A few years ago, Hector fronted an offbeat, entertaining TV series in which he travelled the country and interviewed interesting people on the topics of the time. He asked a bishop of the Roman Catholic Church about the prospects of women being ordained to the priesthood. The reply he received was a conversation stopper. The bishop simply said – “It won’t happen”.
I was reminded of that recently when in conversation with someone whose views I respect on the big ticket issues facing the country. I asked her, “what about Sláintecare” to which she replied, “ It won’t happen”. “Maybe when we have a Taoiseach with a surname like Boyd- Barrett or Coppinger”!
All party support for Sláintecare doesn’t mean it will be implemented. The dates for specific actions, up until now, have all been missed. If the system proposed is to be implemented it will be a monumental task. After World War 2, when Britain needed to be rebuilt in more than the physical sense, the nettle was grasped and a radically new, egalitarian type healthcare service was introduced. The National Health Service was of its time. It proved to be popular and worked really well for many years, but is now struggling to satisfy the requirements of a modern health service.
Even in Soviet Russia, every hospital reserved a floor for the treatment of members of the politburo and their families.
Here, we opted for an approach that prioritised appeasing vested interests over meeting the healthcare needs of the people. Our acute hospitals are largely funded from the public purse but only some of them are publically owned. Our public hospitals cater for some – often the more urgent and complex – needs of the privately insured population. Our private hospitals cater for the mainly elective-care needs of about half of the population who hold private insurance or opt to pay for private health care. They also provide some services to public patients that are paid for by the State.
Community health services are fragmented and amount to a mish mash of public providers, for profit providers, not for profit providers and voluntary organisations. Governance arrangements, for community based health services, at sector level, are not fit for purpose. Service entitlement reforms have been ponderous and have added new layers of administration in a system that has not involved managers in designing and implementing better ways of serving the public. Sláintecare envisages replacing all of that with an egalitarian model of healthcare, the like of which doesn’t exist anywhere in the world. Even in Soviet Russia, every hospital reserved a floor for the treatment of members of the politburo and their families.
Even if universal healthcare, free at the point of use, at affordable cost and without waiting lists could be achieved, would that dispel our dissatisfaction with the healthcare system? Once that sea change approach passes the tipping point, going back will not be an option. Would that type of system succeed in attracting and retaining the high calibre of doctors and other health professionals a modern health service relies upon? The calibre of staff in our hospitals and community health services at present is very high: the problem is that, on the one hand, we have too few of them and, on the other hand, too many of those we have are attracted to jobs abroad where working conditions and facilities are better than they are here.
The pretence that Sláintecare will happen and will resolve our entire healthcare issues will not prevail.
In the Sláintecare report, the importance of developing primary care is stressed and rightly so. That has been the stated policy here for over twenty years now but progress on implementing it has been very poor. It will be pointed out that many new primary care centres have been developed and that’s true. They have not, however, made any real difference in healthcare terms.
Their main benefit is that they provided a better environment for staff and patients and that, in itself, is worthwhile. General Practitioners who do not volunteer to relocate to a new Primary Care Centre are free to remain where they are at present regardless of the suitability or otherwise of their premises to provide a frontline health service. General Practitioners are the latter day equivalent of the barefoot doctor of old. They still rely on hospitals to provide laboratory and imaging services. Waiting lists for outpatient appointments could be greatly reduced if general practices were provided with the diagnostic facilities that would enable them to provide the level and quality of service they are capable of providing.
If the Sláintecare recommendations were implemented, at whatever cost would be involved, private health insurance would virtually disappear. Why would anyone who had access to the services they need, when they need them, at no cost at the point of use, need to take out private insurance? At the point where Sláintecare has been implemented, a huge State monopoly will have been created and we know that monopolies do not have a reputation for either quality services or user satisfaction. If that happens, private health insurance will experience resurgence leading to a new two tier system.
It is not surprising that the implementation of Sláintecare does not appear to be a priority of the Minister for Finance. That report indicates that 70% of the current spend on healthcare here is funded from the public purse, with the remainder met from private health insurance, co-payments and private payments. Even if Sláintecare could be introduced at no extra cost, the Minister would have to find an equivalent amount of funding to replace the healthcare costs that have up until now been met from other than State sources. That would not be easy even if he were not constrained by his obligation to conform to EU and European Bank obligations. The trend here and elsewhere is for governments to facilitate the private sector to fulfill the role it is capable of fulfilling, thereby enabling governments to focus its spending on what has to be met by government.
Our current healthcare system is not fit for purpose. If it is to be replaced by Sláintecare, as proposed, that will involve designing and implementing a monumental change programme, the like of which has never been attempted here before. I’m not aware of any recent examples from elsewhere of successful change on that scale in healthcare either. The challenge of delivering an acceptable level and quality of healthcare while a whole new system is being put in place will in itself be immense. The pretence that Sláintecare will happen and will resolve our entire healthcare issues will not prevail.
While the question of which will be realised first, women being ordained to the priesthood or the implementation of Sláintecare?, might give rise to interesting, harmless debate, neither is likely to happen anytime soon.