Dr. Sara Burke:

Deputy Brassil started by doing the sums and working out that one in five people are vulnerable. I tried to update the no cover figures for him. I had no cover figures in the second slide but I did not put them in because, like everything in life, it is more complicated than it looks on paper for a couple of reasons. There is a proportion of the population which has both medical cards and private health insurance, but currently we only have good information on the over 50s from the TILDA data. There is old data which shows that for the entire population there is a 5% overlap between people with medical cards and people with private health insurance, but we also know that is much higher for older people and it progresses. The older they get, the more likely the overlap, particularly during the time when all those over 70 had medical cards, so any estimates we have for no cover are only guesstimates. Also, some people having free GP care and also private health insurance.

We can say there are people who do not have any of those who definitely have more difficulty accessing the system but everybody is vulnerable at a point in time. Even if someone has the best private health insurance package that might cover them for high end hospital care, and they are back in the community, they might not get public health nursing or access to those basic public health services within the Health Service Executive, HSE, primary care team because they do not have a medical card. It is not as simple as saying there is one group of people who fare badly. Everybody is vulnerable at some stage, but we know that the poorest, the sickest and people with disabilities fare worse and that those without a medical card have the greater difficulties. Everybody has difficulties, however, because if they are waiting 18 months for that first specialist appointment, that puts them in a very difficult position.

The next question was on charges. I am interested in the Deputy's observations about the difference between a 50 cent charge and the €2.50 charge, which is capped at €25. The evidence internationally is that no matter how small the charge, it deters as much necessary as unnecessary use. Charges do deter use, no matter how small. I do not know the details of the dental or the GP charging literature off the top of my head, so I will not pretend to. I understand Dr. Josep Figueras will present to the committee next week and that might be a question to put to him in terms of application to the other areas but also in terms of the next question on whether private health insurance can assist in any way.

The problem with examining systems in other countries is that they have very different systems. In France, one's care is covered generally by a social insurance system but there is also supplementary care by what is a form of private health insurance, namely, a not-for-profit private health insurance. However, that is very different from the model we have here. In terms of our model, if we are moving towards using public money in the best possible way, private health insurance should only cover someone for privately delivered care. It should not cover what is subsidised within the public system.

Deputy Harty asked if staff shortages had an impact. Of course they have an impact. The Deputy sees it every day, but people experience it every day when they try to access services. There is a range of services people cannot access because of the long waiting times or the services not having somebody in a particular area. I refer to undoing the severe austerity cutbacks, but even if we got back to 2007-08 levels we still do not have the public health system GP staffing requirements to meet current population need. We must significantly invest in staffing. Investing in public health systems is a very productive economic measure because it provides jobs for people in their own communities who will then spend in their own communities.

It should be viewed as a positive spend and a resource rather than as a drain on society.

There is significant scope. Better than any of us, Deputy Harty would understand the need for changed work practices and how secondary care always seems to get preference over primary and community care. Staffing needs to be built up in primary and community care particularly. Since that sector does not have the capacity to take on more work, we need more people, but we also need to be doing things differently. We are beginning to see that happening. Colleagues of mine in Trinity College Dublin costed the role of specialist epilepsy nurses in the community. That work showed that, if someone with epilepsy had a link with a specialist epileptic nurse, it reduced or, in some instances, eliminated hospital admissions and the person stayed in work and was able to manage medication better. This was a much cheaper and better quality of life for the person with epilepsy than if he or she had to go to hospital to see a specialist every time. We need to be doing this for all chronic diseases. General practitioners, GPs, need to be paid to manage chronic diseases in the community, as do specialist nurses, occupational therapists and other health professionals.

I agree with Deputy Harty on reconfiguration. We have done a dreadful job of reconfiguration or reorganisation no matter how one looks at it. We shut down units, especially in rural hospitals along the west coast, without beefing up services there or in the major centres. Unsurprisingly, we are seeing the payback for that, for example, the level of demand placed on the emergency department in Galway or Limerick. That is what happens when one stops some services without beefing up others, in particular primary and community care. Had these services been resourced better, we would not have had some of the problems we have experienced.

Deputy Naughton's first question was on life expectancy and whether it was a useful tool. It is, but health services and access to same only contribute a small amount to life expectancy. They are important if one is sick and needs care, to quality of life and to outcomes. Forgive me, as I am only four days back from maternity leave, so I do not have the figures off the top of my head.

Life expectancy is a useful figure in terms of inequalities in health. One of my first policy jobs was in the Institute of Public Health in Ireland where, 15 years ago, we produced data showing that people with poorer incomes had much lower life expectancies than people with higher incomes. There is a case for targeting. One needs to invest in education, infrastructure, housing and career paths in those areas, but one also needs a greater delivery of health and social care services. There is a role for these, not just for meeting the health needs of people in those communities, but also for acting as their employer. In recent years, there has been a run down of HSE-employed home helps. Often they were women from disadvantaged communities who provided care to people living near them. We have contracted out much of that care. Employing local people in what often are deprived areas is a good economic and health measure.

Did Deputy Naughton ask about ethnicity?