Ms Cliona Loughnane:

I will address Deputy O'Reilly's question on the structure and vision and whether it is a matter for the Department of Health or the HSE. There was also a question about when the leaflet drop would happen in Ireland. From our perspective, it has been positive to see the remit of this committee include consideration of a universal single tier system. It is a major development in the Irish health policy sector to strive for that position. Until recently, it was seen as a partisan approach to be interested in universal access to health care. We have come a long way already in that there seems be cross-party support for the idea of a universal care system. We are far closer to a leaflet drop than we have ever been in the past.

There was a question about coming up with a vision. It seems to be for the Oireachtas to come up with a vision and then it is to be implemented through the Department of Health and the HSE. Obviously, the Department of Health and the HSE would have a major impact on how that vision is constructed because they are experts in the delivery of care and policy. Ad hocpolicies are emerging all the time throughout the system. There was a news story today about access to medical cards for people in receipt of the domiciliary care allowance. That seems like a good development but all those developments are taking place without a vision. Therefore, the quicker we can have a vision, the quicker we can commit to what we mean by "universal" in the system. We believe this is what the committee needs to take by the horns. It needs to define what we mean by a universal system, what is in and what is out, who is covered and so on. While there is cross-party commitment to universality, what do we mean by universality in the Irish system?

Deputy Harty began a conversation around moving to primary care and integration between services. I imagine committee members will hear this from almost everyone who comes before the committee. That seems to be the solution to many of the issues we have at the moment. As Mr. Gordon noted, one of the main reasons for this is that disease in the 21st century is chronic disease and multi-morbidity is a feature. The system we have is not really set up to care for people in that way. In the 19th or 20th century if a person was lucky enough to get in to hospital, she would have been in hospital for a short period and the come out better, all going well. Instead, now people are living with disease for long periods and they need to be maintained and managed in the community.

Dr. O'Brien pointed out that our budgets are not really set out to cater for that. We have acute hospital budgets and primary care budgets as well as limited social care budgets. We need far more integration of budgets. As Dr. O'Brien said, often the way funding is available will influence how care is delivered. Integration across budgets seems to be a sensible way to do that.

As we outlined in our opening statement, we are keen for the committee to consider the health system in the round. The health system includes home help and the factors that keep people well in the community. There have been ad hocdevelopments, for example, the fair deal scheme. That has been useful to help people get in to nursing homes. However, it seems to have prioritised nursing home care over people getting the support they need to live at home. We need to think about health and social care together, because in the 21st century, health is often related to social care.

Deputy Harty referred to improvements in the HSE and health care delivery. As Mr. Gordon said, sometimes we see improvements in one area only to see problems in other areas. Certainly we accept that moving to the centres of excellence and the development of the models of care across different chronic diseases are appropriate. We are seeing positive developments but they are not available throughout the country. That is the issue.

A stroke survivor living, for example, in north Dublin does not receive the same service as a similar survivor living in Cork. Given that we are moving towards universality in the system, one would expect people to be able to access the same services across the country.

On Deputy Mick Barry's questions about the tax-funded system, I could give him the broad brush stroke answers in terms of economies of scale and the lack of competition. We could also submit considerable evidence from different countries, including the Scandinavian countries which have tax-funded systems and the United Kingdom. We recognise that there are other ways to provide a universal system. For example, social health insurance is another model in which funds are pooled. It appears to be less expensive than private health insurance delivered models. It is said, with respect to taxation-funded models, that social health insurance models can have higher administration costs attached to them and so on, but there is a good deal of evidence that we could provide for the committee.

The ESRI has been charged with undertaking research projects to examine the different models and costings. I am not sure how its timelines meet the committee's, but any evidence the committee could obtain from that process would be very useful. As we discussed, the Irish system is unique. Therefore, evidence from other counties would be useful to a point, but we also have to deal with the situation in Ireland.

I did not expect to be asked a question on the issue of church and State with respect to health reform, but it is an interesting one. In preparing for the meeting and trying to figure out why the Irish system was so unique, one point that popped up was that we seemed to move away from our European neighbours in developing a universal system in 1951 with the introduction of the mother and child scheme. There was controversy in the development of the health system and we have moved along a different path from that followed in other countries, but this is not an issue that has come up in our discussions. The issue of hospital ownership by the church is not one we have faced. It does not appear to be an issue from our point of view and it is not something we have considered.