Roisín Shortall TD, Co-founder, Social Democrats party, former Minister of State at the Dept of Health
Professor Tom Keane, who oversaw the successful implementation of the Cancer Strategy in 2005, recently gave an interview about the Irish health service on the Sean O’Rourke programme. In it he said that the service was reaching “a tipping point of total system failure”. In a situation where nearly 60% of the population does not have timely access to healthcare, we are looking at what he called “an apocalyptic situation”. Professor Keane went on to say that “in any other country in the world, if this was happening, the government would not survive, it would be beyond what would be even reasonably acceptable” and that it is “astonishing……that people are not taking to the streets”.
The crisis in our health system
Well, people haven’t taken to the streets in any great numbers – not yet anyway – but they have plenty to say when you meet them on their doorstep. As we canvassed for last year’s General Election, household after household spoke angrily and fearfully about the crisis in our health system. Health was, by a large margin, the number one issue of concern. And yet, incredibly, neither of the two largest parties made any new proposal in their manifestos to solve the crisis in in health.
The election took its course, the votes were counted, and eventually the media turned back to the crisis in the health system, to the drip drip of horror stories about years-long waiting lists, soaring insurance costs, and the routine denial of timely, effective treatment to people in direst need. And now at last, in Leinster House itself, there was a growing cross-party sense that “something needed to be done” about Health. For year after year, there had been calls to depoliticize health, and to draw up a long term agreed strategy to settle the problem. Now, as the crisis got worse, there was a real determination amongst politicians of all political stripes to move beyond the talking stage. One accidental benefit of the lengthy post-election interregnum was that it gave many politicians some pause for thought, an opportunity to respond to public concerns and to take a new approach to our dysfunctional health service. It was against this background that the Social Democrats drafted a Dáil motion on cross-party health reform, to which 89 TDs immediately signed their names. Soon after that, the new government was installed and the new minister and his colleagues came on board.
What followed was a unanimous vote of the Dáil to establish a cross-party committee to be called the Committee on the Future of Healthcare. The Committee was tasked with reaching a consensus on a 10-year strategy for reform, and critically, it was specified right from the start that this would include the establishment of a universal single-tier health service, a fair and compassionate health service, which would treat all patients on the basis of their health needs rather than their ability to pay.
Fourteen TDs, representing all parties and groups, came together to form this new committee, and I was elected as Chairperson. The other members of the Committee were Kate O’Connell, Bernard Durkan, Hildegarde Naughton and Josepha Madigan of Fine Gael, Billy Kelleher, John Brassil and John Browne of Fianna Fáil, Louise O’Reilly and Pat Buckley of Sinn Féin, Joan Collins of Independents 4 Change, Alan Kelly of Labour, Mick Barry of Solidarity and Independent Dr Michael Harty.
A disjointed, inefficient and inequitable system
This was a first for us all, in fact it was a first for the Dáil. Never before had a Dáil committee attempted to reach a political consensus on policy relating to an area of major public importance. Unlike most developed countries, we in Ireland have never sought to identify the most appropriate model of healthcare for the Irish people. A very disjointed, inefficient and inequitable system has evolved over the years, which fails to adequately meet many of the most basic care needs of the people. In no other European country are so many people denied access to services or forced into private health insurance. In theory, almost 40% of people are eligible for free public health care. But the key word here is “eligible”. They may be eligible for treatment, but they are not entitled to it. Because in practice, many of the services they are theoretically entitled to either do not exist or are hopelessly inadequate. This is why people can wait years for a routine out-patient appointment to see a publicly-sponsored consultant. And because of the grave shortcomings of the public health system, another 45% of the population feel they have no choice but to take out expensive health insurance, the premiums for which rise every year, just so they can be sure of access to hospitals and diagnostics that, in most cases, are already paid for by taxation.
All service users, whether public or private, are faced with significant out-of-pocket expenses that have risen substantially in recent years, often to a catastrophic level, where many are denied access to essential care. In the Irish context the Inverse Care Law applies with brutal force – those most in need of care are least likely to receive it.
From the start, the Committee on the Future of Healthcare agreed that our approach would be evidence-based, that we would listen to service-users and staff, that we would take expert advice, and that we would learn from best practice in other countries. Importantly also, we agreed a set of principles which would underpin our work and the development of the Strategy. Included in these was a belief in the primacy of the patient, the need to make timely care free at the point of delivery, based entirely on clinical need. And we also agreed that these services would, in the main, be provided in the primary care and community setting, away from overcrowded, overworked and stressful public hospitals, and close to where people actually live. We also determined to support and value the health service workforce while at the same time introducing much greater oversight and accountability.
Over the course of our work, committee members came to realise just how much of an outlier Ireland is in terms of poor access to care, high user-costs, long waiting lists and the fact that some 45% of the population feel obliged to pay for private health insurance. This compares, for example, with the UK where approximately 12% of people have private health insurance. As Dr Tom Keane said, it wouldn’t be tolerated anywhere else.
Make other people believe that change is possible
We resolved to ensure that people in Ireland would have the right to timely access to quality public health services, similar to the rights enjoyed by most of our European neighbours, even in states that are smaller and poorer than we are ourselves. We also recognised that we need to build long-term public and political confidence that a solution is actually possible. Ireland’s health system has been failing its people for so many years now that many have come to assume that the situation is hopeless, that it must always be thus, that there is nothing to be done about it. Yet this is clearly not true. Ireland is not a poor country, and much poorer countries than ours have managed to run decent health systems. We therefore realised that our first and most important task would be to make other people believe that change is possible. And to do that, we had to learn to believe it ourselves.
And so, 11 months after we took up our work, we had convinced ourselves beyond any doubt that we had the solution. We had considered 160 public submissions, held 4 months of open hearings, and worked intensively with an expert team from the Centre for Health Policy and Management in Trinity College. And the fruit of all this consultation, research and innovative thinking was a new cross-party strategy that we called Sláintecare.
Sláintecare, like the committee that produced it, really is a first for Ireland – a fully costed plan which maps a clear path away from the current dysfunctional, inequitable and inefficient two-tier health system, replacing it with a modern, responsive and universal public health service, comparable to the systems of most developed countries.
As a committee, we put a strong emphasis on implementation. We were determined that Sláintecare would not be left to gather dust. That is why we proposed a separate, fully resourced, implementation office, under the auspices of the Taoiseach and working within the health service. The sole remit of this office would be to make the reform programme happen. Fixing the health service can be compared to repairing an aircraft while in flight – it needs to be kept in the air while the work is being done. Similarly, all of the urgent day-to-day demands of a creaking system have to be coped with and responded to, while also implementing a radical and fundamental systemic change. We don’t have the luxury of halting everything to set up a new system. Old and new must work in parallel during the transition.
Of course that transition period needs to be funded on top of the existing expenditure. The Committee was very conscious that in Ireland, we spend more on our failed health system than most other OECD countries pay for functioning services. But we were also conscious that we will not see critical change in the way we deliver services unless we provide up-front funding to make the reforms happen. It is necessary to prime the pump, to spend more now so that in future we can spend relatively less to see much better outcomes.
We are proposing a significant move away from our overly hospital-centric model of care – expensive, inefficient, far too prone to blockages and bad administration – and move instead to a system which puts the focus on primary and social care, close to where people live, and to the networks that sustain them. This means investing in primary care centres and community diagnostics, rather than forcing people to travel long distances to over-crowded hospitals to sit in emergency rooms which they don’t really need, or to access routine out-patient services. It also means recruiting the nurses, doctors and other key health professionals who can provide this much needed additional capacity in the community. In this way we can have a much greater emphasis on prevention and early intervention and ensure that the huge burden of chronic disease can be managed much more effectively in a community setting. If we can make this switch we can achieve much better health outcomes and also much better value for money.
Similarly, we propose early investment in the eHealth programme, which if implemented in full, has the potential to radically transform the information systems in our health service and greatly improve efficiency. eHealth is a programme which would give each individual patient a unique identifier, allowing them and their records to be transferred seamlessly throughout the health system. Such data management is vital to understanding how the population, nationally and regionally, engages with the health service. It would also provide necessary information on the geographical and service areas where resources are most needed. In this way we could have better forecasting and financial planning for services as well as ensuring greater accountability for performance all round.
The Committee has proposed a Transitional Fund in order to make up for the substantial underinvestment in facilities and IT during the austerity years. This fund would also train the additional primary care staff in order to greatly expand capacity at community level. The amount required for this is €3 Billion, spread over the first six years. In addition, we recommend the continuation of the annual 7% increase in the health budget, which we’ve seen in each of the last two years, in order to fund the proposed universal package of care.
Not possible to establish accountability
The need for more accountability in our health system, and particularly in our state-funded hospitals, was behind the most radical, but also the most urgent, recommendation of our Committee. This was the clear and pressing need to disentangle our public health system from private medicine. Our hybrid system, unique in the western world, permits senior doctors to use publicly funded hospitals and diagnostics to treat their private patients. The state invests hundreds of millions of euro in so-called “voluntary” hospitals which, when called to account, comport themselves as private entities, with no need to answer to the public interest.
There is a huge lack of transparency about the level of cross-subsidisation from public funds to doctors and senior managers in publicly funded hospitals, to the health insurance firms that place their clients in those hospitals, and to the supposedly separate private clinics which many voluntary hospitals operate alongside their state-sponsored operations. It is impossible to establish whether we are getting value for money from our public hospital beds, for example, or from our publicly funded equipment, our consultants or other healthcare staff. And without a clear line of sight of resources, transparent data and effective information systems, it is not possible to establish accountability at either administrative or clinical level.
Absurdly, public hospitals are given annual targets, rising year on year, for income generation from private patients. Meanwhile hospital consultants who are already paid generous public salaries are permitted to see private patients on the side, to top up their earnings. This mashing together of public interest and private gain creates a classic perverse incentive, paying publicly funded hospitals and consultants to treat private patients ahead of those in the public system whose needs may well be greater. Is it any wonder that we have 660,000 people on waiting lists for hospital services? The mixing of private incentive and public interest at the heart of our health system creates an ungovernable twilight zone. All we know for sure about them is that public money flows into them, and private money comes out, in the form of “top ups” and special payments for senior doctors and executives. How this alchemy comes about is, we are told, none of our business.
What is required is political courage
Throughout the Committee’s work over the past eleven months, we have been acutely aware that we are facing an historic opportunity to do something of real consequence for the country, to agree a 10-year strategy for a new and comprehensive health system. We have a unique, once in a generation chance to draw up a viable plan to ensure equitable access for all our citizens to a high quality, universal single-tier health system.
Sláintecare is not pie in the sky. It is not just another catalogue of fond aspirations. It is sober, costed and practical, and can easily be delivered in full over the next ten years. Yes, it does require a commitment to provide substantial transitional funds in order to make this change happen. And yes, there are many competing demands for finite resources. But uniquely for Ireland, we now at last have a plan for a health policy based on real political consensus. It has the support of patient groups, advocacy groups and many of the social partners. What is required now is political courage to say “ this is what we must do if we want an equitable, modern and efficient health service, this is the right thing to do”. Slaintecare is now the only game in town. There is no alternative plan.