Health Reform

[Speaking in the Seanad during a Fianna Fail Private Members Motion on Health Services]

Again, I welcome the Minister. He is a young man and is about the same age as I was when I first became a consultant oncologist in Ireland’s medical service. I was full of enthusiasm and optimism and thought a problem was what one was here to fix, not something that made one go away wringing one’s hands, which is a common attitude in Ireland. I like to think I have managed to keep some of that enthusiasm although my youth has waned and I still look at problems that I try to fix and overcome. However, I must state that I am a little weary now of one or two of them, and one about which I am most weary is the structure of the health system here, which is wholly irrational. Lincoln once famously stated, “A house divided against itself cannot stand” and I am afraid that our health service is a house that is divided against itself. It is one that I believe could be fixed and the only real impediment to fixing it is the will to do so.

I am in an awkward position here because I agree with approximately 95% of the contents of the motion tabled by Fianna Fáil. In a number of terse bullet points, its Members here have pointed out eloquently and accurately many of the deficiencies within the system that must be fixed. As has been pointed out by others, I state this with no desire to be personally critical of anyone, the reality is that Fianna Fáil had many years in which to fix it but chose not to. For many years, Fianna Fáil-led Governments had a Minister for Health who came from a party that officially had no policy on health reform because its members stated the health system was too complicated and simply could not be fixed.

I believe it can be fixed and I am not asking people to look at some pie-in-the-sky fantasy. I ask them to look at health systems that actually exist in countries that are similar to Ireland demographically, and on where they fit in terms of OECD wealth scales, etc. I acknowledge no system is without criticism but in such health systems, the torrent of criticism ours faces and which is largely deserved simply is not heard because there is a higher level of satisfaction with the systems. I do not wish this debate to turn into another in which Fianna Fáil criticises Fine Gael and vice versa and where the latter’s principal defence in response to these charges is that Fianna Fáil could have fixed it. That is my job. I am not a member of either group and have been equally critical of both. The one Minister for Health up to now who I thought made a huge difference in fixing something was Deputy Noonan. He is the one who deserves most of the credit for improvements that occurred in cancer care in Ireland. That is another day’s work and I will not go into it today.

We have had the great experiment and the two great hypotheses have been subjected to experimental trial. The first hypothesis was that what was needed to fix the health system was not to change the way in which it was funded but to change the way the administrators were organised. Since I came back, we have had a Department of Health, an Eastern Health Board, an Eastern Regional Health Authority, regional health authorities, ultimately a Health Service Executive and now hospital groups. I believe that none of these will make any difference because they do not deal with the core problem, which is the disconnect between reimbursement and efficient activity. This is what must be done if we are to get rid of the waiting list problem.

Without going into all the details, the waiting list problem is not comparable with any other country in the western world but is absolutely off the bottom of the scale. We have an unbelievable waiting list and once again I must tell the Minister, on the basis of evidence that has been presented to me and which I have discussed in this House with the Minister’s predecessor, I believe the waiting lists may actually be worse than we know because there is a great degree of artifice in the manner in which the HSE and hospital outpatient clinics are now structuring who precisely is considered to be on a waiting list and at what time does a person actually become somebody who is subject to a waiting list. While it is not necessary to go into it all, there is something wrong with a system in which people are waiting two years for paediatric cardiology consultations or in which deaf children are waiting for a year and must strain to hear at the front of a class before they can get their hearing tested. There is something wrong where cataracts or orthopaedic surgery, which may not turn up very much in life expectancy tables but which have huge effects on quality of life, take so long and where people wait five or six days or a week in a hospital bed for a magnetic resonance imaging, MRI, scan because it suits the hospital to have them wait. This is because if one uses the single scanner more efficiently, thereby getting people to go through more quickly and if one has people working at night time, it will cost more money. The bed will be emptied faster but will not be emptied as it will be replaced by the next person who comes in off the list.

This is what happens when one has a disconnect between reimbursement and activity. If one looks at a league table based not on fluffy stuff like whether the hospital system has an ombudsman but on the core value of access to care, in all the scores that look at the various OECD countries, the countries that feature at the top of the list with boring regularity are those that follow the Bismarckian model of health care where there is a connect between activity and reimbursement. Those which are based on the Beveridge model of global budgeting and on that money being given in January with people being told to make it last until midnight on New Year’s Eve are the ones with the waiting lists. They are cheaper systems but one other piece of advice for the Minister is not to fall into the trap of thinking that spending money on health care is bad for the economy. He should think of the United States and Japan in the 1990s, when former President Clinton campaigned on trying to make America more competitive with Japan because Japan’s health care costs were so much lower. He failed and health care reform did not work at the time in the United States, although there has been a degree of health reform subsequently. Nevertheless, America’s economy went through the roof throughout the eight years of President Clinton’s rule while the Japanese economy tanked.

The Minister should consider the countries that spend more than does Ireland on health care at present. Are they failed states with failing economies? I am referring to Canada, Germany and Israel, which faces an entirely different set of challenges that gobble up its GDP. There are examples of countries which have been shown to make it work, such as Switzerland. We can and need to do this.

As for the second major experiment we did, the Minister has been first in terms of peer reviewers who have looked at the experimental details and he has come to the correct conclusion. It was that there was something fundamentally wrong with the position regarding consultant contracts which were causing problems in the health service, so we changed them. We appointed a whole group of younger consultants to, more or less, full-time public jobs with no distracting private commitment. The waiting lists, however, did not go down by one second. What is more, we found it harder to fix the jobs, a problem which the Minister is now addressing.

The problems are manifold and the challenges are great but I believe the Minister is up to them. This is his chance to really put a stamp on the service, to be the Noël Browne of our era. He may not particularly like that accolade ideologically but I mean it in terms of somebody who left a big positive mark on the health system in his brief period as Minister. No one has been given a better opportunity to do this than the Minister, Deputy Leo Varadkar. The tide is rising boats economically and, as the Minister said himself, the era of cuts is over.

I find myself in the strange position of agreeing with the Sinn Féin amendment to this motion because it correctly points out that the problems in the health service come from both sides of the House. There was a commitment made to reform the health services. Fiddling around the edges and introducing new bureaucracies will not fix this. We have to fundamentally reform and fix the system. I hope and believe the Minister is the man for the job.

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