Dr. Josep Figueras:

That is fine as I enjoy these questions very much. I beg the forgiveness of colleagues. I am a medical doctor as well and I was not trying to bully doctors whatever. I hope the members understand that. I am a medical doctor and when I speak of primary care in Ireland, I know there is much goodwill and strong work in the professions to improve the system. It is about dependency. The system started with a model of medical cards and the hope that everybody would have one but nobody would need it. The professions have tried very hard to provide that kind of universal coverage. In no way do I look to undermine them. One of the areas I have been reading about and which I believe is true relates to the quality of the staff. This includes nursing and medical staff in Ireland. It is very high and one of the positive sides of the system. It is more about organisational issues and so on.

The data is there on payments and I cannot ignore it. Whether that reflects reality, I really do not know. One can take it with a pinch of salt. It is worth looking at. Reforms in Ireland do not necessarily mean the professionals should get less money. We should aim to keep the same income and ask professionals to work in a system or with terms of reference that can meet needs better. They work together in correlated teams. It is not about cutting salaries or incomes but rather it is about how to get more value for money by giving a professional the opportunity to do the kind of work he or she probably wants to do. I am not calling for a cut in salaries today. I am not calling for anything but merely reflecting on the issues.

There was a question on the system in Spain. One should take into account that the information hides many differences.

I am Spanish - Catalan actually if I can be controversial - and as one can see, out-of-pocket payments account for 21% of expenditure in Spain against 18% here. However, it should be noted that in Spain direct payments to private providers are not user charges, while in Ireland, if I am not mistaken, formal statutory user charges account for a fair amount of these direct payments. While the Spanish health service is not a great system - there is no such thing as a great system in Europe as all health systems are struggling to do better - the high percentage of out-of-pocket payments in Spain is explained by problems of access and waiting lists. This means people go directly to a private doctor and pay out of pocket for a service. The reasons for the high percentage of out-of-pocket payment are not confined to waiting lists, however, because preferences are sometimes a feature. Some people want to have a private doctor and because they can afford to pay the cost, they will decide to pay a doctor directly. Those factors explain the difference in respect of out-of-pocket payments.

I was asked the reason primary care is stronger in Spain and I do not wish to be too negative about primary care in Ireland, which is low in the ranking. There have been many studies carried out on this issue and one must be cautious in interpreting their findings. Primary care in Spain appears to work well and to be strong because there is good access and doctors are very trained. Believe it or not, I used to work as a general practitioner in Spain before moving to public health policy and economics. As is the case in Ireland, general practitioners in Spain have been trained as family doctors working on prevention as well as cure. We have been taught since we were babies, so to speak, that nurses and doctors are equal, which means doctors work as equal professionals with nurses, physiotherapists and social workers. From day 1, general practitioners will work in primary care centres with teams, which helps a great deal. Money does not explain the reason Spain does better in this area. It is the way in which this money is spent.