Professor Brendan Kelly:

I will start with Deputy Higgins's reference to the recruitment difficulties and changing culture. Culture will change you far quicker than you will change it, which is the big problem. My optimism was referred to earlier. I will return to this because there are many people working in our health and social care systems who are doing fantastic work. There are many organisations doing their best, and committees such as this one are trying to keep the matter on the political agenda. Therefore, there is a great deal that is good.

With regard to recruitment, my experience is mainly in medicine, particularly psychiatry. There are many things going on. For example, the College of Psychiatrists of Ireland, of which I am a member but not a spokesperson, is working hard on recruitment, reforming training processes and streamlining. It is also trying to work on implementing policy and updating the Mental Health Act. All these matter quite profoundly in building a system that will entice people back, although we are competing all the time with pictures of beaches in Australia and landscapes that are very compelling. Nonetheless, we have a very committed generation of medical students who will, indeed, return.

I thank Deputy Cairns for her questions. She talked about the need to protect social and medical well-being. Some of the specific measures I have mentioned would help. I cannot overstate the need for electronic medical and social care records linked by a unique identifier number. This is possible. All of our hospitals have an electronic radiology system, and everyone is identified no matter what hospital they go to. We do not have the same for medicine or social care. For example, if someone is discharged from an inpatient psychiatry unit to a homeless hostel, there is no way for me to know, without a great deal of telephoning, where he or she is two nights later. My prescribing of treatments, while very useful and helpful, is really no substitute for somebody having a bed somewhere and knowing where he or she lives.

The other point on medical well-being, which I mentioned earlier, is that we need an expansion of the counselling and primary care scheme, whereby primary care practices and general practitioners can give people with medical cards, and those without them who are almost eligible, access to the counselling scheme.

The balance between protection and autonomy is a very difficult one to reach. There is a tradition of paternalism. The assisted decision-making (capacity) (amendment) Bill will help in striking a better balance. The programmes of the HSE national office for human rights and equality policy are really focused on this. My main message, however, is that even the passage and commencement of that legislation will not necessarily make what I describe happen in practice. We need an education programme rolled out for staff so people will know the options available to them regarding supported decision-making. Evidence from other jurisdictions on advanced healthcare directives shows that before implementation 90% of people say they are a good idea and that after implementation fewer than 10% actually produce them. That has all got to do with people feeling empowered and supported and staff understanding how to make it happen. My social work colleagues are nodding vigorously at this because they play a key role in this kind of thing.