John Crown (Independent) | Oireachtas source

I welcome the Minister to the House. He has been a refreshing dose of reality and fresh air in the way he has handled commentary about health issues. He has not made unreasonable promises. Clearly, he came in at a time of particular circumstances with respect to the public perception of the health service and in the context of his party's entirely realistic and not extravagant pre-election promises to undertake a very fundamental reform of the health service. The usual way health issues are handled by politicians is to adopt one of two positions which are absolutely independent of ideology or party affiliation. I must give the Minister credit because has not really been a big offender in this regard. The two positions to which I refer are entirely dependent on which side of House one happens to sit on. I have been in Ireland for 23 years and seven-odd Governments. I was trying to amuse myself earlier by totting up the number of bureaucracies that have nominally been my employer in that time. It is rather breathtaking. In fact, it is a Soviet-style list.

Opposition politicians in Ireland traditionally wring their hands, keen, lament and olagón. Typically, they mention hard cases and the unbelievable disasters that strike individual people as evidence not only of the systematic failures of the system but also of the inhumanity of the individuals on the other side of the House. They promise they would fix these problems if they were in power. Irish politics being Irish politics, that flip does tend to occur. We tend to change Governments once every three elections, on average. We may well be heading into a different series of political events in Ireland over the next decade. After there has been a change of Government, the folks who were on the Opposition benches usually assume the opposite role by preaching rectitude, collective responsibility and the concept of opportunity costs. They say we have to be careful in how we spend our health pounds, as they used to be before they became punts and subsequently euro. We are told that every euro we spend on one patient is not available for somebody else. We are reminded that these decisions have to be made by the person in the hot seat. This is all entirely correct.

The sad reality is that I do not think things have improved that much while this ideology-free, positional situational flip-flopping has been taking place over the last 23 years People will quote individual statistics about how things have changed. Things have changed in medicine all around the world. It is not unique to Ireland. Sadly, our relative position has not changed. We are anchored firmly at the bottom of the league table that ranks the quality of the health systems of major OECD countries. I know the Minister will quote the most recent OECD survey, which shows we are now approximately halfway up the list. However, I ask him to look critically at the variables. We are routinely anchored at the bottom with regard to the only variable that really matters, which is access to care. Our only neighbour at the bottom is the system we emulate the most, which has served Britannic majesties. I refer to the UK National Health Service. Every morning, those involved in the NHS must fall on their knees and thank the good Lord that the Irish system exists because we are keeping their system off the bottom of all the waiting list statistics. That is the way the system works. I will not go into all the grim details.

The Minister has probably been bombarded and inundated with lectures on theoretical health economics over the last year or year and a half. I have probably been guilty of doing some of that. The reality is that if one examines a P value that correlates the kind of funding model used for one's health system with access to care, one will find that all the systems which follow the Beveridge model of central taxing and pre-ordained budgeting tend to occupy the lower positions on international league tables of access to health care. Such models unlink activity to reimbursement and thereby disincentivise quality, efficiency and fairness. That does not apply to countries that have an equally social democratic model.

I ask Senators not to think I am advocating a Darwinian approach to health care. I am not advocating a cut-throat, care by ability to pay model. I am advocating a more rational model of socialised health care. I refer to the Bismarckian model, which was introduced in Germany by the Iron Chancellor in the latter part of the 19th century. This model survived two world wars, the Great Depression, communism and the split and reunification of Germany. It will probably survive all kinds of other models. It has stood the test of time. Under this model, as the Minister knows, people have mandatory health insurance. If a person cannot afford it, the rest of us who can afford it pay for it on behalf of him or her. When one gets this, with nuances, one is left with a freely negotiable and equal insurance instrument that one can take to any type of institution one wishes. The idea is that public, private, charitable, academic and other institutions are forced to compete with one another on the grounds of quality and efficiency within a network that is regulated, policed, legislated and enforced to make sure price-gouging, self-serving activity on the part of doctors, hospitals and other for-profit health care providers is not allowed.

I would like to appeal to the Minister in this regard. The subtext to his appointment was not that there was perceived to be a need within Fine Gael for radical reform of the health service, but that there was a need within Fine Gael to radically reform its electoral prospects. The Minister, Deputy Varadkar, was seen as a particularly competent and politically astute pair of hands who had credibility in health. It was considered that he could take the Fine Gael ship off the rocks of electoral difficulty, if not on course for reform. I am sorry if that sounds uncharitable to Fine Gael, but I really believe it is the case. The Minister's appointment was accompanied by an almost contemporaneous statement to the effect that a long-cherished goal of many of us - it was adopted by Fine Gael in recent years - was to be abandoned. I refer to the idea that the health service should be fundamentally reformed and there should be a move to a social insurance-based model. I suggest that officials from various Departments of State and the health agencies that are charged with running the health system deemed this goal to be wholly impractical. I must say it was a very bitter pill to swallow.

The Minister should remember a few things. I ask him to give himself a vision for reform. He should not see himself merely as a narrow technocrat. He is too smart for that. He can do this right. He could be the Minister who fixes the health system. If he is to do that, he needs to confront officialdom, which I believe to be the greatest entrenched force for inertia we have. I will mention a few paradoxes in this context. Ireland is, as it was when I came back here 23 years ago, the country with the highest number of medical schools per head of population in the western world. Paradoxically, it is also the country with the lowest number of career-level doctors. Even though we churn out far more medical graduates than many other countries, we still manage to have a great shortage of medical doctors. Even though we have a shortage of medical doctors, we are exporting them at a rate which is unprecedented in the EU or in OECD countries. Some of the countries of eastern Europe are now doing this on a similar scale, but it has never been done in the traditional western countries. We have one of the highest numbers of hospitals per head of population, but we have one of the poorest levels of access to the hospital system and one of the longest waiting lists for access to care.

This can be fixed. If it is not, we will have the quadrennial or quinquennial performance that involves those politicians who were crying when they were in opposition assuming the reins of power and immediately assuming the powers of their predecessors, while those who had the power to do something to fix the health system find themselves again keening, olagóning and outlining the sad cases about which their constituents have written to them. I expect more from the Minister, Deputy Varadkar. He is a good and smart guy. He is the smartest of this lot. He can put his stamp on this. He has an opportunity to do so. He should not see this as a damage control exercise, or as part of the campaign to re-elect the Taoiseach. He can do this properly if he is prepared to put his bow into the wind, put up the sails and really get the wind going.