Mr. Bernard Gloster:

I thank the Deputy. I absolutely agree with his observation that this is not about doctors. I am not prepared to participate in demonising any one group. This is about a whole health system. We are all people who have responsibilities in it. I want to be clear about that to be fair to everybody.

In respect of governance, of course there are mechanisms of governance. Hospitals make declarations and are part of regions. Regional executive officers have systems. We have financial regulations and procurement rules. The effectiveness of the governance is probably questionable in the context of where insourcing got to. Our focus was predominantly on rushing to do the right thing to get waiting lists down and waiting times reduced. Hospitals and staff are under pressure to do that. We are all under pressure to do that. The very great success we had on the activity side perhaps caused us a risk on the governance side. When you outsource, you can have very good governance on it because it is a very transactional thing. When insourcing is enmeshed in your own system, the governance of it becomes very difficult and, let us face it, quite questionable. It would be wrong of me as the CEO of the Irish health service to come here and say anything different. One of the things that will be seen in my report to the Minister is my recommendation for a robust form of governance improvement.

I saw the Deputy's committee engagement with the Minister. On the voluntary hospitals and who they answer to, my personal view is that while voluntary hospitals do great work, have very good people working in them and are quite similar to our own, they have very historical board constructs that are all different. Some board members are appointed by the Minister and some of them are not. In simple terms, for public money, they report to my regional executive officers through a service level agreement. That comes on up the line to our system and then they may have some governance reporting to the Department, depending on the structure of their board. I personally think, for a health system the size of Ireland's, and I welcome all of its participants, we have too many governance systems. It is very difficult to stay on top of all of those in a country this size. There is a multitude of them, which is not to take from the good work they do.

The Deputy is quite right about the issue of performance. There is incontrovertible evidence of different levels of productivity and performance, depending on the part of the service, whether somebody is working in it at a point in time and what the incentives are. Again, I cannot say anything different from that. Part of my view on that is the best place to go is to look at our capacity, which has improved, to get the best out of the new consultant contract, with increased staffing and five-over-seven working, for the public. After we are satisfied we have maxed out on the productivity side of it, if we need additional capacity, that should primarily be outsourced rather than insourced, as I recommended in the report. That will take a few months to do. The Minister has to come back to give me direction on it but fundamentally it is easier, more clear, more visible and more transparent to manage outsource than it is to manage insource.