John Crown (Independent)

I thank the Minister. That means I have about three minutes to think of what I am going to say for the other two minutes. I am sorry but I did not realise I had such generous speaking time.

I compliment the Minister on his vision for reform of the health service and I wish him well with its implementation. The challenge of implementation will be very difficult and, as I have said to him on many occasions, he will have my support in pushing towards a reform of the system to create an insurance model based on a mixture of public and private insurance in competition, which in my view is the right way to do it. This is my understanding of the synthesised programme of the two coalition parties. I ask also for an acknowledgement that the system which will maximise efficiency, equity and quality is the move towards a single tier of health care where there is a linkage at all levels between activity and payment, in order to provide the appropriately policed incentives for activity.

I would like to bring the Minister's attention to one area which is probably not as high on the agenda but of which I know the Minister has been made aware and which he has had a chance to consider in detail, namely, the question of the integration of research into the activities of the health service. Historically, in Ireland we have tended to regard ourselves as a small, poor, peripheral, investigationally irrelevant society where research was that activity which bright young Irish doctors did when they were abroad to train to build up their curriculum vitae before coming home and becoming rich ex-researchers. Unfortunately, that was the way the career path ultimately ended up developing for many people because they came back to a system that was so desperately and unprecedentedly short of specialist doctors that any notion of attempting to roll up their sleeves and do research when they already had truly unsustainable clinical loads would, I believe, have been considered bordering on immature by many of the more established people who were present in the country. Things are changing. We now have a cohort across the specialties in medicine, including family practice and the hospital-based specialties, of people who have developed major reputations in research.

As I had occasion to point out to the Minister recently, the arguments for doing research in the health service are multiple. The first is that research itself may yield results which are of importance to the advance of the field. Ireland should not regard itself as a country which is in isolation from the worldwide research initiative. Second, while my colleagues in the Seanad might not be aware of this, patients who are being treated on research programmes tend to have better outcomes than patients who are getting identical or similar treatments outside of the discipline and rigour of a research programme. While this may be counter-intuitive, the reality is that the discipline and level of oversight which go into structuring treatments, which have been designed in many cases by teams of truly international experts, mean that the average patient in Dublin, Letterkenny, Cork, Galway or Belfast can get access to research protocols which have been designed by such truly international leaders. This has happened in the case of the All-Ireland Co-operative Oncology Research Group , which now has patients on trolleys in every acute hospital throughout the island of Ireland.

The third reason is the bizarre career structure here. I am delighted we finally have a Minister who understands the issues involved in this. If we are to keep people in this country, we must enable them to continue to spend meaningful portions of their research time in international centres of excellence, of which I am in favour and which has been very good for Ireland, and then ensure they return here. To achieve this, we need to have some research input into their training structures while they are in Ireland. People who will look at the curriculum vitae of young Irish graduates who are seeking jobs in, say, cardiac surgery in a Cleveland clinic, oncology in Memorial Sloan-Kettering or some branch of paediatrics in Sydney or Melbourne, will wonder what the person has done in research to date and whether the person has publications and a track record. This enhances the reputation and recognition of the training which our graduates will receive here.

I support the Minister's notion of introducing an additional level in the career grade which acknowledges the reality that we have many doctors in this country who are completely trained, and the only reason they are not employed as specialists is that we have had a highly restrictive national contract for specialists, which makes no sense. My one gentle criticism of the Minister is that, having come into a new job, he needs to let those around him in the Department know exactly who is boss - I believe he is beginning to do this. The need for change is fundamental. We need to dispense with the notion of a solitary national contract for hospital-based specialists. It makes no sense that somebody who works in the university environment in a teaching hospital in a large centre like Cork would be on the same contract as somebody who is doing very busy but primarily service-orientated work. With the new model of a single-tier insurance base, there will be different models of reimbursement. There may be doctors who set up practices in general surgery or in obstetrics affiliated to hospitals where they will bill insurance companies for their services.