Professor Allyson Pollock:

This is horizontal integration. The market moves towards vertical and horizontal integration. This is rather reminiscent of what happens in the United States, where there are hospital groups and primary and community care service groups. I think it is deeply problematic because the idea of the Secretary of State having a duty to provide is that this duty is then devolved or delegated down to contiguous areas that cover all the population in a country. We really want those areas to be responsible for providing and delivering the services their residents need, including primary care, community care, mental health, acute services, rehabilitation and prevention.

That cannot be achieved if silos are created like hospital groups which become increasingly powerful, or primary care community groups. The funding, 3% of the budget for primary care, is so small that they will never be able to withstand the hospital groups and it is much more likely that they will be incorporated into the hospital groups in a sort of accountable peer organisational model. That is the real risk because these accountable care organisations, ACOs, like the American health maintenance organisations, HMOs, which were the forerunner of ACOs, are coming into play. What is needed are area-based populations with responsibility in those areas for providing and ensuring universal services which are integrated in that area. That can never be achieved through hospital groups and silos of primary and community care. If anything there is a risk, under the HSE, of creating the American type of ACO which would have mechanisms for cherry-picking and risk selection. I think that is a very worrying development, especially if hospitals and these hospital groups will be given more powers to raise their own income through private finance and private income generation. That is a very worrying and disturbing development.

That development has been paralleled in England which has now abolished its area-based structures. We had area-based health authorities, which became primary care trusts but they were always area-based, and in place of them are clinical commissioning groups, CCGs, but they are membership-based and look after only the residents who are members of their CCGs. One becomes a member by joining a general practice. The legislation is in place for us to move much more to the sort of grouping the committee describes. We are seeing this happen with our hospitals and our primary and community care organisations with federated structures in order that hospitals and primary care and community trusts are merging across large areas. We are seeing that under the guise of the national system but it is a move towards a US HMO accountable care organisation with all the dangers and warnings that brings from the Institute of Medicine. If this is happening in Ireland, it makes the case for legislation to bring in a national health service even stronger.