Professor Allyson Pollock:

Okay. The sound quality is not great at this end either.

It is important to note that no country in the world has delivered a universal single-tier health care system through the market, for-profit provision or private insurance. That is because it is in the nature of markets to operate through selection and exclusion. They transfer risks and costs back to service users and inevitably deny care to those who need it most. Risk selection and exclusion is built into the design of market bureaucracies. By contrast, inclusion and redistribution must be built into the systems of public administration for universal health systems. As we all know, risk selection and risk avoidance mechanisms undermine the goal of access and universality.

I would like to refer to the United States, which is the best example of risk selection and risk avoidance at work. With health expenditure of approximately 18% of GDP, the US denies more than one in five of its population access to health care. A report from the Institute of Medicine has shown comprehensively that overtreatment and denial of care, health care fraud, catastrophic costs and spiralling health expenditure are features of the US health care system. Health expenditure in the US is out of control for both public and out-of-pocket payments. The countries that have adopted the US model of mixed public and private funding, together with public and private provision, have more marketisation, higher administration and transaction costs, the greatest inequalities in access and health outcomes, a lack of coverage and the highest out-of-pocket payments. As this committee has repeatedly seen and heard, out-of-pocket payments are major barriers to access in Ireland. They have a major impact on patients and their access to health care.

According to a report on the Irish health system published by the European Observatory on Health Systems and Policies, in 2008 the full out-of-pocket costs for primary health care were being paid by two thirds of the population. This committee has heard evidence from GPs involved in the deep end initiative about the operation of the inverse care law in Ireland. There is maldistribution of funds and services because resource allocation does not follow need. Of course the inverse care law is attributable to a Welsh GP, Dr. Julian Tudor Hart, who wrote in The Lancet:

The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.

The second of those sentences is seldom quoted. To paraphrase, when health care becomes a commodity, it becomes distributed just like champagne: the rich gets lots of it and the poor do not get any.

The UK established its National Health Service in 1948. The legislation had been enacted in 1946. The NHS is a universal integrated public health system which is free at the point of delivery and funded through central taxation. It is generally agreed by all organisations, including the World Health Organization and the World Bank, that central taxation is the fairest and most efficient way of funding health care. There is consensus on this in all the reports. The NHS - the legislation underpinning it and the system itself - is important because it became the model for the health systems of many countries around the world. For the first 40 years of its operation, the NHS was the lowest cost, most efficient and fairest system. In Bevan's words, the NHS guaranteed health care to all citizens without fear of catastrophic health care costs or being denied care. This freedom from fear was very important.

In 2012, following over two decades of market incrementalism, the Government in England abolished the universal public model by removing from the Secretary of State the duty to provide key health services throughout England. Instead, it made commercial contracting virtually compulsory and introduced new mechanisms for fragmenting and dismantling care and reducing services and entitlements. The structure of the foundation trusts that had been brought in was changed in 2004 to make them 49% private. As a result, they can generate up to 49% of their income privately. This has diverted the attention of the boards of the trusts and, as a result, they now have a greater focus on private income. At the same time, US-inspired market risk selection mechanisms have been introduced over the past 20 years. Most recently, there was a switch to membership-based organisations, as opposed to planning services on the basis of need, and to diagnosis related groups, trusts and tax breaks. This has had catastrophic consequences for universal public health care.

It should be noted that Scotland and Wales have retained the universal single-tier integrated public NHS model. As the UK Treasury in Westminster controls funding through the block grant allocation, their systems are coming under severe pressure. However, they are experiencing nothing like the catastrophic chaos that is ongoing in England, where 75% of foundation trusts are in serious financial deficit. Barely a week goes by without a chief executive losing his or her job or a failure regime coming into play. By contrast, no hospital in Scotland is going to the wall because hospitals and community services there are integrated into and directly managed by health boards, which in turn are accountable to and responsible for local health needs. It might be worthwhile for the committee to look at an interesting experiment in Scotland that involves the integration of health and social care.

If universal health care is the goal of this committee, as I understand it is, it needs to understand how the principles of universal health care underpinned by public health need, redistribution, risk pooling and social solidarity are alienated by markets and marketisation. In addition, clear and strong laws are needed to enact universal health care. I disagree with the argument that incrementalism might be the best strategy for Ireland because the pace of change would be too slow and might take the health system in the wrong direction. There has been an erosion of entitlements since 2008. I refer, for example, to the introduction of means-testing for medical cards in 2009 and to the increases in the levels of payments and charges for some services. I accept that the eligibility criteria that apply to the GP-visit card were extended in 2015.

Of course every country must build on its existing infrastructure and take account of its own history and services. All countries with a national health service have put in place laws and strong legal frameworks to ensure that universal national health service happens and that parliament commits to it. It does not remain an aspiration. If what this committee seeks to do is to be done, a strong political consensus needs to be built to overcome the many vested interests that would retain the fragmented and marketised private elements of the service and jeopardise the health of many people for the benefit of a few others. My understanding is that given the committee’s commitment to articulating a vision for a universal single-tier health service, an NHS Bill for Ireland is the essential first step in a ten-year plan.

If a law is enacted which commits the Government to providing universal health care to all citizens and residents throughout the land, the Oireachtas will decide how much it will spend. It is the task of the administrative bureaucracy to determine how the functions will be implemented, to ensure resources are allocated fairly, appropriately and according to need, and to develop formulae accordingly.

A bottom-up approach to change can be adopted. Access to universal health care requires strong systems of public administration and adherence to six common principles: fairness of financing; fairness of resource allocation; risk pooling and social solidarity in service provision; political accountability and control; service integration through geographic units of administration; and public accountability through strong systems of information and monitoring and surveillance systems.

The committee has heard from experts representing the Irish Medical Organisation and many other organisations that primary care teams are essential because they are the gatekeepers to acute and specialist care and have a major part to play in prevention, rehabilitation and working with social services. A strong primary and social care system that is rooted in strong information systems is essential to ensure health care for all. As the committee has already heard, primary care is seriously underfunded and is under-capacity. This creates pressure on acute services, social services and the family. In my opinion, a Bill to put in place the necessary legal framework for a national health service throughout Ireland is essential. It would be the first necessary step in achieving the sustainable development goals for universal health care and access to rational, essential and affordable medicines.