Pat Leahy: Health crisis will not be solved by money alone

If health staff do not change the way they work, then the system cannot change

‘The total spend on healthcare in Ireland is among the highest in the OECD. But our health outcomes – ie, what we get for spending all that money – tend to be comparatively poor.’ Photograph: Getty Images

‘The total spend on healthcare in Ireland is among the highest in the OECD. But our health outcomes – ie, what we get for spending all that money – tend to be comparatively poor.’ Photograph: Getty Images

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Most governments are resigned to being kicked around on the health service as long as it isn’t terminally damaging. In their innermost thoughts, few politicians believe there is a magic solution to the problems of overcrowding, waiting lists, etc. Most of them believe they can’t really cure the malady; they can only treat the symptoms.

Bertie Ahern made Micheál Martin minister for health not in the expectation that he would fix the health service, but that his bedside manner would prevent the issue costing Fianna Fáil the next election. Enda Kenny gave Leo Varadkar the job for much the same reason in 2014.

Their appointments illustrate a fairly standard approach to many political and policy problems in Ireland, especially in the provision of public services: the priority is not to solve problems for the long-term but just to get through them in the short-term. After all, it’ll be somebody else’s problem before long.

The crisis in hospital emergency units since Christmas – and the public and political discussion of it – illustrates this short-termism starkly. Yet as well as an inability to plan and provide for the long-term, it also shows how our national discourse on public services is often dominated by special interests. And as long as this remains so, it will be hard to solve the first problem.

If you thought emergency units were overcrowded in recent weeks, current affairs shows must have run them a close second. Inevitably, most of the many discussions featured representatives of the doctors, nurses and consultants. I didn’t hear a single representative of the people who work in the system say: “You know, my members and colleagues are going to have to change some of the ways we work if the health system is to improve. We will have to be inconvenienced too.”

Not a single one. Readers can no doubt enlighten me if I missed any such instances, but I won’t be holding my breath.

It’s always up to somebody else.

“The doctors want more beds. The nurses want more nurses and more pay. Nursing homes want more money into nursing homes. GPs want more money,” said one high-ranking health source last week. Everyone wants what they always want – more for themselves.

Shout the loudest

That’s okay. The job of representative groups is to agitate for the benefit of their members. And in the Irish system the record suggests that those who shout the loudest get the most attention. But we shouldn’t conflate their interests with the public interest, because they don’t necessarily coincide.

It’s certainly in the interests of nurses that they are more numerous and better paid. But it might not be the best use of public resources. Yet in few discussions is anyone so impolite as to point this out.

Only when a vested interest acknowledges a responsibility to change itself should they be taken seriously on reform

The OECD – which collates data and publishes comparisons between its mostly rich member countries – tends to give fairly consistent messages about Ireland. We have fewer doctors per head of population than other countries. We have more nurses. Health workers tend to be better paid here than many of their international counterparts, and some of our doctors – typically consultants with private and public practices – are extremely well paid.

The total spend on healthcare here is among the highest in the OECD. But our health outcomes – ie, what we get for spending all that money – tend to be comparatively poor.

When inconvenient comparisons are mentioned, health unions tend to say that for some reason Irish health service statistics are different to everyone else. I wonder. The OECD is pretty good at this stuff.

All of this suggests that reform of the way we organise the system and spend the money is at least as important as providing more resources for the system.

But reform of the system necessarily involves inconveniencing some people – doctors who (understandably) want to go on holidays in early January; nurses who want to work shifts that suit them rather than the hospital; consultants who would like time free for their private practices.

But if nobody changes the way they work the system won’t change either. None of this is rocket science; but it’s amazing how it’s never part of the conversation.

Nor does anybody ever mention the wisdom of pending hundreds of thousands of euro training a doctor at public expense only to wave goodbye to him or her when they qualify. Meanwhile, hospital managers have to scour the developing world for doctors to staff hospitals.

Vested interest

Only when a vested interest acknowledges a responsibility to change itself should they be taken seriously as advocates of change in the rest of the system.

Politics often makes all this worse, pandering to special interests and multiplying the political cost of difficult longer-term decisions. However, the consensus achieved by the Oireachtas Health Committee with its Slaintecare report offers an opportunity to change this.

Many senior health figures share a private scepticism about aspects of the Slaintecare report. They doubt whether the complete separation of public and private systems is possible or wise. Some of the implementation plans are vague. And the costings are certainly optimistic.

Yet it is, nonetheless, a mighty achievement by Róisín Shortall and her colleagues to get cross-party consensus on a 10-year plan, and to secure the Government’s endorsement of it.

That consensus offers an opportunity to make politics an ally of reform, not an enemy. But that requires not just that a hard-headed Government makes reform the price of more resources, but that the Opposition backs the Government in doing so.

With economic growth likely to continue and the public finances in pretty good shape, 2018 may actually represent a point of opportunity for the health service even if you wouldn’t think it from looking at the emergency units in the last week. But that opportunity can only be grasped if there is a change in the way the problem – and the politics – is approached.

Never waste a crisis, as they say.

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