Professor Allyson Pollock:

The first question was really about the difference between Scotland and England. One of the important things to note is that England introduced an internal market purchaser-provider split in 1990. That model was followed by Wales and Scotland. However, when devolution came in 2000, Scotland and Wales took the step of deciding to abolish their internal markets. That was pretty much a silent revolution. People do not realise it even happened. It took place through legislation. They abolished the purchaser-provider split and reintegrated hospitals and services into health boards, making them responsible for the needs of the population. This required legislation. It was a legislative process. They have now gone further in that they are now moving to integrate social services into health services using a bottom-up approach, which is an interesting approach. That is the difference between Scotland and England and what has been happening in the past 13 years. Scotland has gone further. There was a political declaration by the Scottish National Party not to have private provision.

The second question was about information systems. These are the lifeblood of any health system. Scotland operates an information system, ISD Scotland. It is part of a special health board or authority. That is how information is managed. It is superb. It is the jewel in the crown of the Scottish health service. It means we can undertake many comprehensive studies. It very much mirrors the systems in place in Scandinavia.

Committee members will be well aware of the debacle over information in England, not only fragmentation but the care data scenario as well. The intention of the Bill we are writing is to put information back under the direct control of the Secretary of State and a health authority. At the moment, information in England is deeply problematic, especially care data, what has happened with general practitioner practices and the ability to get data.

The Deputy asked a good question about accountability on the part of the Minister. Again, my view is that if Ireland were developing legislation, those responsible should strengthen systems of accountability. I am referring not only to the Parliament but to accountability to the people as well. This is an area where we have seen a major weakening in England. We used to have community health councils, which had a direct right of appeal to the Secretary of State. We had a number of good mechanisms at local, district and regional level whereby the Secretary of State and the Parliament could be brought to account by local people. I think the question about accountability is singularly important. This point should be worked out in legislation. I hope that answers the questions of the first speaker.

The question of the second speaker related to the role of the private health care system. I would put it the other way around. I will put the following questions to committee members. What evidence is there that incorporating private health insurance and private providers actually ameliorates the inequity we see in the system? What evidence is there that they can deliver universal health care and social solidarity? What evidence is there that they can keep the costs of health care and transaction costs low and ensure there is no subsidy from the public to private sectors? That is what I would be going on. What is the evidence for private health insurance and private provision in ameliorating and preventing inequalities in health care and in ensuring universal access? There is considerable evidence to the contrary. All the evidence points the other way and suggests it does not.

There was a question about the 44% of people covered by private health insurance. Work needs to be done to understand the extent to which people use that insurance and the extent to which tax subsidies exist. We know there are such subsidies for people who use private health insurance. We know there are tax breaks to private health providers.

It is about building political consensus such that people can believe the system will be there when they need it and such that they do not need private health insurance. I think if there was major legislation setting out the intention, people would find that private health insurance would wither on the vine. It should wither away. Indeed, in the United Kingdom in spite of all the chaos in England, coverage by private health insurance is less than 10%. The figure has been falling since 2008. That is partly as a result of the financial crisis, but the level is far lower than the level in the Irish health system. Some countries prohibit private health insurance, such as Canada. The set-up in Canada prohibits a two-tier system from existing. Under the Canada Health Act health care is provided in the public system and people cannot use private health insurance as an alternative route.

These are things that need to be debated and discussed. The central issue is whether private health care, private health insurers or private providers reduce inequalities, increase access, decrease costs and ensure social solidarity. I am happy to come back in on that.

Deputy Madigan asked me about health promotion initiatives. As a result of marketisation, most public health functions in England have been transferred under Public Health England to local authorities. This has been catastrophic because local authorities have faced major cuts in social services expenditure and are facing cuts of £200 million in public health expenditure. Many vital health promotion and prevention programmes that were in place in areas like school nursing, health visiting, district nursing, smoking prevention and cessation and alcohol intervention are being seriously cut at the moment. Indeed, some of these services will no longer exist in local authorities. At the same time, because there is no longer a duty of provision on the Secretary of State, the individual clinical commissioning groups that have replaced the old primary care trusts and area-based health authorities are now decommissioning whole ranges of services. The criteria for hip arthroplasty and cataract procedures, for example, have been changed. Many preventative services, including some forms of surgery, can be seen as preventative. Hip arthroplasty, which is the most common elective surgery operation, can be preventative if it is done on time because it prevents people from falling and becoming disabled and enables people to continue to live at home. A range of services are being decommissioned, slashed or no longer funded in local authorities. I do not have a good news story for the committee from England. All of this flows from the abolition in 2012 of the Secretary of State's duty to provide.