Professor Tom Keane:

There is a fair amount of repetition in those questions and I do not want to repeat myself about the management of change. I agree with Deputy Harty's point that there is broad general agreement on the direction. Certainly in the discussions we have been having about the policy out to 2026, there was broad agreement on the direction of travel towards the integration of primary and secondary care and linking up the systems. The committee will have the opportunity to have a briefing from that working group later in November. I am encouraged that there is a recognition that the status quodoes not work, essentially.

The issue around competing groups is based on a premise that if people compete there will be a winner and a loser. What needs to be shaped is a situation where everybody is a winner if we come up with the right solution. The media have a lot to answer for in this country in terms of the way in which health care is portrayed. Everything is profiled in terms of winners and losers. There has to be a new way of presenting information so that it is clear that the public is the winner if we come up with a solution that meets the needs of our population.

There is a huge lack of trust. The biggest lack of trust that I encountered here was between physicians; not necessarily between specialists themselves but between specialists and other groups of doctors. There were huge issues around the concept that if one doctor takes this then another doctor will lose that. There was always that sense of a winner and a loser. That is something that needs to be brought out and debated because the losers in this whole system are the patients. All health care systems tend to be very provider focused. It is one thing to mouth the words about being patient focused but ultimately, that is what the system must be. As long as the system is provider focused and dominated by the interests of the constituencies within the system we will have a problem. This is not unique to Ireland. In most health care systems the providers, while mouthing the fact that they have the public interest at heart, are very often simply protecting their own turf. There needs to be a debate on the fact that there are no winners and losers within the system. The system has to work for people.

There cannot be enough communication. I have said previously that there were weeks when I was unable to talk when I went home because I was so hoarse from talking. Communication on its own is a tool for building trust, but it must be accompanied by transparency, integrity and a willingness to listen. Some of the best ideas for improving health care come from the people who are working at the coalface. Time and time again, it is those who work at the front line who actually understand what the problem is. There is a way to engage people at that level. I have to say that a cynicism has built up within the health care system. Somebody referred to it as "report fatigue". People are tired of reports and they want to see action. I think there needs to be an iterative process. I do not believe the problems in the health care system in Ireland are too big to fix. They can be fixed. As part of the public debate, it will be necessary to make it clear that if we want a health care system that is comparable to the systems in the Scandinavian countries, we will have to pay for it. Countries with large and relatively good health care systems that meet the needs of their populations generally have higher rate levels of taxation. In other words, what one gets is what one spends.

The issue of change management could not be more important. I have been involved in major change in three jurisdictions. The first thing that needs to be done is to put in place an overall change management structure. This means making an investment in the business of managing change. We cannot manage change by telling people "we have had a great idea, it is fully evidence-based and we are starting on Monday". We need to engage in a way that makes the people who are going to be involved in change part of the solution. We cannot simply hand them a top-down plan and expect it to work. The silo functionality that Deputy James Browne mentioned is a problem that can be addressed. There may be issues around the funding model that can address that. We tend to build silos when we compartmentalise funding. Everybody tries to protect his or her piece of the pie. My view on the integration of hospitals and communities is that there must be a mechanism that enables hospital care and the care that occurs outside the hospital to be funded from a single envelope. It should not be the case that the hospital gets its money and community care is funded separately. There are some huge disproportions in funding allocations. The funding needs to follow where the system wants to go. We cannot drive the system if the funding model does not support it. That is a considerable piece of work.

I was also asked about getting buy-in from the public and bringing the patient along. I think that is part of the change management issue in Ireland. I had an excellent press officer, Ann McCloon, when I was here. She taught me so much about how to manage the Irish media. We refused to engage in 30-second soundbites. We let it be known to most of the major media outlets that we were prepared to engage in indepth conversations about the future of the system, but we did not want to give 30-second soundbites. That was difficult because the media basically wants a quick story and a quick angle. There needs to be dialogue with the public, but the complicated nature of health care means that these issues cannot be dealt with in a 30-second soundbite. There is a need to find a mechanism to facilitate engagement at local and regional levels. I am sure the committee has heard suggestions around how to engage communities. I am in favour of locally delivered services as long as there is overall national oversight to ensure every region does not deliver the service differently. I think there is a huge need to engage with the public at local and regional levels. People need to be part of the change, rather than simply sitting on the outside and acting as advocates.

Deputy Madigan asked about research. To my disappointment, the national cancer control programme has no mandate for research. I had to make a pragmatic decision. The lack of such a mandate is most unusual because research is part of the mandate of national cancer programmes in most developed countries. I chose to leave it aside at the time because there were many other burning platforms. I believe that down the road, the embedding of cancer research within the cancer programme will have to be a key component of the national cancer programme. This ultimately becomes a major issue when we are trying to attract and recruit world-class individuals. If they are coming into an environment where there is no research support, it is likely that they will go elsewhere.