Why is the Republic’s Health System so poor?

Why is the health system in the Republic of Ireland so poor?  One way to begin to answer this extremely complicated question might be to compare it with the health system in Northern Ireland, which, while being very far from perfect, is widely perceived as superior to its Southern counterpart. Certainly many thousands of people in the Southern border region see it like this, judging by the large numbers of Southerners (many of them with Northern accommodation addresses) who regularly use Northern GPs and hospital services.

Let’s go though some of the essential elements in what makes for a good health service and compare the performance of the two Irish jurisdictions. First, and most important, the North, in common with the rest of the UK, has free universal access to health care. It has a common waiting list for treatment in public hospitals (with a tiny if growing private sector), compared to the South’s fractured system, with 32% of people entitled to free treatment because they hold a medical card and the rest having to take out insurance to pay fees in public or private hospitals (fees which the largest insurer, the semi-state VHI, will raise by a whopping 10-45% on 1 February).

Then there is the North’s higher capacity to implement key reform initiatives because of this largely unified system. Thus in recent years the NI Department of Health, Social Services and Public Safety has overseen a significant reduction in hospital waiting times. In October 2010 over 82% of patients were either treated and discharged, or admitted to a ward, within four hours of their arrival in an Accident and Emergency Department in Northern hospitals(1).  In contrast in the same month over 25% of patients in the Mater (Dublin), over 30% in Sligo Regional and 45% in Cork University hospitals had to wait 12-24 hours for admittance through A&E(2).

Primary care is better organised and funded in the North, with the provision of teams of GPs and allied health professionals (nurses, physiotherapists, chiropodists etc.) who offer free and lifelong care to people in local areas. In the South the nearly 70% of people who don’t have medical cards have to pay €50-75 before they even darken the local GP’s door.

Public health is a much higher priority in the North. The all-island Institute of Public Health in Ireland has consistently shown in its reports that there is a greater understanding of the relationship between social inequality and health in the Northern Ireland system. This has been greatly helped by NI Health Minister Michael McGimpsey’s stated determination to make overcoming health inequalities a top priority, in sharp contrast to Mary Harney’s policy of exacerbating the rich-poor divide by encouraging private hospitals to ‘co-locate’ beside public hospitals. Public health specialists in the Republic say that there was a high level of public health leadership there before it was stifled by the new bureaucracy of the Health Service Executive (HSE).

Morale in the health service is much better in the North. The constant revelations of inefficiencies – and worse – in the HSE must make it a difficult place to work. For example, the revelation last year of tens of thousands of unopened GP referral letters and unread x-rays at Tallaght Hospital shocked even the most hardened critic of the Republic’s sprawling health service delivery body.

Health-related social services are often equally poor in the South when compared to the North. One distressing example is the waiting lists for speech therapists. In May 2010 it was reported that more than 23,000 young people under 18 in the Republic were on waiting lists for speech and language therapy, with almost 4,000 of those waiting for between 12 months  and two years(3). The equivalent figure in Northern Ireland (in January 2008) was 2,358. Specialists agree that early intervention is vital when treating young people with speech problems, who otherwise can be doomed to a lifetime of incapacity and marginalisation.

The explanation for the inferior Southern health system in the past was that the Republic was a poor country which simply could not afford the world-class National Health Service (NHS) that the UK boasted from the 1950s until recently. But during the period of massive – if temporary – increases in public funding brought about by the Celtic Tiger economic boom, this argument started to sound a little thin. Now, of course, it is back again with a vengeance.

In the meantime, David Cameron and his Health Secretary, Andrew Lansley, have decided to take the NHS in England down the decentralisation and part-privatisation road, with their surprising and extremely radical plan to give GPs command of 80% of the NHS budget and freedom to negotiate contracts with hospitals and other health service providers. The question is whether Scotland, Wales and Northern Ireland will be forced by financial pressures to follow this route, which has caused deep concern among doctors, nurses and patients.

For the final difference between the health systems in the two Irish jurisdictions is that Northerners, in common with the majority of people in the UK, are genuinely proud of the NHS, and are very anxious to protect what is left of it. For them, it is a classic example of a universal public service as a ‘public good’. In contrast, in the Republic the HSE is seen as a huge bureaucratic monster that exemplifies all that is wrong with public services in that state. In the end, perhaps that is the most significant difference of all.

Andy Pollak

  • Mack

    Andy, this article is dripping with bias.

    First up you equate free universal health care with being superior to any alternative. No thoughts on whether or not free health care leads to overuse or inappropriate use?

    Presumably you making this argument because it ensures that the poorest can access medical services when they need them, but you also point out that 32% of southern citzenry have medical cards. The rest can afford to pay the relatively small fees for accessing services.

    Incidentally I didn’t see any mention of the areas in which the south undoubtedly excels. E.g. maternity services. Why not?

  • Mack

    There are other points worth noting too –

    The €50 to visit a GP is tax deductable.
    It’s also covered (up to certain limits) under most health insurance plans.
    Health insurers have helplines that you can ring for free which are suitable for diagnosing and treating (with pharmacist support if need be) most ailments.

    GPs are all private practices. If you don’t like your GP or the service you get, you can move. There are advantages and disadvantages of this system, but you are not providing them here.

    I’ve one more comment to make 🙂

  • Mack

    In recent months the debate in Ireland around the public aspect of the health system seems to have revolved around which the models – Beveridge or Bismarck – provides for superior health care. With the consensus appearing to be that the contenintal Bismarkian model is better because it ensures that health care continues to recieve decent funding through severe recessions like this one.

    Newstalk had one of the top consultants on a couple of weeksback in the morning (can’t remember his name, but he’s had a few articles in the press – American accent). He made the point that under the Beveridge model in a recession Doctors will delay admitting patients to hospital (relative to admission times in non-recessionary times) as once they are admitted they become a cost. This is how costs are cut. The NHS also runs on this model.

    The same speaker did also mention that the Republic’s consultants system (grossly expensive as it is, btw, why no mention of much superior salaries in health care south of the border?) – was now attracting much better talent than the NHS in core and important areas such as cancer treatments. You may well see cancer survival rates / treatment outcomes outperform the UK in Ireland in the future.

    Also another issue is unionisation – e.g. working hours and overtime rates, that mean services (e.g. test analsysis) aren’t always available at the weekend, coupled with waiting lists that mean that patients need to be admitted earlier than needed just to ensure they get the tests they need when they are needed. (I.e. working practises can lead to a great deal of extra expense and ineffiency).

  • Mack

    Actually one more –

    Health insurance is itself tax deductable & insurers are not allowed to disriminate among customers & they must make any special corporate plans (which are much cheaper than the plans rising in price) available to all consumers by law.

  • Mack

    Sorry Andy, couldn’t resist, another one 🙂

    In October 2010 over 82% of patients were either treated and discharged, or admitted to a ward, within four hours of their arrival in an Accident and Emergency Department in Northern hospitals(1). In contrast in the same month over 25% of patients in the Mater (Dublin), over 30% in Sligo Regional and 45% in Cork University hospitals had to wait 12-24 hours for admittance through A&E(2)

    This is a statistically crazy (and potentially politically misleading) comparison.

    1. You are comparing the average across all hospitals in the north to (presumably) the 4 worst in the south.
    (Never cross a river because you know it is on average 4 feet deep).

    2. 90% fat free means 10%. 82% in under 4 hours versus 25% in over 12 hours.

    Taking 1 & 2 together, the gap is not necessarily as large as you make it appear..

  • Paul Q

    On the HSE point, there’s quite a misallocation of resources in the South. If they stuffed the doctor’s mouths with gold to get them to agree to the NHS, they stuffed them with some far more expensive mineral in the south.

    http://newswhip.ie/national-2/explainer-why-are-irish-consultants-the-highest-paid-medics-in-europe

  • ForkHandles

    Mack, i think you are being a bit misleading saying the 50eur GP visit fee is tax deductable. When i was living in Dublin i looked into this as i was a contractor and was able to claim lots of things as tax credits. If i remember correctly, you had to have spend a high figure on health/doctor charges before you couyld claim them against tax. Might have been 1 or 2 grand. Sorry memory is foggy. But it was not possible for me to claim my couple of doctor visits i had clocked up over a year. nobody i know was able to claim back the 50eur fees.

  • Mack

    @ForkHandles

    Well you didn’t look very hard, Form Med1 is what you need.

    Here is the link (below), the good news is that if it’s less than 2 years ago you can claiom it back. And no you don’t have to spend a high figure any allowable expense is valid no matter how small.

    Section (a)
    Services of a Doctor or Consultant

    http://www.revenue.ie/forms/med1.pdf

  • Mack

    @Forkhandles

    Sorry, I mean you have 4 years to claim back any tax (including tax due to payments on health insurance, and even on Benefit-in-kind paid on health insurance paid by your employer – reducing the actual cost of health insurance to next to nothin for higher rate tax payers)

  • Cynic2

    “Why is the Republic’s Health System so poor?”

    ….they dont pay politicians enough

  • ForkHandles

    Interesting form Mack, thanks for the link. Its about 2 years or so since i left the ROI and i wouldn’t have any reciepts or even remember any dates, so i won’t be trying to claim.
    But it looks like the form is for claiming tax back. so i would only get a % of what i actually spent back again.

    I recall watching a documentary about the local health service, last year i think. It detailed the improvements that had been achieved under the local health minister (McGimpsy). They had set themselves high targets and had managed to achieve them and organise themselves better to cut costs and deliver better services. Perhaps the ROI health service does not have this drive and organisation?

  • Mick Fealty

    I hear what you say Mack, but the truth is deeper than the €50 GP charge. In truth the problem is not all Mary Harney’s fault. Right up to Charlie McCreevy, Ministers of Finance have fought putting the necessary investment in the country’s haphazard infrastructure.

    That said the co-location plan, for instance, was a policy red herring. It was pitched as taking strain off the publicly funded hospitals, and it has done no such thing.

    Private healthcare is a powerful tool in a very limited set of circumstances. Most severely acute and pretty much all chronic conditions continue to be carried by the public system.

  • Mack

    @ForkHandles

    Your GP will have a record of them, ask him / her for a reciept. Yeah, you only get a percentage back, but it reduces the cost of private health care significantly, even more so if it is coupled with a health insurance plan.

    @Mick

    Yes. But the health system overall isn’t as bad as it is painted. There are definite issues with it, and health is at least partially on the radar in this election. FG will probably get the chance to implement their fair care system.

    I just object to the tone ‘why is the Republic’s health system so poor’ when Ireland ranks reasonably close to the UK on nearly metrics I’ve seen (whether ahead or behind), and the UK leverages effectively the same system for funding public health care (the Beveridge system).

    Or to clarify, I didn’t find think this post really addressed the deficiencies in Irish health care – it couldn’t really inform debate on how to improve it. It was maybe really aimed at the Tories – “we’ve got the best health system, so don’t try and improve it Cameron”.

    There is probably a case for two articles here, maybe an objective analysis of the Irish system or an objective analysis of the Tory health proposals. This was an anti-private health care polemic taking a swipe at both, with selective use of dodgy stats and cognitive biases (why mention an error in Tallaght hospital, but not Harold Shipman etc).