Dr. Sara Burke:

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

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

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

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

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

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

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

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

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

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