Professor Tom Keane:

I will respond to Deputy Collins about whether somebody from outside is required. It was an incredible advantage for me to come in from outside. I did not owe anybody any favours. People were searching through my CV to see which Dublin hospital I trained in and see what side I would be on. In essence, I went out of my way. I refused all social engagements with physicians, golf games and all the usual stuff so I could be seen to be totally impartial and not doing business in the normal way that things are done in Ireland. It is an advantage if one comes from outside but if I had not come from Ireland and I was not as familiar with the Irish system, I probably would have fled after four weeks. There is a complexity about the Irish health care system that is hard to explain to people from outside Ireland. It was good that I was an outsider but it was also good that I understood the Irish system. I hope that answers the question.

Cancer is a very discrete entity. It is a very large disease. After the cancer programme was well up and running, Dr. Barry White implemented what had been very successful clinical programmes around stroke, heart disease and a number of clinical programmes. Essentially, they were modelled in a similar way to the cancer initiative. In other words, they looked at best practice and decided where the complex care should occur. It has already been demonstrated that this type of evidence-based approach can work and deliver results. In many ways that does not require huge amounts of money. It means that national standards should be developed, ensuring that those standards are met.

If one has to bring resources to the table, bring them and then be sure that this standard of care is provided wherever one deems it will be provided.

One of the issues around all health care work, but particularly so in Ireland, is what I would call an attitude of "it if wasn't made here then it won't work". The problems of health care are the same pretty well in every country. There are issues around hospital beds, emergency room waiting times, access and having joined-up care. If there is a best practice model in Ireland, and I note that various groups have presented here already, it should be possible for a best practice model to emerge and then for that to become the national standard. What seems to happen here is that everybody argues that their hospital is different and, therefore, we end up with a hodgepodge of programmes and differences across hospitals. Coming from outside it is not hard to define what best practice looks like. If one gets a bunch of experts in a room they can probably define best practice for most acute diseases. I acknowledge it would be more difficult for some of the chronic diseases but it is not hard to do that. What has been missing is what I call a clinical governance model and an expectation that once best practice is defined, then that is what actually will happen. I believe physicians will support that move. This committee will probably recognise that in order to make change happen it cannot be 16 different models of health care for 16 different regions of the country. What one will have to look at is something that is fairly simple and straightforward. Ireland only has a population of 4.5 million people so it should be possible to define a single standard that will work everywhere.

Legislating that standards for the public and private sectors be the same is a no-brainer for me. There was not very much in the way of resistance.

On the issue of the centralisation of other oncology services, gynae-oncology was mentioned. I am not, quite honestly, up to speed on exactly how many centres provide gynaecologic oncology. Certainly, from my experience in Canada, there needs to be a critical mass and given the population here, the number of centres doing gynaecological oncology would probably be relatively few for the whole country.

In terms of delays in diagnosis and access to diagnostics, there is a particular issue in Ireland inasmuch as the diagnostic centre is highly hospital-focused although things are beginning to change. Clearly, to improve access to diagnostics, diagnostic facilities will have to be developed outside of the hospital sector, possibly attached to primary care facilities and there are pilot projects ongoing in that regard. Right now, Ireland is somewhat unique in the sense that one almost has to go to the hospital to get an MRI. One cannot get an MRI in the public system outside of the hospital system. That is something that can change and there will be significant issues around implementing that change but they are to be faced.

In terms of beds, there has been a dramatic shift in how beds are used in Ireland in the past decade. The amount of day surgery has risen by over 100%, as members will be aware. In Canada we still have the same issue that Ireland has grappled with. We have people in hospital beds who do not need to be in hospital beds. We need to find alternative models of care to free up beds. Finding more beds, and I had this argument with many people here, is not a solution to the problem. The problem lies in identifying who is in a bed, why is he or she there and why can he or she not be somewhere else. A considerable number of people who spend time in hospital beds in Ireland are there because there is nowhere else for them to go, and all the members are familiar with the problem. There are lots of ideas out there about how to address the problem and I am not going to comment on it here.

In the area of legislation, one thing I strongly suggest, and is hugely lacking in Ireland, is a legislated clinical governance model. Practically every day that I open The Irish Timesonline, I read about some other tragic case at the Medical Council of a doctor who was unable to diagnose or was clearly deficient in some area but had worked in two or three hospitals before somebody twigged to these facts. Why should it be at the level of the Medical Council that issues around competency are determined? There needs to be something at the level of the hospital where clinical governance ensures that the physicians or surgeons who work in a hospital meet a standard of care that is assessed and monitored locally. In Canada, I ran a department in Vancouver that had 50 specialists. Every year they had their appointment renewed based on their performance. There was no such thing as privileges to practice for life. Following appointment, one's performance was reviewed annually. If one was deficient in some way it was identified and remedial action was taken. We did not wait for that action to be such that when a patient suffered it ultimately was resolved at a higher level like the Medical Council. There is a real necessity in Ireland for clinical governance. There is lots of evidence available. Ireland needs a clinical governance model that looks at credentialing quality of care and monitoring care at a local level, and not coming from 30,000 ft. to determine how things are going to be.

Beyond that, replicating stuff across the board will work for well-defined clinical scenarios. The classical presentations for heart disease, chronic obstructive lung disease, asthma, etc. or for acute medical problems are well defined and their treatment pathways are well recognised internationally. There should be no real difficulty in saying what is the standard of care, it is a national standard and we will hold people to that standard. A lot of progress has been made through the clinical programmes of the HSE in some of those areas but it only points that that is the direction of travel. We need a national monitoring system to ensure that every hospital that is charged with a particular responsibility to provide a particular care model is doing what best care stipulates.

In terms of leadership, I was struck by the lack of clinical leadership in Ireland. In Vancouver and across Canada, clinician leadership is seen as being essential to make health care work. There is a stream and we have discussed it at the Towards 2026 forum with the college. There is a need to develop a clinical stream for physician leaders who are going to take leadership as part of their job and not as something off the corner of their desk that they do when they get home in the evening after a busy day in the clinic. My position in British Columbia before I came to Ireland was one where 100% of my position was to run the radiation and oncology programme for the entire province. I had little or no clinical responsibility but I was paid for that job. There will have to be an investment in training here and ultimately a career path. It is not enough to say, "Yes, we are going to have clinician leaders just do it off the corner of your desk." There are many incredibly competent physicians in Ireland and, on the same subject, there is a huge number of competent nurses who are grossly underutilised.

There are opportunities to develop clinical leadership and the results from other jurisdictions would encourage one to believe that such investment would be worthwhile. I think that covers all of the questions posed.