Mr. Tony O'Brien:

The Deputy has definitely turned this into a would-be master class in how to fix the health system. As I stated, much of the diagnosis and prescription is contained in the Sláintecare report.

On the functioning of the hospital system, as the Secretary General correctly pointed out, we have a relatively undifferentiated hospital system which has two channels seeking to be serviced within one set of architecture. The elective or scheduled care programme is competing directly and head to head with the unscheduled or emergency pathway in hospitals that are often operating at 115% bed capacity versus an international norm of 85%. This year, for example, we are seeing a 7% increase in attendance at emergency departments, with a higher percentage among the over 65 years cohort who typically have a greater requirement for admission and stay. Until we do some of the things that are specified in the Sláintecare report and have the benefit of the capacity review the Department is progressing and which is in near conclusion and begin to implement it and, consequently, bring a degree of rationality - not rationalisation - to the way we provide elective care, on the one hand, and emergent or urgent care, on the other hand, with differently organised application of resources, we will not have a truly efficient hospital system.

In addition, we need to shift to more effective delivery of primary care and greater utilisation of primary care hubs - I prefer to think of them as diagnostic facilities, rather than primary care centres, in which allied health professionals can deliver therapies and so on - and remove much of the burden that is being inappropriately assumed by the acute hospital system, typically at greater expense than could be delivered elsewhere. The Sláintecare report talks about the transitional funding needed to achieve this and I do not believe we will get to the type of health care system we need until we do this. The Committee on the Future of Health Care does not believe this either. We and the committee are, therefore, saying we agree with each other.

As the Minister indicated, interim steps can be taken. We have the discussion about appropriate levels of discharge at weekends. The vast majority of patients who are discharged from hospitals are discharged to their homes, not another care facility. We need to make sure in every case that this flow is optimised. This is a constant battle in which hospital managers and clinical directors are engaged to ensure patient flow is constantly attended to, day in and day out.

General practitioners, in common with all heath professionals, have experienced a change in the nature of demand and expectation from patients and the health system. They see particular demand and, as the Chairman indicated, we have a particular age profile that is against us. There is no doubt that a degree of disenchantment arises. Let us accept that there is a strong perception of unfairness in the way the burden of the financial emergency measures in the public interest were aligned. I hope all of these matters can be addressed through the ongoing talks and dialogue. All of the issues I outlined play against us, however.

The general practitioner has probably the most important and difficult job in health care and the term "general practitioner" downplays the importance of the role. The generalist, as the gatekeeper, is the most important person in the entire health care system. I occasionally use health care services and I have relationships with some specialists as well as a general practitioner and I have always said my most important health care relationship is with my general practitioner. That is true of the entire country. Strategically and tactically, we need to go through the process that the Secretary General has described, bring that process to a conclusion and create an optimism about the future of general practice that will need more general practitioners to stay and fewer of them to go. This will not be an easy or quick process, however.