THERE is a perception in Ireland that we have a public hospital service which despite minor and inevitable imperfections provides high-quality care to the mass of our citizens on a generally equitable basis. Supporters of our system compare it to that of the United States, where, according to stereotype, financial wherewithal, rather than medical need determines access to hospital care.
I subscribe to another view which holds that our system, while it does contain within it much that is excellent, particularly in the sphere of human resources, is nonetheless characterised by profound intrinsic structural flaws and provides a service which does not adequately meet the needs of the Irish population. Viewed from within the more appropriate context of western Europe, where the principle of social solidarity in health care is more deeply-enshrined than it is in the United States, and where most nations have extremely high quality health services, the Irish system is clearly and measurably deficient.
Ireland is among the lowest spenders on healthcare in the European Union as a proportion of gross domestic product. The lengths of our waiting lists for elective operations, such as coronary bypass surgery and hip replacement, are among the longest in Europe. The Datamonitor report indicated that Irish women with breast cancer have, historically, had poorer prognoses than had their peers in other western countries, although this is likely to improve with the expansion of our cancer services.
European Renal Association data indicate that Irish patients are far less likely to receive kidney dialysis than are citizens of most other developed countries. Ireland has one of the highest number of hospitals per head of population in Europe, but our hospitals are among the smallest, and even the most commonplace of medical specialities are not available in many of them.
Irish medicine is also replete with paradoxes. We have one medical school per 750,000 of population, in contrast to most European jurisdictions which typically have 1.5 to 2 million citizens per school. Despite our abundance of medical schools and graduates, many of our hospitals have difficulty filling their non-consultant medical training positions, as many of our brightest and most ambitious young doctors emigrate to international centres of excellence in search of high quality postgraduate training. We have among the lowest number of specialists per head of population of any European country.
A perusal of our national newspapers provides support for the contention that our public hospital system is a troubled place, e.g. disputes over ward closures in Galway, the ongoing Tallaght Hospital financial crisis etc.
The situation with regard to nursing staffing levels is becoming particularly critical. In some hospitals, services have been curtailed due to nursing shortages, which can ultimately be attributed to the low wage structure of this crucially important profession. There have been recent incidents where nurses resigned from permanent and pensionable posts only to return immediately to their units as better paid contract staff in the employ of nursing agencies. Attempts to reimburse nurses according to the basic economic law of supply and demand are thwarted by the requirement of hospitals to comply with public service wage agreements.
It is obvious to health professionals that our hospital system is in urgent need of increased investment. The general success of public spending restraint in facilitating the rehabilitation of our economy has contributed to a perception, now reaching canonical status in certain quarters in the economics community, that we can have either generously-funded health care, as demanded by health-care professionals, or economic growth as demanded by economists, but may not have both. Successive governments and the civil service appear to have decided that equity can only be provided, in the context of limited resources, by public funding of hospitals through tax-derived exchequer revenues, which must be strictly limited to restrain public spending.
The twin assumptions that health spending is injurious to the economy, and that equity can only be ensured by keeping the hospital service within the public sector are simply inaccurate. There are no economic grounds for believing that healthcare spending is, per se, any more subversive to the well-being of an economy that is spending on cars, houses, holidays, food or tribunals. The hospital sector is, in fact, a crucial component of our economy, providing a societally valuable service, considerable employment and the consumption of goods and services which are often produced domestically. The solution thus seems simple and obvious.
To facilitate the necessary increase in investment which our system needs, while still maintaining restraint in public expenditure, the burden of hospital costs should be removed from the Exchequer. Our hospitals and doctors should, within a regulatory framework which ensures equal access, discourages waste, reduplication and inappropriate treatment, be given the independence to develop the services they provide to the fullest of their potential.
What about social equity? The assumption that direct Exchequer-funded budget-based hospital reimbursement provides the only guarantee of fair and equal access to hospital care must also be challenged.
THE Germans, Dutch and others have proven that socially-informed health care can be financed by non-Exchequer derived funds, generally by a system of compulsory, occupationally-based health indemnification, underwritten by an insurance system which consists of a mixture of publicly administered, non-profit organisations and traditional private carriers. An appropriate governmentally-monitored regulatory framework can ensure that the principle of social solidarity guides the entire system, with appropriate provision for the low paid and unwaged.
The introduction of such a system here would probably result in some net increase in healthcare spending, but also in dramatically reduced public spending. Access to care would improve and waiting lists would be reduced, as hospitals would have an incentive to improve service quality in an environment where they were competing to provide reimbursable services to a population which was universally insured. Such a reform would necessitate a reduction in personal income tax commensurate with the insurance premium.
The implementation of this proposal would also eradicate the major area of inequity in our current system, namely the "public/private split", by ensuring that all of our current public and private hospitals were reimbursed by essentially identical mechanisms.
How would efficiency be improved? In the current system, hospitals receive a fixed global budget for a given year, with minor adjustments. This system strongly militates against efficiency, in that innovations which would decrease both unit costs and waiting lists will be rejected if they result in marginal increases in net global cost. Instead, the hospital sector is encouraged to decrease activity to stay within budget. At the end of most budgetary cycles, wards close, waiting lists lengthen and virtually uniquely in any field of "business", hospitals attempt to discourage potential customers from using their services. A different reimbursement system, in which hospitals were funded according to their activity in a regulated payment-per-service system, or through a managed care mechanism, would encourage both efficiency and quality.
Another benefit to accrue from this type of reform would be the reconfiguration of the relationship between the hospitals and the Department of Health. At present, the discretionary power which the Department has in determining hospital budgets, capital projects etc may provide a disincentive to individual doctors and hospitals who wish to voice public concerns regarding public healthcare policies and practices.
Giving the Department a regulatory rather than an administrative role in the running of the hospital service would allow the talents of our civil servants to be focused on ensuring that society's mandates were fulfilled at the macro level.
Our developing, modernising and increasingly affluent society deserves a developed, modern and well-financed hospital sector. We should follow the example of other societies which have demonstrated that sustained economic growth can coexist with a well-funded, high-quality hospital service. Our increasingly sophisticated population will demand no less.
Dr John Crown is Consultant Medical Oncologist in St Vincent's and St Luke's Hospitals, Dublin
