Mr. Tony O'Brien:

The questions are linked. I mentioned DSRIP earlier as an example because I do not believe, given the current pressures on the hospital system and the amount of work that is waiting outside the doors of the hospital system, that we can expect any time soon to be able to extract the type of funding from hospitals that is necessary to develop the primary care system to the point where it is viable to do that. I believe it is going to be necessary to pump investment into primary care so that the transition can take place. The negotiations on the GP contract are central to our understanding and conceptualising of that. Just before the economic implosion, efforts were made to remove funding arbitrarily from the hospitals and invest it in primary care. The net effect of this was that the hospitals went into meltdown and all of this was unwound in the course of a year. I think the concept of transitional funding is absolutely central to whatever it is the committee ultimately recommends, or whatever it is that any one of us would like to see by way of transformation in the health system. DSRIP is just one example, but it appears to be a very successful example. I shared a book with the committee earlier that gives details of some other examples in other parts of the world that may be of help.

A couple of Deputies have referred to the governance issue. I sit here in a very unusual position. I occupy a job which, as the Chairman will know, I did not actually apply for. I am both the chief executive and the chairman of the largest organisation in the State, bar none. I took up this position in the expectation that I would probably have it for a shorter period than I have had it for to date. At some point, when there is a settled view about hospital groups and so on, there will need to be legislation so that accountability rests where authority lies, which is not the case at present. I would not wish to see a legislative revision of the health service that does not address the fact that we have one person operating as chairman and chief executive of the largest organisation in the State. It is a very uncomfortable position to be in, as I know the Chair is aware. This brings me back to the issue of accountability. This year we introduced a new accountability framework for all of those who hold budgets within the system. It has been effective. It has been difficult to do that in the past because - not to put a tooth on it - we have entered a number of years - probably five years of service planning - where everyone has known that the level of funding provided was not equal to the level of service committed to. That recurrent supplementary funding of €500 million or €750 million has had to be provided is evidence of this. In the current year, the Oireachtas voted a revised budget - not a supplementary budget - which was able to bring that cycle to an end. This enabled us to say to all the budget holders across all of their domains that they can no longer simply say the job is undoable. That has a fundamental impact on the psychology of accountability.

I also believe that just as clinicians, nurses and other professionals are accountable for professional standards to professional bodies, we need to recognise that management, administration and leadership in the health system, where it is provided by people who are not members of those professions, should be similarly regulated to prescribed professional standards so that we have an equal playing field in the health care setting. Without it, we are not valuing that discipline in health care to the extent that we should and we are not providing equal accountability.