Comment: Our health service should be based on the best examples of solidarity that prevailed during lockdown

A few weeks ago in Boston, I struck up a conversation with a Norwegian classmate about our respective health systems, and the issue of healthcare access. As we strolled along, he asked me what would be a typical wait for a hospital clinic in Ireland.

“Uh, depends on the specialty – if you don’t have private insurance, maybe a year?”

I looked around to see that he had stopped walking and was staring at me.

“…Are you joking again?”

I confirmed I was not joking.

“Wow, that is bad”, he stated in a rather Nordic manner, “why do people allow that?”

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The issue of health reform has returned to the airwaves. For most of the four years since publication of the Sláintecare Report, many people were only vaguely familiar with the term. Since the high-profile resignations of key leaders, however, the process has recently attracted all the wrong type of attention.

This is regrettable, for at the heart of Sláintecare is a positive vision too rarely stated: a universal health system in which timely, excellent care is guaranteed to all, regardless of ability to pay. Done right, I believe this is a vision from which we all stand to benefit. However, there are several reasons why the process continues to falter.

Firstly, I do not think the conversation has truly been had in Ireland about healthcare. This sounds strange; sometimes it feels like we talk about nothing else. Yet perhaps we don’t grasp the scale of the issue. Unlike almost every other European nation, Ireland does not have a universal healthcare system. The World Health Organisation has described our complex, mixed system as an “extreme outlier”.

We remain the only country in Western Europe without universal access to primary care – a sector we have chronically under-resourced, as GPs retire unreplaced in towns across Ireland. Our public hospital waiting lists recently topped 900,000 – a remarkable figure for a nation of five million. These statistics contain the stories of real people, and delayed care causes real harm. Moreover, as is often the case, this harm is not felt equally, but tends to concentrate in the vulnerable areas of society.

Delivering healthcare is never easy – even in Norway – but this does not happen in other countries.

Secondly, our healthcare workforce must be genuinely engaged in a reform process, not alienated. At the outset, perceptions of Sláintecare were lukewarm among some staff. Many were wary of top-down change in a system already under strain. Others doubted the requisite political will was present, and worried that botched reform was worse than none.

Recently, this scepticism has turned to outright hostility, particularly among doctors, in response to a needlessly negative draft consultant contract, published without negotiation. The messaging could not have been worse. (It’s literally called “the Sláintecare Contract”.) When reform is done “to” people, it fails. To succeed, change must be inclusive, collaborative and guided by values that are shared and not imposed.

So, thirdly, we must think about values. Our health woes are not mere technical problems with technical solutions. The behaviour of a system is shaped by the values upholding it. In our system, healthcare is not a human right; our problems flow from that.

For decades, our public services were outsourced to the religious and voluntary sectors. Placing healthcare in the realm of charity created a dynamic in which – in the lapidary words of Fintan O’Toole – “we came as supplicants, not citizens”. Today, we operate a two-tiered structure, where those who can pay extra receive expedited treatment versus those who cannot.

I do not believe this status quo reflects who we are as a society. Our healthcare service should be founded on social democratic values like solidarity, concern for the vulnerable, and respect for human rights. These values carried us through the dark months of lockdown; as the pandemic brightens, we must preserve them.

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A common criticism of the aspiration for universal healthcare is that it is over-ambitious: can we afford it? Certainly, reform costs money. More staff – and the pay and conditions to keep them here – cost money. Extricating our public and private sectors will cost money, as outlined by the De Buitléir Report. However, the more salient question is whether we can afford not to do these things. Health systems are expensive. In an ageing society, headaches about resources are not going anywhere. The issue is how we choose to deploy them. However, many neighbours fund universal healthcare systems that are fairer, more responsive, and less expensive.

Another common critique is that progressive health reform is ideological. To an extent, this is true – however, if universal healthcare is an ideology, it is one embraced by almost every other country in Europe. We should question the implication that retaining our outlier status is somehow practical, yet reforming it is radical. Is the opposite not the case?

In 1946, reeling from war, humankind established the World Health Organisation, whose founding constitution declared “the highest attainable standard of health as a fundamental right of every human being”. Human rights are a reflection of the inherent dignity and worth of each one of us: rich, poor, babies in maternity hospitals, pensioners in nursing homes, and everyone in between. If something is a right, you do not need to qualify for it: it is yours. Healthcare is a human right. Seventy-five years after the WHO Constitution was written, it should trouble us that our health system does not vindicate that right.

As a society, we need to take charge of our health system. Its woes are not random events beyond our control, but civic responsibilities that we share. We are not mere recipients of our health system, because it is we who fund it. We are not supplicants, because healthcare is not charity. And we are not customers, because our health is more important than money can buy.

We are citizens, and healthcare is a fundamental right of each one of us. It is time we claimed it.

Domhnall McGlacken Byrne is a doctor training in paediatrics and is studying public health this year