Dáil debates

Wednesday, 15 May 2024

Delivering Universal Healthcare: Statements


2:40 pm

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael) | Oireachtas source

I welcome this debate. I am thankful for being provided with some time to contribute to it, both as a Member of the House and a former Minister for Health and former Head of Government. When we talk about universal healthcare or universal health coverage, one of the most important questions we need to ask is how it is defined. It means very different things to different people. Perhaps the best definition is that offered by the World Health Organization, WHO, which is that universal healthcare means, simply, that all people have access to a full range of quality health services when they need them, without financial hardship. The WHO definition further states that all forms of healthcare should be covered, "from health promotion, prevention, treatment, rehabilitation and palliative care". This is achievable in Ireland.

Some people talk about universal healthcare in the context of having an Irish NHS or copying the form of healthcare provided in Northern Ireland and Great Britain. That is not a good model for the 21st century. Whatever about in 1948, it certainly is not right for 2024. In the NHS, north of the Border and across the water, we see a system in which patients wait longer and have poorer outcomes, staff are paid less and social care and healthcare are not integrated. That is not a model we should follow in this State. We see much better models on mainland Europe, including in Belgium, Spain and Germany. In those countries, there are very strong community health services but they are not necessarily free at the point of use. There may be co-payments, refunds or systems whereby everyone is required to have some form of insurance. The services are not necessarily run by the state. In Germany, for instance, hospitals are run by voluntary bodies, state entities and private entities, thereby providing maximum capacity, competition and good value.

The Sláintecare report encapsulates Ireland's ambition for universal healthcare provision. It is a very good report but it has limitations. It leaves many policy questions unanswered. It favours affordability over capacity, which I believe is flawed. It promotes making everything free or almost free ahead of creating the capacity to cope with increased demand. That is one of the flaws that has not been identified sufficiently. The report speaks to four objectives, all of which I strongly support, namely, making healthcare more affordable, making it more accessible, ensuring better patient outcomes and making sure healthcare is integrated and reformed.

I take this opportunity to compliment the Minister, Deputy Donnelly, and his team on the very significant progress made in the past four years. It is probably more progress than we have seen in decades. Of course, he had the money and he has been able to build on progress made by previous Governments. I hope the Minister and his team get credit for what has been achieved in the past four years because it is considerable. I congratulate the Minister of State, Deputy Colm Burke, on becoming part of that team, having previously been Fine Gael health spokesperson.

The first of the four objectives I identified is affordability. We now have free GP care for everyone aged under eight and over 70 and for those in receipt of carer's allowance. The means test is being relaxed to the extent that middle-income, working families can now qualify for free GP care. Approximately 50%, if not more, of the population now qualify for free GP care for the first time, although huge numbers of people who are entitled to it have not yet claimed it. That is an issue we must address. We have seen inpatient hospital charges abolished. Medicine costs have been reduced through the drugs payment scheme, with no household paying more than €80 a month for medicines. There have been real improvements around sexual health, particularly by way of the PrEP programme and the availability of free sexual health testing through the post. IVF is now being funded. Free contraception is available for a lot of women, but not yet all. We have the vaccine programme.

I encourage the Minister and the Government not to forget affordability. We are not there yet. Healthcare is still very expensive for a lot of people. Medication costs, at €80 a month per household, can still be quite high for a lot of people. The cap should be brought down further or perhaps, like Finland, we should have an annual maximum above which nobody has to pay. Another factor to consider in regard to affordability is the difference between a medical card and a GP visit card. The Department argues that the cost of upgrading a GP visit card to a medical card is hundreds of euro. I am sceptical about that, given that hospital charges have been abolished and drug costs have been capped. Over the past couple of years, we have seen the number of full medical cards go down and the number of GP visit cards rise dramatically. The next step should be to convert more GP cards into full medical cards. Frankly, I do not believe the costings from the Department. I do not think the cost is as large as has been stated.

The second objective I mentioned is access. The case for increased bed capacity was well made by other Members. I do not need to repeat it. We also need to improve access to medicines. I still do not understand why so many medicines are reimbursed in the UK, Germany, France and other places long before they are reimbursed here. I say that as somebody who tried to resolve that problem as Taoiseach and Minister for Health and as somebody whose chief of staff knew the pharmaceutical industry very well, having worked there previously. It was a nut we could not crack. It is still not explicable to me, as a doctor or as a politician, why a medicine that was reimbursed some time ago in a relatively parsimonious health service like that across the water in England is not yet reimbursed here. There is a significant problem in that regard.

It is really good to see better access to diagnostics for GPs. It is good to see waiting lists falling for the past two years in a row, thereby bucking the international trend. I hope that happens this year as well. However, we see huge variability, particularly between hospitals. We know from bitter experience that emergency department overcrowding is only resolved when three things are right, that is, capacity, clinical leadership and strong management. If one of those factors is missing, there will be an overcrowding problem. If two or three are missing, there will be a very severe overcrowding problem.

It is good to see the progress we are making in terms of patient outcomes. People are 20% to 40% more likely to survive a stroke or heart attack than they were in 2011. People in Ireland live longer than ever before, with life expectancy now in the top five in Europe. Most people survive cancer rather than die of it. Those things were not the case as recently as 2011. We should not forget the very real progress that has been made. I am disappointed that in some areas, particularly respiratory illnesses such as COPD, not as much progress has been made.

In terms of integration and reform, it is great to see the Sláintecare consultant contract up and running and doctors signing up for it in good numbers. It is good that the regional health organisations have been established. I am not sure whether it is right to put Children's Health Ireland, CHI, under a particular region. It should be a national entity and it should be seen that way. It is regrettable that the regional organisations are not legal entities and do not have their own boards and their own bank accounts.

4 o’clock

One of the reasons schools are generally well run in Ireland is the fact that they have a principal, a board, legal authority, and their own bank accounts. A very large hospital in Ireland might not be able to procure something very simple such as a new set of bins for the offices without having to go to the HSE. There is a lack of autonomy at local level and RHA level.

One of the real difficulties we have is when it comes to IT, which unfortunately is very bad in Ireland. It requires a big investment. We know that when new services are set up with new IT systems, they work very efficiently. That is not the case with the old systems. We need to invest in AI as well, which is going to transform healthcare, particularly diagnostics.

Finally, I want to make a quick point about resources. Of course it is important that we have a health service that is well resourced, not just adequately resourced, but we need push back against people who always use resources as the excuse for problems in our health service. Politicians do not take it on enough. When doing interviews, the media never question it or take it on. There are those who always default and say the reason for a failure or inadequacy in our health service is a lack of resources, money or staff, but it is not that simple. If we just take the big picture, Ireland's health service is now very well resourced. We are mid-table in spending per capita. When it comes to nurses, we have among the highest number of nurses per bed and per head in the world. We are probably in the top five. We are now above average when it comes to the number of doctors per head. For example, we have more than Australia now. We are poor on bed capacity though and infrastructure. In that context the Government is making the right decision by limiting the extent to which staffing levels can increase in our health services. They can add staff this year, but it is an extra 2,000 on top of the 8,000 last year, but it will not work if there is not redeployment and if people's roles do not change because we have a lot of staff. They are working very hard and they are very busy, but we are not getting the outcomes from them that we would get from the same number of staff in other health jurisdictions. That is not their fault. The system needs to be changed and those who resist that change need to be stood up to. For example, in other health services, work that is commonly done by doctors and nurses in the Irish system would be done by medical receptionists, health advisers, healthcare assistants, scrub techs or physician assistants. Those roles are not properly developed in Ireland and a real part of the problem is that we are not getting the best out of our highly qualified people.

We also need a particular focus on more senior staff and more specialist areas. Where public health nurses are appointed and where we have advanced nurse practitioners and consultant-led services, we see dramatically better services than those that operate on the traditional model with one consultant with a very large team of junior doctors backed up by non-specialist nurses. We can see examples around the country where best practice works but it is not being mainstreamed enough.

I accept of course that the Government and the Ministers have an extremely difficult job. If there is one thing that I have learned about politics, it is that describing and identifying a problem is very easy, coming up with a solution is not always that difficult, but actually operationalising it is the real difficulty because that cannot be done by one person, one Department or one agency. It has to be done by 100,000 people working together from the top to the bottom and that is what, unfortunately, sometimes is lacking. Thank you very much for the opportunity to make a contribution, a Cheann Comhairle


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