No quick cure for the health system - but it can be done

With Drapier on holiday during the Oireachtas recess, his space is being given to backbenchers to sound off

With Drapier on holiday during the Oireachtas recess, his space is being given to backbenchers to sound off. Today Dr Jimmy Devins addresses the health system

Recently the Oireachtas All-Party Committee on Health and Children spent a half-day discussing two issues, both of which have a huge role to play in the current debate about our health services.

In 2004, over €10 billion will be spent on health, more than ever before, and a massive increase on spending 10 years ago.

We now have the highest per capita increase in health spending of the Organisation for Economic Co-operation and Development (OECD). And there are now more employed in the delivery of healthcare than at any time since the State was founded.

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Yet health repeatedly generates spirited debate. Despite the fact that most of those with personal experience of the service report good satisfaction levels, health continues to make headlines, whether in relation to A&E, disability issues or orthodontics.

The list appears endless. Despite the enormous spending, many believe they are not getting the service they want in the 21st century.

So what is the answer? Do we continue to increase the spending? Do we reform part or all of the service? Do we change our expectations? Should we demand more efficiency and less waste - more frontline staff, less bureaucracy? Maybe the answer lies in all of the above.

More money does appear to be necessary - Ireland has had the lowest total expenditure on health as a share of GDP from 1980-2002 of all OECD states.

There are many reasons for this, but the recession of the 1980s, with its resultant tightening of purse strings, has been a major factor.

Ireland is starting to catch up on other countries, but because of medical inflation (currently at 12 per cent) they are spending more. So if we are to catch up with the likes of the UK, France, Germany or the US we must not only continue to spend, but increase the spend dramatically.

Badly-needed reform has started. Many reports have been commissioned, but three recent ones stand out - Brennan, Prospectus and Hanly have shown the way reform is envisaged.

Change in any sphere of life can be painful, and the reaction by some to the first Hanly report showed what can happen. But if any lesson is to be learnt it is that local people must have some input in helping to shape the future of the health service.

Open consultation and communication are essential if these major reforms are to be implemented. The vital role of the local implementation body must have real teeth.

A robust debate on what we want from our health service would be exciting, and perhaps open eyes. Should we continue with what is essentially a treatment service? What is the place of preventative medicine? What is the role of the GP, and what do people expect from general practice or primary care where most contact with the service takes place?

What about complementary medicine? And the debate on public versus private medicine?

The development of research and education foundations, where teaching and research for all involved in healthcare is undertaken, has had a very positive result.

A prime example is the work done by such a foundation at Sligo General Hospital. Driven by the local community and the North Western Health Board, it is a wonderful example of how local people, many non-medical, can come together and raise funds to aid research and teaching through innovative methods.

The looming crisis in personnel shortages in the whole health science area is graphically illustrated by the Report on Restrictive Practices from the health committee last week.

In courses such as physiotherapy, occupational therapy, human health (i.e. medicine) and dentistry there is a cap on the number of Irish/EU students who can enter these courses. This, in turn, contributes to the very high points needed to gain admittance to these courses.

What has not been widely recognised is the fact that there is a potentially huge shortfall in medical personnel.

At the moment there are not enough Irish/EU entrants to medical schools to replace those doctors who are retiring - this does not take into account the extra doctors needed in any expansion of the health services such as envisaged by Hanly. The Higher Education Authority has placed a cap on the number of Irish/EU entrants to our medical schools. Their figures show that while some €9,000 is paid for each of 317 Irish/EU students, non-EU students are being charged €25,000 each.

The medical schools say that the full cost of a year's tuition is approximately €25,000, and that the non-EU students' fees are used to subsidise the Irish/EU student. The Department of Education argues that the amount paid per Irish/EU student is already at the upper range of the free fees paid by the State.

Lost in the middle of this argument is the reality: a severe, and worsening, shortage of doctors in the health service.

Most non-EU students (e.g. American) return to their own country when they qualify, having received what is internationally-recognised as a very good medical qualification. Here in Ireland we face staff shortages. This cap must be lifted immediately as it will take eight to 10 years to get new entrants suitably qualified. Many specialities, including general practice and some hospital specialities, are already reporting great difficulty in recruiting qualified personnel.

There are no easy answers or quick solutions. Health will continue to absorb large amounts of money, and I believe a greater share of our GDP must be spent on health. Staff shortages must be dealt with by the ending of restrictive practices at third level. Reform must be implemented with local agreement.

There seems to be a perception that the needs and entitlements of patient are being eroded. If all involved recognise that the user is the reason, and only reason, we have a health service, then I believe we can move forward to create one of the best, if not the best, health service possible.

Dr Jimmy Divans is Fianna Fáil TD for Sligo-Leitrim.