Why you can’t vote for a better health system

This week the Health Service Executive response to a report by the Comptroller and Auditor General was sent erroneously to Oireachtas members and subsequently revealed in the media. Among other things, it showed that one HSE employee who traveled to New York took a ‘personal guest’ along, literally, for the ride.

The employee claimed the air fare for his/her ‘friend’, and the hotel bill showed that the two had stayed in the same room. Other claims showed that employees were claiming drinking expenses while traveling the world at the expense of the HSE, which is, after all 100% funded by the taxpayer.

Another story this week was the release of National Healthcare Quality Reporting System which disseminated important, if incomplete information about hospitals in Ireland. Valuable information certainly, but lacking in two key aspects:

1) It didn’t explain the reasons for disparities in deaths between hospitals – which is surely the whole point and

2) It didn’t address the problem of adverse events, at all.

So the whole report itself is pretty suspect and is another case of the HSE monolith acting like a duck – a lot of work is apparently going on underneath the water, but all the public sees is a pretty sedate and static duck.

These stories – or stories like them – are a constant in Irish media. And they all follow a certain script. The doctors and nurses who work for the HSE do a fine job, but the management of the system is fatally flawed. When the mistakes and excesses of management are exposed and there is no accountability for wrong-doing, people get frustrated and tend to give up. There is always something new about which they can get enraged.

But nothing ever changes. Nothing ever improves. Nothing can be done.

The latest (and most serious issue) in health these days is the fact that community rating for health insurance is about to be spread over a person’s lifetime. It takes the cut-off point of 34 and legislates that anyone who is over that age and wants to buy health insurance will have to pay a premium for all the years they weren’t covered. In the case of a 50-year-old, for example, they would have to pay for 16 years extra.

This effectively rules people out from buying health insurance if they go beyond a certain age.

We won’t see the effects of this for several years, so for the moment it will achieve its immediate desired effect – which is that it should slow down the number of people deserting private health insurance, and may force (there is no other word) as many as 50,000 to take up health insurance for the first time.

But the law of unintended consequences will surely apply as well – what motivation would a person of 20 now have for taking out insurance? Or even a person of 30?

My expectation is that the age will be lowered in time when this factor becomes apparent, but what does it say about the overall situation with healthcare in this country – reckoned by most commentators to be one of the most badly managed and run public services that we have – not to mention one of the most costly?

And, a more pertinent question, what can be done to change the way we deliver health?

In the bad old days, doctors would use medical terms and scientific language to hide the full truth from patients and supervisors. The adage that the ‘doctor knew best’ was one they all privately believed, and the idea of patients directing their own course of treatment was unthinkable.

But as people became more empowered and educated about their health experience, this ceased to be a reasonable position.

But it still applies in the management of health. Waiting lists, patients on trolleys and adverse events are explained in terms of ‘lack of resources’, yet there is plenty of waste as one lucky tripper to New York can attest.

What is amazing, in my opinion, is that people can protest about a water charge that will cost some people €160, and the State about €1 billion, but there is no groundswell of protest at the €13 billion being spent on the health service and where it goes.

That’s because it’s hard to protest about a complex idea. We are all for a good health service but there’s almost as many opinions on what should be done as there are people expressing and opinion.

This allows the government of the day and the opposition to promise miracles in health in the future, but when that future arrives, the same policies are used to the inevitable same effect; failure.

Of course, it must be noted here that there are some successes. The introduction of eight Centres of Excellence for cancer – which was brought in by Prof Brendan Drumm in his time as HSE CEO – was probably one of the most progressive and useful initiatives of the last few years – it was also the one that attracted the most protest. Health is indeed a difficult area to manage in the face of a populace that prefers localism and parish-pump politics to scientific data on best practice.

But it’s understandable that people protest. Many have been so let down by the health services, it has a credibility problem. And many cynical and self-serving measures have been introduced (such as Minister Reilly allocating extra Primary Care Centres to his own constituency) to show us that promises on health are often ignored once the intense heat of public scrutiny is turned down or off.

Political parties operate in this space too. They don’t really want to propose comprehensive health policies – partly because comprehensive and correct health policies are hard to sell, and partly because they are not vote-winners. Simple suggestions – such as ‘free care for the under 6’s are a much easier, if ineffective, call to arms and much more likely to win any votes out there if indeed there are any votes to be won on health issues.

But, to end on a note of hope, health still remains an area when political parties can make ground over their opponents if they are willing to introduce simple and effective policies that would improve the service. It remains to be seen if any of them however, are willing to grasp that particular political nettle.

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