Fintan O’Toole: The A&E crisis is perfectly acceptable

Exactly seven years ago this weekend, The Irish Times reported: "Waiting times for patients attending emergency departments in many hospitals earlier this month were unacceptable, Minister of Health Mary Harney told the Dáil. She said she had discussed plans with the HSE for ensuring that this situation did not recur."

This week, the Minister for Health Simon Harris used that same word, declaring the current crisis in hospital emergency departments "unacceptable".

It is a word that returns again and again in almost every discussion of the inadequacies of Ireland’s public hospital system. “Unacceptable” or its variants was used five times, for example, in the 2002 Acute Hospital Bed Capacity report.

In the foreword, the then minister for health, Micheál Martin, wrote of “cancellation of elective admissions, long delays in accident and emergency departments, waiting lists for elective procedures and unacceptably high bed occupancy levels in the major hospitals”.

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It is time we admitted that “unacceptable” is a big lie. By definition, if a situation is unacceptable, it does not become an annual event, a kind of grotesque winter festival of suffering that is now as much a part of the calendar as Christmas and New Year.

National emergency

Each year, it is greeted with the same language: unacceptable, intolerable, "bloody awful" (Leo Varadkar, 2015) or even, as Harney declared it in 2006, a "national emergency". ("People who need to be admitted will have beds, not trolleys, and the basics for human dignity. This will be put in place in the coming months. Anything less than this is not acceptable to the public, not acceptable to me and not acceptable to the HSE.")

It took an outsider to tell the truth. Tracy Cooper, who came in from Britain to establish the Health Information & Quality Authority, spoke in May 2012, after a patient had died on a trolley, of the "persistent, and generally accepted, tolerance of patients lying on trolleys in corridors for long periods of time".

'Generally accepted' is the honest description of the misery inflicted every winter on vulnerable, sick people. 'Unacceptable' is a self-serving pretence

“Generally accepted” is the honest description of the misery inflicted every winter on vulnerable, sick people, most of them elderly. “Unacceptable” is a self-serving pretence.

It sounds good. It suggests that there is a collective public and political shock at the realisation that something “bloody awful” is being done to real people. And it suggests that this will end simply because it must, that all stops are being pulled out, that loins are being girded, that this is the very last time. None of this has ever been true.

Because “unacceptable” is a lie, everything that follows it has to be regarded with extreme scepticism. What follows, invariably, is the firm purpose of amendment – the capacity review, the task force, the promise that this time it’s different.

Harris this week declared that 2018 would be the “year of reform”. Like, presumably, the year of reform that has been announced by every one of his predecessors since the late 1990s.

Acceptable cruelty

The UK home secretary Reginald Maudling got into trouble in 1971 when he spoke of "an acceptable level of violence" in Northern Ireland. But we have to confront the fact that there is an acceptable level of cruelty in the Irish healthcare system. Not acceptable to the patients or their families or the medical staff who are doing their considerable best to alleviate the suffering – but collectively tolerable nonetheless.

It is the price that must be paid if we are to maintain a refusal to create a rational national health service that allocates resources efficiently, effectively and above all fairly.

The underlying problem is not money. Ireland spends about €20 billion a year on healthcare, €8 billion of it on hospitals. This is relatively high, especially if we take into account that we have a young (and thus healthy) population. Per capita, it is about the same as Austria, Sweden, the Netherlands or Germany – all countries that seem to be able to avoid the scale of inbuilt cruelties that Ireland routinely inflicts on patients.

We spend enough on a current annual basis to have a decent healthcare system. (There is an obvious need, of course, for major capital investments.) So why don’t we have one?

There are many reasons, but the core problem is not the money itself. It is the way we raise it and spend it. The headline figures for health expenditure mask something that is quite distinctive about Ireland: the weird mix of public and private spending.

Our fragmented, illogical and inefficient health system is full of perverse incentives for hospitals and consultants to chase private money at the expense of public patients

Only 70 per cent of Irish health spending comes from Government revenues – a figure that has declined drastically since 2000 when it was nearly 80 per cent. The rest comes from private insurance and from out-of-pocket payments to GPs and pharmacists. This creates a fragmented, illogical and inefficient system, full of perverse incentives for hospitals and consultants to chase the private money at the expense of public patients. The private 30 per cent distorts the purposes of the public 70 per cent.

Why do we have this system? The answer is quite bizarre and it goes right back to the 1950s. This was the postwar era in which most European countries were creating national health services. But the Catholic Church and much of the medical establishment was ideologically opposed to the creation of a single, unified NHS in Ireland.

Irish compromise

An Irish compromise was reached – 85 per cent of people would be entitled to free care in public hospitals but the top 15 per cent of earners would buy private insurance, thus guaranteeing the consultants they could still have extra, “private” income and guaranteeing Catholic “voluntary” hospitals that they would not become State entities.

Weirdly, however, this “private” care would be provided in public hospitals. The two-tier system was born. And it got weirder over time: entitlement to public hospital care became universal in the 1990s but at the same time the number of people buying private health insurance rose from the initial 15 per cent to almost 50 per cent.

Nobody thinks this system makes any sense. It has many people paying twice for the same service and many other people being displaced because they can’t afford private insurance. It allocates resources chaotically and in ways that are hard to track, never mind justify.

On the one hand, highly efficient parts of the system, such as local general practice, are starved of resources, pushing patients into the emergency-department nightmare. On the other, highly skilled professionals are incentivised to treat people on the basis of money, not of need.

The absurdities multiply to the point where public hospitals are now putting pressure on patients who have private insurance to declare that they are “private patients” and thus cash cows.

But do we really want to change this system? Do we really want a coherent national health service that spends money where there is greatest need? Do we really want a system that starts by ruling out the “unacceptable” – a regular, predictable and “bloody awful” ritual of suffering – and works back from there?

Doing this would limit the incentives for professionals to chase private patients while drawing public salaries. It would also limit the ability of those private patients to skip ahead of the long queues for elective procedures. It would take away the sense of healthcare as a private commodity and make it a public good.

The annual A&E crisis reveals one brutal truth behind all the rhetorical reassurances: you can’t buy your way off a chair or a trolley and into a public bed. The public emergency departments are the arenas in which all are equal – and equally miserable. This truth waits for us all. The question is whether we want to change it before we have to experience it.