Mr. Liam Woods:

For the 20% of patients who do not enter hospitals through emergency departments and are not maternity patients - I am speaking in that regard about inpatient elective work - some of the work relates to national specialties. There is a single queue process within the entire system. The cohort mentioned by the Deputy accounts for 20% of total activity, the limit allowed within the contract. If one looks across the system, it is spread by hospital in small quantums across the full service. As far as I am aware, there is no question of an individual hospital seeking to attract more elective patients to derive income. The key challenge when it comes to elective surgery is presented by access to theatres, theatre nursing staffing levels and the volume of surgeons. Taking orthopaedics as an example, up until recently there were five orthopaedic surgeons - there are now four - delivering the service in the Limerick area which has a population of 380,000. The new norm in the United Kingdom is an orthopaedic surgeon per 15,000 of the population. The key challenge is ensuring volume. What is controlling the volume of elective work is the increasing number of patients in clinical need coming through emergency departments who need to access to a public hospital bed space. My response to the Deputy's question about whether potential funding or the payment arrangements for hospitals are skewed is that it is not visible in the data. Also, hospitals do not actively seek to do it. Fundamentally, the main concern which I am sure will be reiterated by the representative associations is access to theatre time for surgeons and to bed stock for physicians. That is the critical ingredient for us. The points made in the Sláintecare report about the need for investment in primary community care services are pivotal in having a flowing hospital system. That is the biggest constraint. I can assure the committee that the 20% of patients who do not come through emergency departments and are not maternity patients are widely distributed and that there is no sense that patients are being actively sought by hospitals in any way that is different from clinical prioritisation.

On whether there has ever been a breach of contract and consultants have been challenged in that regard, the answer is yes. Obviously, this is a matter for the employer and the employee, but there have been such breaches. By way of example, members may have heard on radio the day after the "Prime Time" programme was shown a consultant from the Mater hospital talking about the normal process there. It includes the receipt of a monthly report, on which there is dialogue. If there is a significant variance, there is discussion about it. There have been such instances.

On whether we are compromised by the court case, factors such as the court case and bed designations do not negate the potential and requirement for the HSE to manage the consultant contract like any other employment contract. It is our duty - it is also the duty of voluntary hospitals - to manage the contract as written and signed and that is what we are doing. There is no sense of contract management being compromised at a local level because of some of these are national issues. Is there a cosy relationship? I suspect there is not.