Sir, – In making the case that Ireland needs a better digital or electronic platform to underpin our healthcare system, Prof Martin Curley quotes some literally incredible data (“Ireland’s health system among lowest performing”, Opinion & Analysis, June 21st).
He cites rankings produced by Numbeo and CEO World magazine, both of which manage to rate our healthcare as inferior to a list of countries he mentions. Among them is Kenya, which according to World Bank data has a life expectancy of 61 years and 0.2 doctors per thousand of population. The equivalent figures for Ireland are 82 years and 3.5 doctors. All of the countries he mentions as having better healthcare systems than ours have much shorter life expectancies. It is difficult to see what meaning a reasonable person can attach to such conclusions, therefore.
That being said, the issue with which Prof Curley wishes to grapple, of creating a robust digital platform upon which to base the evolution of a healthcare system, serves to illustrate a real problem we face. This is that we actually don’t have “a healthcare system”. We have several oddly interconnected processes, with embedded conflicts of objectives, juxtaposed local and general political pressures and significant over-administration widely in evidence.
First, and most obviously, there is the public versus private division of care, with one incentivised to do more work and thereby generate profits, the other to minimise activity and so lower costs. Unfortunately, it is the latter that is landed with the most complex work, and with virtually all emergency work. The Government funds “public” care from taxation, rather than using a social insurance format – but in a model in which average earners pay very little income tax. Meanwhile the private medical sector is largely funded from health insurance but with the State as the owner of the largest insurer, the VHI, itself a profitable enterprise. The extent to which the State wants us to choose private or public treatment is thus riddled with ethical and fiscal conflicts, with public care enormously costly while private treatment generates a surplus.
Within the public component we have HSE hospitals and anachronistically named voluntary ones, which retain greater autonomy over governance and appointments. The latter develop and invest in information technology in accordance with their own budgets, needs and requirements, separately tendering, and so on.
While it would be wonderful to see our current patchwork quilt “evolve into a leading system using digital solutions”, a fundamental prerequisite would be to get to a point where we actually have a coherent system. Ideally, this would, at all levels, include incentives that clinical activity be maximised and costs minimised.
People who work in both HSE and voluntary hospitals (such as myself) generally find the latter to be at least as well, and often better, run. But imposing standards of technology across all State-funded hospitals would require control being centralised. The record on such large projects, from PPARS to the Children’s Hospital, is much more a cautionary tale than an exemplar, however.
Our failure to bring even our public hospitals under a common governance framework is thus arguably not a bad thing. It has, however, been brought to the attention of our Government in a previous report. Lest anyone fail to take it literally, the recommendation “we cannot emphasise too strongly the importance and urgency of successfully coordinating the activities of the voluntary hospitals and the health authority hospitals” appears in bold print, not in Sláintecare of 2017, nor in the Hanley report of 2003. The recommendation goes back to the Fitzgerald report of 1968, available online. It continues observing that “their independent status has been a basic factor in a tendency to reduplicate services excessively”.
The World Health Organisation typically rank our healthcare around 20th to 25th globally, and this reflects our outcomes and experience well. To reach the highest levels will probably necessitate taking and acting on decisions that will be contentious and unpopular. Gathering data on citizens’ behaviours and allowing it to be accessible to health professionals will help, but may raise challenges regarding privacy and related legislation. Our seeming inability to build infrastructure though will stymie any such efforts, though. In most countries, building a hospital appears to be a far more straightforward process. – Yours, etc,
BRIAN O’BRIEN,
Kinsale,
Co Cork.