Mr. Liam Doran:

I will make two points first, but I promise that I will answer then. I wish to address elderly care in nursing and community homes. We are in a race to the bottom in terms of the quality of care given to our elderly. The cost of care is the only fixation that governs under the fair deal scheme and in public nursing homes. We are constantly told that the cost of care is cheaper in private nursing homes than it is in public hospitals and that we must drive the weekly cost per patient in the latter down to the level of the former. That is fundamentally wrong and unfair and is a race to the bottom. It forgets the increased complexity of the public hospital patient and so on. It also negates the likelihood that we will develop services in the nursing home environment. Dr. O'Conor spoke about this. We must keep residents in nursing homes or continuing care facilities where we can manage their acute episodic development, be that via intravenous, IV, antibiotics, managing transfusions and fluid balances, phlebotomies, blood tests, etc. Patients do not need to go as often as they do, but that requires a different skill mix in the nursing home arena. It is a richer skill mix, to use an old-fashioned word, and it costs money. That has an impact on the fair deal scheme, funding and so on. Everything is connected to everything else. If we want to make the nursing home sector do more, it will need more staff of a qualified level, which will have a cost. The same applies in the public sector, but we need to do it.

Regarding accountability and transparency, the only people who are accountable in the public health service are those on the front line who have a register that allows them to continue to work. Consultant, registrar, NCHD and nursing staff have paid the price - patients have paid the greatest price - of flawed decision making by management and the political system with no accountability whatsoever. Accountability rests fully with those who are out there trying to do a job. If they make an error, they are subject to a complaint or whatever. That is the price that they pay, but the general management structure - I do not deny for one second that it works hard and has difficult choices to make - is not around when the situation goes wrong. The consultant, registrar and nurse are, yet all evidence and research shows that they are not empowered to make resource-related decisions. This follows through to clinical-related decisions because we still have a system in which senior management at group and hospital levels oversee what is happening but to whom little accountability attaches. When something goes wrong, the consultant, registrar or nurse is before the regulator, which is happening with increasing incidence.