Dr. Brian Turner:

There is quite a bit of content but there is an overlap between some of the questions. In terms of the under-resourcing of the system, we do not necessarily need to reach the OECD bed capacity average as we have a younger than average population, but I was putting the figure out there to give members a sense of the scale of the challenge facing the Irish system. We need to increase the resources for both hospital bed capacity and to increase the number of doctors.

Ideally, the Department of Health review of capacity should be independent but the last independent review of which I am aware was undertaken in 2007. I suspect that bed numbers have not changed radically since then, and if memory serves, our bed capacity at that point was approximately 15,000 beds. That compares with 18,000 hospital beds in service in 1980. I acknowledge we are trying to move people out of hospitals and the trend is to move from inpatient to day case procedures, which is reducing the need for beds. That reduction of bed numbers from 1980 to the present day, when the population has increased by one third and an increase of two thirds in the number of people over 65 years who are disproportionately likely to have a need for hospital services, puts a significant a significant strain on the system.

As the OECD figures are the figures with which I am most familiar, they are the ones I tend to use. One may ask how did the OECD arrive at its figures? I presume it got them from the HSE and the Independent Hospitals Association.

In terms of private hospitals, I was possibly being a little provocative by saying it might not be feasible to have an entirely single-tier health system. What I was trying to do was stimulate a debate on what we mean by a single-tier health system. It is very hard to think of any country, certainly in Europe, that has an entirely single-tier system for all health services. There is usually a mixture of public and private funding and delivery. Where we need to focus is on trying, as the Chair suggested, to separate out the two systems. For example in the UK, the take up of private health insurance is about 11% to 12%. I remember reading a figure a few years ago that only 1% of the treatment of patients in NHS hospitals was of private patients, which is a very different picture from the one in Ireland.

One other reason I suggest the embedded nature of the private hospital sector and the private insurance sector in the Irish health service will affect the attempts to move to a single-tier health system pertains to the judgment Mr. Justice McKechnie delivered in 2006 in the High Court case that BUPA Ireland took against the State in 2003 on the risk equalisation scheme. One argument BUPA Ireland was making that having set up in Ireland, it had a right to continue its business in the State.

I am not a legal expert. As a non-cognate, my interpretation of what Mr. Justice McKechnie said was it is not beyond the bounds of possibility that the insurance sector could be taken out of the picture in the national interest but an argument would have to be put forward to do so. Given that no system in Europe, that I am aware of, has gone from a two-tier system to removing the private sector, it would be difficult to make an argument for same. I suspect that if one tried to do so one would face significant legal challenges from the insurers and the private hospital operators that are highly dependent on insurers. In addition, depending on whether the private system is completely removed or incorporated into the public system, one could be looking at significant job losses. There are 8,000 jobs in the private hospital sector. I am not sure how many jobs are in the insurance sector but I suspect it is about 2,000 jobs. That means 10,000 jobs rely on the private sector. Care needs to be taken when deciding whether to eliminate the private system or incorporate it into the public system.

We must define what we mean by a universal single-tier health system and whether it is public or private. A universal single-tier public health system is achievable. I am not sure that a universal single-tier health system for everything is achievable but it certainly is not in a ten-year timeframe. Having said that, if we are here in ten years time debating health matters I will be delighted that my assertion has been proved wrong.

I have been asked what one thing I would prioritise, which is a tricky question to answer. Extra funding at primary and secondary care levels is the short answer. We are moving towards increasing our reliance on primary care. Before we can move people out of hospitals we must ensure that resources are available in the primary care sector to deal with them effectively. I would say extra funding is my number one priority if someone put a gun to my head for an answer.

Deputy O'Reilly asked about the suitability of a single-tier system. I have talked a little about an entirely single-tier system. Every European market has a private health insurance market and how it operates can differ. In some cases, private health insurance can be substituted for a statutory system. In other cases, it can be complementary so covers things that are not covered or partially covered by the public system. In Ireland we have a largely supplementary system that gives people additional benefits such as faster access, a greater choice of provider or superior accommodation. The nature of the health insurance system is part of the problem. Interestingly, when the current health insurance market was established in 1957 following the passing of the Voluntary Health Insurance Act, the top 15% of earners did not have access entitlements to public hospitals. The scheme was designed to give them the option of paying for their care if they fell ill without facing significant hospital bills. The scheme was not limited to the top 15% of earners. One can argue that it was a substituted system for the top 15% of earners but a supplementary system for anyone else who decided to avail of the scheme.

The access entitlements to the public hospitals system were increased over time with hospital accommodation taken care of in 1979 and treatment by hospital consultants taken care of in 1991. At that stage the nature of the system had changed greatly but no consideration was given to whether the health insurance system was still needed. Very shortly afterwards in 1992 the European Third Non-Life Insurance Directive was introduced thus ensuring that all member states opened all of the non-life insurance markets to competition. Once that happened it became much more difficult to consider the role of the private health insurance system. We must take this aspect into account when figuring out what we want to achieve. A single-tier public hospital system is achievable. A single-tier primary care system is achievable. I do not know whether it is possible to eliminate the private hospital and private insurance markets.