John Browne: Time for a single-tier, fully funded, public healthcare system

The coronavirus crisis opens up a window of opportunity for us to finally make the right decisions in Ireland writes Professor John Browne

Professor John Browne: 'We suddenly realise that all those small hospitals we routinely denigrated as 'not fit for purpose', are a vital part of our health infrastructure.' File picture.
Professor John Browne: "We suddenly realise that all those small hospitals we routinely denigrated as 'not fit for purpose', are a vital part of our health infrastructure." File picture.

Once a week I leave my family home in the countryside outside Kinsale and head into the local supermarket in Carrigaline.

Like many white-collar workers, I am lucky enough to be able to shelter from the virus while working from home. As I do my shopping, I wonder at the bravery of the supermarket staff who have no such luxury. They work the tills, protected only by a flimsy plastic shield.

They stack the shelves, knowing the social distancing guidelines are virtually impossible to adhere to all the time.

Behind the scenes, there are countless other blue-collar workers on low pay doing similar jobs. They work in distribution centres, they drive the trucks, and they work on the front lines of food production, baking our bread, collecting our eggs, picking our fruit.

In hospitals, similar scenes play out. Clerical staff admit us, radiographers scan our lungs, the porters move us from ward to intensive care, nurses and other healthcare workers monitor and care for us, all knowing they are risking their lives each day they turn up for work.

This fight is not just in the big city hospitals — although it sometimes seems that way from media coverage. It is happening across the country. We suddenly realise that all those small hospitals we routinely denigrated as "not fit for purpose", are a vital part of our health infrastructure.

In many ways, this has been a great time to be Irish. Rich and poor, urban and rural, public and private, we are all playing our part. We have come together and shown a solidarity with the national fight against Covid-19 that is remarkable.

When people step out of line to visit their holiday homes, to panic buy or to break the social distancing regulations on a beach or park, their selfishness is met with contempt.

How long will this last though? Once we are on the other side of the pandemic will we slip back into our old divisive health politics? One queue for the blue collar workers and one, much shorter, for those on higher incomes?

One pay scale for younger healthcare workers, and one, much more generous for their older colleagues? One budget line for the larger hospitals in our cities, and one, much less generous and predictable for their smaller rural counterparts?

The coronavirus crisis opens up a window of opportunity for us to finally make the right decisions about our healthcare system and end these divisions.

John Browne: Time for a single-tier, fully funded, public healthcare system

First, we have to take private practice out of our public healthcare system. It’s remarkable that such a divisive, inefficient, and unethical system still persists, even though the public consistently votes for political parties that reject it in their manifestos.

Who is now willing to stand up for a system that would put our supermarket workers to the back of the queue so that wealthier patients can use their private health insurance to get diagnostic tests done faster, or get priority access to a private room?

A system that means some high-risk patients do not get their flu vaccines every year because they can’t afford another GP visit. A system where a woman with private health insurance can buy extra access to consultant care in a public maternity hospital.

We need a single-tier, fully funded, public healthcare system with no exceptions. ‘Unaffordable’ will be the first response of many, but this is not really the case anymore.

Private income for our public hospitals has been shrinking for many years, and is now a relatively small part of the overall budget. In fact, the amount is small enough that even a modest efficiency programme would cover the gap.

Many administrative and regulatory sections of the HSE are now parked because of the pandemic: Do we need to bring them all back to life when it’s over?

Think of all the resources we currently waste on means-testing for our medical card system. Or the layers of management that characterise our hospital administration.

Regardless of the financial aspects, we have to accept that a public healthcare system cannot be financed the back of unethical compromises.

‘Socialism’ is the other criticism I often hear, but a one-tier public system does not mean there is no room for private healthcare elsewhere. There is more than enough room for a niche private sector providing optional services alongside a properly funded public system where no one has to wait long periods for vital care.

Second, we must never again have healthcare workers doing identical work on different pay scales. The worst example of this is the convoluted pay system for doctors.

At present, new entrant consultants are paid substantially less than their older colleagues due to a specific pay cut for medics that was introduced in 2012. This is wrong.

How can we ask the younger doctors in our emergency departments to risk their lives in the fight against the virus while being paid less than others who are doing exactly the same job?

This, along with the elimination of private work in the public system, will remove a longstanding source of division and rancour and help to heal the rift that has developed between medicine and our broader society in recent years.

Third, Ireland has reconfigured much acute care in recent years towards a more centralised model. The effect of this has been to downgrade services in smaller and more rural hospitals, in favour of care based in the larger urban hospitals.

Although centralisation is presented as ‘evidence-based’, it is no such thing. There are benefits for a small group of patients with serious conditions like stroke and major trauma.

But overall, my research has shown that centralisation was not associated with improvements in safety or efficiency and may have exacerbated the growing capacity challenges we have seen in our acute hospitals.

The pandemic has emphasised what was becoming apparent every January as the latest trolley crisis filled our TV screens: We don’t have ‘too many hospitals’ and we don’t have ‘too many emergency departments’.

Our smaller hospitals are playing a vital role during the pandemic and it is frightening to imagine how fragile our system would be without them. Once the pandemic is over, we must end the centralisation programme once and all and start to reinvest and rebuild our smaller hospitals.

The pandemic gives us a once in a lifetime chance to undo decades of health policy failure. It is the kind of existential crisis that allows a society to reshape its purpose and find its way back to the right path.

French president Emmanuel Macron put it best in his March 16 speech: “Many convictions and beliefs will be pushed aside, will be questioned. Many things that we thought impossible will happen. We will not be surprised, will act strongly, but remember this, the day after, when we will have won, it will not be a return to the normalcy of the days before. We will be morally stronger.”

Professor John Browne is the director of the National Health Services Research Institute in Ireland and principal investigator on the Health Research Board-funded ‘Siren’ programme at UCC.

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