Reshaping our health service - Pragmatic assessment on promises

Speaking on RTÉ radio yesterday afternoon nurses’ union leader Liam Doran said that a universal health system is the mark of a civilised society and, in the most general terms, it is very easy to agree with him and share his noble ambition.

That after so many years — and so many governments with determined ministers — myriad efforts to establish one have failed points to a degree of complexity and disagreement that have become real barriers to long overdue, meaningful social progress.

The fun starts when you try to define a universal health system and who should pay for it and how. Do we, because we will all need its support at one point or another in our lives, pay for it through increased taxes, mandatory government levies or by paying premiums to private health insurers? Would everyone, irrespective of income, make some contribution or would the usual burden fall in the usual place? Might it be the very best of public service in action or a route to profit for private health and insurance providers? One-tier? Two-tier? One queue for everyone?

When — if — those issues are resolved the mandatory Punch-and-Judy knock-and-drag can start about where services might be located or which health centre might be closed, upgraded or relocated. Localism and progress will clash in a familiar, self-defeating conflict of interests.

Then, if the project is still on track and the principles still on talking terms, the debate (more usually a row at this stage) about what service providers can expect to be paid for labour or goods takes centre stage — and this is never a short, two-act play, more usually an Tolstoyian epic where the advantage swings to one side or the other over months or even years. If you doubt this cast your mind back to Mary Harney’s negotiations over consultants’ contracts — the talks, the stonewalling, went on for years but hardly led to radical reforms.

Even though we know we pay far too much, in comparison with our neighbours, for drugs and that our doctors and consultants are still, despite all of the cuts, among the best paid in the world we have been singularly unsuccessful in resolving these issues. Indeed, decisions on reducing consultants’ pay have had to be reversed because essential hospital posts cannot be filled. These cost points, to an uncomfortable degree, define the culture around reward and value for money in our health service and unless they are resolved fairly they will continue undermine so many other reform initiatives.

The annual flight of the majority of our medical and nursing graduates to work abroad, too many permanently has become a real drain too.

That to many of us drink and smoke too much, eat the wrong food and become obese or contract diabetes or heart disease, take too little exercise, and generally regard our personal health as if it was somebody else’s problem all adds to the pressure on our health system.

A litany of health ministers have tried to resolve these issues and, despite energetic commitment, often far beyond the call of duty, from most health workers, failure, frustration and exhaustion seem the order of the day for service providers and service users.

In the last 60 years we have had 24 ministers for health — Fianna Fáil’s Michael Woods served three terms — and even if one of them shamefully derided the Department as Angola most of them were ambitious and hoped to leave the health service better than they found it. The same could be said of Dr James Reilly who was replaced by Leo Varadkar in the recent cabinet reshuffle.

Yesterday’s assessment from Mr Varadkar, that great change might take longer than has been promised is unfortunate but pragmatic. It is not defeatist to recognise that accepting this might be a good first step on the last leg of our long journey towards a universal health system.