Professor Allyson Pollock:

I was asked whether private health insurance should be outlawed for treatments that are being provided by the public sector, as in the Canadian health care system. There is a strong argument to be made for that on the basis of the evidence on private health insurance. I return to my original point about whether there is any evidence that private health insurance reduces or ameliorates inequalities. There is really no such evidence.

The Canadian health model is a very interesting one to look at, although it is under challenge at the moment. There is a constitutional court challenge being made in British Columbia on the very issue of private provision, private payments and private health insurance. Canada is under attack at the moment from a particular doctor, Dr. Brian Day, who has a very large private practice in British Columbia. All the available evidence shows that private health insurance does not reduce equalities or ameliorate health care, does not give the subsidy people argue it gives and results in greater inefficiency. Importantly, it also diverts staff and services. In Ireland, for example, I understand that 20% of beds in public hospitals can be used for private patients with private health insurance. That is a diversion of public capacity and it will get worse if hospitals are given more powers to generate private income. It means that staff and services that should be available for the public health and universal health system are being diverted and leads to distortions in the system.

The second question was on lack of consistency in government policy in England. The government has been entirely consistent in its policy direction. We had the Thatcher reforms on the Internal Market, which was followed by the period when John Major was Prime Minister. Apart from one small period when Frank Dobson was the Secretary of State for Health, the new Labour government was very consistent in pushing through greater marketisation. It introduced foundation trusts, for example, and continued with the private finance initiative, albeit against a backdrop of the largest ever increase in public expenditure. It was this increase that made these changes possible without hurting the system greatly. If one is marketising and privatising, one needs to push in a great deal of money, which is what has happened. We have, therefore, had an entirely consistent ideologically driven rather than evidence-based programme from the late 1980s onwards, culminating in 2012. The dismantling Acts of Parliament, which would not have been possible without all the implementing legislation that went before it.

That takes me into general practice. One of the key Acts of Parliament in 2003-04 was not just the law on foundation trusts but the changes to the way primary care was organised and delivered. Previously, contracts for general practitioners were between the secretary of state and the individual GP. What the 2003-04 Act of Parliament brought in was legislation introducing new contractual forms. After this, in addition to the traditional general medical services, GMS, contract, we also had the alternative providers of medical services, APMS, contract and variants thereof known as personal medical services, PMS, contracts, which could be negotiated with GPs. The APMS contract resulted in companies coming in, running and owning GP practices and employing general practitioners. This has created major problems and schisms in England. General practitioners on conventional GMS contracts are being underfunded and are handing back to the keys to their practices, with the result that some areas of England will no longer have general practices. At the same time, large companies such as Virgin, Care UK and UnitedHealthcare, a big American corporation, came in to run and operate GP practices and to salary the GPs. Some of these practices are not doing very well and the companies in turn are simply walking away from the contracts. As there is no duty on the Secretary of State to provide any more services, there is a very real risk that whole areas of England will be without a service.

One must be very careful if one wants to corporatise and bring in commercial companies to run and operate GP practices. The legislation was accompanied by more recent legislation which will allow GP practices to take patients from anywhere in the country. Practice boundaries were dissolved as of January 2016 and a variety of complex changes have been introduced that have changed health care from being area based to being membership based. I can explain more about that.

In contrast, while Scotland also has a crisis in the recruitment and retention of staff, it is nothing like the crisis affecting England. This is partly because Scotland has refused to introduce the APMS contract form, which means there are no commercial companies providing and delivering care. This is the result of a battle and legislation introduced in 2010 or 2011.

One comes to the very interesting question of how Ireland will retain staff in its national health service. My understanding is that it appears from OECD figures - these may be skewed and I am not sure how true this statement is - that general practitioners and hospital consultants are among the best paid in Europe when compared with their counterparts. I do not know how true that is as there was a problem in that the OECD could not include private practice in its figures.

Retaining staff requires a number of initiatives to be taken. There is the idea of being salaried. Terms and conditions and pay are what the trade unions and Irish Medical Organisation negotiate. However, there are other initiatives to do with professionalisation of the workforce. Our royal colleges have played a major role in this regard. There are lots of other cherries that go with one's status, however. It is not necessarily only related to pay, but also to doing a good job, being appreciated and being able to take and drive forward new initiatives. In my experience, these factors are a much greater motivator for most doctors and clinical staff than money. Salaries are important but much more important for staff is the day to day job they are doing and having the resources and capacity to innovate and drive change. One of the greatest triumphs of the national health service for many years was its ability to drive innovation and, through clinical innovation, to drive change.

The committee heard a great deal about the motivation of doctors in the two most recent sessions of evidence. The retention and recruitment of staff is important. We need to put plans in place but this is difficult when junior doctors are leaving medical school with debts of €100,000 or €200,000. They may not share the public service ethos or commitment that I and all my colleagues had. I did not pay any charges or fees when I did my degree. These issues need to be thought about and one needs to have an education system that encourages people to have a public service ethos and an obligation to give back and pay back for the rest of their lives. This is something we lose sight of in the national health service where there is an extraordinary feeling of obligation and giving back among staff every day. This will be lost now that students pay catastrophically large fees. The health system in Ireland must also think about the higher education system and training.

Deputy Joan Collins commented on her interest in universal health care and the problems with the US health care system and referred to the need to look at the systems in place in Canada, Scotland and Scandinavia. I would advocate looking at the Scottish model. While no model is perfect, the Scottish model always aspires to be perfect and it is a good model to look at. The Canadian health system, which is under threat from the constitutional challenge to which I referred, is another model to look at and think about. It is a more federal system. The Institute of Medicine report from 2012, for which I can send the committee a link, sets out very well that the US health care system is not only the most expensive and unfair system in the western world but also one that has enormous transaction costs.

Up to $3 trillion has been spent in 2012. Almost $1 trillion was actually spent, or was wasted, due to administration costs, fraud, unnecessary tests and unnecessary investigations, including surgery.

I will now turn to the question of trusts and the move in Ireland to establish hospital trusts to raise their own finances and add some services. We have been there before. In 1990 we inaugurated the internal market and allowed hospitals to become corporate bodies and use private finance initiatives, PFI, and outsourcing. The whole idea of raising one's own money is to look to the markets and private finance and of course the private finance initiative is a totally discredited policy on all sides of government. We are left with these major debts and not just in health but also in education, the courts, prisons, roads and so on. We have this extraordinary debt that we are now servicing for the next 30 to 60 years and very little control. So, if one wants to look at the catastrophe of allowing trusts to raise their own finances look at where our foundation trusts are today. Most of them have PFIs. They have been allowed to raise their own finances, they are carrying these debts which must be serviced off their annual income and 75% of foundation trusts are now in deficit with serious financial difficulties.

Allowing trusts to rely on PFI in that source has been problematic. The private finance initiatives, or public private partnerships, PPP, also include a mechanism for outsourcing ancillary staff and services. That was a disaster and many, if not most, PFIs have actually brought their services back in-house when the contract has allowed that to happen. They found that when outsourcing quality and standards fell, the costs were high and they were getting very poor value. That was instrumental in returning services back in-house into the hospitals. Foundation trusts who outsourced and raised finances are left with a very big problem in that as much as 15% or 16% of their income will now be going to service the debts of PFI. Everybody knows it is much cheaper for the Government to raise the money either through Government borrowing or through taxation. Look at the histories and experiences of PFI, including the recent report by the UK's Treasury Select Committee. It is a totally discredited policy.

The other big problem with allowing hospitals to raise more of their money privately is that they become much more keen on looking at income and they are no longer integrated into the health service. They are no longer putting the National Health Service services as a top priority. The income generation becomes really important. If the committee is really interested in the effect of allowing hospitals to do their own thing and to raise their own income only, look at the Mid-Staffordshire NHS foundation trust report, the result of an inquiry which lasted over 18 months. It is an enormous report which shows that at the heart of the problem was that the trust board were focused on income and income targets, including private income, to the detriment of patients and patient care. It is another argument for taking hospitals out of trust status and reintegrating them into the health service. The other argument is that while our hospitals are pursuing their own agendas, they are not now necessarily focused on the primary care, the rehabilitation and the prevention which is what we are interested in. They move further and further away into the risk selection and risk avoidance mechanisms when they are focused only on the bottom line.

Reference was made to universal health care programmes as opposed to targeting health programmes. It is a reality that in many universal health care systems one will also have targeted health programmes. One will have programmes such as breast screening, cervical cancer screening or immunisation. There will be programmes to target specific needs while under the umbrella of universal health care system. Problems arise when one does not have a universal health care system. This can be seen at its extremes in low income countries such as in Africa and India where one has practical health programmes with separate funding that are brought in but there is no universal health care system. They would have a focus, for example, on HIV and AIDS, on TB, malaria or diabetes, but they are not thinking comprehensively or holistically about the patient. Targeted health programmes have their place within the universal health care system. However, targeted health programmes have no place if one has no universal health care system. We should not be dealing with two.

The committee has not asked about the National Treatment Purchase Fund and our experience of using the equivalent of the National Treatment Purchase Fund, which was the fund for the independent sector treatment centres, ISTC. This was where doctors and patients could refer to the private sector under the rubric of choice. Some £4 million was top-sliced by the Government for the ISTC programme, which included NHS and private providers. However, the health select committee reports, of which there have been several, show that the ISTC programme did not provide value for money, it increased the costs, was inefficient and there was no evidence of innovation. That ISTC programme has been significantly rolled back.

I will stop there and I hope I have answered the committee's questions. If not then please come back to me.