Mr. Ciarán Devane:

It is a challenge. Senator Dolan is absolutely right to ask about the people who do not have a voice and are not heard. We need to be very alive to that in the manner in which the HSE, more broadly, and the board, in particular, engage. People across the health sector traditionally use the example of the power of the acute hospital at the expense of its community equivalent, or the power of the physical health lobby over the mental health lobby and so on. We need to be acutely aware of that.

One solution, of course, is that many of the things we need to do are common. I will give another example from my past. One thing which worked very affectively in my Macmillan Cancer Support days was establishing a group of ten charities which covered multiple conditions. Of course, every time Macmillan talked to the Department and said it wanted an early diagnosis for cancer, the Department would say that it could not give it to Macmillan alone and that if it gave an early diagnosis to us, it would have to give it to everyone because otherwise it would be discriminatory. However, when we then went in as ten organisations and identified a common theme of early diagnosis, whether for diabetes, mental health, multiple sclerosis, cancer or whatever, people paid attention. One could partly get one's head around the problem and decide to focus on early diagnosis across all conditions. We then came in behind that as what was known as the Richmond Group of Charities.

There are ways of doing it if one leaves one's tribal hat out of the equation. I tried very hard to be seen not as a cancer chief executive but as a health chief executive. My colleagues in the British Heart Foundation and the Neurological Alliance tried to do the same thing. We all tried to say that while, of course, we had to fight for our constituency, we were much more likely to be heard if we worked collaboratively. That is one answer.

On the question on respecting the budget, we must respect the budget and cannot spend money that has not been allocated by the Government and the Oireachtas. We should not be doing that. We should be ensuring we spend that budget as effectively as possible. The settlement between last year and this year was good. We will travel to the end of this year optimistic about the settlement for next year but we want the credibility of telling the Government which gave us that money that we spent it brilliantly and did not spend money that was not given to us. We could then ask the Government to fund other things as well, whether Sláintecare, addressing a shortage of clinical mental health staff or whatever. We cannot surprise the Department or the Government by saying that we went off and spent more than the amount allocated to us. We are coming off a graph that is going up in any event. That is about us having a financial grip on things that would give the Oireachtas confidence that, if something is funded, the money will be spent well and money we do not have will not be spent. I hope that will allow the Oireachtas to state that it wants to give the HSE more money because it did a good job with the money it was allocated.

From the experience last year, we should not be in a position of coming up with a supplementary budget with a gap larger than in most jurisdictions with much larger budgets and populations, both in terms of a percentage gap and an absolute gap. We have a job to do that must be done in a way that does not damage the fundamental interests of the patient or service user. That is our challenge.