Mr. Jim Breslin:

There are three main funding mechanisms for primary care centres. The traditional pattern for both primary care centres and health centres was that the HSE would build the centre and then, on occasions in the past, invite GPs in. The HSE stilll retains this model and it is an important string to the bow of the executive, particularly in areas where the private sector may not want to get involved. In poorer or in rural areas, then, it remains an option for the HSE to deliver a primary care centre through its capital programme. The second mechanism is to lease primary care centres, which involves the HSE going to the market with requirements for specific square footage in a specific town or urban area and seeking a rental agreement from the private sector to make that primary care centre available over 20 or 25 years. This generally also includes a specification for what other components might also be provided in the building, particularly GP participation. This approach has been broadly successful and there has been much interest in it in many areas. There have also been parts of the country, however, where the HSE has sought to move ahead with this but has not got the kind of response from the private sector that it might have hoped for. The final mechanism has not yet come on stream but will do so shortly. This involves developing primary care centres as public private partnerships, PPPs. Instead of a lease, the HSE pays back the cost of capital to the developer over an extended period.

The distinctions between the three mechanisms are probably of more interest as financial instruments. In every case we get a building built for purpose which we have to pay back over an extended period of time. All three options have to pass the same tests. They have to pass a cost-benefit analysis, for example, establishing that it is an economic way to deliver the infrastructure, and they all do so. Having a combination of mechanisms is helpful because if we were to put all of our eggs into one basket we might find that it might not deliver in the certain parts of the country where we need it to. While we have not yet had any delivery of primary care centres through the PPPs, we feel that using a range of mechanisms is a good way to proceed.

In response to the Chairman's question on private and public practice, I am aware that my own boss has just arrived and he sets policy in this particular area. From a personal point of view all I can say is that this is an issue I have had to grapple with right across my career. When I sit down with colleagues from other jurisdictions I find that they do not face the same complexities as those facing the Department of Health in Ireland, particularly with regard to the presence of private practice in public hospitals and to the differential incentives for different actors in our system. In an ideal world, then, we would not start from here. Everybody's life, my own included, would be a little simpler if we had a more straightforward system. Private practice is embedded in our heath service: 50% of our population has health insurance and we have about 20% private practice in our public facilities, which is the limit. Private health care is a significant feature of the healthcare landscape in Ireland and we cannot wish that away. We have to find the means of moving from where we currently are to the kind of vision set out in the Sláintecare report of single-tier universal access. The Minister's initiative last Friday to set up an independent group to examine this is, I think, the right way forward. Even if we can agree on the destination there are many different ways of getting there, some of which might have more unintended consequences than others. It is an important first step, then, that we undertake this piece of work between now and next summer so that we can fully understand this matter before starting to change anything.

The Department broadly agrees with the principle of elective-only hospitals and it is something that we would like to see brought forward in terms of our bed capacity assessment and our ten-year capital planning. On the question as to how this might work when it comes to new builds, the experience internationally seems to be that while one can certainly build an elective-only hospital on a stand-alone site, others have been established on the site of an existing hospital. In these cases, however, they have been opened as dedicated, completely self-sufficient buildings that are in no way dependent on the rest of the hospital for diagnostics or beds. They can be run very well on that basis. This also allows for the possibility of cross-cover, meaning that if a patient deteriorates, for example, they could be brought over into an ICU. Broadly, then, that would be the preferable model. This is not a wholly new idea, of course. We have single-speciality hospitals that have operated on an elective-only model over the years - I mentioned Cappagh and the Eye and Ear hospital earlier. This has brought a predictability and productivity to their work.

If we were able to develop that more widely, it could give us a very strong basis on which to tackle waiting lists. I, too, am broadly supportive of that and hope to see progress made on it in the planning work one will see over the next few months on capital, bed capacity and the implementation plan for Sláintecare.