A-Infos (en) Ireland, Towards a Cure - Health Pamphlet by Health Working group of the anarchist WSM

Radical health reform, in terms of creating equality and accessibility, and 
stopping the agenda of privatisation and for-profit medicine, is one of the 
great challenges facing Irish society. ---- In this pamphlet, anarchists explain 
the reasons why such change is needed, give examples of important first steps in 
creating change, and describe the type of struggle that is necessary if we are 
going to win. ---- PDFs of this pamphlet can be downloaded: A4 version - 
http://www.wsm.ie/attachments/mar2008/health_pamphlet_1.pdf ---- Introduction 
Despite the “economic miracle” called the Celtic Tiger that has led to Ireland 
having a higher GNP per head of population than much of the rest of the EU, it 
lags behind in terms of public health. At age 65 we have the lowest life 
expectancy in the EU for both men and women. Indeed, the gap between Irish and 
EU life expectancy has been widening. Infant mortality rates are above the EU 
average. We have above EU mortality rates for cancer and coronary heart disease. 
Despite Ireland’s incidence of breast cancer being among the lowest in Europe, 
the death rate from breast cancer was one of the highest in EU15. To cap it all, 
we have a widening income gap, which will of itself worsen the situation since 
greater inequality leads to higher mortality rates.

This state of poor health of people in Ireland, especially when analysed on 
class lines, is a direct reflection of the unequal and inaccessible nature of 
the Irish healthcare system. The barriers to accessing care, in terms of 
availability and cost, mean that the level of health education and preventative 
medicine is severely low and that treatment for illness is often too little, too 
late. The cost of private care, means that many people must wait long periods, 
sometimes too long, for the diagnosis or treatment they require to survive.

Apart from the super-rich and those with vested interests, everyone accepts that 
change is needed in the Irish health system. Increasingly, this change is seen 
to need to be radical and fundamental. However, one of the biggest mental 
barriers to campaigning for such change is the false perception that the 
problems with the Irish health system are impossibly complex and unsolvable. 
"Haven't we been trying for years, and it still doesn't get any better". Sadly, 
the problems are quite straightforward and we haven't been trying for years. In 
fact, a combination of political sabotage and complacency coupled with the 
self-interest of hospital consultants and the medical establishment has ensured 
that our health system has become increasingly more unequal and more 
inaccessible. This has created a sense of apathy and disempowerment among people 
on an issue which directly affects each and every one of us. The vision of an 
equal and accessible health system where waiting lists are a distant memory from 
a barbaric age, where preventative primary care is paramount and where hospitals 
are a place to get better rather than a place to die seems like utopian dreaming 
from a far away land.

However, the aim of this pamphlet is to demonstrate that this equal and 
accessible health system is closer than we might think. In school, when faced 
with an issue, we were taught to analyse it with the "5W + H questions" - What?, 
Where?, When?, Why?, Who? and How? By analysing why change is needed, what 
change is needed, who can create this change, when and where change can be 
created and how we go about creating this change, we hope the reader will be 
empowered to organise to bring about change and not to wait, on a waiting list, 
any longer. An equal and accessible health system for all the people in Ireland 
is closer than we think. We hope to show how we can reach out and grasp it and 
never let it go.

Why Change is Needed


Equality and Access

Cost is the biggest obstacle to receiving medical care, be it just a check-up or 
some more necessary treatment.

Figures for the beginning of 2007 show that there are currently 1.2 million 
people with medical cards [1]. This represents 28.9% of the population. There 
are a further 51,000 people with “GP-Visit Cards” which qualify them for free 
medical consultations but no drug costs. This is actually a remarkably high 
proportion considering that any single person under 65 years of age and living 
alone has to earn less than €184 per week to qualify for a medical card [2]. 
Given that unemployment allowance (i.e., dole) payments are now up to €197.80 
per week and that even on the minimum wage of €8.30 per hour, one would only 
have to work 22 hours a week (the equivalent of a part-time job) to surpass the 
income threshold, it is surprising that any worker is entitled to a medical card.

Without the medical card, GP visits cost on average approximately €40, while 
being higher in urban areas (especially Dublin). These fees act as a strong 
disincentive to access medical care in two important ways. Firstly, they act as 
a deterrent to seeking out any sort of health education or preventative 
examination from a GP. It is commonly accepted that preventative medicine, such 
as cholesterol tests and smear tests, are fundamental in improving people's 
life-expectancy and quality of life. Secondly, they discourage people from 
seeking treatment when they are suffering from an ailment, instead waiting to 
see if the illness gets better or worse before reaching into their pocket to 
shell out at least €40 [3]. Not acting in a timely manner in relation to disease 
is a common reason for more serious complications to develop.

Given the low level of medical card entitlement in Ireland, it is not surprising 
that about 49% of the population purchase medical insurance each year from VHI, 
Vivas or Quinn Insurance (formerly BUPA). This costs between €119 and €143 per 
year for basic GP cover, between €360 and €422 for minimal hospital cover, and 
up to €1800 for specialist treatment. Despite already funding the health system 
through the tax system, 49% of people are forced to pay these sums to access 
adequate care. Of course, this leaves approximately 21% of the population who 
are not entitled to the medical card and cannot afford health insurance. They 
must fork out €40 for each GP visit and €65 for every night they spend in a 
public hospital bed (if they can get one), not to mention the other fees 
accruing. These people, PAYE workers for the most part, although paying their 
taxes, simply have no meaningful access to medical care in Ireland.

Accessing treatment in a public hospital as a public patient is usually a test 
of patience and endurance. Ireland has 4.85 beds per 1,000 of population while 
the EU average is 6.3. Ireland has 3 acute hospital beds per 1,000 while the EU 
average is 4.1. There is no common waiting list to access these beds. 
Consequently, public patients may wait years for treatments which private 
patients may receive within weeks in the same publicly funded hospital, 
irrespective of need. It is a rationing system based on ability to pay.

Systemic Problems

Historic and Continued Underfunding
Ultimately, these forms of inequality and inaccessibility for those that need 
care in the Irish Healthcare System are caused by an unwillingness to invest.

Primary care has never been emphasised by any government in the history of the 
state in terms of funding for equipment, buildings or staffing levels. For this 
reason, the level of health education and preventative medicine being performed 
is chronically low. GPs routinely refer patients onwards for procedures which 
are within their competence and which they could perform in a well- equipped 
local surgery. As a result, a disproportionate amount of medical care takes 
place in hospitals, putting them under undue pressure.

Likewise, Irish hospitals have been historically massively underfunded, meaning 
that we have a lower bed ratio per head of population than any of the EU15 
countries. The Minister for Health, Mary Harney, and her colleagues in the 
neo-liberal Progressive Democrats Party trumpet the fact that Ireland is now 
spending more per head of population than other OECD countries. However, in 
2003, economists Dale Tussing and Maev-Ann Wren calculated that in real terms, 
current expenditure on health per head was less than 90% of the EU average. 
Moreover, this comes on the back of 30 years of neglect. Over the 27 years from 
1970 to 1996, Ireland invested on average each year 63% of the EU average 
(capital expenditure). As recently as 1990, Ireland was investing 38% of the 
average. An increase to 90% of the EU average is clearly not enough to 
compensate for those decades of running down the public health system.

Other examples of underfunding are:

* Ireland has 22 doctors per 10,000 of population. The EU average is 33.
* Even if all of the consultants due to be appointed are employed, bringing the 
number of consultants up to 3,600, we would still only have 9 per 10,000 of 
population, half the level in Finland.
* While the Government boasts of Ireland's 'knowledge economy', medical records 
have yet to be computerised in many public hospitals.

In recent months, a cap on further employment of health workers has been 
reinstated due to the HSE going over budget for 2007. (It's worth noting that 
the reason for this overspend is that the hospitals simply treated more patients 
than the accountants were willing to allow them to) As a replacement, hospitals 
have been hiring agency workers on temporary contracts. Instead of employing a 
health worker in a full-time position, including the benefits (pension, health 
insurance, etc.) that this entails, they take on temporary workers as they need 
them, paying a premium to the recruitment agency for the convenience. Given the 
need for more staff in all areas, and given the increase in the population in 
Ireland in recent years, this will cause greater and greater problems and means 
meaningful planning for the future is impossible. In 2008, the HSE is to receive 
nearly €370 million less in funding from the Government than it maintains is 
necessary to sustain existing levels of service.

Hierarchy
Many of the day to day blunders and terrible tragedies that we experience in the 
Irish health service are created by the problems of its hierarchical 
organisational methods. That is, in every area of the health service there is a 
strong division between order givers and order takers. This problem is endemic 
in the entire medical apparatus. The ethos is illustrated by the axiom “a 
consultant knows better than a GP who knows better than a nurse who knows better 
than a porter”.

Therefore, coal-face workers, those that are at the front line of providing 
medical care, especially nurses, have no voice in how decisions are made about 
the provision of care. There is nothing democratic about these workplaces. In 
terms of implementing policy, the HSE, for the most part, make the decisions. As 
for the everyday decisions in our hospitals, the consultants are king, 
answerable to no one. Nurses and junior doctors are simply expected to obey. 
When they voice objections they are ignored or silenced. Despite the fact that 
they are the ones that are directly aware of the concrete issues and the nature 
of what’s wrong on the ground, their position is simply to take orders, do their 
work and shut up.

This state of affairs is exemplified by the case of the death of Patrick Walsh 
in October 2005 in Monaghan hospital. He died essentially due to the fact that 
Monaghan hospital was left looking after him when it no longer had the means to 
care for him. He should have been transferred back to Drogheda or to Cavan 
hospital but when it came to it they said they couldn’t accept him. Those 
attending him at Monaghan hospital said the problem was ‘happening all the time’ 
and they regularly warned of it leading to a tragedy. They were ignored, being 
merely lowly serfs in the world of healthcare hierarchy. Then the tragedy did 
happen.

The importance of cases like the Patrick Walsh is that they highlight how health 
workers are both aware yet silenced by the current order. Fear is an important 
factor in this, especially in the case of junior doctors. They are dependent on 
their master, the consultant. They need his/her training and reference in order 
to progress in their own careers. One displeasing word to the consultant can and 
does mean the immediate destruction of all job prospects in the Irish health 
service.

Such hierarchy also creates a strong sense of malaise and unhappiness in 
workers, whether they be nurses or clerical workers in the HSE. Daily criticisms 
of the Irish health service, stemming from the mismanagement of a system that is 
deliberately underfunded in order to fail, can hardly lead to high levels of job 
satisfaction. The only escape from taking orders in this system is to be 
promoted to become an order giver. Having spent years resenting being forced to 
take such orders, the prospect of subjecting your fellow workers to the same 
misery is hardly an appealing vision.

General Practitioners
GPs are self-employed. Generally, they practice on their own premises (often a 
converted room or two in their house) and view their practice as a private 
company where they charge what they like. They tender to receive a list of 
patients covered by the medical card, for which they receive a “capitation”, 
that is a set fee per patient depending on their age, gender and distance from 
the practice. This capitation is relatively low (approximately €120 per annum on 
average for people under 65) so they generally supplement this income through 
private practice. For this reason, GPs do not setup a practice in predominantly 
working-class areas with high rates of unemployment. These communities must go 
without a doctor and are forced either to travel to the nearest GP or to the 
nearest hospital.

Given that they receive far more money, proportionally, from private patients, 
given that they can charge per appointment and relative to the treatment given, 
they naturally have an incentive to focus their time and energy on their private 
patients. As they are self-employed and often exist as virtual monopolies, there 
are few incentives to expand their practice to include a larger range of 
services provided by a team of health workers using state-of-the-art equipment, 
something which would provide a holistic approach and optimal healthcare for 
patients.

In addition, in the GP contract there is no stated minimum level of service, no 
incentive towards maximal service, and no mention of preventative procedures. 
Quality of service can therefore not be expected.

Consultants
Consultants' permanent contract allows them to earn between €143,000 and 
€186,000 per year for being present in a public hospital for a mere 33 hours per 
week. During this time they are under no obligation to treat their public 
patients but can treat their private patients who happen to be in the same hospital.

If secondary school teachers were allowed to take private classes or give grinds 
during the school day instead of going to their scheduled classes, the inherent 
contradictions, vested interests, potential abuses, inequitable outcomes and 
unfair costs would be visible for all to see. Not so with the consultants.

Neither do consultants provide the majority of care in public hospitals instead 
delegating it to Non-Consultant Hospital Doctors (NCHDs), also known as Junior 
Doctors. The consultants are the specialists with the training required, yet 
they do not provide it in many instances. Of course, consultants provide 
treatment in person for private patients.

The consultant contract is such that the work balance the consultant strikes 
between emergency/elective, private/public, and teaching/research is none of the 
hospital's business. Consultants are not accountable to anyone, either 
administratively or clinically.

Finally, the serf taxpayer foots the bill for malpractice insurance, picking up 
the tab even for consultants working in private hospitals and clinics over which 
the state has no control. No other profession in Ireland enjoys this level of 
state subvention (i.e., welfare for the rich).

Undemocratic Elitist Medical Institutions
The medical institutions, such as the Royal College of Surgeons, the Royal 
College of Physicians, the university medical faculties and the Irish Medical 
Council, have enormous power in the Irish health system.

They control the training of health workers, having carte blanche to draw up 
their own curricula and also decide which hospitals they will recognise for 
training purposes. Their decisions fix the capacity of hospitals to produce 
trained consultants. They also fix the capacity of hospitals to provide medical 
services for their communities as hospitals depend on medical trainees to man 
their services. A royal college's refusal to recognise a hospital for training 
purposes amounts to a death warrant.

The Medical Council is the governing body of the medical profession. The 
Minister for Health is entitled to appoint just 4 out of a 25 person Medical 
Council. Private medical bodies, such as the royal colleges and university 
medical faculties, control the other 21 seats. With general practitioners given 
only 3 seats on the Medical Council, the regulator is weighted heavily in the 
direction of specialities and academics - the forces that still drive the 
services today Just one member of a fitness to practice committee represents 
'the public interest'.

Current Issues - the Drive to For-Profit Medicine

Having described some of the more glaring institutional problems in the Irish 
Healthcare System, a brief examination of some of the current issues is 
illuminating in seeing where mistakes continue to be made and where the system 
may be heading.

The National Treatment Purchase Fund (NTPF)
The spin broadcast about this policy was that it was to buy treatment for public 
patients from the private sector (either in Ireland or abroad) in order to cut 
waiting lists and waiting times.

In reality, it has created an odd circularity in policy: private patients are 
given preferential treatment in public hospitals, and the public patients whom 
they displace may in turn be treated in private hospitals. This is neither an 
efficient use of public money nor an equitable way to treat patients.

One particularly bizarre statistic is that 36% of all procedures carried out 
under the NTPF occurred in the same hospital the patient was referred from - 
that is to say that the consultant is getting paid an additional private fee to 
treat a patient s/he is supposed to be treating anyway!

Liam McMullin, a surgeon at Roscommon Hospital, made the point that the hospital 
had spare capacity during 2006. 'Curiously enough, 50 miles away in private 
Galway hospitals, public patients are being treated by the NTPF scheme, services 
we could deliver here at Roscommon'.

Ultimately, the NTPF simply acts as a growth promoter for private medicine, 
stimulating both individual private practice and the private hospital sector - 
the real aim of it in the first place.

Co-Location
In the mindset of 'private good, public bad', the PDs came up with the Trojan 
horse policy of co-location. The spin was that it would create 1,000 private 
beds in the hospital system, thereby freeing up beds in public hospitals.

This is to be achieved by inviting private investors to build an extension to a 
public hospital, defraying half the cost of the build, allowing the new private 
wing to be staffed with medical consultants poached from the public hospital, 
and guaranteeing the viability of the enterprise - and the profits of investors 
- by enabling streams of public patients to be rerouted from the public hospital.

This policy would be objectionable enough if it simply amounted to the giving 
away of public land and the waste of €500m on tax-breaks to the private sector. 
What makes it a more fundamental crossroads is that it will institutionalise 
two-tier care in the Irish healthcare system. It would be difficult to reverse 
or reform this system if it goes ahead. Indeed, these private hospitals will be 
dependent on a second-rate public health service to survive - depending on 
treating public patients that the State is paying these private operators to 
treat under the National Treatment Purchase Fund.

Worse still, it is a terrible way to increase bed capacity. Most of the 1,000 
beds to be freed up were occupied by patients who had been admitted as 
emergencies and could not, therefore, be transferred to private hospitals: 
for-profit hospitals don't have the staff to care for the diverse needs of such 
patients. Casualty is too costly to be profitable. When private hospitals have 
emergencies themselves, when their patients become very ill, they transfer them, 
speedily, to public hospitals, where they can be looked after by specialist 
nurses and doctors, who are employed in sufficient numbers to provide 
round-the-clock attention.

Therefore, co-location will simply add 1,000 beds to the for-profit sector. This 
will increase the proportion of money-making hospital beds in ireland, excluding 
psychiatric and long stay, to a national minimum of 42%. This is 3 times the 
proportion that exists in the US!

Of course, this was the intention all along. Investment advisors classify 
co-location as the first step - in an eight-point scale - in privatising a 
nation's health care system. Those who had most to rejoice in this plan were not 
the cancer sufferers or the diabetics in our midst; they were the millionaire 
builders, bankers, developers, investors, financiers, advertisers, auctioneers, 
solicitors, and PR consultants, who needed no reminding of their excessively 
good fortune.

Consultants’ New Contract
Originally, the spin behind the introduction of a new consultants’ contract was 
an attempt at much needed reform. Firstly, it was to bring back the public-only 
contract, whereby consultants may only treat public patients. Secondly, it was 
to start the process of doubling the number of consultants in the Irish 
healthcare system, something which has been recommended for a long time [4]. 
Thirdly, consultants were to be expected to work in teams around the clock 
reducing current reliance on NCHDs.

Of course, considering the fact that the contract was to upset the status quo, 
the vested interests of the consultants have been given some substantial 
sweeteners in order to get them to accept the deal. The deal finally agreed 
between the HSE and IHCA offers a new salary of up to €240,000 - an enormous 
salary for a mere 31 hours a week of public hospital work.

Not only that but the IHCA watered down the restrictions on private practice, 
leaving it more or less untouched. Why would any consultant take a public-only 
contract, thus removing his/her ability to earn considerable sums from treating 
private patients, for a mere salary reduction of €20,000?!?!

Night time consultant cover was also removed from the deal. Weekends will be 
covered for "a number of hours". Finally, increasing consultant numbers at this 
salary level will be a huge drain on public finances. It is estimated that if 
consultant numbers are doubled at these salary levels, that it will consume one 
eighth of the entire health budget.

Of course, the entire charade of the negotiations between the Government and the 
IHCA was always going to end up in such a deal. With the same class interest, 
the Government were never going to stand up to the consultants in the public 
interest and force them into a massively unpopular strike. The negotiations were 
merely a time-wasting device so that the Government could be seen not to give in 
to their fellow members of the elite too quickly.

Congested Accident and Emergency Wards
The main cause of congested A+E wards is that old people and mentally ill people 
are forced to stay in A+E beds because there are no facilities to transfer them 
to. The government has been using tax-incentivised private nursing homes as the 
way to create some of this extra capacity rather than investing in public 
nursing homes. The reason that it is such an issue in the media, in comparison 
to other problems in the health service, is that it is the only place where 
private patients must wait in line with public patients and experience the long 
delays and low standards of care.

MRSA
The existence of MRSA in Irish hospitals has 3 causes: overcrowding, overworked 
hospital workers and the outsourcing of hospital cleaning.

Overcrowding contributes hugely to hospital infections, allowing bugs to jump 
more easily from one patient to the next. Yet the Government's refusal to spend 
money on beds means that hospital infections cannot be dealt with effectively. 
In the 1950's Noel Browne introduced sanatoria in order to isolate patients with 
TB. This was key to eradicating the problem in Ireland. Such isolation rooms are 
not present in Irish hospitals with MRSA. Nor is the funding forthcoming.

However, every patient who has contracted an invasive infection costs a multiple 
of a non-infected person. Up to 5% of total hospital budgets goes on treating 
infections that patients catch in hospitals. In 1999, for example, hospital 
infections cost the NHS in England alone an estimated £1 billion. Effective 
infection control could save up to €50 million annually in Ireland. Enough to 
buy 50-100 beds, depending on how they are priced.

Few public hospitals, if any, employ their own cleaning staff. If hospitals are 
dirty, it is partly because their cleaning has been contracted out to private 
cleaning firms. These cleaners are temporary, their contracts insecure, their 
benefits and their pay low. Under these circumstances, workers are unlikely to 
give of their best. Every hospital in Northern Ireland, bar one, has now 
switched from outsourcing cleaning to employing staff in-house.

The Hanly Report
Although dated at this stage, the Hanly Report is the foundations of the move to 
close down regional second-level hospitals in favour of large, urban hospitals. 
The effects of this have been gradually felt across rural Ireland in the last 8 
years. As recently as 31st January 2008, proposals to significantly cut services 
at hospitals across the northeast region were reported to have been drawn up by 
the Health Service Executive.

This drive towards the centralisation of hospital services is based on the false 
assumption that Ireland has the same demographics as Britain. The Hanly Report 
was based on British population densities, thus informing its conclusions that 
regional hospitals needed to close as they didn't have a sufficient population 
base and thus could not guarantee safety. Of course, this is a nonsensical idea. 
Britain is far more urbanised than Ireland.

Indeed, the idea of safety had been turned on its head. It is universally 
acknowledged that the "golden hour" for an emergency patient to get to hospital 
is critical in terms of rates of survival. In Ireland, "dead on arrival" rates 
vary from 23% for city folk to 74% for small-town dwellers. The vast bulk of 
surgery and medicine carried out in smaller hospitals does not require large 
numbers for good outcomes. Only larger hospitals do the kind of complex surgery 
that requires larger volumes for optimal results.

Furthermore, 90-95% of problems that patients present to county hospitals are 
well within the competence of their surgeons. They suffer from the common or 
garden maladies that afflict everyone - heart failure, pneumonia, gall bladder, 
and appendicitis to name but a few. Why, for the sake of the 5% of cases outside 
the capacity of smaller hospitals, should the inestimable benefit of access be 
removed from the other 90% and at a far higher cost?

Indeed, only five procedures show a link between volumes and outcomes: surgery 
for cancer of the throat and pancreas; child heart surgery; surgery for an 
unruptured aneurism (haemorrage) of a major blood vessel (the aorta) in the 
abdomen; and the treatment of AIDS. These procedures are not done on an 
emergency basis; nor are they usually carried out in smaller hospitals. Using 
them to make the case for closing county hospitals is wrong.

Ironically, one of the arguments used in the Hanly Report to close smaller 
hospitals around the country was that Ireland had 'too many' of them, and that 
this was resulting in a 'costly duplication' of services. Now the Government is 
in the process of running down and closing smaller public hospitals, while 
building no fewer than ten new small co-located hospitals on public hospital 
sites (where they will do maximum damage to the public hospital system).

Clearly, there was no shortage of small hospitals all along. There is no talk 
now of costly duplication, although the new private hospitals will offer to 
precisely the same population exactly the same medical services, in many cases, 
as their public hospital neighbours. Competition is the name of the new unspoken 
game, the creation of an internal market.

Not only that but with vast extensions needed to double or treble the capacity 
of those hospitals that remain post-Hanly, closing the country's specialist and 
second-level hospitals would certainly trigger a building boom. Moreover, a sea 
of hospitals coming on to the market at knock-down prices will be a developer's 
dream. Closing Dublin's single-speciality hosptials, for example, will release a 
tidal wave of extremely substantial properties in prime locations, in Hume 
Street and Temple Street, for example. The National Maternity Hospital overlooks 
Merrion Square, one of the prime sites in the city, while the Rotunda Hospital, 
one of Europe's oldest maternities, would make a perfect city-centre five star 
hotel, rivalling the Victorian red and gold bricked splendour of the Eye and Ear 
Hospital in Adelaide Road.

So basically the Hanly Report and the drive to close down regional hospitals 
treats people living in rural areas, in towns and villages, as though they were 
some sort of unrepresentative and unimportant minority. As HSE CEO Brendan Drumm 
said, "People unfortunate enough to live in non-urban areas will just have to 
get used to it." When you consider that non-urban communities are expected to 
pay the same taxes as everyone else, taxes that are being gift-wrapped and 
handed over to the already rich developers of co-located hospitals, and that 
they are expected to accept, at the same time, that their access to publicly 
funded hospital services is far less, this policy emerges from the spin as a 
blatant form of class war.

The Cost of For-Profit Medicine

While public patients will suffer most under the planned acceleration of the 
two-tierred system in Ireland, even those who hold private health insurance 
stand to lose. The boom in for-profit health care means more tests, more 
procedures, and more 'bed nights'. More costs, in a word. Subscribers will 
inevitably face bigger premiums. A rise of 30% in private health premiums over 
the next 3 years or so has been predicted. Whatever the actual rise, the 
increases are sure to be substantial enough to put private health care out of 
reach for many.

And as competition between private hospitals increases, the costs of healthcare 
will get even higher as these hospitals waste money on marketing and paying out 
large dividends to their shareholders.

For every €75,000 invested in the for-profit sector, investment promoters 
forecast a profit of €62,760. This is an extraordinarily high return, almost 
84%. Private health care is hugely profitable. Croft Nursing Home in Inchicore, 
Dublin, for example, made a profit of €350,000 in 2003.

In terms of health insurance in a private health system, premiums inevitably 
spiral upwards. The cheaper a health insurance premium is, the more people will 
buy it and the more likely they are to avail of medical treatment. But the more 
people are treated privately, the more it costs the insurer; and the more likely 
it is that the insurance premiums will rise.

Private health insurance currently supplies most of the revenue to the private 
sector. As capacity ceases to be a limiting factor, insurance companies are 
going to have to find some way of limiting consumption. This is not consumption 
of medical services but consumption of insurance claims. So they will follow the 
US model by inventing a myriad of small-print clauses to render people 
ineligible to claim for a particular procedure, as seen in Michael Moore's film 
documentary, Sicko. Anyone who has seen this film can safely say that this is 
not a road we want to follow.

What Change is Needed


Short-Term Solutions

Firstly we need to halt or roll-back the drive towards privatisation and 
centralisation of services:

    1. We should retain our network of second-level hospitals, complete with 
24/7 inpatient A&E and maternity care. Acute surgery should form part of urgent 
care; certain surgical procedures need to be available on an emergency basis 
24/7 to prevent avoidable deaths.
    2. The consultant contract should be re-negotiated with a willingness to 
provide 24/7 cover as a minimum requirement for employment. Wages should be 
brought back to previous levels and a public-only contract the only one available.
    3. The policy of co-location should be scrapped immediately. No matter how 
far plans are advanced they should be rendered null and void.
    4. The National Treatment Purchase Fund (NTPF) should be scrapped and 
funding provided and capacity used in the public system.
    5. Funding should be provided, as a priority, for the necessary beds in the 
public system to bring us up to the EU average.
    6. The HSE should be broken up, responsibility returned to the Minister and 
Department of Health, and regional boards reinstated.
    7. Whistleblowers should be given protection to allow front line health 
workers to speak out against the problems in the system.


The following are the most important progressive reforms that could be carried 
out in the next 5 years:

    1. The income thresholds for eligibility for the medical card should be 
increased so that 40% of the population are in receipt of one and this threshold 
should be indexed to the average industrial wage and inflation.
    2. There should be a common waiting list in all hospitals so that treatment 
is provided according to need rather than ability to pay.
    3. More students need to graduate in many areas - doctors of all types, 
children’s nurses, dieticians, chiropodists, radiographers and radiation 
therapists. Funding for the creation of places on these courses should be 
provided. Graduates should be required to practice in the Irish public system 
for a set number of years.
    4. There needs to be massive investment in the creation of capacity in 
public hospitals, and in nursing homes and community care to free up space in 
A+E wards.
    5. The GP contract should be re-examined so that they become public sector 
employees, paid a set salary, with incentives to work in deprived areas. A 
minimum level of service should be stipulated, incentives for a maximum level of 
service should be provided, together with an emphasis on preventative medicine.
    6. A ‘free and frank’ forum should be setup to allow health workers to voice 
their concerns and issues in the public health system.


Medium-Term Solutions

Further reforms that may take up to ten years to achieve would be:

    1. Medical card provision should be expanded to the entire population, 
providing a universal healthcare system, free at the point of access, to 
encourage preventative medicine.
    2. Private practice should cease in public hospitals.
    3. The number of patients per GP should fall under the 1,000 threshold to 
improve access for patients and improve the doctor/patient relationship.
    4. Waiting lists should be phased out by moving towards a booking system as 
they have in France. There, all surgery is planned under a booking system in 
which the patient is given a date for surgery immediately it is prescribed, 
although this may involve a few months wait.
    5. A modern primary care system, with GPs, practice nurses, public health 
nurses, physiotherapists, social workers and others working in teams from 
modern, well-equipped, computerised primary care centres in every community and 
large urban neighbourhood.
    6. Outcomes from the health workers forum should be implemented.


Funding

How such reforms would be funded is an important question.

The existing Irish tax-funded system could be reformed overnight in a Bevan-type 
manner [5] by introducing free primary care in which the state would pay GPs by 
salary, and by banning private practice in public hospitals and investing in 
public care so that the majority would opt to be treated in one-tier public 
hospitals by salaried consultants. This would be similar to the system in the UK 
or Denmark. The health insurers would revert to insuring a much smaller 
proportion of the population for elective care in the small number of private 
hospitals. Provided the state invested sufficiently in the public system, 
private medicine would lose its appeal. However, if the state did not invest 
sufficiently in the public system, there would remain a risk that patients and 
doctors would take flight into the private system and the chasm in Irish 
healthcare would deepen.

And that is the fundamental question. As tempting as it is to simply say, “Tax 
the rich”, as the Socialist Party do, how do we guarantee future funding of the 
health service? How do we lock future governments into such a system and prevent 
them running down the American privatised route? No one really wants to have to 
run campaigns to defend the health service every time a right wing government is 
voted in.

Universal Health Insurance (UHI) is an idea bandied about by diverse groups of 
people – Labour, Fine Gael, economists, etc. all of which have diverse (and 
generally less than equitable) ideas about how it would be implemented. In this 
system every citizen is obliged to be insured for their health care needs. It is 
a compulsory as opposed to a voluntary health insurance system.

The state may pay these premiums directly, funding them from the central 
exchequer, or individuals may pay their own premiums, with the state paying for 
those on lower incomes. A third option, the system in France and Germany, is 
that the individual is insured through PRSI with both employers and employees 
contributing through payroll taxes. The state picks up the tab for those who are 
not in employment or on low wages (preferably, all those below the average 
industrial wage). This is a progressive route since contributions are 
proportionate to income and corporations are obliged to support health care as 
part of the social security system.

A carefully designed universal health insurance system could deliver equity and 
a relatively dependable flow of funding. It can be seen as an earmarked, 
ring-fenced form of taxation. Consequently, society would perceive the cost of 
its health care preferences more transparently and could debate cost/benefit 
trade-offs more openly.

If each citizen is insured to receive the same medical care and hospitals and 
doctors have no incentive to discriminate between them, then this is an 
equitable system. It would end the distinction between private and public patients.

If everyone is covered by a premium then the fund for health care should rise as 
costs rise and in line with population growth. Health care funding should no 
longer be subject to the whims of the Department of Finance. These universal 
insurance-funded systems have consistently allocated a much higher proportion of 
national income and a higher per capita spend to health care than the UK's 
universal but tax-funded NHS.

However, it is important that the such a system is not open to private insurers. 
Free market competition drives up costs. In the US where 13% of national income 
goes to health care, it has been calculated that the profits of insurance 
companies and medical care organisations account for one to two percentage 
points, one to two per cent that is of the entire income of the United States. 
Every television advertisement increases health care costs.

Furthermore, provided that private hospitals continue to exist, the system 
should favour public hospitals except in cases where capacity is very tight.

In conclusion, therefore, progressive funding options are available, provided 
they stick to certain principles. These funding options can introduce equity 
into the healthcare system and provide certain guarantees of funding into the 
future.

Creating Change


Building a Campaign

It is long past time, therefore, to build a campaign which will launch a 
struggle for the soul of the health system in Ireland. In the ascendancy at the 
moment as is seen above is the right wing neo-liberal agenda driven by the 
current government and their friends in big business. This is the ideology that 
openly declares ‘Private good, Public bad’. It is an ideology that is unashamed 
about its belief that a profit can and should be made from everything. It is an 
ideology that believes in low taxes on wealth, leading to low public spending on 
services such as health and education. It is an ideology that is currently in 
the middle of a deliberate run-down of the public health system in order to open 
the way for even greater amounts of money to be made by the profiteers.

Lined up on the other side of the battlefield should be those of us – patients, 
family members, potential patients, health service workers – who know that if 
we’re sick today there’s no point in being told that we’ll have a ‘world-class 
health system’ some time in the future. We believe that the provision of decent 
healthcare should not be dependent on the individual’s ability to pay. We 
believe that when someone is sick he/she should be able to access the very best 
of attention, expertise and care.

The reality of the run-down is the public health system is faced on a daily 
basis in the hospitals and wards up and down the country. We saw with the 
nurses’ strike in 2007 that there is precious little appreciation by the HSE 
bosses for the work and effort of health workers. Instead accountants and 
financial advisors rule – and cutbacks are the order of the day. Sometimes these 
cutbacks happen in small ways but other times they are significant. Occasionally 
we hear about them in the headlines but for most health workers they are 
everyday issues that they have to contend with alongside doing their jobs. An 
example of one that hit the headlines was the manner in which hospitals in 
Dublin and Cork, to name just two places, were ordered to close wards and cut 
overtime and holiday cover in late 2007 so that ‘the year-end books could be 
balanced’. This order was issued by the HSE bosses despite the reality of big 
waiting lists in a wide number of the specialties where wards were ordered 
closed. Nurses at the time spoke out loudly about this disgrace. Another example 
– somewhat different but just as pernicious was in the new Cork Maternity 
Service, which opened in 2007. Here the consolidation and revamping of this 
critical service was used by Cork HSE management to push through new working 
arrangements for midwives which would result in less midwives attending more 
mothers to be. On that occasion in Cork, the midwives successfully resisted. But 
once again we see how cynical and money obsessed the bosses in the HSE are.

For those of us who want to see a decent public health service built, it is 
clear that we have a major battle on our hands. The privateers are currently in 
the driving seat and if we are to wrest back control a massive broad-based and 
inclusive campaign must be built. To be successful in this ambition, there are a 
number of basic and fundamental questions which we must try to address in 
relation to bringing about change – the Who, the When and Where and the How.

Who Can Create Change?

To answer this question, let’s first of all look at past history and let’s rule 
out the ways in which fundamental change will NOT come about. Firstly it must be 
clear both from Irish history and from the history of Europe that the sort of 
fundamental improvements that we are talking about will not come from 
government. The current Fianna Fail/PD/Green government and the past FF/PD 
coalition may be the most recent protagonists, but it is clear that no Irish 
government since the foundation of the state has been remotely interested in 
creating the sort of health system we are talking about. Rather all have been 
complicit in bringing us to where we are and in following the same two-tier 
model creating increasing inequality and subvention of private medicine.

The unique combination of successive Irish governments and the Catholic Church 
has consolidated this increasing inequality and has both failed to face down the 
vested interests of elements of the medical profession, and increased 
centralised control of the health system. After the Second World War social 
movements across Europe forced governments into conceding various degrees of a 
welfare state. In Ireland, however, the Catholic Church’s vehement opposition to 
anything that smacked remotely of socialist ideas, and its desire to have the 
state’s laws reflect Catholic moral beliefs, meant that the southern Irish state 
never developed any tradition of social democratic politics.

Mother and Child Scheme
On the rare occasion when individual politicians or political ideas challenged 
the dominant status quo, it was shot down in a hail of righteous indignation. 
Perhaps the most well-known of these occasions was when then Minister for 
Health, Noel Browne, attempted to introduce what became known as the Mother and 
Child Scheme in the early 1950s. Browne’s proposal was that all children up to 
the age of 16 would be entitled to free medical treatment, and that free pre- 
and post-natal care would be provided for all mothers and newly-born infants.

His proposals met with fierce resistance from the doctors’ representative 
organisation, the Irish Medical Association (IMA) who feared the development of 
a health system based on the British National Health Service which they saw as 
the first step on the road to ending the system of private practice. At the same 
time the Catholic Church, led by Archbishop of Dublin John Charles McQuaid, went 
on the offensive. The Catholic Church feared the idea that Browne’s scheme was a 
first step in giving the state a role in sex education and McQuaid also saw the 
battle as crucial in terms of “check[ing] the efforts of Leftist and Labour 
elements, which are approaching the point of publicly ordering the Church to 
stay out of public life.”

The combination of Catholic Church and the medical establishment would have been 
a formidable ally for a government which was convinced of the ideology of 
Browne’s attempts at reform. However, most of the government were only too 
willing to back down and the sight of their enemy lined up before them 
frightened the life out of them. Taoiseach John A. Costello made it clear 
“Whatever about fighting the doctors,” he told Browne, “I am not going to fight 
the Bishops, and whatever about fighting the Bishops, I am not going to fight 
the doctors and the Bishops”.

That convergence of interest between Catholic Church and medical establishment 
proved successful and the eventual defeat of Browne’s reform attempts drove back 
any notion of taking on the vested interest in the health system for years. No 
politician of any persuasion was going to risk his/her political career by 
trying to emulate Browne’s attempts at reform

Two-Tier System
 From the early 1970s on, the ‘two-tier’ health system became firmly embedded. 
The 1970 Health Act introduced by Fianna Fail re-inforced this and political 
developments of subsequent decades have proven that this inequality of access is 
now an inherent characteristic of the system. And it has also been proven that 
real reform of the type that we would like to see will not be brought about by 
politicians. Even if they had the will to do so (and it’s unlikely that any of 
them ever will) the vested interests of the consultants’ bodies and those that 
are making huge profits from the current set-up will ensure that the status quo 
will remain.

Hospital Candidates
But what about the opposition? What about all the independent ‘Hospital 
candidates’ we’ve seen in the last number of general elections? During the 1990s 
and 2000s a number of independent politicians have actually been elected on the 
‘Health’ ticket. Indeed in the 2002 General election a slate of candidates stood 
under the ‘Independent Health Alliance’ banner and a number of them were 
elected. One of those elected was Paudge Connolly from Cavan/Monaghan. On his 
first day in the Dáil he voted for the election of Bertie Ahern as Taoiseach, 
and in his speech to the Dáil stated:
“The people of Cavan and Monaghan have honoured me by choosing me in the recent 
general election to represent their views and concerns on a number of issues, in 
particular the battle for the retention and upgrading of a fully equipped, fully 
staffed and properly funded hospital in Monaghan. I thank the people of Cavan 
and Monaghan who voted for me. It is obvious that Monaghan General Hospital is 
top of the agenda in Monaghan…. My support for the election of Taoiseach is 
contingent on a number of factors, including the retention of Monaghan General 
Hospital's accident and emergency department beyond the previously announced 
deadline of 4 July.”

As far as protecting services in Monaghan hospital was concerned, electing 
Connolly was a waste of time. Indeed so lacking in success was he that on 25th 
September 2006 over 10,000 people turned up at a protest organised by the 
Monaghan Community Health Alliance at the opening of the new Monaghan town 
bypass to protest at the downgrading of Monaghan Hospital – just one of several 
protests that have been organised by the campaign to save Monaghan Hospital over 
the past number of years. Also elected as part of that alliance was Dublin North 
Central TD Finian McGrath who on his re-election in the 2007 election voted for 
Bertie Ahern as Taoiseach, and subsequently voted confidence in Mary Harney as 
Minister for Health and in her policy of privatisation and co-location!

The lesson is that politicians – government or opposition, party members or 
independents – are incapable of delivering any meaningful reform.

‘Social Partnership’
Maybe we should look to the trade union movement then? The problem here is that 
the leadership of the trade union movement in Ireland has become firmly embedded 
in the status quo through the mantle of so-called ‘social partnership’ which 
they have bought into in the last 20 years. It is in fact the cover given to 
them by ‘social partnership’ that has allowed the government to go down the 
privatisation road to the extent that they have. Since the first of the ‘social 
partnership’ agreements – the Programme for National Recovery – in 1987 right 
through to the current deal ‘Towards 2016’ the Irish Congress of Trade Unions 
has effectively been incorporated as an arm of government and – while they may 
be long on rhetoric, the trade union leadership is severely lacking in any 
meaningful action when it comes to opposing the drive to for-profit healthcare.

In a pamphlet entitled ‘Solidarity not Social Partnership – why SIPTU should say 
no to another partnership deal’ written by Des Derwin (then President of the 
Electronics and Engineering Branch of SIPTU and current President of Dublin 
Council of Trade Unions - writing in a personal capacity), it was argued:

“It’s not a matter of a word ‘partnership’. Embracing the notion of partnership 
affects our behaviour following on from that. The effect of believing that the 
employers and the government have our best interests at heart, that in fact they 
are our partners, is plain: the fight appears to have temporarily gone from our 
movement, as our reactions to privatisation, outsourcing, workplace change, 
closures, dreadful health and social services, super-exploitation, service 
charges, crippling house prices and the jailing of protestors, shows.”

Bottom up

We cannot rely on politicians. We cannot rely on trade union leaders. We should 
not, indeed, rely on any ‘leaders’. What we need is to build a campaign from the 
bottom up – a campaign which will rely simply on the ingenuity and honesty of 
ordinary people – of trade unionists, of patients, of family members, of health 
workers. We need to build a campaign which cannot be bought off or 
‘incorporated’ - a campaign whose ‘leadership’ remains at grassroots level and 
which doesn’t allow itself to become a vehicle for the massaging of egos or the 
grooming of wannabe politicians.

It should be a campaign which rejects both ‘partnership’ and electoralism as a 
means of bringing about change. They’ve both been tried and failed. What is 
needed now is a new approach – one which looks to the strength of street protest 
and the organisational ability of ordinary people as its principal strategies – 
a campaign aimed at forcing change from government. We should have learnt by now 
that the political establishment will not give in to us because it’s the right 
thing to do. They will do so when the combined weight, strength and 
determination of our campaigns leave them with no option other than to concede 
to us.

This is no pipe-dream. The building of such a campaign is a realistic target for 
us to set ourselves. Already throughout the country communities have been 
organising and uniting to defend their local health services. From Tallaght to 
Monaghan, from Crumlin in Dublin to Castlebar in Mayo, from Dun Laoghaire to 
Sligo via Navan and in many many communities in between campaigns have brought 
hundreds and thousands of people onto the streets. The depth of feeling is 
incontestable. It’s clear that people care and that ordinary people want to 
defend and improve hospital and health services. Similarly, around the hospitals 
and wards there can be no doubting that there is both anger and resistance. 
Workers have spoken out on many occasions about the patent wrongs that they 
being forced to deal with by the HSE bosses. Health workers have time and again 
resisted so-called ‘reforms’ that are really about cutting services and 
balancing the books. It is crucial that this anger and resistance among health 
workers is galvanised and given a voice. In this respect a grassroots health 
workers’ network would be a huge and important step forward. Time and again, in 
community campaigns, we have seen people coming together to talk and share 
experiences. Such a process can be the basis for a move towards taking sustained 
political action. So it should be now for health workers. There is need to link 
up, to share experiences and ideas - this is the time for action. The challenge 
is to find a way in which all of these communities can forge links and bonds 
between each other, can federate and co-operate and can build a strong unified 
campaign which will frighten the living daylights out of government.

Hypocrisy
There will always be local politicians ready and willing to jump on the 
bandwagon of these protests and campaigns. Indeed in some instances we have 
witnessed the sorry and almost comical aspect of government TDs supporting 
protests against local hospital closures. Hypocrisy is of course no stranger to 
the modus operandi of your average politician but the sight of Junior Minister 
at the Department of Health, Jimmy Devins, protesting outside the Dáil about the 
threatened closure of cancer services at Sligo General Hospital on 22nd November 
last year was probably the most blatant bit of hypocrisy seen for some time. "I 
am totally and utterly committed to maintaining the current level of service in 
Sligo General Hospital in relation to cancer services,” declared Devins , but 
there was no way he was going to resign his Ministerial position. Indeed so 
principled was his opposition to government health policy that less than one 
week later he dutifully voted full confidence in Mary Harney as Minister for 
Health and in government health policy.

This is the sort of political hypocrisy and opportunism that must be rejected 
outright if a decent campaign is to be built. Government politicians should not 
be welcome near the platforms of any protest. Politicians from opposition 
political parties should also be treated with a pinch of salt. We only need to 
look at the Green Party’s 180 degree turn on issues such as opposition to U.S. 
military flights through Shannon airport, support for the Shell to Sea campaign 
and the Lisbon Treaty to realise that the whiff of getting their hands on a bit 
of power is enough to turn the heads of any politician and destroy any 
principles they might have.

Open and Democratic
So the campaigns we aim to build at local level should avoid the hypocrites and 
the wannabe politicians. We should aim to build genuine open democratic local 
campaign groups in which everyone can have their say and which aim to bring 
together patients, family members, health workers and concerned trade unionists 
and community members. Campaign meetings should be held regularly and should be 
open to all. We should avoid setting up ‘leaderships’ or committees which will 
tell the rest of us what to do.

But the campaigns cannot remain local. While some of the issues might be 
directly local in the sense that they effect a local hospital or service, the 
answers to the problem are national. Local campaign groups need to find a way to 
come together to share their knowledge and expertise in order to support each 
other, and to pool their anger the better to let the powers-that-be hear us all 
shout loudly together.

The manner in which campaigns come together to unite their voices is important. 
In order to maintain maximum democracy, and again to minimise the opportunities 
for opportunistic groups or politicians to take control, the campaigns should 
federate from below. Mandatable and recallable delegates from each local 
campaign could meet on a regular basis to discuss issues of common interest, and 
to plan national activities. What this means in practice is that all issues 
would be discussed fully by the local campaign groups, that the delegate who the 
local group sends to the national meeting would then be given a mandate and that 
the delegate would report back to the local group for final decisions on 
anything controversial.
To get to that point, establishing real local campaign groups is the first step. 
Many of these already exist around the country, although the extent to which 
some of them are free of the control of local politicians with their own agendas 
is sometimes unclear. We would however urge everyone who is passionate about the 
demand for a decent public health service to either join an already established 
local campaign group where you live or help to establish one. We hope that some 
of the ideas we’ve included in this pamphlet will be of some use to you in your 
efforts to do so.

Building the sort of campaign that is necessary to fight for the sort of health 
service we deserve is no easy task. We’re talking here about taking the first 
steps in what will be a long and difficult road. But neither should the task be 
over-daunting. Fear of taking the first step, nervousness about whether we’ll 
get it right should not put us off. Rather we should be brave enough to take the 
first steps in coming together with like-minded people and starting the process.

Footnotes


    1. A medical card entitles the holder to free visits to a General 
Practitioner (family doctor) and free prescribed medication.
    2. The figure for a married couple under 65 years is €266.50 per week 
although there are additional allowances for children in the family. All people 
over 70 years of age in Ireland receive a medical card.
    3. Further costs would be added where minor surgery or prescription drugs 
were required. Drug costs are capped at €85 per month per patient.
    4. Of course, doubling the number of consultants is ineffectual if the 
requisite numbers of nurses and administrative staff are not there to support 
the expanded capacity.
    5. Aneurin Bevan was a Welsh Labour politician. He was the Secretary of 
State responsible for the formation of the National Health Service.


Bibliography


     * Unhealthy State: Analysis of a Sick Society, Maev-Ann Wren, New Island 
Books (Jun 2003)
     * How Ireland Cares: the Case for Health Care Reform, Maev-Ann Wren and 
Dale A. Tussing, New Island Books (1 Jun 2006).
     * Emergency: Irish Hospitals in Chaos, Marie O'Connor, Gill & Macmillan, 2007.
     * The Bitter PIll: An Insider's Shocking Exposé of the Irish Health System, 
Doctor X, Hodder Headline Ireland, 2007.

PDFs of this pamphlet can be downloaded:

A4 version - http://www.wsm.ie/attachments/mar2008/health_pamphlet_1.pdf
A5 booklet version (for double sided printing) - 
http://www.wsm.ie/attachments/mar2008/health_pamphlet_a...t.pdf
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