The myriad problems of our health system reflect society's willingness to tolerate unfairness and poor quality generally, argues Ivan Perry
The crisis of confidence in the care system shows no sign of abating despite a decade of unprecedented increases in spending on health (from €3.7 billion in 1997 to over €14 billion in 2007) and equally unprecedented efforts to analyse and reform the system, as articulated in the Government's 2001 health strategy: Quality & Fairness.
In 2007 the notion of quality and fairness rings hollow to many.
We will never have a perfect health system. However, it is increasingly clear that to improve quality and fairness we need to look beyond resources and organisational structures and acknowledge that our health system is an expression of core societal values and a manifestation of our political culture.
The fundamental problems we face in our efforts to reform the health system relate to our high tolerance for inequity or unfairness in access to care, the lack of a well-defined quality culture and our unwillingness to acknowledge the limits of health care.
Despite the rhetoric of Quality and Fairness, unfairness is the major blight on our health system and the case for a single tier, not for profit, social insurance funding model is now compelling. Of the total health spend in Ireland, approximately 78 per cent comes from the public sector, 12 per cent from out of pocket expenditure and some 10 per cent from private health insurance.
The 10 per cent of expenditure from private health insurance secures preferential access (ie, queue jumping) for close to 50 per cent of the population who can afford the annual premiums. Thus we do not have private health insurance in Ireland. For those who can afford it, we have insurance against delays in the public system and as most care is either provided directly or heavily subsidised by the public sector our health insurance premiums are low by international standards.
It is difficult to argue that this system is fair or that it will be improved by the co-location of for-profit private hospitals on the grounds of public hospitals. However, the clamour for change in our health care funding model is muted because the current system of "private health insurance" works well for the middle classes and in particular for "swing voters" who determine the outcome of elections.
It will be interesting to see, come the next election, whether the debate on health care has moved on to addressing fundamental policy issues, in particular the fairness of the system.
The lack of a well-defined quality culture in health services, while not unique to Ireland, poses a further challenge to reform. The essence of a quality culture in health care is ongoing rigorous review and reflection on the quality of care, including the patients' experience of the system, the outcomes from diagnosis and treatment and the incidence of medical errors by means of systematic audits and related quality improvement systems; all led from the top of health care organisations and involving staff at all levels.
This is a tall order for most health care institutions. Clearly it requires resources and training, but most of all it depends on leadership and culture change. The traditional culture within medicine and other health care professions is sceptical of leadership and quality systems.
The focus is on professional autonomy and care for the individual patient while leaving management to "administrators". Clinical autonomy and advocacy for the individual patient will always be at the heart of health care but we also need greater involvement of health professionals, including doctors, operating at a strategic level to enhance the quality, fairness and economic efficiency of the system.
It is time to ask why do we not have more clinicians, in particular consultants (the highest earners), working at senior management level in our health system?
In recent decades we have experienced at least one significant cultural revolution in health care led by clinicians, the evidence-based medicine movement, the notion that decisions about diagnosis and therapy should be based on scientific evidence of effectiveness from clinical research.Now the challenge is to design systems that aspire to deliver the right care to the right patient in the right setting every time. This will require a further cultural revolution in attitudes towards quality, management and leadership in health care and, unless led by clinicians, it will not happen.
We also need to confront the limits of health care. High performing health systems document and publish statistics on outcomes and error rates and as a society we need to accept and deal with the uncertainty of diagnosis and prognosis, the often fine balance between doing good and harm in health care and the human frailty of practitioners.
We also need to acknowledge that the major determinants of our health and wellbeing and that of our children lie well beyond the health system. We face a global epidemic of obesity and diabetes over the next two decades, a "global fattening" crisis akin to global warming that threatens to bankrupt health systems worldwide.
While we look to government for leadership and increased spending, we neglect at our peril wider societal determinants of health, wellbeing and longevity.
Professor Ivan Perry is professor of public health in the epidemiology & public health department at UCC