THE COST OVERRUN of the National Children’s Hospital has brought public healthcare spending in Ireland into sharp focus.

The causes of the overrun have been attributed to a myriad of factors including inflation, design changes, underestimation of ICT costs and, most damning of all, the contentious decision to locate the hospital at St James’s.

The figures associated with both the cost overrun and its review are staggering.  PwC has been commissioned to undertake a review of overspending between now and the end of March and that review alone will cost €450,000. 

As we cry in frustration over the recurring ineptitude of the state to deliver a decent public healthcare service for citizens, it might be useful to cast our eyes back over a history of decision-making in healthcare and ask whose purpose is being served?

How did we get here?

When Irish citizens voted in favour of the Treaty establishing the Irish Free State, our independence was only half-won.

I’m not referring to the oath of allegiance, or the selling out of Northern Irish Catholics, but to key state functions which were ‘entrusted’ to Catholic religious orders, namely education and health.

The legacy of those decisions and their consequences are sharply felt to this day.

Since Ireland became a Republic, we have pursued a very different path to our closest neighbour in our policies and actions to safeguard citizen’s health.

The British NHS was set up in 1946 when Labour MP Aneurin Bevin faced down the wrath of the British Medical Association, whose members strongly challenged the idea over fears of loss of private income.

Bevin had public support; the country was experiencing a period of post-war solidarity as war veterans returned, many with severe disabilities. The NHS was highly progressive in that it was funded entirely through taxation. This eliminated user fees or out-of-pocket payments, which were susceptible to commercial interests.

Around the same time, Dr Noel Browne tried to introduce the less ambitious plan of free healthcare for mothers and children under 16 years in Ireland.

Despite widespread public support for the scheme, it was ultimately blocked by politicians in the vice-like grip of the bishops and under the influence of the powerful medical profession.

The Church’s stance, that the state should have limited involvement in ‘family issues’ including healthcare, became embedded in national policy.

In the new Free State, healthcare was delivered by family doctors, in people’s home if they could afford it or in religious and charitable hospitals.

Responsibility for public health activities such as sanitation and provision of clean water lay with local authorities. The very first Minister for Health was appointed in 1946 and the Department of Health was established the following year to take over responsibility for all aspects of public healthcare.

The Department focused its resources fighting infectious diseases such as TB and ushered in a period of intensive hospital building with funding from the National Sweepstakes.

Investment in hospitals and public health generally succeeded in reducing the burden of TB and improved national health indicators such as infant mortality. Serious questions remain to this day, however, over the ownership of institutions funded primarily by the state and run by religious orders.

Two-tier system

In 1957, the government established the VHI in its current form, a subsidised semi-state company that provided health insurance to those who could afford it. This policy decision resulted in the creation of a two-tier health system and remains in place today.

The VHI is a critical impediment to the implementation of a system of universal healthcare, which the government has committed to under the SDGs and is envisaged in Sláintecare.

While services expanded, there was little significant reform of our health system in the subsequent decades. The church and medical profession maintained their grip and no national conversation took place around the core values underpinning our systems such as equal access, equitable allocation of resources and good governance.

One significant development, however, was the introduction of tax reliefs for private hospitals, a direct result of government lobbying by private interests.

This policy change, by the Department of Finance, had enormous ramifications for the public hospital system. It encouraged private for-profit operators into the system which increased the complex mix of publicly and privately funded services.

The UK fought to prevent this occurring as it understood the symbiotic nature of public and private systems: if one is strong, the other has to be weak. In other words, if our public health system was strong, there would be no demand for private hospitals.

Universal Healthcare

The Department’s 2001 policy Towards Quality and Fairness, introduced by Minister for Health Micheál Martin, espoused the need for stronger care in the community. It went nowhere.

With Charlie McCreevy holding the purse strings in Finance and calling health a ‘black hole’, the plan never stood a chance.

From 2011-2015, the main policy pre-occupation in the Department of health was Universal Health Insurance. Based on the Dutch model, it proposed a competitive, multi-payer insurance model for the whole population.

An ESRI report in 2015 which costed this approach finally ruled Universal Health Insurance out as a viable policy direction. Between 2015 and 2017 when the Sláintecare report was published there was a policy void with no clear direction for our public health system.

What can be learned?

This is a whistle-stop tour of Irish health policy. There are stark lessons to be taken, however, from the experiences outlined here.

A hospital-focused, insurance-led system may have made sense in the middle of the last century but healthcare and health system indicators today stress the need to change this high cost, overly complex and bureaucratic model.

Ineffective policy decisions since the foundation of the state have at best, curtailed system improvement, and at worst harmed it.

Despite Tory-inflicted damage, the NHS has many distinct advantages over our public system, and it does vastly better on key performance indicators.

It should be pointed out the NHS has benefited from independent evidence-based research and policy advise produced by philanthropic bodies such as The Health Foundation, The Kings Trust and The Nuffield Trust which are entirely absent in Ireland.

More importantly, it has Public Health England (PHE) an executive agency of the Department of Health and Social Care that provides government, local government, the NHS, Parliament, industry and the public with evidence-based professional, scientific expertise and support.

PHE employs over 5000 scientists, researchers and public health professionals looking at all aspects of healthcare systems and services. Ireland has no equivalent.

Policy of inaction

Scandals such as the massive cost overrun of the National Children’s Hospital are damaging to public health on so many levels, not just now but long into the future, through the deferral of other necessary capital projects, the clear lack of governance and accountability and the loss of trust and hope for the future of the public health system.

In the 1920s the Irish people overthrew one oppressor only to hand over the shackles to another. The influence of the church and some self-interested medical professionals on public health policy has never been adequately addressed.

A hundred years after the first meeting of the Dáil, it might be interesting to ask, what an independent health system might look like?

What values would we like to see underpinning our health and social care systems?

Every student of public policy knows that all policy decisions, including a policy of inaction, have winners and losers.

As our public health system continues to be led in a chaotic fashion it begs the question, who is fighting for the public system?  Is it failing because we have, consciously or unconsciously, chosen the path to failure for a long time?

Maebh Ní Fhallúin has a Masters in Public Health. She is a public health policy researcher and advisor with a background in media and communications.