Mr. Ivan Cooper:

Dr. McCarthy referred to taking a step back from it. The role played by the voluntary and community organisations in health and social services is well understood by this committee and it is in every community in the country. It is inextricably intertwined and bound up in our core health and social services. The two are no longer separable and they need to be understood to be part of a system that needs to be re-understood and properly resourced. The independent review group report published by Dr. Catherine Day and her team engaged very deeply with this particular issue and made a strong, central core recommendation - to which Dr. McCarthy alluded earlier - on the idea of essential services. We are never going to escape this kind of circular conversation we are having currently.

In fairness to the folk who work in health services administration in the various departments, they are all under intense pressure in delivering outcomes and scrutiny around budgets, which of course is all right and proper. Everybody is under pressure, but a core recommendation is to agree and identify the essential services people should have available to them in their day-to-day lives in their communities and that we should work backwards from that. It is kind of like the old idea - most of us are familiar with the terminology - of outcomes-based working. There is some theory there. Inside the HSE there are people who think about this, and in the Department of Health, the Sláintecare office is established now. Maybe we can look more towards ideas of commissioning services where we look at the outcomes and then agree if the outcomes are going to be sufficient to meet the community need. Ultimately, however, it starts off with having a clear sense of the need we are trying to serve within communities. Then we can have a conversation about the types of resources and services that are necessary.

This plays back to Senator Burke's point about optimal ways for organisations to do things. Of course, inevitably there are optimal ways of doing things. If reform is to be structured around making central administrators' lives easier, the problem will be administration-led services that will come increasingly distant from communities. If the reform is designed to make services more flexible, innovative and responsive at ground level, then it will be the other way around and we will end up with a devolution and delegation inside the system to the closest possible place where accountability should be experienced by individuals who require services.

Viewed that way, our community and voluntary sector being present in every community is in fact an asset that is already there, if we can find a way of connecting it up better with itself and integrating it in a more cohesive way into our health services' strategic thinking. I would call today for the Department of Health and the HSE to engage the community and voluntary sector more in strategic thinking about the future of the health and social services. The sector will not be found wanting ultimately in understanding the part it needs to play in well-designed services.