Dr. Josep Figueras:

Yes, I will do my best. These are really good questions. I thank the Deputies who have got to the heart of the issues. I very much enjoy having the opportunity to thrash out these issues. I will try to structure my replies around my presentation and I hope I will not forget any points that have been raised.

I will start with the Chairman's questions about the benefit package. Some of the questions raised had to do with that query, particularly the issue of the 10% of the population and the insurance, the benefit packages and whether we should prioritise against those people engaging in harmful behavioural practices, such as smoking, etc. There are some examples that I will share with the committee. I will take the last question first because I would hate to forget that one and not to respond to it properly. I must be cautious. What I am saying is that one of the most difficult concepts to explain to finance Ministers is the difference between cost effectiveness and savings. One can be cost effective and not have savings, one can have savings and not be cost effective and one can be cost effective and have savings. In addition to Ireland, I have been in many other countries hit by financial crises, which I will not mention, and I have worn my more academic hat and talked about their options. The finance Ministers would say, "Yes, Josep, fine, but my new budget is in January and where do I get the money out of that?". It is true that for integrated care, one sets it - for many of these areas, one has to invest first. Even when rationalising hospitals or when closing hospitals, which in theory gives savings, in the first two years, it generates lay-offs, packages which must be provided and the integration of services. I do not want to sound superficial when discussing closing a hospital but one of the biggest complexities when merging hospitals is who is going to be the head of each department of the merged entity. That may sound funny but it is actually an example of the political complexities - political with a small "p" - which create a lot of inefficiencies and create the noise that reduces efficiency. In the long-run, rationalising hospitals will share the savings. Integrated care may share the savings but the other issue there is that the savings for integrated care do not accrue to those who put in the money. All this money is put into community care but who benefits from that? It is the hospitals because they will have fewer admissions. The Deputies may be aware of a basic principle in health care - bed empty, bed filled. One may end up being very cost effective in community care because patients are being treated in a more integrated way but the savings will not be seen as they will go elsewhere, or the savings will be used by other patients. Yes, one has to invest in many of these areas, and I am very glad to see the numbers in regard to Ireland's economy are getting better, and now Ireland has the possibility to do this restructuring and focus on the high tree. The level of the tree will allow it to shed the mid-term to long-term benefits and cost effectiveness.

The second point, which is very important, is that it is true that finance Ministers sometimes do not understand the difference between cost effectiveness and savings, but when they do they are not as worried. I have encountered some people, whose names I cannot say in a public committee, who in discussions with their finance Ministry have said that the curve has to flatten and they cannot spend more than that, but they are mostly concerned about being a black box - they want to be reassured that if money is being spent, then it is cost effective and makes a difference. They are very worried about all this money. We tell them it goes into health services, it is very important and very useful and that health is wealth. Yes, I have plenty of data on the subject of health is wealth but one has to demonstrate it.

The Chairman has asked that I speak about the benefit package. I will address this question. If I am not mistaken, many of the other questions are around delivery of promotions, skill mix and so forth. I will turn now to the package of care, prioritisation and the issue of the 10% of population, which is circumvented by insurers. If the committee will allow me, I will be a bit more structured. Do we have ten minutes for that? How in depth would the Chairman like me to go? Some of these questions require a bit of detail and the Chairman will have to tell me how to ration the time as I do not want to be superficial in the response.