A two-tier healthcare system


Sir, – I forget who said or wrote that one definition of tragedy is a beautiful theory spoiled by an inconvenient fact. It came to mind as I read Fintan O’Toole’s piece “Spare us the scare stories about public spending” (Opinion & Analysis, May 19th). In making his central point that very significant additional public expenditures are called for, your columnist wisely gives himself a little wriggle room. He acknowledges that the money spent could be wasted; “we could stick it in the ground to fertilise cabbages”. One of the possible expenditures which, in his view, would not be a waste is that of yet more billions of euro each year “to shore up a health system in which we have underinvested for far too long”. This is where I part company with him.

In making this claim, Fintan O’Toole is, I think, working back from the effect to seek to identify the cause. Most Irish people, regardless of their political affiliations, would agree that the outcomes from our publicly funded health system are less than stellar. It is thrown into chaos each year by the entirely predictable onset of the winter flu, it has waiting lists extending to years rather than weeks or months and many of our expensively educated and newly qualified doctors and nurses vote with their feet.

In Fintan O’Toole’s worldview, the appropriate response to the unsatisfactory delivery of a public service is to spend more money on it. There may well be cases where that can be justified but health is not one of them. OECD figures show that Ireland has one of the highest per capita expenditures on health in the developed world, despite having the considerable advantage of a relatively young population.

This is the case whether we consider total expenditure or only public expenditure. Another striking fact is that, notwithstanding the point just made that per capita public health expenditure is high by international standards, private health expenditure in Ireland is extraordinarily high by these same standards.

This is telling. About one-third of Irish tax revenues are spent on health. But about 50 per cent of the Irish population has private health insurance.

People generally arrive at rational decisions in making significant expenditures from household budgets. There is a good reason why Irish individual taxpayers, who shoulder one of the heavier tax burdens in the developed world and see one-third of tax revenues expended on the public health system, choose to pay a second time for access to healthcare.

In the new world we will certainly have ongoing expenditures which we did not have before. But it should not be seen as axiomatic that these will all have to be funded from additional borrowing or additional taxation.

Not all existing expenditures make sense at any level, and Michael McDowell in his opinion piece on May 13th highlighted just a few of the more egregious and topical examples (“We can’tafford to spend ¤1 billion a year on single-use PPE in a massive fiscal crisis”). The only possible sources of additional spending in any area of public provision are additional taxation, more borrowing, cutbacks in other spending programmes or a more critical analysis of expenditures already being made in the area seeking additional funding. This last is almost always overlooked: expenditures which made sense in the past – and even those which did not – are seen as sacrosanct. They should not be. – Yours, etc,



Dublin 6 .

Sir, – Am I the only one to be intrigued by recent letters to The Irish Times indicating the metamorphosis of our “private health sector” to the “independent health sector”?

I presume this means the independent airline sector represented by Ryanair is purely interested in getting us safely to our destination of choice and the fact that it makes enormous profits is simply by the by. – Yours, etc,


Rath Maonais,

Baile Átha Cliath 6.

Sir, – The logic in Professor O’Donnell’s argument does not stand up (Letters, May 20th). His contention that “it is time to allow independent hospitals and their staff to return to work immediately and provide a service to those that desperately need it” is all very laudable. However, he seems to be forgetting that hundreds of his consultant colleagues failed to sign a recent contract that would allow them to do just that. – Yours, etc,



Co Wicklow.