Dr. Sara Burke:

That brings us to the issue of the lack of accountability within our hospital system. We have introduced these hospital groups, which brings me to Deputy Harty's question on top-down or bottom-up. There are plans for the hospital groups to go to trust status and given the English experience of trusts, I do not think that is the way to go. Given that we have groups, there are significant issues because we have this mix of HSE-funded hospitals and voluntary hospitals and it is very difficult for the hospitals to operate at present. While they used to get their budgets individually, the funding now goes into the group but legally, the hospital chief executive officer or the board - depending on the status of the hospital - is actually accountable for how that money is spent. There are major difficulties with that at present. I think the bottom-up approach is a much more effective way to go. The really good example of that is the success of the clinical care programmes. It is the one area where we have had good success in improving both access and quality of care. This was pioneered by Professor Tom Keane in cancer care. He asked everyone working in cancer services how can we make cancer services more accessible and improve treatments so that our outcomes start reaching international standards. It was a very bottom-up clinician-led reform of hospital services. It needed political accountability and the then Minister, Ms Mary Harney, making difficult choices about reducing cancer care from 30 to eight hospitals. I think the success lies in the leadership of clinicians and front-line staff rather than in monolithic top-down structures.

In response to Deputy Harty's questions on three game changers, I feel as though I am doing an oral leaving certificate exam. As I am just cranking up my brain after maternity leave and the answers are not at the top of my head, I will send him an e-mail.