Ms Susan Clyne:

I will set off and then Dr. Gilligan will come in. Regarding the numbers quoted by Deputy Donnelly in the context of where doctors are well paid, nobody suggested doctors are not well paid. What they are suggesting is that we are not competitive with the market so what a consultant is paid in France, Germany or the Netherlands is irrelevant. Irish doctors are not going to these places. In the main, Irish doctors are going to Australia and Canada and, in some cases, the US. There is a global shortage of doctors and nurses and we just have to face up to that fact. We are competing in a market. In respect of the data sources shown by Deputy Donnelly, maybe they are earning more but it involves different systems. It is not like comparing apples and oranges. There is a significant issue - not just pay, which is a huge differential.

To answer Deputy O'Reilly's question, there are other reasons why people are driven abroad. It is not just because of the weather. They are driven abroad because they can work. If a person is a trained surgeon, he or she has theatre time. He or she can see patients and refer them for diagnostics. he or she can do his or her training. In almost all these other countries, including Canada and Australia, it is a four-day week that involves seeing patients and being able to refer them on for appropriate testing. It is about getting results back quickly. It is not about seeing a patient and telling him or her that one will see him or her again in a year or two. It is also about huge support for doctors' continuing professional development. For example, Australia has a grant that allows doctors to do their training and continuing professional development. They are supported to do that within the working week. So there are a lot of things happening in terms of recruitment and retention.

Regarding the population, the point we are trying to make concerns investment in healthcare. It is not that we do not spend a lot of money on healthcare; it is that we do not invest a huge amount in new service development or in the things we need for the future. We do not plan and invest for plans to be implemented. We are talking about a fiscal space of €700 million or €800 million. If Sláintecare is not going to be funded, it behoves politicians to stop using it as the plan that will help the health service. If we need €1 billion to fund it in our first year, the public should not be told Sláintecare will happen if that €1 billion is not there, and that is a real difficulty. There are huge patient expectations and people in the health service work really hard every day to deliver on those expectations. Pay is a big issue. There are other issues such as investment. People want to be able to work in theatres. This requires resources. Almost everything costs money but one way in which we spend money inappropriately in our view is through the National Treatment Purchase Fund, which is a short-term measure, and through agency staffing. If the numbers were looked at in the long term, it would probably be discovered that the conversion of agency staff is cost-neutral.

In response to Deputy O'Reilly, there is no big shift or move to convert staff from agency to permanency, and the staff have no real desire to do so because the people who come in on agency work earn more than the permanent staff, choose their hours and do not all reside in the jurisdiction. I therefore do not believe there is any big move happening in that regard.

The Public Service Pay Commission was part of the public service stability agreement last year. Many organisations and unions, including us and the nurses' union, signed up to the agreement on the basis that it would deal with the recruitment and retention issue, which - there is no point in pretending otherwise - will cost money. One thing we are a little anxious about is the idea of picking the top thing and investing in that top thing. We have learned over many years and all the reports show us that if we do that, that is, if we start focusing on one thing in health, something else will break down. We must invest the money across the board and then see where we are. If the plan is going to be Sláintecare, the money should be invested in it. We have objections to some of the areas of Sláintecare.