I thank the committee on behalf of the Health Reform Alliance for inviting us to make a presentation today. We wish the committee the best of luck in the challenging task ahead, but we believe the potential exists for a really rewarding and fruitful exercise. Let us go back in time to July 1948, when a leaflet emblazoned with the title The New National Health Service was dropped into letter boxes across the UK. It stated:
Your new National Health Service begins on the 5 th July. It will provide you with all medical, dental and nursing care. Everyone - rich or poor, man, woman or child - can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not ‘charity’. You are all paying for it, mainly as taxpayers and it will relieve your money worries in times of illness.
The Health Reform Alliance see this committee as the crucial next step in the development of Ireland’s health and social care system as a universal system by 2026. We all dream of a similar leaflet drop or e-mail being sent to every member of the public in Ireland ten years from now.
This committee - with a remit to support the Oireachtas adopting a ten-year plan for health care - has an important task. The committee will be watched closely and supported by people who use the health and social care system.
Let me introduce our alliance, summarise the problems we see, and focus on three solutions which we hope the committee could use as they progress with the work.
Lone voices representing particular patient groups, as all of our organisations do, are often sidelined in the debate about health reform. Reflecting this, the Health Reform Alliance, HRA, was established as a small group of organisations in 2014 with shared concerns about the health service. The current members of the HRA are the Adelaide Health Foundation, Age Action, the Asthma Society of Ireland, Irish Cancer Society, Irish Heart Foundation and Samaritans. We shared a common belief that reform was needed to create a more equitable system. Our main purpose was to develop consensus on the values we believe should underpin reform and to advocate for the policies, systems and services that could best deliver on those principles.
We launched our charter of five principles in January 2016. A copy of the charter has been circulated to all members. We held a consultation event in May which led to more than 30 organisations seeking to join the alliance. We are growing our membership at present. We hope to be a force for change in the system.
The alliance believes that the main problem, which has been identified in the remit of the committee, is that the Irish health system unlike most health systems across Europe, has not developed as a system offering universal access to health care. Our system is regrettably unique. It is a tax based system that fails to provide universal access and which has significant user charges for certain elements of the service.
Without wishing to rehash common complaints about the system that one hears on the airwaves regularly, it is important to discuss why our organisations felt compelled to come together on the issue of health reform. As patient organisations, our organisations hear from people facing difficulties accessing the care they need. We support people who cannot access a hospital bed or a homecare worker; who are subject to different eligibility criteria depending on their location; who are ‘too late’ to access nursing home care subject to a yearly budget cap; and families who are forced to navigate the very difficult situation between hospital and community care. We are acutely aware of how the confusing mix of public and private health care creates problems for people who are treated differently whether they have insurance or a medical card. Conversely, in the social care system, people without a medical card seeking respite, can be refused because they are so-called private patients. Clearly, the system is not suited to meeting the needs of the 21st century. Yet, at the same time we recognise that good care still happens. People will talk about a nurse who took additional time to comfort them, or a GP who showed real skill and compassion in dealing with their case. These too are real experiences of the health service. Yet, unfortunately they are diminishing in comparison to tales of consultant appointment waiting times, people waiting for a potentially life-changing diagnosis, spiralling health insurance costs and emergency department overcrowding. That is a summary of the problems.
The committee is here to talk about solutions. We propose three solutions which could be effected through the committee’s approach to developing a ten-year plan. These would help to achieve our charter principles creating a system which treats everyone equally, taking account of specific needs; provides clear entitlements; integrates care; and is underpinned by a universal, publicly funded system.
We urge the committee to focus on the outcome to be achieved - that is the healthcare system to be delivered by 2026. To date, much time has been taken up with funding models, comparing one country against another. Much less time has been given to what should be the primary concern, namely what we expect the healthcare system to deliver. It seems to put the cart before the horse to talk about how to pay for a system before we decide what we are paying for. The role of this committee is to plan for ‘a universal single tier service’. By achieving this goal people will be liberated from the two tier system. The first step must be a clear definition of what universality means in the Irish system. A universal system would require a commitment by all to pay into the system so that we can receive equal care for equal need. While we will not be able to provide all forms of care to all people, whatever care is available should be available equitably and without discrimination. Such a system – organised through the funding model that is decided – must share the burden of illness collectively, where healthy people subsidise the sick and high income earners subsidise low earners.
Delivering a universal system within a decade is certainly a challenge for legislators and policy makers. We believe sustained commitment and backing of this vision over that period will require a clearly communicable vision which energises supporters. There are so many supporter across the country who want the ten-year plan to succeed. This clearly communicable vision can make it difficult for vested interests, who may not wish to see a strong public health system and make it difficult for them to subvert or derail the plan.
Second, we propose the committee would design a vision for a health and social care system. The experiences of the people we represent indicate the deep interconnection between health and social care. Need for medical care or personal care cannot be clearly divided in the lived experience of being unwell, yet policy up to now has dealt with health and social care needs differently. While health need is to some extent dealt with in the public system, social care is primarily viewed as an individual responsibility subject to heavy means-testing. This reflects a poor law view of social care as ‘charity’ for the destitute. The lack of designated funding for social care forces many families to place a loved one in residential care prematurely, when home help, day-care or respite care could have helped to keep their loved one at home. Consequently, vital social care services are increasingly available only to those with the highest needs and lowest incomes, rather than as a universal service supporting the whole population to be well.
Third, we believe the ten-year plan should focus on the public system and should pragmatically deal with the system as it currently exists - primarily a tax funded system.
Taxes paid for 77% of health expenditure in 2013 and yet, in our primarily tax-funded health system, people with private health insurance have quicker access to health care than their fellow taxpayers without insurance. Policy debates often emphasise the lack of private health insurance as the problem within our system. This appears to overlook the fact that the vast majority of spending on health care comes from taxation with insurance covering less than 10% of health costs. Furthermore, it is likely the reason many people hold health insurance is they do not believe they will receive adequate health care without it and so we urge the committee to focus its attention on the tax-funded public system.
The alliance believes that discussing, arguing if necessary and then reaching consensus on a vision for 2026 is the most important task this committee can achieve, after which will start the hard work of implementing and achieving that vision. The alliance, however, urges members to take heart because as Aneurin Bevan, the architect of the NHS in Britain, stated: "The NHS will last as long as there are folk left with the faith to fight for it."