The Irish health system is a bit like old ocean liner. It’s very large and creaky. There are a wide variety of pungent smells. And sometimes, it takes a slight turn in one direction or another, so that – like a ship – some time may pass before we notice we are moving in a new direction.
Over the coming weeks, consultant doctors will carefully consider a new public-only contract, offered by the HSE. The contract, which could be worth up to €300,000 a year, restricts consultants from seeing private patients in public hospitals, as is currently the norm. The response will be mixed. Some doctors will find it attractive. Others will regard it as an unacceptable disruption of the longstanding public-private dynamic in Irish hospitals. And most doctors will simply get on with things and enjoy the ocean views.
But the introduction of the contracts represents a critical period of transition in the unique context of the Irish health system. This context bears reflection. Ireland does not have universal healthcare. In this regard, we are an outlier among our peers – that is, almost every country in Europe, along with Australia, New Zealand, Canada, and indeed most of the countries to which our doctors and nurses emigrate.
In plain English, a universal health system is one in which all people are guaranteed the right to timely, high-quality healthcare when they need it. On a deeper level, universal healthcare is based on a conception of healthcare not as an economic good or an item of charity, but as a basic and equal right of all people.
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Upholding human rights is the essential role of government. Universal systems, therefore, require significant state involvement. Some societies achieve this through tax; others through universal insurance. But in all cases, universalism is a basic premise.
By design, we do not have such a system. Critically, this is not just to do with funding – or staff, or beds, or computers (though we we do not have enough of these things either). It is in the structure, the way the system is wired. Our public hospital system and private medical sector are intermingled in a way that is inefficient, unfair and highly unusual.
In our primary care sector, we are the only European nation without universal access to GP care. In other words, we are the only country where the majority of citizens – those without a medical card – must pay, out of pocket and in full, to see a GP. The fact that this arrangement is longstanding does not make it right.
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More importantly, I truly believe that nobody wins from the status quo. Citizens – all of us – get a bad deal. If you don’t have private health insurance, it means you may wait months or years before you can access many critical forms of care, from knee replacements to children’s disability assessments to reassurance about a worrying mole. This is unfair. If you do have private insurance, it means you are paying for the same thing twice: through tax and also through your insurance premium. And, in the end, you’re probably going to rely on the public system anyway.
This too is unfair. And if you are a healthcare worker, you must continually navigate a system that is overburdened, disjointed and running on fumes.
Sláintecare is a political process that seeks to address many of these issues, by transitioning Ireland to a universal, exchequer-funded model. I support this aspiration. However, many are wary of health reform, and ask valid questions. Without the requisite funding and follow-through, what if reform just makes the system worse? What if waiting lists get longer, not shorter? What if working conditions get worse, not better? The answer to all these questions, put simply, is that reform only works if we make it work.
We – doctors, patients, citizens – must take responsibility for the system, for it is ours. As a collective, doctors in particular have something of a mixed record when it comes to progressive health reforms. In fact, we generally oppose them. Some prefer the status quo. New consultants may still be attracted overseas ahead of a public-only contract. Existent consultants may prefer the greater freedom – and private income – of their current contract, and decline to move to the new one. Yet doctors are not a monolith. This time last year, Doctors For Universal Healthcare launched an open letter, signed by more than 300 doctors from all specialties and grades, calling for universal healthcare for Ireland.
The achievement of universal healthcare must be an absolutely central aim of all those who wish to bring about a decent and truly modern Irish society, fit for the next century
I would like to work in a universal health system. One in which surgeons have access to the theatre space they need in public hospitals, without relying endlessly on outsourcing to the private sector. One in which GPs have the resources to look after their patients and communities in the holistic way they are trained to. One in which no child waits for basic healthcare, regardless of whether or not their parents can find the money for insurance.
This is a system in which doctors will want to work.
The key question, ultimately, is whether this contract offer – in the form it seems likely to take – makes such a system overall more or less likely. Opinions will differ. My instinct is that it makes it more likely – but only if it is accompanied by the right policy decisions, especially a shift from endless outsourcing to a major investment in the public system’s capacity for elective and outpatient care.
In 1922, the Independent Free State came into being. We took our place among the nations of the world. While there is much to celebrate, so too must we reflect on where we still fall short. The achievement of universal healthcare must be an absolutely central aim of all those who wish to bring about a decent and truly modern Irish society, fit for the next century. In such a big system, it is rare to get the chance to chart a new course. We find ourselves at a turning point – but reform will only work if we make it work. Now is the time.
Domhnall McGlacken-Byrne is a Specialist Paediatric Registrar and has a Master’s in Public Health from Harvard University