Dr. Colm Henry:

The Chairman is absolutely right. The models of care are key. In the absence of a model of care for chronic disease - be it congestive heart failure or chronic bronchitis, which are well known to the Chairman from his other career - we are going to continue to invest in the wrong way, namely. waiting until patients arrive in hospital and join waiting lists or are placed on trolleys in emergency departments. We need to invest in the whole spectrum of care. We spoke about vaccinations earlier. I refer to self-care, self-management and creating hubs of care in the community built around increased capability of nursing to deliver care long before people reach hospital. The key to this is a reform of public health. This is a piece of work that is being undertaken by my office in conjunction with the Department. We want to build up the capacity of the public health workforce to deal with health service improvement. When we are looking at models of care, we do not rely on the expertise of hospital clinicians alone; we look at the entire spectrum of care required, from prevention and promotion right through to specialist care.

On elective care, there has been a move in recent years, perhaps out of necessity but also, going back to the model of care design, to work with the national clinical programme of surgery - led by Professor Frank Keane previously and now by Mr. Ken Mealy, who is with the RCSI - which has done sterling work. What we have seen is a dramatic increase in the number of day cases. We have seen a shift from procedures being done over a few days now being performed on a day-case basis. Some 20% or more of day cases do not need to take a full day, they can be done in outpatient surgeries or even GP surgeries. That is the context in which the GP contract and enabling primary care are really important. We are putting the pieces in place, namely, a stronger public health workforce focused on health service improvement, a stronger more resilient primary care model and building hubs of care in the community rather than waiting for patients to arrive in hospitals and join queues. That is key to reform.

With regard to the attempts to come in under budget in the HSE, Mr. Reid mentioned that there is also increased funding to allow this. We have spoken about moving to changed models of care, where everything can be done more efficiently. There are many processes within our hospital structure and the clinical and management element of hospital services that quite often inhibit patient flow through the system. If we allow certain practices to continue in our hospitals, we will be promoting them. Many structures within our hospital system do not work in the best interests of patients. That is where efficiency and cost effectiveness can be applied. Our hospital structures are not in keeping with modern medicine delivery and many of them are 20, 30 or 40 years out of date. Those models are inhibiting patient flow through the system. If there are to be visits to hospitals on a regular basis, we should examine the way hospitals function as there is much inefficiency in that process.