Talk of reorganising the provision of medical care in Ireland is as old as the health service itself, and has certainly been around longer than the HSE.
Back in 1987, for example, then minister for health Rory O’Hanlon was calling for “a review of the funding arrangements; the rationalisation of the acute hospital system; the development of primary health care services . . . and an improvement in managerial arrangements at all levels in the system”.
It didn’t happen then, or subsequently – not very effectively, anyhow – but now a very similar agenda for change is back on the menu.
The consensus reached in the Oireachtas this week on the creation of a cross-party committee to plan the future of the health service is a novel approach to an acute and long-standing problem.
It represents an appropriate response to the very obvious failings in health – more than 500,000 people on waiting lists, hundreds on trolleys in emergency departments every day and staff shortages.
Whether the committee can reach the desired consensus is another matter. Minister for Health Simon Harris has said he wants to learn "where we want the Irish health service to be over the next 10 years, how we want to get there and, crucially, how much it's going to cost".
On the face of it, there is apparent agreement about major issues, such as a move to wider primary care services or the creation of a single-tier health system.
Yet if this is the case, why haven’t these changes been implemented before? There is real resistance within the health service to changes perceived as disadvantaging one sector over another.
Powerful acute hospitals are likely to resist any move to shift funds away to primary care.
And what happens to private health insurance, and the doctors who make a good living from it, when a single-tier health system is created?
Breathing space
The committee, which is due to complete its work within six months, will give Harris some breathing space as he adjusts to his new job, but the idea originally came from the Social Democrats.
Róisín Shortall of that party says it needs to be properly resourced, with significant input from academics in the universities and the Economic and Social Research Institute.
She suggests it should have two main strands, one looking at the kind of health system most appropriate for Ireland and the funding that should apply, and the other examining how the model of care can be changed away from hospital and towards primary care.
Shortall believes the involvement of private health insurance in the public system needs to be “disentangled”.
Private health insurance would be phased out, or at least reduced to UK levels (where 15 per cent of the population has private cover, compared with almost 50 per cent in Ireland).
Brian Turner, health economist at UCC, points out that support for a one-tier health system is "like world peace – everyone's for it".
Another key issue for the committee will be funding. Many of the stakeholders in health argue they are underfunded but not all their financial demands could be met.
So how much are we prepared to spend on a functioning health system? International comparisons tell us Irish spending on health, both public and private, is above average, so why should we devote even more money to the sector?
Turner says the Irish system has been underfunded historically and is playing catch-up. There are, for example, 3,000 fewer beds in hospitals than there were in 1980.
“I don’t see why we should be spending more, but we should be spending differently,” says Shortall, who says savings can be made by ensuring more care is provided more cheaply in the community.
Ultimately, a switch to primary care will mean less spending on hospitals but a transitional fund may be needed, she says.
‘Moanfest’
There is an obvious danger of the committee becoming a talking shop, even a “moanfest”.
Shortall says it is important TDs focus on the system that needs changing rather than the problems that are apparent.
This exercise has never been attempted in Ireland before but other countries have tried.
The Netherlands reformed its health system after reaching a national consensus, though it took 20 years to implement the changes and even then the results are disputed.
