A tidal wave of critical comment threatens to engulf the health service. People in the community and in the health services, policy analysts and commentators identify longterm under-investment in resources and capacity as the key problem. International comparison certainly supports this - as shown by The Irish Times last week through its States of Health series.
But more money is only part of the answer. Other issues also matter: how money is spent; how quality is improved; how people's concerns are met. Most important of all, how stated values such as equity are translated into action.
Having spent most of my working life in the health service in Northern Ireland, some comparison is hard to resist. The most obvious is the two-tier system in Ireland. As evidence of substantial inequities in access to services continues to grow, this seems indefensible. It is unfair and unjust. Sweeping reforms are needed and promised.
These reforms need to build on the best features of the Irish system. The health service has one essential strength, the huge contribution made every day by people providing care. Many work long hours, in poor conditions, on low pay, caring for those who are most vulnerable. Their commitment and expertise in providing high-quality care, in the vast majority of circumstances, is borne out by first-hand accounts of special attention and care.
I believe that a primary task in any reform will be valuing and supporting the 86,000 people who work in the health service. This has been largely neglected during the seemingly never-ending reforms of the British health service which have left a state of continual confusion and sapped morale.
The first point of contact with the health service is primary care, a service which people particularly value and trust, in which the dominant feature is immediate access and a personal relationship with the general practitioner. Ninety-five per cent of people see their doctor within 24 hours of making contact.
This impressive strength of the Irish system is tempered by the reality that fear of medical costs is a major barrier. The central importance of primary care is explicitly recognised in Northern Ireland where multi-disciplinary teamwork is encouraged. There is real frustration that little funding has gone into developing primary care here.
Few people deny that some hospital and community services in Ireland are stretched to breaking point, in desperate need of resources. But some are now seeing benefits from substantial investment, improving the lives of people whose needs have been largely ignored. Services for older people have increased by 1,000 new day places and 800 new staff. People with intellectual disability have at last got elements of day care and residential care that were missing in the past. In response to shocking scandals, childcare services are now being put in place.
While people recognise the high quality of many hospital services, considerable disquiet about the confusing mix of public and private provision requires change in the interests of clarity and equity.
Questions are also being asked about the best configuration of services, which balance national and local decision making, ensuring that citizens across the State have equal access to high-quality care.
Resources have been identified to combat the huge challenge posed by cancer and heart disease. It is now possible to begin developing the kind of comprehensive action on prevention, treatment and rehabilitation that has been shown to work in other countries such as Finland.
Highly motivated departments of public health are introducing change designed to protect and promote health. Simple but important advances have been made in areas such as immunisation. Screening programmes have begun. An almost alphabetical list of strategies on alcohol, breastfeeding, cancer, dental health, (to name just some) has been published.
A combination of highly effective individual advocates, well developed health promotion services and strong political support has led to Ireland displaying leadership on the world stage in the fight against tobacco.
Change must build on these advances.
Of vital importance to an effective health service is the new strategy for health research, which offers the hope that research and development will become an integral part of the health service, not an added extra.
Effort is now being put into improving public participation in aspects of the service.
Wide consultation involving over 2,000 people was undertaken to develop the new Health Strategy and extend the National Anti-Poverty Strategy to include health targets.
A key message is that people want to be involved in decision making about their own health and the health services they receive.
In both these consultations, time and time again what people wanted was information. Information about their condition, about quality of services, about treatments. Information on which to make decisions about their health or that of their family. Decisions, which at their most critical, affect whether people live or die.
Yet the service generally seems resistant, holding a view that information on health belongs to doctors or managers. I believe that empowering people by making information transparent and widely available is an essential part of a modern health service in which people have a critical part to play in making decisions about all aspects of the service The popular concept of human rights is broadening to include economic and social rights, such as the right to health and the right to access and citizen empowerment and the Good Friday agreement is encouraging interest and action to exploit the great potential of all-Ireland working for health and health care.
Examination of other health systems offers good ideas, imaginative ways of doing things differently. Wherever you go people ask: "What country is doing it right?; What is the formula?"
It's likely there are no simple answers. We need to recognise that all healthcare systems are struggling to meet the challenge of increasing demand and trying to do so fairly.
The health services are a hugely important part of Irish life and they touch every family in some way. They contribute to the overall social and economic development of the State and are an integral part of building prosperity and fairness. This is a contribution which is generally unacknowledged.
Poverty and inequality pose a major challenge for our society and its development. They have a critical impact on health, resulting in an appalling gap between the health of rich and poor. Tackling this requires effort across all Government departments, the public and private sectors and the social partners. In the health services it requires leadership and increased support for programmes for those most in need.
The widespread criticism of the service is an opportunity for a sea change. A chance for an honest and open debate, which involves the ideas, concerns and expectations of the public and professionals as well as politicians and policy-makers. Often the debate is focused on issues such as waiting lists which, important as they are, are not central to the debate about what determines population health.
We need to clarify the society and health service we wish to have. To debate the basic principles. Is there agreement that no one will go without basic healthcare? Should care be based on need rather than ability to pay? Should health information be transparent and accessible to all? How will we use our relative wealth? Prof Amartya Sen, the Nobel Prize winner quotes Aristotle when he says economics is simply a means, what is important is the end we wish it to serve. If we place a high value on health and health services, now is the time to say so.
Dr Jane Wilde is Director of the Institute of Public Health in Ireland, an all-Ireland organisation to promote co-operation for public health.