Mr. Liam Doran:

I will try to fill in the gaps Ms King has left. Regarding the comments about funding, let us have a clear debate about this. Ireland currently spends 10.1% of its GDP on health, 7% through public and approximately 3% through private, out-of-pocket expenses, which the State subsidises through tax allowances and tax rebates for health insurance. Therefore, those who can afford to pay get better access to the health service. That is irrefutable. It is as straightforward as that. In the context of working out what we want to spend, Congress says we must tie up the money in direct public provision. If one wants private health care, one can still have it, but the State will not subsidise it. There will be fully universal access to health care, whereby everyone is treated equally and no one is asked whether he or she has health insurance or is on a medical card. The latter would automatically put one in the old dispensary model whereby one goes in one door and the other door. That is the reality, only we will just dress it up in nice clothes. That is where we are.

The question of private practice will always be there. The NHS is lauded. In the UK, 12% of health care takes place in the private sector, so private practice is there, but people choose to avail of it and fully meet the cost and so on.

Regarding the full utilisation of all health professionals, let me be very blunt with the committee. Members are right that organisational fatigue has set in, but there has not been reform in the front line over the last ten years.

The number of hospital weekend discharges has not changed. We talk about seven-day working of hospitals; it has not changed. I faced the CEO of the Health Service Executive in 2007, Professor Drumm, who accused our people of elder abuse, because the people I represent were not prepared to carry out first-dose antibiotic IV fluid-balance phlebotomy duties in care of the elderly and so they were being sent back to an acute hospital to have an acute episode of care managed. That was a grossly unfair charge. Congress has been sitting waiting for the HSE to engage in that very thing for the past two years and they will not talk to us because of the siloed budget structures that exist in the HSE. In social care, to keep people in a long-term home while providing first-dose antibiotic, a blood transfusion or an IV transfusion will cost the social care budget money. It will save the acute hospital budget money, but that is a different budget. That is the level of myopic structuring we have now.

On reforming health services in the community, why can a public health nurse, who knows the households in the area, who knows the support structures in families and who identifies Mr. Murphy or Mrs. Murphy as having a deterioration - maybe the chest respiration has gone up, there is pyrexia when the nurse visits the home and so on - not be empowered to prescribe within protocols automatically without having to refer to a GP? Public health nurses have done a four-year undergraduate programme, a one-year postgraduate higher diploma, have a minimum of two years' experience and will also have done a prescribing programme to get there. If people are not safe in their hands, they are not safe in anybody's hands. They are willing and able to take that on board. I am also talking about community RGNs. We should also have that kind of protocol in care of the elderly. That is what we mean by health professionals not being fully utilised.

An OT should be able to refer to a public health nurse. A public health nurse should be able to refer to a dietician. A dietician should be able to refer to a physiotherapist. All those things should be able to happen within the team environment without, as is current practice, having a GP as a trigger. GPs are an essential part of the team, but when the condition changes there needs to be a new diagnosis, not when we are dealing within agreed parameters the ebb and flow of managing a chronic condition. That is what we mean by underutilising. That also requires a mindset of the public because we have a medical model of care here where, to a certain extent, if I go to the GP and do not get a prescription for a tablet or a referral to a hospital, the GP was no good because he or she did not listen to me. That also needs to change. That is what we mean by fully utilising health.

On the big bang or incrementalism, with the contracts that exist at the moment - people absolutely have a right to have those contracts honoured - I do not think Ireland can do a big bang because we are not starting in the same place as Britain was in 1948 or whatever. We have to respect people who have contracts. However, we have to replace all those contracts incrementally with public-only contracts so we shift over that 15-year period. If existing contract holders want to move into the new model that is brilliant, but they cannot be made to and have to be respected. A certain court case is being taken over a certain grade of medic. How much will that cost? That is a contractual obligation; that is life. We would love to do a big bang, but we are not starting from that place.

I agree with Deputy Kelleher on staffing levels. In this country we are unwilling to accept best practice as determined by evidence already found in other countries, whether we call it nurse-patient ratio, midwife-birth ratio. Earlier this week we saw a shortage of consultants in the cardiac area and that negative impact. Our staffing must be evidence-based. In a public health service, if we want stable consistent care, whether I am in Bloody Foreland in Donegal or Rosslare in Wexford or Skibbereen or Dundalk, we need to have norms of staffing that are consistent and are maintained. They can be a cousin of the pupil-teacher ratio if one wants to make that comparison. That is how to guarantee consistent care. A hospital should not be staffed on the basis of having a Minister in the right place. They should be staffed by virtue of evidence. That evidence should be determined annually by the front-line manager and we are working on that. The good news is that in my little area there is a task force on nurse staffing. There is a maternity strategy which clearly identifies obstetric and midwifery-to-birth ratios. We can do that. The evidence is there internationally. Part of the transition would be to standardise and normalise. However, that also requires everyone to clearly understand it is a team game. The consultants, NCHDs, nurses, midwives, health-care assistants and allied health professionals, all have a role in a standardised structural approach based on evidence. The best places for outpatient outcomes are the ones with patient ratios. California, New South Wales and Victoria have the best patient outcomes, but it requires a significant investment.

On demographics and the cost of the fair deal, I do not believe anyone understands that we are standing on the edge of the precipice when it comes to the demands for elder care. It is not just a question of them getting older but their co-morbidities will increase, as will their expectation of treatment. That will only come the way of the health service. We have to have regard to the pension situation. Even if we left it as it is, how many of those will be able to afford private health care? They will all come through the public door, which will need to be widened and prepared for that. We have suggested 2030 because we do not believe it can be done in a year or two years. Equally it cannot be limited by the electoral cycle or politics.

Where do I start on health capacity? Let me just provide the committee with some short statistics.