From Socialist Voice, March 2008

The crisis in the health service:
What is to be done?

Everyone is aware that there is a crisis in the health service. There have been public meetings all over the country, prominent medical personnel have spoken out, and numerous radio programmes have been devoted to this disgraceful situation. There are statistics on the number of people on waiting lists, shortages of hospital beds, lack of services for special groups, and lack of community services.
     Recently a packed meeting organised by the Dublin Council of Trade Unions heard from workers in many branches of the health service, and it was agreed to have a national demonstration on 29 March.
     The question of health provision for a country is a complex one. It requires a general policy of meeting the needs of the population as a whole, the funding of such a service, and the distribution of the service to all, fairly and quickly. The policy of the government will be decided by its general political view on the organisation of society. As the World Health Organisation says in its 2000 report, “health systems cannot be held responsible for influences such as the distribution of income and wealth, any more than for the impact of the climate.”
     The WHO now compiles statistics on all countries from information supplied by the governments, or where other reliable information can be ascertained about the state of each country’s health system. Of course these use a lot of average figures, but it is still a useful guide to relative policies.
     Among the statistics gathered are how much a country spends in relation to its total income; how much is spent relative to other government spending; how much is spent by governments as a total of all health spending; and how much is spent publicly and privately on health.
     In an analysis of these statistics, several significant findings have been reported, none of which is any surprise to the Communist Party: that there is a correlation between the general health of a country’s population and the distribution of wealth and income, and of course the availability of public health services to all. It also found that a multiplicity of health providers (as they call them) leads to higher administrative costs and less money spent on providing treatment.
     An OECD report on expenditure on health in twenty-nine countries found that those that had a public health system spent less than those that had not. Less is also spent on administrative costs: as an example, Canada, which has a public health system, spent only 1.3 per cent on administration in 2003, while the United States spent 25 per cent on administrative costs.
     Some countries have been more successful than others in providing a health service; but how much is publicly provided depends on the strength of the labour movement and the organised political opposition to governments that are the defenders of the capitalist class. France and Germany, for instance, both of which had a publicly funded and well-controlled health system, had it because of the strength of organised labour and the threat of losing out to a socialist system if they did not deliver. Now that the threat of socialism has receded for the time being, and the power of the EU right-wing parties is relatively unchallenged, we have attacks on these systems, despite the opposition of 62 per cent of the population in Germany and despite the opposition of the unions in France. Charges have been introduced for attending clinics and hospitals that formerly were free under national insurance plans.
     The excuse for this in all countries that are cutting back on public funding for health is the increasing cost of running a health service. There is no doubt that medicine is expensive, and as more advanced diagnostic tools and medicines become available the cost to the health service increases.
     But this brings us back to the core of the problem: who is controlling the price of pharmaceuticals, medical equipment, research, the wages of doctors and consultants, the price of land, and all the associated costs of providing care? The answer at the moment is that it is privately controlled, and governments are paying more than the real cost of these services.
      But given the fact that we are living with such a system, what are the short-term solutions to the operation and maintenance of a public health system?
     Firstly, there must be the political will to have an equitable system; and the funds available in a country, whatever the total income of the country may be, should be available to provide a fair system for all. This means the provision of a national system of providing health care, a central government fund managed with as little administrative cost as possible, and a social insurance levy based on a progressive rate, depending on ability to pay, with a single system of accessibility and provision.
     Again the WHO identified poor countries that had more equitable systems than rich ones—so the total amount of wealth in a country is not the issue but its fair distribution and the knowledge by the people that they are being treated as fairly as possible. A superb example of this is Cuba, a country impoverished by the barbarous blockade yet that provides a health system that is the best possible within available resources.
     It is essential that people be made aware of the short-term attractiveness of a low personal tax rate but that the Government’s plan is to move out of providing public services and go back to the pay-or-die policies of the nineteenth century. Are we really so individualistic that we have lost all sense of a society that includes all its members?
     According to the latest European figures, Ireland has one of the lowest expenditures on health as a proportion of national wealth. (The only countries lower are the impoverished former socialist countries, whose public services have been destroyed by naked capitalism and asset-stripping.)
     Trade unions must defend the rights of their members, instead of cosying up in “social partnership” deals. One section that is attempting to lead the way is the Dublin Council of Trade Unions. A statement issued by the council in 2002 said that “a radical overhaul of the current health service, which is failing to deliver basic primary care, is needed.” This month a successful public meeting on the question was followed by a decision to organise a national demonstration.
     This can only be a starting-point. There is no more time to lose, as the ruthless dismantling of the public health system is advancing at high speed. The trade union movement needs to have a multiplicity of actions and to mobilise its members. This approach, combined with a broad movement, will have some chance of stopping Mary Harney from destroying our health service.

Some immediate demands

The CPI believes that any campaign should have the following demands, which would make a significant improvement in the present health system and would actually cost less.
  • Stop the building of private hospitals on public hospital land, and end the policy of “co-location.”
  • Stop the sale of public hospital land.
  • Stop the closure of regional hospitals until a national rationalisation plan, based on equitable care for everyone in the country, is implemented. So-called “centres of excellence,” in which the treatment of specific conditions requires specialists and equipment of an exceptional standard, should not be used as an excuse for closing county and regional hospitals. Such closures should take place only if the hospitals have been replaced by multiple local clinics that have facilities to deal with most of the general problems that now bring patients to general hospitals, with facilities for treating acute heart and stroke patients as quickly as possible and with the same referral rights and charges as for public hospitals.
  • Stop “public-private partnership” deals for hospital buildings and the proposed primary care centres.
  • Recruit staff to allow any closed wards and unused beds to be put into immediate use.
  • Restore the frozen vacancies created by the recruitment ban in the public service. (These vacancies have disappeared from local authority and hospital personnel lists.)
  • End the disgraceful long-running dispute with dentists, pharmacists and chiropodists immediately, either by appointing new public dentists and chiropodists or insisting that existing dentists and chiropodists have a proportion of public patients in order to practise, and transfer the distribution of drugs to the health centres.
  • End the subcontracting of cleaning and administrative services to private companies.
  • As well as listing the number of people on the waiting list, hospitals should also list how many times the list is closed in a given period, and for how long it remains closed.
  • Oppose the plans of large pharmaceutical companies and pharmacy chains to open combined pharmacies and doctors’ clinics. This puts medicine in the hands of corporate business and certainly would lead to bias by doctors in prescribing drugs.
  • Freeze the cost of the drug repayment scheme.
  • Freeze the cost of in-patient charges, and end the charges that many hospitals have introduced for out-patient treatment.
  • Raise the income limit for access to a medical card above the 60 per cent relative poverty line—for example for a single person living alone from €184 to €209.87, and pro rata for other categories—and abolish the “qualified adult” category, giving equal status to all. (This by no means suggests that the CPI thinks this is a reasonable living wage, but it would be an immediate relief to thousands of people.)

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