Mr. Tony O'Brien:

This could take a while. I will give the Deputy a list, in no particular order. We are having trouble sustaining our overall level of staffing. While we are heavily involved in recruitment and have slightly new arrangements in place for that, we are seeing a continual attrition of staff, with people exiting the system or going overseas. Maintaining a balance of staffing commensurate with our service needs is a constant challenge. That said, there is some positive news on that front. Approximately 97% of this year's graduating nurses are being retained in our system. Four years ago, that figure was around 3%, with the rest going abroad.

We have rising demand for certain types of services. The number of people being referred for outpatient and consequently inpatient treatment is on the increase, partly as a result of our growing and our ageing population. While that in itself is a good thing, as we age, we become more intensive consumers of health care.

The regulatory environment is very important and some of the standards which are now being applied are long overdue, particularly in the area of residential settings for those with intellectual disabilities. However, our capacity to meet the bill for compliance is constrained and is a significant part of this year's Estimate.

The onward march of technology and the development of new drugs brings great opportunities. There are now cures for diseases which simply could not be cured before but the costs associated with those cures are significant. Most of the new drugs coming down the pipeline are in the high tech and high expense zone.

Not unlike other health systems, I see demand rising and costs increasing. Furthermore, we do not have some of the underpinning systems that a health service organisation of our size needs in order to operate at its best. The fact that we do not have a single integrated financial system, for example, as discussed here before, as well as some other systems means that we are not getting the best use out of all of our resources.

That is a relatively short synopsis of some of the big challenges we face.