By Teresa Corbett
Many changes are taking place in health services throughout the world today and the Irish Health Service is in a process of transformation. But how did we get here… and more importantly… where are we going? My insightful little sister is currently exploring this issue for her final year project as part of her degree in Sociology and Economics at the University of Limerick. Given my own interest in health, and both being the daughters of a nurse, we’ve had many conversations about this project. It’s interesting stuff. Here is some of what I’ve learned:
Beginning of healthcare in Ireland
The first hospitals in Ireland were founded in the 1720’s where people were treated for medical conditions outside of the home. They were funded by donations, legacies and public subscriptions. The British government brought in a workhouse system, which provided infirmaries, dispensaries and medical officers for the less well-off. Patient applied to a poor law guardian for a ‘red ticket’ every time they wanted to attend a dispensary without charge.
The Catholic Church and healthcare in Ireland
The teachings of the Catholic Church indicated that the state should not be responsible for family issues; they should only step in when the family failed in its role. This continued when Ireland became independent, religious beliefs governed most aspects of state policy, including healthcare provision. The Irish project of ‘nation-building’ often deliberately emphasised the importance of Catholicism intertwined with Irish-identity as opposed to Anglo-Irish, or British traditions. Because you know.. we were different.
Healthcare after the First World War
After the First World War (1914-18) there was a sharp rise in inflation, and this impacted the donations that supported voluntary hospitals. In Britain, many of the large voluntary hospitals were saved through public funding, which led to the development of the National Health Service. In Ireland, the Irish Hospitals’ Sweepstake was established to fund the construction and expansion of county hospitals. This provided a substantial amount of money that was available to fund the construction of hospital beds and to subsidise the running costs of voluntary hospitals. With large sums of money available, it was literally like they had won the lotto and hospitals began to indulge haphazard expenditure.
In 1922, the Free State government renovated workhouses into county homes for a wide range of poor people with medical and social needs. However, in this early stage of the new state, health services were not a financial priority, with most hospitals relying heavily on the sweepstakes for funding. By the end of the Second World War Irish county hospitals had plenty of beds in modern wards, but the hospitals were often too small to justify specialist appointments and facilities. Patients had longer (and more expensive!) hospital stays than necessary – waiting for radiologist or anaesthetist who may only visit weekly or bi-weekly, or while laboratory results came back from a regional hospital.
Many changes took place during this era in Irish politics, many of which would influence the healthcare system. The Constitution of Ireland in 1937 and The Republic of Ireland Act 1948 declared Ireland to be a republic. The most significant achievement of the early Irish state was the drive to eliminate tuberculosis (TB) in the late 1940s. The Department of Health was established in 1947 and the Irish government decided that we should also offer a National Health Service for all citizens, free at the point of use. Buuut… these proposals failed due to fierce opposition from the medical profession, the Catholic Church and the Department of Finance.
The 1953 Health Act… and the crowded waiting rooms
Under the 1953 Health Act, the role for voluntary and community organisations was recognised, permitting the the government to fund voluntary organisations for health provision. A state-sponsored health insurance scheme, Voluntary Health Insurance, was introduced in 1957. This contributed to the development of a two –tier health system of public and private hospital care. If you did not qualify for free visits to the dispensary doctor but couldn’t afford to pay the fee for a GP visit… you had a strong incentive to head to the hospital for admission, where all these services were free – resulting in the tradition of visiting hospital casualty units for minor treatments. This was also true for VHI patients, because their insurance covered in-patient, but not out-patient treatment.
So there were two categories of eligibility for public health care. ‘Full’ eligibility was determined by income, where full medical services are provided free of charge. The 1953 Act got rid of the old dispensary system, introducing medical cards. ‘Limited’ eligibility was available to those who didn’t quite make the cut for full eligibility. This type of limited coverage reflected core principles in Irish health care at the time. The State was not considered to have a duty to provide medical and other health services free of cost for everyone, without regard to individual need or circumstances. By 1965, nearly 30% of the population had a medical card and 90% of the population were entitled to subsidised hospital care.
By the 1960s approximately 70 % of health spending went on hospitals and the 1960 public expenditure on health accounted for 2.9 per cent of Irish GNP- higher than many of our European counterparts, such as France, (2.6%), Belgium (2.0%); and The Netherlands (1.8%).This was in spite of the fact that GNP per capita in Ireland was much lower than in these other countries. So the system was expensive… and inefficient… even back then.
The 1970 Health Act created regional health boards, with the goal of creating coherent health services on a regional and not a county basis. These Health Boards were to be responsible for the administration of the Healthcare System.
Irish Healthcare at the end of the 20th century
In the 1980’s illness prevention and health promotion was emphasised. Lycra, shellsuits and exercise were popular. Personal responsibility was in vogue (as was Madonna, incidentally!) The Irish government was determined to reduce institutional and hospital-based care. People spent less time in hospital, several hospitals were shut down, beds were decommissioned and there was a drive to move the care of psychiatric patients into the community. There were 11 regional health boards by the end of the century, and about 40 semi-state agencies concerned with health. These agencies had specific functions including advice, regulation, research and health promotion.
And then… from 1994-2000 the “Celtic Tiger” roared. And guess what? It was like we won the lotto… AGAIN! Ireland grew from a traditional, rural society dominated by the Catholic Church to a modern, urban, industrial, liberal and secular… and dare I say it “cool” society. But this didn’t really help the healthcare system. We continued to lag behind, with Ireland at the bottom of the European healthcare league. For many years, the Irish healthcare system was inappropriately managed, understaffed and loosely funded.
Irish Healthcare in the 21st Century
In 2001, the government proposed wider availability of GP services and the establishment of multi-disciplinary primary care teams (GPs, nurses, health care assistants, therapists, social workers etc).This policy was called Primary care – a new direction, 2001. While most other countries in the EU provided primary care free at the point of use, in Ireland (as had been the case for many years) medical card holders continued to receive free primary care, whereas the rest must pay at the point of use.
But then in 2005, the health service had a major facelift. This reorganisation proposed a more unified, efficient and streamlined health service that would be less vulnerable to local and parochial pressures. This single national health service was called the Health Service Executive (H.S.E) and it was going to solve EVERYTHING. The HSE replaceD the 11 Health Boards. The Department of Health and Children was responsible for policy decisions whereas the HSE was responsible for the administration, management and execution of Health Policy.
So what about now? Well it’s hard to say. To quote Iarnród Éireann “we’re not there yet, but we’re getting there!” (Might just point out here that I think that is an odd slogan for a group that aims to sell TRANSPORT… but I digress…). Policy is no longer developed in line with the ethos of church-run institutions. But we’re only just starting to recover from the hangover of these early influences. Even just today (JANUARY 27TH 2015), it was reported that Section 37 of the Employment Equality Act will be changed, meaning that religious-run hospitals will be stripped of the ability to sack staff for being gay, divorced, or unmarried parents. (Yes.. this is the current rule… and yes… our Minister for Health is a gay man). Apparently Equality Minister Aodhán Ó Ríordáin says it puts a “chill” into workers who fear being fired for private lives that go against the ethos of church-run institutions. Oi! Baby steps…
And in our modern globalised world, we can no longer do what we want. We now work with and answer to international bodies like the European Union, the United Nations and the World Health Organisation. Each of these groups play a major role in the provision and regulation of standards set for healthcare for its members and also disease prevention in order to improve life expectancies. There are proposed moves towards universal healthcare, highlighting how far we have come from the days of the dispensary model.
Funny to think that until the late 1940’s Health Policy was not seen as a priority for the Irish State. Now it’s a national obsession. And a major issue when it comes to election time. And I suspect it’s keeping Joe Duffy in a job. I guess we’ve come a long way.