Fintan O’Toole: It is time for an Irish National Health Service

Even if there is not a second wave of Covid-19 infections, there will surely be a second wave of crisis in the Irish healthcare system. It is not just that there are fearful challenges in maintaining social distancing and enhancing infection control in hospitals that are, even in normal times, often dangerously overcrowded, especially in A&E departments. Waiting lists, already scandalously long, will have all the patients whose treatments and tests have been cancelled in the crisis, added to their numbers.

People will be turning up sicker than they would have been because diagnosis and treatment have been delayed. The habit of leaving the nursing home sector out of sight and out of mind will have been broken by the terrible toll of deaths within it. After this week’s damning evidence to the Oireachtas committee on Covid-19 response, can we simply go back to leaving social care as a distant suburb of the health service?

More strangely, we have the uncomfortable truth that the coronavirus suddenly made the impossible possible. The dearth of intensive care beds could be made up in a matter of days. Staffing levels that nurses have been complaining about forever were, for critical care, suddenly improved.

Above all, the invidious distinction between public and private patients has been largely abolished for hospital care, with the State effectively nationalising private hospitals for the duration of the crisis.

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But as well as making the impossible possible, the crisis has also made what has been accepted as the norm no longer viable. The existing, familiar Irish health system, as it has operated since the 1970s, is simply not feasible anymore. Even if it were not almost universally acknowledged to be deeply unjust and unwieldy, it will be a long time before a return to this “normality” can be contemplated. Health care will be a national emergency for the foreseeable future.

And just as great national emergencies make the impossible possible, they make the unthinkable thinkable. What Ireland has been unable to think about is a national health service. The NHS in the UK, one of the great achievements of civilisation, came about in part because, during the extreme conditions of the second World War, everybody had to be given free access to basic treatment. Once that was done, it could not be undone – the overwhelming logic was to move forward and build a new system that guaranteed equal access to all.

A new health system has to be built for the new world we have entered. And it should start with a bit of reverse engineering.

Ireland’s position is not dissimilar. We’ve been forced to recognise health care as a collective public good in which we all have an equal stake. That cannot be a temporary little arrangement. A new health system has to be built for the new world we have entered. And it should start with a bit of reverse engineering.

This crisis has shown that it is a nonsense to have different health systems on one small island. For once, the Republic should have the humility to think about the process of all-island integration, not as an extension of its systems and values to Northern Ireland, but the other way around. The NHS that operates in Newry and Derry should have a twin sister in Dundalk and Donegal.

This necessity is as much about efficiency and effectiveness as it is about social justice. We are among the highest per capita spenders on healthcare in the world, in spite of the fact that our young population means that 84 per cent of us report being in good or very good health, compared to the EU average of 69 per cent.

In 2018, we spent €4,677 per person on health. The UK spent €3,483. We do have a huge deficit in infrastructure (both at community and national levels), which will have to be made up at considerable expense. But the fact is that, on an operational basis, the NHS is much cheaper and more efficient –as well as much fairer – than Ireland’s system.

Though calling it a system is rather flattering. Our problem is not how much we spend but how we spend it – through a ramshackle, opaque and highly inefficient mixture of public spending from our taxes, private spending from insurance payments and out-of-pocket payments (GP and prescription charges).

There is nothing anywhere in the world quite like the Irish hospital system, and it seems safe to say that no one would ever design it the way it is.

Ten years ago, the Department of Health published the report of an expert group on the funding of the system it oversees. Its chair, Frances Ruane, summed it up in her preface: "Many aspects of the present resource allocation system promote fragmentation rather than integration. The absence of a coherent framework adversely affects accountability, efficiency, governance and clinical care."

There is nothing anywhere in the world quite like the Irish hospital system, and it seems safe to say that no one would ever design it the way it is. There are five different kinds of hospital – public hospitals owned by the State; “voluntary” (usually Church-owned) hospitals that operate within the public system; private not-for-profit hospitals (usually run by groups of medical consultants in conjunction with religious orders), often located alongside a public hospital and sharing some of its senior medical staff; free-standing private for-profit hospitals, often run by multinational health-care businesses; and (at least in theory) private for-profit hospitals co-located with a public hospital. (This latter idea was developed in the Celtic Tiger years and shelved during the crash, but not explicitly repudiated.)

The basic problem in this system is that it is built around an anomaly: everyone is, in principle, entitled to public health care but 45 per cent of the population also pays for private health cover. They do so, for the most part, for one reason: access. People are scared that they won’t get treatment when they need it – often with good reason. But this fear distorts the whole system.

The coronavirus crisis has given us an improvised, temporary and still very incoherent version of what an Irish NHS might look like.

Those who pay private insurance premiums tend to believe they are relieving the burden on public care. In fact, 77 per cent of total health financing comes from taxation, 12 per cent from out-of-pocket expenditure, two per cent from private corporations and just nine per cent from private health insurance. Yet this nine per cent prevents the entire system from being able to function as an integrated and coherent whole.

When the pandemic arrived, this rickety house of cards quickly fell down. Private insurance has become, in the crisis period, essentially meaningless. We’ve ended up with an improvised, temporary and still very incoherent version of what an Irish NHS might look like.

But we are still in a no-man’s-land, caught between an old system that cannot continue and a new one that has yet to be created. The very slow progress towards a universal healthcare system under the Sláintecare plan, meant to be rolled out over 10 years, no longer looks remotely adequate. Its idea of removing private patients from public facilities may be right, but it has been overtaken by the emergence of the opposite imperative: public patients occupying private facilities.

The basic problem in each case is the same: a system that divides patients according to the way they pay for essential health care.

There is already on the island a system that does not do that. It was built in the aftermath of a great crisis and, for all the attempts to undermine it through privatisation, it remains a source of great pride for most ordinary people. A similar system south of the Border could surely command the same allegiance.