Monday 17 December 2018

Take the health service away from squabbling politicians

Politicians will never come together to fix the sector when point-scoring wins more votes, writes Eilis O'Hanlon

Annual crisis: Last Wednesday there were 677 patients on trolleys in Irish hospitals. Stock photo
Annual crisis: Last Wednesday there were 677 patients on trolleys in Irish hospitals. Stock photo

Eilis O'Hanlon

North and South have been hit hard by this winter's outbreak of 'Aussie flu'.

Health services in both parts of the island are struggling to cope. The number of patients waiting on trolleys in Irish hospitals hit a record high last Wednesday of 677, surpassing the previous day's tally of 656, which was also a new record, whilst nurses in one hospital in Northern Ireland were reportedly left in tears because of the number of patients needing treatment.

Cue the predictable dog-fight in both jurisdictions over what should be done to avoid future instances of what the Irish Nurses and Midwives Organisation is calling a "national emergency". Two health services, same outcome.

Fianna Fail health spokesman Billy Kelleher calls it a "damning indictment" of government mismanagement. Minister for Health Simon Harris says in return that "no effort or resource is being spared" to solve the crisis.

Change the names and details, and it could be any winter in any year during the past however many decades one cares to go back and start counting from. Chaos is an annual event, and the divide between what the Government does, and what its critics thinks it should be doing, never seems to get any smaller, despite the fact that everyone is in broad agreement on the nature of the problem.

The all-party Oireachtas Committee on the Future of Healthcare, established in 2016 with Roisin Shortall of the Social Democrats as chair, listed some of them in its final report last May - an ageing population; rising incidence of chronic disease, and co-morbidity (patients suffering two serious illnesses simultaneously); financial constraints leading to an ongoing inability to meet increased demand.

"More money" is the inevitable rallying cry. Whoever sits in opposition always issues that seductive call, and it's a popular stance. Spending on health may never have been higher, but last year saw the highest population growth in a decade, meaning the budget remains painfully stretched. People are also now living nearly three years longer on average than previously, which is wholly positive, but living longer with more complicated conditions, all of which are expensive to treat, puts a strain on resources.

So just pump in more money? Hey presto. Job done.

If it was that easy, then the health service would have been perfect during the Celtic Tiger years, when, despite record increases in spending, levels of dissatisfaction stayed high. There does need to be increased investment at some point, because Ireland lags significantly behind OECD averages in respect of the number of available beds in hospitals. Money, though, is only part of the answer.

As Deputy Shortall told last year's McGill Summer School: "The committee was very conscious that in Ireland we spend more on our failed health system than most other OECD countries pay for functioning services."

How resources are managed and spent matters more. That the greatest pressure last week was being felt in smaller, regional hospitals highlighted a simple truth: some hospitals cope better than others. Does that suggest the ones which don't cope as well are not as well run, or that they're bearing the brunt locally for what is a national problem?

Instinctively, putting the emphasis on organisation and management feels right. If the basics aren't in place, then any additional funding just gets swallowed up, or at least what's left after unions have snaffled up the lion's share. That means reform first.

To have more radical reform, though, involves taking on lots of vested interests, unions included, and no government has the stomach for it.

When the HSE was created, no one from the old health boards lost their jobs, despite the fact there was supposed to be a streamlining of services. Fianna Fail and the Progressive Democrats government simply crumbled to union pressure. Consultants represent a formidable lobby, too. Any health minister who takes on these vested interests all at once could be digging his or her own political grave. Effigies of Mary Harney were burnt around the country when she undertook to reform the Irish health service.

Faced with the intractability of the crises facing health, the temptation must be to rip up the previous blueprints and start again, but that's never going to happen. Here's Shortall again: "We don't have the luxury of halting everything to set up a new system. Old and new must work in parallel during the transition." Working out how to do that was what the Oireachtas committee on health was instructed to do, in pursuit of an agreed 10-year plan.

For the first time ever, consensus was achieved around the basic principle of a single-tier health system based on medical need and funded through general taxation. The aim was to depoliticise the health service, a goal long regarded as the Holy Grail.

When health becomes a campaign football, after all, long-term planning goes out the window. One party gets its hands on health for a few years. An election or two later, the other side snatches it back. Initiatives barely get a chance to work before being ditched for some shiny new plan.

That's why the all-party Committee on the Future of Healthcare was convened in the first place. Its final report, 'Slaintecare', was published last May, and all parties in the Dail expressed satisfaction with its proposals, which ranged from prioritising a need for "clear clinical and managerial accountability" (albeit that this could mean anything), to, most important of all, directing resources into primary and social care, taking care of patients at home in the community so that they never end up in hospital at all.

Many patients were at hospital last week, not because they needed to be there, but because there was nowhere else for them to go, whilst cuts in social care mean people are now arriving in hospital sicker than ever, requiring more complex, expensive treatment.

Having agreed on the Slaintecare principles, sadly, it appeared last week that the parties had promptly forgotten them. Instead one spokesperson after another trooped up to the nearest microphone to demand this or that immediate action, and to call for the financial floodgates to be opened to ease the crisis.

FF's health spokesperson Kelleher, who sat on the committee, didn't mention its findings in his immediate press release on what should be done. Nor did Sinn Fein's health spokesperson Louise O'Reilly, who also sat on the committee. Instead, she said: "On many occasions I have written to (Minister Harris) offering solutions to address the crisis, sending our policies on how to do this."

"Our policies" - this is how the debate on the health service is reduced every single time to crude political tribalism. Somehow we are expected to believe that SF has the solution, if only the obstinate minister would pay attention. For his part, Kelleher explicitly referred to the alleged failures of "Minister Harris and his predecessors Leo Varadkar and James Reilly", as if this crisis had only ever existed under Fine Gael, and would magically vanish if FF was back in government.

What happened to that collective endeavour to depoliticise the health service?

FG would be doing exactly the same if it was in opposition, but why could TDs not have responded to last week's crisis by reaffirming that determination to find a collective, agreed solution?

Instead it sounded as if political parties were in electioneering mode. To the credit of Alan Kelly, Labour's sole member on the committee, he did highlight the need for increased home-help hours; for community intervention teams; for local treatment rather than relying on hospitals - all of which were key recommendations of Slaintecare. This is important because, as Shortall said: "Our overly hospital-centric model of care (is) expensive, inefficient, far too prone to blockages and bad administration."

The idea that a new minister could solve the health crisis is akin to believing in leprechauns. Since Micheal Martin took up the post in January 2000, there have been six separate ministers from three different parties, lasting on average three years, and it's simply not long enough to see through the sort of long-range plans that are needed, especially with so much day-to-day work in the department taken up with crisis management.

It's a self-destructive cycle, with parties attacking one another's policies and ministers until they get their chance to have a go and are shot down in turn. It leads to fatal short-termism. Ministers set up health boards, then scrap them. They set up the HSE, then scrap it.

Polls in the UK suggest huge support for governments having less influence over the NHS in this dysfunctional, flip-flopping way, perhaps in wise recognition that politicians have just never been very good at running things.

The free market Adam Smith Institute has suggested that a panel of health professionals should run the NHS, deciding how the money should be spent. Parliament would agree five-year budgets and then leave them to it. YouGov found 74pc of people would approve of such a move, and the numbers are unlikely to be different if a similar poll was taken here. Nor would it be that difficult to bring into being. It would certainly be easier than trying to reinvent the wheel every four or five years, as new governments are wont to do.

Having technocrats run the health service in Ireland might seem to diminish democratic accountability, but that's mainly an illusion anyway. Ministers have much less control over health than their detractors care to admit. They can tinker round the edges, but the fundamentals defy innovation. When it works, the health service runs itself. When it fails, political options are limited, beyond bunging a few billions at an immediate crisis to take it out of the headlines, whilst simply pushing the problem down the line.

Everyone pays lip service to the desirability of depoliticising the health service, but they do so in a vague "why can't we all get along together?" way rather than agreeing a process to bring it about, as they would if they really meant it.

Lessons can be learned from the private sector, where punishments for failure tend to concentrate minds wonderfully. Paying hospitals afterwards for completed treatments on patients, rather than handing the HSE a huge budget in advance and then hoping for the best, has also been suggested by those who've studied how that system works in other countries to bring down waiting times.

Perhaps hospitals will be required in future to provide only essential services to keep costs down, or even punitively charge people who use facilities excessively or frivolously because of self-inflicted ills. But ultimately, it may only be an independent health service outside the control of opportunistic political parties which is able to push through the hardest reforms. Funding can never keep pace with demand. Choices must be made. Better ones are made when wobbly ministers aren't facing an election round every corner.

Sunday Independent

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