Mr. Tony O'Brien:

Yes. May I come back to Deputy Kelleher's question?

Deputy Kelleher asked about the independence issue in respect of hospital groups. Independence is a word that has been thrown about a lot in the debate around hospital groups. It is important to stress that there is no definition of what independence means. Some people have perceived it to mean something like a foundation trust status in the NHS. Others simply think it means operational freedom to do a set range of tasks in a way that makes operational sense at local level. The truth is at one end or somewhere in between. It is clear that hospital groups will be funded by a central entity against a set performance set of standards using activity-based funding, which drive behaviours. Mr. Liam Woods has spoken about that and can do so again. We would never go back to the type of thing that happened under the health boards, best illustrated by breast cancer surgery where there were 37 hospitals dabbling in breast cancer surgery resulting in sub-optimal outcomes. At central level, individual hospital groups will have to be authorised to provide services that are evidence based, sensible and meet a population need based on our population size and distribution. They would never have the freedom to go back and reintroduce cancer services of a scale and type that are not appropriate. Some hospital groups get distracted by this notion of trust status, particularly because it has been in the air for such a long time. I do not believe that the public sector environment in Ireland would move in the direction of the types of freedoms that foundation trusts have in the UK., which gives them freedom to decide the number of staff they will have, what they will pay them, to step outside of national procurement contracts and all that type of thing - I do not think that will ever happen and it is something of a distraction - all we are really talking about is the opportunity for a set of hospitals - in which it makes some sense to put them together - to decide how services will be organised across their sites. An example was given at a previous meeting of the interoperability that is now occurring between the Mater and Navan hospitals and that is making some sense. There are similar examples between Beaumont and Cavan hospitals. While there are those kinds of ground-based operational freedoms, they would not allow hospitals to go off and deliver services, or to use the example, to become left hip specialists. That would not be permitted by the funding model.

In terms of the GP contracts, there is no set timeline for that. I was asked about my ambitions in this regard. My view is that we need to re-establish the primacy of the generalist. In our health system, as in so many, we have tended to make sovereigns of specialists. One GP colleague put it to me in this way. In general practice, the patients stay the same and the conditions change; in specialist hospitals the condition stays the same and the patients keep changing, which can be rather annoying from their point of view. We need to have a health system that over a period of time recognises the specialty that is general practice, puts general practice at the heart of prevention and chronic disease management and gives it a full range of access to diagnostics. The general practitioners who refer patients to hospitals should not be second guessed by junior doctors there with only a fraction of their experience in general practice. We need to fund general practice in order to do that. We must recognise the workforce base, if I can use that term, in general practice right now is stretched.

We have not been retaining GP trainees in the numbers we once did. We also have an age profile that is concerning. Consequently, whatever we do or do not agree during the GP contract negotiations, it will not be possible to implement the ideal general practice primary care service in one fell swoop. We have to recognise that there is a workforce development issue which will probably take ten full years to address. This will be a long journey rather than a single event. Those are my broad ambitions and hopes.