Mr. Ciarán Devane:

My response would be similar to that I gave Deputy O'Reilly, I am a public sector, public service supporter and fan. The private sector has a role to play but if one takes the American model, it does not deliver the health outcomes. It is vastly more expensive and with a lower life expectancy. Why would one want to implement that?

I wish to reassure the Deputy about layers of administration. We are going to examine this soon, and will ask if it is a question of subsidiarity, how do we get accountability as close to the front line as possible and how we support individuals, as Deputy Durkan noted. There is the question of remoteness. We must ensure that the HSE is neither some small body in Dr. Steevens' Hospital or some remote behemoth that sits over the people who do the work. That is really important. It is not a structural problem; it is one of communication, transparency, motivation and vision.

On pharmaceuticals, I understand there is a big push on biosimilars, which will address part of that. Keeping control of the drugs budget, while providing the drugs when needed, is a big challenge. The healthcare system has more people, living longer with more conditions and improving treatment, which is more expensive. The drivers of health inflation built into it, which is a problem of success, is very real. Health systems will never be cheaper because of that driver but they must be more effective. They must be more prevention-based, community-based and early intervention-based. If we can do that, we will then have the space to cope with the acute, chronic, and urgent and the unmet need.