A sick formula: Too much ideology and too little political accountability
THE oldest story in the book, of course, is the one about the tourist in Ireland asking directions, and being told “if I wanted to get there, I’d never have started from here”.
Every time you start to wonder about how our health system has become so complex, so remote and so overburdened, you find yourself giving the same answer.
I should declare an interest because I know a number of the senior people in the HSE (and a lot of the junior ones, too). I know that all of them are committed to giving the people of Ireland the best possible health service they can.
What’s more, the vast majority of them — probably all of them in fact — are committed to a public health service. It’s the culture they come from. I know, too, that the last thing any of them would want is that the health service would be bogged down in crisis after crisis, to the point where it frequently seems as if we now have a health system that has ceased to serve the interests of the people.
Nobody wants to work in a health system that subjects women to the terror of being told they might have cancer after earlier being told they hadn’t. And certainly nobody wants to work in a health service that has to start treating women for cancer months after they should have been treated.
But it’s happening, despite the endless sums of money being poured into the service. Just seven years ago, in 2000, the allocation for health was approaching €3.5 billion. By 2007, using the same comparison, the figure was significantly in excess of €14bn (a little more than half the budget was for pay).
In 2000, about 91,000 people were employed in the health service. In 2007, just about 133,000 people were employed between the HSE and the Department of Health.
These aren’t just astonishing increases, they are enormous resources in any terms. In 2000, we were spending slightly less than €1,000 per head of the population on healthcare, and one person was employed in the health service for every 42 men, women and children in the country. Now we spend more than €3,300 per head of the population on healthcare.
There’s a full-time health employee for every 31 men, women and children in the country. Don’t get me wrong. I’m not making the case that we are spending enough on health care — we still lag behind a lot of civilised countries. And I fully realise that averaging out the spending on a per-head-of-population basis doesn’t tell the whole story. The funding allocated doesn’t just cover hospital care, it is also intended to provide a wide range of services in the community. But try to imagine, just for a second, what a community of 31 people might look like. In our housing estate, it might represent eight houses, at a guess, and there are about 140 houses in the estate.
If someone were to say to us, just in our estate, that they were so concerned about our health they were going to allocate a full-time healthcare professional for every eight houses, and that professional was going to have a working budget of about €50,000 per annum on top of his or her salary, I’m guessing most of us would be pretty happy about that. It would mean that our entire housing estate would be served by about 18 full-time professionals, with an operating budget of just under €1m a year simply to look after the health and wellbeing of the residents.
It’s fanciful, I know. But that’s how the averages work out. We are spending an awful lot of money on a health service that is going through a crisis of confidence internally and a crisis of trust in the community it is intended to serve.
How did it go wrong? Maybe it has been going wrong for a long time. It’s not that long ago in Ireland when, by and large, all health services were delivered, and accounted for, locally.
Prior to the 1970 Health Act, health services were run by local, county-based, health authorities. Every county, more or less, had a hospital.
The vast majority of the hospitals were in pretty antiquated buildings and operated in antiquated ways. But we all had our own local service.
It wasn’t good enough, and even back then there was a good deal of public debate about the need for larger, better hospitals dealing with more complex health issues. The Fitzgerald report in the late 1960s provoked outrage because it recommended the rationalisation of some hospitals on the basis that that was the only way that expertise could be gathered together under one roof.
Looking back, that may have been the moment of lost opportunity. Instead of debating then how to get the balance right between services that are better delivered locally and services that are better clustered together, the then government set about regionalising all services in the form of the health boards.
The trend towards centralisation of services started in 1970 and has never really stopped. And so, now, a head office in Dublin has ultimate responsibility for the provision of, say, home help services for an elderly woman living in Clonakilty, just as it has ultimate responsibility for the design and financing of a major new hospital for children in Dublin. All decisions and all financing ultimately flow through that head office. And in the process of creating that head office, somehow the principle of democratic political accountability has disappeared.
Of course the head of the HSE feels responsible and of course the Minister for Health feels responsible whenever anyone is hurt or damaged. But the minister says she is only responsible for providing the budget, and the head of the HSE is responsible for executing the policy.
BUT whose policy is being executed? It’s clear, for instance, that the minister believes in lots more private medicine and the head of the HSE doesn’t.
It’s clear that there is conflict over where the right balance is to be found between local provision and centres of excellence, and no one seems prepared or able to even set out the principles on which such decisions should be based.
Somehow, for example, a line in the sand had been drawn around eight centres of cancer excellence.
If it were to be decided now that the region of the country that exists north of a line from Galway to Dublin deserves and needs a centre of excellence, that would be seen as some sort of cop-out or abandonment of the principle of excellence.
That’s just bonkers. A small country like us can’t afford an unlimited number of centres of excellence, but we can afford a reasonable number. And the number has to be decided to take account of regional and community needs as well as clinical needs — that’s just commonsense.
Commonsense, unfortunately, seems to be in pretty short supply, and instead we have an excess of ideology, coupled with an unwillingness to accept political accountability.
That’s a recipe for ongoing disaster, and it’s time someone brought it to an end.
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