Dr. Josep Figueras:

That is an area which is relatively easy to deal with. It is much more complex to talk about the technologies or the treatments of certain cancers or diseases where there is more uncertainty as to where they should be rolled out. In primary health care, it is fairly straightforward, starting with health promotion. I should have said health prevention. Health promotion is important also, but it is partially outside the health care system in terms of health. Clearly, it plays a fundamental role in secondary prevention, and primary prevention to some extent, in terms of screening purposes and areas on which there is consensus such as screening for a number of cancers. Colon cancer is a very good example, but there are many others such as diabetes, blood pressure and cholesterol on which the guidelines are very straight. There is no uncertainty as to what is cost effective and what works.

At the margins, we could debate certain screening. We could go into prostate cancer, for instance, which is an area that is not recommended, but there is plenty of evidence in that area as to the kinds of secondary and tertiary prevention interventions we can do in primary health care.

In terms of the shape of the system, the remaining benefits are from first contact care. I would strengthen the ability of general practitioners and primary care teams to do some diagnostics. There is much more that can be done at that level. The control of chronic diseases should be at that level for most of those, unless there are major complications. We do not want diabetes, chronic obstructive pulmonary disease, COPD, and many other diseases, including asthma and so on, controlled elsewhere. From what I have read, and I apologise if I make a mistake as I do not know the Irish system perfectly well, that is very much the direction in which Ireland is going. I would very much suggest that Ireland move in that direction. I repeat that secondary prevention, control of chronic disease, and being able to address the first contact care issue are important. It is being able to make the first diagnosis or to refer quickly someone with an acute disease who comes through the door. Continuing the gate-keeping is the way to go, although the gate-keeping here is very soft. By that I mean, they are wise to bypass that. There is a huge problem in the accident and emergency services, which I believe is partially because the middle classes have to pay €55 to see a GP. I probably should not say this but I can understand the incentive for the middle classes to go directly to hospital if they have to pay €55 to see their GP. Am I answering the questions?