Let me explain a fundamental fact to the former health minister Leo Varadkar, to whom “it is not entirely clear” why overcrowding in hospitals is increasing again.
More resources were provided, the system accommodated itself
accordingly. More resources in the health service as structured don’t raise the ceiling, they raise the floor.
The outgoing head of the HSE Tony O’Brien has said the system is the wrong shape and size.
That’s true to a point. But it is perfectly shaped and ever increasingly sized for vested interests within it, adept at holding it hostage for more resources to deliver diminishing returns.
So many plans, with so many price tags attached, have been submitted and paid for, but subsequently undelivered.
There is a conclusion that the ultimate currency in health is crisis. Crisis is the commonplace that now ordinarily leverages more money, and moves obligation on, from previous commitments to new targets.
Ministers hardly matter. Their fiat barely extends to the door of their private office. It certainly does not run in any systematic or understood way through their own department.
In turn, insight into and oversight of the HSE by the department is strictly limited. It, in turn, barely controls hospitals which are largely independent entities.
Hospital managers have no effective control whatsoever over consultants, for example. The sector generally, from the top to bottom, is heavily unionised.
Practitioners matter much more than patients. Health in Ireland is a generic term for large, overlapping — but not necessarily connected — organisations.
It is not just the largest in the State, it is the most labyrinthine and opaque. Cynicism, not care, is its fundamental value.
If money alone could fix the health service we would be in clover. We have the fifth highest health spend in the OECD and are near the bottom of the table in terms of delivery.
It is true the health service is doing more with relatively less in places, and it’s also true that there are success stories. The reason those relative achievements receive less attention than they should is because of the misshapen nature.
Its shop window is its backdoor, namely the emergency department. Anaemic levels of primary care push people into the narrowest point of the system, which in turn is the antechamber to its most expensive part, namely the hospital bed. Control of the bed is effectively control of everything.
Greater investment in primary care is obviously a key part of the solution.
But that investment is undermined by a hospital system and those who, through private practice, profit lavishly in it to operate as souped-up GPs for the insured.
The privately insured, of course, can get their chronic conditions attended to relatively quickly and comfortably by consultants.
Sums varying from €100 to €200 routinely change hands in private rooms. This is the comfort blanket that reassures, and the valve that releases pressure, for the relatively privileged.
Were it otherwise, there would be a real crisis in health and one with immediate, asphyxiating political consequences.
One can never be too sure of course, but in over 20 years, hospital trolleys have never yet become the tumbril that brings ministers to their execution.
I don’t think they will now either. The very dysfunction and cynicism of the system allows it divide and rule. If nobody dies except an occasional patient, what harm can come of it?
In health as structured now, more money masks as much as it addresses. The current crisis which isn’t, of course, any crisis at all — it’s business as usual — illustrates that.
It’s the bargaining chip one part of the system plays against the other to leverage resources.
The stubbornness of the system, its deep vested interests that both immunise and work against each other, is also partly masked by the energy and, in purely political terms, the credibility of the current minister Simon Harris and his immediate predecessor Leo Varadkar.
As political practitioners, they are out of the top drawer. Varadkar’s capacity to get out of the
Angola of Health unscathed and ascend upwards is proof of that.
Harris may not be so lucky. Time is the ultimate enemy in politics. But for now, there is a still plausible face to front the argument.
What is more worrying is that, in Harris now and Varadkar before him, we have adept politicians with no real ideas about what to do, or the will to do it.
The last minister with ideas in health was James Reilly. But he singularly lacked the political skills of his successors. None of his ideas are even spoken of now.
Reilly’s ideas were once rousing. A completely new healthcare system was one of the five-point plan that swept Fine Gael into government. The Dutch healthcare system was held out as the model to emulate.
On March 11, 2011, the new taoiseach Enda Kenny addressing the Dáil said: “We will introduce universal health insurance with equal access to care for all.
“Nobody will be left behind — we will ensure universal coverage by paying for those on lower incomes and providing subsidies for those on middle incomes.
Universal health insurance was to be the stuff of two terms of course, but we haven’t even begun. In any event Varadkar pretty much instantly dumped on it on arriving in the job. Best to lower expectations immediately, and he was right. Look where it has got him.
Instead of fundamental reform, we had a shocking waste of scarce resources in primary care, when as a political stunt Labour insisted on free GP care for under-6s. There is every sign the situation is going to get worse.
Firstly, the exchequer will be flush at the next budget, which in turn may be the basis of an election campaign.
It is perfect pickings for a system that is world beating at bottom feeding off public resources, and leaving what it feasts off denuded.
And again, another head of the HSE is leaving. This time it’s Tony O’Brien, previously it was Cathal Magee.
The queue for that job is getting ever shorter. And anyway what job? How can you write a job description for HSE chief when negotiations on a new GP contract are being slow-walked nowhere?
That’s a political and a Government issue. Its central to what O’Brien called the shape and size of the system. Then, of course, there is Sláintecare, the new plan. Well, it’s sitting there with the last.
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