Salsa for Slow Learners

With Michael Moore’s new film, Sicko, coming to cinemas here soon, we are sure to get comparisons between the American and Irish health care systems – which are moving closer with the Government’s privatisation programme and for-profit chain-store GP practices. But we will also get comparisons with one of the most successful health models: Cuba. Even suffering under the US’s criminal economic blockade, the Cubans have managed, on little means to have created an enviable health care system. And it’s all based on very simple, self-evident principles. We could learn from the Cuban experience. Indeed, we started going  down that road only a few years ago. But roadblocks were set up, traffic was diverted and all we get now is a desultory diet of recruitment freezes, ward shut-downs, service postponements and, of course, Professor Brendan Drumm’s bonus.

The British House of Commons Select Committee on Health neatly summarised the main features of the Cuban health care system:

• Integration of public health and primary care: there is almost no divide between prevention and disease management. Indeed, preventative strategies are prioritised before people get sick.
• Extremely high doctor-patient ratio: there are up to three times more doctors per capita in Cuba than in Ireland – with an even higher ratio of GPs and physicians working in the community.
• Integration of hospital/community/primary care: the operation of polyclinics (servicing 10-15 family practices) has a series of community based specialists (paediatric, gynaecology, dermatology, psychiatry) which reduce the referral rate to hospitals and lead to an almost non-existent waiting list.
• Managerial system without professional managers: clinics and hospitals are managed and led by health professionals. Compare that to the massive swelling of non-medical managers in the HSE.

Simply put, the Cuban system works very hard to prevent people from getting sick; when they do they treat them, where possible, at 24/7 multi-disciplinary community clinics; only when absolutely necessary are people referred to hospital. And, of course, all this is absolutely free at the point of use. How different from here.

To apply such principles here would require a near revolution in the way we deliver primary health care. The funny thing is that only a few years ago the Fianna Fail government launched a policy document that would have started this over-due process. Primary Care – New Directions began to apply those principles and were it to be implemented would transform primary care in Ireland (though, it still baulked at providing free universal GP care/prescription medicine). Primary Care started with a withering critique:

The current system has a number of deficiencies. Primary care infrastructure is poorly developed and the services are fragmented with little teamwork and limited availability of many professional groups. Liaison between primary and secondary care is often poor and many services provided in hospitals could be provided more appropriately in primary care. Out-of-hours primary care services are underdeveloped at present.

It proposed the beginnings of a radical new system, the core of which is to establish primary care teams throughout the country, backed up by a primary care network. A primary care team would serve population groups of 3,000 – 7,000 depending on the region. A typical primary care team would be comprised of:

• 4 GPs
• 3 Health care assistants
• 3 Home helps
• 5 Nurses/midwives
• 1 Occupational therapist
• 1 Physiotherapist
• 1 Social worker
• 4 Receptionist/clerical officers
• 1 Administrator

These multi-disciplinary teams would be supported by a primary care network comprised of a Chiropodist, Community pharmacist, Community welfare officer, Dentist, Dietician, Psychologist and a Speech and language therapist. This was to become the cornerstone of a more integrated health-care system. By housing all these professionals together in one community complex, it would greatly increase access to a wide range of services. Further, by extending these polyclinics’ hours to evening/nights and weekends, it could help divert demand away from hospitals, thus increasing capacity at our tertiary levels.

Of course, Primary Care didn’t address all issues. One that was neatly evaded was the cost of access. And some criticised it for being strong on structures but weak on operational details (a real problem is, given the merging of private sector GPs and public sector professionals, who would run the place). Still and all, it represented a potential new departure in Irish health care.

So what happened to it? Curiously enough, no one has the full answer but the consensus is that it was quietly abandoned. Maeve-Ann Wren and Dale Tussing made a valiant effort to find out but not even these experts could get to the bottom of it. While today there are local and regional initiatives, a national strategy seems to have faded.

One explanation is money. The cost of establishing 400-600 of these primary care centres required for two-thirds implementation of the plan by 2011 would have been nearly €1,300 million in 2001 (probably over €1,600 million today). But further considerable resources are needed to train and recruit a wide range of health professionals, in particular GPs of whom we have a growing shortage.

Of course, this is false economising. A substantial re-direction of resources to primary and community care would, in the long-term, reduce demand on capital-intensive tertiary, or hospital care, freeing up capacity. A comprehensive primary care network, combined with sustained public health initiatives, could help reduce demand on disease-management throughout all sectors. In other words, the more healthy a society is, the less costly it is to run a health-care system.

But it's hard to put numbers on this, given that our accountancy of public expenditure is rather rudimentary, dominated by headline figures (e.g. the wages/salaries/pensions of public service workers) but without the bottom line (e.g. the net cost of those same workers after tax/PRSI/VAT, etc. is paid back to the state).

No doubt the cost of a viable primary care network will require substantial up-front investment. Combine that with free GP care and prescriptive medicine and costs would rise even further. This is something the Left should take serious note of.

We are strong on arguing the principle of a modern, efficient and free health service but, in the past, we have not faced up to the numbers. Wren and Tussing estimated the cost of extending free universal primary coverage to the entire population to be over €2.3 billion in 2004. Added to that the cost of a primary care network, and we’re talking about over €4 billion up-front in today’s terms. And that’s not even going near the investment needed in our hospital system.

No amount of ‘soak the rich’ tax proposals will pay for that. And given that other sectors are crying out for resources (the OECD recently showed the desperate under-funding of our education system), never mind the ESRI’s projected Exchequer deficit of €3 billion by 2009, any attempt to make our health care system healthy will be a long-term project indeed.

This is one more reason why the Left must engage the electorate in an open and honest dialogue about services, expenditure and tax. This is why the Left should never again go down the route of participating in ‘tax-cut auctions’ in the run-up to elections. This is why we have to produce road-maps rather than minimalist manifesto demands.

But at least, when it comes to primary health-care we have a model in Cuba and, thanks to Fianna Fail, a policy framework (albeit abandoned).

So let’s get that vision-thing happening for us. And let’s start by enrolling in beginners’ Salsa classes.

[Note:  If you want a comprehensive analysis of Ireland's health care system along with an agenda for progressive change, How Ireland Cares: The Case for Health Care Reform is absolute must-read.]

Comments

[Aidan OSullivan]

I was part of a group trip to Cuba last year. We got a tour of the health infrastructure. It was simply amazing what they achieve living under that embargo.

The Latin American School of Medicine, which trains and then exports doctors all over the developing world, was a true inspiration.

Convincing the Irish people that their tax money will be well spent on services will be a major challenge for us.

Michael, excellent work again as usual. These things do really seep into the political consciousness. I have pondered another health system for some time which I feel might be an easier get to for us and is also an exemplar I feel; Luxembour. Here we have a combination of universal health coverage paid for by a percentage of take home through private bidding hospitals which have negotiated costs that compete for these funded trust based monies. Health professionals negotiate wages similarily to our partnerships already in existence. All workers pay caise de maladie health insurance and can reclaim typically 100% of health expenditure though in some cosmetic treatments this may reduce. Welfare recipients claim free. This is not obviously proposed to be an additional cost for taxpayer as a corresponding cut in taxation would be necessary. This is certainly financially viable if you consider that we currently fund an ineffecient system that spends the equivalent of all personal taxation. I am not the best at explaining the system, but perhaps if someone can get access to a relevant link that would simplify this then it could be posted. I feel this could be a real opportunity to do something of major importance better.

[Michael]

You might be interested in reading 'Social Health Insurance' published by the Adelaide Hospital Society. It puts forward an excellent case for an insurance-based health system. It also surveys other SI systems in Europe, including Luxembourg. You can get it here http://www.adelaide.ie/cms/cms/uploads/files/PolicyReport20061123(1).pdf

In terms of real issue for Labour that makes a difference and differentiates the party I do believe strongly that this is it. Requires huge effort and commitment and bravery in the area of short-term politics; however it could be the rolls royce. Would leave to see an extended debate, perhaps even a convention on this

[Jim]

Really enjoyed your first look at taxation and social insurance etc. Could these combine with earlier comments I made re health insurance, which I now see were sent without signature and could they form a basis for a convention being called for a debat?