Dr. Susan O'Reilly:

I was astonished when I landed in Ireland six and a half years ago by the complexity of hospital governance. Even in the public sector, between voluntaries and statutories there is a two-tier system. The voluntaries have been very effective over many years with their boards in building the resources they need to get the jobs done. As a consequence, there is a balancing act here. Having said that, our voluntaries are highly effective. They have strong legislative authority and strong boards, and I support their carrying on in that role for now. I am not in the business of asking for the decommissioning of that approach because one would have to be 100% confident that what one will do in the future would be better and stronger. One must be very thoughtful about that. We have worked very effectively in collaborating in governance structures with the voluntaries, particularly around elements of policy and patient safety, instead of imposing certain governance structures to try to interact with them. That has been a win.

Recruitment is a huge challenge. We have lost hundreds of thousands of hours, weeks, months and years of experienced nurses from the country and we have lost younger nurses. Now that we are beginning to recruit effectively, both directly through the HSE for the statutories and through the voluntaries that are assisting us - and this is where we are collaborating very well - we find very young nurses coming in who have much less experience, need more training and take a lot of maternity leave. We have a challenge at one of our hospitals now that 20% of our midwives at any one time are on maternity leave. We cannot backfill them from agencies. This is a huge issue and it concerns recovering from almost eight to ten years of being in a very difficult recruitment position. The same goes for consultants. I think consultants will be attracted to work in highly functional environments in which they can do the job well. It is not all about pay, although pay does matter. It is about the environment, the team, the capacity, the career development and the opportunities for research and teaching, being part of an academic teaching unit, which is what we are. There are excellent strengths in St. James's, Tallaght and the Coombe in particular, together with Trinity College Dublin, and these are key to bringing people back on board. They do not only want to care for patients; they want to do many other things too. We are now in a position that we know full well that one will not get the best permanent staffing competing on extremely low-volume jobs on the periphery. One must either move that complex low-volume patient population to where they can get the care or build joint appointments, particularly for surgery, where people can attend for a certain number of days a week. It is a complex process. I do not find the voluntary approach in the mix in our group particularly difficult. I love what is happening in the children's hospital. It is a model for the future in that there is a goal and a direction around legislative authority. However, it must be done extremely thoughtfully before one dives off the deep end on any of this.

Did the Chairman want me to address one other point?