Revealing the illness within

Posted in Book by saraburke on July 11, 2009

Here is a review of Irish Apartheid by John Crown, which appeared in Saturday’s Irish Times 

THE CENTRAL problems of the Irish health system are that it is unequal, inefficient and of generally mediocre quality. In her excellent, insightful, and comprehensively researched book, Irish Apartheid: Healthcare Inequality in Ireland , journalist Sara Burke focuses on the first of these ills, and explains the forces, both historical and contemporary, which have given us such a strangely configured, irrational and ultimately unfair health delivery system.

Right from the start, Burke grabs the reader’s attention. She uses the tragic story of Susie Long, told in that brave woman’s own poignantly eloquent words on the Joe Duffy Show , to set the scene for the detailed analysis which follows. Long was the young mother whose cancer had been allowed to progress to an incurable state, while she languished seven months on a public hospital waiting list for what should have been an urgent, and in truth, utterly routine diagnostic test. In her interview she told the nation that this test was available promptly to privately insured patients, illustrating the grotesque unfairness at the heart of the Irish health system.

Yet, Burke does not fall into the trap of letting emotional anecdote substitute for reasoned argument. She delivers rationally constructed and dispassionately delivered knockout blows with a devastating business-like accuracy. In her chapter The Black Hole Myth and Hospitals, she systematically deconstructs the argument of the Progressive Democrats that demand for health care resourcing is infinite and that Ireland is in fact overspending in comparison to other jurisdictions. It is not.

Similarly the contention that Ireland has an excessive number of nurses compared to other European countries is rationally dissected and exposed for the fallacy that it is (a high proportion of Irish nurses are part-time shift workers who are effectively job-sharing. Ireland has very few nursing assistants).

The private hospital sector has grown dramatically under Mary Harney’s stewardship. Who owns it? The dramatis personae of hospitalliers that Burke introduces to us in her section on the Who’s Who of the private hospitals, reads like the guest register for the Fianna Fáil Galway race tent, with builders, developers, beef barons, hoteliers, and investment fund managers all jostling to take advantage of the generous tax breaks on offer. The author might perhaps have spent a little more time on the hospitals themselves, which are all too often irrationally small “doc-in-a-box” operations.

The book identifies the primacy of spin in the Department of Health, and correctly points out that it comes from the very top.

“All her media as Minister for Health is schemed. All her public appearances managed.”

Burke shows considerable restraint in her account of her multiply frustrated attempts to get an interview with the Minister while preparing for the book.

Throughout the early years of the HSE it was famously plagued by disastrous media relations. Journalists complained of unanswered calls, stonewalling, evasion and dismissiveness. Burke sees the appointment of Paul Connors as the new HSE communications director as a positive development. I for one am more sceptical. Spin doctors act in the interest of their employer, with whom they have an attorney and client-like relationship. Their principal responsibility is to make their boss look good, not to foster communications.

Similarly, I would respectfully disagree with Burke’s assessment of the National Cancer Control Program (NCCP). She states that cancer care previously delivered in 30 hospitals is being concentrated in eight “as a result of the masterful leadership of Prof Tom Keane combined with the political clout and support of Minister Mary Harney”. This is incorrect.

While it is true to say that most components of the cancer care which is currently administered by the HSE will be largely, but not completely, concentrated in those eight centres, politically sensitive areas are being left with rump services to forestall public criticism. Surgery and radiotherapy will be concentrated, but drug treatment will not.

Incredibly, despite the pious repetition of the mantras that concentration of expertise and patient numbers is essential to proper cancer care (it is), cancer will continue to be treated in dangerously small numbers in our growing network of small private hospitals (in some cases by doctors who are affiliated with, or are vocal supporters of the NCCP), institutions which in some cases were officially opened by the current Minister or former taoiseach. While Burke does a masterful job in chronicling and analysing the extent, causes and consequences of the unfairness of our system, she does not offer a comprehensive corrective vision.

In this regard, I believe that the book would have benefitted from a section devoted to comparative health systems.

In particular, there is little or no reference to the debate about alternative models of health funding. Socialised health systems generally follow one of two models of health finance.

The UK and the Irish public system follow the “Beveridge” model, in which tax-derived money is doled out by the exchequer to hospitals in a prospective annual budget, within which the institution must live. The downside of that model is the inevitability of waiting lists and service constraint.

Tellingly, the UK and Ireland rank dead last in the OECD for “access to care”. The alternative model, and the one that is used in all five of the top-ranked systems is the “Bismarckian” system, in which mandatory occupationally-derived social insurance, cross-subsidised by the well-off, finances sickness funds which in turn pay doctors and hospitals according to activity.

Bismarck offers seamless single-tier care, and by linking payment to activity, incentivises efficiency and activity. Ultimately, Susie Long’s diagnosis was delayed because she only began to cost her hospital when she came off the waiting list.

Minor caveats notwithstanding, I would highly recommend this book to any reader with an interest in our health service. It should be read by most Irish doctors, but alas will not be.

John Crown is a consultant medical oncologist and cancer researcher. He holds the Thomas Baldwin Chair of Translational Cancer Research at DCU and is a Newman Clinical Research Professor at UCD

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