Writing on behalf of the All-Ireland NHS campaign, Chris Carroll analyses the limits of the current plan for fixing healthcare: Sláintecare. He argues the lessons of history show that instead of its technical approach we need a broad movement to win a 32-county universal healthcare system.
“Medicine is a social science and politics is nothing else but medicine on a large scale” Robert Virchow
Healthcare is often framed in terms of its importance as a human right. The idea that everyone deserves healthcare is not controversial. Unfortunately, the reality in Ireland is very different. There are significant limits to our current approach to health policy and the need for a social movement focused on radical change to deliver universal healthcare has arguably never been clearer.
Sláintecare is the current overarching health policy of the Irish government. It came about following the 2016 general election. During the period before a government was formed Deputy Róisín Shorthall of the Social Democrats managed to get the go ahead for a special select committee entitled the “Committee on the Future of Healthcare”.
Academics from Trinity College ran workshops with the committee members and their input informed much of the technical analysis for the project. The committee also received a large number of submissions from groups and individuals around the country that fed into the final report, the Sláintecare Report, published in May 2017.
The final report produced was scientifically coherent and included laudable aims for the future of healthcare in the South. It had a vison for a one-tiered universal healthcare system, comparable with the “Beveridge model” of the National Health Service (NHS) in the UK. Specific aims included the phasing out of private care in public hospitals, eliminating charges for access to public hospital care, universal access to GP care without charge and reducing waiting lists for first outpatient department appointments and hospital treatment.
The report outlined broad population needs, changes required to entitlements to healthcare in Ireland, the concept of integrated care, the funding mechanisms available to government and pathways for implementation. Projections used a 10-year timeframe for full implementation with a required frontloading of spending in the initial years.
However, Sláintecare has failed to deliver the change it promised. The recommendations of the report have been for the large part ignored. For example, so far the main funding that has been delivered by the Sláintecare Programme Implementation Office was for over one hundred unique projects as part of the “Sláintecare Integration Fund”. Access to this once-off funding required project managers to submit their individual applications last year, many from within the HSE.
This was contrary to the basic premises of the Sláintecare Report which recommended that healthcare funding should come from a common pot. Instead the Integration Fund introduced internal competition within the health service to determine worthiness.
In fact, the meaning of term “Sláintecare” has totally transformed since the 2017 report. It has been co-opted by the successive right-wing governments and functions as an illusion of a commitment to change, which in reality has never existed. It has even given up on its ideal of universality with instead a focus on expanded eligibility, and with no clear plan for the future of healthcare provision outside the market.
Many were excited by the promise of Sláintecare, myself included. But its focus on leadership, change management and innovation to deliver health reform has shown the limits of such an approach divorced from a wider social movement. It failed to recognise that the potential for change lies with workers and patients and that value in healthcare cannot be realised by such a top-down approach.
A technocratic solution to a social problem
The Irish healthcare system is in a state of perpetual crisis. We have the by far the longest waiting lists in Europe, the highest bed occupancy levels in the EU, high levels of out-of-pocket payments and the total lack of fundamental healthcare services in many areas including community mental health and community rehabilitation.
Both health and social care systems in Ireland have seen neoliberal reforms in the past two decades result in an increasing reliance on the private sector to provide care, examples of which include the use of the National Treatment Purchase Fund and the Fair Deal Scheme. We also uniquely see the situation where private patients can skip queues to access publicly provided healthcare.
The academics involved with the development of the Sláintecare report were very aware of these failings, in fact they are some of the most insightful critics of the Irish healthcare system. Much of the technical analysis of health systems was absolutely correct.
The “Beveridge” model was chosen as the most appropriate transition for an Irish context in the path to universal healthcare. This equates to a health service funded from general taxation, such as the NHS. It contrasts with a social insurance model, a “Bismarck” model, by allowing for increased central control and planning of the health service, but where funding can be more volatile when contingent on political whims.
The Sláintecare Report rightly rejected a private insurance model akin to that of the United States. Private insurance models are more expensive and less efficient than other models. Relying on the free market to provide a societal need, their inability to plan demands a complicated regulatory system. And the need to individually bill for each healthcare intervention results in large bureaucratic overheads.
Latest figures based on 2017 data from the World Health Organization shows that the US spending on health care represents 17.1% of its total Gross Domestic Product, the figure for Ireland is 7.2%, and for the UK is 9.6%. In fact, despite its ideological commitment to private healthcare, 8.6% of the United States’ total GDP is spent by the state on healthcare.
The Sláintecare team understood this, but by seizing on mainstream health policy theory they looked for a technocratic solution to a social problem. The theory, drawing on work by Kingdon, was that there existed a “policy window” for healthcare reform. There was a defined problem (healthcare crisis), there was a solution (Sláintecare) and there was a political consensus. Those involved were upfront in presenting Sláintecare as taking health out of politics.
Historical lessons in health reform
The history of healthcare reform shines a light on its fundamentally political nature. Going back to the English Civil War various elements within the Levellers and the Diggers saw within the revolution, the potential to provide healthcare for those in need. And this social demand for better health was again present at the time of the French Revolution of 1789.
However, it was the 1848 revolutions which saw a turning point in the way in which healthcare was conceived as a social need. Robert Virchow, known as the founder of modern pathology, joined the barricades in Berlin. Influenced by the works of Engels, he became an important theorist of the role of class in creating health inequalities and recognised the need for societal reform, even revolution.
While the revolutions were defeated, there was a lasting fear of further revolution amongst the bourgeoisie and a recognition of the need for concessions in terms of socioeconomic rights. Following the economic depression of the 1870s, working class mobilisation again rose.
In 1883, Otto Von Bismarck, an authoritarian conservative, conceded to the demands of a rising labour movement and granted a form of social health insurance which targeted specific workers under the “Sickness Insurance Law”. While it was designed as an attempt to bribe elements of the working class rather than provide universal healthcare, it marked a significant milestone for healthcare reform in Germany. The turn of the century saw similar legislative healthcare gains in France and the UK in the face of widespread working-class unrest.
In Europe, the period post World War Two saw a mobilised working class demanding socioeconomic rights including healthcare. Backed by a strong union movement, the Labour Party swept to power in the UK in 1945. Building upon the principles of the Socialist Medical Association, and backed by the Trade Union Congress, universal healthcare was a key demand. However, its introduction was opposed by the British Medical Association who sought to defend their private interests. The NHS came into being in 1948 and is now regarded one of the greatest political achievements of the welfare state.
In common with other nations following the war, there was a political move towards universal healthcare in the United States too. But like in the UK, the medical lobby came out vociferously against universal healthcare. An effort led by the American Medical Association was successful in painting universal healthcare as “socialized medicine” and managed to marginalise the movement which lacked the level of backing from organised labour seen in European countries which had succeeded in winning reform.
The United States was and remains the richest country in the world, but this does not guarantee its citizens healthcare. In contrast, social movements in much poorer countries across the world won healthcare reform during the course of the twentieth century.
Take for example Latin America. The 1925 Chilean constitution specifically recognised that healthcare is “the duty of the state”, while a limited National Health Service was introduced in 1952. Further progress towards universal healthcare under Salvador Allende, a physician himself, was halted by the US backed coup of 1973.
Socialisation of healthcare occurred in Cuba during the 1960s, after their revolution. And after the 1979 Sandinista revolution in Nicaragua a Unified National Health System was introduced which saw the percentage of the population with access to professional healthcare increase from 28% before the revolution to 70% by 1982.
In Ireland, there were indications of the possibility of universal healthcare following the end of the second world war. A White Paper was produced in1947 proposing a Beveridge style healthcare system and another in 1949 proposing a form of social insurance. But ultimately reform was defeated by opposition from the medical profession and the church, epitomised by their objections to Noel Browne’s “Mother and Child Scheme” which was an attempt to introduce universal healthcare for mothers and their children up to the age of 16.
There was no social movement in Ireland demanding universal healthcare at that time, and that remains the case today. Likewise, private healthcare organisations immediately attacked the Sláintecare Report on its release, as did the Irish Medical Organisation and Irish Hospitals Consultants Association who opposed the idea of removing private practice from public hospitals. These conservative forces were not seriously challenged by Sláintecare. The rebranding of Sláintecare by successive right-wing governments has won the day and universal healthcare appears as far away as ever.
Markets cannot deliver universal healthcare
“The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.” Julian Tudor-Hart
Julian Tudor-Hart was a socialist GP who practiced in the small mining community of Glyncorrwg in the Welsh valleys. The “Inverse Care Law” as described by him provides a framework for understanding healthcare related inequalities. He posits that market mechanisms cause health inequalities and that this effect acts at a both the individual and the societal level.
For example, at an individual level he describes the historical difference between the care that doctors working in poorer mining communities in England and Wales could provide for large communities with little means compared with those doctors who worked in wealthier communities who could afford their patients more time and resources.
At a societal level market-orientated care results in a perpetual inequality that sees more resources diverted to affluent communities or more lucrative types of medical care developed at the expense of others.
At the time of its formation Nye Beven declared that “the NHS is socialism”. Public control of healthcare meant that money was invested into buildings and services rather than going into the pockets of owners or shareholders. In addition, hierarchies in decision-making and planning were challenged. It was recognised that healthcare can only truly be delivered by healthcare workers, working together with their patients, rather than a system orientated to providing profits.
However, compromises made from the start meant that hopes for the democratisation of healthcare within the NHS were never truly fulfilled. The 1970s saw Thatcher undermine any illusion of management by consensus and reinstate a top down management approach termed “general management”.
In the early 1990s the NHS saw its most radical ideological reform with the introduction of the internal market by John Major, creating a “purchaser-provider spit” relying on the allocative efficiency of markets. This was consolidated by New Labour who made purchasers, now termed “commissioners”, independent of the NHS and introduced increased market regulation. They also increasingly promoted the privatisation and financialisation of capital investment with the promotion of Private Finance Initiatives creating “public-private partnerships”.
This rightward shift culminated in the 2012 Health and Social Care Act which explicitly opened up the NHS to for-profit providers who can now cherry pick the most profitable parts of the healthcare system. Much of the NHS budget now goes to paying back PFIs or to shareholders of very profitable companies instead of being invested in services. In addition, a lack of autonomy over budgets or planning has led to an increasingly fragmented and inefficient system overall.
The effects of this piecemeal marketisation is all too visible in the north, where waiting lists are at an all-time high leading to what is effectively a two-tier system. Successive Stormont Executives have been unable to turn the tide, and indeed have overseen this privatisation-by-stealth.
The south is unusual amongst highly-developed countries in never having provided universal healthcare. It relies heavily on market mechanisms for the provision of services not organised by the state. For example, Ireland has the only health system in the European Union that does not provide universal coverage for primary care. Even within state-provided care most patients are required to pay, although these payments are means tested. Immunisation is one of the only truly universal healthcare services delivered without charge, along with national screening programmes.
The promise of an All-Ireland NHS
Sláintecare attempted to depoliticise healthcare in Ireland. It appealed to a particular sensibility that would see rational, evidence-based decision making prevail. However, this was never going to deliver equitable healthcare. The class forces which reproduce our current two-tiered system were never seriously challenged and this should be a lesson for future struggles.
Covid-19 has, however, shone a light on the potential for radical change. Never was healthcare reform enacted as quickly as it was in the period of emergency preparedness required to manage a global pandemic in a country with such a short supply of hospital and ICU bed capacity. Private hospitals being taken under public control should be the wake-up call for us that shows us an alternative system is possible.
However, the vehicle for change is currently missing. The social change required to reform of our health and social care systems needs a strong social movement behind it. And this must be a broad movement with the backing of left parties, unions and other campaign groups. The All-Ireland NHS Campaign envisions a 32-county universal healthcare system where access to healthcare is not determined by your ability to pay. It has the following key demands:
- Private hospitals, requisitioned during the crisis, should be nationalized
- The exclusion of private practice and fees from public hospitals
- Permanent publics sector-only contracts to be offered to new consultants
- Public ownership and control of voluntary hospitals, including the National Maternity Hospital
- Reward payments and an enhanced career structure for nurses and health care workers
- Publicly- funded Primary Care that includes mental health support, physiotherapy, speech therapy etc.
- An integrated Health and Social Care service
- A publicly established system to regulate access to and pricing of medicines