Róisín Shortall: Now Ireland can have health service that works for all

Oireachtas committee’s plan aims to re-orientate health service towards primary services in community

Fundamental reform is also recommended for our State-funded acute hospitals, which should in future, be exclusively dedicated to the public health service.

Fundamental reform is also recommended for our State-funded acute hospitals, which should in future, be exclusively dedicated to the public health service.


Aneurin Bevan, the architect of the UK’s National Health Service, famously said that “no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”.

The NHS certainly has its problems, but it clearly works much better than the broken down public health system that we have in Ireland.

In addition to the UK, most OECD countries ensure that their residents are entitled to treatment that is free at the point of use. This includes GP visits, hospital care and a range of primary and social care services. In these countries only small numbers of people feel the need for private health insurance, usually for added extras.

Contrast that to Ireland, where 44 per cent of the population, fearful for themselves and their families, feel obliged to dig ever deeper to pay health insurance premiums.

In most cases, these policies don’t even provide full health cover. Instead, they do little more than to allow patients to skip ever-lengthening queues for access to publicly-funded hospitals, clinicians and diagnostic facilities. They might also give holders the chance (though seldom a guarantee) of a private bed in a public hospital.

For the majority of people in Ireland, all of our regular health costs – GP visits, nurse and therapeutic services, dental care, community services, vital medicines and consultant visits, must be paid for up front and in full, regardless of how sick we are, or our ability to pay. This is unheard of in most western countries.

Meanwhile, our mixed public/private hospitals battle to find beds for seriously ill patients on trolleys. Demoralised and overworked, many frontline staff are fleeing overseas to escape chaotic, unpleasant and increasingly dangerous situations.

So why can’t we have a health service that works for all?

The good news is that we can. The Oireachtas Committee on the Future of Healthcare today publishes a comprehensive and fully costed 10-year blueprint for a health system that we can all be proud of.

The Sláintecare plan would deliver for Ireland the sort of fair, affordable and effective public health system that we desperately need and deserve and which most of our European neighbours enjoy.

The cross-party committee of TDs was formed by a unanimous Dáil vote last year. Its aim was to find ways to ensure that everybody in Ireland has access to a universal, single-tier health system, in which people will be treated according to their need rather than their ability to pay.

For almost a year, the committee’s 14 TDs consulted with health experts, patient groups, health professionals and other stakeholders, seeking answers to the many problems posed by our failing health service.

Despite the broad range of political views and ideologies represented on the committee, a refreshing degree of consensus emerged. We agreed a range of measures to profoundly reform and improve our health services on a phased basis over a 10-year period.

At its very heart is a detailed plan to reorientate our health service away from acute hospitals towards much expanded primary and social care services in the community. People should be able to access at least 70 per cent of their healthcare locally in their community, including chronic illness management, diagnostic services and minor injury care.

Not only will this free up resources in our over-worked and overcrowded hospital system, but it will also make many treatments much more accessible, pleasant and convenient for the thousands of people who do not happen to live near a major acute hospital. Providing better primary and social care services ensures better health outcomes and better value for money.

Treatments and services which are currently difficult or even impossible to access in many parts of the country will be expanded and improved – notably, these include mental health services, dentistry, homecare, palliative and childhood services.

A new general health card, or Cárta Sláinte, will be rolled out for the entire population over a five-year period. It will entitle holders to a broad range of treatments and medicines at low cost or for free.

Another key feature of the Sláintecare proposals is a significant new emphasis on preventative public health and the promotion of healthy lifestyles, mental wellbeing, and early detection and management of chronic illness.

Fundamental reform is also recommended for our State-funded acute hospitals, which should in future, be exclusively dedicated to the public health service. The present arrangement, whereby targets are set for public hospitals to maximise income from private patients acts as a perverse incentive for public hospitals to treat more private patients, at the expense of public patients. This results in ever lengthening public patient waiting lists.

No other western country permits such a perverse arrangement. The committee believes that new consultant recruits should be encouraged to work public-only contracts through enhanced arrangements and that existing public-private consultants would be facilitated in meeting their full 80 per cent public work commitments.

Of course, those who still wish to pay for private healthcare in private facilities will, as in many other countries, remain fully entitled to do so. In fact, they will get what they pay for by receiving their treatments in dedicated private hospitals which currently have significant spare capacity.

After careful consideration, our committee decided not to recommend an end to the present tax relief on private health insurance premiums.

If, as we recommend, everyone can access affordable expanded primary care in the community, and reduced waiting lists in acute hospitals, then fewer people will feel the need to pay high prices for private health insurance. The question of tax relief on private insurance then becomes a moot point.

Detailed costings

These major reforms will not come for free, but nor will they be as expensive as one might fear. According to the committee’s detailed costings, a total of €350 million-€400 million will be required each year over a 10-year reform period to expand the package of entitlements that will be available to all. This funding, which will come from planned increases to the general health budget, will pay for primary and social care for all Irish residents, and reduce the present out-of-pocket expenses like GPs fees and prescription and drugs charges.

This investment must be viewed in the context of Ireland’s existing €19 billion per year spend on Irish health. This is above average for a developed country and among the highest spend per capita in the EU. Of this, 69 per cent (€13.1 bn) comes from general taxation. Another 15 per cent represents the cash we pay for GP visits, consultants’ fees and medicines etc. Only 13 per cent comes from the 44 per cent of the population who feel pressured into paying for private health insurance.

The main additional expense then will be in the form of a once-off investment of €3 billion over the first six years of the plan. This transitional fund will pay for new infrastructure such as more local primary care centres with diagnostic facilities and the expansion of hospital facilities. It will also be used to train additional primary care staff, GPs and consultants and to implement the e-health programme.

By phasing in this front-loaded investment over the first six years of the plan, we foresee the significant transfer of tasks from hospitals to community services and the gradual disentangling of the public and private systems.

The level of investment required is not insignificant but if we wish to ensure equitable and fair access to timely quality healthcare for all our citizens, this is what we must do. We should also, of course, factor in the projected savings of €285 per person per year which will result from the removal or reduction of most of the existing charges. In addition, the lower-cost model of healthcare outlined and resultant improved health outcomes, will ultimately result in lower costs to the taxpayer.

Our health system is of course complex, and the radical and far-reaching reforms we propose will require detailed sequencing. We propose the setting up of a dedicated and fully-resourced implementation office under the auspice of An Taoiseach which will report regularly on its progress to the Minister and to the Dáil.

Today, we have a unique political consensus on a fully costed, practical, and highly achievable roadmap for reform. It would be a tragedy indeed if our political leadership let this historic opportunity slip away.

Róisín Shortall TD is chair of the Committee on the Future of Healthcare

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