Professor Garry Courtney:

That brings up the point made by Deputy O'Connell about divisions. When one thinks about it, we had five divisions in the HSE and even the word itself shows one there is not much cross-talk. Consequently, a cross-cutting concept is needed that makes the social division work with the primary care and acute hospital divisions. They are all separate at present. Coincidentally, a new structure has just been announced by the HSE that I do not fully understand. However, we think it is good where the royal colleges, the Irish College of General Practitioners and the HSE came together and developed the clinical care programmes. While the Chairman is aware of the diabetes programme, there are 33 of them and no other country in the world has that. That is the best care and is the plan of care for all patients. While that has been done here in Ireland and is all written down, I believe we have lost focus on the clinical care programmes. It is all written down for asthma, chronic obstructive pulmonary disease, COPD, heart failure, diabetes, liver disease or anything. There should be some cross-cutting ability stating that if the clinical care programme on obstructive lung disease indicates it should be managed in the community, it should be so managed. Moreover, if one finds out that a hospital never discharges such patients to GPs, who incidentally are well able to look after them, that hospital should then not be funded. I probably would pull back at the moment from penalising because if one penalises a hospital by withdrawing funding, it also hurts patients. However, it should not receive additional funding. The old model of having a problem in the winter, doing nothing about it and getting extra money must stop.