Dr. Josep Figueras:

Incrementally. What I am saying is that there are a lot of complex incentives in the system. I wish one could do a big bang, but my impression is that we still cannot predict very well what would happen with a big bang in coverage in primary care. The costs might explode. As such, one has to do it incrementally. At the same time as one has the PCTs working and a good benefit package in place, one tries to have more integration. One wants to do it in an incremental way so that all these other changes in the skills mix happen simultaneously.

I wish a big bang approach was possible. I agree that the legislation needs to be very clear. There is a need to go to universal health coverage for primary care. It may be desired to leave some user charges which are means tested. I link that to the other question. Of course, one needs the money coming from somewhere. Even with user charges, there is a question about private health insurance. We need the money to come from somewhere. I understand that. All countries, as the members have seen, have an element of private health insurance and user charges. I am not suggesting one can or one should. It is a political and societal value. Many people take private health insurance because they are afraid. I understand that and that, as such, one cannot withdraw it. However, what we are talking about is how to use user charges in as efficient and equitable a way as possible. Can we have value-based user charges? Can one use user charges in areas where we know they are less effective, although it may not be ethical to apply user charges for things that are not effective? There are ways to tailor user charges.

There is one area on which I have data but not the time to show that to the committee. It relates to the caps in Ireland which are a bit high. We want to have user charges with lower caps. It becomes almost like a tax because everyone will reach that. However, the €750 cap in Ireland is fairly high. Is it €475 in hospital care after €750? For part of the population, that seems to be a fair amount of money. I cannot remember the examples by heart but I have them there. Sometimes I felt that there may be a wish to introduce caps on that. Certainly, it is the same as to whether antibiotics are free. Clearly, for chronic care, and I think Ireland does it already, one does not want to have user charges. For certain groups, one does not want to have user charges. I have the evidence and there are much better experts in this country to discuss it. Certainly, it is possible to keep user charges while ensuring they are better tailored, have as little impact on equity as possible and are as efficient as possible. The same is true with private health insurance. All countries have private health insurance which has a role to play. However, we should use it in more complementary way rather than in supplementary ways. What about having health insurance in services that are not covered by the package of care? To be more explicit, I refer to dental care and ophthalmic care.

I relate this to the question on what we do with the recession and the limit. I could talk about that. I work with ECOFIN on the complexities of health care in the semester context.

There are recommendations this semester. I guess the committee has read the semester recommendations for Ireland in health care, the sustainability, the Directorate-General for Economic and Financial Affairs recommendations, which try to explain how to work together on these limits and the need to sustain the system and cut costs. I do not want to go far but there are ways in which voluntary health insurance can be used. I think Ireland has a fairly high percentage in comparative terms. It is in the slides if the committee members have the time to look at them. That is fine if that is Ireland's decision. There are ways to operate it better, to make sure it does not have progress incentives for more hospitalisation, ways to make it perhaps a bit more complementary. I would not recommend, however, that it be complementary for user charges. Please consider that before going for voluntary health insurance. I have been working with Slovenia which wants to use voluntary health insurance for user charges and Ireland does not want to do that because if it pays, as in France, if everybody gets voluntary health insurance which pays user charges there is a moral hazard. People will try to use the service as much as possible. The problem with user charges is moral hazard. I do not believe it works but if there are user charges to collect money one has to ensure that the services are used appropriately. If Ireland decides to put in place voluntary health insurance, those who are poor will not be able to access it. The French subsidised the "mutuelles" for voluntary health insurance to complement user charges. Excellent, but what is the point? The patient has an insurer and it pays the hospital which pays the patient back. What is the idea? The money might as well be given directly. We do not need the middle man to do that. Once that is introduced it cannot be changed. We could not change it in Slovenia. It is a no-go area because the population perceived it as very valuable, which is the point the Deputy made. If Ireland reforms private health insurance the Government should read the book and talk to experts - it has many in this country - about how best to keep it because it values the principle but it needs to get value for money and not too many inequities.

To answer the question about the big bang and all those issues, for the universal health coverage in primary health care it is better to have an incremental system within a limited period, perhaps two or three years.