Clinical analysis of our health service
A review of ‘Irish Apartheid’ appeared in the Sunday Business Post on 16 August 2009 by Orla Hardiman.
The Irish healthcare system is dysfunctional, disorganised, fragmented and, for the average citizen, difficult to navigate. It comprises an unusual blend of public and private care, requiring payment at the point of entry for 70 per cent of citizens, but free care for all citizens in the public hospitals.
A parallel structure of private fee-for-service exists in the hospital setting, some of which is embedded into the public hospital system, with an increasing number of standalone, ‘for-profit’ healthcare institutions.
Sara Burke’s book is the latest in a series of publications on Irish healthcare that have been written by female journalists with a strong sense of social justice – two well worth investigating are Marie O’Connor’s 2007 book Emergency, and Maev-Ann Wren’s 2006 offering How Ireland Cares, co-written with Prof ADale Tussing.
This book offers the reader an excellent opportunity to pick up where Wren and Tussing left off. In a breezy and readable style, Burke – a journalist and health policy analyst – sketches out the political and industrial minefield that is the Irish healthcare system. In doing so, her book provides a depressingly compelling reiteration of a litany of missed opportunities, cynical political manoeuvring, leadership errors and administrative ineptitude.
She demonstrates why, since the days of Noel Browne, the mantle of Minister for Health has seen the ruination of many a promising career, including that of at least one aspiring Taoiseach-in-waiting. The book provides insights into how important developments in Irish healthcare have often occurred outside a strategic framework, and frequently as a result of politically motivated interventions by key individuals.
Drawing on her experience as a journalist, Burke acknowledges the importance of the media in effecting real change in Irish healthcare.
She outlines the ongoing scandal of our nursing homes, and describes how the cynical cost-saving antics of the Department of Health and Eastern Regional Health Authority were finally exposed by RTE’s Prime Time programme – and how this led directly to the enforced inspection of all nursing homes by the new agency, the Health Information and Quality Authority (HIQA).
In her discussion of the ‘apartheid’ within Irish healthcare, Burke seems to assume the superiority of private medicine over public. It is an understandable error – stories like Susie Long’s clearly demonstrate that private health insurance can improve access to certain types of interventions.
But the truth is that Irish citizens actually have the worst of both worlds. While there is plenty of evidence that those attending public hospitals receive high quality multidisciplinary care, access to services is poor and waiting lists are excessive. Yet the private sector is limited in what it can offer, and relies on the public sector for complex interventions.
Furthermore, as discussed eloquently by Risteárd Mulcahy in his recent book Is The Health Service For Healing?, there are growing concerns about systematic over-investigation of patients in the private for-profit health sector in the US. It would be naive to assume that such activities might not also be of concern in the Irish context.
The important issue of the increasing allocation of funds to the health budget, with limited evidence of improvement, is addressed in detail in this book.
But it should be noted that much of the recent increase in the health budget has been used not for capital development, but to pay for salary increments, many of which had come from a low base.
Wage inflation has also become part of a larger problem in the Irish public sector. Although Burke discusses the increasing trend by the Health Service Executive to outsource services to the private sector, she does not fully develop the argument as to why this might be seen as cost-effective.
Perhaps it is because, in the private sector, the pay for some services may be lower and other benefits for workers may be less forthcoming.
Burke recognises that many of the current problems in our health system could be resolved by appropriately funding and incentivising our primary care services. In Ireland, there is an anomalous system whereby most patients must pay for access at the primary point of care (the GP), yet can receive care at a secondary point (hospital out-patients) free of charge.
This incentivises patients to continue to attend hospitals, which are more expensive, rather than return to the care of their GP. So, by changing the incentives for patients as well as for doctors, the patterns of utilisation of our health service could be radically altered.
Burke provides a framework for discussion as to why this has not happened. She also describes how for profit healthcare has begun to permeate the primary care system in a manner that differs from the original concept of primary care centres.
But a more detailed analysis of the problems in organising and funding primary care is required.
A discussion of the current dysfunctional interactions between community and hospital-based services and of the complicated structure of the community drugs budget would have been useful. The latter would help to provide an explanation of the background to the recent stand-off with the pharmacists.
Overall, Burke has done a good job on a complex topic. Despite a number of irritating typographical errors in this edition, for anyone interested in understanding the problems of healthcare in Ireland this book offers a compelling and accessible overview.
Orla Hardiman is a consultant neurologist at Beaumont Hospital, a HRB clinician scientist at Trinity College Dublin, and a founder member of Doctors Alliance for Better Public Healthcare