Dr. Stephen Kinsella:

To answer Deputy Brassil's point about where we are in Ireland, in our readiness for workforce planning, my understanding is that the HSE has devised a scoring system on its readiness to produce these data. I myself have not seen the scores. I imagine that, on a score of one to ten, we are somewhere around five, in that we know how many doctors we have. We know because we have a payroll and we know how much we pay them. One can use such a system, but I sense that once one moves away from the two or three main categories, the quality of the data degrades pretty quickly. Deputy Brassil asked if I had been seconded to gather the data. No, I have not; I was asked to write this report for the Health Research Board. I am still teaching classes in UL. I am teaching one at three o'clock. I am tipping along and very happy there. I am very interested in this stuff. It is great.

Regarding timescale and treatment, patient flow data are absolutely vital. They come from a unique identifier system. One needs to have such a system and get over the data protection and privacy issues that surround it in order to gather that kind of patient data. If I bring my ten-year-old son into Nenagh Hospital tomorrow for a broken arm - touch wood - he will be seen and treated, but if I bring him in the next day to University Hospital Limerick, they will not know he has been in Nenagh Hospital unless I tell them. It is therefore a database issue, a big data issue and a very important issue in terms of quality and reliability of care. It is related to some of the efficiency issues about which Deputy Kelleher spoke. I gave a talk at University Hospital Limerick, the grand rounds lecture, at which I asked the doctors present, if I gave them the money to hire the people lost between 2008 and today, what they would do with it. I asked whether they would hire more nurses or more people like them. They said they would put all of the money, every single penny, into ICT systems. These are young doctors who are all vying for registrar positions and so on. To me, that was a really important issue. Deputy Brassil asked whether there are any data on that kind of treatment flow. The answer is yes, but they are case studies. Case studies are typically examples of excellent care, which is great, but one also needs the middling stuff and the bad stuff.

In response to Deputy Barry, that 50% increase is on a low-fertility assumption. The dependency ratio I think he was seeing was using the M1F3 measure, whereby the population explodes, which is reflected in the chart. I think I have seen the chart circulated recently. It is based on an assumption of very low fertility.

I have not seen the INMO stat, but I will check it out, and I thank the Deputy for telling me about it.

Regarding the mental health issue, I am glad to see that it is becoming more publicly acceptable to do this. People in my family have suffered from it, so that it is coming out more is great to see. Medicine and medical care comprise a derived-demand system. The more that people use it, the more it gets used. It is like a road, in that if one builds a new road, it will be full of cars. Do not get me wrong, as it is good that people present with these issues, but it entails a necessary increase in cost to the system. The best example of this is autism services. We are finally getting around to producing really good autism services in some parts of the country, which is producing a natural increase in Exchequer spend. Once autism is diagnosed, it obviously does not go away. The State has rightly made a commitment to the person and his or her family for the next 40, 50, 60 or 70 years. When these diagnoses are made, they do not tend to be associated with one-time spikes in expenditure, but with long-term increases. Nonetheless, it is the hallmark of a good and decent society that we do these things, so the State should do them. However, in a world of constrained resources, by definition this means that the money in question is not being spent on early childhood education, higher education, etc.

In general, there will be an increased need for staffing across almost all grades, but my sense is that this is not true at the fine grain or service level. I will give an example. If we decided that we wanted to route more services into the community care space, we would fund that area and not other areas, but we would route people to that area in order to decrease demand there. To do this, one needs a plan. One cannot just stop something and hope that it gets built up by the private sector or the like. That tends not to work. The private sector tends to take options that maximise its profits, as it should. There is an issue with that. I do not want to give a two-handed answer but, while worker levels would increase, they would not increase by the same amount everywhere. I only have anecdotal data on this.

No workforce planning model that I have seen plans for agency staff. Models plan for full-time or part-time staff on a full-time equivalent, FTE, basis. We are discussing worker equivalence, not agency staff. Agency staff are seen as a sticky plaster to solve the problem. My strong preference is for permanent and pensionable people in positions where they can do their best work. One does not get a professional system if one does not hire people for professional reasons and pay them appropriately. In fact, one overpays for agency staff.

May I ask Deputy O'Connell for clarification on the divisions issue? Does she mean funding or the actual locations of the systems, for example, mental health services in one place and coronary care somewhere else?