Approach to health reform must be comprehensive not piecemeal

[Speaking in the Seanad during Order of Business]

A probably apocryphal story is told about a country which had been decolonised following a long association with the UK and decided as a symbol of its independence that it would move from having all the traffic driving on the left British-style to driving on the right as happens in most other countries in the world. Having had a high-level bureaucratic and civil service analysis of the implications of this, they came to the conclusion that the shock of doing it might be too great and that initially it should only apply to trucks, buses and heavy vehicles.

I sometimes think the same philosophy is being applied in our attempt to reform the health service. The reality is that we are moving towards a model of complete independence for the health service from the bureaucracy of the HSE and the Department of Health if the programme for Government agreed by the two Government parties is initiated. If we move to a system where everything is based on insurance, hopefully mostly but not exclusively not-for-profit social insurance, there will be a market of hospitals competing against each other, some of which are publicly owned, some of which are owned by charities like universities or perhaps professional associations and some of which will be owned by for-profit companies. My hope is that most of them will be owned by not-for-profit companies. As part of that, there will be a move from the current beauty contest used by the Department of Health in deciding where the funding goes to one based on productivity. Institutions that are good and high-quality and which attract more patients – patients who will have absolutely equal access based on a single-tier, freely negotiable insurance instrument which is equal in its access but not equal in its premium because rich people will pay more than poor people – will end up doing better because they will attract more business. With appropriate policing to prevent doctors from over-diagnosing, over-testing and price gouging and institutions from profiteering, the system can work. It is the German system, which works very well.

We must understand that the – I guess the more polite word is half-baked – attempt to move us gradually towards a reform of the health service is like the country that is putting some of the traffic on the left and some of it on the right. We have a system right now where some hospitals are entirely funded by the State but act entirely independently in terms of their management and board structures. This is the ultimate reason that we have had this understandable reaction to the disclosures concerning the top up of executives’ pay. We have in-built inconsistencies because these hospitals have their hands completely on public money but still have entire independence to appoint not only their boards, which are uninterrupted by freedom of information and are not appointed by Governments, but their research committees and entire management structure as they see fit. While we are looking at reforming our health system, we must have a very critical look in the short term at the board structure of hospitals, who appoints them, how answerable they are, who they are responsible to and how they make decisions without being answerable to anyone. Clearly, these were board-level decisions to top up these salaries. I ask the Leader to ask the Minister for Health to visit the House to clarify this and to tell us if he has any remedial action to suggest.

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