Professor Tom Keane:

I do not know how well I can answer the Chairman's questions. I am shocked to recall that nine years have passed since I sat in this room, or some similar room, to be questioned at length by Senator James Reilly and a number of other individuals about what I was trying to do for cancer. In light of my lack of up-to-date knowledge on how well the HSE is doing with the integration of services, I do not think it would be fair of me to comment. I know it has been pushing hard to develop integration. There have been some good examples. I understand the committee has heard from the Carlow-Kilkenny group. I do not doubt that there are other such examples. While it would be unfair of me to state any current view, I will say that I think the HSE is signalling seriously that it is working very hard in this area.

The Chair also asked whether I believe legislation is necessary to deal with the issue of entitlement under the two-tier system. I have never worked in private health care. In Canada, public health care is accessed by 99% of the population. The 1% who do not access public health care have to go to the US to get private health care because it is not available in Canada. That is covered under the Canada Health Act, which is the most popular piece of legislation with the Canadian public. They treasure it. It is iconic. If one asks Canadian people what distinguishes Canadians from Americans, 80% of them will say it is the existence of publicly funded health care.

The health care system is something in which Canadians take pride, although I am not for a minute saying it is not without problems. Canada has a publicly-funded system and it has many significant issues, a number of which resonate here. However, it is a single-tier system based on the premise that a co-existent private system ultimately will bleed away resources and expertise from the public sector. The issue is being tested in the Supreme Court of Canada this year as some physicians are taking the Government to the Supreme Court to appeal the legislation that prevents physicians from seeking additional funds for privately offered care. This matter, which is covered under legislation, has been highly controversial but publicly-funded health care was introduced in Canada in the late 1930s. The predecessor of the National Democratic Party, NDP, Government, which was a labour movement, brought publicly-funded health care to Canada in the 1930s and 1940s. Since it has been in place, it is the only thing the public generally agree that the government does right.

While I obviously have a bias in favour of publicly-funded health care, if one looks back at the cancer programme, the vast majority of patients in Ireland are getting their cancer care in the public system, far more than for other non-cancer diseases. One of the reasons for this was that we were able to assure people that their access and quality of care in the public system were good. If one provides all of the key features that people are looking for in the public system, there is no reason for a private system to exist. If people are to pay out of pocket for private care, there must be an underlying premise that somehow they believe they are buying something extra and better than what is available in the public system. Until that belief disappears, one will have people hanging onto privately-funded care. I understand approximately 45% of people in Ireland now have private insurance so it is a big mountain to climb.

In terms of monitoring, the cancer programme has key performance indicators. While I am not up to speed on all of them, many dozens of performance indicators are published by the programme either every month or every three months and if the programme is not meeting certain performance indicators, the issue is addressed immediately. There is also a fair amount of competition between the cancer centres to be seen to be the best performing. This is very healthy because it means they want to be able to state, for example, that 90% of patients will be seen within two weeks. Undoubtedly, the rapid access clinics that were instituted by the cancer programme for prostate, breast and lung cancer have provided a level of access that is totally satisfactory and comparable with any publicly-funded system in the world. There is no reason this could not exist elsewhere in the system.

I do not believe the problems of the Irish health care system are too big to fix. They can be fixed but what is required is political will, which comes back to the committee, and education of the public to enable people to understand the issues in order that they could be persuaded to pay more in taxes to fund health care compared with some other alternative if asked to do so. I am not pessimistic in this regard. An iterative approach is needed, one which demonstrates that this can be achieved through a number of steps. Trying to take on system change across the whole system at once is unlikely to be successful. A strategy that is iterative, extends over five or ten years, identifies a number of milestones and takes each one of these in sequence is the way to build trust.