What should our healthcare system look like after the pandemic?

Opinion: the coronavirus outbreak has exposed key weaknesses in Ireland's healthcare system, which we must learn from for the future.

By Brian Turner, UCC; Julien Mercille, UCD and Sean Lucey, UCC

In 2016, Leo Varadkar, then Minister for Health, said that giving more beds and resources to hospitals is not so good because it can lead to staff working slower and decreased productivity. That mindset appears foolish today, but gives a clue about why health care systems around Europe have been overwhelmed by the ongoing pandemic. Governments have been too cautious about funding public health infrastructure, professionals and equipment.

Capacity problems in our health care system were known long before the coronavirus reached our shores. Our number of hospital beds per 1,000 population is significantly less than the OECD average, and occupancy rates, at about 95%, are the highest in Europe. For the all-important intensive care beds, we have 5.2 per 100,000 population, compared to a European average of 11.5. Germany's figure of 34 has allowed it to deal with the pandemic better than most European countries.

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From RTÉ Radio 1's Today With Sean O'Rourke, a April 2020 discussion on the future of healthcare after Covid-19 with Dr. Paddy Smyth (Dublin GP), Dr. Sara Burke (Assistant Professor of Health Policy at TCD) and Dr. Cliona Ni Cheallaigh (consultant in Infectious Diseases, St. James' Hospital, Dublin)

Our health system is not resilient enough in normal times to deal with the thousands of people on waiting lists and trolleys in normal times, let alone a pandemic. The problem is that successive governments have historically adopted a hands off approach to health and social care, relying on religious organisations and commercial providers to fill the gap left by lack of government action. This has been especially true during the recent austerity period following the 2008 financial crisis and in the 1980s, when drastic cuts were made.

Consider the following:

- Between 2007 and 2015, acute public hospital bed numbers dropped from 12,121 to 10,473.

- In 2017, there were 2,641 fewer nurses and midwives working in the HSE than in 2008.

- In 2001, the landmark Primary Care Strategy suggested that up to 600 primary care centres should be established within a decade. Nearly two decades on, only 140 are operational.

- The waiting list for HSE home care rose to nearly 8,000 people on the eve of the pandemic.

But the commercial sector has actually expanded. Hospital beds in private for-profit hospitals increased from zero in the mid-1980s to 1,075 in 2015, while beds in public hospitals dropped from 15,111 to 10,473 over the same period. Governments have supported private medicine by giving tax breaks to investors in private hospitals and subsidising private insurance, among other things.

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From BBC Newsnight, how prepared is the NHS for the fight against the coronavirus?

However, from crisis can come great change. In the United Kingdom, the Second World War had a revolutionary impact on the health services and in many ways paved the way for the establishment of the National Health Service. Where previously access to healthcare was based on poverty, charitable notions of deservingness and ability of patients to pay, the state was now obliged to provide medical attention to a civilian population suffering from exogenous threats of aerial attacks.

For the first time, much of population was entitled to free healthcare which helped to set a precedent for the universal, free at the point of contact service which arrived in 1948 with the establishment of the NHS. Modern Ireland may be some way off a universal healthcare system, but the crisis is raising questions at the very least about entitlement and the public/private split in access to health.

Other parallels from the experience of Britain's Second World War health services are evident in today’s Covid-19 response. Prior to the 1940s, British healthcare was made up of varying - and often competing - voluntary, local government and private providers and was marked by much localism and limited integration. For the purposes of war, all hospitals were coordinated together under the civil defence regional administration. This regional organisation provided the soon-to-be-established NHS with a blueprint on how to organise the post-war health system.

From RTÉ Radio 1's Drivetime, Dr Brian Turner on the government's plan to give private consultants jobs in the public healthcare system

The current crisis provides us with a unique experiment in combining the public and private hospital systems in Ireland. This situation goes well beyond what is envisaged in the Sláintecare strategy, which aims to separate the public and private systems, including by removing private practice from public hospitals, and expand the capacity of the public system.

Under the Sláintecare plan and the associated Health System Capacity Review, the public system will require an additional 2,600 hospital beds and 593 additional consultants. This is more or less what the HSE will have access to with the private hospitals and private-only consultants. However, it is important to note that Sláintecare envisages a private hospital system running alongside the public system.

The incredible reaction to the Be On Call for Ireland initiative, with over 72,000 registered, suggests that there is a potential to fill the additional capacity requirements in other areas of the health system as well, and is very encouraging.

From RTÉ Radio 1's Morning Ireland, Dr Brian Turner discusses the past, present and future of Sláintecare

However, the current arrangements are designed to be temporary and there are a number of reasons why they might not be continued once the crisis abates. One is the cost of adding the private hospitals and consultants to the public payroll (notwithstanding the fact that contracts would be quite different, not least in the area of pay). Government debt is increasing rapidly as a result of the pandemic, and this will likely be reflected in future belt-tightening.

Another is the private health insurance market, worth over €2.5bn a year in premium income. Currently, members are getting significantly reduced benefits from their insurance policies, and this is being reflected in refunds from insurers. While most will likely accept this in the short-term, many will question the benefits of having insurance and may discontinue their coverage if the integration of the public and private systems continues longer-term. This will significantly increase demand for public health services.

While a contraction in private health insurance is envisaged under Sláintecare, it is important that this is done in a carefully managed way in response to improvements in the public hospital system. Amid all the uncertainty, one thing is certain: we live in interesting times!

Dr Brian Turner is a lecturer and health economist at the Department of Economics at the Cork University Business School at UCC. Dr Julien Mercille is Associate Professor in the School of Geography at UCD. Dr Seán Lucey is the Research Manager in the College of Business & Law at UCC. He is a former Irish Research Council awardee.

The views expressed here are those of the author and do not represent or reflect the views of RTÉ

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