Stephen Donnelly (Wicklow, Fianna Fail) | Oireachtas source

I thank the witnesses for their time. Having listened to the exchanges for the past two hours, I have to confess that I am thoroughly depressed on behalf of the good people of Ireland because, as has been laid out, the witnesses have dedicated their lives to healthcare but patients are suffering. Much of the time, patients and staff are going through completely unacceptable situations in many emergency departments. Regularly, patients and staff in acute settings are in completely unacceptable situations. When patients are trying to be discharged from the hospital they cannot necessarily get an appropriate step-down facility. If we want to move them back into their homes they cannot necessarily get the home care package or the home care hours they need. We have a crisis.

The IMO represents GPs, but we have not really been speaking about the latter today. They say they are in crisis. Our GP and primary care sector is in crisis, our acute sector is in crisis, our emergency departments are in crisis and patients are suffering, as we all know, every day.

The reason I am depressed is that obviously there is very little money. I heard solutions from the INMO that do not involve more pay. Obviously, its representatives focused on pay as well but they have laid out solutions that do not involve more money, just running the system properly and making the HSE a desirable entity for which people will want to work, regardless of pay and regardless of their colleagues in Johns Hopkins Hospital. Perhaps they will get a pay cut coming home. However, they will be excited about returning because there is a wonderful academic centre of excellence they can come to where they can invent wonderful new treatments.

I took a look at pay and examined data from the OECD and various data sources around the world. What is happening is perplexing. Starting with doctors, numerous sources say our doctors are still some of the best paid in the world. They are not the best paid and we are no longer in the top three countries. However, we are in the top ten. The problem is that the other English-speaking countries they can go to, such as Australia, Canada and America, pay more. That does not necessarily mean that we should pay our doctors more than any other country in the world. We cannot compete with American pay scales. We never could and we never will. That is not the value proposition when it comes to the Americans. Australia is trickier. It is paying a great deal of money and the nurses and doctors I have spoken to say it is a great place to work. It is also warm more often than it is warm here. It is a tricky place with which to compete. The same is true of Canada. It gets snow and sun. However, the reality is that our doctors are not badly paid, but well paid. Yes, they have taken an unmerciful hit. They were extremely well paid and now they are just well paid. I reiterate that we are still in the top seven in the world.

Matters are also tricky when it comes to nurses. As the INMO correctly pointed out, the nurses are badly paid relative to other healthcare professionals of similar education. Relative to private sector new entrants, however, they are very well paid as new entrants. When it comes to a nurse versus an engineer, the private sector pays engineers, architects, lawyers and other professions that require a degree significantly less than the public sector. I also took a look at nursing salaries around the world. In 2013, nurses in this country were the third highest paid. We were still in the top five countries in 2016. I have looked at multiple data sources and all of them say that Irish nurses are among the best paid in the world. I have looked at the various career sites and, in each case, Ireland is in the top ten. There is something that has to be figured out there because, looking at it without having knowledge of what Irish nurses are dealing with, it appears that our nurses are pretty well paid. Our doctors also appear to be well paid. However, there is a strong feeling among the nurses and doctors that they should be paid far more, and that the reason they are leaving the country is that they are not paid more. That is something we will have to figure out.

Deputy Durkan asked the question I also wish to ask. I fundamentally disagree with the earlier statements about chronic underinvestment in healthcare in Ireland. The data simply do not show that. In fact, they show the opposite. This country invests more in healthcare than practically any other country on earth. Again, the Americans are out on their own, but that is because of utterly dysfunctional system issues relating to private health insurance. It is not the type of healthcare system I would like. It is a great healthcare system if one can afford it, but America is not a good country in which to get sick if one is poor. It is not true that we do not invest in healthcare. The data are unambiguous. We invest shedloads of money in healthcare whether one assesses it by percentage of GNP, purchasing power parity or investment per person. In addition, our people are much younger than those in most other countries, so if one does an age adjustment, we spend more on healthcare in this country than anywhere else on earth except America. We invest a vast amount of money in healthcare. Perhaps we should pay even more but relative to other countries we pay our clinicians quite well. In every data source I can find, we are listed in the top ten around the world. That is not bad. Clearly, it is not enough for the doctors and nurses, but it is not a small amount of money.

I wish to push further on this. If we are spending more money on healthcare than virtually anybody else and we have a GP sector that is falling apart, emergency departments that in many cases on a Friday or Saturday night are simply not okay for either patients or staff and we have 95% occupancy of beds and so forth, where are we wasting money? Clearly, we are wasting vast amounts of money somewhere if we are spending so much and our clinicians are so annoyed that they are leaving the country to work in other places. We must be wasting billions of euro every year which we should be investing in drugs, doctors, nurses, beds, GPs and primary care but which we clearly are not doing. The witnesses all work in the system so they can help us find the money. Where are the billions that we should be pulling out of some parts of the system and reinvesting in the people the witnesses represent? That is my first question.

Second, can the representatives of the three groups give us the top two cost neutral things they would do immediately, be it for capacity, their members or whatever? I will briefly give the framework for this. The fiscal space is €800 million. Different political parties have different interpretations of it, but that is the one that Fine Gael and Fianna Fáil accept. There is €800 million available. The confidence and supply agreement provides for a 2:1 ratio on tax and spend. I believe that is wrong because I would not reduce taxes at present, but that is not my call. However, if one does what is in the agreement there is approximately €550 million left for investment. If one pulls one quarter of that for health, which is the pro rataamount spent on health as a percentage of the total spend in the country, there is about €150 million. That does not include healthcare inflation so we can knock off another €80 million for that. Before we start there is approximately €70 million available in the budget for new things. To put that in context, Sláintecare in year one requires approximately €1 billion. What are the cost neutral measures?

Third, what are the investment priorities? Do they include pay? The witnesses have laid them out but what is the first priority? Is it 10%, 15%, 20% or 25% more pay? Is it hiring the extra doctors and nurses that are needed? Which of those would come first or is there something else? Is it implementing the eHealth agenda or fixing the numerous HR issues which doctors and nurses face every day and which drive them crazy? Given that there is very little money available if we comply with the European guidelines on budgets, where is the first place the witnesses would spend the money in terms of wages, more staff or elsewhere?

My final question is a technical one for Mr. Varley. He spoke about the 57% to 70% gap between new specialists - they are not new entrants - and old specialists. Can he give the euro figures for that? What is the starting salary for new specialists and what salary he is comparing that to, which is 57% to 70% higher? Mr. Varley said that while our total healthcare spend is very high by international standards the spend in the acute sector is mid-level. I am not denying that is the case but, if so, we must be spending vast amounts of money somewhere. Obviously the acute sector sucks up a great deal of the money so if we are at medium level in that sector we must be at the top in other places. Does he know what they are?