A Government-appointed commission has called for sweeping structural changes in the State's health service, including giving greater financial responsibility to GPs and hospital consultants.
The commission, established to examine value-for-money in the health system, says there is no clear accountability in the service, with no single institution or person responsible for its day-to-day management.
It also also expresses serious concern at the cost of the State's medical card scheme, describing it as "one of the biggest challenges and financial risks" to the health service nationally.
Chaired by Prof Niamh Brennan, the commission calls for the establishment of a new health service executive agency to manage the health services on a national basis.
The hard-hitting report, seen by The Irish Times, states that accountability should rest with those who spend health service money.
All costs incurred by the health service should be allocated to individual patients, and good financial control should not be seen solely as a finance function.
The proposed new health service executive agency would tackle what the report described as a "management vacuum" at the heart of the health system.
The commission says the cost of the State's medical card scheme is posing a huge financial risk to the health service and that the choices facing the Government in this area are "stark".
Rather than continuing with a system whose costs are likely to continue to spiral, it suggests that budget limits for the scheme be negotiated.
Another recommendation from the commission, which could directly impact on patients, is a proposal to limit reimbursement of GMS drug costs to the cheapest medication on the market.
Otherwise, the commission says, the cost arising should be regarded as a private prescription which would not be covered by the medical card or drug payments schemes.
The commission warns against its proposed new executive agency becoming an additional layer of bureaucracy.
Accountability and authority for the management of the health service must be "explicitly devolved" to the head of the executive body, the commission says.
It also wants the national health executive to look urgently at providing alternatives for the long-stay patients who occupy 25 per cent of the 12,000 acute hospital beds in the State.
In a move that is likely to anger hospital consultants and their representative organisations, the Brennan commission recommends that the secretary general of the Department of Health "take immediate steps" to agree amendments to the consultants' common contract which will set out consultants' duties in planning and controlling the resources allocated to them.
It also wants clear accountability for medical consultants, to include a cap on the number of private patients treated in public hospitals as well as the setting of core times when a consultant must be available to patients in public hospital.
Furthermore, the commission wants to see "formal active monitoring of work commitment [by consultants] in respect of public patients".
In addition, the report recommends that all new consultant appointments should be made on the basis of a contract to work exclusively in the public health sector.
The Brennan report is one of two major reports on the health service due to be published in February.
Another report from the Department of Health, carried out by Prospectus Management Consultants, was exclusively revealed in The Irish Times earlier this month.
The Commission on Financial Management and Control Systems in the Hospital Service was set up by the Minister for Finance as part of his 2001 Budget statement.
It is chaired by Prof Niamh Brennan, professor of management at the department of accountancy, University College Dublin. She is married to the Minister for Justice, Mr McDowell.
At the time, Mr McCreevy said that there was a need to ensure that both quality and quantity of health services matched increased health spending.