An Unhealthy Health Service

PEOPLE on this side of the Atlantic are fond of dumping on the American health service. We're always hearing horror stories, like how someone goes into a hospital over there with a broken leg and comes out a week later holding a bill for $10,000.

I have seen Michael Moore's polemical film Sicko on how mercenary the American system is and how wonderful the National Health Service in the U.K. is in comparison. But once again, Moore is only telling as much of the story as suits him.

PEOPLE on this side of the Atlantic are fond of dumping on the American health service. We're always hearing horror stories, like how someone goes into a hospital over there with a broken leg and comes out a week later holding a bill for $10,000.

I have seen Michael Moore's polemical film Sicko on how mercenary the American system is and how wonderful the National Health Service in the U.K. is in comparison. But once again, Moore is only telling as much of the story as suits him.

The system on this side of the Atlantic, whether it's the free NHS service in the U.K. or the half-free system we have here in Ireland, has very serious problems as well.

One illustration of this emerged here over the past two weeks when it was discovered that eight women with breast cancer had been misdiagnosed at Portlaoise Hospital in Co. Laois in the midlands. The women had been given false negatives when they had mammograms done at the hospital.

It subsequently emerged that the radiologist working at the hospital had no specialist training in reading breast X-rays. And that the scanner being used was a 15-year-old machine that was producing X-rays that were smudged with dirt and hard to read.

Even worse, concerned medical staff had written to the hospital management warning about the situation, about the possibility of mistakes and the huge legal consequences this could have for the state. Yet nothing was done.

Nothing, that is, until last week when public outrage over the plight of the eight women swept across the country and turned the situation into a major national issue that has dominated the media and politics for days now.

The outrage is understandable. These eight women had been given the all clear after having mammograms done at Portlaoise. Subsequently, when doubts were raised about the system by other medical staff, thousands of tests were reassessed and the eight were among dozens called back to be retested.

Most were clear. But these eight women were told they had breast cancer.

Now, with the start of their treatment delayed for months because of the false all clear after the first test, they are in a much more uncertain position. Their chances of beating the disease have been reduced. The women are devastated by the mistake, and the whole country watched their anguish and fear last week as some of them were interviewed on television.

One of the women put it very simply. "I'll never trust the health service again," she said.

For many people this tragic case has summed up what is wrong with our health service, that it's badly run, under-resourced and unacceptably slow in a supposedly rich country. It has magnified the general unhappiness there is in the country about the health service into a high level of anger that has the politicians deeply worried.

To understand how this kind of thing could happen here, one needs to know a bit about the Irish health service in general. Problems in the service have been mounting in recent years, with hospital A&E departments unable to cope with the numbers, sick people being left on trolleys for days on end because no hospital beds were available, people being forced to wait for months to see specialists and some patients having to wait for a year or more for what should be routine operations.

To try to fix this, a reorganization of the system has been underway for the past few years and, as well as that, huge amounts of money have been thrown at the problem. State spending on the service has mushroomed in recent years to the point where it now absorbs all of the income tax paid in the country every year. (The rest of government spending has to be funded from other kinds of taxation.)

Yet it's never enough. There are still queues at busy times and waiting lists for some procedures.

But it has to be said in fairness that the lines and waiting times are much shorter than they used to be a few years ago, and some have been eliminated altogether. Even so, in spite of all the billions being spent every year and the 120,000 people working in the service, there are still major problems.

One of the biggest problems over many years has been the lack of political leadership at national level, followed closely by serious mismanagement at individual hospital level. After all the billions that have been spent, people are now starting to realize that this has been a far bigger problem than a lack of money or resources.

The reorganization now underway is necessary, but it is also extremely difficult because it means taking some very tough decisions about the distribution of resources and about making the system more efficient.

The roots of the problem go back a century or two to the time when hospitals were set up by religious orders and charitable groups. The control by the religious persisted here longer than it did in other countries, and one result was that the development of the system was not always rational from a national perspective.

But eventually the new Irish state began to exert more control since it was paying the bills. This was done through the setting up of health boards, local bodies in the main regions around the country which had a lot of the responsibility for health services in their areas.

The boards were manned mainly by local politicians. But the result sometimes was that health became a local political football, used by the politicians to get votes.

So if your granny needed a hip replacement and there was a two year delay for the operation, the first person you contacted was not your doctor, it was your local politician who might be able to get her bumped up the line.

Similarly, if there was a proposal to downgrade an old hospital in one town and concentrate resources in a newer hospital in another town, local politicians from the first town would fight it even if it made absolute sense. It was hard to get anything done to rationalize the system from a national point of view, even though it was clearly inefficient.

So a few years ago, the government abolished the Health Boards and set up the new Health Service Executive (HSE), an independent professional body that would run the service. This not only did away with the boards, it also took the day to day running of the national health service out of the hands of the Department of Health in Dublin.

Putting this into action took great courage on the part of Minister for Health Mary Harney. Sticking with it is taking even more.

There has been progress. But it is slow and very difficult. And every time another crisis emerges, like the one at Portlaoise Hospital, there are calls for her head and for the HSE to be dumped.

This is not going to happen, however, because even the opposition politicians realize that if the hard decisions are to be taken and implemented (and they must be) it is better done by an independent body like the HSE. Then the local politicians cannot be blamed and it becomes possible to get things done.

At least that's the theory. In practice it's proving to be much harder than anyone imagined.

The main problem, it has to be said, is ordinary people. They want their local hospital to have a full range of services (like cancer care) and they don't care if that costs a fortune and leads to duplication.

The HSE, using reports by international consultants, has said that instead of the present number of inadequate hospitals scattered around the country, what we need are fewer hospitals that become "centers of excellence," offering the very latest high tech care with a multi-specialty capability. And cancer care is a very good example.

It is simply not practical to offer the full range of cancer care that modern medicine and science allows in every hospital in the country. But getting people to accept that is difficult.

In Ireland people think that to have to drive 70 or 80 miles to a center of excellence is unacceptable. They want the best care to be on call in their local hospital in the big county town 20 miles away. And that is why old county hospitals like the one in Portlaoise are still in business.

There are other complications in the health service here, of course. There can never be enough money because more expensive treatments and equipment are being devised all the time, and people will always want the best. That in itself means that hard choices have to be made by the NHS.

And that also means that there will always be a gap between what privately insured people can pay for, and what poorer people who rely on the state budget can get. It may not be nice and you may not get many people here to say that openly, but that's the reality. And for that very reason, more than half the population here have private health insurance.

Having said that, the basic level of health care here for people who cannot pay is very good. In most hospitals the same consultants treat both public and private patients, and the system is set up to encourage them to do so. The difference is that a private patient does not have to wait at the end of a long waiting list.

Harney has been accused of trying to privatize health care here and make everyone pay. But that view forgets that she is the one who has fought a long battle with the consultants to get them to do the public work they are being paid by the state to do instead of devoting too much time to their private patients. And she has also taken on the nurses, doctors and local political interests in an effort to push rationalization and efficiency forward.

The sad thing is that the present case in Portlaoise Hospital is in microcosm a perfect example of the problem she is trying to solve across the country. Instead of getting praise for this she is continually criticized and even ridiculed.

But that goes with the territory. A previous incumbent of the Health Ministry (Brian Cowen, now minister for finance) once described the Department as Angola.

Harney is not looking to be popular. She's looking to get the job done before she leaves politics. And she might just do it, in spite of all the outraged headlines here over the past week.