It’s time to kill off the hydra-headed monster and start all over again

IT IS difficult for anyone — and that includes Health Minister Mary Harney and HSE chief Prof Brendan Drumm — to understand what has happened to the health service over the years.

An understanding of the way services were traditionally delivered is necessary if one is to understand where it all went wrong and why we find ourselves in such a pickle today.

The health services in Ireland were traditionally delivered by primary care in the first instance. GPs saw patients, instigated appropriate investigations and referred them either to specialist colleagues or directly to hospital for admission as the occasion demanded.

The hospital services were provided, by and large, by voluntary charitable committees and/or religious orders of nuns. They ran the hospitals with a limited political input by local health authorities with representatives from county councils, city corporations, nursing organisations, doctors’ unions and a local clergyman or two.

Funding of the hospitals was by the local authority, charitable trusts and by central government. This system worked well for the most part. There were drawbacks of course. There was a certain autocracy in the hospitals where the consultant was king. Let it be said that he also took responsibility.

The nuns ran the nursing side of things also in an autocratic way. Thus the chief consultant and the reverend mother ran the show. Democracy was not high on the agenda of either.

In those days if a patient needed admission to hospital his or her family doctor arranged the admission directly to the appropriate section of an appropriate hospital. The idea of going to casualty with anything other than an injury was anathema and did not arise.

The patient was admitted directly to the ward under the care of the appropriate specialist and investigation/treatment began. All fairly simple.

Then, in the late 1970s, an insidious change began in the way hospitals were run. Central government took a more active role; health boards replaced the local health authorities; bed numbers were cut.

It was considered that investigations (even simple ones like barium studies) could only be ordered in a hospital setting.

Thus, if a patient needed a barium meal for investigation of a possible stomach ulcer he/she had first to be referred to a specialist outpatient clinic where the investigation could be ordered. It mattered not a whit that the patient might be seen there by an intern and that the investigation was therefore rubber-stamped by a practitioner with virtually no clinical experience.

The seat of power had altered and this change accelerated over the following 30 years. The next step was an attempt to take management of bed occupancy out of medical hands. Bed bureaus were set up. These did not work. With a rising population, falling bed numbers and an increasing demand for services, it was decided that a hospital bed could only be accessed through the casualty department. This was an attempt to take clinical decisions out of the hands of primary care physicians and, by and large, it succeeded in so doing. This system did not work either.

At this stage all medical decision-making was done on an ad hoc basis. Such decisions, virtually without exception, were politically motivated (I include medical politics in this criticism also).

Each decision was wrong and made things worse. The proverbial remedy was to appoint more administrators, write green and white papers on the issue and ultimately set up the HSE to replace the health boards.

An unwieldy bureaucratic monster was replaced by an even bigger and more unwieldy system which ultimately imploded, as was inevitable. The functions of the HSE so overlap those of social welfare as to make the fringes of both organisations indistinguishable.

It is not any good one section blaming another. Healthcare has been turned into a political football. While the medical profession did not cause the problem, it stands indicted of masterly inactivity. This is particularly true of the organised profession which should have called halt years ago. We are now left with a multi-headed monster reminiscent of the one defeated by Hercules who cut off its heads, leaving only one.

Ms Harney probably had the right idea in appointing only one head.

Unfortunately, she omitted to cut off the other heads. Recent events confirm the mistake she made.

The health service is broken. It cannot be fixed. One needs to dismantle it completely and start afresh. A hospital service run by healthcare professionals, funded by central government possibly through health insurance, with proper checks and balances is needed.

These services are probably best provided in a private setting. Those who can afford to pay medical insurance do so; those who cannot have their premiums paid for by central government. This does away with the two-tier system at a stroke. It sounds simple, but the general thrust is well based.

This will leave more than 100,000 HSE employees in limbo. Here really is the crux of the matter and the bullet Government will not bite. Nonetheless any other approach will just postpone the day when this, or a similar, step becomes inevitable.

Do it now before the number rises to 200,000.

Dr Billy Christopher

West End

Mallow

Co Cork