We have failed to get our health system right since foundation of State
Published 26/02/2014 | 02:30
THE National Maternity Hospital was literally about to fall down for want of essential repairs.
Its board could not raise funds, government could not help, and closure seemed inevitable. It was 1929 and the new Irish Free State was just seven years old.
A year later 'an Irish solution to an Irish problem' emerged as the Irish Hospital Sweepstakes began operation. Eventually, the worst fears of fraud among those in government, who had only reluctantly approved the 'Sweep's' creation, would be realised.
But for the next 30 years the 'Sweep' helped transform Irish health funding and was a major help in the successful campaign to defeat tuberculosis, led by one of Ireland's earliest Health Ministers, Dr Noel Browne.
By mid-1931 IR£1m was raised for the 52 voluntary, largely church-run hospitals which dotted the country and our larger towns and cities. Health historian Ruth Barrington estimates that 90pc of this money came from the US and Britain. But in the greater health system the pace of change was slow.
For 25 years Ireland's health services were actually headed by the Minister for Local Government. Taoiseach Eamon de Valera had an eye to history when he appointed the country's first dedicated Health Minister in 1947.
Dr James Ryan had been the medical officer in the GPO for the duration of the 1916 Rising. But his standing as a medical doctor could not stave off inevitable clashes with an alliance comprising his former medical colleagues and the Catholic Church.
Even before Noel Browne was stuck in a bitter clash over his notorious 1950 'Mother & Child Scheme' with this alliance, Ryan had his own battles with the same line-up from day one in office. The same principles would underlie health battles through the late 1940s and 1950s.
The Government was trying to extend free healthcare and the Catholic Church was jealously clinging to its power and influence in the hospital system, especially teaching hospitals. The doctors feared losing private income, leaving them entirely dependent on a state salary or fixed per capita patient fees.
Successive governments were looking at what was happening in Britain's new welfare state and across the developed world generally.
The Irish government focus was moving away from dealing with various disease epidemics and upholding minimal public hygiene standards.
Developments in modern medicine meant far more effective healthcare was available in theory. The challenge was to deliver it as widely and fairly as possible.
The Mother & Child Scheme is still a source of controversy and division. Noel Browne's plan offered free healthcare for all expectant mothers and their children up to 16 years of age. The Church of Ireland attacked it as 'communist'; the Catholic bishops and many doctors effectively torpedoed it; Browne showed poor political judgment.
Similar battles were fought with far less publicity and ferocity through the 1950s. Overall, services improved and by the start of the 1960s an Irish person's chances of dying from complications of childbirth, infectious diseases or horrors like tuberculosis, lessened considerably.
The main outcome of the three-cornered government-church- doctor battles was the means test – or income thresholds.
This determined where the state role ended – and individual responsibility kicked in. Ireland is left with a massive distinction between those who pay the doctor and those who have a card which says they have state cover.
The other big outcome is the strange relationship between public and private medicine which appears not to benefit the taxpayer who funds the lion's share of both sectors.
The principle of private medicine having access to public facilities and back-up is now well enshrined in the system and is among the anomalies which remain to be tackled.
Administratively, there have been two huge developments in the organisation of the health system.
First was the creation of a seven regional health board system in 1970 after a decade of reflection and debate.
Each board was subdivided into a section dealing with general hospitals, special hospitals and community care, and functioned until 2004.
Then these were merged in what is arguably the most unloved Irish institution ever created, the Health Service Executive (HSE), which brought the seven regions into one unit.
Just a few short years later, we were immersed in a debate about ridding the country of the HSE.
Dr James Reilly's officials have been busy for three years planning the extraordinary task of dismantling and replacing what is also the State's largest employer with 100,000 staff.
Now those plans are about to be given a first public airing. The National Maternity Hospital is not in danger of falling down and a 'Sweep' to pull in money from America and Britain is no longer an option. But many parts of the overall system are creaking and everyone agrees we could get far better value for money.