Dr. Brian Turner:

Deputy John Brassil is correct when he states roughly half the population have very good access to care. When we read analyses of the health system we tend to look at the overall funding for the public and private sectors and focus on the worst outcomes which tend to be in the public system. There is a dichotomy in access to hospital care, in particular.

On how we would achieve a single tier public hospital system which would focus on public patients only, we need to renegotiate the consultant's contract. I am not sure of the numbers, but to the best of my knowledge there are still some consultants on the old category one and category two contracts. The new category A consultants have been contracted to work in public hospitals only. The category B and category C consultants have different terms and we need to re-examine these contracts. One possible way of doing so is to say that if a consultant is able to treat private patients, he or she can only do so in a private hospital. I think the old category two consultants had an entitlement to engage in private practice off site, whereas the new category one consultants do not. If one wants to treat private patients, one should treat them off site. Another option which was discussed in the context of hospital trusts five or six years ago would involve a consultant being contracted to work for a hospital or a hospital group and only being allowed to work within that group. As I am not an expert on contract law, I do not know how one would do that.

On incentivising the treatment of public patients, having the money follow the patient might help in that regard. The difficulty is how would one cap the numbers to ensure spending on hospital patients would not spiral out of control because it is a demand-led service. Again, it would depend on the relativity in reimbursement for treating a public and a private patient. Currently, having an additional public patient does not mean any additional income, whereas having an additional private patient does. Under a system under which the money would follow both patients would bring additional income. Therefore, it would becomes a matter of relativity, but the incentives would be greatly reduced in that regard.

Deputy Michael Harty raised the issue of transitional investment funding. It will certainly be needed because before we start to move patients out of hospitals, we will need to ensure the necessary infrastructure at primary care level is in place in order that they will not fall through the cracks.

On the funding of health service reform, it must be borne in mind that costs will accrue in the short term, whereas savings will accrue in the long term. This might prove difficult politically. That is the reason having a ten year plan is worthwhile.

On the issue of taxation versus social health insurance, while I am not against the latter, we already have a tax based system and I do not think the nature of the funding is the issue. I do not think a move to social health insurance will necessarily improve matters for us. It will, however, take up a lot of resources in terms of time and effort. I do not see that as being a necessary step towards improving the situation.

There is some merit in the co-payments option. The report from the group chaired by Professor Frances Ruane which was published in 2010 looked at that issue in the context of payments for GP services. The report suggested that people below a certain income threshold would not pay anything for GP services, while people in the next income band would pay no more than €5, those in the next band would pay no more than €10, those in the next band would pay no more than €20 and so on. Such a model, with a certain amount of co-payment linked to income, might work. The roll-out of free-at-the-point-of-use GP care does not necessarily have to mean that all GP visits are covered. We could decide that everybody gets five free GP visits per year and after that we go with the banded co-payment system as suggested by the Ruane group. There are options there that could be explored further.

In terms of services, anything that is not medically necessary should not be covered under a universal, tax-funded health care system. For example, if someone wants cosmetic surgery, the taxpayer would not be happy paying for that. If a service is medically necessary, then it should be either free at the point of use or available with a subsidy or some kind of co-payment, depending on the nature of the service. Not everything has to be covered.

Deputy Joan Collins asked about recruiting and retaining staff in the public sector. That is certainly an issue and I do not have a short answer to it. I am not sure exactly how to do it. I certainly would not be opposed to having a stipulation that people who received their medical education in Ireland, subsidised by the State, should repay the State by working for a certain length of time in the public system after graduation. That would be an acceptable way of getting junior staff into the system. The issue then is how to recruit and retain senior staff, which is more complicated. If the necessary investment is made in the health system and if it becomes a better system in which people want work, that will help. Part of the problem at the moment is that some elements of the system are quite chaotic and frustrating for medical personnel but if we invest in the system and improve it, some of that will naturally dissipate and we might be able to recruit and retain more senior staff. Certainly at a more junior level, the idea of a payback for the State subsidisation of medical education is a worthwhile option to pursue.