An ill-fated system

With our health system becoming increasing inefficient, Colm MacEochagain looks at whether the general election will heal the wounds of the HSEIn the run up to the forthcoming general election, media consensus appears to be building behind the need for a dramatic restructuring of healthcare in Ireland. The Health Service Executive (HSE), established only six years ago, has become the target of intense criticism from the public services despite substantial investment.Despite a quadrupling of our health budget since 1997, Ireland is currently ranked 15th amongst European nations for the quality of its healthcare, and 24th in value terms. It is becoming increasingly obvious that money alone is not enough to put the health service back on its feet.The HSE itself is the outcome of Fianna Fáil/Progressive Democrat policy negotiations in 2001-2002, the central tenet of which was an acknowledgement and an understanding that broken systems produce poor results, regardless of expenditure.Those FF/PD negotiations culminated in the 2004 publication of the Health Act, which saw the abolition of ten regional health boards and a number of corollary agencies involved in health provision and care management. The Health Act was greeted with enthusiasm by healthcare professionals as well as patient representative groups, who regarded it as a potential step towards a more efficient and egalitarian model, whose predominant focus would be frontline issues: waiting lists, A&E trolleys, and the provision of equal access to care.And yet, six years on, those issues, and many others besides, remain unresolved. Despite some significant successes, and high approval ratings from patients within the HSE system, external criticism of the Executive abounds. The media regularly caricatures the HSE as the epitome of civil service excess that has failed not only in many of its own core strategic objectives but also in some of the more immediately visible problems.Recent cases such as the Tallaght Hospital x-ray scandal, have added to public frustration and impatience with the HSE. Christmas 2010 saw the highest ever numbers of patients waiting on trolleys in emergency departments around the country, peaking at 569 patients: a 68 per cent increase on already-high 2007 numbers. And although the redundancy package recently offered to long-term HSE staff has been met with tepid approval, it serves as yet another reminder of the extent of over-staffing and bureaucratic waste that’s endemic.With a change of government almost certainly on the cards, it seems as though the HSE is likely to undergo significant reform, if not complete dissolution over the term of the next government. With that in mind, here’s a quick rundown of what the major parties are proposing.Fine GaelFine Gael’s Health policy, ‘FairCare’, is modelled on the Dutch system of Universal Health Insurance, under which all citizens are required to purchase private health insurance, with varying levels of subsidy available to those less able to contribute. The policy, which would effectively abolish the current two-tier system, would be introduced on a phased basis, and would see the abolition of the HSE in its current form by 2014. Full implementation could take as long as ten years.Labour Labour’s proposals, like Fine Gael’s, centre on the introduction of a subsidised Universal Health Insurance mandate that would see the abolition of the current two-tier system by 2016. Labour have committed to the rollout of community-based medical ‘Primary Care’ teams, which would be free of charge and fully operational by 2014.Fianna FáilFianna Fáil’s healthcare plan would not substantially alter the structure of Irish healthcare, but would focus instead on implementing reforms within the existing system, and on supporting its ongoing development and improvement, while making it more directly answerable to the houses of the Oireachtas. Fianna Fáil will instead continue to support the policies of the outgoing government.Given the recognised likelihood of a Fine Gael/Labour coalition emerging in the wake of the general election, it appears as though the introduction of Universal Health Insurance in some form will occur with the next government. Such a system, the proposing parties argue, has been proven to lower costs and produce significant improvements to patient outcomes in Northern Ireland; capable of producing similar outcomes if implemented here.But can we believe them? Decades of election manifestos are littered with promises to overhaul the health service, and yet, despite significant progress in some areas, much remains to be done. Can another significant structural overhaul deliver as much as it promises? And are untested, untargeted policy manifestoes a sound basis on which to instigate reforms of such critical national importance?Besides simple funding issues, there are also concerns that the implementation of free primary care could not be sustained by the current infrastructure. Estimates show that free primary care would increase GP visits by over two million per year, at a time when GP services in Ireland are already under considerable strain. In the short term, rollout of the Primary Care initiative depends principally on the recruitment of foreign GPs, which has thus far proven very difficult.Significant though those battles may be, it appears that inaction is no longer an option if Ireland is to bring its health service into the 21st century. This election has the potential to change the way we manage our healthcare for generations. Get out and cast your vote. Some day, your life could depend on it.