A world-class health service starts at primary care level and this must be where our highest priority lies, writes Prof Orla Hardiman.
Everybody in Ireland subscribes to the notion that we should have a health service that is equitable and accessible. This is why stories such as the case of young Ann-Marie Kelleher have offended and outraged people.
We are constantly reminded that we spend almost the equivalent of our PAYE taxes on health, and yet our public health service is not working. The system is perceived as being bad value for money, inefficient, and poorly managed.
There is a growing move to deliver some of our healthcare through the private sector, which is perceived as being better managed and more efficient.
Our health system comprises five interlinked elements: primary care; hospital services; the HSE; the Minister/Department of Health; and the private sector.
Primary care is the first contact point. It comprises GPs, public health nurses, and a range of clinical professionals. Primary care gives good value. Keeping people healthy is much better than treating them when they are sick. Yet our recent debates have paid scant attention to this.
Ideally, everybody working in primary care should be part of a team. But in Ireland this is not happening, because fully functioning teams do not exist in most places. And where a team does exist, there are barriers to access that are based on medical-card eligibility.
Ironically, those who exceed the income threshold cannot automatically access key members of the team, such as an occupational therapist. And although GPs may be available privately, most of the other professionals are either not easily found within the private sector, or they work as independent practitioners.
The overall effect of our lack of investment in primary care is that we encourage people towards hospitals, where services are more expensive.
We must, as a matter of urgency, remove all the barriers that limit access to primary care services. This would mean that GP visits should not be rationed based on income, and the services of clinical professionals, such as occupational therapists, should not be rationed based on qualification for a medical card.
A visit to a proper primary healthcare unit should provide the entire range of integrated services delivered by doctors, nurses, physiotherapists and others.
Who pays for the services is obviously important, but if we decide what we really want first, we can surely work out a system that is fair and accountable. A world-class health service starts with a world-class primary care service and this must be our highest priority.
Public hospitals are being targeted by the HSE for being "inefficient". Funding for large hospitals is capped. Smaller hospitals are being closed down. Hospitals are now penalised if people have to wait too long in Accident and Emergency.
But there are too few hospital beds, there is a shortage of long-stay units, and a shortage of professionals in the primary care system that could facilitate those who might manage at home.
All of the front-line clinical departments in hospitals are short staffed since the employment embargo last September.
Essential jobs that were "suspended" by the embargo have now been eliminated. This contraction of essential posts has had a severe effect on patient care.
We are clearly not getting the best out of our hospital service. This is because hospitals are trying to provide a service in continuous crisis mode, on a budget for front-line staff that is being constantly pared back.
But the public hospital system is fixable. Firstly, we need more beds.
Large hospitals should be funded to provide specialist multidisciplinary care, and these should link closely with less specialised but properly funded services close to people's homes. This will cost money that is not currently in the system.
The HSE operates the public health service and comprises some 40 different administrative bodies, which were merged into one large organisation without any redundancies. The HSE has generated some aspirational documents outlining how our public health service should develop. Yet the view of most public health professionals is that the HSE seems to disregard what is really happening "at the coalface".
Fixing our health service will demand a greater degree of transparency and accountability within the HSE. It must be restructured so that it becomes easy to navigate, and funding should "follow the patient", not the other way around.
The Minister and the Department of Health define our health policy. Current policy is to limit investment in the public sector, and to encourage the private sector to take over aspects of what has heretofore been provided by the State.
There is a rigorously enforced ceiling on the number of people that can be employed in the public sector. Generous tax breaks are provided to multinational "healthcare consortia" to build for-profit private facilities on public hospital land. This is the "commodification" of the Irish health service.
As a result of the current policy, and because of the ceiling in public sector employment, the HSE must buy facilities and services such as kidney dialysis and nursing home beds from private hospitals, and to franchise primary care services to private companies, rather than building capacity within the public sector.
But the HSE operates the public health system, which is not congruent with a Government policy that is increasingly reliant on the private sector. This leads to difficulties in integrating care and regulating quality. We need a coherent public-health policy that is equitable, quality driven, and adequately resourced.
It is not economically viable for the private sector in Ireland to engage with complex illnesses. Much of existing private care is provided by a combination of access through the private sector, and co-management through the public sector. This is not very equitable and will have to change.
This does not necessarily mean that services should be shifted to the private sector. There is evidence from other countries that public hospitals can actually perform better than private hospitals, if they are directly compared on a level playing pitch. Shifting to the private sector would greatly inflate costs, as is evident from other countries.
With proper targeted funding, healthcare provided by the public sector could out-perform the private sector in Ireland. But it will not come cheap. Our health service could be accessible, equitable, and quality driven. We just have to make it clear that this is what we want, and be willing to pay for it. Therein lies the challenge.
Prof Orla Hardiman is a consultant neurologist and HRB clinician scientist at Beaumont Hospital and Trinity College Dublin