John Crown (Independent) | Oireachtas source

I welcome the Minister. I am very proud that he, as a representative of my profession, is in this high office and I have no doubt that he will bring his well documented and considerable organisational, intellectual and analytical skills to bear on the broad array of problems he faces. I am very taken by the fact that at the outset of the debate six Members of Parliament are present in the Chamber, two of whom have medical degrees and one of whom is a nurse. This is perhaps the highest level of technically relevant representation we have had in either House since the last occasion on which the Dáil debated the registration of public houses Bill.

It is well recognised that in Ireland we have a crisis in medical litigation. We have one of the highest medical litigation rates in the world. This is considered to be one of the most dangerous environments for doctors to workin; historically it has been one of the most challenging environments in which medical indemnity insurers such as the Medical Defence Union and the Medical Protection Society act. Premiums in many specialties are typically many times higher than for equivalent specialists in the United Kingdom, reflecting the sense that there is a much higher rate of risk associated with practice here.

I tried to find the exact figures. I teach a course on risk management and oncology. The United States is No. 1, but historically Ireland and New Zealand have been behind it. There will be much cultural analysis of what aspects of the Irish personality or the structure of Irish society lead to a high rate of medical litigation. The explanation is simpler and sadder than one might think. We have generally a fairly mediocre health service which is in urgent need of improvement and reform. The Minister knows these facts, but it is important, given that this is one of our first public engagements, that I have the chance to make some points that I know he will consider and address.

We have the lowest number of career level doctors per head of population of any country in the OECD. The closest country to Ireland, the United Kingdom, is not particularly close. The United Kingdom is substantially below the third closest country. We have a very abnormal career structure in Ireland. Built into the health system, especially the hospital component, is an understanding that most of the care provided will be provided by trainees. We use highfalutin terms like "registrar" and "specialist registrar", but they are trainees. If the Minister or I lost a wedding ring or a precious piece of jewellery down a drainpipe, we would call a fully trained professional plumber to find it. If, however, one of our precious children appeared in a public hospital and required surgery for acute appendicitis or an injury, there would be a very high chance that his or her care would be provided by a trainee. This is wrong and it is not because of some closed shop operated by consultants because no consultant can create consultant jobs. Only the Government, through its agents which historically have been Comhairle na nOispidéal and the HSE, can create jobs. Successive Governments and Ministers from different political parties have made a structural, ongoing and, as yet, unreformed decision that this is the shape the health service will take. As a result, many people who engage with the health service do not engage with a fully trained specialist in a specific area and receive care which, I am afraid, does not meet the standards to which a modern, educated, sophisticated country that is in the top 22 of the OECD's list of economically developed countries would aspire. That tension will cause medical malpractice.

The case for fixing the problem of medical malpractice in Ireland is not, as is the case in the United States, based on a case for tort reform but rather on health care reform. We urgently need to reform the system. We need to make sure decisions are made by fully trained, rather than junior, doctors. We need to do something to address the extraordinary shortage of specialists. I include specialists in family practice in that. We have an extraordinarily small number of specialists.

We are hanging off the bottom of the charts in respect of everything from neurosurgeons to oncologists to cardiologists to urologists to neurologists and, as a result, even if a person is in a system where it is likely that he or she will be seen by a fully-trained specialist, this will not happen for a long period because there will be waiting lists involved. Bad things happen to people who are on waiting lists.

I have stated for many years that if - as both the Minister and I do - one believes in social democracy as it applies to medicine and health care, then it is not a question of public versus private or whether the system is run by the State. Rather, it is a question of what is the right way for society to assume collective responsibility in order to ensure that what would be regarded as a basic set of guarantees will be extended to people. The most basic of these guarantees is that if one needs care or treatment, one will receive it and that this will not be determined by one's ability to pay. I am of the view that there is general agreement throughout society in respect of this matter and I suspect no one would suggest that we should adopt a more neo-Darwinian approach based on the survival of the fittest. The consensus will break down in the context of how we achieve that to which I refer. A large number of theoreticians believe that such services can only be administered if they are delivered by a single entity, namely, the Republic itself via its Government, and that the system must be funded, regulated, delivered, staffed and policed by the same monopolistic entity. I differ from the group that espouses the view of social democracy to the effect that everybody should pay their taxes to the State and that the latter should decide how health care should be provided.

The most successful social democratic health systems in the world, namely, those which according to OECD figures and statistics on speed and quality of access and outcomes, deliver alternative models which are firmly based on the precepts of social democracy and which involve a diversity of contracts and providers. There is, however, one aspect to these systems which is not diverse, namely, all of those in society are in it together, everyone pays over what is probably a fixed percentage of his or her income and this is specifically invested in health care. Rich people pay more, poor people pay less and those who have no incomes pay nothing at all and are paid for by others, which is fine. With such systems, everyone has a freely negotiable insurance instrument which he or she can take to the doctor or hospital of his or her choice. This instrument may be administered by a state-run insurance company similar to the VHI or some of the non-for-profit health systems in Canada, Israel and elsewhere. Some of the entities involved may be private concerns but they should only be allowed to enter the market on the proviso that they play by the same rules, namely, community rating, no cherry-picking and equality of access. If such providers want to put in place additional policies whereby people can obtain access to different types of hospital rooms or menus during their stay, that is fine. However, the actual care provided must be the same.

I am not describing some pie-in-the-sky utopia, I am outlining what happens in most of the countries which have Bismarckian systems of health-care delivery. The cliché that was thrown about in the run-up to the most recent general election - during which I specifically espoused the cause of the Minister's party and that of its prospective coalition partner because I liked their health policies - involved reference to the "Dutch model". What actually emerged from the synthesised post-election negotiations was the Deutsche or German model. Germany has the most successful health care system of any large country in the world. A salutary lesson can be learned from the fact that such a large, complex and diverse entity which faced extraordinary challenges in the past retains the system introduced by the Iron Chancellor, Otto von Bismarck, in the 1880s as a bulwark against the encroachment of the new movement of Marxism. The system in question survived the Franco-Prussian War, the First World War, the abdication of the German monarchy, the Great Depression, the Weimar Republic, the rise of Hitler, the Second World War, the partition of Germany, the Cold War and the reunification process. It remains in place and is essentially the same as when it was introduced 140 years ago. I accept that the German system is a little more expensive than others.

One final message I wish to convey to the Minister from the John Crown book of guerilla health economics is that there is nothing wrong with spending money on health care. It is always wrong to waste money and Government should never waste money on anything. However, the mere fact that money is being spent on health care does not mean it is money badly spent. It must, however, be spent efficiently and in a fashion which incentivises appropriate social outcomes and economic returns.

I have really great hopes for the Minister. I informed his predecessor that he was dealt a rotten, awful set of cards when he entered office and I still believe that to be the case. I also believe that members of the previous Minister's party, when they had voted in favour of the various austerity budgets, did not treat him particularly well when expressing great surprise about the fact that things were not going well within the health service. That is the reality but let us draw a line under the matter. The new Minister will have a relatively short tenure in his current position. He may enjoy a longer tenure there if his party is returned to power and if he elects to remain in the Department of Health rather than moving elsewhere. I hope he takes an ambitious attitude to the cause of health care reform and understands that the opportunity is there for the taking. The person who has the vision to tackle the bureaucracy and who understands how the system can be made to work can put his mark on Irish history if this is done right. I am certainly of the view that what I have outlined can be achieved in a year to 18 months.