When Sinn Féin launched a document two weeks ago promising “an Irish NHS” within two terms of office, it will have been hoping to foster conversations about a Sinn Féin government and to reassure northern nationalists about healthcare in a united Ireland.
In this it has been rather unsuccessful. Most reaction has been gloomy and dismissive, noting the NHS is falling apart and has in effect collapsed in Northern Ireland, partly under Sinn Féin’s watch.
The party is now scrambling to clarify what it means by an Irish NHS, yet that has only sowed confusion. Interviewed last week by The Irish Times, Sinn Féin health spokesman David Cullinane said “we’re not looking at any other country as a model. What we’re calling for is the principle of universal healthcare.”
That could mean any public healthcare system, so which is it?
In a letter to this newspaper on Tuesday, Gerry Adams said “citizens have the right to a public health service based on need, free at the point of delivery and paid for by direct taxation”. That can only mean the UK system, so why not say so?
It might be helpful to move away from a British conception of the argument, with all its associated baggage.
There are two broad models of public healthcare across the developed world. They might be crudely categorised as nationalised healthcare versus nationalised health insurance. In expert circles, they are usually called the Beveridge or the Bismarck models.
The NHS, designed by Liberal MP William Beveridge, obviously epitomises the first but it is not unique to the UK, as often claimed. Italy follows it, as to varying degrees do Finland, Sweden, Denmark, Spain, Portugal and New Zealand.
It is Ireland that is unique. The third of the population with a medical card are in a de facto Beveridge system. Everyone else has what president Obama wanted for the United States – highly-regulated private insurance. From the outside at least, Irish Obamacare looks like a bargain. The security and hint of queue jumping it offers to the middle classes might have significant appeal north of the border, if only left-leaning nationalism felt able to praise it.
Sláintecare is unquestionably aiming for a full Beveridge system. Sinn Féin’s policy mainly differs by promising better funding and a quicker rollout.
The distinction between the two basic models has begun to blur throughout Europe, as countries adopt bits of both to try combining their advantages.
Debate is turning instead to central versus local control. Which is the best way to manage changing demand as medicine advances and populations age? Or to put it crudely, which is better at closing small general hospitals, the obsolete blockage in every system?
Ireland, north and south, could benefit from seeing this debate in its full European context. There is a trace of it in Sinn Féin’s long-standing policy to centralise hospital waiting lists. But there is no real awareness of how Beveridge and Bismarck systems have localised if they were centralised, or vice versa, creating a treasure trove of policy evidence across the Continent.
Italy has conducted the most varied experiments in health devolution. Few have been judged a success but all provide relevant lessons. Conversely, devolving control to local areas and politicians is seen as the bedrock of success in Scandinavia.
It would be tempting to read cultural stereotypes into this but there are concrete explanations. For example, the Italian economy is unusually dominated by small businesses, who benefit in multiple ways from local health facilities.
Stormont’s inability to rationalise hospital services is the overriding reason healthcare is failing in Northern Ireland. Collapses of devolution are irrelevant when Stormont is paralysed on the issue regardless. Mandatory coalition, small five-seat constituencies and the suspicions of a divided society prime the parish pump. All-Ireland healthcare is increasingly presented as a way to keep small facilities open in northern border areas, without acknowledging their southern equivalents would have to close – or it is simply presented as a vague panacea.
Is Sinn Féin going to import this paralysis into the south, or can its All-Ireland ambitions extend to confronting it in the north?
The party could take the health portfolio in a restored Stormont, push through reform, or transfer the task to independent managerial bodies at local or regional level, who could take contentious decisions out of political hands.
Running the NHS in Northern Ireland – correctly, it is the HSC (Health and Social Care) – is a test of office for creating a similar system in the Republic. If it continues to fail, access to services will have to be protected for those who cannot afford alternatives, while the middle class buys its way out and demands better regulation of insurance. Then convergence of healthcare on this island will be less about an Irish NHS than a British HSE.