Mr. Ian Carter:

The use of levels 3 and 2 makes eminent sense. As I said in my presentation, we apply the capability of the surgeon to the capacity of level 2 and a classic example is Louth. The hospital in Louth is totally suitable for simple elective surgery and outpatients. We have started but not fully rolled out a service whereby vascular surgery is now routinely undertaken in Louth. The location has several other benefits. There is no emergency department competing for space and the site has the appropriate infrastructure. The earlier witness is right. As services are further rolled out we will consider the outpatient specialties as well so that is just a continuation.

In terms in making this attractive from a recruitment point of view, we have found that the best way, as has been alluded to, is to appoint a consultant to two sites. The aim is for him or her to do his or her specialist interest, if he or she has one, in the centre that has the specialist and the more general aspects of his or her service is normally in the level 2 or level 3 hospitals. The scheme works well.

As was said earlier, not all consultants want to be experts. A large number of consultants are general medical or general surgical. Let us remember that over 50% of the work that is done in the health care system is done in level 3 or lower hospitals. A relatively small amount of specialist work is done in level 4 hospitals. The recruitment of split posts works very well.

There are other reasons staff are not attracted to some of the smaller hospitals. In particular, on the consultant side it is on-call provision. If a consultant works in the Beaumont Hospital he or she will have an on-call commitment in his or her speciality of maybe one in eight. If a consultant works in a smaller hospitals that might be one in three or one in four. There are other issues relating to this matter as well.