Private Activity in Public Hospitals: Discussion

This morning we are going to look at the report of the Independent Review Group on Private Activity in Public Hospitals. I would like to welcome Dr. Donal de Buitléir, chair of the Independent Review Group on Private Activity in Public Hospitals, and Dr. Conor Keegan, research officer with the ESRI. We will be having a second session at around 11.30 a.m. at which Laura Magahy from the Sláintecare Implementation Office will give us an update on progress in relation to Sláintecare.

I wish to draw your attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to do so, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given, and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any person, persons or entity by name or in such a way as to make him or her identifiable. I also wish to advise you that any opening statements you have submitted to the committee may be published on the committee's website after this meeting.

Members are reminded that the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I ask Dr. Keegan to make his opening statement.

Dr. Conor Keegan

Thank you, Chairman.

I would like to thank the committee for the opportunity to present on our research. I am here in my capacity as a research officer at the ESRI. I am an economist by training and I am a PhD in the area of in the area of health economics. I am the lead author of the ESRI working paper, An Examination of Activity in Public and Private Hospitals in Ireland 2015, which was published last October and which the Joint Committee on Health has invited me to discuss. The analysis was undertaken as part of the ESRI-Department of Health research programme in healthcare reform, which has the broader objective of projecting demand for and expenditure on healthcare services in Ireland. The working paper was prepared in light of the independent review group's work examining the implications of the Sláintecare proposal to remove private practice from public hospitals.

While the ESRI did not provide any direct input to the deliberations of the review group, the working paper was subsequently cited as part of the review group's final published report in August 2019. The ESRI working paper examines the extent of private activity in public hospitals and provides an overview of service delivery across public and private hospitals in Ireland in 2015. The analysis expands on research undertaken and findings presented as part of the ESRI research series report, Projections of Demand for Health Care in Ireland 2015-2030, the first report from the Hippocrates Model published in October 2017. The report contained new analysis of private hospital activity, which had not been previously published for the Irish healthcare system. The working paper expands on that analysis by examining the extent to which care in public hospitals was delivered on a public or private basis.

In 2015, nearly 1.5 million day patients, those admitted and discharged on the same day for elective, that is, scheduled treatment, and nearly 4.2 million inpatient bed days relating to either elective or emergency care were recorded across the public and private hospital system in Ireland. The public hospital system delivered the majority of this care.

In 2015, approximately seven out of ten day patient cases, and more than eight out of 10 inpatient bed days were estimated to have taken place in public hospitals. Some 16% of cases in public hospitals were treated privately.

Looking at private care across the hospital system, more than 75% of all private day patient activity was recorded in private hospitals. In contrast, we estimate that less than half of all private inpatient bed days were recorded in private hospitals. These findings suggest that the private hospital system is primarily specialised in the delivery of elective care, with all day patient care being elective by definition.

In considering the removal of private care from public hospitals, it is important to note that most private inpatient activity in public hospitals are emergency inpatients arriving through hospital emergency departments. Elective private inpatient activity accounts for less than 4% of total inpatient bed days in public hospitals in 2015.

It is unclear, therefore, whether the types of private emergency inpatients currently treated in public hospitals could access the care they require in private hospitals. Traditionally private hospitals have not provided many of the more urgent and complex treatments associated with emergency care that are available in public hospitals. Data on public and private activity in public hospitals were available from the hospital inpatient enquiry, HIPE, scheme managed by the healthcare pricing office. HIPE collects detailed clinical and administrative data on discharges from and deaths in acute public hospitals nationally. However, we did not have access to comparable routinely collected administrative data on private hospital activity.

To try to fill this gap, private hospital activity profiles were estimated using aggregate information on health insurance claims provided by the health insurance market regulator, the Health Insurance Authority. We would have liked to extend this analysis further, for example, to compare public and private activity at the level of diagnoses and procedures or to compare the roles of the two types of hospitals with respect to elect and emergency inpatient care. Data limitations meant this depth of analysis was not possible. The absence of good quality data creates difficulty for both researchers and policy makers to inform important policy proposals, such as the one being discussed this morning, with evidence.

The full working paper has been circulated to the committee and is available on the ESRI website.

Thank you very much, Dr. Keegan. I ask Dr. de Buitléir to make his opening statement.

Dr. Donal de Buitléir

Thank you, Chairman.

The Sláintecare report by the all-party Oireachtas committee recommended the phased elimination of private care from public hospitals. There is cross-party political support for this for a very good reason: quite simply, access to public acute hospital services is unfair and that needs to change.

Ireland is unusual in that those with private health insurance or who can pay out of pocket are able to access services in public hospitals quicker than those who do not have health insurance or cannot afford to pay. This is not fair. It is difficult to think of any other public service where people are treated more favourably simply because they can pay more for a service. Our recommendations are designed to eliminate this unfairness. Our proposal would also help to move us towards the accepted norm in almost all advanced countries.

Ireland’s system of private practice in public hospitals is very unusual. We asked the OECD to report for us on the Irish system, and it found Ireland to be a striking outlier. We have a very large private health insurance market. The overwhelming number of hospital consultants have rights to private work and almost 30% of our total hospital activity is funded privately, a situation comparable only to the US.

I would like to refer briefly to the widespread misunderstanding about the cost of removing private care. The recommendations we make are costed, and costs are phased in a way that makes the change affordable, and I will come back to this point.

We recommend legislation to ensure that public hospitals are used exclusively for the treatment of public patients from the conclusion of the ten-year Sláintecare implementation period. Our other recommendations ensure a reduction in private activity over time, but over the lifetime of Sláintecare, private activity must eventually cease entirely and the legislation should provide this.

The key recommendations in the report concern the consultant contract and there are five recommendations. First, all new consultant appointments should be to a Sláintecare consultant contract. This would allow consultants to conduct only public activity in public hospitals. It is important that this recommendation is implemented soon. There is no point in continuing to issue contracts with private practice rights when these will have to be bought out in the future. This recommendation is the key to removing private activity from public hospitals in a progressive, orderly and incremental way.

Second, we recognise that there are significant consultant recruitment problems in our public hospitals, with approximately 370 vacancies at the moment and a further 380 posts occupied by non-permanent staff. While working conditions, hospital rosters and matters such as training opportunities for non-consultant doctors play an important role, pay is also a factor. In October 2012, the starting pay of consultant doctors was cut significantly. We recommend that the payscales for all new entrant consultants to the Sláintecare consultant contract and for existing consultants appointed since 2012 on public-only contracts are restored to the scale that existed pre-October 2013. In current terms, the starting salary of a type B consultant appointed today is €131,000. The starting salary of a new consultant should our recommendation be accepted would be €182,000, a very considerable differential of €51,000. This new salary would compare very favourably with salaries in other countries and would put Irish consultants among the highest paid consultants anywhere.

Third, while our recommendation about new consultants being appointed to a public-only contract will ultimately lead to the removal of private activity from our hospitals, this will take some time. In order to speed up the process and encourage existing consultants to change to the new contract arrangements, we have recommended that existing consultants should be offered a contract change payment to move to the new Sláintecare consultant contract.

Fourth, we are concerned that there are some consultant posts, and I stress the numbers are likely to be very small, where it may prove almost impossible to recruit a suitable candidate. A scheme exists in the third level sector that allows a special derogation from pay service caps to address recruitment to highly specialised posts in a very limited number of cases, and we have suggested that this also needs to be considered in the public health service.

No doubt members are aware of some concerns that have been aired over the amount of private activity in public hospitals conducted by a small number of consultants that is above the amount allowed in their contracts. It is our view that the HSE needs to ensure that this does not happen, so the agreed monitoring and reporting system to robustly monitor and enforce the existing consultant contract must be implemented. We made two further recommendations, namely, the Department of Health should ensure that HIQA’s quality and safety regulatory functions are extended to all healthcare settings, including those in the private sector, and that a better data collection system would be put in place relating to the nature and scale of activity in the private hospital system.

Obviously, the implementation of these recommendations gives rise to increases in public expenditure. The additional costs arise mainly from the loss of private income of public hospitals but also in relation to consultant pay - for those taking up the public-only contract - and the increased cost of treating greater numbers of public patients, and we have set out the final costs at the end of ten years and it comes to approximately €650 million per annum. The main element of this is the private income of hospitals - now just over €500 million - paid mainly by insurers. This income is declining in any event due to the campaign by insurers to inform patients that they gain no advantage from using their insurance when admitted via the emergency department of a public hospital. While the loss of this income will result in a cost to the Exchequer, people are already paying for this in the form of higher insurance premia, and the loss of this income will result in higher taxes but lower insurance premia. Even if there is no change in the existing system, this source of income will decline, and it would be very risky to rely on this income continuing into the future.

It is important to note that €650 million is the annual cost which arises after all private activity is removed. In the initial years of implementation, the costs will actually be quite modest, primarily arising in relation to additional expenditure on consultant pay. This would amount to around €12 million if recruitment targets are met. An additional public activity which would be caused by the recruitment of these public-only consultants would cost a maximum of €40 million per annum.

One matter which is important to highlight is the effect these recommendations would have on the capacity of our public acute hospitals. We believe that the vast majority of patients being treated privately in public hospitals will become public patients under our future arrangements. This is because they are in a public hospital as emergency patients or they require complex care or multidisciplinary services, or maternity services where there is no equivalent services provided within easy reach in the private sector.

In our report, we also advised the Department of Health should examine the clinical indemnity scheme to ensure that there is a level playing field in relation to the clinical indemnity between private work carried out in public and private hospitals. This would address the situation where consultants conducting private work in public hospitals currently do not have to make any contribution towards their indemnity insurance for their private work. We have been careful to develop our recommendations in a way that ensures there is no shock to the system. While the policy change can be commenced quickly, the effects will happen incremental over time. While it will take ten years to fully remove private activity, significant progress can be made relatively quickly. Also, implementing these recommendations over the lifetime of the Sláintecare programme makes it more affordable and ensures that they happen in parallel with improved care models, better availability of diagnostics, and improvements in primary and community care that will be necessary to ensure the successful implementation of the proposal.

There will be little immediate effect for those who rely on private health insurance. People will still be able to use their insurance should they wish to, but over time, our public hospital system will be better able to provide services for all public patients, and people will have less need to take out health insurance. People will still be able to access services in private hospitals with their private health insurance should they wish. Our recommendations represent a significant part of the Sláintecare programme of reform and map out a small number of policy actions which can be taken which would see the change implemented progressively in parallel with the wider health service improvements already under way in Sláintecare. The costs are phased in a way that makes the change affordable. Thank you, Chairman.

Thank you very much, Dr. de Buitléir. We will open the meeting to our members, and our first contributor is Deputy Stephen Donnelly.

I thank Dr. Keegan and Dr. de Buitléir for their time and for all of the very extensive work they and their teams have done in producing the ESRI report and what is called it the de Buitléir report. Who needs a formal title on it? We all know it as the de Buitléir report.

Can I ask Dr. de Buitléir about one of the things that is not recommended, maybe because it is so glaringly obvious it should not have needed recommendation? If we are going to move to a world where we do not have private practice in public hospitals, which is something I and Fianna Fáil support, we should not build new private facilities into new public hospitals. Maybe it is just assumed that we would not do that if we are all signed up to removing private care. However, as it happens, the Government is building dedicated private facilities into the new national children's hospital, and it is building very substantial private facilities - physically separate facilities - into the new National Maternity Hospital, which are both public hospitals and both built with public money.

There is a line in the report which says the Government should send a clear signal that at some future date private activity will no longer be permitted in public hospitals. It is not one of the key recommendations, but maybe because it is the kind of thing that one should not really have to recommend. Does Dr. de Buitléir believe there is any issue with dedicated, private facilities being built into the new children's hospital and the new maternity hospital in a world where we are trying to take private care out of public hospitals?

Dr. Donal de Buitléir

We were not asked to look at that. The terms of reference were pretty tight. We had enough complicated issues to address not to mention taking on ones that we were not asked to look at. As a committee, we do not have a particular view on that. It would strike me that if one has no private practice in public hospitals, within ten years, it would be recommended that these facilities would have to be used for something else at the end of ten years.

Let us hope so. It strikes me as an extraordinary up yours to Sláintecare - not by Dr. de Buitléir, obviously- by the Government to build physical private facilities in at a time when it says it is taking them out. Dr. de Buitléir referenced in his report and in his opening statement the idea that the vast majority of private care in public hospitals is coming from patients who have come through the emergency department, and one could argue, therefore, that removing those insurance payments is like saying there is no such thing as a private patient in a public hospital anymore. One is coming in as a public patient. If we are running a hospital, in essence all that would happen is that virtually the same number of patients would come in. We would have to provide the same level of care to the same number of patients more or less, but we would have substantially less money to do it. Obviously, we have to square that circle because we want to take the private care out of the public hospitals. Is that a reasonable reflection of the current situation?

Dr. Donal de Buitléir

One of the things we were concerned to clarify was what I thought was implicit at the Sláintecare Oireachtas committee, that is, that many of these patients would decamp to private hospitals and there would be a substantial increase in capacity for public patients. Nobody knows the answer to that; it is a judgment call. We took a view that that might be a very optimistic assumption, and that it was likely if I ended up in an emergency department that I would probably stay there, in that I would not be transferred. There might be some transfer. If people accepted this proposal on the basis that it would free up a lot of capacity in public hospitals for public patients, that assumption might not be realised, and we were anxious to point out that when we embark on this policy proposal, it is not based on an assumption that would be unachievable and that would lead to disappointment. It was a judgment call. Some people will transfer, but my opinion and that of my colleagues is that there will not be a wholesale transfer.

It seems from the report that removing private care from public hospitals on the basis that people are still going in through the emergency department is not going to free up capacity. One is going to have the same number of patients in the hospital, but one has less money to treat them. One could argue that it is going to reduce capacity.

Dr. Donal de Buitléir

Yes, from an Exchequer point of view, there will be less money if people are no longer being charged, that is, the 50% of people who have private health insurance. At the moment, insurance companies pay out I think €2.5 billion. If they do not give €500 million to public hospitals, they only pay out €2 billion. Insurance premia should fall. The tax relief on the insurance premia will fall. From an Exchequer point of view, there is an effect, but from the point of view of the people out there, they are just paying for it in a different way.

I would like to ask Dr. Keegan a question. One of the things I think this comes down to, from a financial perspective, is that we have bought into the principle, but we have to pay for the principle. Does Dr. Keegan have a sense as to whether public hospitals, when they charge insurance companies for private work, fully recoup the costs with a bit of a margin? Do they recoup less than the costs? In other words, if one is running a hospital, and let us say 10% of one's patients are private patients, from the money one gets from them, is one covering the costs and does one have a little bit extra to spend on the public system, or is one losing a bit and having to subsidise private work with the public budget?

Dr. Conor Keegan

Our work did not look at costs. It was more focused on activity than on the cost or expenditure implications. There has been a move in terms of unwinding the subsidisation for private insurers in the system in the last number of years. One is capping tax relief, another has been the charging of-----

Sorry, I just do not want to get lost in the detail. Maybe Dr. de Buitléir knows. Does private work subsidise cover its costs?

Dr. Conor Keegan

There has been a closer charging of the true economic costs to insurers for the work they have placed in public hospitals in recent years.

In regard to true economic costs, in cash terms, if I am running a hospital, and I am treating private patients, are their insurance companies fully covering the costs of that treatment?

Dr. Conor Keegan

That would be more a question for the insurance companies, especially hospital managers. It is not something we looked at.

I am not sure one would get a perfectly straight answer from the insurance companies. Does Dr. de Buitléir have a view?

Dr. Donal de Buitléir

The Department of Health, I gather, does an exercise. I have not seen the exercise.

Okay. It is pretty important.

Dr. Donal de Buitléir

Somebody knows, but I do not know.

Okay. If we are talking about funding the removal of private care, it is pretty important whether or not we know if that private care is covering its costs right now. What we could be doing, if the public system is getting the costs plus a margin, is stripping more money out of the public system, which the Exchequer's going to have to cough up for. Neither Dr. Keegan nor Dr. de Buitléir know.

Much of Dr. de Buitléir's report focuses on changing the consultant contract, and we have an unusual consultant contract in Ireland which allows for this. Just on a point of clarification, the new Sláintecare consultant contract essentially would disallow private work in the public hospitals, but would it allow consultants do private work in private hospitals? Could they do four days a week in a HSE hospital and then do Friday, Saturday or Sunday in a private hospital?

Dr. Donal de Buitléir

One hospital manager gave evidence to us. As long as they fulfil their public commitments, what they do in their spare time, whether they play golf or do something - teachers do grinds - was not something we were concerned about. What we are concerned about, and what is going to be critical in this, is the negotiation of a new contract with flexible rostering - a proper consultant contract that would apply to most public servants, that they fulfil the requirements of the job on a full-time basis. That is really where we are.

Yes. Would Dr. de Buitléir be recommending flexibility within those contracts? Would he be recommending a contract where a consultant can say he or she wants to sign up to three days a week in the HSE, leaving him or her with other time?

Dr. Donal de Buitléir

That is clearly an option. One of the things that needs to be watched in doing that is that any contract arrangements are enforced and managed properly, and there was some evidence in the past that the contract was not fully enforced by hospital management.

Yes, there needs to be monitoring. Would Dr. de Buitléir be okay about a contract that says one can work one to five days in the public system and fill one's boots with whatever one wants to do in one's spare time?

Dr. Donal de Buitléir

One of the things I thought was quite interesting when I looked at the demographics of consultants is that it used to be virtually an all-male profession. It is now much more representative of society and more people require more flexible working arrangements and the heath system has to accommodate that like everybody else.

Dr. Donal de Buitléir

Yes.

More flexibility.

One of the things the report talks about is a payment to consultants to encourage them to move to the new contract and potentially looking at the salary levels to account for the fact they would not be doing private work. However, there is a wide variance in how much money one can make in private practice versus public work, depending on specialty. My understanding is that in emergency medicine, psychiatry, and other areas, there are very few private opportunities, but that in orthopaedics, plastics and other areas, one can make quite a lot of money. Has Dr. de Buitléir given any consideration to how one would treat specialties differently, depending on the opportunity cost, or would he do a blanket contract across the consultant body?

Dr. Donal de Buitléir

I think all options are possible. Deputy Donnelly is right that if one gets a distribution of private earnings, it is quite skewed. Some people have relatively little. What we were keen to get was a critical mass of consultants onto this new contract, so that if one gets the bottom half of the distribution of private earnings to switch, one gets a significant number in the new contract. Some people would find it very unattractive and might never want to give up their rights, which is why the ten-year legislation piece is quite important. One is giving people ten years' notice.

Sure.

Coming back to the core principle, underlying the Sláintecare report - I think Dr. de Buitléir mentioned it today and it is in the report - is a belief that removing private patients from public hospitals will lead to an increase in capacity for public patients. On the basis that most of the private patients are still going to come into the public hospital, that assumption is probably untrue.

Dr. Donal de Buitléir

We were very conservative of the-----.

That is okay. I ask Dr. de Buitléir to bear with me for a second. The first reason for doing it is that it will free up capacity in the public hospitals. The data would suggest that that is probably not true. The second reason for doing it is that it might free up financial resources, but if we do not know if private is subsidising or being subsidised by the public budgets, we do not know whether or not that is true. There is an ideological reason. None of us would stand over a situation where private patients jump the queue and get special treatment in public hospitals. The ideological or principled statement still holds very strongly but the mechanics, the rationale and the improvements in the system do not. Those arguments do not appear to hold, according to the report.

There is one other possibility, which concerns what this does to work within the hospitals. For example, if any group of people end up making much more money by seeing private patients, then some people might have accused some consultants of being encouraged to make sure there were lots of private patients to see and that perhaps, within a given hospital, the same consultant treating patients in a public hospital might spend much more time taking care of their private patients than their public patients. Other than the principle of removing private care, if it is not down to cost then it is not down to capacity, which does not seem to be the case, are there any other actual tangible advantages to doing it? We want to improve the system for public patients. Is anything Dr. de Buitléir can see on a day-to-day basis that, in real healthcare terms, would improve?

I thank Deputy Donnelly. On the answer of this question, we will move on.

Dr. Donal de Buitléir

The key reason for doing this is what the Deputy calls ideological, which is a somewhat pejorative term in some quarters. It is that to me, it seems completely unacceptable that in a public institution, people are treated differently based on their income. For example, my daughter is in primary school. Would anyone think it was sensible if I could pay the teacher extra money to give her special attention in the class compared to other children?

I am agreeing on the principle but my question is whether it will make an actual difference to the public patient.

Dr. Donal de Buitléir

It will also make a difference in that people will access care based on their medical need rather than on their income. At the moment, one of the reasons - insurance companies told us this - people buy insurance is that they perceive that they can get special treatment or jump the queue.

That is true but for that to apply, doing this has to make things better for the public patient. Can Dr. de Buitléir tell the committee how it makes things better?

Dr. Donal de Buitléir

It is better to the extent that private patients jump the queue and when one gets rid of that, the waiting times for public patients will be less.

Dr. de Buitléir believes it will bring the waiting times down. That is fine.

Dr. Donal de Buitléir

I am not making any comment about how significant that change will be but it is fair to say there will be an improvement.

I thank Dr. de Buitléir and Deputy Donnelly and call Deputy O'Reilly.

I thank the witnesses for their submissions and attendance. On Dr. de Buitléir's reference to "ideological" being a pejorative term, it is not in my house. It never was and I pride myself on consistency in that.

On the notion of private facilities within the confines of public facilities, I have a serious concern that although we are saying we want to remove private health care from the public system, which is good and laudable and there is cross-party support for Sláintecare on the one hand, we can see two big facilities being built into which private care will be stacked on the other. My fear is that if those consulting rooms and facilities were not available to private patients, they would be available for public patients and therefore would have an impact on the waiting lists.

Perhaps this question is for Mr. Keegan because he outlined that while he did not have access to comparable routinely collected administrative data in private hospitals, he could collect some of it. My difficulty is that does not give us the total cost. We have asked the HSE repeatedly the cost to the public system of effectively subsidising private healthcare. It is very difficult to put a money amount on it. We previously have had people in here from the HSE who described to us what they called stretch income targets that are set for them, whereby they must collect a certain amount of money back from private health insurance. This creates a perverse incentive. I have never been able to see a definitive cost put on private healthcare. We know the impacts on the waiting lists because clearly it will be public patients who will benefit from the availability of additional capacity. On the actual cost, I refer to when a private patient is treated and where he or she skips the queue. If two people with the same level of acuity happen to be in the accident and emergency unit - one with private health insurance and the other without - in my estimation, in all likelihood the person with private health insurance would be admitted in that instance. If that person has already been in the accident and emergency unit, one cannot quantify the actual cost to the public system and the subsidy that is provided to the private system or am I wrong in that assumption? Can it be quantified if so, how much is it?

Dr. Conor Keegan

Within the public system now, for all discharges whether they are public or private, the hospital in-patient enquiry, HIPE, scheme collects information on expenditure and the cost to the hospital. There is activity-based funding now whereby there is a unit cost of care and for each discharge, there will be a complexity-associated score for that discharge. One will also have information as to whether that discharge is public or private. That captures the cost to the hospital. For public patients, it will capture things like salary and consultant costs, nursing costs, non-pay costs and so forth. For the private discharges, it will just capture the cost to the hospital and there would be no consultant costs included, which are paid separately by the insurer.

One could get an idea there of the expenditure but returning to Deputy Donnelly's point, the question is whether the income coming from the insurers actually covers that. That is an issue that unfortunately we currently cannot get at.

I suspect it does not but we have no way of knowing. This pokes a hole in the argument that we will fall off the edge of a cliff if that income is taken away. The full extent of that income is not known because the level of subsidy cannot be identified. This is a problem.

As for this State being an outlier, are there other examples from well-developed countries of people doing what we do in respect of the mix of private and public patients? Internationally speaking, is the model we operate with its mix of public and private patients an outlier?

Dr. Donal de Buitléir

In the OECD work we have commissioned, which I do not have in front of me, all of the data are there. We are a clear outlier.

We are out of step with everybody.

Dr. Donal de Buitléir

Not everybody has a pure system but we are unusual.

When the group's report was published, there was some concerned talk. I note and thank Dr. de Buitléir for moving very quickly to draw a line under the argument that we cannot afford this. Ultimately, this is going to be a gradual phasing-out and is not intended to be a falling off the cliff. Can Dr. de Buitléir describe to the committee how this will roll out over the ten years?

Dr. Donal de Buitléir

The key to it is that an early decision needs to be made whereby we stop issuing contracts for new people that allow private work in public hospitals. We need to pay people properly to do proper public service. That is going to have to be done anyway, because the emergency salary cuts are going to be restored and we should get some value for that.

Moreover, the €524 million that insurance companies pay hospitals is very unstable income. There is a lot of talk about ephemeral corporation tax revenue but this is another element here. If we do nothing and maintain the existing system, that money will drift away in any event. People are waking up to the fact that when they are given this form in the emergency department, their treatment does not really change. They may get slightly more attention from the private consultant but effectively, they are paying for something they get for nothing anyway. This is putting up the cost of their insurance premia and the insurance companies are waging a very effective campaign to draw this to people's attention and this money collected is falling.

The question is how far will it fall. I would not bet on this money continuing to be available. People say our proposal would cost €650 million, but if we maintain the existing system, we will have a lot of these costs. It could be phased. I pride myself on being somebody who is very concerned. I have spent 40 years looking at the public finances. I started in Revenue and we would not want to do anything stupid that would actually wreck the system. I am satisfied that if we were to do this in an orderly and progressive way, it could be afforded. It is a question of whether we want to do it. How important is it and how important is the principle that people should be treated equally in the public system?

Dr. de Buitléir is 100% right. It comes down to having the will to do it.

Dr. Donal de Buitléir

When Sláintecare came from the Oireachtas committee, one of the concerns was if there could be unintended consequences. We were asked if it could be done. I am satisfied, as are my colleagues who contributed hugely to the preparations for the report, that if we want to do it, it can be done. The question we have to ask ourselves as a society is if do we want to do it.

Dr. Donal de Buitléir

Technically, it is feasible.

That is the key. I was a member of the Committee on the Future of Healthcare and shall hold my hands up that I was not enthusiastic about the review. I will be straight. I believed it could be done. I am glad, however, that the review has happened because it means that we have a report to which we can point that backs up what some of us on the committee said. It also gives those who might have had doubts comfort that it could be done. What we need is a step change in political will.

The issue of monitoring of the consultants' contract comes up again and again. It is hard to blame the consultants if no one is monitoring their contracts. They are not going to do it themselves. On the slippage between public and private practice, Dr. de Buitléir said: "The HSE needs to ensure that this does not happen, so the agreed monitoring and reporting system to robustly monitor and enforce the existing consultant contract must be implemented." Is it being implemented to any great extent?

Dr. Donal de Buitléir

If the Deputy recalls, after the "Prime Time" programme that pointed to certain consultants exceeding their private practice rights, a new system was put in place. We finished the report last February. A new system had been put in place and we said it was important that it worked and that an eye had to be kept on it.

But it had not been monitored in the run-up to it.

Dr. Donal de Buitléir

I would not necessarily assume there was no monitoring across the system - I do not know - but clearly there were cases where it was not effective.

If one talks to the consultants, they have a view on the matter also.

Dr. Donal de Buitléir

One of the things that came out of it was that there were perverse incentives for hospital managers to generate income from private practice. They were asked to do two opposite things. Some of them were under huge pressure to generate income from private practice.

That is exactly to what I was referring in talking about the stretch income targets: "This is how much private practice income you are getting and we now want you to accelerate it." It is extremely difficult for a hospital manager to operate within those constraints.

Dr. Donal de Buitléir

I agree.

What I take away from the report is that it is possible. Without an increase in capacity and staff, waiting lists will not improve, but the changes would lead to an improvement for public patients to an extent because the system would not include people who were being fast-tracked on the same road beside them. Ultimately, as Dr. de Buitléir said, it comes down to whether there is the political will to do it. I thank Dr. de Buitléir for the report because it goes a long way towards us being able to encourage our colleagues to come along with us.

I welcome the two delegates. I am fully supportive of the report which is an excellent piece of work. Like the previous speaker, I sat on the Committee on the Future of Healthcare for 11 months. It is welcome that the report endorses the journey we were on.

This is totally doable. It is really about ideology. It is a "will we", not a "can we", question. It is welcome that the Minister for Health has said he wants to do it and I hope his colleagues agree with him. Tying it into the Sláintecare timeline is completely achievable.

I have some questions about how we will do it, rather than if we do it. Where I come from we are 100% in favour of doing it. It is a core belief of my party. In his opening statement Dr. de Buitléir said, "significant progress can be made relatively quickly." What are the three or four steps a Government should take? The cost of this measure would be cumulative over a number of years. While they do not all have to be financial, some of them will have to be and obviously there may be an immediate impact. What are the three or four immediate steps Dr de Buitléir believes the Government should take to implement it?

Dr. Donal de Buitléir

I would, first, like to see the legislation, with signals for ten-year implementation.

Dr. Donal de Buitléir

Yes, that in ten years' time there will be none of this. The most important thing is that new consultant appointments should be made under the Sláintecare contract. That would mean restoring pay and having new contracts for new consultants. It is critical that this be done early. The longer we continue to issue the existing contract we are pushing up costs because we would have to buy them out. If consultants are given contracts and we then want them to change to something else, they will have to be bought out. It is a normal rule of life that if one is in a hole, one stops digging and making the problem bigger. With the legislation and getting the newer consultants onto the Sláintecare contract, the third piece would be getting into negotiations on the contract change payment. We did not put a number on it because it would be a matter for negotiation or judgment. The negotiations would try to get a reasonable number of the 3,000 consultants working under the existing arrangements onto the new ones. They are the three things I would do early.

I thank Dr. de Buitléir and agree with him. In my next question I am asking for his personal opinion. I am aware that the terms of reference have been defined. I am a huge supporter of the national maternity strategy, but it is way behind. We are all aware of the issues surrounding the national children's hospital. There will also be other developments. Given that the Government supports it and while not all politicians will support it, most will, should we not just block having private facilities in public hospitals or public healthcare facilities under construction? I am probably asking this questin based on what is contained in the report.

Dr. Donal de Buitléir

I am not here to give my personal view, but to represent the committee. What I would say is what I said to Deputy Donnelly who made the same point.

In fairness to the Deputy, he also raised it, but I am moving it on a little.

Dr. Donal de Buitléir

I have not considered why we are doing this-----

It would seem to jar with Dr. de Buitléir's report.

Dr. Donal de Buitléir

All I am saying to the Deputy is what I said to Deputy Donnelly, that is, that if we implement this, those facilities will be redundant in ten years' time. Then the question will be-----

This is a significant moment for the committee. In fairness to the witnesses, the report is excellent, but this was not part of Dr. de Buitléir's terms of reference. The Government has committed to implementing this report, the Minister said he supported it, but now its author, in a personal capacity, has articulated the question: what is the point in having these facilities if we are going to implement this report? They will be redundant. Is there not a significant issue, which many of us have been raising here for a considerable time, with the implementation of the national children's hospital and the national maternity strategy? We can probably pull the latter back because the Government does not have the capital funding to carry out much of it at present, as people in my area know. However, do we need to write to the Minister and the Department of Health about this, based on what we have heard today? Perhaps we should talk about the matter at another point.

I thank Dr. de Buitléir for his responses and his honesty.

Dr. Donal de Buitléir

I gave a personal view-----

I understand that, but personal views are important. We all have personal views.

Dr. Donal de Buitléir

I will give the Deputy personal views-----

We have had the consultants' representatives before the committee. I do not wish to make generalisations because consultants have many different opinions, to which they are entitled, but there will be some opposition to going down the proposed route. Dealing with the pay issue will help considerably. There is significant support for dealing with that issue, recruitment and retention and so on. What other significant opposition will there be from consultants in respect of the implementation of this report? At what points or junctures does Dr. de Buitléir see this opposition?

Dr. Donal de Buitléir

Consultants have concerns-----

Rightly so. I agree with them.

Dr. Donal de Buitléir

-----as to whether we will be able to attract people to work in the public sector for the kinds of realistic public service salaries we are recommending. According at the Revenue income distribution tables, the recommended salaries that would be paid to consultants would put them in the top 0.7% of income earners in Ireland. I think that was the figure when I worked it out. Adding to that the public service pension, these are attractive posts, so it should be possible to recruit people of the requisite standard to do the work in public hospitals. If that turns out not to be the case, we may have to consider adjusting the salary in future to ensure that people can be attracted.

Dr. de Buitléir made a specific point about that.

Dr. Donal de Buitléir

What came up was that-----

Restricted, specialised posts.

Dr. Donal de Buitléir

-----there might be a small number of highly specialised posts, and that it would be possible to recruit people. We came across this system in the third level sector, which is tightly controlled and seems to work. If we have a difficulty with highly specialised posts, a model such as that might address it.

As per my question, we know about the pay issue, but is there any-----

Dr. Donal de Buitléir

By the way, it is also important to point out that it is not just a matter of pay.

I agree. It is also a matter of working conditions.

Dr. Donal de Buitléir

There are a lot of other issues, including working conditions, rostering and administrative support. All that-----

Would it be fair to say that dealing with the new consultants' entry pay levels, specialised posts and so on in tandem with working conditions would have to happen over the timeframe we are discussing?

Dr. Donal de Buitléir

Yes.

Did Dr. de Buitléir come across any other issues besides that? No significant ideological-----

Dr. Donal de Buitléir

I am satisfied that if we want to do this, it is perfectly feasible. The question, which is a question of values in society, is whether we accord sufficient priority to do it.

I know, and I believe it is a small number of people because I have met all the groups. What I am trying to get at, though, is the level of resistance there would be from those who are bringing in quite significant amounts from private practice on top of public contracts. Basically, the pay level Dr. de Buitléir talked about which-----

Dr. Donal de Buitléir

In my judgment, one cannot compel people-----

I accept that.

Dr. Donal de Buitléir

-----to give up their existing contracts, so they can continue.

Deputy Kelly has just one more minute.

I have only one more question. It concerns something I speak about a little and something I was very much taken aback by. Is the move of HIQA into all healthcare settings contingent? As for the jigsaw of sorting this out, does Dr. de Buitléir feel that this is a significant factor? From the point of view of the timeframe, does he feel that doing this, ramping up to it and conditioning it is a significant programme of work?

Dr. Donal de Buitléir

It is desirable that it be done but it does not affect any of the other stuff, frankly.

That is what I wanted to know.

Dr. Donal de Buitléir

That is my view.

Dr. Conor Keegan

An important part of the expansion of HIQA and the proposed licensing Bill that is to come in next year and which some in the Department are examining, is that as the private hospitals become licensed, a condition of that is that they report requisite data and information on a similar basis to the public hospitals to some kind of centralised system.

Dr. Conor Keegan

A huge issue in looking at this and generating evidence-----

Dr. Conor Keegan

-----is the data.

Dumb data in, dumb data out.

Dr. Conor Keegan

That is seriously being considered.

The full collated data are not available.

Dr. Conor Keegan

Yes, exactly.

I thank our witnesses for coming before the committee and for the information they have given. I will ask a couple of questions. First, I know that this may not have been specifically mentioned in Dr. de Buitléir's brief, but to what extent have private patients in the public hospital system tried to jump the queue? Is it happening and, if so, to what extent?

Dr. Donal de Buitléir

The extent to which it happens cannot be quantified, but it was clear from the evidence we received from the insurance companies that the reason 50% of the people in this country take out private health insurance is that they believe they can do that. It is a big selling point for insurance. We asked the question to what extent. We cannot get the data, but the people who have experience of the system experience it in their day-to-day lives. They have a perception that if they do not have private health insurance, they will be disadvantaged in some way.

In the public health system?

Dr. Donal de Buitléir

Yes.

Given that private health insurance is costly, is it not an expensive way of creating an assurance, perhaps not factual, that people can speed up their access through the public health system? We all get replies to parliamentary questions in which we are told that nobody can speed up the process. We do not want the process speeded up; we want it dealt with such that people are not forever moved from the back of the queue to the middle or the front of the queue but moved along the system. I have no ideological hang-ups, good, bad or indifferent. As far as I am concerned, the patient who requires treatment should have access to effective, second-to-none treatment as quickly as possible - and throughout the European Union, for that matter.

I emphasise that we need to get some evidence of that, otherwise large numbers of people will waste their money by providing for something they can get through the private system in any event. It is not clear why those patients are paying through the private system and going through the public system to ensure they can get through the public system quickly. It is an expensive way to go about it and it is a duplication that will cause snarl-ups in the system. Based on the examination of everything that happens in the system, has anything been discovered that we cannot see from our vantage point?

Dr. Donal de Buitléir

In addition to this proposal, there is another element of Sláintecare. The additional capacity is 3,000 beds by 2030 as far as I recall, which may be something the committee teases out in its later session about all the other improvements. This is just one part of a programme to improve the health service for the people. It is an important part of that but it is not the only part. A lot of other things happen. For example, one of the key problems is the availability of diagnostics. Apparently, it is quite slow to get access to diagnostics in the public system but access to diagnostics can be had much more quickly in the private system Dublin. That means a patient can have the evidence of diagnosis more quickly and that puts him or her up the queue because he or she knows what his or her health condition is compared to someone who does not know because they have to wait. That is an important part of the programme to improve the health service.

Dr. Conor Keegan

Another important point is that having private health insurance only allows one to skip the queue for elective care. The vast majority of private care in public hospitals is emergency care. If one is hit by a car for example, it does not matter if one is a private or public patient. One will not jump a queue and will be seen in the same time by the same consultants. The value of holding private health insurance in that context has to be questioned. The benefit of skipping the queue is only seen only for a small proportion of private activity.

We have been instructed to listen carefully to what we have been told over the past 20 years regarding hospital beds. We were told all along that we had too many hospital beds and we did not need them. We were admonished at a high level for spending money on bricks and mortar because it was seen as unnecessary, and different ways were to be found to deal with patients in the future. That did not happen. It now appears we were misinformed by people who should have known better. We have now moved to another scenario. I realise that in the position we find ourselves, conditions in the workplace, insofar as our hospitals are concerned, are not ideal. That is presumably down to overcrowding and the pressure on consultants, staff, doctors, GPs and everybody else. Our system is not large enough to cater for the population, which I understand.

However, how do we compete? We have been told by the HSE that in appointing consultants, we have to compete with New York, Boston, Sydney and London, and if we do not, we will not get the staff. The independent review group held exchanges with the various stakeholders and reference was made to consultants' pay, which was the subject of a considerable increase that will put them among the best paid in the world. There are a couple of other issues we cannot deal with. We cannot offer the 24 hours a day of sunshine they have to offer in Australia. That is a decided disadvantage in attracting high-calibre people to high-calibre positions in this country. Similarly, we cannot compete with Canada and we cannot compete with the weather conditions in many areas, including in the Middle East. Are there issues other than consultants' pay that the independent review group considers might make that sufficient impact? We have asked this question on a number of occasions and we have not been given an answer. What is the total cost of that? Dr. de Buitléir made a stab at that in terms of the millions of euro required on an annual basis, which is hugely important. It would probably result in a cost of approximately €6 billion over a ten-year period. We tried to get that information from some of our guests in recent weeks. They were reluctant to tell us exactly the cost but they should be able to tell us because if there is dissatisfaction with the system as it is, it must be possible for those directly involved to identify what the problem is and to identify that it needs to be addressed.

Dr. Donal de Buitléir

As I said in my statement, and as is stated in the report, while money is an issue, it is not the only issue. Working conditions, rostering and the lack of proper facilities are all pertinent issues. Money is a factor in respect of hygiene in the workplace. It is one aspect but it is not the whole story and the problem will not be solved by just throwing money at it, even though we are going to do that anyway because there is a commitment to unwind the €131,000 annual pay threshold at some stage, although there is debate about the timing.

Dr. de Buitléir said:

Obviously, the implementation of these recommendations gives rise to increases in public expenditure. The additional costs arise mainly from the loss of private income of public hospitals but also in relation to consultant pay - for those taking up the public-only contract - and the increased cost of treating greater numbers of public patients, and we have set out the final costs at the end of ten years and it comes to approximately €650 million per annum.

Dr. Donal de Buitléir

That is correct.

That brings it up fairly close to what I was suggesting.

Dr. Donal de Buitléir

Some press reports said everything will cost €6.5 billion. It will be €650 million at the end of the period. By the way, if things stay as they are, nothing will change and some of these costs will be there anyway because consultants' pay will have to be restored. The money coming from insurance companies is unstable as well. It is similar to corporation tax receipts. It would be foolish to bank on that continuing as permanent income. To say all that is lumped into the cost of this proposal is an exaggeration. A lot of that money will have to be paid out anyway. While there is a cost, the people are already paying for this. This would change the method by which they pay. When I get my annual bill from my health insurance company, which is due next month, I do not regard it is as voluntary. It would be a big risk for me to decide not to have health insurance anymore because one never knows what might happen. If, for example, that was transferred and my premium reduced, I would be content if my taxes went up a little to pay for it. There is an Exchequer cost to this but the Exchequer is not the whole story.

Dr. de Buitléir also made reference to the numbers of temporary staff, locums and agency staff. What is the extent to which he feels that impacts on the efficient delivery of health services? What intervention is required apart from making the staff permanent? I fail to see why that cannot be done.

Dr. Donal de Buitléir

I do not know any more about this than the Deputy does, but it would strike me as reasonable that there would be a better standard of service from somebody who is there all the time, is fully committed to the experience and knows the patients, compared to somebody who is coming into the workplace temporarily. Sometimes locum or agency nurses are in a workplace for one day and they are not there the next day so there is no continuity. The Chairman will be able to better inform us on that than I would but it seems to be fairly obvious.

We noted at our previous meeting that permanent staff take greater ownership and responsibility, although people in temporary positions will resent that view. It is natural, however, that permanent staff will have a certain amount of pride that goes with the job and will try everything possible to ensure they are seen to be doing a good job.

I will allow only one more question. I am sure the Deputy does not want me to give him preferential treatment.

I have waited patiently for a long time, which seems to be my wont. I note there are 380 posts occupied by non-permanent staff and 370 vacancies. How do the 370 vacancies relate to the 380 posts? Are there 380 occupied posts plus 370 vacancies?

Dr. Donal de Buitléir

I got the figures from the Department so they must be right. There is a problem. The Hanly report of 2004, which is very good and well worth returning to, recommended doubling the number of consultants and halving the number of non-consultant hospital doctors. We have not done that. Perhaps we should look at that recommendation again.

The recommendation was that consultants should deliver services rather than having a consultant-led service.

Dr. Donal de Buitléir

The report is very good and still relevant.

I will conclude momentarily because I have to go to the Dáil Chamber for questions.

I thank Dr. de Buitléir and Dr. Keegan for their presentations and the work they have done in this area.

I am concerned about some of the myths that abound. The review group's report shows that since 2009 the total number of doctors, including junior doctors, has increased from slightly over 7,000 to more than 9,400, an increase of 33% increase. In the same period, the number of consultants increased by more than 1,000. The number of consultants has, therefore, increased by approximately one third. I agree with what Dr. de Buitléir said about the excellent Hanly report. Many of Hanly's recommendations need to be implemented much faster.

This morning we discussed the idea of private practice being take out of the public hospital system. I have no problem with that idea. The number of outpatient appointments in public hospitals stands at approximately 3.5 million per annum. As such, around 63,000 people attend outpatient appointments each week. The review group's report states that 1,333 consultants have access to private rooms on site only and 600 consultants have access to rooms off-site in private hospitals and clinics. This means nearly 2,000 of more than 3,000 consultants do some form of private practice. Let us take a consultant employed in the public system who also sees 20 patients a week privately. If we average that figure over 2,000 consultants, it equals 40,000 appointments per week. Taken over 52 weeks, we have 2 million appointments per annum. Could the public system with its current structure absorb an extra 2 million outpatient appointments?

Dr. Donal de Buitléir

I am not sure I follow the Senator.

At present, 2,000 consultants do some form of private practice. They do private work either on-site in private rooms in hospitals or off-site in private rooms. I calculate that there are approximately 40,000 private outpatient appointments per week. If private work was removed from the public hospital system, in other words, consultant were not allowed to do any kind of private work, we would have an extra-----

Dr. Donal de Buitléir

Presumably, the consultants still work full-time in the public hospital.

If consultants work their full 39 hours in a public hospital, where is the scope?

Dr. Donal de Buitléir

Some of the 39 hours is spent doing private work.

Not necessarily.

Dr. Donal de Buitléir

I think the figure is 20%.

That still does not take into account the figures I have mentioned. If all private work is removed, the number of consultants will have to be dramatically increased. I am not convinced that the public system could absorb an extra 2 million outpatient appointments.

Dr. Conor Keegan

The public system cannot currently deal with the demand for public outpatient appointments. That is evident in waiting lists and so forth.

Dr. Conor Keegan

The review group states in its report that the removal of private practice from public hospitals would not be a magic bullet. It has to be done in the context of increasing public capacity now to deal with current undercapacity. We know from previous work we have done in the ESRI that there will be a significant increase in demand for outpatient appointments.

Dr. Conor Keegan

There will also be a significant increase in demand for inpatient bed days in public hospitals. The removal of private practice from public hospitals must be done within a broader set of objectives to increase public bed capacity in public hospitals and increase public infrastructure to bring down waiting lists.

Dr. Keegan has agreed with my point that the infrastructure is not currently in place in the HSE to absorb an extra 2 million outpatient appointments a year.

Dr. Conor Keegan

Based on waiting list figures, that does not appear to be the case.

How should that issue be dealt with over the next ten years? I have given a very conservative calculation. If consultants can no longer do private work of any description, either outside or inside hospitals, there will be an extra 2 million outpatient appointments. How do we now work towards creating capacity for that?

Dr. Donal de Buitléir

I am not sure I follow the Senator. The existing cohort of consultants sees patients both privately and publicly in public hospitals. If one waved a magic wand and insisted that consultants had to see everybody equally, the capacity of the system would not change. I cannot see where the Senator gets the figure of 2 million extra appointments.

The 2 million people are already being seen privately.

Dr. Donal de Buitléir

They are being seen during working hours in public hospitals.

No. The figures show that many private consultations take place outside of the hours that are done in hospitals. I ask Dr. de Buitléir to look at the figures for off-site consultations by consultants who have public contracts but also do private work outside of the hospital. If he adds up the figures, he will find that consultants see 2 million outpatients privately. What could happen is that private practice that is totally disconnected from the HSE could develop further.

I understand the new contract allows doctors to do private work but not outside the hospital. In other words, consultants cannot go off-site at any stage. The current contract is for 39 hours per week. If a consultant wants to do extra hours but is not allowed to do these in the hospital, it reduces the amount of work that he or she can do. Does Dr. de Buitléir agree?

Dr. Donal de Buitléir

Is the Senator referring to the current type B contract?

Yes. Consultants are not entitled to work off-site and are confined to working within the hospital structure. They are restricted in that they may not do any additional work other than what they can do within the hospital.

Dr. Donal de Buitléir

We need a new contract. That is what we are recommending.

Dr. Donal de Buitléir

I think the existing contract is something we should get away from as soon as we can. People who are working full-time are contracted to fulfil their obligations to public patients. Like teachers or other people, what they do in their spare time is a matter for them.

The contract does not allow them to do that.

Dr. Donal de Buitléir

I am not talking about the existing contract. I am talking about the new contract. We need a new contract.

I am concerned that if a new contract is agreed, we will see a recurrence of exactly what occurred previously when people who were supposed to be on site were not on site when they should have been. That was the issue.

Dr. Donal de Buitléir

If people sign new contracts that require them to spend a certain number of hours in the public system, the management of that system must ensure they comply with those contracts, just as every other civil servant complies with his or her contract. When I was a civil servant, I could not skive off in the afternoon to run my private business. It had to be managed.

The problem is that working as a doctor is a little different from working as a public servant. A doctor with a 39-hour contract will have other duties on top of that. In some cases, consultants are on call every second, third or fourth night. They may be on call every second or third weekend. It is not just about the 39-hour element of the contract. It is also about the on-call element of the contract. Is Dr. de Buitléir suggesting that the on-call element should be done away with? Does he believe people should be permanently in the hospital regardless of whether there is work to be done?

Dr. Donal de Buitléir

I am suggesting that we get to a system where people who are essentially public servants comply fully with their public service obligations like all other public servants do. They are not special. They are neither better nor worse. Such a system must be managed and its terms must be enforced. In my view, there is no reason this cannot be done. I cannot understand why it cannot be done. It applies right across the board to everybody else.

I accept what Dr. de Buitléir is saying. I will mention as an example the case of someone who wants to do research, is unable to do it within the HSE structure, but is able to do it in connection with a third party. Under his or her contract, he or she might be restricted from doing the research. One of the big complaints we hear from many consultants is that they are not given an opportunity to do research to help to develop further the care they can provide. That is a simple example of what I am talking about. In this case, the off-site work that they are not allowed to do is research and development work.

Dr. Donal de Buitléir

We have engaged in pretty extensive consultation with a range of interested parties, but the issue mentioned by the Senator has never been raised by consultants or anybody else. I am surprised that it is an issue. If it was a critical issue, it would have been raised with us. It is not in any of the submissions, as far as I recall. It was not raised at any of the public meetings. It did not come up when we met hospital managers. I am not saying it is not an issue.

I will give an example from Cork. Twelve consultants have left CUH to work privately. One of the reasons they chose to walk away from the salaries they were getting, and to go working privately, is that they believed they were unable to do things they were good at. They felt that working privately would give them the freedom to do such things. Twelve very good consultants have left the system in Cork.

Dr. Donal de Buitléir

When we visited CUH, we were very impressed by the work being done there. Frankly, we were not told there was an issue in attracting sufficient numbers of consultants in that facility.

All I am saying is that 12 consultants have left and have gone into private practice only. One of the challenges in the present system is that consultants who want to do a lot of work in addition to what is provided for in the contract are unable to do that under the HSE structure. I am not sure whether we can develop the system sufficiently quickly to recruit people while retaining the people we have.

I thank Dr. Keegan and Dr. de Buitléir. I would like to make some comments. Most members of the joint committee sat on the Committee on the Future of Healthcare, which produced the Sláintecare report. The fundamental principle we were trying to introduce as part of the efforts to move private practice out of public hospitals was that preferential treatment would not be given to patients with private health insurance. It was suggested as a strategy that there should be a common waiting list for private or public patients with no preferential treatment. The idea was that people should be treated on the basis of need and not on the basis of whether they are insured.

When we looked at other countries, we learned that Ireland is an outlier in this regard. In other countries where there is private health insurance, supplementary insurance gives people additional access to services but not additional access to public services. In France, for example, one can have top-up insurance if one wishes. It allows one to access private facilities, but it does not give one any preferential treatment in the public system. Everybody in Ireland is essentially entitled to free public care in a public hospital, regardless of insurance status, with the caveat of paying €800 a year, or €80 a day for ten days. If someone with private health insurance ends up in a public hospital, that is bonanza money for the hospital. It is almost an accident that the person who has ended up in the public hospital has health insurance. The perverse incentive that arises in these circumstances has been outlined. The hospital wants to maximise the insurance income and the insurance company wants to minimise the amount of money it pays out. In fact, it is accidental money that comes in the door of the hospital, most likely through accident and emergency admissions.

It must be impossible to police the 20% private work that is allowed in a type B contract. If there are not many private hospitals in an area, as is the case in the mid-west, the percentage of people with private health insurance who are treated in the hospital can increase to 40%. We cannot refuse people treatment because they have private health insurance. We have to look after them.

If there is to be a public-only contract, medical indemnity insurance will cover public-only contract work. My understanding is that if one has a type B contract, a proportion of one's medical indemnity insurance is not covered through the public purse. I presume that consultants with public contracts who choose to do private work outside their 39-hour contracts will have to take out additional medical indemnity insurance to cover their private work. At the moment, they are probably getting an advantage because their public-paid medical indemnity insurance is covering much of their private practice.

We have discussed the cost of inpatient cover. A substantial amount of private practice takes place in our public hospitals. Private facilities are used for diagnostics. A consultant who carries out a private clinic in a public hospital has access to all the public facilities to carry out his diagnostic tests and his follow-up work, at no cost to the insurance company and at no cost to himself as a practitioner. I ask Dr. Keegan and Dr. de Buitléir to comment on that.

We discussed the provision of elective-only hospitals in the context of Sláintecare. As a result of capacity constraints, most people who are admitted to hospital come through accident and emergency departments. This involves urgent work. Elective work is being pushed out of public hospitals because they do not have the capacity to cope. Most of the work that is being carried out in public hospitals now is emergency care, urgent cancer care or perhaps some elective day-care procedures. More and more, the work in our public hospitals is urgent work. Unless we provide elective-only hospitals, we will never clear our waiting lists for elective work. I ask the witnesses to comment on these issues.

Dr. Donal de Buitléir

I agree with the Chairman's perfect analysis.

I have no argument at all. It is a very good analysis of where we are.

I come from a discipline in which there is no discrimination between public and private patients. People come in the same door, sit in the same waiting room and are seen by appointment. It is a different system. We have created a system which is a little like Brexit. Once someone becomes entangled in a system, it is difficult to disentangle him or her from it, even though that is the right thing to do. Does Dr. de Buitléir see the introduction of a public-only contract as the first step in the disentanglement?

Dr. Donal de Buitléir

That is what I would do first. If someone said I was dictator for a day and could do one thing, that would be it.

According to the report, there are eight types of consultant contract dating back to 1991. What Dr. de Buitléir is proposing is that in the public system, there be one contract type, namely, a public-only contract, and that if someone wished to practise private medicine, he or she would do it outside his or her public hours or as a private-only consultant.

Dr. Donal de Buitléir

That is right.

I thank Dr. Buitléir. I call Deputy O'Connell. We will then go around again.

I apologise for being late. I had another meeting which went on.

I sat on the Sláintecare committee. Although this issue was part of it, I felt it was ideological in terms of the proposals for how it should be done. I get what Dr. de Buitléir is saying in that staff numbers are the same, as is the number of sick people who require care. His response to Senator Colm Burke was that it was just about moving people to receive treatment in the public system.

On the 39-hour contract, the lack of autonomy is an issue for consultants. I am not sure if the research and development element is an issue in the context of the 39-hour week. Obviously, their contracts would have to have on-call and other activities sewn into them. On restricting someone at the top of his or her game professionally to a 40-hour week, is it anyone's business if they want to work 15 hours somewhere else? I am not saying they should or should not, but I wonder if this is the way to bring the profession with us.

We have heard in the last couple of sittings of the committee that there is a very significant draw from the public into the private sector. Senator Colm Burke referenced the situation in Cork where 12 or 14 consultants have left Cork University Hospital to move to the Bon Secours Hospital. A number of dermatologists have left Beaumont Hospital, while an emergency department consultant recently left Tallaght Hospital to move to the Beacon Hospital. With this in front of us, how do we pull them back? Is the stick rather than the carrot approach the way to do it? No amount of discussion here will make a consultant return from a private hospital to the public system. With all the ideology in the world, we still need consultants to deliver care. I am not sure how what is in front of me shows that is possible.

I refer to the figure of €650 million a year and Dr. de Buitléir saying it is going up to that amount. I sat on the Sláintecare committee and get that it is building up to that amount. Every year there is an increase in the health budget and the money seems to be absorbed into a bottomless pit. My concern is that the €650 million will be layered constantly into the overall budget with no improvements in service in return. It might be €250 million one year and then €650 million, but I cannot see how we can show that money will improve services to the extent that it will encourage people to stop paying for private health insurance because they are happy with the public system. Am I wrong in saying that?

Dr. Donal de Buitléir

Trying to step back from it, our instruction was there was cross-party agreement that private medicine should be taken out of the public system. There was a concern that the Oireachtas committee or someone else might have missed something and we were asked if it could be done in a way that was achievable. I had four very helpful colleagues who made a significant contribution to this work and our considered view is that it can be done. As such, it is now a matter for the political system. It is a question of values and whether one believes it is proper that people in a public institution should be treated equally, regardless of their ability to pay. That is a question for the political system. I remember when equal pay was introduced in 1974, some said we could not afford it, but it is a question of values. There are some issues where one either believes something or one does not. If one believes it and wants to make the change, my committee was able to establish that it could be done, albeit there would be a price. It is up to the political system to decide, in the face of competing priorities, whether achieving the goal of equal treatment in a public institution is worth it. That is a deeply political question.

I believe people should be treated equally but belief does not produce consultants. We can have political ideology and all of that, but beliefs and thoughts do not produce consultants and deliver better services.

Dr. Donal de Buitléir

I accept that, but if one looks at the report, significant pay increases are recommended to attract new consultants. A salary of €131,000 is not sufficient. If one goes to €182,000 and we find in the light of experience that it is not enough, a future public service pay commission will have to look at it. We have to pay people the salaries that attract them. For example, it was found recently in respect of two critical posts, namely, chief executive of the HSE and Garda Commissioner, that the initial salary offered was insufficient. It was, therefore, adjusted. That is what we have to do. I am not pretending that we have all of the answers, but if we want to have a decent health service, we will have to pay people properly to deliver it. By the way, there are very few of these people. There are 3,000 consultants in a population of 4.5 million and half their pay comes back in tax. The incremental cost of paying people properly to deliver a public service is a rounding error.

The proliferation in the private hospital sector has been apparent in recent years with the opening of emergency department services during the day and so on. We are well aware of the power of lobbying and large corporations in the private sector. That will always occur. Can we win the battle? Are those of us who want to deliver a uniform service to which everyone will have equal access based on need rather than ability to pay fighting a battle we cannot win? Major investors who have invested huge money to siphon off the bread and butter operations and elective surgeries - the handy stuff - have shareholders who want to achieve a return on their investment. We are on the other side seeking to deliver healthcare services. How do we avoid losing out to them? Does Dr. de Buitléir envisage that the larger private hospitals, the names of which we all know, will only be offering cosmetic surgery and bits and bobs in ten years' time? What does he see as the future for them? How will standards in the public service increase while the corporations move away?

Dr. Donal de Buitléir

The private system may or may not develop depending on demand. It could get bigger having extended its services. God only knows what it will do.

There is nothing intrinsically wrong with having a high-performing public sector and a vibrant private sector. My experience from the education system is that, in my view, we have a good national school system but we still have some private schools.

We do not have many private national schools. We have a few.

Dr. Donal de Buitléir

We have some but it is not the number; it is the principle. It is there to some degree in secondary education. There is no dichotomy between having a high-performing-----

Does Dr. de Buitléir believe they can both have a symbiotic relationship?

Dr. Donal de Buitléir

For example, if the public had confidence in a high-performing public system, my guess as outlined in the appendix of the report is that the market for private health insurance might decline. We are a complete outlier where 50% of people think they have to have private health insurance, some of which is for non-advanced plans that only apply in a public hospital. That market would decline. An international benchmark of about 15% would be typical. We can get a high-performing public system with the Sláintecare programme and the private system can go off and supplement that or compete with it.

It can operate by itself. On the fallout from private hospitals, maybe this is a question for Dr. Keegan but there is anecdotal evidence that it has emerged that some treatments are being done in private hospitals, especially in the field of elective cosmetic surgery, and then the sick person is ending up in the public system. If the damage is done in a private hospital and then the patient arrives into the public hospital, is there any recourse for the public system in cleaning up the mess it has had nothing to do with publicly? The patient is obviously a public patient at this point but how does the public system manage the fallout from possibly unnecessary operations when it has plenty of people who require necessary and urgent operations? I have seen an emergence of people being admitted from elective cosmetic surgeries recently. How do we deal with that situation where the likes of St. James's Hospital ends up with a person who has undergone a botched procedure? Do we bill them?

Dr. Conor Keegan

As the Deputy said, this is anecdotal so in order to understand the extent of that we must come back to my point about the need to have data on the activity in private and public hospitals in comparison to each other. Without that, we cannot really understand if something is happening in the private hospital system that is then becoming a burden or a cost in the public system. It is only anecdotal at the moment. To flesh that out and really get an understanding of the relationships between the private system and the public system, we need better data collection from the system as a whole. That is an important point.

We have a second session starting at 11.45 a.m., so I ask Deputy Donnelly to put a quick-fire question.

I have a few quick-fire questions. I want to go back to the fact that the new national children's hospital and the new national maternity hospital will have dedicated and separate private facilities. To the best of Dr. de Buitléir's knowledge, is there any requirement under the consultant contract for the treatment of private patients in public hospitals to be in dedicated and separate private facilities?

Dr. Donal de Buitléir

I am not aware there is but there could be. Maybe that is a matter for the next session.

Thanks. I want to clarify something because statements were made here earlier that are grossly unfair to our healthcare professionals. It was suggested, not by our witnesses, that private patients going into accident and emergency departments in Ireland would receive more favourable treatment than non-private patients. To the best of my knowledge that is absolutely untrue and would be a grossly unfair and scurrilous thing to say about our emergency medicine healthcare professionals and all the other healthcare professionals in our hospitals. I believe that was implied pretty directly earlier on in the committee and from my perspective, that is fundamentally untrue. If one walks into one of our accident and emergency departments, he or she can sign the form to indicate he or she has private insurance or not, but our healthcare professionals will treat them regardless. I just wanted to state that. What was said earlier on-----

Dr. Donal de Buitléir

I do not know if I implied that but-----

No, Dr. de Buitléir did not. It was a member of the committee.

Dr. Donal de Buitléir

Well it is not true.

Yes, it is not true. I want to disassociate myself from any suggestion there is preferential emergency care in this country. Not for a moment am I suggesting the witnesses implied there was.

Maternity care is a good example of where a lot of women, if they can access and afford private care, will go for it. The main reason one hears for that decision is the woman wants the same consultant. She feels that if she goes in and is dealing with one obstetrician the whole way through, that is really valuable. Has the independent review group looked at how those real concerns can be dealt with if we remove the option for women to avail of private maternity care, thereby removing the option to avail of having the same obstetrician through the care and delivery?

Dr. Donal de Buitléir

That matter has not come up. I know from my personal family experience that even if one signs up for that arrangement it is not necessarily delivered upon. It does not happen.

Did the independent review group look at that from the patient's perspective in the report?

Dr. Donal de Buitléir

No, we did not.

I understand why this happens so it is not a criticism, but a lot of the report focuses on the consultants and on what we need to do for them. I would like to bring it back to the patients. Let us put the consultants aside for a minute and ask how things would be affected for patients. The ESRI report is good in the numbers it gives on what is going on in our public hospitals. Those numbers will come as a surprise to many people. For example, three quarters of the beds in public hospitals have people in them who have come through the accident and emergency departments. Most people probably intuitively think the number is much smaller but three of every four beds in our public hospitals are filled with patients who have come in from the accident and emergency departments. Whether we take private practice out of public hospitals or not, three of the four beds will still be filled with those people. We will still have to care for them but we will have a lot less money because we will no longer be taking money from the insurance companies. Three out of four beds will still be full with the same people but we will be behind because we will not be getting paid for any of that, whereas we were getting paid for about one in five of those patients. That leaves one of every four beds. The vast majority of those bed days are for public patients. The ESRI report shows that less than 4% of the bed days in public hospitals are for elective private care. That is the only bit that would change because the people will still come through the accident and emergency departments. Less than one on 30 of the beds would have people in them who may not have been in them if we took elective private care out. On the basis that some of those patients are in the public hospitals because the public hospitals might be able to deal with more complex matters, of those one in 30 beds, a load of them will still be filled. Those patients will have to go through the public system because they will be availing of public facilities. Let us assume that if we remove private practice from public hospitals, in reality it will free up about one bed in 50 in our public system. That is broadly what it will do and that is the actual change we will see. At the same time, we will also remove the money that pays for that one bed in 50. We would not suddenly have one bed in 50 free and have doctors and nurses ready to treat the public patient who would go into that bed. We are not funding that and we have a lot less money available because we are not taking any money in from the patients from the accident and emergency department.

If we just said that in principle it is no longer allowed to have private care in public hospitals, one bed in 50 might be freed up but we would not have the money to pay for that bed or for the doctors or nurses, and we would have significantly less money available to treat the patients in the other 49 beds.

I fundamentally and wholeheartedly agree with the principle of equal care in public hospitals, and I think it is enough that it is a principle. The narrative to date has been that doing this will somehow reduce waiting lists and improve access for public patients. Based on the analysis we have been given, it will do the opposite. It will reduce capacity for public patients, thereby increasing waiting lists. Is this a reasonable analysis of the numbers we have just seen?

Dr. Donal de Buitléir

I am with the Deputy most the way but I am not sure it would reduce. It is something we might need to debate.

The argument is that if we have less money to treat patients, waiting lists will increase.

Dr. Donal de Buitléir

Looking at the money is taking a narrow Exchequer view. I am looking at it from the point of view of the voter, the patient and the people out there.

We have to look at it from the perspective of the person running the hospital.

Dr. Donal de Buitléir

That is part of it. It is proving very difficult to reduce health expenditure. If we took out the funding of €524 million, which is decreasing, the hospital system could not survive and it would have to be funded from the Exchequer. If the costs of health insurance decreases, taxes must increase. Tax will increase anyway because of demographics.

I hear Dr. de Buitléir-----

Dr. Donal de Buitléir

I am looking at-----

Sorry, we will have to move on. I know the Deputy has many questions as do we all.

I thank the Chairman and the witnesses.

Following on from Deputy Donnelly's question, some people have always had private health insurance, perhaps as part of their job, but I am focused on maternity and paediatric care. Deputy Donnelly asked a question about continuity of maternity care. A fundamental reason women and their partners go for private maternity care is the continuity of care with a consultant. I understand that people are not always guaranteed the same consultant but, in my experience, a consultant will introduce the patient to his or her colleague as the consultant who will look after the patient when the original consultant is on holidays and that he or she is aware of the situation. Women want this. They do not want to be examined by somebody different every time, particularly with complex pregnancies. They want the assurance that they do not have to tell the whole story every time they go in for a check-up. It is regrettable this was not examined because it is a key reason for private health insurance. My only access was at that time. It is a critical point in people's lives and there is definitely a desire for continuity of care.

With regard to the children's hospital, the committee has heard there will be four or six suites for private paediatric care. While I understand why this is, if this is where we are going, it sends the wrong message to have private rooms in the new hospital. I understand why the contract is as it is and why doctors want it but it seems wholly unfair that if my child has an eye problem that is not an emergency and Deputy Donnelly's child has a similar eye problem but he does not have private insurance, one of the children will get preferential care in the new hospital.

Is there an answer?

Dr. Donal de Buitléir

I do not think there was a question.

There was a question.

Dr. Donal de Buitléir

Was there? Sorry.

Why did Dr. de Buitléir not consider the reasons women often go for private treatment when having babies and perhaps do not use ever use private treatment again and get rid of it after having the baby? Why was that not examined?

Dr. Donal de Buitléir

It did not come up as an issue. It was not raised in the very extensive consultation we did. We put out a public call and visited hospitals. We met various interests and it was never raised.

It was never raised.

Dr. Donal de Buitléir

This is the first time I have heard it.

Did the group ask any women?

Dr. Donal de Buitléir

I have four children and I can tell the Deputy about my experience.

I do not think it is relevant that Dr. de Buitléir has four children. I am asking about the women engaged with as part of the research.

Dr. Donal de Buitléir

It did not come up as an issue.

Dr. Donal de Buitléir

That is a fact.

Perhaps on a related commentary based on my experience, people want personal care and they feel they will get personal care if they go privately because they will see the same consultant. They may not necessarily get the same personal contact with the same doctor. With regard to maternity care, the public system is excellent and superb. Irish maternity care provides one of the top services in the world with regard to maternal and infant mortality.

We will have to finish this session, unfortunately, at 11.30 a.m.

I have a question.

Only one, with no commentary or soliloquy With regard to what Dr. Keegan and Dr. de Buitléir have said, the issue is that we have a system in which private health insurance is inadvertently subsidising the public health service. This is the fundamental issue examined by the committee on the future of healthcare. That subsidy is perverse. We have to finish at 11.30 a.m. so the two Deputies requesting can have one question each.

I thank Dr. de Buitléir for coming before the committee. I was a member of the Sláintecare committee chaired by my able colleague, Deputy Shortall. With regard to hospital care, the single biggest principle in the report is the separation of public and private. The witnesses have completed a comprehensive report. Do they think it is possible to achieve the target we have set to separate private treatment in public hospitals?

Dr. Donal de Buitléir

Absolutely, yes.

We did go through that extensively earlier and Dr. de Buitléir explained how it can and should be done in a stepped way over ten years.

Is there a summary or opening statement of which I can get a copy?

I apologise because I had to be elsewhere earlier. The jury is probably out on the Chairman's point that private health insurance subsidises the public system, as I am not sure whether anybody has established which system is subsidising which.

As Chairman of the committee on the future of healthcare, I want to say a very special thanks to Dr. de Buitléir who carried out the tasks set for him in an exemplary way. The report he produced was exceptionally comprehensive and thorough and I thank him for it. I also thank him for the very important role he is playing in fulfilling the expressed wishes of the committee with regard to this very important aspect of developing a universal single-tier healthcare system that will be available to all. I thank him very much for the work he has done.

I thank Dr. Shortall for those comments.

On behalf of the committee, I thank the witnesses for coming before the committee and for their evidence. Their report has been well received and will stand up in future as we reform our service.

Sitting suspended at 11.30 a.m. and resumed at 12 noon.