Dr. Josep Figueras:

Yes. Thank you, Chairman. I will start by addressing the way the Irish system operates. I hope I have not offended anybody by using some expressions such as a pinch of salt or whatever. The reason I have used such phrases is that I could talk about these issues at length and they are such big issues that one needs to use that type of approach to highlight the elements, but I do not want the use of those phrases to sound superficial. In responding to the many questions I have been asked, I have to highlight flat-sitting areas in very superficial ways but I would be more than happy to return with my colleagues to address the members' questions in one session or separately, or to brief their staff properly in each of these areas with all the nuances that I have not been able to go into because if I were to describe these areas with any nuance, we would not get anywhere even after spending a few hours.

I would make another qualification. In the context of the Netherlands, I used the example of my son. He probably did not need antibiotics right away but I wanted to point out the importance of culture. Perhaps I can address Deputy Kelleher's question. With respect to prescriptions, there is a mix of factors involved. It is a mix of the professional culture, how people are trained and how they view saving the use of antibiotics or saving the use of benzodiapzepines as important. The Deputy made the point effectively regarding the expectations of the population. Patients want a service as a consumer. A substitution drug can be used. A GP may decide not to give a patient an antibiotic but they may spend ten minutes explaining that the patient has a virus, that it is a bacteria and the patient may accept that. There are issues about incentives, the issue of naming and shaming - again that comment can be taken with a pinch of salt - providing profiles of a GP's prescription practice against his or her colleagues, against the averages. Guidelines can be provided, the health sector can work with a pharmacist and - to go further than the scope of the Deputy's question - not paying the pharmacist according to cost involved but rather reward generic prescribing and substitution, and prescribing according to generics rather than commercial names.

To talk about prescribing alone would take a session of this committee. Members should avoid falling into giving them what they want. There is a very sophisticated understanding among the policy makers of the issues. I must congratulate the members on that, as I work in many countries. They should avoid falling for the notion that one pill cures all ills. With many reforms, there is the consideration of whether reference pricing will resolve all the problems. We can say we will argue with the profession and we will punish the doctors but this issue is how these incentives will work together and align. If I had more time, I would be more than happy to explain that further.

The secret of my work is that if I do anything well I am standing on the shoulders of giants. In that sense I will start with Ireland because the observatory is financed by a number of organisations and countries, including Ireland. I would be happy to forward materials to the committee and I do not know if there are any other ways in which we can help, but it would be a privilege for me to do that.

I work with teams in Finland. I mention Finland because this was done on Monday, not because it is more important. We work in Slovenia, Sweden, France and many other countries, all partners of the observatory. Depending on the evaluation involved, we gather different groups. The case in Finland is an example. It was very much a pre-evaluation of a reform proposal, which was particularly complex. It is not dissimilar from what is being done in Ireland. I wrote to colleagues in the OECD, in the WHO and members of various academic groups and others who were interested and then we had three weeks to examine this. We said that if Finland wants to implement a particular reform, these are the questions they need to take into account. There were not recommendations.

Finland is shown in green in the presentation. It wants to reform its primary health care system. If we look at the pendulum, it considers its primary health care does not allow sufficient choice. I link that with the Deputy's question on health coverage. Finland's system does not allow patients to choose their GP. It is too strict and too vertical. It is good quality but is not responsive. There is too much waiting in the system. Finland wants to change it in a direction of having more choice and more responsiveness. In this case I was the chair of a panel. I presented yesterday and I met their Minister for Finance as well because they wanted to reduce the costs and we were explaining where the problems were. In this case the panel brought experts from different organisations and different countries that are relevant to Finland. Over two visits we then reflected on their worries. For instance, if we want to introduce a certain reform, we could say countries A, B, C are similar to Ireland and these are the kinds of issues with which they struggle and we need to be careful with issues one, two and three. That is what we did. We are always very cautious, we are never normative and we never recommend; we just reflect.

That brings me to the idea of universal health coverage. The question on it was asked well. Universal health coverage does not mean, and I know the members know this, but I will say it anyway, a rigid, solid, non-choice health system.

We have Greens here and in many countries. We have been in the Netherlands. We have Greens in Denmark. I talk about the Netherlands but let us talk about Denmark. Denmark is a country where one can go to a general practitioner and it is paid per capitawith some adjustments. One can change one's GP every year. However, they say "No, I prefer choice". I choose whatever GP I like and I pay a percentage, not all of it, out of pocket. The rest is paid by the state. If I want choice, it is like France. In France, they have been trying very hard to move from the fee for service to have GPs working on lists. That is one of the areas we worked on with them. That is why we are talking about payment for performance because they want to change from a fee for service to some form of payment for performance. That is because there is no way to move a doctor who is paid by fee for service to a capitation model. It is terribly difficult. They do not like it and I understand that. That is why we debate payment for performance with them. What they did in France was as follows. As a patient, one is happy to join a GP and accept gatekeeping. Then, there is a charge. One pays to go to a specialist and it is much lower. If one wants to shop around and go directly to a specialist, that is fine but the user charge will be higher. Unless one uses that to bypass the waiting lists as happens in some countries like here, actually, for hospitals, it is a way to make the system sustainable and have good quality care. Those who want more choice, pay an additional amount to have it. What I am trying to say is that self-coverage systems do not need to be rigid with doctors and so on and only one choice. One can still have choice of different kinds. In terms of paying the providers, one can have elements not only of salary, but adjusted capitation, some fee for service, incentives and some elements of payment for performance. One can achieve a good universal health coverage system while having flexibility of incentives and choice to respond to consumers, or patients, as well as to the professionals.

As to the question of the percentage, the big bang, and the numbers, I do not have the data with me and I would not trust it in any event. It is impossible to know how much goes into primary health care and hospital care because there is a world in the middle. If the committee invites the OECD here, it will tell the members that it is doing the numbers, but it is very difficult to know how they are calculated. I cannot remember the numbers. One of the members asked me about the percentage of primary health care in terms of the budget not being very high in Ireland. Did I understand that well? I do not have the numbers with me and I will not be able to comment. However, I am happy to respond in written form. Whatever my response, I ask the committee to understand that these numbers are very difficult to assess. We need to look at whether we are providing the proper benefit package in primary care and whether treatment is being provided at the right level. These are the ways to look at it, not the percentage, unless one has a scandalous and very clear difference in the amount put into primary health care versus hospital care. Most countries are in the range of €1,000 to €2,000 and most towards €1,500. Again, it all depends on what one asks a GP to do and whether he or she has a team to assist. Is it a rural area and is there a payment for deprivation? One wants to provide an incentive for GPs to go to deprived and rural areas. Therefore, talking about the numbers is not the right approach. It is about services and risk adjustment.

That links very much with the question about the small big bangs and big bangs, not only for primary care but for the whole system as such and, as part of this big bang, what do we do to help insurance and universal health coverage. I really like only to do reflections not recommendations. Ireland has very good professionals that serve it here and who can work with the committee and would be better than me. My impression would be "Why not do it progressively?". If the members think it is a good idea, put it in legislation. As Ireland has this medical card system, it could try to increase the number of cards over a short period to a point where no one needs one. New populations could be brought on board in a progressive way so that the impact can be examined. Ireland has the funding for that. If it links it with the appropriate benefit package simultaneously with the PCTs, much more effective primary care will result which will save money in hospital care and waiting lists. Ireland can manage that with some savings. While I said savings are difficult, that could be managed by having more cost-effective services. Inefficiencies in the system could be shed quickly so that it does not need to be much more expensive. The way to cover oneself is to do it incrementally. To be very clear, I think this committee may wish to say - sorry that is almost a recommendation - that-----