Media coverage of Irish healthcare has two distinct themes: sins of omission and sins of commission. The sins of commission are evident. We are embroiled in repeated scandals, all real and all serious. No-one can read the reports on Grace, Áras Attracta, Leas Cross, Savita Halappanavar's tragic death, and not appreciate that we have serious problems. Many people did things they should not have done – or, more often, failed to do – that were their basic duties.
The sins of omission are becoming more visible too. Children waiting for scoliosis surgery, as their condition deteriorates; long waiting times for urgent colonoscopy; under-reporting of outpatient waiting lists, although the reported figures are bad enough; many people above the medical card limit unable to afford necessary medical care; and wholly inadequate mental health services for children and teenagers.
Robert Francis, who reported on the UK's Mid-Staffordshire hospital tragedy, where elderly patients died of thirst and starvation in acute hospital beds, wrote: "The story [the report] tells is first and foremost of the appalling suffering of many patients."
We cannot and should not accept this for Ireland. So, what's wrong here?
Our population is getting older, but it's still one of the youngest in the EU, which makes our high costs even more bizarre
It's always said that we need more resources. In 2015 we spent €4,335 per head, the second-highest figure in the euro zone. Allowing for our higher cost of living, we spend less than Germany but more than Canada, the UK, Finland and New Zealand, all of which have better health services than us. We spend 11.7 per cent of our gross national income on healthcare. This is well behind the United States, (17 per cent of GDP), but far ahead of other wealthy countries, whose average is just over 9 per cent.
Bed utilisation
So if it's not the money, then maybe it's staffing or facilities? It's certainly not hospital beds – we are one of four rich OECD countries with low numbers of hospital beds, but all of the others have better health services than we do. We have dangerously high hospital bed utilisation rates, mainly due to a lack of alternatives to inpatient care. We have a low number of practising doctors, but more per head than the UK and the US, and only slightly lower than Belgium or New Zealand.
Perhaps it’s just the unhealthy Irish, or a rapidly ageing population? Our population is getting older, but it’s still one of the youngest in the EU, which makes our high costs even more bizarre. There’s no evidence that Irish people are, overall, less healthy than people in other rich countries. None of these is the real reason.
What is really different about Irish healthcare? To outsiders, some things stand out. We pay about €2.9 billion annually for private insurance, mostly for private hospital care. We spend another €2.9 billion, out of pocket, on top. Some goes to GPs but rather more is spent on drugs, on consultants and other private healthcare. Much routine care happens in acute hospitals, while GPs are underused and under-resourced. There’s little effective integration between primary and secondary care. All of this is made worse by exceptionally high user charges for GP services.
To insiders, our obsessive focus on hospital care, the extremely limited development of primary care (GPs and other community-based services), the toxic (but improving) culture in Health Service Executive and the crisis in staffing for nurses and doctors may be more obvious.
We have chosen to have the second most expensive, and one of the worst, healthcare systems in the developed world. After the second World War, when most European countries reformed healthcare, we chose not to. Instead we kept an archaic system, a double two-tier system – public versus private patients, and voluntary versus State hospitals. This survives because it suited us. It kept public expenditure on health low for many years; my medical colleagues could earn very high incomes, at the price of long hours; and health insurance was, and is, a cheap and accessible way to show higher social status. The price of this was always high but is now becoming unacceptable.
We need to put far more resources in primary care, and I'm quite certain that we can't fix it by going on as we are
Rising costs of care and increasing demand are swamping the system. The queues, empty posts and excessive workloads, all say that our hospital-centred system has run out of road. The saga of the National Maternity Hospital and St Vincent’s is one example of the weak governance and accountability in our hospitals. In primary care, services are very limited: GP’s and others can’t raise money for necessary investments. Young doctors don’t want to run struggling small businesses but want a reasonable life and a fair income and are emigrating to find it.
Healthcare committee
In the middle of this we wait, with hope, for the report of the Committee on the Future of Healthcare. There have been leaks suggesting the necessary shift to primary care and integrated care; changes in private health care, including an end to tax breaks; and a complete separation of the two systems. We need to put far more resources in primary care, and I’m quite certain that we can’t fix it by going on as we are. However, I don’t see that we can add enough capacity in the public hospital system to provide adequate acute care quickly.
An alternative to splitting is to merge: to build a single payer system, with strong regulation, tight cost controls and no subsidy for alternatives. This has been done elsewhere. It means one fairer queue for all, much shorter for current public patients, and a little longer for the private patients. To make this more affordable we need to move much care, and substantial resources, out of private care and acute hospitals, into lower-cost services, mostly in general practice
We can afford a decent, fair healthcare system for all. We have the money and we have the people. The question for us is do we have the moral courage to choose it? If we do, our politicians will follow. It’s time for all of us to put up or shut up.
Anthony Staines is professor of health systems at DCU