Saturday 15 December 2018

Terence Cosgrave: Sick health system needs radical surgery, not a financial band-aid

Patients have always come second, and the luckless poor fare even worse, in the health equation, says Terence Cosgrave

OPPOSITION: Student nurses protest outside the HSE headquarters against a proposed scheme to pay graduate nurses 20 per cent less than other nurses. While Irish healthcare workers are well remunerated by any standards, particularly those higher up the scale, there are still ghetto areas of pay, such as that of student nurses and junior hospital doctors
OPPOSITION: Student nurses protest outside the HSE headquarters against a proposed scheme to pay graduate nurses 20 per cent less than other nurses. While Irish healthcare workers are well remunerated by any standards, particularly those higher up the scale, there are still ghetto areas of pay, such as that of student nurses and junior hospital doctors

Terence Cosgrave

THERE has always been an element of mystery about medicine and most people in the medicine business want to keep it that way. It's what makes change difficult. Doctors and nurses are careful when they make pay demands – always framing them in the context of the suffering of sick people who need 'the best care', as opposed to healthcare professionals who need 'the best pay' to give that care.

That, of course, is nonsense. Irish healthcare workers are well paid by any standard and the higher up they go, the better the pay gets.

Our top hospital consultants, for example, made on average almost €470,000 each in 2009, not just one or two of them – 1,800 individuals.

And yet there are 'ghetto' areas of pay – junior hospital doctors spring to mind – where improvements in pay and conditions would lead to better care. The patient is often stuck with a junior hospital doctor late at night when he or she is exhausted from shifts that can last days.

And we have a lot of nurses by international standards.

But patients have always come second in the Irish medicine equation – the withdrawal of support by the Health Service Executive to the Irish Patients' Association is only the latest example of that.

The health service is a microcosm of Irish society in general – a disengaged public gets a poor service from those in the know, those with jobs and power.

And that's one of the major problems – the Irish public, in general, only worry about their health when they're unhealthy, and when it's often too late.

But the 'public', as it were, is only that section of the public that is on the second tier. People with money and power have health insurance – the vile, corrupting force that makes your child more valuable than mine, that keeps my elderly relative alive while yours, sadly, doesn't make it to the hospital on time.

It's also a major factor in slowing down and preventing change.

There isn't a judge, TD, government minister, banker, lawyer, or doctor's mother who is going to be asked to wait for treatment.

They are the people who can force change, who understand best practice and the right policies but they have no need to force change when their own families are already looked after.

And that means that the only outlet for the anger of those left behind is the pointless wailing on Liveline, where the individual tragedies are wheeled out like so many purgatorial patients on trolleys.

But the system perpetuates itself because those who benefit from it aren't going to change it without some guarantees that they will not end up like the luckless poor.

And when reform is suggested, it comes in the form of money. We have been putting money into the health service for years without results. We might as well be applying leeches.

Yes, money and investment are needed, but it's not just a matter of money, it's a matter of changing the fundamental dynamic.

We are getting older and sicker, we are running out of money, and the demands are increasing all the time. Most people either don't know or understand this, or they don't care because it's not the here and now.

But medical inflation and demographics suggest that we are facing a situation where health services face ever-increasing demand, which means the service will get worse, not better, in the years ahead.

The only effective solution is to spend the money in a different way and change the nature of what the health service does.

It starts with patients.

Even if we could allocate increasing resources to health, we couldn't hope to keep up with demand.

There is a solution, of course. Our health spending is not the biggest per capita in the world, but it's not the lowest either.

Ireland ranks about average in most measures, according to the OECD – we spent 9.2 per cent of our GDP on health in 2010, just behind the OECD average of 9.5 per cent.

We had the OECD average number of doctors in 2010 – more than the US, Canada or the UK, but fewer than France or Germany.

What we have to do is create equality of service, ration certain services, reform some of our systems, change the health dynamic and build a health system that can adequately deal with the problems ahead.

But if we were serious about reform, here's what it might look like. The first big problem to be faced is that things will get worse without change.

Medical inflation

Medical inflation is higher than regular inflation and runs at up to 10 per cent a year. It's not just paying doctors and nurses more – it has a lot to do with rising standards in healthcare and people's expectations and demands.

People expect that they will be provided with excellent medical care, and people who would have died 30 years ago are now kept alive by modern techniques. This means that there are costs now that just weren't there before.

The demographics are simple – we are living longer and have more and more old people. They need more medical services than younger, healthier people. And we have many younger people emigrating. It means fewer people paying for more services. And every year the ratio gets worse.

How do we solve the money problem?

Chronic care accounts for over 80 per cent of our healthcare spending and in the briefing notes to the incoming Minister for Health in 2011, it was estimated that we could save from 25 per cent to 40 per cent of this spend – while at the same time improving care. There are many aspects to how this could be done but the main idea is to move the care of most chronic diseases into primary care.

At the moment, because so many services for chronic care are located in hospitals, patients have to be in-patients to avail of them.

Acute hospital beds and all their ancillary supports are expensive, yet much of the patient interaction could easily be done at primary care level.

The difficulty here is that it means cutting money from hospitals and investing it in primary care. Politically, it's hard to cut money from any institution as local politicians want to hang on to resources and there is usually strong opposition to cuts.

Universal healthcare

We have to become progressive about paying for healthcare. Everyone should be forced to pay through their taxes and the richer they are, the more they should pay. Just because you're young and healthy now shouldn't mean you can 'postpone' paying for your health by choosing not to have health insurance. By the time you're sick, you might have paid nothing, yet the State will still have to take care of you.

And there should be no deductions, reductions or tax breaks on your health contribution. You pay your share, full stop, for now and your future.

Poorer people will have their contribution paid by the State, but everyone should give a little – if only as a token – to create the sense of a shared enterprise.

Access for medical services should be the same for the prince and the pauper, but the wealthy who want to pay more to be in a particular hospital, or have a particular doctor attend them, can pay extra for the privilege. It shouldn't make a difference, however, medically.

Make it about keeping people healthy now, not curing them later

The 'system' is designed to intervene when there is a major problem. And solving major problems costs a lot of money. Many people could live much healthier, happier lives if the interventions came sooner and were aimed at improving their health. Diabetes is one obvious case. Mental health is another.

Since obesity is a major cause of diabetes, addressing the causes of diabetes would be a major step in reducing serious health damage to those affected. It would cost money but nothing like the money it costs when a person succumbs to the disease and requires chronic care for the rest of their lives.

In the Government's new plan to introduce 'free' primary care, the visit to the GP is free, but if he or she recommends therapy for someone displaying mental problems, for example, they will have to wait, or they will have to pay.

'Free' GP care in that instance is just a political slogan, a tick on a political box that is of no use to people who have a need of the services to which a GP will refer them.

Change the focus at the top

It starts at the top. The Department of Health should be changed to Department of Public Health and its job should not be to oversee 'sickness services' but to integrate every single government policy towards the goal of improved health.

The minister intends to abolish the HSE, but the management of the health service requires some kind of executive that outlasts governments and has the management powers needed to re-deploy staff and cut the number of administration posts.

What the minister should be doing is trying to reduce health inequality through government policy – something that was attempted through the recent 'Healthy Ireland' initiative, but something that wasn't worthy of the Taoiseach's attendance – remarkable when he shows up for any job announcement of over 20 people.

For government to take health seriously, it requires an effort beyond the health department and the minister.

It involves polices and interventions aimed at reducing health inequalities – the avoidable differences in the prevalence of diseases between people of higher and lower socio-economic groups.

A key reform has to be the alignment of policies that target ill-health.

The big challenges, obesity, for example and other 'lifestyle' diseases, are problems of society, and they can only be effectively tackled by government policy in a wide range of areas.

The range of areas that determine health include inequality, poverty, social exclusion, socio-economic position, income, education, housing, transport, the built environment and many other factors.

Approximately 60 per cent of the predicted disease burden is accounted for by seven preventable risk factors – high blood pressure, tobacco, alcohol, high cholesterol, obesity, poor diet and physical inactivity.

Tackle those issues and the health service will be well able to tackle the smaller number who require intervention.


The drug situation in Ireland is a huge cost to many individuals, and the system as it now operates is untenable. Even the latest reform bill will have limited effect because even though it promotes the use of generic drugs, generic drug prices in Ireland are still high by international standards.

We need to tackle this discrepancy at European level to ensure that people in Ireland pay the same prices for drugs as citizens of other countries.

For the moment, and to push prices down, we need some agency to allow people to purchase their drugs from other countries.

People who buy their drugs on the internet (and many do) should be free to do so – and helped and advised by their doctors to do so until a point is reached where drug prices in Ireland are at least close to what they are elsewhere.


Political reform is happening and Health Minister James Reilly certainly has a better approach than his predecessor, but even he is still subject to the political stroke. The 'selection' of Balbriggan and Swords as areas suitable for primary care centres when the facts suggested otherwise, is typical of what happens, and of what most people think happens, when political decisions are made.

People are not so much afraid of losing services in their local hospital as they are afraid that their area will be neglected in health terms if they don't speak out when that issue comes up.

So we need to make the system fair, empower people to become healthier and make health a value that we all share equally.

We need to accept that every family and individual deserves to have proper healthcare, but more importantly, that they have the healthiest life possible.

In medicine there is a known phenomenon that when a person gets a drug that they believe will cure them, in many cases they recover, even if the drug contains no active ingredient. This happens in double-blind medical tests where half the participants get the drug and the other half don't.

But in many cases, those who don't get the drug but are given the placebo recover because they think they're going to.

In the same way, if we don't believe in the possibility of a reformed and efficient health service that improves all our lives, then it's definitely not going to happen.

But if we believe and work for it, if we demand it, there's no real reason why we can't have it.



TWO of the largest teaching hospitals in Dublin were the result of mergers – Tallaght and Beaumont. When that happened, as with the health boards, it was a case of doubling up rather than letting people go.

When the 11 regional health boards were merged into the Health Service Executive in January 2005, nobody was laid off at all – achieving zero gains in efficiency.

When the HSE was created to run the health service, the Department of Health just went on as before without any cuts to staff numbers, even though the HSE was supposedly doing the job the Department of Health had previously done – running the health service.

And so a massive bureaucracy was created and continues to exist. A lot of these positions are surplus to requirements. In any normal business, the extra people would be made redundant. We need doctors and nurses, of course, but there is a huge number of ancillary staff employed in jobs that are no longer needed.


AS we introduce a full universal healthcare system, we should be able to drive down the basic costs of treatments and if someone wants all the facilities of a private hospital, they should only be paying extra for the food or the pretty pictures on the wall. Every medical intervention should be provided at the same quality across the board for everyone.

The principle of 'centres of excellence' is well-established and proven. Treating certain diseases in smaller numbers of hospitals is proven to improve outcomes because the specialists specialise, and get better.

A surgeon performing 100 operations a year will get better results than one doing 30. It just works that way and the evidence is there to prove it.

That means closing down some smaller hospitals or changing them into primary healthcare centres. This almost always meets local opposition. But most people oppose change because they feel they will be treated unfairly – not because they can't see the logic of the argument.


THE bureaucracy of the health service is enormous. And yet there are some areas where we will need a lot more people. Yet any attempt to rationalise staff has always been ham-fisted and usually counter-productive.

Recent attempts to offer voluntary redundancy have seen situations where specialist medics take redundancy and are rehired the next day because it's difficult to replace them. It's an almost Kafka-esque situation – when medical staff leave, we replace them with agency staff at a much higher cost. And often, the people who left are working for the agency that provides their replacements.

The health service is simply too complex to hope that voluntary redundancy will reduce numbers effectively without damaging medical services. We need to be able to pick and choose which jobs are no longer needed and which ones can be removed with the least damage to services. This just doesn't happen at the moment.

Management and general support staff accounted for 17 per cent of the workforce of the HSE in 2011 and that needs to be reduced substantially.

Irish Independent

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