Extra health spending must be accompanied by reforms

The relationship between our health services and funding has been described as similar to that of a barrel of sawdust and water: you can just keep pouring and it will keep soaking it up. Officials in the Department of Health will tell you that no sooner has one difficulty been sorted out than another one crops up needing more money.

The Minister for Health, Mr Cowen, has spent the last few days batting defensively over whether his Department is spending all the money available to it, and criticism over closures by health boards which have run out of money.

He has refused to bail out the health boards because they are now operating under accountability legislation. This legislation (which was introduced by the opposition when it was in government) means the boards present service plans to the Department, a budget is allocated for the following year and they are bound to stay within that.

Mr Cowen probably would no sooner have handed over extra money to prevent ward closures in University College Hospital, Galway, than a queue would have formed (there are seven other health boards and almost 60 hospitals). There would also be a temptation for those who had stayed within budget to overspend next year with the expectation of being rescued.

It is possible to see the logic of Mr Cowen's approach in relation to "rescuing" the health boards at this stage. There are clearly problems in Galway but a trawl through the rest of the State would come up with a hundred equally worthy situations which deserve funding.

We have seen from the approach to hospital waiting lists that simply throwing money at problems in the health services does not work. More than £60 million will have been spent on waiting-list initiatives in five years but the number of patients awaiting admission to hospital for elective surgery is growing alarmingly. Over 34,000 people are waiting for treatment. Despite the investment, they still wait years, and in many cases die waiting.

In its recently released policy document on tackling waiting lists, Fine Gael revealed that one Dublin inner city general practice was shocked that its patients were having to wait five months for an initial appointment with a consultant dermatologist, eight months for an appointment with an ophthalmologist and six months for an appointment with a gynaecologist. Several of its patients for whom letters of referral were sent in August of this year received appointments for June 1999.

In the Southern Health Board area there are more than 1,000 people awaiting neurological consultations.

When you see these figures it hardly seems to matter that Mr Cowen got an extra 11.3 per cent in the health Estimates last week. Put in the context of a State which has a Budget surplus of around £1 billion, it is extraordinary that people are having such difficulty getting necessary, and often life-saving, treatment.

At present public health expenditure makes up more than 20 per cent of Government spending. With a budget of £3.4 billion, of every £4.50 spent by the Government, £1 is on the health system. There is no "right" answer to the question of what level of resources should be invested in a health care system, writes Dr Miriam Wiley, head of the health policy research centre at the ESRI, in a recently published book, The Irish Health System in the 21st Century. Dr Wiley, who edited the book, said it may be more appropriate to look at what level of funding is considered "affordable".

She points out that the evolution of health expenditure in recent decades in Ireland is "increasingly appearing quite unique in a European context". While Sweden and Germany ranked as the biggest spenders on health throughout the 1980s, the Irish estimates show that the rank occupied by Ireland was progressively declining. The proportion of GDP devoted to health in Ireland ranked joint fifth relative to other member-states in 1985, and 11th in 1990. Since 1993, the only EU member-states to spend a smaller proportion of GDP on health are the UK, Luxembourg and Greece.

When the 1980-96 period is assessed, only three EU member-states show a reduction in the allocation to health, with by far the biggest reduction of 20 per cent shown for Ireland, followed by Sweden at 9 per cent and Denmark at 8 per cent. Also, Ireland is one of just four states which spend 7 per cent or less of GDP on health.

DR Wiley points out that a recent OECD review concluded that: "The Irish health system is based on a mixture of public and private care which has resulted in good provision of health care at relatively low cost to the taxpayer."

Further on, the OECD report states that the principal problem facing the health services in Ireland appears to be related to the "control of spending and ensuring that resources are used and allocated efficiently". All of the indications, according to Dr Wiley, suggest that health expenditure trends will continue to increase in the absence of explicit spending controls.

We do need spending controls and many other changes. There is clearly a need to overhaul our health services, and once proper reforms have been effected, a case for increasing funding. The waiting-list initiative is a lesson that there must be changes introduced before this further investment is made. A bank, before handing over additional funding to a company which is in trouble, will insist on seeing a plan of reform.

However, these problems in our health services did not blow up overnight or simply during the tenure of this Government. They have been accumulating over years and nobody, including the current administration, seems interested in grasping the nettle. Until they do we will simply see more of the same.