May 2017 marked a landmark in Irish healthcare planning. Under the leadership of Parliamentarian Roisin Shortall, the report of the Houses of the Oireachtas (National Parliament) was published and signed up by all political parties. Professor Ian Graham warns against the many barriers towards its proper implementation.
The “Slaintecare” (“slainte” is the Irish word for health) report of the Committee on the Future of Healthcare proposes to establish a universal single-tier service where patients are treated on the basis of health need rather than on ability to pay.
This is great news – except that every report on health since the 1970s has promised equality and access – and these have not been delivered. This has been termed in the health-related environment as the “Implementation Deficiency Disorder”. Discussions with healthcare professionals in other healthcare jurisdictions suggests that many countries may face similar challenges. If we are to change history and actually implement change, we need to understand the roadblocks.
These may include:
- A short political cycle of five years that militates against long term planning;
- A political system that is one of opposition and confrontation;
- The lack of culture of, or apparent expertise in, conflict resolution or positive decision making;
- TDs (Members of Parliament) are elected democratically, but with no requirement for appropriate knowledge, training or skills in healthcare. Despite this, we have had brilliant Ministers for health- who have repeatedly proved to be unable to deliver effective reform;
- Local politicians may have a power of veto over unpopular local decisions such as the reform of small local hospitals;
- We have a centralized, clumsy Health Service Executive (HSE) with separation of power from responsibility – a failure is often a “system” failure, however someone must be responsible for the system. But, refreshingly, the Chief of the HSE stated recently – “there is abundant evidence that vesting authority, empowerment and responsibility as close as possible to the delivery of care produces better outcomes”;
- Private medicine, including consultant physicians such as myself, benefit directly from the status quo in that citizens who can perhaps ill afford it take out private health insurance just to gain access to the timely healthcare that should be their right;
- It is all too easy for vested interests to undermine a report like Slaintecare by questioning, for example, the costings rather than endorsing and supporting the principles.
So, the challenge facing Irish Health Reform is not defining what is needed, but implementing the excellent reports that we already have. This implies a need for a formal stakeholder analysis to see if the above roadblocks can be confirmed, if other active or passive blocks can be defined, and to set the basis for dealing with them.
*Ian M Graham, FRCPI, FESC, FTCD
Ian’s current positions are-
Professor of Cardiovascular Medicine, Trinity College Dublin
Professor of Preventive Cardiology Emeritus, Royal College of Surgeons in Ireland
Professor and Head of Cardiology, Tallaght Hospital (retired).
Honorary Fellow of Trinity College, Dublin
Secretary-Treasurer and Board member, European Society of Cardiology
Chair, Adelaide Health Foundation Health Policy Initiative
Project Leader, SCORE CVD risk estimation system
Project leader SURF international audit of CVD risk factor recording and control.
Co-Chair WHO CVD risk estimation project
Co-Chair ESC/EAS 2016 Guidelines on the management of hyperlipidaemia
Member 6th Joint European Task Force on the prevention of CVD in Clinical Practice
Chair, Irish Heart Foundation Council on CVD prevention