Professor Garry Courtney:

I thought it was a great question. Deputy O'Connell was talking about magnet hospitals. I love that phrase, which is used in the US. Many hospitals in the US are closing because of chronic care. Dr. Fawsitt has mentioned the disaster in terms of funding. Some hospitals in the US have said "We are not in the diabetes business any more" and used that as a means of getting rid of diabetes patients, many of whom are black and poor, are losing their legs and are in need of dialysis or surgery. Patients can become costly when they are badly managed at the beginning. We need to stop those patients becoming complex in the first instance. This must involve GPs treating them correctly.

Junior doctors love working and training with the very small number of complex patients who present at our hospital. We have a three-year waiting list for specialist registrars to come to our hospital. We have low number of locums. By taking on complex patients and moving chronic care to the community, we attract many junior doctors and we spend less on locums. Complex care is quite expensive, but a hospital that does not offer complex care is not an acute hospital. We have to do it. We think we have achieved good outcomes. We need to go to outcome-based management and activity-based funding. We are saving a great deal of money.

I am very interested in the concept of magnet hospitals. A study in America examined why hospitals were closing. It was found that people were not coming to work in certain hospitals even though they were being offered 20 types of flavoured ice cream, running tracks on the roof and free access to health gyms. The simplest outcome of the study was that doctors and nurses want to work in hospitals where they feel valued and are allowed to do their jobs. People do not feel valued in our hospital system at present. We cannot get at the patients to do our jobs because of the chaos at the front door of emergency departments, as Dr. Fawsitt has put it. At Beaumont Hospital, there might be five trolleys bounced up against each other and a guy against the wall who is not being seen. Nobody wants to work in such a system. Nurses and doctors are fleeing the country.

The acute floor would work in an urban environment as well. The deprivation index, which was mentioned by Deputy O'Connell, is much higher in Limerick and north Dublin than in Carlow-Kilkenny. There is no denying that there is a relatively affluent population in Carlow-Kilkenny. Two thirds of the people in Carlow-Kilkenny live in rural areas. Kilkenny is quite a small urban area. The way we get around the urban-rural split is that all the GPs come to the local integration committee. I would say we have a disproportionate representation of rural GPs because they want to get into Kilkenny to talk to the hospitals. That answers the question about the attractiveness of complex care.

We do not have a domino service. We would like a domino service. I think that is the future. Women who are delivering should be allowed to deliver in line with the Holles Street domino model, which is very good. We do not have that model. I would like to have it. Not having it is a big gap in our system.