Dr. Tom Ryan:

I might deal with the questions out of the order in which they were asked as they overlapped a lot. I might deal with Deputy Kate O'Connell's question about beds first.

It is clear when one looks at the hospital system, with only 10,000 beds in it, that we do not have enough beds for the population. We have about half the OECD average. As an association, we compare the figure in Ireland to the OECD average. What we are comparing in that regard is mediocre rather than the best solutions around Europe. There is no attempt to achieve excellence here. If we were to achieve excellence and have a superb health care system as in France, Germany or Holland, we would have almost double the number of beds. As we have so few, hospitals are continuously full. They are at 97% all the time. Patients are discharged very quickly from hospital and there is no room to squeeze extra capacity out of existing hospitals. Even with the absence of extra capacity, we are not hospitalising very many people in Ireland compared to other European countries. We hospitalise approximately 25% less than the OECD average. If we compare Ireland to Germany, France and the Netherlands, we hospitalise about 30% or 40% less.

We do not have a particularly hospital-centric system. However, we are stuck because the population is increasing and ageing. The demographics show that increasing numbers of 60 and 70 year olds will drive the need for hospital care. The ESRI stated recently that in the next decade we would need to increase hospital capacity by 37%. If we have 10,000 hospital beds now, we will need an extra 3,500 to 4,000 by 2030. That is the core problem in the health care system and it is what leads to waiting lists. The lack of capacity makes it difficult for people to work in hospitals and makes them unattractive to consultants. There is obviously a problem with remuneration, while there is a huge problem with capacity, particularly where surgeons are unable to gain access to theatres because there are not enough hospital beds, operating theatres and ICU beds.

What has to be accepted is that 50% of the population have private insurance in the 40 to 80 year old age group. The reality in Ireland today is that there is a dual funding model health care system. That is where we are. The word "perverse" has been used about this model, but it is difficult to characterise the behaviour of 50% of the population as perverse. That thought process is a problem. If one accepts what the ESRI states about the need to increase hospital bed capacity by 37% and OECD comparisons which suggest we need even more hospital beds than that number, these matters were not recognised in the Sláintecare report. Consequently, it would drive health care costs significantly in the next decade if we were to provide for that hospital bed capacity. It may very well be that the Sláintecare report was under-costed. There are problems with Sláintecare in recognising that ours is actually a dual-funding model and recognising the need to increase capacity dramatically and somehow figure out how we will fund it in the next ten to 15 years.

All of this makes it difficult to recruit consultants as there are not enough facilities available. It makes it particularly difficult for clinical directors who are the people who make everything hang together. If the clinical director spends all of his or her time trying to patch a broken system, it is very difficult to hold him or her to account when things go wrong. I have a great deal of sympathy for clinical directors, given the role they fulfil in Irish medicine in just trying to get things to work.

I hope I have answered the Deputy's questions.