Dr. Brendan O'Shea:

It is deeply regrettable and it is the fact of the matter. It is difficult for us to criticise our colleagues in the HSE because we know many of them are passionate about what they are doing. We have a consensus among ourselves that the independent contractor model, properly resourced from 2.5% up to 8%, delivers efficiency.

I am moving on to another question, which relates to waiting lists and what can be done about them. There are 600 patients occupying hospital beds who are delayed discharges. If we had more capacity in social care and more community-based home-care packages and if general practitioners were enabled to do more in nursing homes so that they could build their function, one would suddenly have 600 expensive beds transferred to less expensive beds in the community. These are the things we believe will actually deliver efficiencies. We have 540,000 people on waiting lists. Most of them are on waiting lists for investigations. If we had access to those investigations, we could do them in general practice. We could do ambulatory care and keep these people out. In the same way that we have 600 delayed discharges occupying beds, it is a cause of huge demoralisation to us that we have to send people to these hospital beds while our colleagues in the NHS, in Perth and in Vancouver can do an awful lot more to keep people at home.

Going back to Deputy O'Reilly's question, I refer to Deputy Murphy O'Mahony's observation that co-operatives are in charge of 1 million consultations a year in the out-of-hours setting. They are delivered efficiently, quickly and powered by the independent contractor model that is run by general practitioners. That is efficiency. It is with deep regret that I note that the HSE has inherited a situation where it is in charge of enormous waiting lists. The co-operatives are the independent contractor model. Our practices are the independent contractor model. We did a very odd thing in the Irish College of General Practitioners, which was to carry out some research. We asked patients what they would like. We asked them what they would like in chronic disease management which is the big enchilada in all of this. We asked them if they would like consultant-delivered management of their chronic diseases or specialist nurse-delivered chronic disease management delivered in a hospital. We asked them if they would like nurse-delivered chronic disease management or GP-delivered chronic disease management. We collaborated with our colleagues in pharmacy on this study. We asked 600 patients, the majority of whom said they wanted GP-led primary care management of their chronic diseases.

There are some things we are not certain about. We know with respect to our health system that we appear to have more administrators relative to other more efficient ones. We know that they are paid a little bit more than in other systems. We know that they have managerial tools that are based on paper. None of these things is enormous, but they compound.

We guesstimate that over €20 billion is spent on payroll. We want more than 2.5% and we want that money to go into one of the most productive spaces, which is the interaction between clinicians and patients in the community. We want more care at home.