Despite the heroic efforts of overworked and underpaid frontline workers, the pandemic has exposed the sorry state of health services north and south. Conor Reddy argues that the case for an All-Ireland National Health Service has never been stronger.
As Covid-19 case numbers rise and hospitals once again come under strain, the devastating consequences of years of cuts and underfunding of health services North and South are cast into sharp relief. With winter, and the now annual ritual of “winter crisis”, approaching, the human cost of this neglect, amplified by the toll of the pandemic on health services, could be enormous.
Recent decisions to return to lockdown have by and large been necessitated by the sorry state of healthcare on the island, and by the failure of both the Southern Government and Stormont Executive to address the issue of healthcare capacity since the pandemic began. Similarly, the absence of an integrated, cross-border public health strategy on Covid-19 has undoubtedly contributed to the significant outbreaks of the virus across the North West – from Donegal to Derry, from Lifford and Stranorlar to Strabane.
The case for an All-Ireland National Health Service has never been stronger.
Covid Casts A Light
In the early and most acute phase of the pandemic, during the so-called, “First Wave”, the threat of hospitals being over-run was a real and present danger.
News clips and reports from Italy and China showed doctors and nurses struggling to cope, faced with impossible decisions, forced to ration access to ventilators and Intensive Care Units. These pictures weren’t coming from countries with supposedly primitive or under-funded health systems; they were coming from countries with systems far better equipped than either the Northern NHS or the Southern two-tier system.
In Italy, where some of the most distressing stories were coming from, there were far more hospital beds available in the public system and roughly 12.5 ICU beds for every 100,000 people. In Ireland, there were between 5 and 5.5 per hundred thousand, and significantly less acute hospital beds available.
Furthermore, as a consequence of a decade of austerity, both systems on the island were experiencing dangerous staffing shortages. Recruitment freezes, pay inequality and poor conditions for healthcare workers have forced large numbers abroad to work in systems where their work is valued and better rewarded. Covid cast a light on these long running structural deficiencies in healthcare and showed the need for transformative change.
The devastating, destructive potential of Covid in context of these deficiencies forced a truly unprecedented set of interventions, from both the Southern government and Northern Executive. Almost overnight, politicians did the impossible. Health budgets were beefed up, recruitment embargoes were lifted and perhaps most significantly, Dublin and Belfast signalled their intention to put private hospital capacity to public use.
In the South, on the 24th of March, acting Health Minister, Simon Harris remarked:
“We must of course have equality of treatment, patients with this virus will be treated for free, and they’ll be treated as part of a single, national hospital service. For the duration of this crisis the State will take control of all private hospital facilities and manage all of the resources for the common benefit of all of our people. There can be no room for public versus private when it comes to pandemic.”
Against the backdrop of a two-tier system that health policy academic Sara Burke labelled “Irish Apartheid”, the significance of this statement is hard to overstate. Immediately, people were asking, if care can be provided for free, and accessed according to medical need for Covid-19, then why not in other circumstances? Why should the ability to pay for care or take out insurance dictate outcomes for cancer patients, waiting times for those suffering and in need of hip replacements, or whether or not older people blinded by cataracts get to see again? Unwittingly, Harris and the caretaker government in the South raised the possibility of a radically different approach to health in Ireland.
It was in this moment that a fully public, National Health Service became a possibility, as well as a necessity, in the minds of people across Ireland and it was in acknowledgement of this new reality that a group of activists, healthcare workers and campaigners established the Campaign for an All Ireland National Health Service.
Before Covid, healthcare existed in a state of almost permanent chaos. Along with the problem of under-resourced services, came a “Do More With Less” managerial approach which emphasised efficiency and cost-effectiveness over people’s health and the interests of those working in healthcare. This managerial style justified cuts to health budgets, vilifying person-centred and more localised provision of care as “excessive” and in need of “rationalisation”.
The managerialist approach to healthcare, encapsulated by the HSE and the NHS under New Labour and the Tories, is more than a convenient justification for cutbacks. It was the consequence (and necessity) of commodification taking place elsewhere in the Sector. In the NHS, the arrival of Private Finance Initiatives (PFIs) and the establishment of internal market mechanisms from the 1990s through the 2000s, opened up a previously public system to private profiteers and market logic.
In the South of Ireland, the rapid growth of private medicine, the privatisation of nursing homes and the expansion of the Health Insurance Industry over the same period had a similar effect on the delivery of public healthcare, with which private medicine is more enmeshed than is the case in the NHS in Britain or the North.
These processes of commodification drove ideological spill-over, where impossible market standards of efficiency were applied to public systems not set-up to meet them. Their aim, of course, was to deliver care. This has meant that “inefficient” services are opened up to cycles of cannibalisation and erosion. In the south of Ireland, almost 50% of people have private health insurance, because the public system has been so thoroughly eroded by successive governments with close ties to private insurers, private medicine and private care providers.
While these trends are particularly neoliberal, the vested interests in private medicine that drive them forward have a longer provenance. There has never been a coherent publicly controlled health service in the Southern state – primary care is provided by private practitioners and over 51% of hospitals are under private control, as non-profit, “voluntary hospitals” or as private profit-making outfits, which have grown significantly over the last three decades.
The historical lineage of voluntary hospitals is particularly interesting, as many of these institutions remain in the hands of the Catholic Church and its religious orders – important bulwarks against the development of a public system in Ireland. When Dr. Noel Browne proposed rolling out free primary care for mothers and children under the age of 16 in 1951, it provoked a ferocious backlash from the Church and the medical profession.
The scheme proposed by Browne was immediately tarred as a plot to implement “Socialised Medicine”, wrenching control from those of “good moral standing” and opening up the possibility of such horrors as “gynaecological care not in accordance with Catholic principles”. The guild-like medical elite of the day were as avidly opposed to Browne’s scheme, but more to protect their own privileged position rather than Catholic moral teaching (although the Church exercised close control over appointments to the top of the medical hierarchy).
Today, although the conservative stranglehold of the Church on society has been broken, religious orders retain control over much of the southern hospital system. Their control now is qualitatively different, less concerned with upholding moral purity, the holy orders influence is channelled through high-powered legal and corporate representatives who sit on the boards of hospitals and hospital groups, with more profane, material interests in mind.
Today, the largest provider of private healthcare in the Southern state is the Bon Secours Hospital Group, which is owned by the same Bon Secours order who ran the Tuam Mother and Baby Home, where the remains of over 800 babies were found buried in a disused Septic Tank in 2017.
The ongoing debacle over the ownership and control of the National Maternity Hospital (NMH), which is being built on the St. Vincent’s Hospital campus in Dublin (Sisters of Charity), is another case in point, demonstrating the changing relationship that religious orders have with Irish healthcare. This shift by religious orders, to a more commercial engagement in healthcare is worrying, given their influence in the private, non-profit voluntary hospital sector – in the case of the NMH and St.Vincent’s Holdings CLG, the blurred lines between private and public allow for profiteering on the back of the public system.
This of course, is nothing new. Private medicine is practiced in almost every public hospital in the state and without state incentives, the private system would collapse. What is novel about the NMH is the legal acrobatics that the Sisters have practiced, placing the hospital under the control of a corporate structure, whilst claiming that they were “gifting” their stake “to the people of Ireland” – this signifies a colder, more mercantile approach to health than their purely religious interference in the past.
Sláintecare – Dead on Arrival
While the pandemic cast new light on deficiencies in healthcare on the island, these deficiencies weren’t hidden or unacknowledged before Covid. After housing, healthcare was identified as the most important issue to voters in the historic February election, where Fianna Fáil and Fine Gael combined, secured less than half of the vote for the first time since the foundation of the Southern state.
The experience of three hugely significant strikes involving healthcare workers in both jurisdictions in 2019 is testament to disquiet inside the system too.
Recognising the sorry state of healthcare in the South, all parties in the Dáil signed up to the 2017 Sláintecare Report, which recommended the establishment of a single-tier Universal Healthcare System, with access granted on the basis of clinical need. The initial report, which came from the cross-party, Committtee on the Future of Healthcare, was from the outset, a technocratic solution to a social and political problem.
Despite laudable policy objectives, Slaintecare failed to address the structural and historical realities that explain the state of healthcare delivery today. Since its publication, Sláintecare has been picked apart and diluted by politicians that only gave their assent to the original report because they were not in a position to contradict the evidence of the medics, academics and patient groups that made contributions in the drafting process.
In the 2019 Sláintecare Implementation Strategy, the commitment to Universal Healthcare was qualified as “healthcare which would not put people at risk of financial harm”, opening the door for the preservation of two tier healthcare in Sláintecare. This year, in the Programme For Government document, the concept of free and universal access was eroded even further, with an assertion of the importance of “choice in healthcare” in the Sláintecare implementation process – in other words, the preservation of the private health insurance industry and private medicine.
These moves to dilute and frustrate the intitial intent of the Sláintecare project are perhaps not surprising, because the whole process was alienated from the social forces that could defend and deliver it from its inception. Sláintecare, despite its progressive policy objectives, was in effect, dead on arrival.
A Movement for An All Ireland National Health Service
Recognising the immediate need and potential for transformation across our health services, and the weaknesses of previous attempts to reform healthcare, we need a movement that engages healthcare workers and the public in the fight for an alternative.
The Campaign for an All Ireland NHS was founded as a broad coalition of workers, political parties, activist organisations and academics, all committed to the basic idea of a fully public, 32 county health service.
Since its inception in May of this year, the Campaign has gathered significant support – receiving endorsements from local councils, several political parties, trades councils and prominent public figures, like Vicent Browne and Úna Mullaly. The Campaign have hosted a series of online discussions, covering key questions related to healthcare – including responses to Covid-19, health inequality and the broad issue of womens’ healthcare.
With Covid-19 restrictions making mass mobilisation difficult, the Campaign have focused on small, local demonstrations of health workers and campaign supporters, rather than large scale demonstrations or protests. A key challenge moving forward will be growing the Campaign’s presence on the ground in spite of Covid-19 restrictions – safe, socially-distanced protests and closer integration with workplace activity by healthcare workers and unions will be the backbone of our strategy to mobilise people in the coming months.
Although the campaign is relatively new, it is significant as an expression of an emerging progressive, All Ireland politics. For the Left, this campaign and others like it, present an important opportunity to project our vision of a radically different Ireland and to practically articulate our opposition to partition as Socialists. To paraphrase Eamonn McCann, our campaign is not a campaign for a United Ireland, but a campaign “of a united Ireland”. Socialists across Ireland should get involved.