Waiting lists are the result of a skewed system, the lack of innovation and a too ready acceptance of inequality. Money is important, but it is not the real issue. It is the system that's the problem - a system that will continue to eat resources without improving.
Health boards and hospitals have initiated important programmes to address the problem of waiting lists and waiting times. Total government spending has doubled, to some £5 billion, since 1997. At the same time, the strains within the system have become increasingly evident. Fundamental reform - encompassing both the public and private components of the system - is inevitable and increasingly pressing. The system needs to be re-engineered.
The Government's present strategic review is, therefore, a central element in an even wider process of soul-searching about the status of acute healthcare in Ireland. Healthcare is a public good, but that does not mean it should not embrace the best of world practises, drawn from other areas of business management.
Unless we move in this direction, the failings within our system will become progressively more evident. We have a chance over the next year or two to position the Irish acute system at the leading edge of a revolution in European healthcare. What it comes down to is vision, strategy and process. That is, a vision of what standard of acute healthcare we want and can fund on a sustainable basis; a rigorous and innovative strategy prepared, where necessary, to think the unthinkable; and a change process that can get widespread support.
The public-private acute hospital system is inequitable, regressive and skewed against those who are the most disadvantaged. In addition, the public perceive the quality of hospital care to be better in the privately financed/private health insurance (PHI) sector.
The statistical evidence of the forthcoming Bupa Ireland/Economic and Social Research Institute survey on these points is compelling: 90 per cent of people believe hospital care can be obtained more quickly in the private system. For pretty well all but urgent cases, public patients admitted through outpatient referrals face successive hurdles to getting the surgery they require.
Privately financed patients do not have these hurdles. That is one reason people will take out private cover even if there is a free, universal system. But a measure of strain in the current system is that those using the private sector are now beginning to experience delays and cancellations.
Levels of educational attainment and social groupings are closely correlated to those people who take out private health insurance. Some 60 per cent of those with third-level education have private health insurance, compared with, for example, 37 per cent of those who have the equivalent of the Junior Certificate. Equally, whereas 68 per cent of those in professional/management categories have private coverage, less than 40 per cent of skilled manual and 18 per cent of unskilled manual workers are covered.
In terms of public perceptions of quality of care, only half as many people rate the public system as very good/good compared with the private sector. Upwards of 60 per cent of the population support compulsory private health insurance.
There are caveats. Acute public hospitals have a more complex case mix and operate under different constraints to the private sector. But, in a way, that is precisely the point. The two systems are one, except that those who take out private cover pay twice over and those who can't afford to are subject to rationing. The two components are not integrated. The system is inequitable, structurally flawed, characterised by perverse incentives and disincentives.
We cannot keep increasing public spending to solve the problem. We have been able to keep the share of Gross Domestic Product spent on health at a relatively low level of 6 per cent only because of the exceptional growth rates of the economy.
We are a small, open economy. To ratchet up public expenditure which, by its nature, is inflexible (over 70 per cent is accounted for by salary-related costs) and cannot be cut back in a less benign economic environment, is hardly sensible.
Also, future trends in the affordability of private cover are problematic. And not just because of a possible relative deterioration in the economy over the medium term.
Commercial insurers, as well as private sector service providers, require an appropriate return on capital. The religious nursing orders did not think in these terms. The market does. Strategy needs to bridge this gap from an acute system that is receding into the past to one sufficiently robust to support future demand.
Equally important, the prospective costs of underwriting health insurance are, because of developments in medical-cost inflation, likely to accelerate over the medium term. These trends in the affordability of insurance are important in themselves. They are also important because any major shift in the public system - for example, a major increase in bed capacity - will have knock-on effects throughout the system.
In a scenario of lower growth and rising premiums, a major investment in the public sector delivery capacity - in principle very desirable - could have the perverse effect of undermining the stability of the private insurance funded sector.
This reinforces the case for compulsory private insurance. And it provides the context for a rebalancing in the public/private mix which is at the heart of the Irish acute system.
The business of government should be to fund continually rising levels of a universal public entitlement - but not necessarily to deliver it through a system of public hospitals and a fragmented health-board regime. The Government should focus on articulating a vision of what we want our acute system to be and developing a sustainable strategy to achieve this. It should seek to develop the kind of physician-determined protocols necessary to ensure that outcomes are the best obtainable and providing clinical audit.
It should not be in the business of delivering the healthcare, except where there is a market failure and services could not otherwise be provided.
Acute healthcare is now at what is known as a strategic inflection point, just as the economy was in 1959, in 1978, in 1986-87. It could go either way. We need a radical National Economic and Social Council-type strategy to cut through an inertia of mindsets and structures.
We need to begin to shift a prospectively unsustainable burden away from the public sector. We need to enhance the supply of medical manpower and facilities in a manner that is not dependent on prospectively unsustainable increases in public expenditure.
We need to allow government to use its weight as funder and standard setter, to sit on escalating costs and to leverage the effect of increased competition within a compulsory private health-insurance system.
Prof Ray Kinsella is Director of the Centre for Insurance Studies at the Graduate School of Business in University College Dublin, and is author of the paper Waiting Lists: Analysis, Evaluation and Recommendations, which is based on a case study of Irish waiting lists by the Harvard Association of Ireland