International Health Care Systems: Dr. Josep Figueras

I remind people to turn off their mobile telephones or to put them on airplane mode. I would like to welcome those watching the live streaming of this meeting. I would especially like to welcome Dr. Josep Figueras to our meeting. He will provide us with a briefing on international health care systems. Dr. Figueras is the director of the European Observatory on Health Systems and Polices and is also head of the World Health Organization Centre for Health Policy in Brussels.

He has served as a health policy adviser in more than 40 countries. Dr. Figueras has edited numerous studies on health systems, including a 2012 study assessing the case for investing in health systems and an important 2015 WHO study on the impact of the financial crisis on European health systems. I thank Dr. Figueras for taking the time to come over and join us at our meeting. We are extremely interested to hear his views on the Irish health system and how it compares with European health care systems generally.

At the outset, I have to go through a formality. I wish to advise the witness 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 the committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or 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 House or an official by name or in such a way as to make him or her identifiable.

I warmly welcome Dr. Figueras and invite him to make his submission.

Dr. Josep Figueras

I thank the committee for the privilege of being here. I will say a couple of things about where I come from because it will very much guide my remarks to the committee. I am the director of the European Observatory on Health Systems and Policies which is hosted by the WHO, the European Commission, the World Bank and a number of member states in Europe. Ireland is part of it and so are Switzerland, England and many others, including the Nordic countries. I am not doing marketing for my organisation, but rather trying to give a sense of where I am coming from. Our job is to gather and compare evidence. One aspect of that, which may be of help to the committee, is that we have been doing a number of comparative studies to develop evidence and work with policy makers in their role. We are concerned with knowledge brokering and how we use evidence in a way that is practical for work. As the English say, the proof of the pudding is in the eating so I will tell the committee what I have to say today.

I wanted to do two things and I will ask for the committee's suggestions. The first is to give the committee a sense of how Ireland looks in the international and European context against a series of measures of performance. I will not make it an academic exercise but try to draw lessons about what we can learn from other countries in the region. In addition to that, I will suggest a possible framework - not a normative framework - to think through the various issues the committee is concerned with. My terms of reference, like those of the committee, were very wide. It would take me several hours to go through all the areas the committee is looking at and which are in my terms of reference. There are two ways to go about it. I will not subject the committee to all my slides. They are a background so that I can answer the committee's questions with evidence. There are two ways to go about it. One is to have a bit of a menu in ten minutes of introduction and then go into detail on any of the areas the committee wishes me to address. The second way is that we could go into each of the areas. For instance, we could start by looking at funding issues, supplementary ways of financing, or the role of the private sector. We could also talk about the skill mix. Many of these areas are in the committee's terms of reference. I could take them one by one and we could then stop and divide them. I will do whatever is best for the committee. The slides have been distributed to members of the committee but they should not worry, I will not go through all of them. I will use them as a background to be able to address questions with actual evidence.

I congratulate members for putting this committee together. One of the things we have learnt elsewhere is the need to have some stability in the reform process. The idea of putting a multi-party committee together to create consensus is a very wise decision that I wish would happen in many other countries in the region where we work. The second aspect is that what the health care system is facing is not only an Irish issue, it is an issue across the region. Two days ago I was in Helsinki presenting to a committee similar to this one with senior policy makers and civil servants where we did an evaluation of the health system reforms there. Many of the issues we addressed there were very similar.

Another concept I will refer to a lot today is that of specificity and what academics call path dependency. There is no such thing as a technical decision that applies to all countries even if academics like certain ways. It has to be very much tied to the history and the system. I am sorry for these long preliminary comments but, as I said, I could do ten minutes and give the committee the menu. Perhaps I could even start with my conclusions and then ask members to push me to any of the areas I have mentioned or I can take it area by area, whatever the committee prefers. I hope I am not being too informal in my approach to the committee. I hope it is okay that I do it this way.

Perhaps Dr. Figueras should give an initial presentation on how Ireland rates relative to other European countries in terms of our health care system and then we might go through it area by area. Is that okay?

Dr. Josep Figueras

Yes. As the committee can see there is a lot of data in my presentation. I will start by discussing whether Ireland is getting value for money. What do the indicators look like in comparison and how much is being spent? One of my slides shows the percentage of health care expenditure against GDP. It is typical of most presentations on the subject so it will be no surprise that Ireland's health care expenditure as a percentage of GDP is so low. I got one of my research fellows to update all our figures and data for this meeting so the slides I have given to the committee contain the most recent data from the WHO, the OECD, EUROSTAT and so on. The available data are from 2014 and 2015. I will be very happy if the Chairman wants me to give a detailed analysis of expenditure trends. I have the figures here so we can go back to that.

Life expectancy is the other main indicator but I have other indicators such as preventable mortality and avoidable mortality, which we can come back to later if the committee wishes. Life expectancy in Ireland is above the average in OECD countries. The committee will see the data for women on the left and the data for men on the right. I looked at these figures with a colleague and it is interesting to see that healthy life years in Ireland are higher than in other countries. Ireland is above the average.

If the committee looks at the data for healthy life years, it will see that life expectancy is broken down into healthy life years and life with activity limitations. That is how that is measured. It is quite high, which is a really interesting element. I have more data on a form of benchmarking that looks at issues of life expectancy and risk factors. It will remind the committee that Ireland has challenges with regard to obesity. It is a reminder because the committee knows this very well. Despite this challenge, Ireland was the first country to introduce a novel tobacco ban. Many countries followed Ireland and used its example and research. Ireland still has challenges with regard to tobacco and alcohol.

I am very familiar with the Healthy Ireland strategy. One of the elements I would like to talk about later on is how that relates to other health policies and approaches in Europe. In terms of cardiovascular diseases, Ireland has made huge, amazing improvements that explain improvements in the life expectancy figures. There is a mixed picture but one that shows Ireland is going in the right direction. Researchers never manage to get the data for amenable mortality right. It is an indicator that is meant to look at mortality that would be amenable for health care services. There is amenable and preventable mortality. It is terribly difficult to disentangle mortality that can be addressed through the health system from mortality that is addressed by determinants. This data is an attempt to do that. As the committee can see from the slide, there has been a measured improvement.

The green pertains to 2014 and the pale pink to 2000. One can see the huge improvements. Ireland is fairly low down the ranking in terms of amenable mortality for both males and females. A lower ranking is more positive. With females, interestingly, the ranking is a bit higher. We ought to be very cautious about how we interpret some of these data. Let us not attach too much importance to them. They help to give a sense of what is occurring, however. Ireland's health services are doing pretty well if we take the data as an indicator of their impact.

I will return to the issue of preventable mortality. Is it satisfactory for me to give an overview and then refer to the options?

Dr. Josep Figueras

I really want to tackle the members' questions but an overview could be helpful. I shall return to the indicators in a minute, if members wish.

Consider the question of whether value for money is being obtained. The relevant slide is very simple and I do not like its approach but it is still fairly solid. On the vertical axis is health expenditure and on the horizontal axis is amenable mortality for males and females. I refer to mortality that is amenable to health care. Is value for money being obtained? The vertical line shows countries such as Luxembourg, France, Belgium and Ireland, which is clearly pointed out, and also Finland, Italy, Spain and Cyprus. They are all on the line that shows relatively low levels of amenable mortality for males. For the same amount of money, there is a huge variation. One could argue, therefore, that Ireland could be lower down and get the same levels as Spain, Italy or Cyprus, for instance. That is an indictment of the data, however, because the system in Cyprus still does require a fair number of reforms, yet it has low levels of amenable mortality. I should be cautious in saying this. Perhaps this measure of the impact of the health system may also be affected by diet and lifestyle factors. Cyprus, which is in the Mediterranean, has a very good diet, as with the Greeks. If one makes a comparison with the countries on the right of the graph, such as Portugal, the Czech Republic, Estonia and some others, one can see they do not spend very much money per person and have higher levels of mortality.

That is an overall picture of Irish life expectancy, health outcomes and risk factors. I will discuss this area for ten minutes and then I will be happy to answer questions on the details. My job is to reflect with the members on how international comparisons can help them to think about how to proceed. The questions in the data are very much the ones faced by Ireland and elsewhere.

The EOHSP's approach is the one it has been using for other countries. Consider the question of whether Ireland should reform its statutory funding system. I refer to the debate on taxation and social health insurance. Clearly, the experiences with competing insurers have not been very positive. I will be very happy to discuss in detail the Czech and Dutch experiences. I know these very well because I participated in the reform evaluations. Perhaps this debate should be on whether Ireland should reform its general tax system or its social health insurance system.

What we say, in a slightly superficial tone which I hope the members do not mind, is that it is not a matter of a Bismarck or Beveridge system. Both Otto von Bismarck and Beveridge are dead. The current debate is not about social health insurance versus taxation but about whether the system is sustainable, efficient to administer and flexible in a crisis. I have a fair amount of experience of how various systems in Europe have reacted in times of crisis in terms of compensating for the shortfalls. We can discuss and debate that but I believe the question is how we adjust either the social health insurance system or taxation system in such a way that the health system can remain stable, deal with crises, provide the appropriate amount of resources, and account for progress and differences between taxation and insurance in some instances. I have data on this so I invite members to push me on whatever area they wish, as long as I have the answers, of course.

Most countries have a mixed system. The other kind is very rare and the trend is in the opposite direction. Owing to the impact of social health insurance on labour costs, most countries tend to increase the amount of taxation to compensate or subsidise the insurance system. All in all, if I were to dare to make a suggestion for the committee's consideration based on international experience, it would be on the fact that a move to social health insurance would not bring additional resources. There has been a fallacy in other countries that social health insurance will flood the system with resources. They are not available, basically, and if they are very large, they will end up having an impact on the labour costs. Second, the administrative cost of transactions may be high so one may need to proceed cautiously if one wants to move to a social health insurance model. I will be very happy to debate this.

On statutory resources, are there any other sources of statutory funds that we can use? I have a list of what other counties have been doing, particularly in times of crises. There are some interesting insights from our studies. All of the studies are available. We produced one on the impact of the crisis in Ireland, which I hope the committee has seen. Has the Chairman seen it?

I read some of Mr. Figueras's work in that regard.

Dr. Josep Figueras

The study was from 2012. We were trying to examine some of the options for Ireland in dealing with a shortfall in resources. I can show some of the slides.

One point I will be making throughout my presentation today is that I want members to keep in the back of their minds when they do their work that it does not matter whether the cat is black or white as long as it catches mice. It is a no-brainer that political values are extremely important in this decision but it is important to separate from other values the values we give politically to the role of the public or private sector, the role of competition and the role of private insurance. Politically, we may give value to the private sector but the important point is to disentangle the political debate from the technical debate in some instances.

One of the more complex issues debated with policy makers when we go on the road is the considerable confusion arising from saying one wants a system because it fits one's values. Consider the value of choice, for instance. Choice, even if it does not lead to efficiencies, is valued by populations and member states. I live in a country called Belgium, where choice has proven to lead to inefficiencies and inequalities, yet it is valued so much by the population that it is maintained in spite of the evidence. It is appropriate as long as we distinguish between the value debate and the technical debate. What I am saying is not rocket science; the members know that a million times better than I do but I assure them this is the kind of debate we often face when we work with other member states on these issues.

On raising extra funds statutorily, Ireland has some taxes on alcohol and tobacco and is considering a sugar tax and taxes on unhealthy foods. That is the way to go. We have an increasing amount of evidence on this and I will be happy to thrash it out in a minute, if members wish. I am referring to the direction member states are going. It is a way of having your cake and eating it. That is not a very good metaphor since I am talking about taxes on unhealthy foods. The tax does change behaviour. There is elasticity clearly, particularly with fizzy drinks, such as Coca-Cola and others. One may raise additional taxes to further finance the health system. Of course, the problem is that if this is effective, it kills the source of funding. I have to hand a picture showing Jamie Oliver very happy about the recent developments. There are some issues on this subject that I will be very happy to discuss with members if they wish.

Going through my list today, the third area deals with the question should Ireland change its statutory funding? Should it find additional statutory resources by other means or should it try to shift costs to the private pockets by further increasing the role of private health insurance and out of pocket? Again I have plenty of data to show what other countries are doing, the pros and cons, the use of charges, the role of private health insurance in other countries, and some of the issues and incentives. This is a very useful framework that I will use, if the committee wishes to go through it, which tries to ask three questions. The blue box in the middle cube is what one is providing.

So there are three questions. First, what would be the benefit package? Should we expand it further or reduce it? What is one producing? Second, how much of that is one paying in the form of user charges? Is one paying the whole package or, as is done in Ireland, where there are large charges? We will talk about that shortly. They are fairly substantial, not in overall terms but very large in comparative terms, in primary care in Ireland. I have data on that. In percentage terms it is around 15% of Ireland's overall expenditure. It is about the borderline - I will show the committee the data in a committee - where one may endanger financial protection, particularly because it is very much aimed at a particular area, which is primary care and hospital care in spite of the medical cards that may lead some users not to use the services properly because the user charges are quite large.

The third question to the committee is should we reduce the universal package and take some of the population out of the coverage. That is not something that member states are doing. One thing we have in Europe, where the changes have been minimal, is that there is a commitment that makes sense not just in terms of solidarity but in terms of efficiency; there is commitment for universal health coverage. So there has been very little on the "who" of reducing the universal health coverage. There is a lot of debate about the user charges - again I will give the committee details on that - and there is debate about the cost of the benefit package.

On the benefit package, most of the debate is focused on the issue of before we start rationing perhaps we should do much more work on those areas that are not cost-effective. There are many interventions in Ireland as well as anywhere - I have data on that as well - that are basically not cost-effective. If one wants to reduce the benefit package one should start in that particular area and there is evidence on that.

I would like to summarise this paragraph for the committee. As members can see I have data here on how Ireland compares with other countries on public and private expenditure. I hope I do not overwhelm the committee with so much data. Let me give one thought before we go back to that. If there is one slide that members would wish to remember today, it would be this one. I am sure they have seen it before, but I still ask them to consider it for me. We have to remind ourselves of the 20:80 distribution, the 5:50 or the 10:70. This tells us that 10% of the population in all countries will use 70% of the resources. That may vary a bit but this is based on many studies - I have data from many countries - and this is an average. Voluntary health insurance out-of-pocket will not resolve this issue. Ireland has a number of health insurers and a fair amount of regulation. No health insurer, not even some of the best regulated ones will ever cover the 10% which involves the chronically sick and so on. Private expenditure of that kind will not resolve the cost-containment issue. It may play a role if properly designed, but it will not resolve the issue.

I ask members to look at the yellow bubble. One of the problems arises because the insurers are far better than the civil servants in the Department of Health in selecting risks. Irrespective of the amount of data available, the insurers will always find ways to select risk. I know Ireland has lifetime community rating, but we all know that with a very large number of packages in Ireland there are multiple ways for the insurers to select risk. I am not criticising the insurance market. The insurance market is there to make money in many instances and therefore it is only normal to try to select risk - the incentive is there. Even with good regulation that is a very difficult issue to address.

My fourth question is about rationing. I am talking so much even in my introduction because I had all these questions in my remit so I am trying to do it in as short a time as possible. This is another slide I would like the members to remember. This is very well known data and was published in the BMJ in 2009. More recent data will look exactly the same. It tells us that out of 2,500 treatments in a hospital today for as much of 50% of them we do not know whether they are effective. Even scarier is that a number of those, like the green segment here, 8%, plus another 8% referring to trade-off benefits and harms, may be harmful although they may be unclear. While one may wish to cut the benefit package, it should be done in such a way that we start targeting first.

There have been some good developments in Ireland with pharmaceuticals, for instance, not just on price but in looking at those pharmaceuticals that are more cost-effective. We talked about the funding, a package of care and the use of charges. What can we do to squeeze more efficiency from providers? What is the menu there? The menu that the committee has in its terms of reference as well - we know there is a lot of waste - is in these slides. I will go through it again very quickly and then I would be happy to go back in detail.

There are guidelines on protocols and innovation in ICT. Ireland has a fair amount of developments in this area, but there is more scope in the sector. I am aware of Ireland's reforms in the area of payment for performance - around the DRGs, increasing the amount of payment according to activity is clearly the way to go to have a higher percentage of that to adjust for severity. Clearly we could do more work in the area of pharmaceuticals.

I know integrated care is very much part of the committee's terms of reference. Context specificity is a debate. The last country I visited, Finland, developed a very interesting pilot on experiences of integrated care. The committee there was looking for structural top-down reform. Finland is relevant to Ireland as well. Like in many other countries, Ireland wants to do things very much bottom-up and build on groups of nurses, social workers and those in community service, who are already working together, and try to strengthen that rather than try to impose new models. Integrated care has a high variability of models. What we want is teams working together offering the kinds of framework incentives and structures so that they can work together. It is good to have some top-down but also to have some bottom-up.

Ireland has a lower number of hospital beds. I know it is in the process of bringing together hospital groups. I was very impressed by one of the documents I had the opportunity to read. It was the Department of Health document, Better Health, Improving Health Care. It goes through these issues very effectively. I guess it is one of the documents of this committee.

The hospital groups may be a way to create this type of network. Due to its geographical nature and size, Ireland is not a country in which one wants to provide competition except in Dublin or large cities. Instead, groups should work together, particularly in cases of horizontal and vertical integration. There is a fair amount of scope for efficiencies. Although Ireland's number of beds is relatively small compared with others, there is more scope for horizontal integration and volume outcome. The volume-outcome relationship is another commandment, to use an almost religious term, in that there is a consensus across the region that we are not treating certain patients at the right level. That relationship is important. I do not know the details in Ireland, but I am taking an international perspective. I do not know whether the volume-outcome relationship is a major problem, but I imagine that it may be an issue.

Another area of interest for Ireland is that of skills mix optimisation. I will cite numbers in a moment. Ireland has more nurses than doctors, which is the international trend. Ireland has considerable potential to get more nurses and similar professionals into the skills mix, given the shortage of doctors. The observatory is undertaking a major study of different skills mixes. There is plenty of evidence that nurses are better than doctors - I should be cautious, as I do not know whether the rules of the committee allow me to say this - at chronic care and prevention because they spend more time with and are more empathetic towards patients. I am a medical doctor as well as an economist, so I am not against the medical profession at all, but there are many ways in which we can use nurse practitioners. Ireland is in the process of implementing, and could step up in this regard, the concept of primary care teams, PCTs. The role of nursing and similar professions is important, in particular as we move to community care. We could discuss this matter in a minute.

Interestingly, I got recently updated data on 2014 for the committee. These data show Ireland's peculiar situation. They take a bit of time to understand. The middle is the average of the EU 28, with two axes. The vertical is the number of nurses. This is in comparative terms and I am not saying whether it is good or bad. I am careful about averages. There is a sense that, if one is average, one is fine, but that is not true. At the top are countries with a high number of nurses. I believe that the green is Norway, but I cannot remember. Ireland has a higher than average number. To the right on the horizontal access is a high number of doctors. I hope that I am not making a mess of this. In the upper left quadrant is Ireland, which has a high number of nurses and a low number of doctors. What does the spread of countries tell us? Is it not an interesting presentation? It tells us that there must be a great deal of uncertainty if there is such a variation between member states in the most basic mix in health care, namely, between doctors and nurses. Imagine what the case is in respect of specialists, surgeons and other professionals. We do not know what the right mix might be.

Next are recent data from my colleagues. The observatory has done a great deal of work on migration and these data are based on the OECD's figures. It does not mention that in my presentation, so I apologise. My colleague, Dr. Irene Glinos, put these data together. They show that Ireland relies heavily on foreign doctors, accounting for as much as a third. The committee will better understand the situation of doctors coming from other countries than me. In spite of this path dependency, Ireland is the only country in Europe - I will dare to speak strongly on this point, with the Chairman's permission - that does not have universal coverage in primary health care. Primary health care is free to access in every country in the EU regardless of income or economic strength. I know about Ireland's path dependency, the significant positive strides and recent changes that have been made to cover people aged under six years or over 70 years of age with medical cards and the importance of equity in access, but universal coverage in primary health care is a principle elsewhere. Time and again, reforms have told us that primary health care provides value for money when it works well. As with any study that is shown to the committee, this one presents problems, but it tries to highlight variations in the strength of primary health care. In Ireland, primary health care does not look good. Ireland is in the red based on this.

I am cautious, cautious and cautious - I say this three times - about data and benchmarks of these kinds. I am presenting these to provoke debate in the committee.

For instance, these are the data on which we based our work. Kringos et al worked with us as well. We have been using that study, which examined issues of structure, accessibility, continuity of care, co-ordination and comprehensiveness. These numbers are indicators. Actually, there is another slide. I am sorry, and I hope that I am not confusing the committee by showing so many slides. This one may be easier to understand. It shows the structure of primary care and the delivery process. For Ireland, it is weak, weak, strong, weak, strong, weak and medium. Service delivery is on the right-hand side of the slide. Access is weak, continuity of primary care is strong, co-ordination is weak and comprehensiveness is medium. All in all, it counts as weak. We can discuss this study, as it is worth consideration.

I will make my next comment with a great deal of caution. Ireland has experts from whom I learn. I am just drawing from others and the international comparisons. Dr. Sara Burke appeared before the committee recently. She, Dr. Steve Thomas and Professor Charles Normand have done much important research and know far more than I do but, based on this research and others, user charges plus alleged access issues may explain Ireland's hospital-focused system and its difficulties in returning people to primary and community care. The committee may wish to consider this matter further. Here are more data in that regard.

In discussing primary health care, this is a good indicator. These are OECD data on hospital admission rates for patients who should not be in hospital because they would be better treated elsewhere. That they are in hospital may mean that primary care is not as effective as we wish. Look at Ireland in the spider's web on this slide. In terms of chronic obstructive pulmonary disease, COPD, Ireland has one of the highest admission rates in Europe. Why would so many patients be admitted to and treated in hospital for this? I must be cautious, as there may be many reasons. For example, it may be an incentive for some because they do not need to pay user charges or they may not be taken care of in general practice. I do not know the exact data, but the committee must examine the issue.

Other issues are also worth considering. For instance, the blue represents diabetes. Ireland is around average, although it could do better. Green is asthma and over there is CHF. Is that chronic health failure or cardiac heart failure? It is chronic heart failure. I am sorry. Sometimes, the chronics confuse me as well. Ireland is doing well in this regard and the figure shows that it is better controlled. I know what members are thinking, namely, that this does not quite make sense.

It is not a coherent picture. There are some indicators that may explain why primary care is not as effective as it could be, as well as data on the quality of hospitals and so on. Ultimately, we must work on health determinants and policies.

I am fascinated by the factors behind the decline in coronary heart disease. A comparative study into the decline in coronary heart disease looked at treatments, risk factors or unexplained factors. The results are very interesting, depending on where one carries out the study. In Finland, for example, 76% of the decline was attributed to addressing the risk factors and 24% to treatment. In the United States, 47% is explained by improvements in treatment and 44% by addressing risk factors. I must remind the committee that risk factors play a very important role in decreasing coronary heart disease. That is obvious. Ireland has a very good policy in this area, Healthy Ireland. It is worthwhile supporting and continuing to push this new policy. The work on obesity, alcohol, tobacco and so on is very important. Obesity is one of the major issues facing this country. It will have an impact on sustainability.

If committee members have time and cannot sleep some night, they could look at the OECD and WHO research data. It is actually very good but it is deep. It systematically goes through the various interventions that yield value for money by looking at determinants. There are lots of data there which show value for money is related to determinants. In terms of various policies in Europe, Ireland, with its new policy, is very much in line.

I will move on to sectoral governance covered in my last slide - I know I keep saying that but the terms of reference the committee gave me were very broad. One of the complexities that we see in reforms elsewhere is in implementation. It is a question of how one aligns incentives. It is fairly easy to look at this area by area and say that is what we should do. The really difficult thing is how to phase it in. How do we make sure that the incentives do not push us in opposite directions? We may want to rationalise hospital care but then private health insurance provides a number of incentives not to do so. We may want to have open access but then introduce a reform that goes against this. One of the elements is the alignment of incentives or reforms and then staging or phasing them in, particularly in the context of fairly complex structural reforms. The ability to stage them, to go to the low-hanging fruit, not to burn out the system or run out of capacity to implement the reforms is crucial. Many of the reforms are very complex to implement.

I presented a paper to the Council of Ministers of the European Union recently and I hope to be able to explain that here. One of the things we learned about reforms was the impact of the financial crisis. The apple tree diagram was developed by Dr. Bengoa and myself and it deals with the kinds of reforms that can be done. When there is political pressure, as was the case in Ireland and many other countries, one must go for the low-hanging fruit. A word of caution - I mean low-hanging fruit in two senses. First, starting the reforms in areas that are cost-effective, easy to do and with which one will get results. Second, low hanging fruit can also refer to situations where the Minister for Finance, as happened here, knocks on the door and says "I need a 5% cut". What has happened in many countries in Europe is that they have gone for the low-hanging fruit because of the pressure. Some of these reforms were good, including price control on pharmaceuticals which Ireland did. This was excellent because Ireland was one of the highest spenders on pharmaceuticals. Ireland's negotiations with the pharmaceutical companies and its work on generics and so on has been very much in the right direction. However, in other areas, it was not so good. Cuts to training and research, increasing use of charges, staff cuts, population exclusions, rationing benefits and so forth may save money very quickly but may not necessarily give the system sustainability in the long run. What has happened in many of the member states is that the high apples that are difficult to do, many of which will not show savings very quickly, have been left. Let us take integrated care as an example. We did some research recently which shows that integrated care increases the cost-effectiveness of the system but will not yield short-term savings. With integrated care, you treat patients better, which is the way to go. However, cost-effectiveness is not equal to savings. These are the complex areas that do not yield immediate savings but which increase cost-effectiveness. If we concentrate on those, we may have less energy to undertake the complex, structural reform implementation. Some of what needs to be done in Ireland is rather complex. It is important to focus on it, stage it, look at the alignment and so on.

I will make a few concluding remarks and then we can go into detail on any aspects of my presentation about which members have questions. In terms of implementation, caution must be taken with structural reform. I know structural reform is necessary but caution is needed. It is important always to remember context and part dependency. Marginal reforms might be more effective. It may be better to strengthen the current system rather than embark on major structural reform of insurance, for example. I spoke about alignment and the importance of the process and pace of implementation. Ireland and many countries in the region have a lot of uncertainty in their models. We do not have evidence on what is the best way to integrate services or to pay doctors and nurses, for example. I was working on a reform of the French system involving payment for performance, for example. We have some evidence on this but we do not know how actors will react. Bob Evans used to say that the only way to pay doctors is to change it every year so that they do not have time to adapt; you keep confusing them and moving them around. He suggested that the answer was to move them all of the time. That sounds cynical and I hope the committee does not mind me making such a joke. This is not a good way to pay doctors or nurses.

Technical capacity is important. I am particularly impressed with the ability and capacity of researchers and the Department of Health in this country. I had the opportunity to work with them in a number of areas. There is a lot to be done but if one tries to do it all at the same time, it will not work. Flexibility and bottom up reform are also important. If it is necessary to pass legislation, I would recommend using framework legislation that allows flexibility. I wish, if I may dare, to make a suggestion to the committee. This committee is extremely important but if it is very normative, with a big blueprint, it may find that it cannot predict what will happen in the next five years. It is impossible to predict how things will work out. I apologise for being so direct. I have seen similar committees. I wish to congratulate members for this initiative but if the committee tries, in the context of such a complex area, to devise a detailed blueprint, it may prove very difficult to implement.

The issue for this committee and similar ones in other countries is to devise a good framework, with guiding principles and a consensus on the fundamentals but to allow flexibility so that the reforms do not end up working in different directions. In terms of the low hanging fruit, political resources for change are always limited, even if this is a consensus committee. Human resources in particular, are always limited. It is important, as I said before, to concentrate on those areas that are easy to implement and about which there is consensus.

Finally, as policy makers, members of this committee know already that communication is the essence of everything. How one communicates with the medical profession is very important. It is very clear what the medical profession in this country, and elsewhere in Europe, wants. It is essential to have all of the medical professions on board. Attention must also be paid to communication with the press and the public. I know this is all very obvious. I would just point out, without mentioning any names, that I was presented with five business cases for reforms recently. They were excellent reforms but they were totally misrepresented by vested interests and they failed, even though they were technically excellent and necessary.

I apologise for taking so long, even though I was attempting to give the committee an abridged version of my presentation.

I thank Dr. Figueras. He said in the course of his presentation that our terms of reference were very wide. That is true, but there are two key ones. The first is a request for us to make recommendations on a universal single tier health service. The second is to reorientate the health service away from acute hospitals to primary care. We are very keen to learn from best practice and what has worked well in other countries, recognising the particular features of the Irish situation. I ask Dr. Figueras about those two areas. In terms of primary care, Dr. Figueras said we are the only country that does not have universal access to primary care. If we were to start by providing universal access to good quality primary care services, what would he recommend in terms of the basket of care?

My second question relates to the universal coverage cube. How do we best approach the three questions contained in that cube?

Dr. Josep Figueras

With regard to the benefit package, is the question on primary health care or in general terms for the entire health services?

There is a view emerging from the committee that, in terms of phasing in reforms, we should start with primary care. If we were to look at bringing Ireland into line with the rest of Europe and having universal primary care, what is the package of care that should be covered by any kind of guarantee?

Dr. Josep Figueras

That is an area which is relatively easy to deal with. It is much more complex to talk about the technologies or the treatments of certain cancers or diseases where there is more uncertainty as to where they should be rolled out. In primary health care, it is fairly straightforward, starting with health promotion. I should have said health prevention. Health promotion is important also, but it is partially outside the health care system in terms of health. Clearly, it plays a fundamental role in secondary prevention, and primary prevention to some extent, in terms of screening purposes and areas on which there is consensus such as screening for a number of cancers. Colon cancer is a very good example, but there are many others such as diabetes, blood pressure and cholesterol on which the guidelines are very straight. There is no uncertainty as to what is cost effective and what works.

At the margins, we could debate certain screening. We could go into prostate cancer, for instance, which is an area that is not recommended, but there is plenty of evidence in that area as to the kinds of secondary and tertiary prevention interventions we can do in primary health care.

In terms of the shape of the system, the remaining benefits are from first contact care. I would strengthen the ability of general practitioners and primary care teams to do some diagnostics. There is much more that can be done at that level. The control of chronic diseases should be at that level for most of those, unless there are major complications. We do not want diabetes, chronic obstructive pulmonary disease, COPD, and many other diseases, including asthma and so on, controlled elsewhere. From what I have read, and I apologise if I make a mistake as I do not know the Irish system perfectly well, that is very much the direction in which Ireland is going. I would very much suggest that Ireland move in that direction. I repeat that secondary prevention, control of chronic disease, and being able to address the first contact care issue are important. It is being able to make the first diagnosis or to refer quickly someone with an acute disease who comes through the door. Continuing the gate-keeping is the way to go, although the gate-keeping here is very soft. By that I mean, they are wise to bypass that. There is a huge problem in the accident and emergency services, which I believe is partially because the middle classes have to pay €55 to see a GP. I probably should not say this but I can understand the incentive for the middle classes to go directly to hospital if they have to pay €55 to see their GP. Am I answering the questions?

Dr. Josep Figueras

It is fairly straightforward. I could go through the process disease by disease, if the Chairman wishes, but it is quite straightforward. The Chairman can interrupt me. I talk too much.

In addition to the areas Dr. Figueras has mentioned, the area of screening is a public health measure-----

Dr. Josep Figueras

That has to be implemented.

-----that has to be delivered through primary care.

Dr. Josep Figueras

I am sorry but I forgot to mention a very important issue. In terms of Ireland's current system of gate-keeping, it has a per capita and a registry system, but several doctors can be used for the same procedure. If Ireland ensures compulsory registration for GPs or primary care teams, screening can be integrated into primary care. Am I making sense? I apologise for interrupting the Chairman.

In the best performing systems where there is universal primary care, does that provide an entitlement to therapeutic care as well such as access to speech and language therapy, physiotherapy and so on?

Dr. Josep Figueras

That is a very good point. Not always, no. The variation is huge. We need to look at them case by case, and I will not remember them off by heart, but the answer is "no" in terms of areas such as physiotherapy, speech therapy and so on. There is a huge variation as to how those community rehabilitation types of health services are provided. With regard to physiotherapy, for instance, some countries provide a number of sessions, depending on the disease, paid by the system. Following that there would be a user charge or the patient would need another inspectorate or GP to refer them. In countries such as the Netherlands, which is the first example that comes to mind, they had to limit that because there was an abuse of the physiotherapy service and so on, to the point where it was no longer cost-effective. They had to reduce that. The answer is "no". It is true that for some of these areas there is not universal access. That is a very good point.

I thank Dr. Figueras. We might return to the universal coverage cube later. I will call other members in groups of three, following which Dr. Figueras might respond to the questions.

I thank Dr. Figueras for his presentation. I was wondering if he wanted a job. In terms of the 10% cohort of patients that insurance companies are able to circumvent, had they defined diseases? Can we plan for dealing with the 10% that are missed by the insurance model?

Other presenters spoke about a menu of services and not having an endless treatment menu. In terms of the more than 49% of ineffective treatments, would Dr. Figueras recommend that we edit down our menu of services? If we opt for the universal health care model, should we slim it down first to ensure we have services that are effective and evidence based?

Dr. Figueras said we had a relatively low figure for bed numbers. Does he have any data or a chart on that? There seems to be a chart for everything. Do we have a chart to show how we compare to other countries?

In terms of the doctor-nurse mix quadrant graph 4, is there any data to show the links of those mixes with outcomes?

When we consider primary care workforce development, Ireland is considered strong when it comes to how we are developing our workforce. With regard to other countries that have a more developed primary care workforce, how did they get to that good place? Do we have data on that? With our strong measure for workforce development, is that where other groups came from? Does that make sense?

I thank Dr. Figueras for his presentation, which was very interesting.

Dr. Figueras spoke about framework legislation that allows flexibility, perhaps he will elaborate on that. My next question is a bit of a novel question. In the Dáil last night we spoke about cigarettes and the fact that 50 cent has been put on a packet of 20 cigarettes in the budget. They now retail at €11. My sister died seven weeks ago from lung cancer. She was 35 years of age. She was a smoker but they said it was nothing to do with smoking. The reason I say this is that she had a stroke before she died and when she was in the acute stroke unit in St. James's Hospital, there were many stroke patients there who were a lot older than my sister Edwina and who were going outside to smoke even though they had just had a stroke. The staff were losing their senses over this. They were angry and upset that people who had had a stroke were still continuing to smoke. I phrase my question in the context of knowing people who smoke. It is not that I want them penalised but when one looks at insurance companies, for example, a person will have a more favourable policy if he or she is a non-smoker. Does it happen in other jurisdictions that non-smokers are prioritised in regard to health care or in some other way? My question comes from the premise of trying to help people and to incentivise them to give up smoking. Does Dr. Figueras believe this is something that could happen in this State and does it happen in any other country? I would be very interested to hear his view.

Dr. Josep Figueras

I hope I remember all the Deputy's points or that she or the Chairman will help me. I have written down some notes.

I thank Dr. Figueras for his presentation this morning. He notes the extent to which the crisis has achieved some positive results and he refers to the generic medicines and value based procurement. Perhaps he could speak to us a little more about that with regard to cost-effective measures that could be put in place. Dr. Figueras also spoke about areas where immediate savings had to be made which did not affect the quality of our health outcomes and he made reference to low-hanging fruit as opposed to greater reform. Will he expand on, or give examples of, that? It is interesting that he noted that measures to make health care more cost-effective do not often produce outcomes in the short term. Is it the case that additional expenditure is required upfront to see the benefits at the back end of the process?

If the witness could do his best to respond to that wide range of questions I would appreciate it.

Dr. Josep Figueras

Yes, I will do my best. These are really good questions. I thank the Deputies who have got to the heart of the issues. I very much enjoy having the opportunity to thrash out these issues. I will try to structure my replies around my presentation and I hope I will not forget any points that have been raised.

I will start with the Chairman's questions about the benefit package. Some of the questions raised had to do with that query, particularly the issue of the 10% of the population and the insurance, the benefit packages and whether we should prioritise against those people engaging in harmful behavioural practices, such as smoking, etc. There are some examples that I will share with the committee. I will take the last question first because I would hate to forget that one and not to respond to it properly. I must be cautious. What I am saying is that one of the most difficult concepts to explain to finance Ministers is the difference between cost-effectiveness and savings. One can be cost-effective and not have savings, one can have savings and not be cost-effective and one can be cost-effective and have savings. In addition to Ireland, I have been in many other countries hit by financial crises, which I will not mention, and I have worn my more academic hat and talked about their options. The finance Ministers would say, "Yes, Josep, fine, but my new budget is in January and where do I get the money out of that?". It is true that for integrated care, one sets it - for many of these areas, one has to invest first. Even when rationalising hospitals or when closing hospitals, which in theory gives savings, in the first two years, it generates lay-offs, packages which must be provided and the integration of services. I do not want to sound superficial when discussing closing a hospital but one of the biggest complexities when merging hospitals is who is going to be the head of each department of the merged entity. That may sound funny but it is actually an example of the political complexities - political with a small "p" - which create a lot of inefficiencies and create the noise that reduces efficiency. In the long-run, rationalising hospitals will share the savings. Integrated care may share the savings but the other issue there is that the savings for integrated care do not accrue to those who put in the money. All this money is put into community care but who benefits from that? It is the hospitals because they will have fewer admissions. The Deputies may be aware of a basic principle in health care - bed empty, bed filled. One may end up being very cost-effective in community care because patients are being treated in a more integrated way but the savings will not be seen as they will go elsewhere, or the savings will be used by other patients. Yes, one has to invest in many of these areas, and I am very glad to see the numbers in regard to Ireland's economy are getting better, and now Ireland has the possibility to do this restructuring and focus on the high tree. The level of the tree will allow it to shed the mid-term to long-term benefits and cost-effectiveness.

The second point, which is very important, is that it is true that finance Ministers sometimes do not understand the difference between cost-effectiveness and savings, but when they do they are not as worried. I have encountered some people, whose names I cannot say in a public committee, who in discussions with their finance Ministry have said that the curve has to flatten and they cannot spend more than that, but they are mostly concerned about being a black box - they want to be reassured that if money is being spent, then it is cost-effective and makes a difference. They are very worried about all this money. We tell them it goes into health services, it is very important and very useful and that health is wealth. Yes, I have plenty of data on the subject of health is wealth but one has to demonstrate it.

The Chairman has asked that I speak about the benefit package. I will address this question. If I am not mistaken, many of the other questions are around delivery of promotions, skill mix and so forth. I will turn now to the package of care, prioritisation and the issue of the 10% of population, which is circumvented by insurers. If the committee will allow me, I will be a bit more structured. Do we have ten minutes for that? How in depth would the Chairman like me to go? Some of these questions require a bit of detail and the Chairman will have to tell me how to ration the time as I do not want to be superficial in the response.

We have another hour.

Dr. Josep Figueras

That is a help.

There are, however, a number of other members who are keen to contribute. Perhaps Dr. Figueras could respond to specific questions first.

Dr. Josep Figueras

Perfect. I will go as fast as possible.

Then we might look at some of the overarching issues.

Dr. Josep Figueras

Let me spend a little time on the question that then leads us to the issue of the 10% of the population, which is circumvented by insurance companies. The typical figure, which I believe the Deputies have seen many times, shows the percentage of statutory funding - in this case it is coming from general government taxation - is 67% in this particular data. This data is for 2012, but it has not changed that much. I was looking through newer data - my research fellow did not send me the data from 2015 - but it is not that different now. The figure of 67% in relative terms is under the OECD figure. I apologise if I am confusing the committee. For some figures, I am using the relevant numbers from OECD data while for others, I am using the EU 28 data for 2017.

There are two interesting aspects of the situation in Ireland. One is that its level of funding from private health insurance is one of the highest in the OECD, at 12%. France has a very different funding model but Germany is at only 10%. Slovenia is interesting, and one to look at if Ireland wants to reform its private health insurance. We did an evaluation of Slovenia's reform and studied the role of private health insurance. The United States is not relevant for Ireland so I will not discuss its system.

I am not against, or in favour of, private health insurance but I ask members to read the book about it I have brought along to the meeting It is a very recent book and I can send electronic copies to members if they wish. No country has managed to use private health insurance appropriately and it is terribly difficult to do so. The companies select their markets and always work in the most profitable areas so they will not resolve sustainability issues. I do not say they do not play a role and they are often highly valued by the population. In one country, three Ministers lost their jobs trying to reform private health insurance. The population believed private health insurance was so important that it was a no-go area.

If a country has private health insurance it should make sure it is not subsidised by the public sector, though I am not talking about Ireland in this case. If private health insurers cover 10% of the total market they should pay the full cost to the hospitals, they should not benefit from special subsidies or prices or gain equity benefits from bypassing queues.

There are two issues. One is the issue of efficiency and the other is equity. In countries like Ireland, which have supplementary insurance enabling people to bypass the queues, there is a negative impact on equity. According to data I have, Ireland has among the largest supplementary insurance coverage in Europe. There is also an efficiency argument too, because if the funding is there one will want it to be used for a cost-effective package of services. An economist once said that financing the health service is taking something from one pocket and putting it back into the same pocket. It is a fallacy to say that private health insurance does not affect the treasury. I pay for it as a citizen, so why do we not have the same rigour for private health insurance as we have for general taxation? I pay my money to an intermediary, namely, the State to the social health insurer or the private health insurer. There is a consumer, an intermediary and a provider - that is what the economics of health care are. People want the citizen not to pay too much and the system to be as progressive as possible. They also want the intermediary to use the money and to get good results from the provider. Private health insurers have not been shown to be more cost-effective and they have higher administrative costs. They select markets, are more expensive administratively and tend to be less cost-effective when it comes to purchasing, as these studies show, and it is a fallacy to say otherwise.

I will summarise the general findings on health insurance from the book. There are concerns about financial protection for equity. One has to take account of the fact that tax discounts for private health insurance amount to paying them with public money. There are efficiency concerns and there is no evidence of superior efficiency in purchasing. This is the broader perspective on the 10% question. There have been many debates about this but it has not proved possible in any country to have a lot of competition in the private insurance sector for the 10% to whom Deputy O'Connell referred. The 10% in question are chronic diabetics and chronic patients in general. For the 10% one would need to have integration of services and a chain of services. One would want to pay providers by bundled payments. The mechanisms of private health insurance include shopping around and market competition but if one wanted to introduce market competition one should start with areas where there is a clear product to measure, such as surgery, where one can readily measure the quality and the cost. No private insurer is going to take the very expensive patients. We have information about what such patients spend and it is practically impossible to create premiums for them. The young will never join such schemes because there is no incentive to join a scheme where one has to pay for those patients. Am I answering the question?

Yes, but there was another question on how the doctor and the nurse related to outcomes.

Dr. Josep Figueras

There was also a question about the benefit package and the priorities in that regard. I do not know whether Ireland has an Haute Autorité de Santé or some other such organisation but it is worth having more support in identifying the 50%. There is enough evidence about what is cost-effective and in the pharmaceutical area a number of treatments are not cost-effective. The same is true of many diagnostic treatments in hospitals, which are very well known but which I will go not go through. If we have to reduce the benefit package let us start by identifying those interventions. It is important to separate what is cost-effective for some patients from what is cost-effective for others. Often a new drug, a me-too drug which is a copy of a previous drug, emerges. The pharmaceutical companies will say the drug is very good and more cost-effective for certain types of patient. One such drug is for blood pressure, which is good for malignant hypertension and cost-effective for the group which has it. If it is put it on the market there will be pressure from companies on GPs to prescribe the more expensive drug rather than diuretics, which are good value for money. One of the most cost-effective interventions for strokes is measuring the blood pressure of everybody and making them urinate. I am sorry to be so graphic but primary care can save lots of money in this way because strokes are one of the main causes of expenditure, involving huge rehabilitation costs and outlay on drug units.

What I am getting at is an issue about what is cost-effective and for which patient is it cost-effective. There is plenty of evidence out there to identify the 49%. Here, another suggestion is to work with the medical profession. They know that. One needs to develop guidelines with them to identify these interventions.

The second question was about Deputy Madigan's family loss. I am sorry, it is horrible to face that in one's family at such a young age. As to whether this benefit package issue relates to that, this is an area where we did some work with the Netherlands, a member of the observatory, which wanted to see whether they should adjust premiums for risk behaviour for obesity, tobacco, etc. Taking a clear case, hepatitis and the treatment of hepatitis, if someone gets re-infected, should one provide that or not? Here it is a value issue that the committee needs to address. A school of thought that I personally would identify with - it is my personal belief it is about ethics and values - states that we are determined by our environment, social class and family when we make these decisions. Could one blame me because I decide to eat more or could one blame me for risk behaviour? Is it my decision or is it because my social economic decision is such because I have been unemployed, etc? I tend to be less victim-blaming and accept that someone will smoke, and even if he or she smokes, I will provide treatment. I suppose I would not facilitate a second transplant or whatever in these cases, but I am wary of victim-blaming. My values would be not to adjust premiums according to risk behaviour.

Having said that, there are some marginal adjustments made in this regard. Elsewhere, it occurs. One has that in the private sector all the time. Private health insurance is always adjusted according to risk. In the public sector in Europe, interestingly, there are only examples in the area of dental care. In Germany, if one goes to the hygienist for one's preventable visits, one would not have to pay for a filling afterwards if one has a problem with caries; if not, one must pay for it. The Dutch wanted to do that with more harsh incentives but they decided against it because of the equity impact. I do not know whether I answered. Is that the point?

Yes, that is perfect.

Dr. Josep Figueras

Let me move now to the workforce issues, the framework legislation and the cigarettes issues. I am not sure I remember the question on cigarettes. It was an issue about the benefits-----

Prioritising.

Dr. Josep Figueras

Prioritising. Yes, I am sorry.

Linked to that, let us go quickly to the skill mix. We do not know the outcome based on that. The same is so with the question about the beds. It is frustrating. When I started in my career, I got a scholarship. I come from Spain. I got my first scholarship from the regional government when I was in my mid-20s to study in the UK and they said that they would pay for my scholarship but I would have to come back and tell them how many beds they needed. They said that in the UK, they know everything and I would have to tell them that. It sounds silly, and I thought I could find out. It took years to understand there is no such thing as the right number of beds or the right skill mix, but there are principles.

It is not about the number of beds; it is about how to use them. It is not about the beds. The number of beds will depend on how primary health care is working. It will depend on day-care surgery. I must say I look at some of Ireland's numbers and if I am not mistaken, there has been a significant increase in the use of day-care surgery. That is worthy of congratulations. A lot has to do with the way one pays. The committee has not asked me that but let me say it anyway. If one pays in a way where there is a greater incentive for day-care surgery and if one pays in a way where there is greater incentive for primary care, one can resolve some of one's problems at hospital level.

As for the number of beds, I have data here. It is not in one of the slides - my fellow forgot to put it there. However, I can say it by heart and if the committee gives me a minute, I can find the slide on my computer. I agree that Ireland has one of the lowest number among countries in Europe. In the UK, for instance, England's is lower. That does not mean they are far worse in their use of beds. It is really the way one uses these beds, turnover and continuity of care. The problem of Ireland's waiting times is not the number of beds, I would say. It is much more how one uses them, how patients can be discharged into community care, how one pays for that, how one further uses day-care surgery, how efficient one is and how one networks these hospitals rather than, necessarily, the number of beds. I agree Ireland's number is low in comparative terms but I would not say that is necessarily the problem, although I do not know the country well enough. I have not had the opportunity to look at it recently.

On the question of the skill mix between doctors and nurses, it all depends how one uses the doctors and nurses. One can have lots of nurses and fewer doctors, and say: "You see, I am more cost-effective." If one uses the nurses to do certain jobs, one is not that cost-effective. With more doctors, it depends on how one uses the doctors. In some countries in Europe, there are paediatricians who weigh children as they operate alone. That is not cost-effective. That is wasting resources. I do not have this data. No one has it. We know that if one looks on the nurses and doctors as the basic level, there is much more that one can do. When one looks at nurses, it is fascinating that one says the problem is doctors do not accept nurses in the jobs of doctors. One of the problems when we suggest a skill mix is the politics of doctors accepting nurses in new roles but what is interesting is that when nurses acquire these new roles, the nurses do not accept nurses to take some of the roles. One of the issues of skill mix is the political debate and how one brings the profession to understand it is not a threat to them, but rather a way to make it cost-effective. Surely that paediatrician prefers to see children rather than weighing them, but the paediatrician is worried about his or her income. One should find a way to pay him or her appropriately. Whatever is appropriate is not a debate - the committee will be aware that Ireland, according to OECD data, has the highest paid doctors in Europe. I note there is much debate about whether the numbers are fine or not, but that is what the OECD says. Maybe the committee will invite the OECD. I will tell the committee where the numbers came from. I do not have the details of whether that skill mix has better outcomes or not, but certainty a better skill mix with nurses doing more jobs that belong now to doctors is bound to increase cost-effectiveness and quality of the system.

I am getting there. I am really sorry.

There was an important question asked about legislation and working with a framework.

Dr. Josep Figueras

What do I mean by framework legislation? I do not know the legislation in Ireland well enough to tell the committee what it should do. In some countries, one has framework legislation and regulations, but one can develop the legislation progressively by regulations. One can have legislation that states one will move to integrated care, one will develop - as Ireland has at present - community health services with linkage to the skill mix, etc., but one does not legislate for the details of the models one wants to apply, etc. I do not know enough legislation in Ireland to be able to add any value to the question but I can give a general suggestion. One of the most useful factors when I talk with countries on reforms is to have a lawyer in the room because what we have learned is one can do an awful lot within current legislation. Sometimes the cost in parliament to pass legislation is so high that one can do an awful lot using current legislation. One suggestion in Ireland is to talk to those who within current legislation have done lots of good work in the right direction and have built on that rather than passing new legislation, which is costly and complex.

Am I missing any one?

On the legislation question, our legislation is not strong in terms of eligibility and there is a big gap there. It is a matter of custom and practice, local arrangements or whatever. It is not set down in legislation what public patients should be entitled to and that certainly is a problem. Recently, we had Professor Allyson Pollock speaking to us. She was strongly in favour of a recommendation that we should start with legislation which puts a duty on the Minister for Health to provide a particular package of services and if one starts with the legislation, the services will follow. That was her view. I would be interested to hear Dr. Figueras's view on it.

Dr. Josep Figueras

Absolutely. I would very much agree with Professor Pollock. Of course, as the Chairman can see, I do not know enough about Ireland. One should take my comments with a pinch of salt. Clearly, that would be an area I would prioritise. Universal health coverage in Ireland is something I, as an outsider, feel one should prioritise. In some areas, legislation is fundamental. I am talking much more about framework legislation in areas such as more choice, such as new models of provision and such as integrated care, where one wants flexibility and one wants the system to adapt to that.

We are talking about this fundamental principle of legislation. I did not know there was not clear legislation in the system. I very much agree with that. The step towards full health coverage is fundamental, with primary health care in particular. I very much agree with that. We do not want legislation that goes into detailed benefit packages either. I would not recommend that.

I thank the witness for the presentation, which has touched on many of the issues I wished to raise. My main issue is primary care and the bottom-up approach we need to examine. Having seen the presentation slides, I find it strange that Spain and Ireland had very similar proportions of spending. There was 67% or 68% in government funding, with private out-of-pocket spending at 21% in Spain and 20% in Ireland. They were very similar but Spain seems to have one of the best primary care systems across the OECD. Why is that?

The witness mentioned the raising of extra statutory revenue from taxes on fizzy drinks or fatty foods. We spoke about legislation a while ago. If we were to legislate for that, would it be a good idea to ring-fence the funding and put it directly into the health system? We speak to people at the doors and they do not mind spending money if they get a proper service for it. I had many more issues to raise but the witness covered most of them in responding to previous speakers. The skill mix and the strengthening of primary care has been covered, as well as performance issues. There is the matter of linking provider payment to performance. I do not know if that would work here or if it would cause friction. Will the witness elaborate on that?

I am a general practitioner and I take Dr. Figueras's comments on doctors in a very open and reflective way. My questions really relate to efficiency and effectiveness in the system. One of the slides seen by the committee showed a pie chart with 49% of treatments being of unknown effectiveness. That seems to be a huge failure in delivering an effective health service. Will the witness comment on that? Is that because we are practising defensive medicine or is it because the treatments generate income so they are a good source of finance for certain parts of the health service?

A slide indicated how to improve performance, transparency, accountability and participation in our health service. We feel that our health service is not transparent or accountable and we are about to put an extra €900 million in funding into our health service. I would like to see that delivered in a very focused way, so will Dr. Figeuras's comment on how to focus funding to effective services?

I thank Dr. Figueras for a very interesting presentation. I understand there is a view that our doctors are among the highest paid. As our Government keeps getting fined by the European Union for breaches of the European Working Time Directive, I am sure we can all agree that they are among the hardest working. I am not sure I would agree that they are among the highest paid but that is neither here nor there.

With the system of integrated waiting lists, we have a difficulty in particular in this country as we do not have a unique patient identifier. There are many people waiting for health services on multiple waiting lists. They may be on a waiting list for area A when the procedure could be performed more quickly in area B. We do not have a linked system and I am interested to hear Dr. Figueras's views on the extent to which the integrated waiting list system has worked in Portugal. I believe it has one of the best examples. There is also the necessity to invest in information and communications technology to support that system.

We keep coming back to primary care teams and I hope we are shifting, albeit very painfully and slowly, into a model that is more focused on primary care. The witness touched on the need for fully resourced teams and perhaps there should be a system taking in physiotherapists, for example. Is there is a gold standard or model we should aspire to in terms of staffing and skill mix for a functioning primary care team? Are there any data on the best ratio of patients to members of staff on a primary care team? Is there a case for deprivation weighting, meaning there would be more staff and resources, depending on the socio-economic make-up of the community that is being served.

I am not a nurse but I spent many years representing nurses. We have a serious issue with the skills that our nurses have, as they are very often wasted. We have health care assistants trained to qualification level five who could take on the work. It is a little bit like changing from driving on the left to driving on the right. One cannot do it incrementally and one must go for a big bang on it. I am just wondering if we could look at a model in this regard. I appreciate that nowhere gets the skill mix right. Is there somewhere that does it better than here? Currently, I know we have skilled nurses who are not using their skills to the best of their potential and doctors not doing the work they could and should be doing. Health care assistants are willing to take on some of the duties of nurses. It is a question of how we can shift that up. Is there a model we can look at? I appreciate that nowhere gets it 100% right but perhaps they might be doing better than we are.

There are many questions.

Dr. Josep Figueras

That is fine as I enjoy these questions very much. I beg the forgiveness of colleagues. I am a medical doctor as well and I was not trying to bully doctors whatsoever. I hope the members understand that. I am a medical doctor and when I speak of primary care in Ireland, I know there is much goodwill and strong work in the professions to improve the system. It is about dependency. The system started with a model of medical cards and the hope that everybody would have one but nobody would need it. The professions have tried very hard to provide that kind of universal coverage. In no way do I look to undermine them. One of the areas I have been reading about and which I believe is true relates to the quality of the staff. This includes nursing and medical staff in Ireland. It is very high and one of the positive sides of the system. It is more about organisational issues and so on.

The data are there on payments and I cannot ignore them. Whether that reflects reality, I really do not know. One can take it with a pinch of salt. It is worth looking at. Reforms in Ireland do not necessarily mean the professionals should get less money. We should aim to keep the same income and ask professionals to work in a system or with terms of reference that can meet needs better. They work together in correlated teams. It is not about cutting salaries or incomes but rather it is about how to get more value for money by giving a professional the opportunity to do the kind of work he or she probably wants to do. I am not calling for a cut in salaries today. I am not calling for anything but merely reflecting on the issues.

There was a question on the system in Spain. One should take into account that the information hides many differences.

I am Spanish - Catalan actually if I can be controversial - and as one can see, out-of-pocket payments account for 21% of expenditure in Spain against 18% here. However, it should be noted that in Spain direct payments to private providers are not user charges, while in Ireland, if I am not mistaken, formal statutory user charges account for a fair amount of these direct payments. While the Spanish health service is not a great system - there is no such thing as a great system in Europe as all health systems are struggling to do better - the high percentage of out-of-pocket payments in Spain is explained by problems of access and waiting lists. This means people go directly to a private doctor and pay out of pocket for a service. The reasons for the high percentage of out-of-pocket payment are not confined to waiting lists, however, because preferences are sometimes a feature. Some people want to have a private doctor and because they can afford to pay the cost, they will decide to pay a doctor directly. Those factors explain the difference in respect of out-of-pocket payments.

I was asked the reason primary care is stronger in Spain and I do not wish to be too negative about primary care in Ireland, which is low in the ranking. There have been many studies carried out on this issue and one must be cautious in interpreting their findings. Primary care in Spain appears to work well and to be strong because there is good access and doctors are highly trained. Believe it or not, I used to work as a general practitioner in Spain before moving to public health policy and economics. As is the case in Ireland, general practitioners in Spain have been trained as family doctors working on prevention as well as cure. We have been taught since we were babies, so to speak, that nurses and doctors are equal, which means doctors work as equal professionals with nurses, physiotherapists and social workers. From day 1, general practitioners will work in primary care centres with teams, which helps a great deal. Money does not explain the reason Spain does better in this area. It is the way in which this money is spent.

Is staffing also an issue?

Dr. Josep Figueras

It is the mix of staffing. Nurses play a very important role, for example, they do some prescribing. In my case, which was 20 years ago, I would share the prescribing duties with my nurse, although the practice is not totally approved. At that point, one had to be very cautious about legal issues. However, for chronic care and so on, this approach worked very well. Nurses also do prevention tasks, some screening tasks and so forth. There is also a good integration of services with the hospital level and so on. These are some of the reasons for the findings on primary care in Spain.

Another feature of the Spanish system is that Spain has adopted soft purchasing as opposed to hard purchasing, the approach taken in Britain which provides hard incentives and encourages provider competition. While strategic purchasing takes place in Spain, the country is associated with soft purchasing, agreements, contracts and transparency. I am reminded of the question on transparency and where the money goes. In any case, this approach could explain the strong goodwill shown towards public health.

Spain has a long coastline and grows large amounts of vegetables and fruit, which also helps. We also drink appropriate amounts of wine, rather than hard alcohol.

Spain has more sunshine than we have.

Dr. Josep Figueras

That is right.

Does Dr. Figueras wish to respond to the questions on performance and extra taxes?

Dr. Josep Figueras

Yes, I will speak briefly on those matters. I remember a Minister, whose name I will not mention, who once told me over dinner that he managed the treasury and increased taxes but he could not get any of the additional revenue. He had been very successful but all the extra taxes were used to finance the deficit and none of the revenue went into health care. I totally agree with the Deputy who put it very nicely in stating that the population is happy and accepts it when extra taxes are earmarked for health care. This is a very good idea and a palatable and acceptable approach. However, as I stated, if one is successful, the Minister for Finance will ask why one wants more funding. If one is successful, achieves high elasticity and people have stopped smoking, one may jeopardise funding. One has to be cautious in this regard.

One must also be careful about what are known as sinful taxes. We learned a great deal about the "fat" taxes introduced in Denmark. If members wish, I could spend five minutes explaining the position. One must target these taxes very well and be cautious about harmful alternatives. If, for example, people switch to sugar when fat is taxed, what is the point of a fat tax? Second, there is no point introducing taxes on sugar if one does not subsidise healthy food, which we know is expensive. The issue, therefore, is how one tailors measures to make a difference. It is not just about the treasury introducing a 10 cent tax on Coca Cola or Fanta. I apologise for using brand names, although it will not make a difference as Coca Cola does not like me in any case. I am referring to fizzy drinks in general.

We know that Ireland faces serious challenges with childhood obesity. Malta has a similar problem. We need to deal with vending machines and fizzy drinks because they are not okay. If members wish to prioritise, as parliamentarians and politicians, they should be strong and act on these issues, advertising and so forth. That would be value for money. As I stated, I have a large volume of material on this issue and I will send a copy to the committee. The figures on how much can be achieved through these types of interventions are impressive.

If one earmarks funding, one may get into trouble but it is more palatable and acceptable. All in all, I would choose to earmark taxes as much as possible.

I was asked a question on payment for performance. We are working with the French social insurance system. In principle, payment for performance is the way to go because one wants to pay according to outcome. However, it is terribly difficult to achieve. Ireland could do a little bit more in this area. I can relate this to deprivation payments in primary care. I believe Ireland has scope to adjust the capitation a little bit better in relation to age, some diseases and deprivation. I will return to the issue of chronic diseases but I totally agree with the view expressed on deprivation. Clearly, one wants doctors to work in certain poorer areas and geographical areas with greater deprivation. I am also in favour of adjusting payments as much as possible to risk or outcomes.

Economists, of which I am one, love this idea. One has this wonderful formula of paying for outcomes but it just does not work that way. One must be very cautious. While increasing the percentage of payment by outcomes is a great idea, there is a ceiling. We are examining this issue for the third time in France and we have realised the importance of having transparency for the profession and providers. We want them to know we are paying attention and we will tell them we will link payment to performance but one should not go beyond a figure of 10% or 15%. Payment should be adjusted for risks and one should also pay some adjusted capitation for services and outcomes. However, this should not be done on a case-by-case basis because we do not have enough good data to say what are good outcomes and to measure and pay by outcomes.

Professor Allyson Pollock probably spoke about payment by outcomes in the United Kingdom. The UK decided to pay by outcomes and succeeded in doing so but this resulted in significant inflationary pressure. What does one do when this happens? If one wants to pay by outcomes, the way to go about it is to shift the target. This means one does not say what one will do from one year to the next and one can change outcomes in different years. Hopefully, if one stops paying for outcome A in one year and starts paying for outcome B, the service providers will still work well in achieving outcome A. If not, one would be missing the point by not hitting the target because the provider would do very well in respect of the outcomes for which payment is being made but would do well in respect of other outcomes. One cannot pay for every single outcome. This issue is very nuanced.

Another advantage of paying by performance is that it involves transparency and allows data to be collected. By virtue of observing professionals, they become more cautious and work better. That is my view of the issue expressed in a simplistic way.

I was asked a question on the 49% figure. I will show another figure on the United States which is as interesting as the 49% figure. Unfortunately for us, I have more data on this. This is the wrong way to look at this issue. It is taken from a study carried out by a very influential institute of medicine in 2012, which tells us how much waste is in the system and tries to reflect on this issue. The study found that 27% of services were unnecessary. I referred already to the figure of 50%. The position in Ireland would be different because incentives here are different.

A total of 70% is inefficiencies. It is not that the services are not effective but they are provided inefficiently. Here it is about how it is provided at hospital level or at community level. More and more we want to move the concept of hospital from a vertical structure to a horizontal structure together with units working together across levels of care rather than being totally integrated. It is about severity hospitals rather than specialties.

If one were to go in the direction of insurance competition, like in the US, one has the problem with 24 excess and administrative costs, which is almost as much as unnecessary services. There are inflated prices and prevention failures. The Chairman asked whether the 40% is about perverse incentives. I have to be cautious and everything should be taken with a pinch of salt. There may be some inefficiencies in the way private health insurers are paid and the way they bypass the lists and so on. I do not know how they are costed in detail. Sometimes in other countries there is a hidden cross-subsidy when private patients are treated in public hospitals. I do not know whether that is the case in Ireland. That may be inefficient and a perverse incentive, as economists describe it. The 40% is not a criticism of the profession and it is a genuine uncertainty. Sometimes the system does not reward the professionals to save and to ignore these incentives. For instance, I have the privilege to facilitate research into antibiotic resistance. Doctors know they should not prescribe as many antibiotics. There is huge scope for savings but, not only that, for quality. Antibiotic resistance is a threat to our society. If the Chairman wants a priority for this committee, she should adopt this. I do not have data for the difference in prescribing antibiotic among doctors but I could look at my computer because we did a study for the Dutch Presidency on that subject. The difference is massive. It is sixfold between the Dutch and, say, the Italian and Spanish doctors, partly because of the pressure from patients to have an antibiotic. If they have an antibiotic for a cold, that is a bad job. It is not about blaming the doctors for this uncertainty; it is about giving them the mechanisms, evidence and ways to change. In the case of antibiotic resistance, there have to be campaigns to work with citizens and say, "More drugs after you see a doctor is not better care".

Is Dr. Figueras saying Dutch doctors prescribed more antibiotics than the Italians?

Dr. Josep Figueras

No, they prescribe less. It is a matter of principle for a family doctor in the Netherlands not to prescribe antibiotics. I am married to a Dutch lady and I am a doctor. I tried to get an antibiotic for my son because I knew he had acute bronchitis. I could not get an antibiotic because she said you have to wait three or four days to make sure it is a bacterium. Perhaps one can go too far. It is a matter of principle. It is good practice and part of their culture. The population does not push to have antibiotics prescribed. I am not blaming the profession for part of the 50%. It is about lack of evidence, genuine uncertainty, lack of incentives to do better and lack of structural incentives to do things better.

This links nicely with the Chairman's point about ICT, which is fundamental. Electronic medical record exchange between hospital, community and primary care saves a lot of money. For instance, one of the major problems we have in recurring patients is side effects or counter indications by so many treatments. Some recurring patients have 25 drugs. Electronic records allow at any level of the system the ability to identify that to eliminate many of those drugs. This not only saves money but improves the health status. I do not know the position in Ireland. I understood that electronic health records were well in place in primary care. I read that somewhere but I cannot quantify that. I also read there was a need for more integration between the primary, secondary and tertiary levels and access to them. Important issues such as confidentiality need to be taken into account but electronic records exchange works well elsewhere. Denmark and the Netherlands are doing well regarding integration, as is Finland, from which I have just returned. They are making major efforts in this regard. Let us be cautious about one aspect. Not all technology and information will save money. Yesterday, I attended a POLITICO summit. The former Irish deputy prime minister, Mary Harney, was speaking there and she did a good job. Private sector representatives were saying innovation and technology would result in savings but that is not true. Technology is good and sometimes it is not. Sometimes it wastes resources and is not cost effective. The most important thing about information systems and technology in general is not whether the tool is cost effective but how it is integrated into the health system and where are the incentives for the nursing and other medical professionals to use it. What is the incentive for a hospital to use telemedicine if in reality patients are being pushed away? Perhaps that is what they want. Introducing information systems in a way that fits the incentives of the organisation and of the professionals is what is helpful.

There was a good question about the big bang and the skills mix. I am in favour of big bangs. My philosophy is what is needed is incremental reforms with small big bangs. If you do a big big bang, you are bound it get it wrong. I have funny slides on that. We have studies on the process of change. We want incremental change and whenever there is a consensus, people should go for it and introduce the reform so it is a small big bang. There is consensus with certainty. I apologise for my way of speaking in a formal setting. I hope members do not mind but I know in Ireland one is allowed to talk that way. Members will appreciate that even if I am on television. I hope that is okay.

Skills mix is one of the few areas that is difficult. It is a political issue but it is a no-brainer. We have plenty of evidence about the role of nursing and I totally agree with what the Chairman said about the role of nurses in community care and so on and the fact that we do not need so many professions to provide home care. A nurse visiting the patient to give insulin or to check on treatment could give him or her food that day. The cleaner, the home help or whomever could learn to do the dressing. I am not trying to interfere with the role of the professionals and there are normative elements and regulatory and legal issues, of course. Another issue is the incentives. Why should nurses and so on give the food when another professional is there to do that? Where are the incentives? I will do that if I work on a team and know the others. I will do that if I work in a team in a centre where I work with a social worker and with the home help. If they work together, they know one another by name and are bound to help one other. It is not just about regulation; it is about how these professionals work together. However, the legal and regulatory issues are important. Training is also an issue. It is not enough to say that from tomorrow nurses have to do this new job. Then there is the culture of the profession and, ultimately, the politics. If, in Ireland, people manage to get the different professions sitting around a table and agreeing, I will congratulate them because that is difficult. The professions will feel threatened but it is possible. This works and the Chairman asked for examples of where it works.

One of Ireland's nearest neighbours, Scotland, is doing very good work on integrating home care, community care, social care and health care. It is a very good example. Some of the Nordic countries, including Finland, which I mentioned, have very good pilots. I can forward to the committee evidence gathered in my capacity as an observer about good experiences there. The Swedes are also doing good work, as are the Italians because at regional level they have the same budget for social care as for health care. That helps because then there is no concern about protecting budgets. There are other mechanisms about which I could speak in more detail if I had more time.

On the question regarding the ideal skill-mix in regard to addressing obesity, there are plenty of studies of how this works in different countries. If context is important, it is very important here. I will give an example for doctors. Many countries believe general practitioners, GPs, should be incentivised to do more surgery. However, many people would not want their general practitioner to be incentivised to carry out surgery on them because they do not believe their GPs are qualified to do so. My wife recently brought our daughter, who was experiencing a gynaecological problem, to our local GP and the GP almost ran out of the surgery because he had never before dealt with a gynaecological problem in a child. He was very afraid and was not prepared to deal with it. There is no point prescribing a particular skill-mix if the doctors or nurses are not prepared to engage.

In an ideal world, the skill-mix would include nurse practitioners, who would do a lot of the prescribing for chronic care, clinical control and screening; doctors who would have some level of specialty between them, all of whom would be working in health centres, if geographically possible; some general practitioner input in particular areas and more consultants - I do not think there are many incentives here in this regard but perhaps there are and I do not understand - working directly with the health system to support GPs in the area of specialised support of chronic care and much more work and incentives for co-operation with social, community and health workers, including physiotherapists and so on in a much more integrated way. By way of example, in Belgium there are no gynaecological children services. Even if it makes sense, it does not make sense to have a paediatrician in primary care. There is no point telling a person, who is not trained for that, that paediatricians should be in primary care. I am happy to send information on how the models in different countries work.

The committee would be very interested in having that data.

Dr. Josep Figueras

They makes for good reading in bed. They are long and detailed.

Thank you.

I will brief because Dr. Figueras has already covered many of the issues I was going to raise.

Dr. Josep Figueras

I apologise, I did not respond to the question on governance but I will respond to it later.

Dr. Figueras alluded in his submission to Ireland having the only EU health system that does not offer universal coverage in primary health care. The committee has met over the past number of weeks with many people from the primary health care sector. If the committee were to suggest that as a first stop we should fund our primary health care system and properly manage it would that, in Dr. Figueras's opinion, be a good starting point for its work? Spain appears to be top-of-the-class in this area. I accept that there are issues in the Spanish health system but because of the work that it does at primary level, it rates far higher than its EU counterparts. I am interested in hearing Dr. Figueras's opinion on that issue.

In terms of the percentage spend of GDP, Ireland is below 8%. What does Dr. Figueras think the optimum spend is? In other words, what amount, in terms of Dr. Figueras experience around the EU, should we be spending in this area? I note that Ireland ranks third highest in the EU in terms of alcohol consumption and fourth highest in terms of smoking, which is not something of which we should be proud. Is this relevant to our health issues; is there a need for us to strive to remove ourselves from among the top ten countries in that regard and would that have a significant impact on our health system?

I am interested in hearing Dr. Figueras's opinion on bed capacity. I believe that we are somewhere in the region of 1,500 beds short of what we need in the country. Would sufficient bed capacity in itself lead to a much better set out outcomes? Dr. Figueras may be aware that this committee has only been in a place for a few months now. He mentioned earlier that he recently carried out work in Finland similar to that which this committee is undertaking. In that regard, does he work alone or does he have a team of people working with him and is the detailed analysis and statistics gathered in that regard a body of work in respect of which he needs assistance or does he do all of the work himself and how long does it take to do such a body of work? I am interested in hearing Dr. Figueras's response to that question in the context of the work being undertaken by this committee and the type of back up we might need.

I will take questions from two more members.

I welcome Dr. Figueras to the meeting. We have a ten-year strategy for health that is primarily focused on how we will deliver a universal health care model. Universal health access is something we would all very much strive to achieve. However, we could have a universal health care system but bad health care if that system is under-funded and under-resourced. In the context of universal health care and the provision of same across the European Union, during the downturn, for example, many budgets were squeezed and while universal access was still maintained I am certain that in some countries the quality of care available diminished, waiting times escalated and outcomes also diminished. How do we put in place a system that provides for universal health care and also plan a funding model, which would be critically important, to guarantee some form of certainty in terms of the service? When a country experiences a recessionary period there will be cutbacks, which goes back to the point about low-hanging fruit and high fruit and so on. There is a need for us to address that issue. For example, almost half the population of Ireland have voluntary health insurance. One could argue that it is out of fear of the public health system that people take out private health insurance but, at the same time, it is seen to be voluntary. Should any government untangle what is effectively a voluntary tax by people in the sense they are willing to pay for private health cover and thereby lighten the burden on the public health system? If we have to move to a model of universal health care in this country where or how do we fit the private health insurance and private health care system into that? Reference was made to a big bang and small bangs but it would require a very big bang to move to such a system. I do not expect an answer but perhaps some observations on that issue.

Dr. Josep Figueras

It is a very important point.

Dr. Figueras spoke about Holland - where I worked many years ago for a year - and the attitude of GPs there to prescribing. He said that it is almost impossible to get antibiotics in Holland.

Dr. Josep Figueras

I was exaggerating the issues.

Dr. Josep Figueras

The Deputy should take that comment with a pinch of salt.

We have had many pinch of salt comments here today-----

Dr. Josep Figueras

Too many.

-----and we will have a handful soon. In terms of prescribing, I am aware there is an ethos within the medical profession and within the training programmes of the various countries, but are antibiotics free in Holland? Are they cheaper in Spain? If I go to my GP and pay €60 to him see him, I like to go home with a prescription. It is almost a yearning people have to feel they have got something-----

Dr. Josep Figueras

I totally understand.

-----for the money they have paid. I would be interested to hear Dr. Figueras's view on the issue of prescribing. We have a major issue of over-prescribing which we need to address. We have a dependence on drugs such as benzodiazepines and there are other areas where there is a propensity to prescribe more than is needed.

An area where all member states could have problems, particularly when there are tight budgetary problems and a requirements to stay within EU fiscal rules, is the issue of investing now for the future. Most member states have to run budget deficits of less than 3% per annum because of EU fiscal rules. It is difficult for a country to invest a large sum of money now in, say, the areas of health and well-being and tackling obesity - I know vaccines are exempt from these rules - in that it would put pressure on governments because they would be breaching the fiscal rules now-----

Dr. Josep Figueras

Yes.

-----but potentially they would save many times that money in the years ahead. Has Dr. Figueras come across those challenges in other European countries?

Dr. Josep Figueras

Indeed.

Is the European Commission willing to examine the issue of investing now and thereby securing savings in the future?

Deputy Kelleher has covered three quarters of the question I had on universal health care. As a final component of that question, we as a committee are faced with a job to make a recommendation, obviously going down the road of universal health care. My question is, when do we jump and what do we jump to? If we are going to jump, do we pick a date in the future and say we are going to have a universal health care system, but what will it be? Do we take the big bang approach and say now is the time we are going to do this, or do we opt for a date into the future, and how do we itemise what would be in it? In totality, when we put forward a proposal, as is the job of this committee, in a defined period of time, are we better off to set it in a staged process, or to identify what it is and say that we want this now, we have the budget for it, and this is the timeframe for doing so, or is it a mixture of both?

Those are some very big and fundamental questions. It has gone 12 o'clock and I am conscious that Dr. Figueras has to catch a flight around 3 p.m.

Dr. Josep Figueras

Yes. My assistant did not calculate enough time but I could change the flight if necessary. It is important that I address the members' questions.

There is always the option of responding to us with written replies.

Dr. Josep Figueras

Yes, of course.

If that is possible, we would be very happy with that.

Dr. Josep Figueras

Yes.

Big questions were asked in that last group and it would take a long time to respond them. We will continue for another ten minutes up to 12.15 p.m., we then want Dr. Figueras to have refreshments and he would need to leave here for the airport by 1 p.m.

Dr. Josep Figueras

Yes. Thank you, Chairman. I will start by addressing the way the Irish system operates. I hope I have not offended anybody by using some expressions such as a pinch of salt or whatever. The reason I have used such phrases is that I could talk about these issues at length and they are such big issues that one needs to use that type of approach to highlight the elements, but I do not want the use of those phrases to sound superficial. In responding to the many questions I have been asked, I have to highlight flat-sitting areas in very superficial ways but I would be more than happy to return with my colleagues to address the members' questions in one session or separately, or to brief their staff properly in each of these areas with all the nuances that I have not been able to go into because if I were to describe these areas with any nuance, we would not get anywhere even after spending a few hours.

I would make another qualification. In the context of the Netherlands, I used the example of my son. He probably did not need antibiotics right away but I wanted to point out the importance of culture. Perhaps I can address Deputy Kelleher's question. With respect to prescriptions, there is a mix of factors involved. It is a mix of the professional culture, how people are trained and how they view saving the use of antibiotics or saving the use of benzodiapzepines as important. The Deputy made the point effectively regarding the expectations of the population. Patients want a service as a consumer. A substitution drug can be used. A GP may decide not to give a patient an antibiotic but they may spend ten minutes explaining that the patient has a virus, that it is a bacteria and the patient may accept that. There are issues about incentives, the issue of naming and shaming - again that comment can be taken with a pinch of salt - providing profiles of a GP's prescription practice against his or her colleagues, against the averages. Guidelines can be provided, the health sector can work with a pharmacist and - to go further than the scope of the Deputy's question - not paying the pharmacist according to cost involved but rather reward generic prescribing and substitution, and prescribing according to generics rather than commercial names.

To talk about prescribing alone would take a session of this committee. Members should avoid falling into giving them what they want. There is a very sophisticated understanding among the policy makers of the issues. I must congratulate the members on that, as I work in many countries. They should avoid falling for the notion that one pill cures all ills. With many reforms, there is the consideration of whether reference pricing will resolve all the problems. We can say we will argue with the profession and we will punish the doctors but this issue is how these incentives will work together and align. If I had more time, I would be more than happy to explain that further.

The secret of my work is that if I do anything well I am standing on the shoulders of giants. In that sense I will start with Ireland because the observatory is financed by a number of organisations and countries, including Ireland. I would be happy to forward materials to the committee and I do not know if there are any other ways in which we can help, but it would be a privilege for me to do that.

I work with teams in Finland. I mention Finland because this was done on Monday, not because it is more important. We work in Slovenia, Sweden, France and many other countries, all partners of the observatory. Depending on the evaluation involved, we gather different groups. The case in Finland is an example. It was very much a pre-evaluation of a reform proposal, which was particularly complex. It is not dissimilar from what is being done in Ireland. I wrote to colleagues in the OECD, in the WHO and members of various academic groups and others who were interested and then we had three weeks to examine this. We said that if Finland wants to implement a particular reform, these are the questions they need to take into account. There were not recommendations.

Finland is shown in green in the presentation. It wants to reform its primary health care system. If we look at the pendulum, it considers its primary health care does not allow sufficient choice. I link that with the Deputy's question on health coverage. Finland's system does not allow patients to choose their GP. It is too strict and too vertical. It is good quality but is not responsive. There is too much waiting in the system. Finland wants to change it in a direction of having more choice and more responsiveness. In this case I was the chair of a panel. I presented yesterday and I met their Minister for Finance as well because they wanted to reduce the costs and we were explaining where the problems were. In this case the panel brought experts from different organisations and different countries that are relevant to Finland. Over two visits we then reflected on their worries. For instance, if we want to introduce a certain reform, we could say countries A, B, C are similar to Ireland and these are the kinds of issues with which they struggle and we need to be careful with issues one, two and three. That is what we did. We are always very cautious, we are never normative and we never recommend; we just reflect.

That brings me to the idea of universal health coverage. The question on it was asked well. Universal health coverage does not mean, and I know the members know this, but I will say it anyway, a rigid, solid, non-choice health system.

We have Greens here and in many countries. We have been in the Netherlands. We have Greens in Denmark. I talk about the Netherlands but let us talk about Denmark. Denmark is a country where one can go to a general practitioner and it is paid per capita with some adjustments. One can change one's GP every year. However, they say "No, I prefer choice". I choose whatever GP I like and I pay a percentage, not all of it, out of pocket. The rest is paid by the state. If I want choice, it is like France. In France, they have been trying very hard to move from the fee for service to have GPs working on lists. That is one of the areas we worked on with them. That is why we are talking about payment for performance because they want to change from a fee for service to some form of payment for performance. That is because there is no way to move a doctor who is paid by fee for service to a capitation model. It is terribly difficult. They do not like it and I understand that. That is why we debate payment for performance with them. What they did in France was as follows. As a patient, one is happy to join a GP and accept gatekeeping. Then, there is a charge. One pays to go to a specialist and it is much lower. If one wants to shop around and go directly to a specialist, that is fine but the user charge will be higher. Unless one uses that to bypass the waiting lists as happens in some countries like here, actually, for hospitals, it is a way to make the system sustainable and have good quality care. Those who want more choice, pay an additional amount to have it. What I am trying to say is that self-coverage systems do not need to be rigid with doctors and so on and only one choice. One can still have choice of different kinds. In terms of paying the providers, one can have elements not only of salary, but adjusted capitation, some fee for service, incentives and some elements of payment for performance. One can achieve a good universal health coverage system while having flexibility of incentives and choice to respond to consumers, or patients, as well as to the professionals.

As to the question of the percentage, the big bang, and the numbers, I do not have the data with me and I would not trust them in any event. It is impossible to know how much goes into primary health care and hospital care because there is a world in the middle. If the committee invites the OECD here, it will tell the members that it is doing the numbers, but it is very difficult to know how they are calculated. I cannot remember the numbers. One of the members asked me about the percentage of primary health care in terms of the budget not being very high in Ireland. Did I understand that well? I do not have the numbers with me and I will not be able to comment. However, I am happy to respond in written form. Whatever my response, I ask the committee to understand that these numbers are very difficult to assess. We need to look at whether we are providing the proper benefit package in primary care and whether treatment is being provided at the right level. These are the ways to look at it, not the percentage, unless one has a scandalous and very clear difference in the amount put into primary health care versus hospital care. Most countries are in the range of €1,000 to €2,000 and most towards €1,500. Again, it all depends on what one asks a GP to do and whether he or she has a team to assist. Is it a rural area and is there a payment for deprivation? One wants to provide an incentive for GPs to go to deprived and rural areas. Therefore, talking about the numbers is not the right approach. It is about services and risk adjustment.

That links very much with the question about the small bangs and big bangs, not only for primary care but for the whole system as such and, as part of this big bang, what do we do to help insurance and universal health coverage. I really like only to do reflections not recommendations. Ireland has very good professionals that serve it here and who can work with the committee and would be better than me. My impression would be "Why not do it progressively?". If the members think it is a good idea, put it in legislation. As Ireland has this medical card system, it could try to increase the number of cards over a short period to a point where no one needs one. New populations could be brought on board in a progressive way so that the impact can be examined. Ireland has the funding for that. If it links it with the appropriate benefit package simultaneously with the PCTs, much more effective primary care will result which will save money in hospital care and waiting lists. Ireland can manage that with some savings. While I said savings are difficult, that could be managed by having more cost-effective services. Inefficiencies in the system could be shed quickly so that it does not need to be much more expensive. The way to cover oneself is to do it incrementally. To be very clear, I think this committee may wish to say - sorry that is almost a recommendation - that-----

Sorry. Is it that one extends the cover incrementally?

Dr. Josep Figueras

Incrementally. What I am saying is that there are a lot of complex incentives in the system. I wish one could do a big bang, but my impression is that we still cannot predict very well what would happen with a big bang in coverage in primary care. The costs might explode. As such, one has to do it incrementally. At the same time as one has the PCTs working and a good benefit package in place, one tries to have more integration. One wants to do it in an incremental way so that all these other changes in the skills mix happen simultaneously.

I wish a big bang approach was possible. I agree that the legislation needs to be very clear. There is a need to go to universal health coverage for primary care. It may be desired to leave some user charges which are means tested. I link that to the other question. Of course, one needs the money coming from somewhere. Even with user charges, there is a question about private health insurance. We need the money to come from somewhere. I understand that. All countries, as the members have seen, have an element of private health insurance and user charges. I am not suggesting one can or one should. It is a political and societal value. Many people take private health insurance because they are afraid. I understand that and that, as such, one cannot withdraw it. However, what we are talking about is how to use user charges in as efficient and equitable a way as possible. Can we have value-based user charges? Can one use user charges in areas where we know they are less effective, although it may not be ethical to apply user charges for things that are not effective? There are ways to tailor user charges.

There is one area on which I have data but not the time to show that to the committee. It relates to the caps in Ireland which are a bit high. We want to have user charges with lower caps. It becomes almost like a tax because everyone will reach that. However, the €750 cap in Ireland is fairly high. Is it €475 in hospital care after €750? For part of the population, that seems to be a fair amount of money. I cannot remember the examples by heart but I have them there. Sometimes I felt that there may be a wish to introduce caps on that. Certainly, it is the same as to whether antibiotics are free. Clearly, for chronic care, and I think Ireland does it already, one does not want to have user charges. For certain groups, one does not want to have user charges. I have the evidence and there are much better experts in this country to discuss it. Certainly, it is possible to keep user charges while ensuring they are better tailored, have as little impact on equity as possible and are as efficient as possible. The same is true with private health insurance. All countries have private health insurance which has a role to play. However, we should use it in more complementary way rather than in supplementary ways. What about having health insurance in services that are not covered by the package of care? To be more explicit, I refer to dental care and ophthalmic care.

I relate this to the question on what we do with the recession and the limit. I could talk about that. I work with ECOFIN on the complexities of health care in the semester context.

There are recommendations this semester. I guess the committee has read the semester recommendations for Ireland in health care, the sustainability, the Directorate-General for Economic and Financial Affairs recommendations, which try to explain how to work together on these limits and the need to sustain the system and cut costs. I do not want to go far but there are ways in which voluntary health insurance can be used. I think Ireland has a fairly high percentage in comparative terms. It is in the slides if the committee members have the time to look at them. That is fine if that is Ireland's decision. There are ways to operate it better, to make sure it does not have progress incentives for more hospitalisation, ways to make it perhaps a bit more complementary. I would not recommend, however, that it be complementary for user charges. Please consider that before going for voluntary health insurance. I have been working with Slovenia which wants to use voluntary health insurance for user charges and Ireland does not want to do that because if it pays, as in France, if everybody gets voluntary health insurance which pays user charges there is a moral hazard. People will try to use the service as much as possible. The problem with user charges is moral hazard. I do not believe it works but if there are user charges to collect money one has to ensure that the services are used appropriately. If Ireland decides to put in place voluntary health insurance, those who are poor will not be able to access it. The French subsidised the "mutuelles" for voluntary health insurance to complement user charges. Excellent, but what is the point? The patient has an insurer and it pays the hospital which pays the patient back. What is the idea? The money might as well be given directly. We do not need the middle man to do that. Once that is introduced it cannot be changed. We could not change it in Slovenia. It is a no-go area because the population perceived it as very valuable, which is the point the Deputy made. If Ireland reforms private health insurance the Government should read the book and talk to experts - it has many in this country - about how best to keep it because it values the principle but it needs to get value for money and not too many inequities.

To answer the question about the big bang and all those issues, for the universal health coverage in primary health care it is better to have an incremental system within a limited period, perhaps two or three years.

When Dr. Figueras talks about being incremental does he mean extending the different cohorts?

Dr. Josep Figueras

Coverage.

He started saying benefits packages.

Dr. Josep Figueras

If there is consensus in this group, by all means, I do not know enough of the politics, go ahead. If this multi-party group has a consensus it is worth having a big bang. Even in spite of my saying it has to be aligned with the PCTs, integrated care, the benefit package, if there is consensus in this group I think it is overdue. It should do it.

It is important to clarify that the Government has been in the process of extending universal general practitioner, GP, care to different cohorts but it is an entirely different matter to have a benefits package.

Dr. Josep Figueras

They go together. If the Government decides to go to another cohort then it has to decide what is the benefit package for that, if I understand that well.

It is for age profiles.

Dr. Josep Figueras

Yes I know.

Apart from the 43% of people who have medical cards, the political decision was to extend free GP care to different age cohorts but not universal primary care. It is only GP care. The other services are not covered.

There is only GP care in the basket of service.

Dr. Josep Figueras

It is a question of terminology. I understand very well the difference between GP care and primary health care, which is broader. The Chairman is absolutely right. I apologise for misleading the committee. I am talking not only about GP care but about primary health care. It needs to be universally accessible. I would not have universal GP care without universal community care. They have to be done side by side. I have read a bit about that. Part of the study I mentioned was studying data and we can discuss that in more detail but I think both have to be done side by side, otherwise the professional incentives that would be included by having GPs for free and paying for community care would not work. I am sorry I misled the Chairman. The Government has to be progressive with GP care and the others-----

We know it does not work.

Dr. Josep Figueras

I am sorry. I know I do not discover many things but I agree with the Chairman for whatever it is worth.

As for investing 3% in the future, I agree absolutely. We are concerned about the limited targets the European Union is imposing on member states. The semester process, however, is becoming more complex and sophisticated, not that it was not sophisticated before but it understands much better the health element, that well-being is something measurable, that productivity and a healthy population are the only way to compete in this global economy.

The first point I made to the Minister for Finance is that he can negotiate with it and demonstrate that when it understands the country's situation it may be more relaxed about the 3% and allow for a larger deficit if it is to prove that it is investing in integrated care and primary care and so on. I do not think the targets are so fixed, even at that level. There is some flexibility.

Yes, there should be an investment fund. I wish I had the time to tell the committee about the experience of the crisis. During the crisis there was rationing and there were waiting lists but at the same time we saw improvements in primary care; there was more discerning use of some cost-effective services; better use of technology; and there were huge, important necessary cuts, such as cost-effectiveness in the pharmaceutical bill. It is true there is not money for everything, and rationing and waiting lists are on the horizon. There will be a need for some private insurance for the less important elements of the package of care. I wish that was not the case but we need to do that. Before doing that, please do some more work on the 50% we talked about. There is a lot of savings to be accrued there that we can work on. There are lots of savings in the long term. Integrated care will not yield savings in the short term but in the long term it will give more help and may accrue in savings, particularly in Ireland, in the way the resources are used at hospital level. There are ways to be sustainable but some element of private insurance will be there. Let us not have it just because of its value but make sure that money comes from my pocket as a pension as well, let us use it cost-effectively and equitably if possible.

I am sure I missed a lot of points. I apologise. That is as far as I could go. Thank you very much.

Thank you. If it is alright with Dr. Figueras we might pick up on some of those questions and forward them to him. We would very much appreciate written responses to them if Dr. Figueras is in a position to given them.

Dr. Josep Figueras

I sent the committee a very basic two-page document. I hope the members understand it and if they want I can develop a longer one. I really did not know what to write and it could have been a 50-page document. Is there anything the committee would like me to reflect on from the two pages or the things I talked about? I could write ten pages.

We will pick up on some of the issues and follow up with Dr. Figueras.

Dr. Josep Figueras

The committee will come back to me. I am happy to expand it to ten pages to reflect more directly. I am sorry if I talked too much. I thank the committee for its attention.

Dr. Figueras covered a huge amount of ground and responded to the questions extremely well. We very much appreciate his time and the trouble he took to fly over here. We have really benefited from his experience.

The joint committee adjourned at 12.30 p.m. until 9 a.m. on Wednesday, 19 October 2016.