The norms of the public health service here, which was modelled on the British National Health system, are imposed from above rather than being sensitive and responsive to needs coming up from below, writes Dr Hugh Staunton
A great deal of time has been devoted in the recent past to discussion of hospital waiting lists and how to deal with them. All of this is predicated upon an a priori acceptance of the concept of waiting lists.
Two events occurred last year which did not receive a great deal of interest in Ireland. Firstly, a mathematical paper on "power laws", entitled Are Hospital Waiting Lists Self-Regulating?, was published in the prestigious British scientific journal Nature.
In it the authors make the point that in a complex system such as the delivery of healthcare, there is a self-regulating element which buffers against differing levels of waiting-list demand, so that a relatively constant state of such demand is maintained.
As it applies to a health service, the authors take this to be a good thing and a sign of efficiency. That is so, however, only if one regards a waiting list to be an acceptable intrinsic part of the system, like consultations, operations etc. It has been very much part of the system in Britain for many years.
But what if one does not accept it as part of the system? This brings me to the second event or rather series of events.
A number of European countries began to market medical procedures, offering to operate on British patients at a price, including Germany and France. This prompts the question: How can these countries, currently less powerful economically than Britain, do it? It is unlikely that the German and French doctors are cleverer, better trained or constitutionally quicker at doing things. It is more likely to be a function of the system.
Although we have a mixed system of public and private healthcare, our public hospital system, with creation of consultant posts and financing from above, is very much modelled on the British system (Irish doctors can adapt overnight, as I have done, to working in a British hospital).
The British National Health model, in which control is central, has not allowed the system to be sensitive to demand.
Thus, for instance, taking my own speciality as an example, an ideal figure (now modified) of one neurologist in 200,000 was handed down from above in Britain and taken on board here (though not even that figure was ever implemented) as a recommendation.
The alternative approach would have been to allow demand, coming up from below, to determine consultant appointments. Thus, broadly the number of neurologists in other European countries would range from 1/25,000 to 1/40,000.
Ironically, Britain is now overcoming much of the consultant number problem, due to the the Trust method of handling funding. For example, the Liverpool area had three neurologists a short few years ago, it now has about 17. It is ironic that the British are looking for inventive ways around the system, while in Ireland we continue to follow a system of dominant central control.
Consider the system which obtains in Ireland for the creation of a new consultant position. A labyrinthine series of committees, sometimes taking years, sits in succession to agree an appointment.
The centrality is such that the Department requires to vet every single such appointment. It also has policy rules. Thus, for instance, it is extremely unlikely that it would agree a consultant neurological appointment in the Sligo-Donegal area.
Even if a position is finally agreed, its implementation is sensitive to budgeting constraints.
There are a number of defects in the foregoing system.
a) It is centralised, totalitarian and unresponsive to local needs. It is imposed from above rather than sensitive to needs coming up from below.
b) While consultants have very widely varying tasks and different demographic areas have differing requirements, all consultant contracts are contractually almost identical. Why should they be? To date, consultants have resisted any change in this principle
c) Funding comes from the central taxation fund. It is not insurance-based. One can only sympathise with the frustration experienced by a finance minister pouring money into a system over which he has no measurable end-point or control.
d) Statements such as "reducing the waiting list" (waiting list for what? For an appointment? For an operation?) imply an acceptance of the system and are in themselves relatively meaningless. Does a reduction by 50 per cent mean that only 50 per cent wait a year or do all patients wait six months?
Furthermore, reducing a waiting time from 12 months to six is a 50 per cent achievement, but hardly a success from the patient's point of view. Insurance-based systems are not perfect. Centralised funding is also required in such systems. Details are important.
We do not, however, have a cadre of civil servants with practical experience of anything other than what we have had in the way of management of healthcare to date. If challenged with the European experience, they may say they have looked at it, but that is not existential experience.
It is now more than a year since I made the following two recommendations to the Minister for Health.
1. Identify those countries (preferably in Europe) who do not have our type of waiting list problem;
2. Analyse why so.
My instinct tells me that the difference lies in insurance-based funding, but let's await the analysis.
Dr Hugh Staunton is a consultant neurologist