Dr. Brian Turner:

On Deputy Kate O’Connell’s question on who should determine medical services, it has to be clinician-led. Based on the thematic review of responses received on the White Paper on the universal health insurance proposal, one area of concern for many was with the basket of services. This would need to be handled carefully. Who decides what services are covered in public hospitals now? It basically seems to be medically necessary services. I am not sure there is a menu anywhere of what that covers.

Demand is increasing on an ongoing basis. If one looks over time, the proportion of GDP, gross domestic product, spent on health care across the world is on a long-term upward trend. There have been debates in several countries about sustainability. A good report written by John Appleby for the King’s Fund in 2013 suggested public spending on health in Europe, as a proportion of GDP, could increase from 6.7% to 13% by 2060. He discussed sustainability issues around that. There is no assumption that new treatments do not become available. Medical technology is improving all the time. If anything, there is an implicit assumption that treatments will advance on that.

On the changing eligibility for GP-visit cards from age-based to income-based, I was looking at it from the point of view of who has the most trouble accessing services and for whom is there a significant financial barrier to accessing services. There are two groups, namely those who visit their GP more often and those on low incomes. With the under-sixes and the over-70s, we have largely covered the people who visit more often. In expanding it to the six years to 11 years age category, I stated in a submission to the public consultation on this that at the press conference on budget 2015, the then Minister, Deputy Varadkar, suggested expanding free-at-the-point-of-use GP care to that age group would not cost a huge amount because the capitation rates are lower as that age category would not visit the GP as often.

If that category does not, then maybe we should focus instead on those for whom there is a significant financial barrier to accessing GP services. The people who delay going to their GP may end up needing hospitalisation by the time they go about getting treatment. There are always trade-offs and no right or wrong. My suggestion, however, would be that we should focus on income rather than age. Those with complex needs is another issue to be considered.

On the question of a certain number of visits per year, I threw five out there as an example. The Central Statistics Office quarterly national household survey module on health in 2010 broke down the number of GP visits per year by various different cohorts.

If memory serves me correctly, the average number of GP consultations among adults who reported those consultations was 4.3. If we include the number of people who did not see a GP, then the average number of consultations was 3.2. There is evidence to suggest that the typical number of visits per year is somewhere between three and four. Obviously, that is complicated by the fact that some patients have medical cards and would tend to go more frequently. Others may be younger and, therefore, would go less frequently. If one were to go down that road, more analysis would be needed to come up with a figure. That is one option to deal with it.

I was asked about distinguishing between public and private health care. The provision of maternity services is an interesting example. In Cork, Cork University Maternity Hospital is the only show in town in terms of maternity services. Public and private patients are mixed together there. Maternity services are unusual in that we cannot exactly have a waiting list for certain maternity services. Maternity services are also unusual in that they are not fully covered by health insurance. There is a significant co-payment, even for those who have private health insurance. Certainly, it is an example of where we could start to examine the system.

Reference was made to the high health spend per capitarelative to the OECD average. Yet, people say more resources are needed. Again, to a certain extent this stems from the under-funding for over a decade in the 1980s and 1990s and the fact that the resulting deficit was never fully unwound. Our bed numbers are still below what they were in 1980. The number is approximately 15,000 at the moment, compared with 18,000 in 1980. We are below the historical figures in terms of bed numbers.

A question was asked about moneys versus efficiencies. I do not think it is a question of either one or the other. We need to spend more but we also need to ensure that we spend wisely and that efficiencies are harnessed.

Reference was made to waiting lists as one way of rationing care. I am not for a moment suggesting that people should be made to wait until they give up. From an economic point of view, no health system in the world has sufficient resources to give everyone the care they need when they need it. Resources have to be rationed in some way. The use of waiting lists is one way of rationing services. Eligibility to services on the basis of ability to pay is another way to ration services, but it probably has more adverse consequences for those who cannot get into the system.

Deputy O'Reilly referred to the possibility of medical staff being asked to stay on while we do not ask the same of those working in other areas. To a large extent we do not have the same shortages in others areas as in health. However, I understand Deputy O'Reilly's suggestion that we are perhaps singling out one cohort.

The question of incentivising health professionals to work in Ireland or to return to Ireland was raised. Again, if we invest in the system and improve the public system, there will be a natural element of people seeking to work in the system or, to put it another way, not wanting to not work in the system.

Deputy Barry referred to the Canadian system. I would not profess to be an expert on the Canadian model. I was under the impression that rather than private health insurance being banned, there is a ban on private health insurance covering anything that is covered by the statutory system. In other words, private health insurance can cover care not covered by the statutory system and it operates purely as a complementary health insurance system. I am open to correction on that point. Certainly, the Canadian model has been proposed as a good model, although in terms of health spending as a proportion of GDP, Canada is at the higher end of the scale. I gather it is one of the higher spending countries, notwithstanding the fact that we are, temporarily at least, one of the highest spending countries.

Another point to note relates to the peculiarity of the figures in looking at health spending as a percentage of GDP. Given the 26% increase in GDP in 2015, our health spending as a percentage of GDP in 2015 will, I imagine, suddenly come down below the OECD average again. We will come down the rankings simply because our GDP has gone up and the denominator has increased. Health spending per capitamay be a more useful measure in that sense.

Deputy Durkan asked about the hospital services generally retaining and recruiting professionals in other countries. The honest answer is that I am unsure how they do it or what the mechanics are. Certainly, we are facing a shortage of professionals. Some other countries are below the OECD average in this regard. However, I have not undertaken any investigations into why that is the case – I would rather not hazard a guess.