Professor Garry Courtney:

Deputy Billy Kelleher walked through the hospital and saw the patients. Woodrow Wilson said that if one wished to make enemies, one should try changing something. I have written down the term "overspecialism". We have the best doctors in the world. For example, renal doctors want to provide the best care for their kidney patients, while diabetes doctors want to provide the best care for patients with diabetes. However, they do not talk to each other such that if a patient gets something, it is off that doctor's plate. There is incredible competition among overspecialists.

To be fair, I am the lead in the acute medicine programme and there are 33 acute hospitals in the State, 32 of which have acute medical assessment units. The 33rd in Portlaoise is due to open. We had a communication the other day about a local hospital that was withdrawing care services. I will deal with that matter. Acute medicine and the generalism the committee wants are hard and risky because doctors forget their training. They can be very busy and work very hard, as do GPs. Even if a consultant wants to meet and talk to GPs and do what is best for the patient, the nurses must also be involved, with the physiotherapists and the manager. There are unions everywhere.

Some time ago we were brought to Farmleigh when Mary Harney was Minister for Health and Children. We met the leaders of the unions, including Mr. David Begg, Mr. Peter McLoone and Mr. Liam Doran, and told them what we wanted to do. The manager was present, with Dr. Fawsitt and the director of nursing, and everybody listened very carefully. However, the leaders told us that we were living in a bubble in Carlow-Kilkenny and that they would not disrupt it as it was working grand. They said there were too many moving pieces to be linked. This is where I think the GP local integrated care committee works. It is the only time a nephrologist, a diabetes doctor and a lung, heart and liver doctor might sit down together. There is the realisation that if we do not work together, we are just fighting with each other. I have noticed that at a medical board meeting the consultants may be aggressive or even a little rude to each other. GP meetings can be similar. However, when everybody is put into a room, the participants are much more polite and try to see things from the other person's point of view. It is a big deal to roll back specialism which is destroying medicine in the United States. I agree that geriatricians and GPs are of the pure specialist model. I am not a gastroenterologist; I am a general physician with a special interest in gastroenterology. I must engage in gastroenterology for outpatients, but the needs of my inpatients relate more to general medicine and it can be incredibly difficult.

Why would the old funding model change? The hospitals used to get X amount and X plus 5% the following year, regardless of change. I want to see activity-based funding, meaning that if there is change, there will be extra beds provided, if required. If there is no change, there will be no extra beds provided. To be fair to the HSE, it is introducing an activity-based funding model, although I would rather if it were an outcome-based funding moel. In any case, activity-based funding model is good. Chief executive officers are not interested unless we hit them in the pocket. If they realise that if they change the system and discharge diabetes patients to GPs, for example, they can shorten the time for new patients and be rewarded. This is related to a new-to-return ratio and if it is greater than two, the hospitals will be penalised. The Legislature could help as legislation would be needed at some stage to push people to change, which is very difficult.