Brendan Ryan (Labour)

No. It will most assuredly not be kept if Senator Feeney keeps interrupting me.

It is extremely important in dealing with reform of the health service to ensure the action taken is designed effectively to make it better. The word "reform" is one that is used too loosely. We must ask ourselves what type of service we want to provide. I am not sure everybody on the other side of the House would agree with my definition in this regard. What we should seek to provide is universal, guaranteed, free at point of use access to the services necessary to sustain and restore well-being. Where such sustenance and restoration is not possible, we must provide care and comfort, either at home or in hospital, that is universal, guaranteed, and free at point of use.

That is my definition of a good health service, devised while wearing my engineer's hat and arising from my enormous obsession with having ideas clear in my head. It is the curse of an engineer that one is not allowed to fudge. One must say either this or that; there is no room for "maybe". That is why engineers and economists do not mix well and engineers and social scientists mix even worse. Being married to a doctor, I will not say how doctors and engineers mix.

I make no apologies in referring to the observation of the leader of the Labour Party that health care is not a market commodity but a community service. This is not to get away from issues such as value for money and so on. However, the market is a poor measure of value for money in the health service. Neither is it a guarantee of discipline, nor a particularly useful instrument. It was considered a glorious triumph when, in the interests of competition, the Competition Authority forced VHI to stop negotiating with consultants as a group.

The ideology of the Competition Authority is that competition controls prices and that people will be drawn towards the best price. The difficulty, however, is that a person suffering from an illness such as cancer will examine the prices charged by consultants and may well choose the cheapest rather than the best. Which consultant is the best? VHI is not available as a mediator because that is no longer allowed. In the absence of any other information, who will patients consider the best — the cheapest or the most expensive?

This turns on its head the entire ideology of competition. A person suffering from a life threatening illness will want to choose the best treatment. The only index available to patients in making that decision is cost. Many will conclude that a consultant who charges half the rate of a competitor is doing so because he or she is not as good and cannot attract patients. That may not be true but it is the perception that will arise.

There will be an orgy of investigations by the Competition Authority as it tries to prove collusion among health service providers in keeping prices high. The first chapter of a first year economics text book will tell us that consumers seek to maximise their utility. The Competition Authority seems to believe this is true in all cases and that patients will balance their health against a price. That is not the case, however, because people do not see their health as a commodity, like buying oil for the winter. That is why the market model is suspect. Similar activity is now taking place in regard to pharmacists.

I am aware that many negotiations such as this are ineffectively carried out. Given its poorly supervised monopoly, VHI was less than rigorous in its negotiations with both doctors' organisations and hospitals in agreeing what was value for money for a particular procedure or service. I agree with Senator Henry that it is a great pity the National Treatment Purchase Fund considers itself entitled to withhold the type of information that commercial entities like VHI, Vivas and BUPA are obliged to make public. I cannot accept there is any rationale for this other than a protectionist mentality on the part of the National Treatment Purchase Fund. The irony of a pro-competition Minister defending that secrecy and the absence of the rigours of the marketplace is astonishing. Perhaps a better service is being provided because more is being paid. There is no reason we should not know whether this is the case.

Discussion of the health service is infected by claims about the advantages of the alleged rigours of the marketplace. One need only read the eulogies on competition written by the eminent economic correspondent, Mr. Marc Coleman, of one of the newspapers that claims to be the newspaper of record. Perhaps there is a competitive model of a health service that works. I am not aware of such, however. The best health services in northern Europe, including those in Germany, France and Sweden, are funded by government to the tune of between 7% and 10% of total spending. According to all the commentators, however, that is unaffordable for this State. We are repeatedly told there must be an insertion of the disciplines of the marketplace.

Those disciplines are in place across the Atlantic. Two comparisons are sufficient to point to the failings of this model in the case of the United States. Infant mortality rates in that country are higher than in any state in northern Europe. This is one index of the quality of universal health care. The other is life expectancy. Life expectancy in Sweden is far higher than it is in the United States. This may be because the price of alcohol is so enormous in Sweden that its inhabitants cannot drink themselves into an early grave as we in this country are trying to do. There is no doubt, however, that on these two indices of performance, the Swedish, French and German health services, and even our own, are superior to that of the United States.

Moreover, the costs of that underachieving health service are such that I cannot understand why people in senior positions in Irish public life nod in that direction. Some 16% of GDP in the United States is spent on health care. This means that instead of us spending €12.7 billion per year on health care, we would have to spend €25 million to match the percentage of GDP spent by the United States. Has anybody faced up to the reality that where one takes a marketplace approach to health services, one is dealing with a commodity for which there is a limitless demand and for which people will pay a limitless price. It is therefore entirely unsuitable for market rigours. An attempt to introduce such rigours will merely distort it and make people rich without any significant improvement in the service itself.

This is where the issue of private hospitals on public land comes into question. It introduces into the context of public health provision issues to do with the way the market works. I do not refer to the silly old hard-line lefty stuff to the effect that private health providers are only in it for profit. It is possible to run good quality services that are profitable. Profit and good quality service are not inimical but given the nature of the commodity, as some people regard it, there is limitless demand because people want ever better services for which they are prepared to pay limitless amounts. Principles of supply and demand and elasticity do not work in health care so we should be wary of going down that road.

If the market model does not work, what are we to do? I do not dispute that things have improved in some areas and everybody acknowledges that inside the hospital system, despite MRSA, the quality of medical care is as good as one could ask for. I know affluent people abroad who are able to pay for high quality private care where they live but return to Ireland to give birth in Irish maternity hospitals because of the quality of care. Who delivers that high quality service? Coming from the left, as I like to think I do, I say it is the doctors and nurses who deliver that service, among them the much-maligned consultants.

I will declare that my wife is a hospital consultant. She works very hard, entirely in the public sector, and the only time she ever worked in private practice was when the public sector declined to give her a job. The minute she landed a public sector job she gave up private practice because she had no interest in it, as is the case with the majority of her colleagues in psychiatry in Cork, although I cannot speak for every region. Consultants, who receive much criticism, are the central deliverers of the quality health care about which this country boasts, as are the nurses who are threatening to strike. The debate ought not to be about beating consultants over the head or silencing them. The most effective and vocal lobbyists for the quality of public health care are hospital consultants, yet it is proposed that they be silenced by a clause in their contracts.

I work in a public body, Cork Institute of Technology. Short of defamation and libel I can say what I like about what is wrong with the service and I can make public its deficiencies when and where I like. I can be warned of the consequences for student demand if I say foolish things, and the Department of Education and Science might be upset at what I say but I cannot be silenced. Why would anyone want to silence hospital consultants unless they thought there was something to hide? The suspicion is now widely held that one of the strategies of the Health Service Executive is to make its problems internal, invisible and silent, which is a dreadful prospect. The health service will only be reformed by open, transparent and accountable decision making. If we take the opposite path, we will make it worse, although it might look better.

Is the allegation true that there has been a directive to move people out of accident and emergency units and into corridors, so that they are no longer regarded as being on trolleys in accident and emergency units? Why do we have to reinvent the wheel in connection with MRSA? Other countries have sorted out the problem and I will shortly say why that is the case.