Dr. Sara Burke:

Good morning. I thank the committee for inviting me here this morning. I really welcome the work of this committee, which is long overdue. It is the first time in the history of the country that any attempt has been made to reach a cross-party consensus on the future of our health services, particularly the development of a universal health system where access to care is based on need, not income.

The committee has asked me to speak on the issue of inequality in access to health care. As Deputies will know from their lived experience and from the constituents they meet every day, there are many inequalities in access to health care in Ireland. This country is exceptional in terms of the fragmented, complex nature of health care and in the unequal access to diagnostics, treatment and care.

Internationally, when one refers to universal systems one is talking about an entitlement to package of care, that is, the health and social care services to which citizens are entitled. In Ireland, because we do not have a universal system, there simply is no such thing as a package of care. People do not know what services they are entitled to and accessing social and health care services depends on whether one has a medical card, a GP visit card, private health insurance, an ability to spend money from one's own pocket on health services, where one lives and what type of services one is trying to access.  Decades worth of research shows that it is the poorest, the sickest and people with disabilities who find it hardest to pay charges no matter how small those charges may seem and who find it harder to negotiate access. Indeed, any of us who has accessed the system - and GPs in particular know this because they do it every day - knows how difficult it is to negotiate one's way through it. It is also the poorest, the sickest and those with disabilities who have to wait longest for care.

Medical cards, which currently cover about 36% of the population, are a proven pro-poor measure. They are a positive safety net for the poorest third of society. It is actually the poor, the sick and people with disabilities who do not have medical cards but who are on lower incomes who fare worst in terms of coverage and access.  I do a lot of international work in Europe and with the World Health Organization, WHO, and when I present data showing that we do not have universal access to primary care, people do not believe it. We are absolutely unique in a European context in not having universal access to primary care. When I present data showing that 54% of the population has to pay, on average, €50 for each GP visit, people are really stunned by that amount. At the moment, 64% or two thirds of the population may have to pay up to €144 per month for essential medication. That is an awful lot of money out of anybody's income.

Technically, we do have universal access to the public hospital system - or at least we did - in that everyone is entitled to public hospital care. However, measures that were introduced, such as the €100 fee for accident and emergency departments and the €750 per year charge for inpatient care mean that people without medical cards often cannot afford this. Even if one does have free or without charge access to the health system - we are all paying for it in lots of different ways - the very long wait times for accessing public hospital care mean these public patients are denied access. This is further exacerbated in the Irish context by what is called our two-tier hospital care, which incentivises and pushes people into private care. 

The inequalities in access we have manifest themselves in different ways, people without free general practitioner, GP, care or a medical card delay or do no not go to a GP in the first place due to cost.

When people present at a GP, often she will often need to send them for diagnostic tests. The Irish College of General Practitioners, ICGP, told the committee last week that it has done comprehensive research showing the poor access for patients who could not afford to pay privately to access an essential scan or test. One part of its research showed that 10% of GPs had direct access to a MRI scan in the public system with an average waiting time of 22 weeks whereas all GPs had access to MRI scans in the private sector within seven working days. This public-private divide further delays diagnosis and treatment for people who cannot afford to pay privately.

When a GP decides that a person needs to see a specialist we know there are extraordinarily long wait times to access that appointment in the public hospital system. We hear these figures generally every month when the National Treatment Purchase Fund, NTPF, publishes them and when they come out they are in the news. What hits the headline is that there are approximately 450,000 people waiting for that first outpatient appointment. In a way that number is not the problem because that is probably the amount needed within any population of our size. The problem is the numbers waiting a long time. I updated the figures in advance of this meeting from the August figures which show there are over 74,000 people waiting more than a year for that first outpatient appointment and over 110,000 waiting six to 12 months and 95,000 waiting three to six months. By any international benchmark zero to three months is a reasonable time to wait, any time after that is too long. We have hundreds and thousands of people waiting too long.

When a specialist decides that treatment is needed, after this first outpatient appointment wait there are also long waits for this. Despite the efforts of the last Government to reduce waiting times for treatment, and they had some impact in 2012 and early 2013, there have been longer waiting times for all groups since then, except those waiting over two years. Nobody should have to wait over two years for either that specialist first outpatient appointment or that specialist treatment.

None of these points touches on the inequalities in access to community services such as home helps, public health nursing, physiotherapists, occupational therapists, speech and language therapy, mental health services mainly because the data is so bad or does not exist. The HSE has begun to collect it in some areas but only in the past year or so. That means I cannot present that time series data we have for hospital services but such services are equally if not more important than hospital services. There are huge inequalities in accessing these, often depending on whether one has a medical card and on the existence or capacity of a service in the area where the patient lives.

Part of the complexity of the Irish system is the result of the existence and overlap of private health insurance on the public health system. We are unique for a high income Organisation for Economic Cooperation and Development, OECD, country for the way we marry private health insurance and the public hospital system. We know that people who can afford to pay privately can get their diagnostic tests quicker, get to see a specialist quicker and if insured may be able to get their treatment quicker.

My current role in the Centre for Health Policy and Management in Trinity College Dublin is co-ordinating a Health Research Board, publicly funded, project called 'mapping the pathways to universal healthcare'. In this project we are monitoring Government progress, or perhaps the absence of it, towards a universal health care system. Initial policy analysis work that we have done, which was published at the end of last year, found that despite the rhetoric and the intention of increased universalism between 2011 and 2015, there was in fact less, not more, universalism now than there was in 2011. This is due to the further increase in drug charges for people with and without medical cards, the introduction of lifetime community rating and the failure to reduce waiting times for access for public patients. The one exception to some progress on universalism was the extension of free GP care to those aged over 70 and under six years. We know internationally that insurance-based systems, such as those in the USA or the Netherlands, are more expensive and cause inequalities. In Ireland, 45% of population have private health insurance yet it contributes less than 10% to the overall health budget.

In the project in Trinity my colleague, Dr. Sarah Barry, is leading on a systematic review on the organisational challenges of introducing universal health care. Professor Steve Thomas, who the committee has met privately, and Bridget Johnston, are doing groundbreaking work on financial protection. This is the first time this work has been done in Ireland. Financial protection is a core component of the World Health Organization's definition of universal healthcare which in effect means that health and access to health care should not cause impoverishing or catastrophic health expenditure. The terms are quite technical and I will spare the committee the detail on them. Catastrophic, however, means that people are forgoing essential expenditure in other areas to meet health service needs, usually out of pocket payments.

Initial work we have done on quantifying the amount of out of pocket spending is presented in the accompanying graph. This does not count everything people spend privately on health care, it counts only what we were able to count. It showed that in 2014 Irish citizens paid €580 million more out of their pockets for essential, generally hospital care or drug charges, than they did in 2008. We are doing more detailed work using the Central Statistics Office, CSO, national household budget survey data. It went into the field again earlier this year but we do not have the data from that. We have, however, analysed the 2009-2010 data, exploring the extent of affordability of private health expenditure and what proportion of Irish citizens are financially protected, or not, when they access health care. We found that the poorest people who experience catastrophic levels of private health expenditure, almost 50% of the poorest fifth of the population reported unaffordable levels of private health spending. I have given the committee the breakdown of expenditure according to those income quintiles. Two interesting observations arise from this data, one is that the poorest 40% of the population spent most on private health insurance and the highest level of out of pocket, unaffordable spend from those with middle and higher incomes was on dental care. These figures come from a diary people keep of what they spent their money on so they do not catch unmet need. They catch only what people actually spend. We know that low income groups do not go to the dentist because of the barrier of cost.

Providing timely access to appropriate care for the whole population, which is in effect a universal health system, will cost more money and require more staff. Professor Thomas is studying workforce requirements and our current staffing profile as a basis for getting to universal health care. He is also reviewing potential areas for positive rationing. In other words, how we can use the resources we have more efficiently so that universal health care is affordable and deliverable.

The work we are engaged on in this project, 'mapping the pathways to universal healthcare', aims to devise tangible steps towards a universal health care system, work we hope will be of use to the work of this committee. Delivering a universal health system is a political choice which is in the power of the committee. It is a political choice that is a matter of life and death to some people. It can improve all people's lives, our quality of life and indeed our deaths. I wish the committee well with its work and am happy to answer any questions members may have.