The chicken and the egg – which comes first? - Reforming or funding our healthcare system?
Posted on July 27, 2018 by Tom Healy
The publication, in the Republic of Ireland, of the Sláintecare Report over year ago was a landmark achievement. For the first time it appeared that almost all political parties were united in a commitment to a single-tier, comprehensive and a well-funded system of healthcare with the commitment of additional investment and resources for reform. The aim was to make healthcare largely ‘free’ for the population and remove, over time, the inequitable two-tier system driven in part by ability of users to pay and obtain faster access to consultation or treatment. This Report and the subsequent statements might have been just that ‘Bevan’ moment in 1948 when the British NHS was born.
Time has passed and with Budget 2018 as well as a winter of discontent, A&E overcrowding and many scandals in the sphere of diagnosis and follow-up. There is a growing narrative that runs as follows:
We are spending more and more on health every year – well above our allocated budget – and there is little to show for it. Ireland – for its age profile – spends far too much already on health. Healthcare is like a black hole – the more money you shovel in the more it gobbles up. It is not possible to implement the ambitious range of reforms and additional funding recommended in Sláintecare given the lack of (a) reform to date, (b) the lack of money to top up the additional money already spent and (c) the political impossibility of reform given the strength of various interests.
So the narrative goes.
Whatever the veracity of claims about alleged overspending (these claims are contested in a recent NERI Working Paper “Equity in Irish Healthcare – Time for a new deal”), it is clear that the system is in an acute state of crisis all the way from primary healthcare to acute hospital care to long-term care in the community. If ambulances are backed up in major acute hospitals because crew members are waiting to find a trolley to discharge a patient then there is a knock-on effect across a city or region where an elderly person (for example) has fallen and needs hospital care and is being looked after in an already over-stretched GP practice while an ambulance may arrive hours later.
Stepping back from questions of how much needs to be spent and how this money can be raised (these questions are considered in the recent NERI paper) we may ask the following questions:
“What values should inform healthcare reform and what vision do we have of a new healthcare system fit for purpose in the 21st century?”
I suggest seven principles to guide reform:
The first priority – equality first
Healthcare does not exist in isolation from the rest of society. Policy needs to be driven by a social equality agenda which (i) promotes greater equality of access to, and equality of reward from, the labour market, (ii) redistributes income more effectively through taxation and welfare payments, (iii) enlarges the ‘social wage’ through provision of public goods and services on the basis of need, and (iv) enables and empowers individuals to participate in organisational and political decision making.
The second priority – reset our values
We need to reset our national mind-set, viz., move away from the notion that one’s healthcare is something to be purchased as a commodity in a competitive struggle over scarce resources rather than something seen as a fundamental human right and responsibility.
The third priority – educate for health
We need to drive a programme of education in healthy living styles specially targeted at young people and the elderly.
The fourth priority – invest in primary care
We need to invest in an effective system of primary healthcare in the community to keep, as much as possible, people out of acute hospitals and other high-dependency care settings.
The fifth priority – dismantle the two-tier system
We need to start dismantling the inefficient and inequitable two-tier Irish health system by creating a European-class health service which removes the incentive for many people to pay to ‘jump the queue’ for consultation and treatment.
The sixth priority – empower health professionals
Health professionals and staff together with healthcare institutions should be empowered to make safe health decisions at a local level and remain accountable to the appropriate bodies.
The seventh priority – integrate healthcare in social policy
We need to integrate healthcare more effectively with other areas of social policy including housing, income support, social care, education, community connectivity and engagement, transport so that people can be cared for, as much as possible, in the community and in ways that avoid unnecessary costs and system breakdowns along the line when people end up in acute health need.
Reform is difficult, painful, sometimes conflictual and unavoidably costly. It will require additional resources earmarked for reform and transition just as proposed in the Sláintecare Report.
Reform to be effective needs to have strong leadership and support of key stakeholders. ‘Whatever it takes’ should be the motto.
People would be prepared to pay an extra Euro on every €100 of earned income if they thought that this money would be genuinely used effectively and efficiently to provide better health services and follow-up in their communities. It is difficult to make the case for higher taxes given the ‘black hole’ argument. It is hard to remove the ‘black hole’ when all we are doing is running to try to catch up with a growing and ageing population on the back of an already dysfunctional system. The paradox is that our healthcare has been so successful in keeping us alive much longer than was the case in previous generations that we now face the inevitable new and higher costs associated with diagnosis, treatment and on-going care for those of us living longer. And so it should be. People are worth it. However, we should ensure that everyone regardless of means, age or social background has access to quality healthcare. This could become the first example of where we have successfully delivered on the Democratic Programme (of the First Dáil in 1919) in at least one area of social policy and care. Are we serious about it?