Berlin, Boston, or Ballybofey

Berlin Boston or Ballybofey

Sunday Independent - March 2007

The excellent Primetime series on the ongoing health reform debacle made for very depressing viewing. The most upsetting parts were the harrowing stories of the women who suffered the consequences of delayed cancer diagnoses. Tragically, one died. Another had to wait seven months for utterly routine tests, tests which, when they were finally performed, revealed that the cancer which had caused her to seek medical attention in the first place, was by now incurable. This type of occurrence is not rare in our public hospital system. Good GPs are frequently thwarted in their attempts to practice good medicine by the waiting list phenomenon.

Nor are these occurrences accidental. They happen because our public health system operates on a principal of viciously rationed health care. Put bluntly, the lady with the delayed diagnosis of cancer cost the hospital and the health service nothing while she was on the waiting list. It was only when she was actually engaged with the system that it incurred costs. Equally critically, the hospital she attended would receive not one penny more nor one penny less whether it did or did not perform her tests within an appropriate time frame. Add to this a system of appointing medical specialists which might just possibly have been suitable for appointing dog catchers in the South Riding of Tipperary after the Civil War, and you begin to understand why public patients are treated so slowly, and all too often, so poorly.

Without trivialising the awful tragedy that these ladies suffered, the second part of the Primetime program was nearly more depressing, in that it suggested that these deficiencies will, like the Biblical poor, remain with us forever. The first sign that we were in for a dose of HSE/Department of Health Houdini/Orwell fusion speak came when Miriam O’Callaghan announced that both bodies declined to send a representative. Instead, Minister Harney issued a statement in which she appeared to say that she was developing two-tiered health care in order to end two tiered health care. I was reminded of war correspondent Peter Arnett’s story about the American officer solemnly telling the Vietnam press conference that they had to destroy the village in order to save it.

The panel debate which followed was yet another recitation of the Cold-War era Boston versus Berlin arguments, which can be summarised as follows. The Berlinistas believe that equitable care can only be administered in state-owned, state-funded, state-run, state-regulated hospitals which are staffed by pliant socially-responsible doctors who recognise that the rights of their individual patients must be subordinate to the common good, and who answer to government-appointed hospital administrators and civil servants (HACS for short). According to the Berlinistas, the fundamental principals and management structure of the current public system are essentially correct, and the evident deficiencies outlined on Primetime would all disappear if we increased investment, and punished the Evil Consultants. This model actually bears less resemblance to Berlin (well perhaps to East Berlin circa 1959), than it does to Birmingham. It is in fact the British NHS model, an appalling mess characterised by waiting lists and treatment denial, a system that German doctors and patients revile. The recent disclosure that patients with learning disabilities were denied basic life-saving treatments in Her Majesty’s Health Service will come as no surprise to observers of that discredited system, which denies kidney dialysis to 9,000 British patients annually.

The Bostonians on the other hand, would have us believe that an American-style, profit-driven health-care market place, with for-profit hospitals, and for profit-insurance companies would in fact provide an equitable social service. I’m reminded of Colonel Sanders asking the already bread-crumbed chicken to trust him.

There is a third way, a grey way which lies between these black and white ideological extremes. It is a way which is totally fair, and which gives hospitals and doctors incentives to work hard, and to work efficiently. It is in fact, a variation of the real German system, a system of mandatory social insurance. In short, all citizens will pay a premium which is deducted from their paycheck. As every wage earner will pay the same percentage, the rich who make more, will continue to subsidize the poor and the unwaged. Income tax must fall by the amount of this deduction, ensuring that the moneys accrued will not go into the general government coffers, where there are subject to waste, but will go into insurance funds. Patients will pick their hospitals and doctors, who will in turn compete for their custom on the grounds of quality and efficiency, and will bill the insurance funds for their services. The patient on the waiting list costs you money, the patient on treatment makes you money. Critically, there will be no private and public patients. We will all use the same doctors and hospitals. Most hospitals will be not-for-profits, many will be owned by universities, some will be voluntary not-for-profit. Our teaching hospital specialists will become university employees. The system would cost more, but not much more, due to hugely increased efficiency.

So Ballybofey, Baltinglass and Bagnellstown should all say no to Boston and to Birmingham, and say yes to Berlin. Acthung Mary.

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