Official Report (Hansard)

Session: 2008/2009

Date: 02 October 2008


Health and Social Care (Reform) Bill

02 October 2008

Members present for all or part of the proceedings: 
Mrs Michelle O’Neill (Deputy Chairperson) 
Mr Thomas Buchanan 
Dr Kieran Deeny 
Mr Alex Easton 
Mr Tommy Gallagher 
Mr Sam Gardiner 
Mrs Carmel Hanna 
Mr John McCallister 
Mrs Claire McGill 
Ms Sue Ramsey

Dr Brian Dunn ) British Medical Association (NI) 
Mr Danny Lambe ) 
Dr Brian Patterson ) 
Mr Ivor Whitten )

The Deputy Chairperson (Mrs M O’Neill):

We will now take evidence from the British Medical Association (NI) (BMA (NI)). I welcome Dr Brian Patterson, chairman of the Northern Ireland council of the British Medical Association; Dr Brian Dunn, chairman of the general practitioners committee; Mr Danny Lambe, deputy secretary of the British Medical Association (NI); and Mr Ivor Whitten, the association’s Assembly and research officer. I invite you to make your presentation. The evidence session will last for approximately 30 minutes.

Dr Brian Patterson (British Medical Association (NI)):

The British Medical Association (NI) thanks you for the opportunity to attend the Committee. I listened with interest to the evidence from the representatives from the Royal College of Nursing Northern Ireland, and, for the most part, I echo their sentimentsIt is interesting that two medical professions fundamentally agree.

I shall begin by making a few points on the overall view of the BMA (NI) to the reform of our Health Service. We will then take questions from Committee members and try to answer them as best we can.

The BMA (NI) welcomes the Health and Social Care (Reform) Bill as progression of phase two of the review of public administration (RPA), which deals with the reform of health and social care. It has the potential to improve the lives of many people in Northern Ireland. At the outset, I wish to clarify that our reservations are not related to the proposals for structural reform; rather, they are concerns about the function of those structures. However, we in no way wish to impede the Bill’s progress.

We also welcome the proposed establishment of a regional health and social care board. The BMA (NI) has long had the policy objective of reducing that which is totally unnecessary, and that includes the four health and social services boards in Northern Ireland. We strongly welcome that proposal. We also support the slimming down of the Department of Health, Social Services and Public Safety. We look forward to the savings that will be made from a reduction in bureaucracy, and to those savings being released into front-line patient care. It is vital that the reduction in bureaucracy produces those savings. Moreover, it is essential that any such savings are visible and audited, and that the Department communicates with health and social-care organisations and other stakeholders on how the savings will be redistributed to front-line patient care. It must a visible and transparent process.

The BMA (NI) welcomes, with reservations, the creation of a new regional support services organisation. In response to the proposals in ‘Transformation of Business Services in Health and Social Care — Shared Services’, which was published in 2007, our recommended option was for a single, centralised support service to provide a range of shared services. However, the size and bureaucracy of that support function is a concern. The BMA (NI) hopes that the huge bureaucracy is structured in such a way that it is flat and divisionalised, which is to say that there should be a streamlined hierarchy with only a few managers, as opposed to directorate upon directorate. The provision of any outsourcing of work must be subject to the application of stringent business cases and must be progressed openly and transparently. We have some concerns that such an organisation will be structured in such a way that it will be taken over by the private sector.

The establishment of a regional agency for public health and social well-being, as well as the priority given to public health in the new structures, is welcomed in principle. It is vital that the role and functions of public-health doctors are enhanced and backed up by the necessary staffing levels and support. The regional agency will need to interface with the Department, the regional health and social care board, the regional support services organisation and the trusts. It is essential that bureaucracy be minimised in the regional agency and among the other bodies. We are slightly concerned about the lack of clarity on how the organisations will communicate with one other.

There should be no clash of functions between the proposed director of public health and the Chief Medical Officer. There must be clarity in their relationship, and in the relationship of the advisory roles of the director of public health and the Chief Medical Officer to the Minister. We would also be concerned were the director of public health not medically qualified. It is quite common for that to be the case in England.

The BMA (NI) has concerns about the lack of engagement with public-health doctors by the public-health work-streams project team. The mechanism currently used for transparency and to involve staff does not compare to the mechanism used in the previous consultation process.

The mechanism by which people are selected for different work streams is unclear. As a single issue that is perhaps not terribly important; however, constraints have been placed on the ability of the people selected to consult fully with their colleagues. In particular, they have not been allowed to share relevant documentation. That appears to be illogical, as the documentation could probably be obtained through a freedom of information request. It causes much unnecessary suspicion and resentment, and it does not allow for open and transparent working.

The BMA welcomes the patient and client council. Its role, personnel, and finance should be effectively resourced, and its local offices should be based in the new trusts, the new LCG areas, or the new local council areas.

In turn, those bodies must be more strategic and visionary than reactive, as has previously been the policy. That will require the proper resourcing that we mentioned earlier. The BMA has major concerns about the top-down approach to managing commissioning. From listening to the discussion with the first set of witnesses, I understand that that is a widespread concern. An opportunity will be lost if we create local commissioning groups, but ignore the potential for further development at a community level, at groups of local practices or at individual practices.

The BMA strongly believes that any commissioning body that wishes to have a general practitioner involved must have the freedom — as long as they operate within the regional strategic framework — to commission services, and to place or to move contracts. Commissioning is about assessing, prioritising and commissioning according to clinical need. That must be evidence-based, and decisions must be taken by people with the appropriate level of expertise.

Our next point will not be popular. The BMA opinion is that elected local representatives should not be included on local commissioning groups. That is no reflection on local councillors; we do not want to minimise the importance of elected local representatives. The BMA fully supports the principle of local commissioning groups and local government working closely together on local health improvement plans.

Furthermore, we are realists, and recognise that our wishes will not be fulfilled. However, we will be keen to ensure that that works effectively.

If elected council representatives are on LCGs, the scrutiny and accountability of local councils may be eroded. The practicality of having four local representatives on each LCG is a concern. For instance, in the Northern Health and Social Care Trust area, the proposed community group will cover eight current local government areas.

The BMA has consistently called for more powers for local councils, especially with regard to well-being and community planning. That is essential if local councils are to engage with multiple stakeholders in planning healthier spaces for ratepayers. It would be difficult if local councillors were to commission services which they would then be required to scrutinise. The scrutiny role is more important. Historically, lack of scrutiny is an area where the Health Service has fallen down.

Thank you very much. We are happy to answer member’s questions.

The Deputy Chairperson:

Thank you very much for your presentation. Tommy, do you want to start?

Mr Gallagher:

Thank you for your presentation. I return to the issue about the lack of shared information in work streams. Elected representatives have found that, under RPA, in the case of local government, it has been felt that the Department has not shared information with the elected representatives who will be involved in the new set-up.

I presume, therefore, that the Department is also the body that is not sharing with the professionals information about all that is happening in those work streams. Is that the case?

Dr Patterson:

The situation is even more complicated than not sharing — the difficulty is that it prohibits those who have the information from sharing it with their colleagues.

Mr Gallagher:

Did the Department impose that restriction?

Dr Patterson:

Fundamentally, yes, because they are the only people at present who have the information. There is little enough information available on which we can comment, but we would like to see whatever information there is to make an informed comment rather than have to fight and use legislation to get information. If the process is open and transparent — and it is hardly the Official Secrets Act — why are we not seeing that information?

Ms S Ramsey:

When I was growing up, there was an advertisement on the television saying that one does not need a pill for every ill. I agree entirely with that.

Your submission states that local commissioning groups should be led from the local community upwards, that iii should not be a top-down approach, but a bottom-up approach. I agree with you totally in that respect. Therefore, I am slightly concerned at your point about elected local representatives.

I am not now a local councillor, but I was one for a long time. The Bill aims to achieve a holistic approach to health and social services to ensure that Departments other than Health, Social Security and Public Services play their part, whether in education, sport and leisure or on local councils. How does that fit with your view on elected local representatives? They are probably the only ones — especially at local council level — who have a holistic approach to the community’s needs, especially when councillors have grown up, live and work in that area. You need to be careful on that, which brings me back to my original point that it is not always a pill for every ill.

Medical practitioners, for whom I have a great deal of time and respect, do not always have the right answers. The challenge to treating heart disease or obesity could, for example, be to provide more leisure facilities. Therefore, if this Bill is to be a root-and-branch change in the approach to community health inequalities, the BMA, which is probably one of the larger medical unions, must be careful.

Dr Patterson:

Do not get us wrong: we do not suggest that the local commissioning groups should be composed entirely of professionals, and that there is no place for community representation. That is not what we are saying. Four seats are allocated for local councils, and that could cause a problem with regard to scrutiny. That is our objection. However, that is not to say that those four seats could not be filled by other lay people from the community, empowered through various bodies. There is another way of approaching the issue which preserves the right of councils to provide firm scrutiny.

Dr Brian Dunn (British Medical Association (NI)):

Commissioning is not a democratic process — it is not about voting whether somebody should have this or somebody should have that. The BMA(NI) believes that the political decisions are taken by the Minister, the Assembly, and the local commissioning groups. Hopefully, smaller groups below that would work within that overall strategy.

I am a GP. I live in, and am involved with, my community, and I am chairman of various organisations. I recognise that the local council has a big role to play. Living as they do in the community, GPs live with their mistakes as well as their successes, and that makes them human.

I do not think that I am infallible; I know my fallibilities. I am happy to work with other people to improve the health of the community. The Minister’s document does not recognise what true commissioning is. Northern Ireland has not had true commissioning. Boards have given huge sums of money to trusts, assuming that the volume of service will be the same as the previous year. Whether the trust either delivers or does not, in the next year, it receives the same volume of money plus an uplift.

Proper commissioning, as we envisage it, involves groups of practices coming together to assess the needs of their community and considering how the service is provided. It involves assessing whether there is a more efficient way of providing the service, holding the trust to account for what it does provide and cutting out inefficiencies, such as unnecessary outpatient appointments and considering drug budgets. For instance, it should look at practices having the same drug formulary as the hospital. Sometimes, patients go into hospitals on one tablet and come out on a different one just because the hospital does not use that tablet. Huge efficiencies can be made, but those efficiencies can only be made by professionals if they are fully engaged in the process.

Ms S Ramsey:

We are not disagreeing, but a more proactive approach is needed when commissioning and local knowledge and information is considered. For example, my constituency of West Belfast had a high level of asthma for several years. People were being given the medication to deal with asthma, but no one was dealing with the Housing Executive to get rid of the cause. Local elected representatives are crucial for finding out information, and a proactive approach is required that recognises that a pill for every ill is not necessary.

Dr Dunn:

We agree entirely with that. As doctors, we realise that the improvement in health in these islands has not come about because of better medicine. We recognise that it has come about because of better diet and better social conditions. We do not see the LCGs not working with the local councils. Local elected representatives must work closely together with the LCGs, not only to treat illness but to prevent illness and improve the health of the community. We both want the same outcome, but my perspective is slightly different from yours and that of the Minister.

The Deputy Chairperson:

Agree to disagree.

Mr Easton:

Thank you for your presentation. You mentioned that local councillors might not be on the local commissioning groups. Slightly before that, you suggested that another layer below that might be created that would include local representation. Can you explain more about that?

Dr Dunn:

The Woodward proposals, the Goggins proposals and the Sissling proposals envisaged a local commissioning group. Under that, they envisaged groups of practices who use the same provider, which cover perhaps up to 50,000 patients, coming together to consider the needs of their community and how the provider was providing those needs. They envisaged that those groups would have the ability to have a devolved budget, and, if necessary, the ability to move the budget to another provider to improve the health of their community.

GPs did that, and fundholding was not universally popular, but the reason that fundholding patients got a better service than non-fundholding patients was not because extra money was spent on them. They got a better service because of better commissioning by the GPs.

For example, a fundholding practice with a practice on the Antrim coast was an isolated, single-handed practice that had a laboratory service collection twice a week. When fundholding ended, the GP had a laboratory collection twice a day, in-house physiotherapy, in-house podiatry and other services. His patients benefited, without any extra money being spent on them, and that is the way that we see services should be provided.

Ninety per cent of our budget is spent on hospitals, and, by increasing the efficiency and improving the service to local communities, money could be saved without sacking people or making people work harder. A year or two ago, GPs were up for that type of system, but they have become more and more cynical as delays have gone on, and they think that it will never be implemented. Our big problem will be in motivating GPs to join LCGs.

Dr Patterson:

We do not advocate a one-size-fits-all approach. However, where local need exists, it seems strange to call it local commissioning when populations of 300,000 are involved. Most of us are familiar with practices with approximately 7,000, 11,000 or 15,000 patients. Issues in our Health Service could be sorted out at that lower level, and, although the Bill does not deny that possibility, why has the proposal changed significantly since the previous proposal? It is silent. When I explore the proposal, I am told that there is an option for local commissioning groups to suggest a lower figure. Our health boards have had many options over the years, which they have chosen not to exercise. It is difficult for large organisations to recommend smaller bodies to carry out particular tasks. There are areas in our country where local need could be addressed through smaller areas of commissioning, rather than populations of 300,000.

Mr Gardiner:

Thank you for your presentation. I am disappointed and do not accept item 12, which refers to locally elected representatives. I declare an interest; I have been an alderman in Craigavon Borough Council for many years. I do not agree with your sentiments about locally elected representatives on this new body. Local representatives have their feet on the ground. Doctors work their hours and, afterwards, are free to play golf or go sailing. Councillors and MLAs are on call around the clock. We communicate with the public, and the public know who represents them. Therefore, I do not accept that point and your presentation is, perhaps, damned by its inclusion. I do not support you on that matter.

Dr Patterson:

As I said during the presentation, we know that we are out on a limb on that matter. I tried to argue that the reason is not about —

Mr Gardiner:

Why not be sensible about it?

Dr Patterson:

I think that we will be compelled to be.

Mr Gardiner:

You had better change your tune.

Dr Deeny:

I disagree with Mr Gardiner. Like Brian Patterson and Brian Dunn, I am well known in the community, and I do out-of-hours GP duties.

Mr Gardiner:

But you are a public representative.

Dr Deeny:

That is true. My questions have, mainly, been covered. I agree with Brian Patterson that 1·7 million people spread across five local commissioning groups — amounting to over 300,000 in each area — does not constitute local commissioning. That is a concern. The Committee should consider that point.

The previous proposal was for the community care associations, and they covered areas of, roughly, 50,000 people each. That is local commissioning. As a GP, an elected representative and a member of community, I know that people consider 300,000 too large. We must consider reducing that figure to approximately 50,000. Our practice has over 8,000 patients, and we could amalgamate with other local practices that are aware of their specific local needs. How can the Committee address that matter — as I believe we should — to secure local commissioning and meet local health needs?

I accept Sue’s point, and accept the point made by the BMA; there must be a close link with councillors. Indeed, I have no problem with councillors’ being represented, because leisure centres and other facilities are involved in healthcare. Councillors are in touch with local needs in that area. How can the Committee’s response to the Department consider local need, rather than allow a regional board with five local commissioning groups to deal with more than 300,000 patients?

My second question is about the problems the BMA may have in communicating with the various bodies that you mentioned at the beginning. Again, I ask for your suggestions or solutions: how should communications take place between the new bodies proposed for next year?

Dr Patterson:

To answer your second question, it is obvious that communication must be effective without involving a huge bureaucratic machine. Our major concern is that this proposal is silent on how the bodies will communicate. There is silence in other areas, for example, the number of seats available on these bodies and the persons likely to fill them. Silence always raises suspicion. I can live with it when someone states his position, and then one can argue for or against it; but silence implies a plan that we have not yet been told about. My worry is that communication must be effective, therefore people must be accountable for it. There is no need for a huge, complex machine, in which it is obvious that no one will be accountable when communications go wrong.

We have had a long history of being given the runaround. We speak to a trust, which tells us that the board that commissioned it is responsible; we go to that board, which says that, though it is commissioning, the trusts are not acting and the Department will not let the board do anything about it. We have spent light years running round in that circle, and we never succeed in getting the three in one room. My fear is that these bodies will act in the same way. To make communication effective, someone must be accountable for it, and we should not have to chase up 17 different culs-de-sac. To keep it simple, structuring communications is all about accountability.

There is something else you can do to ensure that there will be commissioning at a lower level. I am assured that what is on the table does not preclude that; however, I want firmer assurance. I want to know that it will be encouraged. With populations of 300,000, the question must be asked: are the LCGs are so very different from health boards? We may simply be moving from four health boards to five. The needs of local people are vital. We differ, in some respects, as to how those needs will be communicated, but that can be resolved. The important thing is that the ability to address those needs is definitely — not just potentially — present.

Dr Dunn:

Regarding accountability, there was an instance recently where a board wanted to do something, but the trust said no. The board replied that it was the commissioner; the trust responded by claiming that it was not accountable to the board, but to the Department.

The new arrangements must ensure that the provider will be accountable to the commissioning body, rather than to the Department or anything else.

I must prolong the argument on elected representatives: I pushed that fairly hard in the BMA. In my community, I am a GP and an elected councillor. I know the rules of councillors, and what councillors will bring to LCGs is only peripheral and could be worked out in a meeting between the LCG and the local council. Commissioning will be about who will receive breast cancer drugs, dialysis, to where heart disease should be referred, how asthma should be treated. There are items around the periphery that will be of interest to elected local councils, but a co-ordinating committee could sort those out. There is no need to have councillors there, making decisions that, at times, will be very unpopular. However, as the Deputy Chairperson has said, I am sure that we will agree to differ.

Ms S Ramsey:

Councillors will be the only independent element; they alone will have no agenda to push.

Dr Dunn:

We see GPs as independent.

Ms S Ramsey:

We’ll beg to differ on that as well. This issue is also about protection. Councillors are the only ones who are independent. The BMA — [Inaudible.]

Dr Deeny:

Just on the back of that —

The Deputy Chairperson:

If there is time at the end, I will return to Dr Deeny. Carmel is next.

Mrs Hanna:

Good afternoon, gentlemen, and welcome. I take on board the point that has been made and I am concerned to ensure that savings from a reduced bureaucracy are directed towards front-line services. However, those savings must be subjected to proper accounting and auditing procedures; otherwise it will not be possible to assess their benefits. My biggest concern is how the bodies relate to each other with regard to their partnership, decision making, top-down and bottom-up relationships, where they meet in the middle, and how well they communicate.

The witnesses say they are concerned about the large scale of the regional support services organisation. It is so big that I wonder what it will do. It will not want to commission other services that can be obtained in-house. In a previous submission to the Committee, the Child Support Agency (CSA) stated that it was concerned about the impact on it of being subsumed into another body.

I am also concerned that not enough consultation has taken place with public health doctors through the Institute of Public Health. A serious effort to create a new public health body requires a lot more public consultation.

How do you envisage the make-up of a commissioning body? What decision-making role will its members have? Will there be a partnership role for GPs and other health professionals? I am not hung up on the number of councillors that may be involved, but in principle I support a councillor being appointed. If their role is regarded as peripheral, there is no reason why there cannot be capacity-building with councillors. There is no reason that councillors should not have a far more meaningful role.

I want to hear more about the proposed breakdown of that commissioning body and how to ensure that it will be a real partnership that will incorporate health professionals and others in the decision-making process. Mention has been made of Dr Brian Dean’s comments on the efficiency savings that doctors might bring to the body. If that is not happening already, surely it should be, partly as a result of a reduction in prescribing and generic drugs. Problems like clostridium difficile have informed the public about ongoing problems associated with the overuse of antibiotics.

I want to see commissioning groups made even more local, but there must be a real partnership in both the membership and the decision-making process.

Dr Dunn:

I emphasise that GPs are not seeking power. As a GP myself, the only thing I want from the secondary sector is that my patients are seen and treated or operated on as soon as possible. I have no other agenda.

Adopting a central direction approach will not lead to savings. Generic drugs, for example, are always trumpeted as the saviour of prescribing budgets.

Mrs Hanna:

That was just an example.

Dr Dunn:

At any time, 30% of generic drugs are more expensive than the branded equivalent. Sometimes generic drugs are cheaper, at other times they are a lot more expensive. Reorganisation alone will not create savings. Like most reorganisations, this one will result in bureaucrats generating more bureaucracy. Therefore, savings accrued through reorganisation will be small.

Savings can be made by involving the practices. I want to emphasise that savings can be made by getting practices to sit down together — which involves extra unpaid work for GPs — to establish how to get more people through the health care system for the same amount of money. That involves considering referral patterns and talking to trusts about how to provide better services through increasing the number of new appointments, and reducing the number of review appointments by having those looked after by GPs rather than by hospitals.

I am passionate about this because it can work, and I want to see it work. It must be more radical than rearranging the deckchairs on the Titanic and declaring that everything will be OK. Trusts must provide what they are paid to provide, rather than being given huge sums of money in the hope that they do.

Mrs Hanna:

I agree. However, all other health professionals must do exactly the same in their roles.

Dr Dunn:


Mrs Hanna:

Therefore, my question is more about the breakdown of that partnership.

Dr Dunn:

We envisage that locality commissioning will involve GPs, nurses and other health professionals working with people in the local community, assessing local needs, and deciding how best to meet those needs. There is no question of GPs dictating what happens. It is just that GPs hold patients’ medical records and are responsible for approximately 90% of referrals to the secondary sector. That is the only reason that GPs feel best placed to perform that function. GPs want to work with people, not boss them or tell them how things should be done.

Mrs Hanna:

I take your point on that. We have been so concerned about making the decision-making role right in the two main bodies, but it is equally important that we are aware of how it works — right down to that level — and that we know the detail.

Dr Patterson:

That partnership happens day and daily on the ground. When we look at the proposals, we see that there is huge potential for that partnership to flourish. In the past, people always said that that is what should happen. However, they placed so many obstacles in the way that they prevented it from happening, and we are concerned that such a situation will reoccur. They do not want that to happen at a local level, because a local level is much more effective but less controlled. This is about top-down control rather than about genuinely assessing and meeting need from the bottom up.

On the issue of savings, and the visibility of those savings, we have gone through phase one of the RPA for two years. Are you impressed by the level of savings resulting from the reorganisation of the trusts? I do not think that there have been any savings.

Mrs Hanna:

The concern was always that no savings would really be made. We want to ensure that the reform of health and social care works and provide a better service for patients. We are hopeful that there will be savings in future and, if there are, that they will be visible.

Mrs McGill:

I declare an interest as a district councillor. I do not wish to labour the point, but it would be remiss of me, as a district councillor, not to comment. Your submission demonstrates your strong opposition to local councillors sitting on local commissioning groups (LCGs). As you have declared that you are a councillor yourself, Dr Dunn, I wonder whether that opposition is a result of your personal experience of councillors. It may not be the same across the entire North —

Ms S Ramsey:

Which means that you are not a good councillor. [Laughter.]

Mrs McGill:

My colleague Sue Ramsey said that councillors bridge the gap between some bodies. Furthermore, you made referred repeatedly to the threat of increasing bureaucracy. I feel that councillors often do a good job in highlighting such bureaucracy.

My question concerns the transfer of the Mental Health Commission to the Regulation and Quality Improvement Authority (RQIA). Do you have any comment to make on that issue?

Dr Patterson:

We have commented on that in our documentation.

Mrs McGill:

I only require a brief answer. If you have not got the information with you, you can respond to me at a later date.

Dr Patterson:

We are all aware of the situation surrounding mental-health services in the Province. We see the RQIA as having a huge role to play in the development of mental-health services. However, to place that body in such a position is a little like the previously mentioned scrutiny issue. How can that body scrutinise something for which it is responsible? That is our argument.

Mr Ivor Whitten (British Medical Association (NI)):

The transfer of the Mental Health Commission to the RQIA is somewhat problematic, mainly as a result of staffing and training issues. The RQIA is already stretched, and the absorption of that extra responsibility will mean that it will be further stretched. We are not necessarily against the idea, but our real concern is whether the RQIA will be able to take on the extra responsibility. It is a very sensitive area, which must be properly resourced.

Dr Deeny:

I am not going to ask what you think I am going to ask. [Laughter.] I wish make a point as a GP. Many people say that 300,000 people being cared for by a single LCG is too high a number. I feel strongly about that, and I wish to stress that fact to my fellow Committee members.

The Western Health and Social Care Trust provides healthcare for a population of almost 300,000 — I believe that 297,000 is the exact figure. That trust encompasses quite a large area, and the people’s health needs in that region are differ greatly. For example, the needs of those living in Derry city are different to those living in rural Fermanagh or Tyrone.

Given that the LCGs will be commissioning, it is important that Committee members take that point on board. It may be argued that it is fine for a LCG to cover a population of 300,000 in Belfast because everyone there has the same needs, but we all know that that is not the case. People living in different areas of Belfast have different needs.

We must consider seriously the proposal to bring the population covered by a LCG down to approximately 50,000. For example, my patients’ needs differ from those of patients in the Creggan estate in Derry. It is important that we take that on board, and I ask Committee members to consider it.

I was not asking a question; I just wanted to make the point that 300,000 patients are too many for a single LCG. The needs of the people in the west are different from those of the people in Belfast, and, similarly, the needs of the people in south Belfast are different from those of the people in north Belfast.

Ms S Ramsey:

We could make a note to consider that during clause-by-clause scrutiny of the Bill.

Dr Deeny:

As Brian Dunn mentioned, GPs, primary-care professionals and community representatives are prepared to make an input to the LCGs at no cost.

Ms S Ramsey:

May I ask a question that may not be popular with the BMA? It does not annoy me to be unpopular. Please explain to me, as if I were a two-year-old, how the commissioning system will work. For example, if GPs are in control of the commissioning service and 90% of Brian Patterson’s patients have asthma and 90% of Brian Dunn’s suffer from allergies, who commissions for which patients? The commissioning process will be subject to a budget, so if Brian Patterson makes a stronger argument to the commissioning group, will his patients receive the treatment that they need ahead of Brian Dunn’s patients?

Dr Dunn:

Budget setting is much more sensitive when performed at a local level. It will not be the case that a decision will be made to buy X number of drugs, which is what happens at present. Currently, the Eastern Heath and Social Services Board allocates approximately £1 billion to Belfast Heath and Social Care Trust each year. That body then requests a volume of drugs, but frequently that is not delivered. With a local commissioning system, doctors will know how many patients suffer from asthma, allergies or heart disease, for example. The doctors in the LCG will then get together and calculate the total number of patients with different conditions in that group, and they will place their contract accordingly. In that way, the contract will be much more sensitive to the local need.

Ms S Ramsey:

I do not want to criticise, because I have a very good GP, whom I hope is listening to this. [Laughter.] However, rightly or wrongly, GPs will want to fight for the rights of their patients and will not consider people who are not their patients — the only people who will do that are those who are independent. The only people who are totally independent are elected representatives.

Dr Patterson:

Certainly, a huge issue exists and it relates to Carmel’s point about partnership. It should not be only GPs who are determining how the system operates. GPs have a valuable input to make, as was shown when they did not participate in the local health and social care groups (LHSCGs), but that was because that scheme was doomed to failure. We do not want the LCGs to be doomed to failure. We suspect that the scheme is being manoeuvred into an LHSCG mode, and we are relying on the Committee to prevent that happening, during its clause-by-clause scrutiny. The LCG scheme is about getting everyone with an interest involved. I am not particularly hung up on people’s disciplines or professions because I recognise that a variety of people will have a legitimate interest.

The new scheme will be much more sensitive to the needs of individual patients if it is operated at a level of 50,000 patients or fewer, rather than at a level of 300,000 patients. The scheme should not focus solely on doctors. Doctors have a role to play and, as the Committee heard earlier, nurses have a role, as do pharmacists, dentists, and opticians, and those roles are vital. It is all about communication. Communication at a genuinely local level will produce better outcomes for patients than communication in some lofty chamber.

Dr Dunn:

We are not particularly concerned about what form the bodies will take; we are concerned about their function. We want to see them as effective commissioners; otherwise, there will be a secondary-care-led service. That kind of service has created the waiting lists that now exist. We must have a service that considers what the patients in the community need and delivers on those needs, rather than delivering what the secondary-care service wants to provide, which is sometimes the case.

The Deputy Chairperson:

That brings our evidence session to a close. Thank you very much for coming along and presenting your views, even those that were unpopular. [Laughter.]

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