Dr. Austin Byrne:

I will respond to Senator Burke. It is refreshing to hear insight in terms of sound economic assessment and evaluation of capacity issues, bed numbers and GP numbers. The committee, thankfully, appears to have a very good grasp of that. The Senator mentioned that we are the second highest in the OECD in spending and asked why we have such a problem. The key issue is that over the past eight or nine years we have built up a huge deficit in capacity at both hospital and general practice levels. We have also built up a deficit in funding. Capital infrastructure spending has been almost non-existent. Our bed ratio is 2.8 beds per 1,000 in population, which is really low. The committee is not seeking to discuss accident and emergency departments but it is worthy of mention.

On addressing the immediate issue of bed capacity, and Deputy Kelleher mentioned beds being blocked through accident and emergency attendances in terms of elective surgery planning, unless we get down to an 85% bed capacity the hospital system simply cannot function efficiently. There is a view that it costs €1 million to open a bed, but it does not. Certain types of bed cost a great deal and certain types do not cost quite as much. That is the first matter. We must add bed capacity and it need not all be high dependency bed capacity. If we offer extra capacity to our hospitals, we will free up beds for movement of patients and patient flow. As we add beds, the cost per bed will drop off. The other key issue is that our bed structure is highly fragmented and our cost per bed is highly variable throughout the system. That requires careful examination, and it is not a job for today.

With regard to the separate groups, the Irish Medical Organisation, NAGP and ICGP are here today and there is the Irish Nursing and Midwives Organisation. Everyone is looking for funding. Looking at the fundamentals, we can say categorically that we have the lowest number of general practitioners per head of population in the western world. That is a fact. We have the highest number of nurses per head of population in the OECD. That is also a fact. Rather than looking at absolute numbers, we must look at the structures and patterns of work flow. It is fair to say that many of our nursing colleagues would prefer to be working differently and smarter and, to use Dr. O'Shea's phrase, to be working to the upper end of their contracts or their skills sets. We must develop the mindset of passing units of activity down to the lowest level of skills sets. We need to farm certain activities down through the chain of activity - work our nurses and our GPs up to their game.

There must be serious amounts of front-loaded investment. Our CEO announced in the past two weeks that he estimates €9 billion is required. That is quite a conservative estimate, and it is difficult to state a number such as €9 billion without swallowing hard and taking a breath. However, €9 billion in the broader scheme of things, in terms of investment and the accumulated deficit over the last eight to ten years, is not an awful lot of money. Bear in mind that if we do not make that front-loaded investment, and the Department of Public Expenditure and Reform finds it very difficult to sign off on the like of that, the cumulative deficit will continue to roll over and expand and the cost of providing care into the future will enlarge.

We then look to general practice as a solution. I do not like the term "primary care". Primary care is not general practice. There has been much investment in primary care over the past number of years. Centres have been developed. They cost quite an amount of money to put in place. The general experience among general practitioners, myself included, is that they are good buildings in good locations and easy for patients to reach, but they are largely unstaffed. Where they are staffed it is by staff who have been relocated from hospital sector locations into the community on a part-time basis. There are no additional units of activity or workload carried out by the staff who are relocated and who are working at capacity.

The further issue for the GP next door is trying to access a physiotherapist, for example. A GP referral will receive a low priority triage, priority four, unless it is an acute injury. A hospital discharge will be priority one because it comes from the hospital silo. The physiotherapist who is now relocated to the primary care unit, therefore, at additional cost of room occupancy and the additional cost of mileage allowances to and from the primary centre of work, is largely performing the same activity they always performed. They are working at capacity but we have brought another layer of inefficiency and another layer of cost into the system.

This brings us back to the initial question: Why are we spending so much? We are spending so much because we are carrying out the wrong activities in the wrong centres and we are carrying out activities at higher levels of cost than is necessary. We are carrying out routine disease reviews and medication reviews in costly outpatient settings because we do not have the capacity, the funding or the ability. We are simply not allowed to perform it under contract in the community. If we do perform it, we are straying out of contract and incurring a cost to the practice which is currently on the edge of viability in enough cases.