Mr. George MacGinnis:

I will expand. Some of what I say is based on my wider experience of working in the Irish health system. On the international comparators, I would draw the Deputy's attention to the comparator on activity on page 21 of the report, specifically the average length of stay rates for inpatient acute care. In Ireland the performance in this area has been declining. One of the points made about integration is that patient flow is blocked and people get stuck in hospitals, which means that the productivity of the workforce, in OECD terms, declines, so patients do not get as much health care as they might otherwise with that same workforce.

The Deputy mentioned GPs, which was one of the things that came up in the review. We very deliberately described a primary care workforce in the review. The advice from New Zealand was that the mix is currently very GP heavy. We have not looked specifically at that, but in other areas where we have looked at this question GPs operating alone tended to have different productivity outcomes to GPs working in larger teams where there is a degree of specialisation, for example women's services, diabetes and things like that within the GP community. In particular, the nurse GP ratio could be looked at. In New Zealand many general practice tasks are carried out by nurses, with issues escalated to doctors when appropriate. Nurses are able to carry out many of these tasks. My understanding is that the Department has put in place a programme for building primary care centres, but is having difficulty attracting GPs to relocate and work from those centres. We believe that productivity within the system is hampered by some of these workforce factors. It is also hampered by the lack of integration. On a practical level, how many different forms have to be filled out and how many different people have to be contacted to move someone on? That is affected by the fragmentation within the system at present.

Ireland still has a long journey to take in terms of resourcing healthcare. The way that budgets work does not encourage an output, let alone an outcome, review of what is being achieved. It is very much an input-based strategy, and things will not change until that approach is altered. I do not mean changes at a managerial level. There is a very real sense among clinicians that they understand and own patient outcomes. They know that the decisions they make every day not to discharge someone from an acute ward condemns someone to an extra stay on a trolley in an emergency department. Those are risk-based decisions, and they are difficult, but that is the kind of real cultural change that is required across the system.