Is the two-tier health system on its last legs? Probably not, but the flight into private health insurance might be set to level out or go into reverse, if last week's debate at the Royal Academy of Medicine in Ireland is anything to go by.

We have arrived at the point where everybody is entitled to free public hospital treatment, but 45 per cent of us take out private health insurance, mainly out of fear of long waiting lists for public treatment.

A clear indication that this public-private health mix is coming under critical scrutiny came from the secretary-general of the Department of Health and Children, Mr Michael Kelly.

The fact that too little money is invested in the health service is no excuse for the two-tier system we have, he told an audience mainly of hospital consultants.

Whatever the size of the health "cake", it should be distributed fairly as a principle, Mr Kelly declared.

With the Department developing a new national health strategy, Mr Kelly's remarks suggest that the role of private hospital treatment - heavily subsidised out of the public budget - may well be curbed as part of that strategy.

Health spending had roughly doubled in the past five years, he said, and the system was coming out of "a bad period when literally bits were hacked out of the health system".

To those who complain that too little money is spent on the health service, Mr Kelly pointed out: "We live in a low-taxation, low public-spending economy by European standards. That's a fact that's by choice of the Irish community. We live in a democracy."

Having delivered that reality check - one that is too often forgotten - he added his voice to the criticism of the two-tier health system.

"I think no matter what size the cake is, whether it's big, medium-sized or small, fair distribution is a principle which should run through anyway," he said.

"So the fact that we have an under-invested health system is no excuse for the two-tier system that's in place at the moment."

A roomful of hospital consultants might be expected to disagree with Mr Kelly. After all, they are popularly seen as people who would knock you down in the public hospital car-park as they run to the Merc to get to the private hospital and the big bucks.

But that isn't how it was. No one spoke up for the two-tier system, and some condemned it.

Prof Shaun McCann, of St James's Hospital, Dublin, described the two-tier system as "totally and utterly wrong". It was also condemned as "embarrassing and shaming".

It should not be assumed from this that the State's hospital consultants are ready to drive a stake through the heart of the two-tier system. Perhaps those who have an interest in perpetuating the system are slow to speak up in the present climate.

Nevertheless, consultants appear to feel genuine disquiet at the continuing flight into private health insurance by people who fear long waiting lists, and nobody there was pretending that the motivation was anything other than that.

No one contradicted journalist Maev-Ann Wren when she described as "iniquitous" a system in which "one in 10 of the poorest 10 per cent of the population has taken out private health insurance".

BUT where do we go from here? Some advocated a combination of extra beds and fewer hospitals to provide a higher-quality, more accessible public service. Prof McCann advocated the closure of "half the hospitals in this country". Mr Finbarr Fitzpatrick, secretary-general of the Irish Hospital Consultants' Association, pointed to the fact that the North Eastern and Midland Health Boards with a combined population of 500,000 people have eight acute general hospitals, six obstetric units and four psychiatric hospitals.

Small numbers of consultants in small hospitals cannot be expected to provide the round-the-clock consultant service now envisaged by health planners, he argued.

However, there also seemed to be a universal acceptance that hospital closures would not happen this side of an election or afterwards either.

Some advocated a system of insurance-based cover for everybody, with the State paying the premium for the poorest, and the consultant being paid the same for each patient regardless of status, which might bring greater fairness into the system. Others were quick to assert, however, that regardless of how doctors are paid, if you haven't got the beds the fundamental problems remain the same.

Which is where Mr Kelly said that regardless of the size of the cake, it should be divided fairly.

But it was Dr Cormac McNamara GP, a former president of the Irish Medical Organisation, who remarked at the start of the debate that in talking about health we tended to be obsessed with acute hospital services whereas, if we waned to make a real difference, we should be focusing on community-based services and, especially, on prevention of illness and disease.

But prevention, he made clear, is the Cinderella of the health system, both in terms of public funding and its low status among health professionals, who are far more impressed by people who can fix hearts and do transplants.

And, true to Dr McNamara's analysis, prevention didn't get a mention for the rest of the night.

pomorain@irish-times.ie