First things first: we must invest in primary care to revive health service

Primary care centres need to become the place of first resort. They need to be open seven days a week, writes Fergus Finlay

First things first: we must invest in primary care to revive health service

IT WAS around this time of year, though an awful lot colder.

A chap in a tweed jacket, carrying too much weight, but with a good head of hair and a fine, bushy beard, stood on the steps of Government Buildings — steps that in those days opened onto Merrion Street — and handed out a prepared statement.

The statement said that four members of the government, who all represented the Labour Party, were resigning with immediate effect, because they could not support the Budget, which had just been voted on.

Their action precipitated a general election.

The chap in the bushy beard was me, and it was thirty years ago, almost to the day, that I stood there, in the middle of a great political crisis.

Garret Fitzgerald was Taoiseach and Dick Spring Tánaiste.

Spring’s colleagues were Barry Desmond, Ruairi Quinn, and Liam Kavanagh.

They, together with their Fine Gael counterparts, had just been through four of the toughest years imaginable.

The funny thing was how civilised the break-up was.

All the members of that government had soldiered together through a terrible economic downturn.

They had grappled with massive government debt and had had to make really difficult decisions for years.

The Labour people knew they couldn’t support a budget that they believed to be unfair, but they nevertheless delayed their departure for a week.

The reason was the weather.

Ireland was in the grip of a really cold snap that week.

It was so bad that the looming political crisis was the second story in most of the newspapers.

The army was called in to help with cut-off farms and stranded animals.

And one of the budget proposals that Labour ministers couldn’t support that week was a significant increase in the cost of home heating oil.

They resigned, and they were replaced, after a general election, by Ray McSharry.

He was given a free hand on the economy by his boss, Charles Haughey, and, in 1987 and 1988, he introduced two budgets that contained the deepest cuts in public spending ever in this country.

(They were his only budgets in that period — he had also brought in a very tough budget in the short-lived Haughey government in 1982 — before he went off to become a European Commissioner.)

I won’t argue here about whether those budgets were necessary.

There was no doubt that the previous government, for which I worked, had failed to get debt under control.

But the shape of those McSharry budgets, concentrating, as they did, on social spending, was brutal.

Fianna Fáil had come into office on the back of a famous slogan — ‘Health cuts hurt the old, the sick, and the handicapped’ — and promising ‘a better way’.

But the health cuts imposed then have lived with us ever since.

Effectively, by the time that government left office, there were 3,000 fewer hospital beds, and our health system has never recovered.

To add to that, the population of Ireland when Fianna Fáil started removing those beds was 3.5m people.

Now, it’s 4.76m.

That’s an increase of a third in thirty years.

Much bigger population, far fewer hospital beds.

How is it possible, in those circumstances, to avoid an annual health crisis?

A rapidly growing population doesn’t just need more hospital beds, it needs more hospitals.

But in the years since McSharry, we haven’t built extra hospitals — or when we have, it has been at the cost of closing down existing ones.

And yet, and yet.

The way things are now, if we built the hospitals we need, it would take years, and then it would probably bankrupt us.

To be sure, we won’t solve the problem of access without more hospital beds, but there has to be a better way.

And the better way is going back to basics.

There was a time in Ireland when a doctor would come to your house.

There was a time when public health nurses were plentiful, and frequent visitors to the home.

There was a time when patients in hospital were sent home on time.

There was a time when people who were ill were supported at home.

In short, the investment that needs to be made now, and in the future, is not in more hospitals, but in more care.

The CEO of the HSE, Tony O’Brien, has talked about the need for a transitional fund of several hundred million euro.

I believe he should be given that, but it should be strictly ring-fenced and controlled, to enable a radical shift.

In the fullness of time, if it is managed correctly, a decent investment in alternative approaches to care would save billions.

But management is the key.

All of the health experts say one thing.

At the same time as there are 500 people waiting to get into hospital — on almost any given day — there are 500 people waiting to get out.

The management of medical discharges is ensuring that appropriate medical staff are rostered on duty, not to admit new patients, but to sign the discharge forms for those well enough to leave.

The hospitals that don’t have trolley crises are sending patients home when they should be sent home.

But the big change that needs to be made is in primary care.

According to their own figures, the HSE completed seven new primary care centres in 2015, with a further 14 tendered for last year.

When all these are operational, we should have about 50 in Ireland.

That’s perhaps a third of what we need.

Primary care centres need to become the place of first resort.

They need to be open seven days a week and services need to be available out of hours.

I’ve looked up some on the web, and very few offer opening hours after 6pm, although most give emergency phone numbers.

And we have to get to the point where primary care is free for the great majority of the population.

Side by side with the development of primary care in well-equipped centres, there is an urgent need to revitalise community nursing.

Public health nurses ought to be the backbone of a community health service, but the profession is in decline.

It should be growing.

If we got a few of the little things right — more home help, more public health nurses, better access to more flexible primary care — perhaps we wouldn’t have an annual trolley crisis.

In fact, perhaps we could build a health service that wasn’t beset by crisis at all, but was meeting need, as it arises and where it arises. That would be worth paying a bit more for, wouldn’t it?

Primary care centres need to become the place of first resort. They need to be open seven days a week

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