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Tuesday 5 December 2023 Dublin: 5°C

Column Ireland has the worst managed healthcare system in the developed world

While Ireland does not have the worst quality of healthcare, it is run by technically deficient, medically illiterate bureaucrats, says Professor John Crown. What healthcare model should we be looking to?

AS IT IS currently structured, the Irish healthcare system ensures that people spend an inordinate amount of time not being treated for what ails them. The current structure incentivises inactivity, not efficiency. Patients are seen as a cost, and one that only has to be realised when a patient enters the hospital.

This is why most of our healthcare spending is outside of hospitals. We spend an inordinate amount of money on patients who are waiting for expert treatment, while those who run the bureaucracy think that they are saving money by not treating the patients properly.

Everyone accepts that there are grave failings in the Irish healthcare system; the only thing that divides us is how to solve them. Some would argue that we should move towards an NHS style service, others look for lessons in Berlin, and still others would find solutions in Havana.

The influence of political ideology

What typically happens, is that people bring their political ideology to the table and then pick the health service which most closely matches it.

Take for instance the former Minister for Health, Mary Harney. She was of a school of thought that believed that we should have a health care system populated by private for-profit institutions.

Harney believed, as an article of faith, that private for-profit businesses are, in and of themselves, a good thing, and so she sought the solutions to our healthcare problems in private, for-profit, businesses.

While there are major problems with the US healthcare system, the best managed institutions I have ever worked in were in New York. When I was working in the Memorial Sloan-Kettering Cancer Centre, the only waiting the patients did was in the room outside my clinic door – similarly in Mount Sinai Hospital. Sloan-Kettering and Mount Sinai are private, entirely not-for-profit institutions, founded by wealthy philanthropists and financed by insurance revenues; they are meccas for cancer specialists, researchers and patients alike.

The US model: medics leading medical institutions

Any insured cancer patient can access this hospital (ie 80 per cent of the American population). Care is single-tier. Politicians, millionaires, pop stars, actors and ordinary citizens were all seen in the same clinics, admitted to the same wards, operated on in the same theatres, and critically, all cared for by the same doctors. There was no co-located hospital for the wealthy.

The main problem with US healthcare is the lack of universal healthcare insurance – we should not emulate that. But, in terms of working hospitals you will find the best doctors, the best treatments, and the best outcomes for patients in the US. The chairs of these institutions are doctors. These clinically excellent medics lead their medical institutions, supported by technically adept managers, whom they guide with medical brilliance. At an institutional level we must move towards the US model, what we should avoid is the US insurance model.

Also problematic in the US system, is that for those who have insurance, doctors and hospitals are incentivised to carry out medical procedures which may not be necessary. With an unfettered free market approach, and a fee per item system, this is inevitable; as inevitable, as the incentivised inactivity in the Irish system.

The German model: healthcare based on need – not wealth

There is a middle route between these two extremes which is a model based on the principle of social solidarity, where access to healthcare is based on need and not wealth. Looking at the international landscape, the model I think we can learn most from is the German model, if we are aiming for an egalitarian system which is also efficient and effective.

In Germany, the typical worker contributes 9 per cent of their gross income to their health insurance. There are many ways of structuring this. Some huge employers have their own schemes, others buy commercial insurance from the market, and all those who are unemployed are insured by the state.

This is progressive, those who earn more, pay more; despite the fact that people who earn more typically have fewer health problems than those who live more difficult lives.

Every person has their own freely negotiable insurance credit. They can go to whatever institution they choose to go to, individual institutions decide what areas of care they offer, and the degree of care they offer within those clinical areas.

Ireland: the least efficient healthcare sector in the world

This approach is anathema to the bureaucrats which currently govern this country; they are not interested in patient outcomes, but in controlling admin budgets. They do not care if money can be better spent, they choose instead to manage the devils we know rather than risk devils we don’t know.

Dr Don Thornhill of the National Competitiveness Council argues that we have the least efficient healthcare sector in the world. We spend a very average amount on healthcare. Had we the same demographics as other European States; we would have the most expensive healthcare system in the world. With 100,000 young Irish people emigrating every year, our country is aging much faster than anticipated, the inevitable funding crunch will arrive far sooner than we would like.

We do not have the worst quality of healthcare in the developed world, we have instead the worst managed healthcare system in the developed world, run by technically deficient, medically illiterate bureaucrats.

It is not even their fault that the healthcare system is so bad – how else could it be, given the dysfunctional nature of what we have asked them to do? We ask them to ration healthcare, they do as we ask of them.

Professor John Crown is a Senator in Seanad Éireann. He trained in cancer medicine in New York in Mount Sinai Hospital and Memorial Sloan- Kettering Cancer Centre and was appointed as a consultant in St Vincent’s Hospital, Dublin in 1993.

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