Mr. Liam Doran:

If we start from the back end, our population is only 4.75 million. The reason congress welcomes the hospital groups in the context of what was there before is that we have some level of cohesion and reduction in duplication. Prior to that, we had years where we had hospitals all competing for lung and liver transplants and so on. Therefore, the hospital groups is a step in terms of co-ordination and we will certainly come back on this issue. Let me be quite clear on this, there is no rhyme or reason to having seven hospital groups, nine CHOs, seven mental health areas and numerous section 39 facilities, all doing excellent work in their own way. We are not knocking the work but the management of that, as Mr. Eamon Donnelly said, leaves it impossible for people. On top of all that, we have a centralised HSE. To link that back to this being about devolving power, how does one run a health service where the local manager of a hospital is not empowered to fill posts that fall vacant within a hospital's stated staffing complement?

They have to go up through three rungs of a ladder to live within pay and budget control and make a business case to people they never see who are up to 100 miles away.

I no longer want to hear the phrase "business case" in terms of running a health service. A manager of a local hospital or health service must make a business case to fill a post that has fallen vacant due to a person retiring, leaving or emigrating and wait six months for the position to be filled. That is why these posts fall on to the agency spend. What happens then is they cannot do it through the permanent pay structure yet they determine, as the lead clinician, that they need a staff member because otherwise patient care is compromised. The easy opt-out clause is to go to King and Doran Agency Limited and get the staff. A person could be in place for months, while waiting for the business case, at a cost of 5% on the shift premium and 21% VAT on the health service. That is how one ends up with an explosion in costs.

The other reason one ends up with an explosion of this practice is because the pay and conditions are unattractive, particularly with respect to our medical colleagues. They can choose to work via the agency model knowing that the hospital has to take them because they have no other way of filling the senior clinical decision-making gap. The medical agency spend has increased significantly in recent years because, in fairness to our medical union colleagues, they would say the pay and conditions are uncompetitive and so on. When we talk about devolving we are referring to those people who are responsible for the care. They must be empowered to maintain a staffing profile and be accountable for that expenditure. Everyone has to be accountable when spending taxpayers' money. At the moment, one has to be accountable but one has no autonomy to do it right and one is still accountable for the misadventures.

In terms of single tiered freedom, the health service is free at the point of use and no hidden charges have crept in. In terms of agency care, mental health and an increased drive towards congregated settings, the Deputy is right that it has become fashionable to talk about decongregated settings and forgetting totally about the needs of the person concerned, whether they have an intellectual or mental disability, to survive in a more normal community setting. Maybe he or she will blossom, be more productive and involved in the community if he or she has a more protected environment. It is not that one goes from all residential to all community because there is that blend in the middle. The current Kerry situation is an example of that. No-one knows better than the relatives of the person as to how he or she blossoms. When the system dictates to the family what it thinks is right and the family's view is disregarded then we no longer have a public health service.

The final query was about hospital groups and rights. The only thing I would say, in deference to my colleagues, about what happens to the report is we would have a view that one has a right to a public health service. When one leaves it to discretion that is not enshrined. We had this with disability services. No-one wanted to pass legislation that gave a person a right to a service but one has the right to seek access to a health service.

In terms of a public health service, free at the point of use, universal and single tiered, yes if that can be brought forward and underpinned by legislation then I believe it would serve the community and the economy.