Ms Patricia King:

Regarding Deputy Madigan's comments on the 10% of GDP and the taxation system, fundamentally, this is down to Government choice. As we have described in the submissions made to the committee, which we will not repeat, it is about choices. We are very clear that the private health system should not be subvented by taxpayers' money. If one wants to build the universal, single-tiered system, one makes choices to do so. At the moment it seems that 70% of the health service is funded by Government. According to the figures for 2014, that is about €13 billion. We are clear, as we said in the submission, that we should not have a system that has perverse incentive to uphold the private system. Anybody is fully entitled to make a judgment that this is an ideological and aspirational position and so on, but the people in power who make decisions must make the choices. The choice in the health sector at the moment is that if one has money, one gets cared for quickly, but if one does not have money or if one's income level does not lend itself to care, one waits. That causes people on lower income scales to die or to spend a longer time being ill than somebody who can buy health care. That is a perverse system and is down to the decision of the political establishment and policy-makers that that is the kind of health care system they want. I have no doubt that the politicians who must make those decisions, particularly those in power, must make decisions about all the other leans on the taxation system and on public funding and so on, but that is really what it is down to. Even if we just take Europe, other European countries have made different decisions, which is why, skipping briefly to Deputy Kelleher's question about whether we have facts or statistics, it would be desperately difficult to get anywhere other than to start comparing apples with oranges when one makes comparisons with the Irish health system because it is unique in the way it treats its citizens in terms of inequality. There is a much bigger preponderance of equality in the French and UK systems than there is in the Irish system.

I will leave the issues about medical science and so on to my colleagues. I will deal with an issue Deputy O'Reilly raised. She mentioned the ambulance service. There are two aspects to this. There is either a myth or a belief that some policy-makers have that once they outsource something, it will be cheaper. If one looks even across the water, very recently many studies have been done on this. Great Britain is now starting to go back to insourcing. We are usually about five to six years behind such thinking.

On the question of outsourcing, first, this country does very little monitoring of what happens to its money when it puts it out to the private sector to spend. Second, Paul Bell, my colleague, and I are very familiar with the national ambulance service. I am very familiar with the ambulance service provided through the Dublin Fire Brigade in the city of Dublin and the surrounding counties. Mazars did an in-depth report, in which I was involved because I represented the firefighters for a number of years. They would say the service, which is provided on a 24-7, 365-day basis and is integrated with the fire service, is beyond doubt and beyond comparison the cheapest. There has been a plethora of both public servants and luminaries in the private sector who want to get their hands on that service and have it outsourced. Given that the firefighters provide a service par excellenceto the citizens, as does the national ambulance service, very few would be able to replicate the excellence of that service, but there is a push all the time. When one examines in-depth that segment of the ambulance service, one will see there is no way the private sector, which is in it to make a profit, could replicate the level and standard of service being provided at that price level. Therefore, over many years, in my positions both in SIPTU and now in Congress, I have advocated insourcing. This privatisation and outsourcing is certainly not all it is cracked up to be, and the State does very little in the order of following the money and seeing what value taxpayers get in this regard.

Restructuring fatigue, in my judgment, is a very big issue in the HSE in particular. Throughout the staff, regardless of grade, whether one earns at the very top end or the lower end of income levels, restructuring fatigue leads to the belief that the restructuring will be an ongoing feature. This is a big challenge that this group will face for any transformational propositions it faces because when one wants a change of staffing in any organisation, one must win hearts and minds. One has a major mountain to climb when restructuring has taken place about 101 times and has not worked. The people supposed to be delivering the service will say it has happened before and that they have no faith in it. Winning the hearts and minds of workers is a big problem for the health sector. Over decades I have walked into many canteens and many workplaces and had discussions there with workers. It does not matter how good or wonderful the manager is or what good ideas he or she has because the workers will have heard it all before.

Another point is that to make restructuring work, the people, both those at the policy development level and those charged with implementing it, must have confidence and show confidence that what they are proposing will actually work. They must believe it will work. That is not the case at the moment. They do not believe it will work. They do not know whether it will work and they shift from one big idea to another. When one pushes it and asks them whether they think it will work, they do not know because the basic, fundamental principles such as, for instance, the perverse incentive, are usually not changed. The perverse incentive will usually be in the new plan. Unless one grasps the major aspects of transformation that must happen and shows willing from the top to the bottom that this will happen, people will just see it as another restructuring. That is a big challenge for this committee and for us on the ground who work with the people who work in the health service. The health sector is 95% unionised so, from that perspective, we are in there all the time listening to such concerns. At that I will hand over to my colleague.