Result: D
A poor vision that failed.
Everyone who is ordinarily resident in the country has access to public hospital services, whether they have health insurance, a medical card or nothing at all.
The services may not be free and may be subject to waiting times depending on medical condition.
Without a medical card patients are charged €100 for all treatment received in a public hospital accident and emergency room, though a referral letter obviates the charge.
A White Paper on Universal Health Insurance was published in 2014 with a report on the potential costs of the White Paper model published in November 2015. The debate was always too much about the cost of this rather than on how a focus on insurance might actually serve the presumed goal of universal healthcare. In the end Leo Varadkar suspended it, likening universal health insurance to Irish Water. He claimed it would have been impossible to impose the extra fees without a backlash from struggling families. While denying the Coalition had performed a U-turn on its central health policy, he was unable to give any specific year as to when a new version will be introduced. He also appeared to criticise his predecessor James Reilly by alleging there had been an “obsession” with the Dutch form of UHI. Varadkar insists the Coalition remains committed to introducing the policy at some unspecified stage in the future.
The Irish health system ranks 21st in the 2015 Euro Health Consumer Index, up one place from 2014 but down from 14th in 2013. Lower-income countries such as Macedonia, Croatia and Slovenia all rank ahead of Ireland in the index, which is led by the Netherlands and Switzerland. And there has been a litany of specific scandals and failures that have characterised the media discourse on health. Or the consistent overspends. Enda Kenny says his greatest disappointment as Taoiseach is ongoing stories of people’s negative experience with the health services.
Most of the health issues in the general election arise inevitably not from abstract policy but from crises and failures to address long-standing problems. Unfortunately for the government the public perception of the health service remains that it is a sort of dysfunctional “Angola”: Rebecca O’Malley, Susie Long, Leas Cross, Áras Attracta, Savita Halappanavar and ‘Grace’, the woman with intellectual disabilities who was tortured and sexually abused in a foster home over thirteen years.
Worse still the proportion of the Irish population that was over the age of 65 has been static at 11% for years. But forecasts suggest that the percentage of people over the age of 65 will rise to 26% by 2026. About 20,000 additional people turn 65 each year and the actual number of people over that age will double in the next few decades. Within that the number of “older old”, people over the age of 80, will double.
Minister for Health Leo Varadkar no longer repeats the 2011 election pledge to bring an end to the hospital trolley crisis. The Government should move towards a similar system to that of the UK where trolley counts are not relied upon to examine waiting times.
Meanwhile, though there has been some marginal improvement since last year, overcrowded Emergency Departments (EDs), famously described by actor Brendan Gleeson in 2004 on the Late Late Show as “unspeakable… like a military field hospital… a disgrace… a war crime” continue to make it difficult for staff to fully examine and adequately treat patients, risking cross-infection and patient safety. There have been improvements in the number of emergency consultants (though problems subsist at weekends and nights) and the out-of-hours availability of GPs but the biggest problems are the maintenance of too many EDs (30 countrywide) and the under-resourcing of alternative primary care. Furthermore there has been for example no systematic introduction of minor-injury clinics, or deployment of techniques like acute medical assessment and early-discharge planning, no improvement in GPs’ access to diagnostics to enable them to avoid sending patients to hospitals, or improvement in hospital IT.
Report Card – Health
PROGRAMME FOR GOVERNMENT COMMITMENT |
ACTUAL PERFORMANCE 2011 – 2016 |
Overview |
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| “This Government is the first to commit to developing a universal, single-tier health service, which guarantees access to medical care based on need, not income. By reforming our model of delivering healthcare, so that more care is delivered in the community, and introducing Universal Health Insurance, the aim is to reduce the cost of achieving the best health outcomes and end the unfair, unequal and inefficient two-tier health system”. | That’s the theory in the 2011 Programme for government. But both of the key elements have failed. |
End to two-tier system:
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| “A system of Universal Health Insurance (UHI) will be introduced by 2016”. “The Universal Health Insurance system will be designed according to the European principle of social solidarity: access will be according to need and payment according to ability to pay”. “UHI will provide guaranteed access to care for all in public and private hospitals on the same basis as the privately-insured have now”. “Insurance with a public or private insurer will be compulsory with insurance payments related to ability to pay. The State will pay insurance premia for people on low incomes and subsidise premia for people on middle incomes”. |
As of now Universal Health Insurance is in disarray – suspended. The idea was no discrimination between patients on the grounds of income or insurance status. The two-tier system of unequal access to hospital care would end, even if a vision centred on private insurance might be deemed a jolt towards privatisation and profit-taking. Currently health funding is 80% government, 9% insurance (half the population has insurance) and 9% out-of-pocket consumer payments. The shift would have been radical. The ESRI reports underpinning the initial costing exercise for UHI were published in November and concluded that more research is needed in this area before definitive conclusions can be drawn about the best type of model to implement universal health care. |
Primary Care |
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| “Universal Primary Care will remove fees for GP care and will be introduced within this Government’s term of office under a Universal Primary Care Act”. | Leo Varadkar confirmed before the election was called that Fine Gael could not commit to the introduction of universal care in the next Dáil term due to a shortage of GPs. Free GP care for children under 6 was introduced in 2015 and by late December over 219,000 children and 93% of GPs had signed up. GP care without fees for persons aged 70 and over was also implemented in July and over 50,500 people have signed up to this GP service. Of course, these changes prejudice needy patients and anecdote suggests there has been a big increase in visits to GPs by under-sixes. These steps to wider non-needs-based healthcare mean, for the first time, some 800,000 of the eldest and youngest in our society are now able to access GP care without being charged, a small fraction, of course, of the 4.5m people envisaged. Budget 2016 announced the plan to extend universal GP care without fees further to include all children aged 11 years and under, subject to the negotiation of a comprehensive new GP contract with the Irish Medical Organisation. But Fine Gael has abandoned plans to introduce free GP care for all citizens over the lifetime of the next government. Leo Varadkar said extending free GP care to “everyone for everything” would overwhelm the primary care system: “We set out to be very honest and what we believe to be achievable reforms in health over the next couple of years and we do not think it is achievable to extend free GP care to everyone in the country, to all adults and children in the space of five years because we are already short on GPs”. Prescription charges, which former Minister James Reilly promised to eliminate, in fact rose from €.50 to €2.50. |
Cost Reductions |
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| “This Government will act speedily to reduce costs in the delivery of both public and private health care and in the administration of the health care system”. “Action will be taken to reduce the cost of procurement for medical equipments and construction of facilities”. |
The Health (Pricing and Supply of Medical Goods) Act 2013 provides for cheaper generic drugs and reference pricing. The Department of Public Expenditure and Reform says Irish hospital costs were an extraordinary 80% higher than the European average in 2014. Scandalously the health budgets have had to be supplemented by an unanticipated €2.4bn since 2011. €5bn and 1,250 beds (of which 300 have been reinstated by the coalition) have been taken out of the Health Service. Ireland spends 8.1% of GDP on health compared with an OECD average of 8.9%, though we have an unusually young demographic and GNP is a more appropriate measure. The HSE had a budget (capital and current) of €14.5bn in 2015. €13.5bn is current expenditure, of which more than half goes on staffing. €4.8bn goes on hospitals, €2.6bn on publicly-funded GP care, €1.3bn on nursing homes, and support services for older people, €1.56bn on disability services. Legal claims are high at €70m up from €21.7m six years earlier. The HSE says salaries for doctors, managers and other healthcare professionals are too low and generating a brain drain. But there is no consensus on this issue. |
