Professor Allyson Pollock:

Yes. The question really is whether we should have a single piece of legislation to create a national health service for Ireland. I said my opinion is "yes". If one looks at all the countries that have introduced a national health service, theirs were usually fragmented, inequitable and a patchwork of services. However, that is not a reason not to introduce a single national health service. One builds on what one has got. Legislation will take a year or two years to enact and a further year to implement. During that time, the Civil Service and politicians need to be working in great detail to plan that service so that, as Deputy Harty said, it can open on a particular day. I think 6 July 1948 was the inaugural day for our national health service.

I would advocate having a single piece of legislation that makes the duty on the Minister very clear. Some of the best brains in the country are in the Civil Service and around this table and they could be working and planning for it. Of course, it does not just happen by enacting an Act of Parliament. It needs all the work that underpins it to thrash it out. I would go further in advocating that one would want to understand all the legislation that came before and bring it all together in one comprehensive piece of legislation. I worked with a brilliant barrister on our NHS Bill over a period of five or six years. I would say, "Go for it". Go for a really clean universal health care and a single tier health care system, I say, "Do it." One will never get there on the back of incrementalism. The lobbyists and vested interest groups are too strong and powerful and will always hold one back.

I thank Deputy O'Connell for the second set of questions. They were dating from 2003 and 2004, which was really a time of increasing marketisation.

This was the time of the new general medical services contract, which brought in the alternative providers of medical services.

I was asked a good question about pensions. Pensions in the NHS have always been pay-as-you-go. Actually, they have returned more to the UK Treasury than they have taken out. Last year, I gather £2 billion was returned to the Treasury, but I will need to double-check that. Anyway, more money was returned than taken out. Since then the UK Government has acted in a number of ways to put a brake on the total pension sum that a person can hold and to change benefit and pension entitlements. There are always things that governments can do if they believe pensions are out of control. However, pensions have never been out of control in the NHS. It is a pay-as-you-go model and it has been a good system, unlike other pensions.

The second question was whether Ireland was providing better specialist or tertiary services. If that was put to the people in our teaching hospitals, I wonder how they would respond. I have in mind Guy's Hospital and St. Thomas' Hospital, as well as St. Bartholomew's Hospital, where I work now. I think people can only make those sorts of claims in two ways. The first is using the research and evidence available. I would look at treatment rates for common things, including hip, plastics, cataract and cardiac treatment. I have a feeling that the United Kingdom is doing equally as well as Ireland. I am not meant to say we are doing better or worse unless I have the comparative data to say as much. In Scotland we recently finished a study looking at elective hip and cataract replacement. Can the health services here provide me with similar data to undertake a similar study in order that we could show that we are providing the same sort of access on the basis of need? That is why information is really important. We need to collect the data to look at that. Patients' perspectives are important as well. The Commonwealth Fund continues to rate UK health services highly, indeed, above Ireland, if we are to believe the ranking scores and surveys.

The third question related to phamacoeconomics. We have two issues. We have the dilemma of prioritisation and how we prioritise resources and services, as well as the issue of effectiveness, in other words, the evidence of effectiveness and benefit. The UK Government set up the National Institute for Clinical Excellence in 1999 or 2000 especially to examine evidence of effectiveness of drugs. The institute includes the quality and cost dimensions in its considerations. There is an issue here for Ireland because when I have looked at the health systems and transition reports, it appears that Ireland, even though it could be a monopsony purchaser on the part of Government, has very high drug costs. Of course those costs get passed on to patients. If those involved were to do more negotiation with the drug companies, they might be able to get drug costs down and that would have a significant impact on the budget in Ireland.

The UK National Institute for Health and Care Excellence is important because it brings some evidence of efficacy and effectiveness, as well as the cost-benefit analysis. It has been an important body in terms of negotiation on the entry of drugs into the public system, as well as helping as part of the negotiation around cost. It is a model we should look at to see whether it is something that would suit Ireland. One of the major problems we have with drugs in all countries arises when we give a drug marketing approval. Our regulators give approval for the market and then, it is a free-for-all. One of the issues for a public system is the nature of the evidence of the benefit and on what basis should we give access to the public system. That is always a dilemma, whether for vaccines or drugs. That is why we need a scientific approach. We also need to negotiate hard with the manufacturers, because the prices of drugs and technologies are one of the greatest inflationary costs, much more so than staff costs. They are an enormous inflationary driver. We have to control those costs and ensure far more rational medicine and diagnostic use.

I was asked a good question about targets for general practitioners, GPs, and whether the targets were actually preventing them from being more holistic in their approach. Indeed most GPs would argue in favour of this view. The NHS quality and outcomes framework, QOF, has been greatly disliked by GPs because it links payment to targets. They believe this undermines their more holistic role. The system was brought in as part of the new corporate framework, the alternative provider medical services and general medical services contract revisions. Scotland now has abandoned and got rid of its QOF and England is beginning to move away from it more and more. I hope that answers the question. Targets were part of a market critique. The idea was that we had to have market incentives and payments but what resulted was that these market mechanisms created perverse incentives to focus not on the patient but on the numbers. The focus was on the numbers rather than what the needs of patients were and whether given treatments were the right treatments.

I was asked about FP10 prescription charges. In England it is indeed the case that the majority of people who receive a prescription are actually exempt because they fall in to the category of pregnant women, children under 18 years of age or older people. Scotland and Wales have now abolished prescription charges completely. There has been no obvious evidence of an inflationary effect. I will offer some anecdotes here. Some GPs argue that it has actually improved their prescribing. Before, they were conscious that patients had to pay for the prescriptions and therefore gave the patients double or triple courses and far more drugs than they needed for longer periods. Now, they can give short courses, see the patient again and, as a result, there is less waste in the system. The evidence of prescription charges is that they curtail access. They are a major barrier to access. There is no evidence that having a prescription charge is a good thing or that it results in rational medicine prescribing or use. Again, Scotland and Wales would be good to look for. There is still a movement in England to abolish prescription charges. There is also evidence that the cost of collecting those charges is problematic. The cost of the administration is greater than the prescription charges income. There is good evidence on that as well. I can send the material to the committee. I hope I have dealt with those questions.