Book review – Burke, Irish Apartheid (2009)

Triona MackenTriona Macken is a UCD Politics Joint Major. The best book reviews written as part of the course requirements for POL30080 Irish Politics and Policy are posted here to let UCD students contribute to critical reflection on key issues in Irish political and social life.

Burke, Sara (2009) Irish Apartheid: Healthcare Inequality in Ireland, Dublin, New Island.

In this book Sara Burke, a journalist in health matters, provides both a lay person’s and an academic’s guide to understanding the complexities of the Irish health system. Throughout the book she is critical of how successive ministers failed to deliver a comprehensive public health service. She is particularly critical of the health strategies of governments from 2001 to 2007 which escalated inequalities. Her book, written in 2009 at the onset of the Great Recession, gives an authoritative perspective on health policies during the years of boom. This gives us a good context in which to understand what has happened since the crisis.

The book explains the evolution of Ireland’s two-tier healthcare system. In brief, she argues, a lack of planning and a lack of clear strategy failed to deliver good-quality performance, while successive Health Ministers’ political ideology of increased privatization and a market-driven notion of value for money drove the delivery of health services. Burke devotes chapters to specific themes in the evolution of Ireland’s health system: among the highlights are the consultant’s contract, the implications for social services of a low-tax economic model, political difficulties with the Hanly reforms, the aims and shortcomings of the then relatively newly established HSE, and the sources of the ongoing A&E trolley crisis.

Particularly illuminating is her account of the ‘sweetheart deal’ consultant’s contract. In 1979, Fianna Fáil Minister for Health Michael Woods gave consultants state-salaried, pensionable posts on the basis of a thirty-three-hour week in the public hospital system, while also permitting them the right to unlimited private practice both inside and outside the public hospitals. But there were no mechanisms for monitoring their public work commitments. This arrangement, which remained in place until 2008, contributed hugely to the entrenchmentover over time of a two-tier service in which consultants have strong incentives to devote more effort to their private practice than to their public duties. However, I do not think Burke gets to the root of the problem of medical staffing. The fact remains that consultant numbers in the public system continued to be too low. The result is a system where non-consultant hospital doctors (NCHDs) provide the bulk of the service. NCHDs work dangerously long hours (in spite of EU directives), giving rise to patient safety concerns and high overtime bills. Under-resourced and under-appreciated NCHDs, who also lack clear routes to career development and have poorly integrated service supports, have high rates of burnout and tend to emigrate in large numbers: this is poor value for money, considering the cost of their publicly-funded education.

Irish Apartheid also tackles the barriers faced by politicians when attempting to effect change in the health service. As ministers bow to electoral pressure, poor strategies result. Citing Hanly, Burke outlines the merits of the plan to downgrade smaller hospitals to favour high-quality care in tertiary centres of excellence. She documents how this plan was side-lined to placate local action pressure groups: she is frustrated by political leaders who fail to show leadership in difficult decisions. However, she omits to highlight the public’s culpability in blocking progress. Voters as well as politicians are responsible for the dictum that ‘all politics is local’ in Ireland. While Hospital candidates like Denis Naughton in Roscommon continue to be re-elected, campaigning on narrow localist issues regardless of the need for quality improvement across the service as a whole, it will be difficult for policy-makers to drive through real reform.

Burke usefully details how, under Finance Minister McCreevy’s tax breaks in 2001 and 2002, ‘for-profit’ hospitals and nursing homes were strongly incentivized. The drive towards increased privatisation has led to an unfair and inefficient services provision, further weakening the scope for invsetment in high-quality public services and thus compounding inequality. Burke believes that this model does not result either in better quality care or in cost-saving. Others would argue that having a private component in the health care model, as espoused by the PDs, allows us to keep our low tax policy, frees up more beds in public hospitals, and reduces waiting lists. However, Burke’s argument is supported by other researchers who find that the dual-track policy of incentivizing the private sector while paying lip-service to the public sector entails an unacknowledged bias toward growing reliance on private health care and a reinforcement of established inequities.

Burke shows how the Irish health system favours private patients’ access to specialist care. The cost of the care of private patients is largely subsidised by public money, and the insurer does not pay the full economic cost of private patients in public care. 50% of the population before the crisis had private health insurance (dropping to 40% at the height of the crisis, but rising again more recently), and although in principle there is supposed to be a cap of 20% on the number of private patients gaining access to public hospitals, the hospitals rely on this insurance revenue to support their budgets. A report in 2008 by the Combat Poverty Agency supports Burke’s analysis. It recommended that the reduction of health inequalities should become a government priority, and that health inequalities need to be mainstreamed into all policy areas: ‘Working for health equity requires a joined-up approach across government departments. Health Impact Assessment could usefully inform this process enabling policy makers to assess the health implications of a wide range of public policy decisions.’

Subsequent to the book’s publication, Fine Gael did try to address this issue, focusing on equalising access to care through the extension of insurance cover to everyone. The 2011 manifesto promised universal access to health care by 2019. Under this ambitious plan everyone would have equal access to care regardless of means, in a single-tier system delivered through universal health insurance (UHI) for all, where the State would pay or subsidise premia for those who could not afford them. However, a report on UHI commissioned by Reilly’s successor Leo Varadkar deemed the cost to be prohibitive at €3000 per person per annum. The advice from health economist Brian Turner in 2013 was ‘to remain with the status quo while making changes to the elements that are not functioning optimally, rather than embarking on a radical redesign of the entire system’. To date, little enough progress has been made on this crucial matter.

In conclusion, Irish Apartheid will prove valuable for both academics and the public alike. It does not provide solutions or recommendations as to how an equitable health service available to all can be achieved. Notwithstanding this, the book is very accessible and informative. Backed by reliable empirical data, it provides a very good overview of Irish health services, and does indeed convincingly make the case that when it comes to equal access, the Irish health system falls short, and that ‘apartheid’ in health care is no exaggeration.

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