We support Colin McGrath's amendment, despite the misnaming of Northern Ireland in the midst of it. It is important to remember that we need to embrace change for there to be transformation. If we do not embrace change, services will collapse — we are seeing that — and we will then be transforming services on an ad hoc basis that suits nobody and will not give us a proper vision of primary care. Mr McGrath is fortunate that his constituency saw the roll-out of a fully staffed multidisciplinary team. That is important, because, in Northern Ireland, fewer than 8% of those teams are fully staffed and equipped. We need to look at how we can manage to do that even though the budget is challenging.

Liz Kimmins mentioned the experience of patients and the need to respond to them before conditions become so bad as to be intolerable for them to bear and to cause the time spent in hospital to become much longer. She talked about a permanent solution for the GP indemnity issue and the importance of the community and voluntary sector. Nuala McAllister talked about the impact of handing contracts back and the large number of services involved across primary care.

Mr Chambers was a little perturbed that the motion was too late. I think that the motion is very timely, because we are here talking about the importance of primary care, GPs and supporting those services. I wish the Minister or his successor well in achieving suitable and practical solutions for GPs. Mr Chambers also talked about multidisciplinary teams. I have no wish to bring politics into this, but I remind Mr Chambers that the initial funding for multidisciplinary teams came from the additional billion pounds that was found in the DUP confidence-and-supply money. It is really important to remember that. I want us to continue to fund those teams, and I will support the Minister in his bid to do so, because they are fundamental to resolving the issue.

Linda Dillon talked about the importance of primary and social care and of taking a holistic approach to well-being in our community. That is important. Well-being is underrated as a value, and it is really important for us to remember that.

My colleague Deborah Erskine made really important points about the impact of the crisis in GP surgeries in rural communities and access to those services. I accept that trusts have done an enormous amount of work to ensure that those GP surgeries continue, even though contracts have been handed back. That is massively important.

There is also the issue of having accountability for GPs, so that we can understand that the services offered are the same and do not encounter a theme that has been commonly expressed in the Chamber today: the inequality of service across Northern Ireland, which is intolerable.

The Deputy Chair of the Committee, Danny Donnelly, talked about the workforce strategy, the plan to retain GPs in general practice and the need to improve core funding. Other colleagues talked about it being important to remember that many in our community have absolutely positive experiences of visiting their GP —

Photo of John Blair John Blair Alliance

The Member's time is almost up.

Photo of Diane Dodds Diane Dodds DUP

— and it is important to remember that.

Thank you, Mr Deputy Speaker. This is a hugely important motion, and I hope that those involved in delivering the service understand that we support them.

Photo of John Blair John Blair Alliance

Thank you for concluding the debate.

Question, That the amendment be made, put and agreed to.

Main Question, as amended, accordingly agreed to. Resolved:

That this Assembly values the enormous contribution of those working in primary care across Northern Ireland; notes that this includes GPs, nurses, health visitors, physiotherapists, social workers and mental health practitioners; recognises that primary care is generally the first point of contact within the health service for those who become unwell; further notes the recent Northern Ireland Audit Office report on access to general practice, which found that almost one in three local practices has sought crisis support in the past four years; regrets the absence of a specific workforce strategy for general practice; believes the failure to train, recruit, retain and reward staff has limited progress toward the roll-out of multidisciplinary teams in local primary care settings; calls on the Minister of Health to publish a timescale for the full implementation of multidisciplinary teams across the North; and further calls on the Minister of Health to provide an indemnity scheme for GPs in Northern Ireland in line with arrangements in other parts of the United Kingdom; and calls on the Minister to increase the number of GP training places and invest in an enhanced fellowship programme for newly qualified GPs as part of an ambitious, costed and time-bound plan to grow the primary care workforce.

Photo of John Blair John Blair Alliance

I ask Members to take their ease while we change the top Table.

(Madam Principal Deputy Speaker [Ms Ní Chuilín] in the Chair)