Obstacles to universal healthcare


Sir, – Prof Allyson Pollock makes a compelling case for universal healthcare (“How Ireland could have a national health service”, Opinion & Analysis, September 30th).

Clearly, Ireland needs a national health service that is effective, efficient and equitable. The funding mechanism is just one element of this. Similar emphasis needs to be placed on governance.

Significant steps have been taken in clinical governance in recent years with mandatory continuing professional development requirements for doctors, and the Medical Council’s 2016 “Guide to Professional Conduct and Ethics”, which places strong emphasis on “open disclosure and duty of candour”. We urgently need better legal processes to facilitate this in practice.

But there is also a need for ongoing improvements in corporate governance, involving clear strategic direction nationally, accountable boards at all levels, and enhanced, mandatory continuing processional development requirements for health service managers.

Ultimately, the amount of good health that any individual enjoys is shaped largely by a triad of decision-making groups: individuals themselves, who make their own decisions about diet and lifestyle, in the context of the (often inadequate) social, economic and educational resources available to them; government, which makes political decisions about creating social conditions for health, how much healthcare to provide, and how to provide it; and clinicians, who make choices at the level of individual patients, in a decision-making landscape that is shaped decisively by the decisions of the other two groups.

For all of this to work in harmony, there needs to be strong political will to optimise circumstances for each of these decision-makers, based on the ideas that opportunity for good health is a fundamental human right, and that we are willing, as a society, to work together to create the circumstances required to make universal healthcare a reality. – Yours, etc,


Professor of Psychiatry,

Trinity College Dublin.

Sir, – Prof Allyson Pollock seems to think that a simple piece of legislation, committing the Government to providing universal healthcare, would give us a good national health service.

The part of our health service that operates a bit like the traditional UK NHS model (free at the point of use, publicly owned, and exchequer financed) is widely criticised, and legislating to make it truly universal does not impress me. Imagine giving the HSE responsibility for all of our health services?

Prof Pollock demonises the US health system, and asserts that “the US . . . denies more than one in five of its population access to healthcare”. She omits to refer to the role of Medicare, Medicaid and the Veterans Healthcare Administration, which between them provide for over 27 per cent of the population. Obamacare has expanded insurance cover significantly (to about 90 per cent of the relevant population), and several states have taken their own steps to improve access to healthcare. The US system has huge faults, but please let us not exaggerate them.

Prof Pollock makes no reference to mainland European healthcare systems, many of which have a significant role for both social and private insurance, and for both public and private provision. The UK system generally scores badly by comparison with most of them. The ideological fervour with which the British seem to believe that they have (or had) the best health service in the world never ceases to amaze me. – Yours, etc,


Dublin 14.