Belfast Telegraph

Tuesday 21 October 2014

We need to stop saying ‘no’ to radical reform

I have never thought of the US as a paragon of administrative efficiency. Not after going through New York immigration. But it looks like I have been wrong.

Since the Obama administration took office, the financial system has been rescued, legislation to up-end the entire healthcare system of 300 million people has been prepared and passed, and a couple of wars fought and a couple of peace processes pursued. All in less than 18 months.

There is, of course, no shortage of comment on all these events. But not much that I can see on how, physically, it was done.

Presumably it helps that the president must face re-election in just four years.

Could it be that the longevity in office of Fianna Fail might explain the equally astonishing immobility of the Irish administrative and political system? Not only has nothing of note happened in the past 18 months; nothing much happened in the past decade, apart from greed, corruption and folly.

The creation of the motorway system — admittedly at vast expense — was an exception. So, oddly enough, was healthcare.

The creation of the Health Service Executive was undoubtedly a major change. The re-negotiation of the bizarre arrangements with hospital consultants was a major challenge. The idea of separating public and private patients was a major policy shift.

None of these things has gone to plan. It will take a while longer to see how the implementation of the more radical Obama plan works out in the US. America is greatly prey to vested interests.

But Americans do believe that things can change. They do not share our palpable pessimism and opposition to all things new.

The HSE was nobbled at birth by trade union objections, based on perceived threats to the status of health service managers.

The new arrangements with consultants are only a bit less bizarre and expensive than before. They are related to the sharing of facilities among public and private patients. But everyone prefers that this should continue, unless any change is the one they themselves favour.

In typical fashion, the suggestion is even being floated that the answer to these failings is to go back to what we had before — regional health authorities.

Any day now, I expect to hear the Government is to leave Merrion Street for Dublin Castle again.

The US experience is proof that structures do matter in healthcare (I shall gloss over the media idiocy which maintains that what matters is who is the Minister for Health).

Health systems vary enormously between countries, and produce different outcomes.

None are as strange as those of the US. It spends significantly more on health as a proportion of national income than any other country.

Since it has the highest income per person, the amount per patient is even larger in comparison. And most of that is spent on about 60% of the population.

Naturally, they get the finest healthcare in the world but not so fine as the rewards which accrue to the providers of the healthcare. Strangely, the great US companies that were the financial bedrock of this system were more generous in their payments to the healthcare industry than any taxpayer. Lots of studies do go on, but there is not much prospect of radical reform. I have no doubt that Maurice Hayes will find out what happened in Tallaght General Hospital. We might even be told his findings, and something might even be done. But the characteristics of the Irish system make it essentially irreformable.

It has improved, but it took lots of money. It may improve a bit more, although there will be no more new money, but I cannot see how such a ramshackle design can ever rank among the best.

The obvious answer is to turn it into a European-style service, funded by insurance and regulated, rather than provided, by government.

Fine Gael is proposing something like this, as the Labour Party did before.

But Enda Kenny and Eamon Gilmore must worry, as I do, that the policy levers in this country are broken. They can put in the policies and pull the lever, but nothing may happen.

Mr Kenny’s ideas for reform of the system suggest he does recognise the danger. If he gets the chance, he will implement those changes — probably more — in his first 18 months, to have any prospect of success.

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