Inequality in Access to Health Care: Discussion

Good morning everyone. I wish to remind everyone in the room to turn off their mobile phones or switch them to airplane mode as they interfere with the sound recording equipment. I welcome everyone, particularly viewers who are watching the live streaming of our meeting this morning.

In establishing this committee, the Dáil was giving recognition to the fact that there are considerable shortcomings in our health service. A big element of that is the two-tier nature of the service and the expense involved in getting access to services, whether one is a public patient or paying for services through private health insurance. There is a genuine shared hope among committee members that we can do something worthwhile and can take the key strategic decisions which will enable us to move from the current somewhat dysfunctional two-tier health service with all of its problems to having a modern, accessible, single-tier health service.

In our first session today we will meet Dr. Sara Burke, research fellow at the centre for health policy and management, Trinity College Dublin. Dr. Burke will make a presentation on inequality in access to health care. I wish to take this opportunity to acknowledge the input to our earlier planning sessions of Dr. Burke's colleagues from the aforementioned centre, Dr. Steve Thomas and Dr. Catherine Darker. In our second session we will meet representatives from the Seanad Civil Engagement group, who will make a presentation on the importance of a citizen-centred approach to health care.

I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair 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 now invite Dr. Burke to make her presentation.

Dr. Sara Burke

Good morning. I thank the committee for inviting me here this morning. I really welcome the work of this committee, which is long overdue. It is the first time in the history of the country that any attempt has been made to reach a cross-party consensus on the future of our health services, particularly the development of a universal health system where access to care is based on need, not income.

The committee has asked me to speak on the issue of inequality in access to health care. As Deputies will know from their lived experience and from the constituents they meet every day, there are many inequalities in access to health care in Ireland. This country is exceptional in terms of the fragmented, complex nature of health care and in the unequal access to diagnostics, treatment and care.

Internationally, when one refers to universal systems one is talking about an entitlement to package of care, that is, the health and social care services to which citizens are entitled. In Ireland, because we do not have a universal system, there simply is no such thing as a package of care. People do not know what services they are entitled to and accessing social and health care services depends on whether one has a medical card, a GP visit card, private health insurance, an ability to spend money from one's own pocket on health services, where one lives and what type of services one is trying to access.  Decades worth of research shows that it is the poorest, the sickest and people with disabilities who find it hardest to pay charges no matter how small those charges may seem and who find it harder to negotiate access. Indeed, any of us who has accessed the system - and GPs in particular know this because they do it every day - knows how difficult it is to negotiate one's way through it. It is also the poorest, the sickest and those with disabilities who have to wait longest for care.

Medical cards, which currently cover about 36% of the population, are a proven pro-poor measure. They are a positive safety net for the poorest third of society. It is actually the poor, the sick and people with disabilities who do not have medical cards but who are on lower incomes who fare worst in terms of coverage and access.  I do a lot of international work in Europe and with the World Health Organization, WHO, and when I present data showing that we do not have universal access to primary care, people do not believe it. We are absolutely unique in a European context in not having universal access to primary care. When I present data showing that 54% of the population has to pay, on average, €50 for each GP visit, people are really stunned by that amount. At the moment, 64% or two thirds of the population may have to pay up to €144 per month for essential medication. That is an awful lot of money out of anybody's income.

Technically, we do have universal access to the public hospital system - or at least we did - in that everyone is entitled to public hospital care. However, measures that were introduced, such as the €100 fee for accident and emergency departments and the €750 per year charge for inpatient care mean that people without medical cards often cannot afford this. Even if one does have free or without charge access to the health system - we are all paying for it in lots of different ways - the very long wait times for accessing public hospital care mean these public patients are denied access. This is further exacerbated in the Irish context by what is called our two-tier hospital care, which incentivises and pushes people into private care. 

The inequalities in access we have manifest themselves in different ways, people without free general practitioner, GP, care or a medical card delay or do no not go to a GP in the first place due to cost.

When people present at a GP, often she will often need to send them for diagnostic tests. The Irish College of General Practitioners, ICGP, told the committee last week that it has done comprehensive research showing the poor access for patients who could not afford to pay privately to access an essential scan or test. One part of its research showed that 10% of GPs had direct access to a MRI scan in the public system with an average waiting time of 22 weeks whereas all GPs had access to MRI scans in the private sector within seven working days. This public-private divide further delays diagnosis and treatment for people who cannot afford to pay privately.

When a GP decides that a person needs to see a specialist we know there are extraordinarily long wait times to access that appointment in the public hospital system. We hear these figures generally every month when the National Treatment Purchase Fund, NTPF, publishes them and when they come out they are in the news. What hits the headline is that there are approximately 450,000 people waiting for that first outpatient appointment. In a way that number is not the problem because that is probably the amount needed within any population of our size. The problem is the numbers waiting a long time. I updated the figures in advance of this meeting from the August figures which show there are over 74,000 people waiting more than a year for that first outpatient appointment and over 110,000 waiting six to 12 months and 95,000 waiting three to six months. By any international benchmark zero to three months is a reasonable time to wait, any time after that is too long. We have hundreds and thousands of people waiting too long.

When a specialist decides that treatment is needed, after this first outpatient appointment wait there are also long waits for this. Despite the efforts of the last Government to reduce waiting times for treatment, and they had some impact in 2012 and early 2013, there have been longer waiting times for all groups since then, except those waiting over two years. Nobody should have to wait over two years for either that specialist first outpatient appointment or that specialist treatment.

None of these points touches on the inequalities in access to community services such as home helps, public health nursing, physiotherapists, occupational therapists, speech and language therapy, mental health services mainly because the data is so bad or does not exist. The HSE has begun to collect it in some areas but only in the past year or so. That means I cannot present that time series data we have for hospital services but such services are equally if not more important than hospital services. There are huge inequalities in accessing these, often depending on whether one has a medical card and on the existence or capacity of a service in the area where the patient lives.

Part of the complexity of the Irish system is the result of the existence and overlap of private health insurance on the public health system. We are unique for a high income Organisation for Economic Cooperation and Development, OECD, country for the way we marry private health insurance and the public hospital system. We know that people who can afford to pay privately can get their diagnostic tests quicker, get to see a specialist quicker and if insured may be able to get their treatment quicker.

My current role in the Centre for Health Policy and Management in Trinity College Dublin is co-ordinating a Health Research Board, publicly funded, project called 'mapping the pathways to universal healthcare'. In this project we are monitoring Government progress, or perhaps the absence of it, towards a universal health care system. Initial policy analysis work that we have done, which was published at the end of last year, found that despite the rhetoric and the intention of increased universalism between 2011 and 2015, there was in fact less, not more, universalism now than there was in 2011. This is due to the further increase in drug charges for people with and without medical cards, the introduction of lifetime community rating and the failure to reduce waiting times for access for public patients. The one exception to some progress on universalism was the extension of free GP care to those aged over 70 and under six years. We know internationally that insurance-based systems, such as those in the USA or the Netherlands, are more expensive and cause inequalities. In Ireland, 45% of population have private health insurance yet it contributes less than 10% to the overall health budget.

In the project in Trinity my colleague, Dr. Sarah Barry, is leading on a systematic review on the organisational challenges of introducing universal health care. Professor Steve Thomas, who the committee has met privately, and Bridget Johnston, are doing groundbreaking work on financial protection. This is the first time this work has been done in Ireland. Financial protection is a core component of the World Health Organization's definition of universal healthcare which in effect means that health and access to health care should not cause impoverishing or catastrophic health expenditure. The terms are quite technical and I will spare the committee the detail on them. Catastrophic, however, means that people are forgoing essential expenditure in other areas to meet health service needs, usually out of pocket payments.

Initial work we have done on quantifying the amount of out of pocket spending is presented in the accompanying graph. This does not count everything people spend privately on health care, it counts only what we were able to count. It showed that in 2014 Irish citizens paid €580 million more out of their pockets for essential, generally hospital care or drug charges, than they did in 2008. We are doing more detailed work using the Central Statistics Office, CSO, national household budget survey data. It went into the field again earlier this year but we do not have the data from that. We have, however, analysed the 2009-2010 data, exploring the extent of affordability of private health expenditure and what proportion of Irish citizens are financially protected, or not, when they access health care. We found that the poorest people who experience catastrophic levels of private health expenditure, almost 50% of the poorest fifth of the population reported unaffordable levels of private health spending. I have given the committee the breakdown of expenditure according to those income quintiles. Two interesting observations arise from this data, one is that the poorest 40% of the population spent most on private health insurance and the highest level of out of pocket, unaffordable spend from those with middle and higher incomes was on dental care. These figures come from a diary people keep of what they spent their money on so they do not catch unmet need. They catch only what people actually spend. We know that low income groups do not go to the dentist because of the barrier of cost.

Providing timely access to appropriate care for the whole population, which is in effect a universal health system, will cost more money and require more staff. Professor Thomas is studying workforce requirements and our current staffing profile as a basis for getting to universal health care. He is also reviewing potential areas for positive rationing. In other words, how we can use the resources we have more efficiently so that universal health care is affordable and deliverable.

The work we are engaged on in this project, 'mapping the pathways to universal healthcare', aims to devise tangible steps towards a universal health care system, work we hope will be of use to the work of this committee. Delivering a universal health system is a political choice which is in the power of the committee. It is a political choice that is a matter of life and death to some people. It can improve all people's lives, our quality of life and indeed our deaths. I wish the committee well with its work and am happy to answer any questions members may have.

Thank you for the presentation. What are Dr. Burke's views on how this committee might determine the basket of care and what is the best practice internationally?

Dr. Sara Burke

That is a difficult question to start with. The White Paper on Universal Health Insurance spectacularly avoided dealing with the basket of care. I gave the committee a conceptualisation of what we are working on as the basket of care in co-operation with our WHO and European colleagues. We went for the put everything in rather than keep some services out approach - put in social care, mental health services, drug charges, emergency departments - because we have to start by knowing the entire basket of care.

Then, it is political choices to decide who gets access to what. We could all argue that pretty much everything in there is essential health and social care. Therefore, having a broader basket rather than an narrower one is the way to go.

I will invite members to speak in groups of three and bank the questions.

I thank Dr. Burke for coming here and for her presentation which, as ever, was incredibly informative. My first question relates to evidence the committee heard from Professor Allyson Pollock on universal access underpinned by legislation. What are Dr. Burke's views on whether it is preferable to put legislation in place and frantically work towards it or to incrementally build to a point where we are in position to put the legislation in place with the heavy lifting already done? While Dr. Burke could probably guess my personal views on it, I would be very interested to hear her view.

I view the NTPF as privatisation by stealth, and probably the worst form of privatisation, given that people are being told it is not privatisation and it is good for them. There is a backlog, and there is a role for outside providers to clear the backlog. I would be interested to know the extent to which Dr. Burke thinks it might be possible to switch off the tap of the NTPF and how quickly it could be done.

Bizarrely, I read on Twitter that there is another new structure in the HSE. I have not heard the rationale for it and I do not understand it. I am sure it has something to do with governance and accountability. Professor Pollock would have spoken to us about it. Although in Britain the buck stops with the secretary with responsibility for health, they have very much strengthened local accountability. Does Dr. Burke believe the structures in the HSE are fit for purpose? I hesitate to use that phrase given that I do not mean it necessarily in that way. I refer to the manner in which they could be improved. Would we be better to focus on more local accountability rather than high-level accountability, which is where the HSE is focused?

What is the new structure?

The one Fergal Bowers very kindly tweeted last week. It was the first I had heard of it.

Is it a national structure?

Yes. It is the overall national structure. When I asked the Minister, he said it was to do with filling a vacancy at the level of assistant director general or similar.

The old structure with all the directorates is being merged and there will be only a certain number of people over-----

There will also be nine community healthcare organisations, CHOs, all of which will have their own internal structures too.

It is another layer.

There is another layer again, given that the CHOs will have their own internal structures. There is an awful lot of structure.

And the hospital groups.

Yes, but the hospital groups do not match with the CHOs. If Dr. Burke could fix it for us, that would be grand.

I had not seen it.

I thank Dr. Burke. One of my questions was the one Deputy Louise O'Reilly raised regarding the NHS legislation and whether it should be brought in initially. She was very adamant that it would have to be the case. The committee is established to be evidence based regarding what is the best health service for our country. Reports such as this are very important for us to see the evidence on whether private health care is good or bad. The item that strikes me is that out of pocket spending had increased since 2008 to €580 million. This was during one of the worst periods austerity and cutbacks that we have had, and people have had to fork out extra money along with it. Dr. Burke said if we went to the NHS style of health care it would cost money. How do we determine this cost if we are saving in some areas and having to pay in others, for example, the €580 million in out of pocket expenses? How and when do we know what the costs will be?

Dr. Burke mentioned more staff. Could she develop this issue? We are losing staff. How do we retain our staff? What is Dr. Burke's opinion? If we are processing the idea of a national health service - I do not know if the entire committee agrees - we will need resources and they must be put in place early to ensure we have staff in the future to retain them. Should the State pay for nurses' and midwives' training and insist they stay in Ireland for the following ten or 15 years and be embedded in rural areas to pay it back?

Many of my questions have been asked, especially the issue of accountability which Deputy Louise O'Reilly raised. It comes up over and over again. Dr. Burke touched on dental care. Poor dental care leads to underlying problems later, such as heart problems. We keep raising the issue that we are a cure society rather than a prevention society. Would Dr. Burke look at initiating it very quickly and start rolling out the schemes we used to have with free dental checks and care such as cleanings? It is a preventative measure on a huge scale. We probably have the worst dental record in Europe among young children, never mind adults. In her opening statement, Dr. Burke mentioned that while 45% of the population has private health insurance, it contributes to only 9% of the total cost of care. Could she explain more about it?

Dr. Sara Burke

I listened with interest to Professor Pollock very strongly make the case for NHS-like legislation. It is an issue. Do we go for the big bang reform or do it incrementally? Professor Pollock has been working on NHS legislation during recent years as a mechanism of undoing the breakdown of the NHS and the marketisation that has happened in England. It is specific to there. The bread and butter of my academic research is policy making processes. In the literature, there is the big bang legislative change, which is what the universal health insurance was planned to be, very much driven by then Minister, Senator James Reilly. Ireland tends to take the path of incremental change. There are other methods of doing it somewhere in between. What the committee is doing fits into what is conceptually written about in the literature as a blueprint method. The committee is reaching a consensus and developing a detailed plan, and there is a body of work to be done with the public, the heath service and politicians to deliver on it within a reasonable period of time. We have not come down either way. I do not know which is the best answer.

The committee is to produce its report early in the new year. It will not be able to say, on 1 February 2017, that we will have a national health system, universally accessible to all and free at the point of delivery. We simply do not have the capacity to do it. We do not have the resources or the staff in place to do it. The blueprint methodology of reaching political consensus is very important, but we must also reach a public agreement that we want a certain type of service.

We hear all the time that Irish people are very discontented. Public services top opinions polls when it comes to things about which Irish people are most upset. If we want European-style public services, we must start paying European levels of tax or PRSI to pay for them. Politicians, many of us carrying out research and leaders in the health system must win the argument that if we want really good public services, we must pay for them.

Part of my PhD involved looking at the National Treatment Purchase Fund. I agree with Deputy O'Reilly that it worked for the people who got treatment. If someone has been waiting for a very long time and receives their treatment privately, obviously that is good for that individual but it does nothing to solve the long waits within the system. We have seen it. It has been in existence for all the years in respect of which I have presented the committee with data and the figures have gone up. Yes, there is a role for the private sector to play in getting rid of that backlog but there are political choices to be made. Do we want to use elective capacity within the private system on an ongoing basis or do we want to build up the public hospital system to deliver that care? We need to build up the public hospital system to deliver that care.

I saw the report concerning the proposed structure. I think it was a draft report from Tony O'Brien concerning reorganising the top of the HSE. Colleagues of mine in Trinity College have done more work on it than I have but we can prove absolutely that most of alleged reform in Ireland over the past ten or 15 years has been just been reorganisation. Has that reorganisation improved service delivery? I think the large answer is "No". There have been improvements in health and social care provision but they have nothing to do with the reorganisation that has happened. I would advise against another reorganisation or restructuring and in favour of much more work on what can we do to improve access to services for people. In a way, that is what we are doing. The project in Trinity College involves looking at the barriers to access and how we can address them. There is an issue around local accountability and yet what were the health boards? Were the health boards a form of local accountability? We got rid of them. Do we really want to go back to having politicians decide? I would urge against further restructuring and reorganisation and in favour of really reforming the system.

I hope I have answered Deputy Collins's question on the NHS. The €580 million in the graph involved austerity measures introduced in successive budgets - the emergency budget in 2008 and thereafter. Among other measures, it involved taking medical cards away from those aged over 70. It always astounded me, particularly as we were mapping these over time, that people were taking to the streets on other matters but not the fact that we as citizens are paying hundreds of millions more for essential public health care than we did eight or ten years ago.

There was a very good question about how we cost it. It is part of what we are working on in the project, although it is not the specific aim of the project. I know the ESRI is carrying out some work on that. There is a big part of unmet need so we can cost demand or activity at the moment. It is very hard to cost private sector activity because we do not have good information on it and it cannot be got. We need a substantial piece of work on what is unmet need because we know there is a huge amount of it. It is a hard thing to do but we can probably do ballparks on it. We will lose some in certain areas that we gain in others so that €600 million can be got through progressive tax measures rather than people having to pay out of pocket.

We need more staff. I looked at the staff figures in recent days. They have been increasing since 2013. I cannot remember the figures but there are a few thousand more staff now than there were but we are just playing catch-up. We are still not at pre-austerity levels of staffing so there is a body of catching up to do. There is also the issue of meeting demographic needs never mind the unmet need about which we spoke.

Should we make people who train in the system stay here for ten or 15 years? My PhD was publicly funded and I have said on the record much to everyone's delight that we should do so. If someone is educated with public money, they should be giving something back. It goes down like a lead balloon. There is good evidence from other countries that it does not really work. It is quite hard to keep graduates here so the trick is having a health system in which people want to work and where people are proud when they go to work every day and do not leave it really stressed and under pressure in the evenings. That is about improving our health system but also retaining good quality staff.

Deputy Buckley spoke about dental care. I am far from being an expert on dental care. Some of the most severe austerity measures early on involved cutting back dental care to people on medical cards and in the PRSI scheme. There is a huge body of work to be done in Ireland in terms of making dental care accessible to most people who need it. Anybody who has children needing orthodontic care will say that it is next to impossible to get that within the public system.

Been there, done that.

Dr. Sara Burke

It is very expensive and that is not caught in the figure of €580 million.

How would I explain how 45% of the population has private health insurance when it only contributes 9% of the cost? It is because private health insurance in Ireland largely insures someone for inpatient or day case elective hospital care. It does not cover most other bits. It does not cover outpatient care generally, outpatient appointments with specialists in the first place, the cost of drugs and most primary care payments. In effect, it is inpatient hospital insurance that people are scared into taking out because it gets them faster access. It can be seen from the figures that it is very bad value for money because it does not cover the cost. This shows that the public system is subsidising the private system because 45% of the population has private health insurance but the majority of the expense of health care is not paid for by private health insurers.

That private health insurance only contributes 9% to the health spend is remarkable. From memory, I think 77% is funded through the tax system so it seems that represents more than three quarters of the health spend. That should be the starting point on which we build.

I thank Dr. Burke for her presentation. Could she expand on the statement that private health insurance contributes only 9% to the health spend? It does not seem to-----

This was raised with us initially by the ESRI when it presented a pie chart showing the different elements of health spending.

And that is the contribution that private health insurance makes?

Yes, to the total health spend.

And the rest of the money goes on-----

From memory, 77% comes from taxation. Out of pocket expenses-----

Dr. Sara Burke

Does 16% or 17% get it to 100%?

We can get that chart.

Dr. Sara Burke

That is the ESRI data.

That is a fairly significant fact. Looking at Dr. Burke's figures, if 37% of the population has medical cards and 45% has private health insurance of some sort, that would mean that 18% has nothing. These people do not have medical cards or private health insurance. This means that close to one in five people is in a very vulnerable position. Will Dr. Burke comment on that, assuming I am reading her figures correctly?

Does Dr. Burke believe a better system would be for everything to be free or does a small charge act as a disincentive? I work as a pharmacist and I give the example of the prescription charges. When they were introduced initially, the charge was 50 cent per item up to a maximum of €5. My experience of that was that it did not disincentivise anybody from getting their medication. However, when they were paying 50 cent for them, people who did not want certain items on a monthly basis said they did not need them, so it actually saved some money for the system. Increasing it to €2.50 an item up to a maximum of €25 is a disincentive, but the small charge was not. I am interested to hear Dr. Burke's opinion on the entire suite of services. Would she have an issue with a small charge or is it something that could be considered?

Third, the Canadian model was mentioned a few times last week, which is a very good example of a universal health care model. The other side of that, however, is that prescription charges, dental care and home care are not covered. People go to the private market for that level of cover. Does Dr. Burke believe there is a role at some level for private health insurance to assist in the delivery of an effective health system?

To clarify the Deputy's question about the division of health spend, we have figures for 2013 which indicate that 77% of total health financing was from taxation, 12% from out of pocket expenditure, 9% from private health insurance, and 2% from private corporations.

Dr. Sara Burke

That 2% is probably private corporations paying health insurance for employers.

They are significant figures.

I thank Dr. Burke for coming before the committee. I have been reading her writings for many years. I am a general practitioner, GP, and I understand intimately the problems faced by the health service. I have a number of questions. First, how significant are staff shortages with regard to the delivery of services? In particular, how significant are our work practices, both in general practice and within the hospital? I believe there is a huge gap between primary and secondary care, and a lack of integration, communication and information technology? How significant are those factors?

Second, does Dr. Burke believe that primary and community care have the capacity to take on a significant increased workload in chronic disease management? Can it be an equal partner in the primary care-secondary care interface? With regard to reconfiguration, which Dr. Burke said probably has not led to much improvement in the health service, reconfiguration went ahead without actually reconfiguring the services to a new location. They closed down services but they did not put them into the centres of excellence.

I thank Deputy Burke for her presentation. I have two questions, one of which is on using the metric of life expectancy. I understand Ireland is ranked 25th in the world with regard to high life expectancy. Japan and Singapore have higher rates of life expectancy, but on the suitability of using that metric when we discuss health inequalities, is it accurate? Is it a useful tool?

Also, on the issue of geography, a Harvard study found that race, poverty and ethnicity are key divides between ill-health and wellness, and that geography is often a factor that is not taken into account when we are considering them. From an Irish context, could Dr. Burke expand on the way geography impacts on people's wellness and their ill-health?

Dr. Sara Burke

Deputy Brassil started by doing the sums and working out that one in five people are vulnerable. I tried to update the no cover figures for him. I had no cover figures in the second slide but I did not put them in because, like everything in life, it is more complicated than it looks on paper for a couple of reasons. There is a proportion of the population which has both medical cards and private health insurance, but currently we only have good information on the over 50s from the TILDA data. There is old data which shows that for the entire population there is a 5% overlap between people with medical cards and people with private health insurance, but we also know that is much higher for older people and it progresses. The older they get, the more likely the overlap, particularly during the time when all those over 70 had medical cards, so any estimates we have for no cover are only guesstimates. Also, some people have free GP care and also private health insurance.

We can say there are people who do not have any of those who definitely have more difficulty accessing the system but everybody is vulnerable at a point in time. Even if someone has the best private health insurance package that might cover them for high end hospital care, and they are back in the community, they might not get public health nursing or access to those basic public health services within the Health Service Executive, HSE, primary care team because they do not have a medical card. It is not as simple as saying there is one group of people who fare badly. Everybody is vulnerable at some stage, but we know that the poorest, the sickest and people with disabilities fare worse and that those without a medical card have the greater difficulties. Everybody has difficulties, however, because if they are waiting 18 months for that first specialist appointment, that puts them in a very difficult position.

The next question was on charges. I am interested in the Deputy's observations about the difference between a 50 cent charge and the €2.50 charge, which is capped at €25. The evidence internationally is that no matter how small the charge, it deters as much necessary as unnecessary use. Charges do deter use, no matter how small. I do not know the details of the dental or the GP charging literature off the top of my head, so I will not pretend to. I understand Dr. Josep Figueras will present to the committee next week and that might be a question to put to him in terms of application to the other areas but also in terms of the next question on whether private health insurance can assist in any way.

The problem with examining systems in other countries is that they have very different systems. In France, one's care is covered generally by a social insurance system but there is also supplementary care by what is a form of private health insurance, namely, a not-for-profit private health insurance. However, that is very different from the model we have here. In terms of our model, if we are moving towards using public money in the best possible way, private health insurance should only cover someone for privately delivered care. It should not cover what is subsidised within the public system.

Deputy Harty asked if staff shortages had an impact. Of course they have an impact. The Deputy sees it every day, but people experience it every day when they try to access services. There is a range of services people cannot access because of the long waiting times or the services not having somebody in a particular area. I refer to undoing the severe austerity cutbacks, but even if we got back to 2007-08 levels we still do not have the public health system GP staffing requirements to meet current population need. We must significantly invest in staffing. Investing in public health systems is a very productive economic measure because it provides jobs for people in their own communities who will then spend in their own communities.

It should be viewed as a positive spend and a resource rather than as a drain on society.

There is significant scope. Better than any of us, Deputy Harty would understand the need for changed work practices and how secondary care always seems to get preference over primary and community care. Staffing needs to be built up in primary and community care particularly. Since that sector does not have the capacity to take on more work, we need more people, but we also need to be doing things differently. We are beginning to see that happening. Colleagues of mine in Trinity College Dublin costed the role of specialist epilepsy nurses in the community. That work showed that, if someone with epilepsy had a link with a specialist epileptic nurse, it reduced or, in some instances, eliminated hospital admissions and the person stayed in work and was able to manage medication better. This was a much cheaper and better quality of life for the person with epilepsy than if he or she had to go to hospital to see a specialist every time. We need to be doing this for all chronic diseases. General practitioners, GPs, need to be paid to manage chronic diseases in the community, as do specialist nurses, occupational therapists and other health professionals.

I agree with Deputy Harty on reconfiguration. We have done a dreadful job of reconfiguration or reorganisation no matter how one looks at it. We shut down units, especially in rural hospitals along the west coast, without beefing up services there or in the major centres. Unsurprisingly, we are seeing the payback for that, for example, the level of demand placed on the emergency department in Galway or Limerick. That is what happens when one stops some services without beefing up others, in particular primary and community care. Had these services been resourced better, we would not have had some of the problems we have experienced.

Deputy Naughton's first question was on life expectancy and whether it was a useful tool. It is, but health services and access to same only contribute a small amount to life expectancy. They are important if one is sick and needs care, to quality of life and to outcomes. Forgive me, as I am only four days back from maternity leave, so I do not have the figures off the top of my head.

Life expectancy is a useful figure in terms of inequalities in health. One of my first policy jobs was in the Institute of Public Health in Ireland where, 15 years ago, we produced data showing that people with poorer incomes had much lower life expectancies than people with higher incomes. There is a case for targeting. One needs to invest in education, infrastructure, housing and career paths in those areas, but one also needs a greater delivery of health and social care services. There is a role for these, not just for meeting the health needs of people in those communities, but also for acting as their employer. In recent years, there has been a run down of HSE-employed home helps. Often they were women from disadvantaged communities who provided care to people living near them. We have contracted out much of that care. Employing local people in what often are deprived areas is a good economic and health measure.

Did Deputy Naughton ask about ethnicity?

Yes. I read the Harvard study, which examined race, ethnicity and poverty in terms of having an effect on whether people were well or had ill health. The report also stated that geography was often not taken into account when considering the divides between those who were healthy and those who were not. Has Dr. Burke considered geography in the Irish context?

Dr. Sara Burke

There is no excuse for not taking it into account. It is named in Healthy Ireland: A Framework for Improved Health and Wellbeing 2013-2025. Addressing inequalities is a key priority, but there are also significant ethnic issues. Travellers have a life expectancy of ten to 15 years less than the rest of the population. Good health policy is about anti-poverty measures and employment measures as much as, if not more than, health services, but I was asked to discuss the health service aspect at this meeting. Health services have a role to play.

Dr. Sara Burke

As well as disadvantaged urban areas and, for different reasons, rural areas.

I wish to revisit a number of issues. Total health spend is approximately €19 billion, which puts us close to the top in Europe in that regard. The issue seems not so much to be about how much we spend but how it is spent. It does not necessarily follow that, if we are to have a universal health care system that meets the population's needs, it will entail much additional spending. Does Dr. Burke accept that it is a question of replacing the private health insurance spend and out of pocket spend, given that 77% of funding comes from taxation? It is down to finding mechanisms for replacing these two blocks of spending.

Dr. Sara Burke

Replacing them, but also spending money in a better way on what Deputy Harty referred to as changed work practices.

Doing it differently.

Dr. Sara Burke

There should be a greater use of care assistants as well as nurses in the community and GP practices. It is about getting others to do the work that more senior doctors and nurses are doing now. We have begun using health technology assessments for new treatments and appliances, but thousands of treatments and appliances are provided within our system without evidence that they improve people's quality of life or health. We need more rigorous decision-making processes regarding what types of service are provided and how they are provided.

We do not know the basis on which decisions are taken on the allocation of resources.

Dr. Sara Burke

No, although the Chairman would know better than most.

Right. The other issue is that of restructuring. There is restructuring fatigue within the health service and the constant churn of the past 20 years or so has been disruptive. Each time that there is a change in Minister, there is a restructuring. As a committee, we must address the question of how our health services are structured and the administration of health. For example, our six hospital groups and nine community health groups are not aligned. Given that integration is critical in a well-functioning health service, it is difficult to know how we can operate and conduct an assessment or measurement of outcomes when these two parallel systems have not been integrated. The committee is grappling with the question of whether we should take on the issue of the current structure and recommend a restructure. Bearing in mind what Dr. Burke said about the constant churn, this fundamental question needs to be addressed. How do we get integration and how do we measure activity and outcomes when never the twain - hospitals and community services - shall meet? What are Dr. Burke's views on this?

Dr. Sara Burke

I do not have the answer. There has been constant reorganisation since 2001 - the Eastern Regional Health Authority, the HSE and then a continuous change in HSE structures. I agree with the Chairman that the current structures are not optimal. That we have hospital groups that are not matching with community health organisations is problematic. I agree that we cannot ignore it, but we should not undertake just a reorganisation. Previously, the only thing that happened was the reorganisation, which did not improve how people accessed our health services or their experience of those services.

I do not know whether the committee has spoken to some of those within the HSE or internationally.

Perhaps Professor Josep Figueras can talk to the committee on this issue again next week. There are many models around integrated care pathways and last week we were talking about care pathways for people with multiple morbidities. There is a growing international literature on that which is not necessarily about restructuring. It is about improving the patient experience and pathway through health services. What needs to be the focus is the citizen's experience of the health system rather than the top-down structures that we have, faulty and all as they are.

The management and oversight of it can be difficult.

Dr. Sara Burke

Yes. There needs to be much greater accountability and oversight. The systems we have are the systems put in place by the Oireachtas with the Health Act 2004.

I thank Dr. Burke.

I wish to raise the questions of structures. I do not want to get bogged down because I spent enough of my life dealing with them to want to leave them behind. I wish to raise the issue of local versus national accountability. I am aware of the Carlow-Kilkenny model - I am not sold on it as the be-all and end-all, as there are as many problems as there are fantastic things going on there - but there is a degree of local co-operation and local accountability that does not have any political involvement. On the structure, what exists, exists and as for trying to change it, I think the Chairman is correct that people have restructuring fatigue. Would it be more beneficial for us to look at what is there and try to build in the accountability, rather than change it? Should we try to structure accountability into the structures that are there already, rather than spending our time trying to devise another structure, which will simply sit on the system that exists at present and will not deliver the type of reform needed? We all recognise the need for reform but reform and restructuring are not the same thing. Is it a case of parking the restructuring and looking at accountability and of trying to build in accountability at a local level and facilitate the level of co-operation that goes on at local level? If one has ever hosted a conference for nurses, they will talk to one other about what is happening in their own areas and will learn from one other. A significant amount of that goes on anyway without anyone trying to facilitate it. Would we be better to ignore the restructuring that may or may not be required and has been done many times and try to build in more accountability at local level?

On the question of whether change should come from the top down or the bottom up, if one takes a bird's eye view of the health service, hospital groups are organising hospital structures and how the structures work but the patients are out in the community and only come into hospital for a short period and they go back out into the community. Organising hospital groups is great for hospitals but it does not actually deliver care to everybody because most people are out in the community.

It was mentioned that in Kilkenny, there is a bottom-up approach in which the integrated care committees, comprised of people on the front line, deliver a service and stream patients into the hospital group in a structured way. Rather than people coming into hospital in an unstructured way, when local groups are in place the patients are streamed into hospital in a structured way. I would like to hear the witness's views on top-down versus the bottom up.

If the witness were a member of this committee, what would be the three game changers she would recommend?

Dr. Sara Burke

Deputy Louise O'Reilly referenced Carlow-Kilkenny hospital group. I am aware that a delegation from it appeared before the committee but it might be worthwhile for members to go down to see what they are doing and to witness the meetings where the GPs and consultants share information. The Minister has recently done that. I think it is really good practice. If one looks at what is happening there, it has nothing to do with the structure, because they have the exact same structure as anywhere else but it has to do with work processes that have been pioneered by GPs in the community and a couple of visionary people in the hospital. It has, however, taken decades to develop and it is not like they started to try to do this two or three years ago; they have been doing it for decades. That brings us to a useful point. This is about resourcing processes in order that it is not dependent on the goodwill of a few innovative GPs and hospital doctors. There is a GP and a hospital doctor who are married to each other and I bet that is crucial to the success of the Carlow-Kilkenny model. It is about putting in place the processes in order that they are resourced and that people are paid to take time out to work out what is the best way for Sara Burke. Does she need to go into hospital today or can she be managed at home or in the community for two days and then can she go in a planned way, rather than her ending up on a trolley tonight? That is the nitty-gritty work they do at those meetings. I think the effort is about resourcing those processes and putting them in place. The processes in Bluebell might be different from the processes in Carlow-Kilkenny or in the Beara Peninsula or in Ballinasloe. That is something about respecting the services but also the people and the needs within the local communities.

The voluntary hospitals are involved as well.

Dr. Sara Burke

That brings us to the issue of the lack of accountability within our hospital system. We have introduced these hospital groups, which brings me to Deputy Harty's question on top-down or bottom-up. There are plans for the hospital groups to go to trust status and given the English experience of trusts, I do not think that is the way to go. Given that we have groups, there are significant issues because we have this mix of HSE-funded hospitals and voluntary hospitals and it is very difficult for the hospitals to operate at present. While they used to get their budgets individually, the funding now goes into the group but legally, the hospital chief executive officer or the board - depending on the status of the hospital - is actually accountable for how that money is spent. There are major difficulties with that at present. I think the bottom-up approach is a much more effective way to go. The really good example of that is the success of the clinical care programmes. It is the one area where we have had good success in improving both access and quality of care. This was pioneered by Professor Tom Keane in cancer care. He asked everyone working in cancer services how can we make cancer services more accessible and improve treatments so that our outcomes start reaching international standards. It was a very bottom-up clinician-led reform of hospital services. It needed political accountability and the then Minister, Ms Mary Harney, making difficult choices about reducing cancer care from 30 to eight hospitals. I think the success lies in the leadership of clinicians and front-line staff rather than in monolithic top-down structures.

In response to Deputy Harty's questions on three game changers, I feel as though I am doing an oral leaving certificate exam. As I am just cranking up my brain after maternity leave and the answers are not at the top of my head, I will send him an e-mail.

We look forward to receiving that e-mail. I thank Dr. Burke for coming in and being so generous with her time and sharing her expertise with us. Dr. Burke's input has been very helpful to the committee and we appreciate that she responded to all of the questions so well, especially appearing before us when she has only been back a few days from maternity leave.

The committee went into private session at 10. 20 a.m. and resumed in public session at 10.58 a.m.