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Coronavirus has created an opening for a fairer health service

Legacy of crisis should be a system based on health need, not ability to pay

It took a crisis as cruel and enormous as the one we are facing to finally hear an Irish minister announce a national health service.

In asserting this week that all private hospitals would be public or run by the State for the duration of the pandemic, Simon Harris said "There can be no public versus private here", alongside the Taoiseach's commitment that "public and private patients will be treated equally".

The Taoiseach also invoked the ghosts of the War of Independence era; that it is necessary for us to match “their courage or example” and that we can surpass them in showing “our greatest generation was not in the past”. One way to give meaning to that is to ensure this pandemic permanently alters the approach to equality of health access and care.

Our first minister for health, Dr James Ryan, appointed when the new department of health and social welfare was created in 1947, had impeccable republican credentials; he had been chief medical officer in the GPO during the 1916 Rising and one of the founders of Fianna Fáil.

The politics of Irish healthcare ensured the War of Independence veterans never achieved a national health service based on equality between all patients

He was not given to high oratory, being better remembered as one who sought to win agreement from entrenched opponents. Those skills were certainly put to the test in attempting to reform healthcare.

The context then is relevant to our current predicament. What existed in 1945, in the words of Ruth Barrington in her seminal book Health, Medicine and Politics in Ireland 1900-1970, was "a coherent and radical blueprint for reform of the health services" including a long-term strategy to provide a free health system. What had prompted such a plan was the emergency of the second World War, which in Barrington's words became "a dividing line in the development of the health services.

Firstly, there was a recognition that access to medical services would have to be widened and that the old code of medical relief was no longer adequate. Secondly, there was a great burst of administrative zeal directed at eliminating the black spots on the nation’s health; tuberculosis, other infectious diseases and infant mortality, and at planning a comprehensive health service.”

Blocking mechanisms

But the politics of Irish healthcare ensured the War of Independence veterans never achieved a national health service based on equality between all patients, as powerful vested interests, including senior members of the Catholic Church and private medical practitioners, joined forces to supposedly defend the interests of patients against "state bureaucracy" or "socialised medicine".

Then, and for decades afterwards, reform of the health services was bedevilled by the haughty and destructive sulks and blocking mechanisms of powerful interest groups who refused to embrace change in the interests of the wider community and often emerged triumphant from encounters with reforming politicians.

As minister for health Brendan Corish put it in a Dáil debate in 1974 in relation to those blocking his proposals for free hospital care for all, funded by a weekly flat rate contribution from all employees, they would resist "until such time as they decided the population should have free hospital and medical services".

Our current crisis should change the way we look at everything, especially our health system

And on it went, with far too much fragmentation, institutional inertia and inequality as a result, to the point that the World Health Organisation could assert Ireland is "unique among EU countries in not providing universal coverage of primary care . . . its system of entitlement to publicly financed healthcare is complex . . . Gaps in coverage in Ireland create significant financial barriers to access, particularly for those without medical cards or private health insurance.

“This results in not only unmet need but also in inequitable and inefficient patterns of use . . . These barriers are substantial relative to most EU countries, especially for primary care.”

Make it permanent

This assessment is cited in the 2017 Sláinte Healthcare Report, the product of the deliberations of the all-party Oireachtas Future of Healthcare Committee, whose terms of reference specified both the need to critically assess the operating assumptions that drive Irish health policy and services and also "the need to establish a universal single-tier service where patients are treated on the basis of health need rather than on ability to pay".

In recommending such a system, it achieved an exceptional political consensus.

Our current crisis should change the way we look at everything, especially our health system, and one of the legacies of this crisis should be a determination to get rid of the caveat “for the duration of the pandemic” regarding equality of treatment.

This requires not just crisis leadership, but ongoing leadership: as the nurses collectively put it in their submission to the Oireachtas healthcare committee: “Shaping, forming and sustaining this single-tiered, universally accessible, public health service (including ownership and delivery) will require political consensus stretching far beyond the normal electoral cycle.

“It will require this, and future, governments, and oppositions, to accept that the transformational change required cannot be interfered with for political reasons.”