Dr. Josep Figueras:

There was also a question about the benefit package and the priorities in that regard. I do not know whether Ireland has an Haute Autorité de Santéor some other such organisation but it is worth having more support in identifying the 50%. There is enough evidence about what is cost-effective and in the pharmaceutical area a number of treatments are not cost-effective. The same is true of many diagnostic treatments in hospitals, which are very well known but which I will go not go through. If we have to reduce the benefit package let us start by identifying those interventions. It is important to separate what is cost-effective for some patients from what is cost-effective for others. Often a new drug, a me-too drug which is a copy of a previous drug, emerges. The pharmaceutical companies will say the drug is very good and more cost-effective for certain types of patient. One such drug is for blood pressure, which is good for malignant hypertension and cost-effective for the group which has it. If it is put it on the market there will be pressure from companies on GPs to prescribe the more expensive drug rather than diuretics, which are good value for money. One of the most cost-effective interventions for strokes is measuring the blood pressure of everybody and making them urinate. I am sorry to be so graphic but primary care can save lots of money in this way because strokes are one of the main causes of expenditure, involving huge rehabilitation costs and outlay on drug units.

What I am getting at is an issue about what is cost-effective and for which patient is it cost-effective. There is plenty of evidence out there to identify the 49%. Here, another suggestion is to work with the medical profession. They know that. One needs to develop guidelines with them to identify these interventions.

The second question was about Deputy Madigan's family loss. I am sorry, it is horrible to face that in one's family at such a young age. As to whether this benefit package issue relates to that, this is an area where we did some work with the Netherlands, a member of the observatory, which wanted to see whether they should adjust premiums for risk behaviour for obesity, tobacco, etc. Taking a clear case, hepatitis and the treatment of hepatitis, if someone gets re-infected, should one provide that or not? Here it is a value issue that the committee needs to address. A school of thought that I personally would identify with - it is my personal belief it is about ethics and values - states that we are determined by our environment, social class and family when we make these decisions. Could one blame me because I decide to eat more or could one blame me for risk behaviour? Is it my decision or is it because my social economic decision is such because I have been unemployed, etc? I tend to be less victim-blaming and accept that someone will smoke, and even if he or she smokes, I will provide treatment. I suppose I would not facilitate a second transplant or whatever in these cases, but I am wary of victim-blaming. My values would be not to adjust premiums according to risk behaviour.

Having said that, there are some marginal adjustments made in this regard. Elsewhere, it occurs. One has that in the private sector all the time. Private health insurance is always adjusted according to risk. In the public sector in Europe, interestingly, there are only examples in the area of dental care. In Germany, if one goes to the hygienist for one's preventable visits, one would not have to pay for a filling afterwards if one has a problem with caries; if not, one must pay for it. The Dutch wanted to do that with more harsh incentives but they decided against it because of the equity impact. I do know whether I answered. Is that the point?