Trinity College Dublin: Sláintecare as much a reputational as a quality of life issue

The recent controversy surrounding the implementation of Sláintecare brought healthcare reform back into the media. Much of the focus was on obstacles to regionalisation and e-health and the priority of reducing waiting lists. The media and reform agenda should, however, maintain a strong and continual focus on the overriding Sláintecare programme aim of delivering a universal single-tier health and social care system, where everyone has equal access to services based on need and not ability to pay. This reform of the health system is essential for the quality of life in Ireland and the country’s international reputation.

The Irish health system is often described as a two-tier health system in which those able to afford private health insurance can skip the queue and gain faster access to hospitals. While people with medical cards can access care without charge (except for prescribed medicines), they face long waiting times in accessing hospitals.
It is perhaps less well-known that the public-private mix within Irish hospitals is distinctive in the OECD. Ireland is the only country in Europe which does not provide free or subsidised access to GPs for the majority of the population (and the fees that GPs set are comparatively high). Indeed, those without medical and GP card entitlement face cost barriers to GP care, with some people putting off going to the doctor because of the cost. Furthermore, while private health insurance provides a faster route into the hospital system, this also comes at a significant price via both insurance and out-of-pocket spending. In fact, Ireland ranks high in Europe with regards to private healthcare expenditure.

Far from happy

The Irish health system developed in the decades after Independence in a markedly different context in terms of wealth, education and social norms. Survey research has found that, due to socialisation, people living in countries where there are high cost barriers to healthcare tend to be more accepting of inequality. While this may be the case, Irish people are far from happy with their health system. According to the European Social Survey, satisfaction with the healthcare system has been low compared to other EU countries over the past 20 years at least. Survey research shows this dissatisfaction is not due to a negative perception of the quality of care provided. It has rather found high levels of dissatisfaction with the accessibility of healthcare, in particular cost constraints to access.

Difficulties with the financial costs of covering doctors’ appointments started to increase dramatically prior to the 2008 economic crisis and subgroups that face the most difficulties in accessing healthcare are women, younger individuals, the employed and individuals with poor health status.
Reforming the health system to make it more equitable has been on government agendas since 2011, leading to the historic cross-party agreement on the Sláintecare programme in 2017. Sláintecare aimed to provide entitlement for all Irish residents to all health and social care, no charge to access GP, primary or hospital care, and private care phased out of public hospitals, among other reforms. Some important moves in the right direction have been made. For example, half a dozen years after free GP care for the under-sixes and over-70s was introduced, the Government has legislated for free GP care for all children under 13 and the budget for 2022 includes free GP care for six and seven year olds. In May 2021, the new Sláintecare contract, which requires consultants in public hospitals to carry out solely public work, was released, and is now being discussed with the medical profession. Finally, the Covid 19 pandemic highlighted the capacity constraints of Irish hospitals and resulted in the largest health budget in the history of the State in 2021.

Capacity and access

The gradual pace of change is not surprising. Sláintecare is a 10-year programme and involves increasing capacity and access. With regards to capacity, prior to the Covid 19 pandemic, Ireland had a below-OECD-average number of hospital beds and doctors, which has had implications for increasing access. Academic literature on welfare and health system reform also shows how, once institutions are established, they tend to be “sticky” for many reasons including stakeholders’ fears about the unpredictable, long-term effects of changing a given set of rules and pressure from groups benefiting from the status quo. Regarding the latter, much has been written on the opposition of the medical profession to the establishment of universal health systems in Europe and further afield, and how particular reforms prevailed.

The Government needs to articulate in a clear, accessible way the timeline for delivering the programme, its progress and the various constraints and challenges. Continuing media attention on Sláintecare’s progress and a more manifest public desire for change would also give impetus to governments. Public mobilisation around the abortion referendum in 2018 and the over-70s medical card in 2008 are examples of such people power.

The international reputational issue of having a universal health system should also stimulate governments to drive through the reform programme. There has been much focus on our corporation tax rate but the availability and cost of healthcare (not to mention childcare and housing) is of utmost importance to the quality of life in Ireland and to the country’s reputation as a place in which to live and work. Indeed, the habitual political promise of reducing taxes obscures the necessity of raising revenue in order to finance services such as healthcare, thereby reducing people’s private spending and alleviating the rising cost of living.

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