Socialist View (Summer 2006) - Who is to blame for the health crisis?

According to the government, the health crisis in the South is due to bad management practices. An investigation of the real causes of this crisis shows up a different reality.

The health service in the South of Ireland is in crisis. Too few beds and staff, long waiting lists and patient care which is wholly inadequate. Despite the parroting of government ministers about the €12 billion they are spending on the health service and the assurances by Minister of Health Mary Harney that "we" are building a "world class health service," the reality is far different. Ireland, one of the richest countries in the world according to the OECD, has a major A&E crisis. For example at the high point of the crisis so far this year, incredibly 489 people lay on trolleys in A&E departments because there were no beds available. Due to cuts and budget constraints in various regions, hospitals are unable to carry out medical procedures and lives are being put at risk. Patients are having to travel long distances for treatment, even emergency treatment, and in one case this led directly to the death of Bronagh Livingstone in Monaghan two years ago. This child was born prematurely on route from Monaghan General hospital to Cavan General hospital.

While there has been an increase in health spending, the reality is the health service has not recovered from the savage cuts of the 1980s carried out by several Fianna Fail governments and Fine Gael/Labour coalitions. It is ironic that one of the tributes to the former Taoiseach Charles Haughey mentioned how he dealt with his illness with dignity. Many ill people unfortunately are denied that dignity in hospital today precisely because of the legacy of Charles Haughey and his good friend "Mac the Knife" Ray Mc Sharry who butchered the Irish health service in the late 1980s, taking thousands of beds out of the system. This has left many people suffering on trolleys with no personal dignity whatsoever. The current problems of the health service have their roots in the early days of its inception. Through initiatives like the Mother and Child scheme, Noel Browne attempted to begin the establishment of a public health service in the 1950s. This scheme would have meant free medical care for all children up to 16 for which doctors would receive an annual capitation fee. Doctors opposed this at the time though they would have benefited financially, as they saw it as a first step towards a salaried profession rather than the existing network of private GP clinics which still survive to this day. Noel Browne also put forward proposals that would have increased the role for the state in public health initiatives and on issues in education, such as sex education, which the Church and particularly his great nemesis, Bishop John Charles Mc Quaid, were not going to tolerate.

Browne’s scheme was dealt a fatal blow by a coalition of right-wing politicians, the medical profession and in particular the Catholic Church, led by the reactionary Bishop Mc Quaid who had a key influence over the government at the time. Mc Quaid was extremely close to Eamonn De Valera, Taoiseach and leader of Fianna Fail. Indeed so powerful was he that he played a key role in formulating the 1937 Constitution which copperfastend the privileged position of the Catholic Church in Ireland. Mc Quaid, reflecting on the defeat of the Mother and Child scheme said, "we shall have saved the country from advancing a long way towards the socialistic welfare. In particular we shall have checked the efforts of leftist and Labour elements, which are approaching the point of publicly ordering the Church to stay out of social life". Moves towards privatisation

The Irish health care system is a hybrid mix of public and private services. We don’t have, nor have we ever had, the type of National Health Service like in Britain, neither do we have the health insurance model of the United States. The Fianna Fail/PD government’s approach, which reflects their general political ideology, has been to push the health service much further in the direction of a service where access is based on income rather than need.

Public health care is paid for by all citizens in the form of general taxation, but is not available to everyone on the same basis. Those on the lowest of incomes and the over 70s are eligible for a medical card that entitles them to visit their GP and hospital for free, as well as receive free medicines. However everyone else, even those surviving on low incomes have to pay for GP and A&E visits as well as their medicines. On average it costs €50 to visit a GP! In public hospitals, patients who have private health insurance skip the queues and can gain faster access to treatment and superior care to public patients, who face long waiting lists.

This has led to approximately 50% of the population or two thirds of those who are not entitled to a medical card taking out private health insurance, subscribing to the likes of VHI and BUPA. People take out this private insurance so as to receive what in reality should be provided free by the state – treatment and consultations within weeks rather than waiting months, or in many cases years, for treatment as in the case of public patients. 20 per cent of in-patient beds in public hospitals, 24% of patients who receive elective day treatments and 33.4% of patients who receive elective in-patient treatments in public hospitals are private. When we include private hospitals in the figures, more than two thirds of all acute beds in the health system are private! More than two thirds of all GP care is privately purchased with a similar figure for drug expenditure. Yet the taxpayer pays 78% of all health costs, private health insurance covers less than 7% of spending compared with 13% paid out of patient’s pockets. In reality a very small amount of private money bought an incredible amount of private health.

Hospital consultants are paid huge sums of public money to work in public hospitals for 33 hours per week. Yet they can spend any amount of time they like treating private patients and the time spent treating a private patient can count as part of their 33 hour public contract – another example of public money subsidising private medicine. They are also completely unaccountable to anyone either administratively or clinically.

Medical card scandal

In 1983, 38% of people had medical cards by 2004 this had fallen to 26%. It is estimated that as many as 350,000 low-income Irish people who did not have medical cards in 2005, would have been entitled to them if the income threshold for a medical card had stayed at the 1996 level. This is in effect a cut back in health spending and impoverishes low income families even further because they now have to pay to see a GP, visit the A&E, pay for medicines and are even charged a fee for every night they stay in hospital. It also forces people to pay for private health insurance. Fianna Fail and the PDs introduced the national treatment purchase fund (NTPF) in 2002. Under this scheme if an adult has been on a waiting list for a year or longer (six months for a child), the government effectively buys them care in another hospital often in Britain, Northern Ireland or in the South where the patient is treated as a private patient. It is clear that some consultants have exploited this system whereby they end up treating their own patients privately rather than publicly. The NTPF have stated that they try to avoid this happening but it is clear from anecdotal evidence that it does occur. In other words, a consultant hasn’t deemed a particular patient ill enough for prompt attention but when they are shifted to a private hospital under this fund, they are seen immediately.

Health spending

The Fianna Fail/PD government has been unable to provide a decent health service, despite being in power during the biggest economic expansion in the history of the state. In the context of a downturn in the world economy, these same politicians or their parliamentary colleagues in Fine Gael and Labour will once again introduce draconian cuts in health spending.

The Celtic Tiger years and since have seen a significant increase in health spending and a catching up with other "advanced" countries, although despite government propaganda we have not caught up entirely. The problems facing the health service are fundamentally about funding. The government and sections of the media have attempted to portray the health service as a "black hole" into which the government pours money that has no effect on improving the service. There are of course other problems to do with management and structure, but funding is the central and key problem.

In the 1980s, the Irish health service suffered massive cutbacks. Irish public health spending fell to 57% of the EU per capita average in 1989. Between 1970 – 1996, Ireland spent on average 63% of the EU average and in 1990 Ireland only invested 38% of the EU average. Ireland’s health spending was estimated to be 94.4% of the EU average in 2003, but this figure is probably nearer 90%, when you take out non-health social spending. However, Ireland’s capital investment in health is considered to be the highest in the EU, but this really illustrates the very low base from which the Irish health service was starting after decades of neglect. According to the OECD, the proportion of Irish national income devoted to health was 8.9%, slightly below the EU average of 9%.

The government spent 28.7% of its entire day-to-day budget in 2005 on health, second only to the Department of Social and Family Affairs. It also spent 9.6% of its capital budget on health. This obviously represents a significant amount of money and there is no question there has been a huge increase in the amount of money being spent on health, it actually trebled between 1997 and 2004. However the figures are somewhat mis-leading and this is why the so-called "Black hole theory" has been developed. If there is so much money being invested, why then are there so many problems? There is a significant difference between the "nominal health spending " and the actual amount of money spent on hospitals. Health spending in Ireland includes money spent on many social issues, which would not be included under the health banner in many other European countries, for example care for people with disabilities or certain care provisions for the elderly.

In 2004, only 46% of the current health spending went on hospitals, including some long stay institutions. If the cost of care in district and health board hospitals, which is generally long stay care, were included, these social programmes would take up 27% of the total current health budget.

Poverty and ill health

People’s class background is a significant factor in their health. Poorer people are much likely to die young and also experience ill health. Unskilled and semi skilled workers have three times the mortality rate of professionals of the same age. The poor are more likely to suffer chronic disabling conditions or to be admitted to a psychiatric hospital. Their children are more likely to be stillborn or die shortly after birth. The government focus on real causes of illness such as obesity, smoking, drug abuse, poor diet and lack of exercise as the causes of ill health although true to an extent, is a simplistic attitude which seeks to blame the victim rather than address the possibility that the real inequalities in health flow from poverty, unemployment and unequal access to the health service. There have been many studies to illustrate why the poor are more likely to be sick. They have shown that many low income families suffer from a poor diet because fresh fruit and vegetables are often beyond their means. Also many people who are on low incomes will tend to buy so called "convenience" foods simply because they know their kids will eat them. Apart from this, the stress and pressure of managing on a very low income puts people under massive pressure, which has an impact on their health both mentally and physically. It is clear that poor people don’t choose to be unhealthy or sick, it is a product of their existence and a consequence of their poverty. Despite the boom, relative poverty in the South has increased in recent years;16-17% of people lived in relative poverty in 1994, by 2000 (after the best years of the Celtic Tiger growth) this had risen to 22%. The richest 20% of the population received over 40% of the budget giveaways from 1997 to 2002, the poorest 20% of the population received fewer than 5%.

Accident and Emergency – Crisis without end?

There are 53 acute hospitals in the South, of which 35 have A&E departments. According to the Health Service Executive (HSE), these departments treat 3,300 people per day, of which 2,500 (75%) are treated and sent home and 800 (25%) are kept in overnight.

When most people talk of the health crisis, invariably they mean the A&E crisis. Many people don’t bother going to a GP, partly because of expense, but also because they feel that the GP will simply refer them on to A&E. There are many urgent problems that cannot be dealt with by the primary care system so in essence they cut out the middle man. Incredibly, if a GP has deemed a patient warrants medical attention in a hospital, that patient is likely to wait hours just to be seen by a doctor, who in general will be a junior doctor often still in training. After this consultation, patients can be on a trolley for a number of days waiting for a bed in a ward so that they can receive proper treatment.

Patients on trolleys suffer huge indignity having to sleep, eat and even use bedpans surrounded by other patients in confined areas, and with stressed medical staff trying to treat emergency patients. This is a nightmare situation, and seriously ill patients have died in these conditions. A recent exposé by RTE’s Prime Time gave a real glimpse of the crisis in the country’s A&E departments. The actor Brendan Gleeson’s explosive tirade against the government about the A&E crisis on the Late Late Show in March 2006 hit a chord with many working people who have seen family members and friends suffer the indignity of lying on a trolley for days. There is some evidence emerging now, though unquantified at the moment, of a number of people who present themselves at A&E and receive an initial consultation, but having waited for hours get fed up and walk out. In one case, there are reports that a man suffered a heart attack and died in the car park of an A&E department having been fed up waiting for treatment.

The beds crisis

There are fewer beds in the Irish health service in 2006 than in 1996 yet in that period the population of the country increased by approximately one quarter. The numbers of beds in the Irish health care system remained relatively unchanged during the 1990s. In 1993, there were 11,809 beds in the system and in 2001 there were 11,985, an increase of just 176 during some of the years that experienced massive growth rates in the economy. The government’s own health strategy in 2001 outlined the need for 3,000 extra beds in acute hospitals, which they promised over a ten year period. The reality is that the figure necessary is probably nearer 5,000 beds. There has been some increase in staffing numbers, and in funding and the population has increased - yet incredibly no increase in beds. Of the 3,000 beds that the health strategy promised, only 709 have been provided. On re-election in 2002 the Fianna Fail/PD government in a rash of broken promises and health cutbacks announced they couldn’t pay for the provision of the 3,000 extra beds.

The number of acute hospital beds per 1,000 of the population was 2.96 in 2005 compared to an average of 4 beds per 1,000 of the population in the EU 15 states (the 15 states of the EU prior to its recent expansion). The figure for the South was 5.1 beds in 1981 and it fell to 3.3 in 1993, which in turn fell to 3 in 2000. In the 1990’s in the EU the average number of acute beds per 1,000 of the population had remained at 4.1 a full 25% more than in Ireland. The number of people on trolleys has obviously been the subject of much debate in the last couple of years. The key issue here is not the numbers, but the fact that with the economy growing and the government exchequer in massive surplus, there are hundreds of people lying on trolleys every single day. The figures in June 2006 given by the Irish Nurses’ Organisation (INO) indicates that there were about 150 people on average every day on trolleys during the first nine days of the month. Obviously, this is a significant decrease from the nearly 500 people in February and March of this year, but people don’t get sick as much in the summer and this is especially the case for elderly people who in the main make up the majority of A&E patients.

The A&E crisis cannot be solved on its own. The problems in A&E are partly as a result of a back log in the availability of beds which are occupied by patients who should be cared for in long stay or extended care institutions or even community care facilities or their own homes if real support services existed. If these resources were in place, it is estimated that up to 10% of beds in acute hospitals could be immediately freed up. The provision of these facilities is likely to be quite expensive due to the massive underfunding of these services in the ‘80s and ‘90s. The government’s 2001 health strategy outlines a range of proposals to deal with these problems including 800 additional extended care/community nursing units per annum over the next seven years. This would have meant an addition of 5,600 beds. However, in the three years from the end of 2001 to 2004, the number of extended care beds available increased by only 1,823. However, tellingly 72% came from private nursing homes, for which the providers receive huge tax incentives.

Health workers on the front line

Nurses and doctors along with patients have borne the brunt of the health care crisis. Overworked doctors and nurses are often the ones on the receiving end of patients’ anger at being left unattended for hours and in some case days on trolleys. The INO which represents 35,000 nurses has been extremely vocal on the health crisis. However, they have consistently stopped short of organising an active campaign of their members linking up with working people who are suffering due to the crisis. In opinion poll after poll health is the number one issue in society. The reason why this has yet to be translated into an active campaign of opposition to the government’s neglect is due to the absence of leadership from the trade union movement. While the INO leadership were correct to have a go at Mary Harney’s snub of their recent conference – they would be better to run a real campaign for resources rather than begging for the attendance of a Minister for Health who has failed miserably in her job. Harney is pursuing an ideological agenda of privatisation and has waged a battle against increases in pay and better conditions for nurses. She has also along with her predecessors failed to reduce the overworking of nurses and has stood over a situation where approximately 9,000 nurses have left the service in recent years.

If the INO and the other health unions linked the general conditions in the health service to the plight of nurses and doctors, in particular junior doctors they would get a tremendous response. In Britain the discredited Blair government is engaged in an all out assault on the NHS which is being resisted by health workers and working class people in many communities throughout the country. Blair is engaged in a parallel attack on the conditions and pay of nurses and doctors as well as shutting wards and clearing beds out of the system. Our sister party in England and Wales, the Socialist Party, has been to the forefront in many areas fighting on these issues and in the local elections Dr Jackie Grunsell won a council seat, having played a key role in opposing the closure of local health services. In May, 7,000 demonstrated in Letterkenny because of a shortage of resources at Letterkenny General Hospital which has meant no radiotherapy services or Breast Check programme. As a result, the hospital is no longer seeing new breast cancer patients because it does not have a breast surgeon! The announcement of further cuts in cancer services in the northeast region, which even by the admission of the HSE could jeopardise patient safety, is a further indication of the need for a national campaign by the trade unions on health. The HSE has proposed a series of cut backs to offset a deficit of €9.7 million in that region this year.

A socialist alternative

The Socialist Party stands for a fully comprehensive publicly funded health service free at the point of access, which will deliver a better health service for all. This is not just about investment in the health service now, but also about addressing the causes of ill health to prevent disease and sickness arising in the first place. This means ending poverty and inequality in society as the key causes of ill health among working class people.

Not withstanding the recent increases in spending in the health service, we stand for a massive increase in spending. The resources exist to achieve this. The banks alone are making billions in profit each year. This money instead of filling the pockets of greedy bankers could be used for the benefit of society by assisting in the provision of a decent health service. We demand all private services be taken into public ownership, including all nursing homes and residential homes and services. We demand an end to the National Treatment Purchase Fund and other such schemes where public money is used to buy private care. We call for no private hospitals to be built on public land and the end of all public private partnerships.

Consultants should be employed to work in public hospitals, if they wish to work in the private sector they should do so in their own time. General Practitioners should become employees of the health service. Primary care, dental and optical services should be completely integrated into the health service and should be administered in community health centres. We demand the ending of any role for the Catholic Church or any other religious institutions in the affairs of the health service. Hospitals should be run by committees made up of one third of members representing staff in the health service, one third representing voluntary groups, patients’ groups and the wider trade union movement and one third locally elected public representatives. These committees should be democratically elected by the communties they serve and subject to recall.

In a socialist society where the wealth and resources of that society are used for the needs of the majority a free and equitable national health service could be created that would end the current reality of health care being provided on a person’s ability to pay.