Mr. Liam Woods:

To return to the Deputy's original question as to what the problem is and where he quoted some data, the expenditure in the health system, whether it is understood at a European comparative level or OECD volumes at a glance in terms of doctors and nurses, I would look at the numbers of doctors in Ireland vis-à-viselsewhere. We are considerably lower and bed numbers are considerably lower. The point about nursing is a point well made. The capital infrastructure in our environment is not comparable with some of the other environments with which we would be compared and we know that it does need serious investment.

Underlying the Deputy's question and hypothesis is a very fair challenge to say that if we look at orthopaedics, an area he referred to himself, it is very true to say that the model of care for orthopaedics, part of which was developed jointly by a consultant in Cappagh, would clearly identify that up to 85% of an outpatient list can be addressed by a musculoskeletal, MSK, physiotherapist and a consultant will deal with the balancing 15%. We need to shift the model of care and provide more of that in the community is the goal and that is happening. There is a primary care centre in Galway where an MSK physiotherapist has been appointed and it is having a very good effect in terms of referrals to hospitals and providing care in the community. That is the kind of investment that is not the same as saying we simply need more consultants.

The model of care for orthopaedics, the demand-supply analysis and the onset of growing demand based on obesity for knees, because the volume of knees to be done in the future will far exceed hips because of obesity, means we need to double the current number of orthopaedic surgeons we have, which is around 80. That is over a period of time but the other point about ageing is true because on an age-adjusted basis, we are still younger than many of our comparator environments. One of the challenges that we face, and Mr. Gloster can probably talk more on the operational side on older persons' services, is that we are growing old at a faster rate than others. The rate of change is what is being dealt with on the ground and that is a real factor. There are opportunities and I share the view that it is not just about getting more stuff, it is about getting the best that we can out of what we have and investing in capital sensibly. Deputy Kelly referenced working outside the normal day and looking at our level 2 hospitals. We are going to face frail, elderly and chronic condition challenges right across our whole healthcare environment, many of which may be able to be addressed in primary care and model 2 hospitals, as well as focusing the major hospitals on precisely what they need to focus on. I agree with the Deputy's point. I query some of the data because there are questions in that regard. Our capital infrastructure, which, based on the new plan is growing substantially and is helpful, is a key driver so that we can be what we need to be. The investment we need in equipment today is approximately €350 million to bring it to where we would want it to be. There are efficiency opportunities and productive opportunities within that.

In comparison with other environments, we are a cost-based funded hospital environment and many of the others are insurance and transaction based and that may be having an effect on some of the comparative data. The shift to private spending by individuals in the Republic of Ireland has been quite high over the past few years and that contributes to the cost when we look at it at a macro level. Often that data is not talking about HSE costs but about global health spend, which is very appropriate but there are real variations in what the HSE spends and what society as a total spends.

If an emergency department in Ireland is considered, four to five consultants would be as high as would be seen in an emergency department. In Scotland they are targeting having ten emergency department physicians per department to provide care so there is strong evidence on the consultant side that we need significant additional resources but I entirely take the point that the need to drive performance and improvement and model change within what we do is also a piece of that.

It will not work and it will be too slow to wait for new buildings to appear to resolve the service challenges that we face. I take the point.