Fair health to you

When we think about health and wellness, or more rarely, its converse, death and illness, we are troubled by the unfairness and arbitrary nature of it all. Now that modern medicine has conquered a great many illnesses (especially infant disease and death) we assume that we will have longer and healthier lives than our parents, and that most other people will too.

But then we hear of tragic cases and it seems so unfair. Suicides, rare diseases and a seemingly random genetic lottery strikes one person down with a fatal disease, while others smoke their way into their nineties. “It’s not fair”, we think.

And then we read about some particular case where someone’s life might have been saved by receiving treatment that others can access easily, and we think of this as being doubly unfair. Our big problem with the health service, and every hack politician and manager who has responsibility for it, is that rather than try to resolve this inequality, this unfairness, they claim that fairness is not part of the equation, when it should be the central tenet.

Imagine, if you will, the HSE in this instance as the parent and the public as the child. The public says it is unfair that some people should wait for services while others who can afford them can access them straight away. But the HSE knows that everybody can’t be provided with every service unless the budget is unlimited. There has to be a budget, and they have to choose who gets what.

So they do what every parent has done to a child complaining about unfairness. They tell them that ‘fair’ is where you can go on rides and buy ice-cream. ‘Fare’ is what you pay on the bus. There is no ‘fair’ that can be applied to the health service because neither the Minister, the government, the HSE or most importantly, the public, can decide what the parameters of ‘fair’ are, and therefore, everything is arbitrary, ad hoc and based on luck and circumstance.

It is this conundrum that confounds, and yet it is very simple. Since we haven’t established (or even discussed or postulated) who should get what and when, and more importantly, who should not, we can’t ever hope to be satisfied with our health system. Such is the case with medical cards. Such is the case with pretty much everything. You rob Peter to pay Paul. The opposite works well too. The only deciding factor is not fairness, but whether it is Paul or Peter that will create the most stink.

Our answer to a crisis in the health service is to take money from somewhere else and give it to the crisis. It’s a self-perpetuating crisis creator, because money taken from one sector will eventually lead to a crisis there.

So let’s ask ourselves a few questions. Where would we cut? And please don’t say “I wouldn’t cut”, we can spend billions more. We patently can’t.

Do we think that people who are morbidly obese should have access to potentially life-saving surgery? This service was cut recently and though it only affects a relatively small number of people, for them it is vital. Do we believe that obesity is a disease and therefore one where people in danger of dying should have access to surgery? Or, do we believe, at some level, that people who are obese are partly responsible for their own illness and therefore the money should be spent on other patients who acquired their illness through no fault of their own?

Since there is no choice for the public other than to give the surgery or not, most would say, ‘yes’. But that is not the question faced by the HSE. In their case the question is to give the surgery or cut elsewhere. And that is a different choice.

Or take the case of Cystic Fibrosis and the drug Kalydeco. The drug seriously improves and extends the life of people with Cystic Fibrosis, but comes at a cost of €234,000 per patient, per year. That comes out to €28 million per annum for about 100 people or so. Former Minister for Health, James Reilly, made the drug available to Irish patients recently and it will undoubtedly help those people immensely. But you and I will pay for it, as we will pay for more and more expensive drugs for rare conditions, as they become available. Those drugs are coming on line all the time, at greater costs, and for fewer people. Does everybody get everything? At what point do we say it’s not worth it?

You might perhaps answer the question easily by saying that you wouldn’t mind spending €28 million out of a €13 billion budget to help people with Cystic Fibrosis. But again, that’s not the question. The question is where would you trim €28 million from somewhere else in the health service to do this, and, faced with that choice, would you do it at all?

If you agree that you are willing to endure any cost for drugs to help patients, I need a lifetime’s supply of tequila at your expense to enhance my quality of life, and who’s to say I am not worthy or needful of it? Certainly not you. You’re not a medical person. How can you be expected to understand that my doctor recommends a bottle of Jose Cuervo Gold a day to keep me psychologically together?

I admit I’m drifting from the subject to the ridiculous. But if 100 years ago you told an Irish person that we would operate on patients to limit their food intake, you would have been treated as a figure of fun. If you had said to parents then that none of their children would die in childhood, it would have been greeted with deep scepticism. We look at ridiculous things in the health service all the time, and yet they don’t seem as fundamentally ridiculous as they are.

For example, we haven’t hired anyone in the health service for years. Yet we have thousands of people working in human resources for the HSE right across the country. What on earth are they doing?

Just this week we were told that we have no way of reducing health managers pay in Section 39 organisations. There are 24 managers in Section 39 organisations who receive more than €100,000 in pay, along with other benefits such as health insurance and company cars, but we can do nothing about this. They have a contract that can’t be broken. They drive around in government cars filled with petrol you paid for, but nobody can do anything about that.

On the other hand, we can reduce GP’s incomes by up to 40%, forcing them to reduce services and frontline medical staff, and in many cases forcing them out of practices where finding replacements will be difficult.

We need to see these things as ridiculous and demand they change. That’s what we all want done (well, all of us except senior HSE managers) and we want it done now, not just tinkering at the system and placating the masses with promises of a better future.

We need to take a scalpel and cut deep into the management fat of the HSE.  We need to eliminate the horrendous cost of a service that functions first of all for management, then institutions, then doctors and then, finally, patients.

We need to treat all sick people when they are sick and try to do the best we can for everyone, realising that there are limits, and not everyone is going to get everything. We should enact measures to help groups, such as children, where those measures will have the greatest effect and give us the best bang for our buck.

But we have to have a national conversation first about fairness, a conversation which is not based on our own personal interests, but the best way to bring the most fairness to the most people in the shortest time.

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