Saturday 1 October 2016

Harris needs to avoid radical surgery in health system reform

The minister for 'Angola' has put the onus on TDs to come up with a workable model that will endure, writes Eoin O'Malley

Eoin O'Malley

Published 05/06/2016 | 02:30

'By asking others to agree the long-term vision for the health service, Harris recognises that he cannot deliver radical change and that reforming the health service will take decades, rather than years.' Photo: Gareth Chaney Collins
'By asking others to agree the long-term vision for the health service, Harris recognises that he cannot deliver radical change and that reforming the health service will take decades, rather than years.' Photo: Gareth Chaney Collins

The French architect Le Corbusier thought that crowded cities were bad for people. He tried to refashion them and create new urban designs with a building style that became known as Brutalism. He thought he could change how cities worked.

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As an experiment in urban planning, it failed. Many of the attempts at redesigning cities have been knocked down or those living in them wish they would be.

It shouldn't surprise us. Most attempts at fundamental reform fail. They either fail to get off the ground or, if implemented, they fail to achieve what they were meant to.

The new Minister for Health, Simon Harris, last week announced the formation of a new Oireachtas committee into health. Its remit will be to find a "singular vision for the health service over the next 10 years".

He should have said 20 or even 50, because that's how long radical reforms take. Even pretty simple issues, like building a new children's hospital, seem to take an inordinate amount of time.

The need for the Oireachtas committee is based on the assumption that ministers come and go and that their changing agendas mean that no reform is ever fully enacted.

By forming a consensus across parties, that plan will be progressed, regardless of any change of government.

Is that assumption valid?

The last government did not implement its singular vision of a Dutch-style health system mainly because it was too bold a plan. If we baulked at water charges, we were hardly going to look kindly on mandatory health insurance.

Leo Varadkar recognised this and scaled down expectations. The cynic in me might suggest that Simon Harris is going further, he is handing over responsibility to others.

By asking others to agree the long-term vision for the health service, Harris recognises that he cannot deliver radical change and that reforming the health service will take decades, rather than years. He also recognises the politics of the situation. He won't be able to push through radical reform without the approval of Opposition parties.

It's especially important because this is the issue that more voters cited as the one determining their vote. Removing it as a political issue can only help Fine Gael. Harris's actions are good politics.

To be fair to Harris, he has asked that the committee reports back to the Oireachtas within six months. Even on a pessimistic view of the current Government's durability, that will require Harris to do something.

But we know what it will say. There is already a consensus that we should have a single-tier health system, which delivers treatment based on clinical need, not means.

The trouble starts when you try to agree how to deliver that. This is where politics comes in. Essentially, the committee will be asked to consider two models: Beveridge and Bismarck.

The Beveridge model, named after the architect of the British NHS, is one in which the funding and delivery of healthcare are all within one organisation, such as the NHS. It's thought to fail, except in small population countries, because the organisation is simply too big to manage. The Bismarck model is based on (not necessarily private) health insurance, in which funding and delivery are independent. You tend to see (not necessarily private) hospitals compete with each other. Unlike in the Beveridge system, a single policy mistake isn't automatically repeated across the whole system.

The Beveridge system also becomes too expensive to administer. Money gets spent on management, not on patients.

We should know from our own experience that money doesn't correlate with outcomes. Ireland trebled its spending on health during the boom, but few made claims about an improving service.

Even if a committee agrees on a roadmap to reform healthcare, there's no guarantee that other interested parties will play ball. The church, which controls many hospitals, and health professionals - nurses and doctors - have shown themselves able to block even modest changes.

Harris should be sceptical of big structural reforms. Remember that the last big reform in health was the formation of the HSE, something that the current Programme for Government is committed to dismantling.

Nor should we carelessly buy into the idea that the health system is as terrible as we are continually told. There is a problem with waiting lists, but according to the Euro Health Consumer Index, Ireland performs well on the things that matter: patient outcomes. The rising life expectancy shows Ireland is also very good on preventing illness. The Healthy Ireland initiative has been a singular success.

The committee and the new minister should recognise that small-scale reforms often work best. The State's cancer strategy, including initiatives like Breast Check, has worked well. The National Treatment Purchase Fund succeeded, albeit at some cost, in reducing waiting times for a number of standard procedures.

Simon Harris won't just want to get out of the Department of Health politically alive. Despite James Reilly's experiences and Brian Cowen's now infamous moniker, Hawkins House is not 'Angola'. Harris is smart and ambitious. He'll want to have something to show for his time there.

Charles Haughey recognised that as a minister you would want to try at least one innovative idea in each department. It can make your name. Haughey produced a litany of small measures, such as the free travel pass and the artists' tax exemption, that had a big impact (not least on his reputation). Mary Harney dined out on the smokeless coal ban for years.

Harris should pick something manageable. If it were to change the way GPs are structured and introduce a proper primary care system, that would certainly be enough to build his reputation.

Anything bigger might end in failure, or worse he might be the architect of something that we want to tear down 20 years later.

Sunday Independent

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