Dr. Josep Figueras:

No, they prescribe less. It is a matter of principle for a family doctor in the Netherlands not to prescribe antibiotics. I am married to a Dutch lady and I am a doctor. I tried to get an antibiotic for my son because I knew he had acute bronchitis. I could not get an antibiotic because she said you have to wait three or four days to make sure it is a bacterium. Perhaps one can go too far. It is a matter of principle. It is good practice and part of their culture. The population does not push to have antibiotics prescribed. I am not blaming the profession for part of the 50%. It is about lack of evidence, genuine uncertainty, lack of incentives to do better and lack of structural incentives to do things better.

This links nicely with the Chairman's point about ICT, which is fundamental. Electronic medical record exchange between hospital, community and primary care saves a lot of money. For instance, one of the major problems we have in recurring patients is side effects or counter indications by so many treatments. Some recurring patients have 25 drugs. Electronic records allow at any level of the system the ability to identify that to eliminate many of those drugs. This not only saves money but improves the health status. I do not know the position in Ireland. I understood that electronic health records were well in place in primary care. I read that somewhere but I cannot quantify that. I also read there was a need for more integration between the primary, secondary and tertiary levels and access to them. Important issues such as confidentiality need to be taken into account but electronic records exchange works well elsewhere. Denmark and the Netherlands are doing well regarding integration, as is Finland, from which I have just returned. They are making major efforts in this regard. Let us be cautious about one aspect. Not all technology and information will save money. Yesterday, I attended a POLITICO summit. The former Irish deputy prime minister, Mary Harney, was speaking there and she did a good job. Private sector representatives were saying innovation and technology would result in savings but that is not true. Technology is good and sometimes it is not. Sometimes it wastes resources and is not cost effective. The most important thing about information systems and technology in general is not whether the tool is cost effective but how it is integrated into the health system and where are the incentives for the nursing and other medical professionals to use it. What is the incentive for a hospital to use telemedicine if in reality patients are being pushed away? Perhaps that is what they want. Introducing information systems in a way that fits the incentives of the organisation and of the professionals is what is helpful.

There was a good question about the big bang and the skills mix. I am in favour of big bangs. My philosophy is what is needed is incremental reforms with small big bangs. If you do a big big bang, you are bound it get it wrong. I have funny slides on that. We have studies on the process of change. We want incremental change and whenever there is a consensus, people should go for it and introduce the reform so it is a small big bang. There is consensus with certainty. I apologise for my way of speaking in a formal setting. I hope members do not mind but I know in Ireland you are allowed to talk that way. Members will appreciate that even if I am on television. I hope that is okay.

Skills mix is one of the few areas that is difficult. It is a political issue but it is a no-brainer. We have plenty of evidence about the role of nursing and I totally agree with what the Chairman said about the role of nurses in community care and so on and the fact that we do not need so many professions to provide home care. A nurse visiting the patient to give insulin or to check on treatment could give him or her food that day. The cleaner, the home help or whomever could learn to do the dressing. I am not trying to interfere with the role of the professionals and there are normative elements and regulatory and legal issues, of course. Another issue is the incentives. Why should nurses and so on give the food when another professional is there to do that? Where are the incentives? I will do that if I work on a team and know the others. I will do that if I work in a team in a centre where I work with a social worker and with the home help. If they work together, they know one another by name and are bound to help one other. It is not just about regulation; it is about how these professionals work together. However, the legal and regulatory issues are important. Training is also an issue. It is not enough to say that from tomorrow nurses have to do this new job. Then there is the culture of the profession and, ultimately, the politics. If, in Ireland, people manage to get the different professions sitting around a table and agreeing, I will congratulate them because that is difficult. The professions will feel threatened but it is possible. This works and the Chairman asked for examples of where it works.

One of Ireland's nearest neighbours, Scotland, is doing very good work on integrating home care, community care, social care and health care. It is a very good example. Some of the Nordic countries, including Finland, which I mentioned, have very good pilots. I can forward to the committee evidence gathered in my capacity as an observer about good experiences there. The Swedes are also doing good work, as are the Italians because at regional level they have the same budget for social care as for health care. That helps because then there is no concern about protecting budgets. There are other mechanisms about which I could speak in more detail if I had more time.

On the question regarding the ideal skill-mix in regard to addressing obesity, there are plenty of studies of how this works in different countries. If context is important, it is very important here. I will give an example for doctors. Many countries believe general practitioners, GPs, should be incentivised to do more surgery. However, many people would not want their general practitioner to be incentivised to carry out surgery on them because they do not believe their GPs are qualified to do so. My wife recently brought our daughter, who was experiencing a gynaecological problem, to our local GP and the GP almost ran out of the surgery because he had never before dealt with a gynaecological problem in a child. He was very afraid and was not prepared to deal with it. There is no point prescribing a particular skill-mix if the doctors or nurses are not prepared to engage.

In an ideal world, the skill-mix would include nurse practitioners, who would do a lot of the prescribing for chronic care, clinical control and screening; doctors who would have some level of specialty between them, all of whom would be working in health centres, if geographically possible; some general practitioner input in particular areas and more consultants - I do not think there are many incentives here in this regard but perhaps there are and I do not understand - working directly with the health system to support GPs in the area of specialised support of chronic care and much more work and incentives for co-operation with social, community and health workers, including physiotherapists and so on in a much more integrated way. By way of example, in Belgium there are no gynaecological children services. Even if it makes sense, it does not make sense to have a paediatrician in primary care. There is no point telling a person, who is not trained for that, that paediatricians should be in primary care. I am happy to send information on how the models in different countries work.