Professor Tom O'Dowd:

They are not actually and that is why they are interesting. Capital development is easier, of that there is no doubt. There is also the matter of human capital. As regards what specialties we need in the future, we need a workforce that takes on board ongoing training and that must be adaptable.

If we appoint a number of cardiothoracic consultants and cardiologists get on with stenting people, so that there are no more bypass operations, we will have a problem so there has to be flexibility in the system.

Managers have improved in the use of the data. They used to be administrators but are now involved in management and data cannot be left just to doctors. Policy makers, politicians and managers have to be involved.

If something does not work and we are left on a mountain without any trousers, we are in a very difficult position. All systems are on a journey and all are orientating themselves towards primary care. I have divided the systems into new and old. The old systems, such as ours and those of the Netherlands, Denmark, New Zealand and Scotland, provide a really good service and a broad range of trusted services to patients. The new systems provide a lot of data and include Vermont, which has legislated primary care into its system. The governor recently ran for election and was re-elected on health care, even though health care usually takes a back seat to economics in elections. He ran for election on a programme of reorientating the system towards primary care. His rationale was essentially economic because for every dollar he put into primary care he saved $5. Dr. Craig Jones headed up the policy and published the results. Nobody is visiting Ireland to say they want to see our wonderful health care system and replicate it. Even the countries of the Middle East do not come here and they have lots of money to spend on American-style hospitals.

The point about nurses is right. I come from a family of nurses and they bend my ear regularly about how badly they have been treated. We need to look at practices and at having nurses as partners so that they are involved in the decision making.

There has been a lot of talk about pharmacies. I would like it if we could send prescriptions online to the local pharmacist as it would make my life, and that of patients, a lot easier. There are regulatory issues in respect of this, about which the Medical Council and the Pharmaceutical Society of Ireland, PSI, have to get together but pharmacists would be able to reorientate their IT systems very quickly. It may limit patient choice but it would increase patient safety.

Senator Dolan's questions go to the core of the issue. Things are not joined up and the GP-hospital interaction is often poor or non-existent. The IT systems are completely different and if they change their IT in my hospital they never even tell us, even though we are the people who refer patients. It is poor. There was a question on access to procedures and I do not see why I cannot refer patients indirectly to the room where they carry out gastroscopies or colonoscopies.

The other area where we have to join things up is the local community. In my own, we have nearly 300 self-help organisations, many funded by the State, and we now have a member of staff who keeps a library of these organisations, to whom we now refer patients. Our consulting rate and our prescribing of psychotropics has gone down for those patients, whom we have entered into the social prescribing module. This is a very interesting area and is something we have stolen from the US, where there is a lot of volunteer activity.

I am always asked if the system can cope. The system analysis is predicated on things not coping and if these do not change they become unaffordable. We have an American-style system of inappropriate secondary care built on an old British-style system of general practice, as Deputy Durkan described it. The two do not mix and there is a systematic bias, which is driven increasingly by private health insurers. We all have private health insurance and when I came back to Ireland I was told to make sure to get my VHI in line because, if anything happened, I would not be able to afford it. People took out insurance unquestioningly and it is rising in price, incentivising inappropriate and secondary care.

Senator Burke spoke about the lack of connection between GP and hospital, which I have dealt with. Many people get years of training and people often say we "end up in general practice" which upsets us because we do not want to think of ourselves as ending up anywhere. The system has become very inflexible and rigid. One of my colleagues, who is very well trained in dermatology, does a session in the local hospital on dermatology but is not paid much for it. She does it because she is interested and because it is a skill and an area of medicine she loves. Many of my colleagues are getting involved in teaching because medical schools are expanding teaching in general practice, though it is not as well remunerated. There will be more than 200 GP trainees this year and they all need mentors and teachers. There was a good question on the GP cohort over the next ten years and there are interviews today for new GPs to start in July. Between 70% and 80% of those will be female and this is a factor in workforce planning, to which Deputy O'Reilly referred. Both males and females are working less but this is true to a lesser extent in the case of females, who also retire earlier. This would not have happened 20 years ago so we need to build it into workforce planning.

There is a huge conflict between dedication and availability. GPs are like everybody else and at every meeting to which I go there is a module on self-care, because the job is so stressful. They say we should not be available all the time but should look after ourselves but that leads to a conflict. On the other hand, it is good for the GP and for the system if a patient sees the same GP all the time. Incentives work and if one incentivises the availability of GPs after 6 p.m. it will work, even if they are not available at 9 p.m. Young people take their children from the crèche and bring them to the out-of-hours service when it opens, which has driven demand in that sector.

I was also asked about changes in respect of under sixes and I believe a report on the out-of-hours service is coming out shortly. I think it may be quite imaginative in its approach. We will need to tell people about managing minor illness.

I think we have overdone it on meningitis. Everyone who comes in with a snotty-nosed child with a rash thinks it is meningitis. We have got that message through but now everyone is fearful about it, rather than having heard a complex message. Online stuff works with young parents as does telemedicine, which is to say telephone conversations over FaceTime or the old-fashioned way. We had a meeting with the CEO of the Department of Veterans Affairs, which looks after 9 million US veterans who can be quite damaged people. She told us that from a primary care point of view, 50% of the administration's consultations are by telephone. People are willing to use the telephone albeit one has to develop new skills and there is clearly a risk.

Moving on to Deputy Murphy O'Mahony's question on thoughts about the new contract, to call it a "fire brigade contract" was a good way to put it. The problem is that with modern contracts, people are moving the dial, as the Americans say. They move the dial every five years. The idea that a contract will see out several generations is bad management. We need a contract for five years so that in five years time when behaviour has improved or set, or things, including diseases, change, one changes the contract. One has that expectation. Our negotiators need to be in permanent negotiation. Things change and people take on new stuff and it needs to be much more flexible than it is. It needs also to be based on incentives. Sole traders respond to incentives. That is very unfashionable to say in some quarters but it is how things work. When they brought in the National Health Service in the UK in 1948, it almost led to the abolition of general practice. That almost died off because of the demand. If one brings in a sudden change at the interface between general practice and the public without some expansion in GPs and allied health professionals, including nurses, the system will collapse. It is very fragile at the moment, following a long, miserable winter.

I cannot comment on the lack of broadband for the Deputy, although my family in the west complain about it a lot. That is their worry-----