Open Letter to the future Minister for Health 2020-2021

On a comprehensive Health Service after COVID-19
16/4/2020

My mum was born in Dublin just before WWII, the year the Third Reich invaded the Sudetenland. Last week she tested negative for COVID-19, this week she died from that same virus in a County Dublin Senior’s Home run by Ireland’s Health Service Executive (HSE).

All her life my mum had paid for increasingly expensive private health insurance. Since the onslaught of the virus responsible for COVID-19 my mum’s insurance payment hasn’t made a blind bit of difference to her care under COVID-19. I’m fine with that.

If this latest health crisis taught us anything it is that there is no reason at all for a private health insurance industry, quite the opposite, it is an expensive luxury we can no longer afford.

European Health Insurance Cards are printed on blue plastic the size of a credit-card. They give EU citizens the freedom to travel, to work abroad and to get sick, and to get treated within the EU. Within this scheme the HSE provides a service that economists call a free rider. If a French, German, Dutch or Spanish visitor presents their blue card in an Irish hospital or if an Irish person does the same in any of these countries. Well guess who receives the better treatment?

Private health insurance implies paying twice for one’s health services while not buying private health insurance means lacking a reasonable health service which you already paid for in your taxes. The profit from this double payment by those who can afford it is absorbed by overcharging by health professionals, exorbitant private health facilities and profits for firms selling health insurance. Private health profits have risen massively in the current pandemic since COVID-19 is paid for by governments and elective procedures are on hold.

Ireland has no national health service, this is not a result of privatisation, rather Ireland never had a public service. That is not because the concept is unpopular but because it is unprofitable. Ask any Irish voting tax payer and they’re emphatic, the vast majority require that our next health minister, yes, you minister! will provide a national health service for all: young, old, rich and poor. We wish to be able to confidently rely on this service for our very lives. Health care is a human right, one that costs money. Like public housing and public transport, a working national health service is a basic necessity for any functioning state yet many people pay taxes for health then they also pay insurance companies to supplement a service that is insufficient. That is crazy; it is like paying for a seat in a train because the only seats free are in first class.

Before COVID-19 Ireland had two health systems which operated in parallel drawing resources from the same limited pool of healthcare workers, hospitals, medical equipment and patient beds. Most doctors worked in both the private and the public sectors, being paid by both! Then came the virus and private health resources were nationalised so that they might defeat the virus. The neoliberal doctrine of the former governing party, Fine Gael, mandates limiting the power of the state, so why did they do this? Fine Gael nationalised private facilities, albeit temporarily, because they had to, because it made sense (at least until wrangling over consultants pay meant that it didn’t) and because that Minister recognised that the current (dual) system could not cope with COVID-19!

In retrospect it is not hard to argue, Minister, that the health system you are taking on now, never made sense. Ireland’s health services are an ‘executive‘, a management structure with its own internal rules, supplemented, for some, by ad-hoc private health systems duplicating certain healthcare resources on a for profit basis. In practice, however, the costs of private healthcare services are subsidised by the public purse.

Take larger city hospitals for example. In Southern Dublin the largest hospital is called Vincent’s Hospital, a training hospital for Ireland’s future health professionals. It is divided into public and private. Both offer equivalent services, often with the same specialists working both privately and publicly in the same hospital on different days. The hospital has two separate entrances, two car parks, two administrations, duplicate wards for the same diseases and various legal offices (outsourced of course). In practice these equivalent, but separate, facilities are interlinked via hidden tunnels allowing healthcare professionals to move between private and public wings without having to venture outside as necessitated by Ireland’s weather.

Only certain profitable hospital services are shared. The morgue, for example, is neither profitable nor fashionable, nor does it require it’s own parking, so Vincent’s has only one public morgue. If linking up public and private hospitals via hidden tunnels is not a sufficiently clear reflection of the false dichotomy that is public and private health, then, dear Minister, let me explain with a personal anecdote from this same hospital.

At the turn of the Millennium my father died of MRSA in Vincent’s. Towards his end he was being treated in a private ward. Dad was also careful to pay for private health insurance (in fact he worked in the insurance industry). His treatment required intensive care so we were rather confused when his private nurse suggested that my father move from his luxury private room to an equivalent ward in the public wing of the same hospital. Consultants, the nurse explained, are “on call” in the private wards which means in practice, she explained, that they were rarely present late at night. In the public wards, however, busy doctors are present 24×7.

Again, Minister, is this not further evidence that we need one system focused on everybody’s health, funded once, by our own State taxes?

History shows that national medical emergencies (a plague, a war) are great levelers. Measles, polio, cholera, MERS, SARS (and the new SARS we call COVID-19) affect all humans without class distinction. To fight a national (or even a global) health emergency we need a public health response from a national health service coordinating through the WHO. This 2019 corona virus kills many older people, it killed my mum today.

Many of Ireland’s older people are members of society who, relatively speaking, are richer. They’re unaccustomed to vulnerability and less accustomed to asking the state for help. Their life’s work has funded this state all of their lives. If your predecessor, Minister, had not decided to temporarily nationalise private health resources in the COVID-19 emergency many many more of these people would be dead. Mr Harris said there was “no room for public versus private in these times“. When is there ever such room for duplicate and overlapping systems when it comes to human health?

How did Ireland come to this? Why did we have to choose between Boston or Berlin*? Ireland has historic and language links with the United States since both were part of the British Empire but today Ireland is a very long way from Boston. Given the current pandemic I think most people, those who pay for private health insurance or not, would choose Berlin over Boston any day. COVID-19 killed so many more people in New York than it did in Frankfurt. Many of these deaths in US cities were untimely or unnecessary. The US does not lack resources, but it is the epitome of the duplicate health system, neither the public nor the private system function in a comprehensive way for public health.

Ireland’s short history as an independent state and a conservative resistant to change, has left the nation stuck with a model that reflects the differences in health care between London’s Harley Street and the care for the poor afforded to the Victorian terraced slums of the late British Empire, one health service for the rich and another for the poor. But Britain was an Empire and a bellicose state needs a military hospital system. Ireland inherited that health system too but most are now museums. Britain was forced to recover from this dichotomy after WWII, when my mum was a toddler, the post-war government launched the National Health Service (NHS), the same system that saved the life of their current public-school educated conservative leader Boris Johnson when he contracted COVID-19.

Mr Johnson is not a man to allow his private health cover to lapse for want of payment. Ireland kept out of WWII. In the interwar years the nascent state delegated social services (including many health facilities) to Catholic charities. Effectively this meant that the Irish taxpayer subsidised the Catholic church to provide social services. This did not work out so well then either and leave the state with many conundrums in religious-run for-profit hospitals like St. Vincent’s in Dublin where it is currently planned to build a new national maternity hospital with abortion services.

In 2005 Ireland integrated regional health services all across the Island merging them into a bureaucratic Health Service “Executive” (HSE). Some years later the state hospitals were re-organised regionally; again avoiding the creation of a national service, neoliberal governments do not like to compete with the private sector even if they know that this makes no sense. In 2020 COVID-19 showed Ireland that it also makes little sense to duplicate health care and administration across the private and public sectors.

Rather, dear Minister, the valiant solution is to build a national comprehensive public health service in Ireland comparable to the best available in other European Nations and better than the current NHS which is plagued with privatisations and quangoes.

This is your task Minister! Please do your job and take the necessary steps for Ireland’s national health needs. In the current health industry absurdities abound and they are none too cheap. Let’s fix this! Health is a human right not a private industry. Time to bite the bullet, in time to solve this plague and future health emergencies too. In this age of climate change and global travel we cannot afford divided health services for rich and poor. Instead it is time to provide a comprehensive solution for a healthy society.

Post-Script

Two years ago COVID came to Ireland bringing with it a clear and present need for a public health solution. This has not happened. COVID helped focus plans to change a two-tier, public-private, health industry into a functional public national healthcare system. In Ireland previous governments had promised to take a baby step toward this goal called SláinteCare. It would have been insufficient but even that baby step was not even given a chance. Even Sláintecare proved impossible as evidenced by the resignation of those who were trying to make this plan a reality.

Post- or endemic-COVID we shall return to the run-of-the-mill requirement on the health system such as planned surgery, hip replacements, and cancer treatment… For those who cannot afford private health insurance the waiting lists will be impossible, and sometimes fatal. While COVID now fills public beds, it creates even longer waiting lists for essential. often life-saving, care. During COVID private hospitals private hospitals have been essentially empty for fear of contagion, you sir, subsidised them overly generously with taxpayer funding renting private beds to the public sector at inflated prices (approximately three times the cost of per bed in the UK).

COVID has made both private and public health systems essentially unworkable; the workers in that sector have sufered dreadfully and been given a pitiful 1% pay rise. The only health system that can work for Ireland is a properly funded national health system but this is anathema to neoliberal political parties like Ireland’s two centre-right equivalent political parties: Fianna Fáil and Fine Gael (or FFFG). These civil war legacy parties, currently in coalition, are attempting to survive their first century but it isn’t looking good for either of them.

The Irish people must demand a working health system in the streets as the did when these same parties tried to charge citizens of Ireland for rain water. If we fail to call for a working health system we will continue for another 100 years with healthcare available only to those willing to pay for it twice (once through taxation and once more by buying health insurance).

[*] Irish welfare policies (such as health) are often compared to those of the United Sates or Germany; the press uses the alliteration “Boston or Berlin?”

This article has been updated to internationalise the message for those unfamiliar with the Irish health system and its history in the 100 year-old State.