A system in permanent crisis

by Diana O’Dwyer

Article originally published in Issue 1 of Rupture, Ireland’s eco-socialist quarterly, which is sold out. You can purchase the digital version here:

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The Irish health service is in a state of permanent ‘crisis’. Its scale and intensity, and the level of media attention to it, wax and wane but the condition is chronic and seemingly incurable. After decades of political neglect, cutbacks and now Covid, public hospital waiting lists have grown exponentially. As of September this year, one in every six people were on official public hospital waiting lists.[1]  

Long waiting lists mean long waiting times. Even before the current crisis, Ireland had the worst access to healthcare in Europe[2] with two-thirds of public patients[3] waiting over 6 months. This is so normalised that the HSE’s ‘Key Performance Indicators’ only aim to reduce the number of people waiting more than 15 months![4] 

The stories behind these statistics are heart-breaking. Children’s spines bending into agonising curves while they wait years for surgery, people going blind because of delays to simple cataract operations, public patients dying of cancer because they had to wait up to 25 times longer for diagnostic tests than private patients.[5] 

The crisis in A&E is just as bad. Last year, 44% of A&E patients waited more than 6 hours or gave up and left without being treated.[6] Such long waits cause emergency department overcrowding, which even before Covid made full capacity protocols ‘the norm’ in many hospitals.[7] This means cancelling elective surgeries and vital treatments like chemotherapy, leading to even longer waiting lists. 

How did things get so bad?

Under-investment & inequality: the two tier health system in Ireland

At the root of the problems in the Irish health service are under-investment and inequality. The public health system has been starved of resources for decades and access to healthcare is unequally distributed. If you’re poor, inability to pay for private health insurance means inequality of access to healthcare and under-investment by the state means that when you finally do manage to access the public health system, the service you receive as a public patient is often inferior. Exacerbating this two-tier public/private divide is a complex three-sector model of healthcare providers consisting of: public; private/for-profit; and voluntary/non-profit providers. The result is a system that is both inefficient and unjust - for patients and for healthcare workers. 

Under-investment in the public health system & a historically weak state

Given the crisis in the health service, it might seem surprising that Irish health spending per person is higher than the OECD average.[8] But the public component of Ireland’s health expenditure (73%) is lower than in many countries with superior universal healthcare systems, including Norway (86%), Sweden (84%), Denmark (84%), the Netherlands (82%), Japan (84%) and the UK (79%).[9] Public health spending leads to much better outcomes because healthcare is allocated according to need rather than ability to pay, which is inherently more efficient, and because transaction costs are much lower. In public systems, transaction costs average only 7-8%[10], compared to an eye-watering 30-50% in the US, due to billing, advertising, tendering and risk selection by insurance companies, as well as profiteering and provision of unnecessary services to boost profits. It’s estimated that almost a third of US health spending is “wasted, due to administration costs, fraud, unnecessary tests and unnecessary investigations, including surgery”.[12] 

Public spending on health in Ireland has increased in recent years but decades of under-funding, followed by €11bn in austerity cuts from 2009-2017[13] have left their mark, maxing out the health service and leaving it running on empty. A report for the Department of Health two years ago advised there was a need for a 37% increase in the primary care workforce (including GPs), a 40% increase in residential care beds, a 70% increase in homecare and an extra 7,150 hospitals beds, including an extra 190 in ICU.[14] Ireland also has the least consultant specialists in the EU[15] and only 3 hospital beds per 1,000 people, compared to an OECD average of 4.7.[16] This has led to incredibly stressful conditions for healthcare workers and huge problems in recruitment and retention. Last year’s nurses’ strike was just as much about unbearable working conditions as it was about low pay. 

The savage cuts to healthcare after the 2008 crash worsened the permanent healthcare crisis but the truth is that Ireland has never had a single tier, accessible, high quality, universal public healthcare service. The history of healthcare in this country is the history of a weak state unwilling to provide for the needs of its population that outsourced healthcare, first to the Catholic Church and later to a hodgepodge of private for-profit and not-for-profit organisations. 

A brief history of Ireland’s two-tier system

Maev-Ann Wren’s critical history of healthcare in Ireland, Unhealthy State, shows how attempted reforms in the direction of universal healthcare have repeatedly been blocked by powerful elite coalitions. The best known example is the defeat of the Mother & Child Scheme by Catholic clergy, GPs, consultants and right-wing politicians, but there have been many others. Since the 1980s, the state-subsidised expansion of the private healthcare industry has created an equally powerful lobby of private hospitals, insurance companies, nursing homes, homecare providers, and their capitalist owners. They are equally as determined to block reform. Uniting them all is a shared class interest in perpetuating private ownership and control of healthcare and the right to profit it. 

Reflecting the class interests of doctors and the private healthcare industry, maintaining the two-tier system of public and private healthcare has long been the policy of Fianna Fáil and Fine Gael. Rory O’Hanlon, Fianna Fáil’s Minister for Health from 1987-1991, declared that “A two tier system…has been the position since the foundation of the state and this system, with its integrated mix of public and private care, has serviced the nation well.”[17] Likewise, Michael Noonan when he was Minister for Health described the two-tier system as a “fundamental plank” of the health service.[18] Noonan later suffered a road to Damascus conversion during the 2002 election campaign and condemned the “outrageous form of apartheid in our two-tier health service”[19], but the effect was only temporary. In office, Fine Gael has always enforced healthcare inequality and the social and economic inequality that underlies it. 

The same goes for the Labour Party, which like Fine Gael and Fianna Fáil, has fulminated against the two-tier system in opposition but done nothing about it in office. Labour’s Brendan Howlin, when he was Minister for Health, stated in his health strategy that the government was committed “to maintaining the position of private practice within the well established public-private mix.”20 Yet (typically for Labour) after he was no longer Minister he complained that,

“The government wanted a chunk of the population … to pay for private health insurance but, in order for that to happen, they really required the public system to be inferior. Why else, if it was first rate, would people pay for a private system?”[21]

Prior to independence, some healthcare services were independently funded by the Catholic Church, but for most of the twentieth century, the state has heavily subsidised the provision of healthcare by religious orders rather than investing in a universal public health service. For example, St. Vincent’s University Hospital in Dublin was originally paid for via a state-run hospital sweepstakes[22] and gifted to the Sisters of Charity, similar to how the state intended to hand over the new National Maternity Hospital to the same religious order. 

Even today, major public hospitals like the Mercy University Hospital in Cork and the Mater, Temple Street Children’s Hospital and Vincent’s in Dublin, as well as disability, mental health and elderly care services like the Brothers of Charity, Daughters of Charity and St. John of Gods, remain under the ownership and control of religious congregations (see Box). Despite being overwhelmingly state-funded, they are still permitted to enforce Catholic religious dogma on public and private patients. For example, the Mater Hospital pharmacy refuses to stock the contraceptive pill and the Sisters of Charity prohibit the morning-after pill, IVF, vasectomies and female sterilisation in their hospitals.[23] 

Top 5 religious orders funded by the HSE (2019)

• Sisters of Mercy (including Mater Hospital, Mercy University Hospital) - €432m

• Sisters of Charity (including St. Vincent’s University Hospital) - €373m

• Brothers of Charity - €218m

• St. John of Gods - €166m

• Daughters of Charity - €122m

Total Funding = €1.311bn

Prior to the 1980s, religious orders also ran the majority of private hospitals[24] but falling numbers of nuns have since led to some of them being sold or closed.[25] However, the largest private hospital group is still owned by the Bon Secours, the same order that disposed of hundreds of dead babies in a septic tank in Tuam. It owns five private hospitals, in Limerick, Cork, Dublin, Galway and Tralee, with an annual turnover of €230m.[26] The Sisters of Charity’s healthcare empire combines public and private, with St. Vincent’s Private and the public St. Vincent’s University Hospital occupying the same grounds. Even where religious orders have ended direct ownership, it rarely means the end of religious influence. For example, in 2000, the Sisters of Mercy sold the Mater Private “but made the sale contingent on the continuation of Catholic ethics, to be overseen by the Catholic Archbishop of Dublin.”[27] An examination of the four largest religious healthcare providers found “they all have rules that require that their assets are transferred to other charitable bodies with a Catholic ethos” in the event they are wound up.[28] 

From the 1980s onwards, secular non-profit organisations and private for-profit healthcare providers increasingly joined in the state’s outsourcing of healthcare provision. In 2019, the HSE spent over 31% of its current budget (€5.4bn) on outsourcing to outside agencies[29], including religious organisations, for-profit nursing homes and homecare providers, non-religious voluntary hospitals like Beaumont and St. James’ and big secular NGOs like Rehab, the COPE Foundation and Enable Ireland. 

Like their religious predecessors, NGO healthcare providers are overwhelmingly state funded and in reality are extensions of the state. However, at least three major problems arise with outsourcing healthcare in this way. Firstly, it situates essential public services as charity, with NGOs dependent on fundraising to fill in the gaps and more susceptible to cuts. An ICTU study estimated a 35% contraction in the voluntary sector from 2008-2012 compared to overall cuts in government current spending on services of less than 3%.[30] NGOs were expected to compensate for this by increasing fundraising and using more volunteers and ‘interns’. This highlights the second major problem of outsourcing to NGOs, namely that pay and working conditions vary substantially and are often inferior to the public sector. Staff in so-called ‘Section 38’ organisations, which include voluntary hospitals and big healthcare NGOs like St. Michael’s House and the COPE Foundation, are on public sector rates of pay and conditions but non-Section 38 HSE-funded NGOs are not, even though many of them are just as dependent on state funding.[31] 

Thirdly, relying on NGOs leads to inconsistent service provision both geographically and by service type. In some areas, very few services are provided whereas in others, many small NGOs proliferate and there is inefficient duplication of services. For example, as many as 48 separate agencies provide suicide-related services[32] yet the standard of mental healthcare in this country remains woefully inadequate (see box: Mental health epidemic). 

Private for-profit healthcare expands with state subsidies 

Just as with NGOs, the expansion of private for-profit healthcare came off the back of large state subsidies while at the same time the public system was starved of resources. As recently as 1998, the Blackrock Clinic and the Mater Private, both founded in 1986, were the only two private for-profit hospitals in the state. Now there are 18[34], accounting for one in three acute hospitals and one in six acute hospital beds.[35] This rapid expansion was encouraged by tax breaks for building or refurbishing private health facilities. Initially introduced in 2002 by Fianna Fail and the PDs[36] in response to lobbying from private hospital interests, they were continued under Fine Gael and Labour. From 2011-15 alone, property-related tax breaks for private hospitals, clinics, nursing and convalescent homes cost the Exchequer over €100m.[37] Under the terms of the tax breaks, private hospitals had to make at least 20% of bed capacity available for private patients at a 10% discount.[38] The Department of Health pointed out that this made their “continued viability” ‘dependent’ on a continuing subsidy from the state.[39] The same is true today. Without massive ongoing subsidies, the private healthcare industry would be completely unviable. 

Subsidising private healthcare is usually justified with the claim that it will “take pressure off the public system”. What this really means is that it will take pressure off right wing politicians and the state to properly fund it, while also providing opportunities for capitalists to profit. The example of the National Treatment Purchase Fund (NTPF), which pays for the treatment in private hospitals of patients who have endured especially long delays in the public system, shows that from the outset the relationship between the private sector and the public system has been more inefficient and parasitic than genuinely helpful. The NTPF mostly pays for simpler, more profitable procedures like cataract removal, varicose vein treatment, and hip and knee replacements[40], leaving more complex and less lucrative operations to public hospitals. From 2002-2013, the NTPF spent approximately €676m on outsourcing public patients to private hospitals[41] - money that could have been invested in the public system. According to Dr. Peter Boylan, 

“The NTPF is a bad idea. That money should be invested in the health services immediately. What happens is that somebody who is on a waiting list for years is sent to a doctor they have never seen before for a pre-planned procedure that might not be appropriate. They get the procedure and never see the person again … It is just bad clinical practice and it should be abandoned.”[42]

The NTPF was suspended in 2014 due to cutbacks but Minister Harris announced its reactivation in October 2016.[43] It had a budget last year of €75m[44] but despite its relatively small size and non-applicability to many procedures is invariably touted by the right-wing parties as the go-to solution for endless public waiting lists. It plays a key ideological role in enabling the private sector to be presented as more efficient, as the experience of patients is that they wait years to be treated in the public system but then are transferred to the NTPF and rapidly treated in a swanky private hospital. What isn’t immediately obvious is that the NTPF perpetuates long public waiting lists by operating as a safety valve that can be activated through throwing increased funding at it whenever waiting lists get especially out of hand, rather than making the long-term investments needed in the public system to prevent the waiting lists from arising in the first place.  

Tax reliefs on health expenses (€156m) and private health insurance (€356m) dwarf the NTPF in terms of subsidies to private healthcare, costing the state upwards of half a billion euros a year.[45] About two-thirds of the tax expenditure on insurance subsidises treatment in private hospitals[46] while the remainder subsidises private patients to skip the queue in public hospitals. In both cases, the relief acts as a huge subsidy to the insurance industry, which can charge higher premiums as a result. According to the Health Insurance Authority, the average health insurance premium has increased from €423 per person in 2002[47] to €1,200 today.[48] This has led to a tripling of premium income for the insurance industry, from €822m in 2002[49] to €2.5bn in 2016[50] as the numbers taking out insurance have also increased substantially.[51] The more horror stories about the public system the better from the private healthcare industry’s perspective, as it means more people frightened into taking out health insurance to avoid it. 

As mentioned above, a large chunk of the HSE’s outsourcing budget goes to for-profit healthcare services. Top of the list are homecare and nursing homes, which have been privatised en masse since the 1980s. Between 2008 and 2015, a time of savage cuts to public healthcare, the top five private homecare providers enjoyed a seven-fold increase in HSE grants. Likewise, the ‘Fair Deal’[52] scheme introduced after the 2008 crash accelerated the process by providing private nursing homes with a massive new income stream, now amounting to over €600m a year.[53] As with private hospitals, the state also provided massive (100%!) tax relief on capital expenditure.[54] By 2019, 80% of nursing home beds were private, up from 66% in 2009[55] and 25% in the 1980s.[56] The problems this has created were cruelly exposed during the first wave of Coronavirus when the state washed its hands of the private nursing homes, allowing almost a thousand people to die while it hoarded PPE and healthcare workers. 

Profits in the private nursing and homecare industries are hard to quantify as “many nursing homes don’t publish accounts because they are unlimited entities” or are “registered in offshore havens such as the Isle of Man or … the British Virgin Islands.”[57] The same is true of the private healthcare industry as a whole but the resulting wealth is evident among Ireland’s richest. Two of Ireland’s billionaires, Denis O’Brien and Larry Goodman, are major owners of private hospitals. They operate complex tax avoidance structures that funnel the profits through companies in Luxembourg.[58] On top of directly undermining the public health system, the private healthcare industry deprives the state of the taxes needed to fund it. 

The overall outcome of subsidising private healthcare while starving the public system of resources has been to create a monstrously complex and unwieldy three-sector system with large overlaps between the public, for-profit and non-profit sectors. Private patients get treated in public hospitals and public patients get treated in private hospitals; voluntary hospitals also treat public and private patients; the vast majority of consultants working in public hospitals treat both public and private patients, either in the public hospital or in private hospitals as well; GPs supplement their income from private patients with capitation fees for GMS/medical card patients. All of this has led to inefficient duplication of structures, intractable organisational problems, lack of integration and fragmentation of care - on top of the primary problem of severe health inequality.

Mental Health Epidemic

by Kay Keane

During this pandemic, we have had a total lockdown, phased reopening and regional lockdowns. Rightly our focus was on protecting our older population and those with underlying medical issues. Yet within the measures implemented to safeguard the vulnerable, a section in our society were mostly left to cope alone.

Figures in the Galway Daily show that across the state there are 8,011 children and teenagers waiting for treatment from a psychologist; 3,359 have been on the waiting list for over 12 months. A report by UNICEF puts Ireland in 26th place out of 38 in terms of mental wellbeing. The report highlighted that more than six in 100,000 Irish adolescents aged between 15 to 19 die by suicide. Many experts also fear a ‘tsunami’ of mental health problems due to the coronavirus pandemic. There has been an upward trend in suicide and self-harm as reported by the National Spinal Injuries Unit in the Mater Hospital. Seventeen percent of patients admitted had sustained injuries in a suicide attempt compared to 1% the same period last year. The increase here coincides with studies being done elsewhere in the world. A recent study in the U.S. shows 45% of people with suicidal thoughts explicitly linked them to Covid-19. “A large proportion of consultants are reporting an increase in people experiencing both new onset and relapse of mental illness compared to the early stages of lockdown, but also before the lockdown came into place,” Andrea Ryder of the College of Psychiatrists of Ireland said. The last part of her comment is perhaps the most telling in the way mental health is ‘prioritised’ here. The crisis within the Mental Health Service has not happened overnight nor is it because of Covid-19. Instead, it is the result of consecutive governments and health ministers refusing to invest in vital services. The government of Fine Gael congratulated themselves on economic growth pre-Covid-19 and yet a mere 6% of the health budget was allocated for mental health services. This underfunding of services has had major consequences on the care and treatment of patients, and report after report written by those who work within the service have pointed to the lack of resources and low morale among staff. GPs assessing the needs of individuals face a vicious circle of medicating while trying to get referrals to psychologists and psychiatrists. Those suffering from mental health issues were in the most part left to struggle alone without adequate publicly funded services available. We have never had a publicly-funded 24/7 service, and whatever community services were available then were quickly withdrawn when the 2007-2008 economic crash happened. While acknowledging this crisis cannot be fixed overnight it cannot be allowed to worsen. Post Covid-19, it is vital we support all who need our help. Isolation has impacted everyone no matter the state of our mental health. The figures here and internationally are frightening. We need to remember that behind the number is a person who is loved by family, but whose family are not experts nor counsellors. Before Covid-19, we had a crisis in housing, health, low wages, and zero-hour contracts. All these issues have impacted the mental health of many, including children. Now as we face an economic downturn how will the already woefully inadequate service be further decimated?

Inequality of care 

Access to healthcare in Ireland is grossly unequal. We are the only country in Europe without universal free or subsidised primary care.[59] Less than half the population have a medical card (32%) or free GP card (10%) so most of us have to shell out €50-€70 every time we go to the doctor.[60] This deters low and middle income workers from seeking medical treatment. Eighteen percent of the population “did not go to a doctor in the last year due to cost”, ten times the rate in Northern Ireland[61] which has free primary care under the NHS. According to the World Health Organisation (WHO), 

“Direct payments have serious repercussions for health. Making people pay at the point of delivery discourages them from using services (particularly health promotion and prevention), and encourages them to postpone health checks. This means they do not receive treatment early, when the prospects for cure are greatest.”[62]

This is the definition of a false economy. When people finally manage to access healthcare, they end up needing more complex and expensive treatment, driving up costs, hospital admissions and waiting lists. The absence of free GP care therefore increases spending on hospitals. 

Access to hospitals is also based on the ability to pay - for health insurance or out of pocket - which guarantees unequal access. Private hospitals only accept private patients (with the exception of public patients outsourced by the HSE), but public hospitals also offer preferential access to paying customers. Until 2014, 80% of beds in public hospitals were supposed to be reserved for public patients but the real number was habitually far lower[63], prompting the former head of the HSE, Tony O’Brien, to describe it as “a farce in practice”.[64] Rather than remedy the farce, the HSE abolished the rule. According to the OECD, nearly 30% of public hospital services in Ireland are paid for by private health insurance, which is “much higher than in any other country besides the United States”.[65] Combined with the one in six beds in private hospitals, this means that almost half of all hospital beds can potentially be allocated on the basis of income[66], rather than need, dramatically reducing access for public patients with no other option. Less than half (46%) of the population have health insurance[67] and 32% have a medical card.[68] It’s estimated that around 5%[69] have both - mainly over-70s who qualify for a medical card at higher incomes than other groups. This leaves well over a quarter of the population with neither, who face a choice between charges of up to €800 a year if they need to stay overnight in a public hospital as a public patient[70] or much higher fees if they go to a private hospital and pay out of pocket. Given all this, it’s no accident we have endless public waiting lists or that one in three people with a healthcare need have forgone or delayed treatment because it was unavailable or they couldn’t afford it.[71] 

Even when public patients finally get to access hospital treatment, the care they receive is often inferior compared to private patients. An OECD report on private care in public hospitals tactfully suggests that “private activities might create competition for time and attention of the consultants and the support staff to the detriment of public patients, who may experience reduced service availability and less responsive care with less attentive medical staff.”[72] Health researcher, Maev-Ann Wren, is more blunt, explaining that consultants “have an economic incentive to favour private patients, which contributes to public patient waiting lists and leaves much of public patient care in the hands of poorly supervised and trained junior doctors.”[73] Meanwhile the consultant they would have been treated by if they were a private patient is off treating private patients, who are often less sick because they haven’t had to wait as long for treatment, on a fee-per-service basis. This takes place in private consulting rooms built into our public hospitals or off-campus in private hospitals.[74] Eighty-four percent of consultants have contracts that allow them to treat private patients during their publicly contracted working hours[75], enabling them to double-job on the state’s time. Despite repeated efforts to move consultants onto public-only contracts, this continues to be allowed to happen because public hospitals starved of funding rely on private patients to boost their income and because of the power of the consultants’ lobby.[76]  

Opposition to a single-tier system

Any moves towards a single tier public health service[77] have historically been opposed by the medical profession and are likely to face similarly strong opposition in the future. The Irish Hospital Consultants’ Association (IHCA) (which represents 85% of hospital consultants) claims that “[t]he adoption of a single tier approach is unlikely to lead to an efficient, effective and sustainable public health service” and “may be counterproductive in terms of negating the benefits associated with having complementary and competitive networks of public and private healthcare providers.”[78] Similarly, the Irish Medical Organisation (IMO) opposes removing private patients from public hospitals.[79] GPs’ attitudes are somewhat more varied. The Irish College of General Practitioners has said that universal free GP care must be “contingent on manpower, IT and built infrastructure capacity”, “an adequate number of GPs” and “a new GP contract”.[80] By contrast, the now defunct (but politically well-connected) National Association of General Practitioners (NAGP) described Sláintecare proposals for free GP care for all within 5 years as “utopian” and trotted out the right wing trope that “[a]ll societies that have universal free point of care access struggle with capacity. It keeps building and escalating”.[81] 

It will be difficult to overcome the opposition of doctors to a single-tier health service but two measures that could make a difference would be to open up access to free medical training and write off the debts of junior doctors. The fact that at present junior doctors leave medical school with debts of €100,000 or €200,000 and must also pay extortionate levels of liability insurance are part of the reason many consultants are so focused on maximising their earnings. Extending access to consultant posts for non-EU doctors who at present are often barred from progression would also help to increase the number of hospital consultants. 

Towards an Irish NHS?

Without a strategy to defeat the powerful interests that oppose universal healthcare, an Irish NHS is unlikely to be achieved. As left-wing health academic, Alysson Pollock, puts it, the challenge is “to overcome the many vested interests that would retain the fragmented and marketised private elements of the service and jeopardise the health of many people for the benefit of a few others.”[82]  

For RISE, this means building a mass campaign of public support for a single-tier, universal public health service, free at the point of use. Crucially, this has to be joined with a fighting trade union campaign involving the majority of healthcare workers who don’t benefit from the emaciation of public health system and who already support the introduction of universal public healthcare, such as the Irish Nurses and Midwives’ Organisation (INMO). 

Incorporating private and voluntary sector healthcare workers into the public sector would elevate their pay and conditions to the highest levels, including full job security and pension rights and restoration of equal pay and conditions for public sector healthcare workers. According to the Private Hospitals’ Association, trade unions do not exist in private hospitals[83] whereas a universal public system would allow all healthcare workers to participate in the democratic management and control of their workplaces as part of the wider democratic planning of public health, involving patients and communities. 

Combined with improved pay and conditions, this would help to address problems of morale and recruitment and retention. Central to this is recognising that truly universal public healthcare can only be achieved by eliminating profiteering in health, taking the major private and voluntary healthcare organisations into public ownership to massively expand capacity and ensure equality of access, separating Church and State and democratically transforming the health service. 

Notes

1. 844,053 people https://www.ntpf.ie/home/nwld.htm

2. Health Consumer Powerhouse, Euro Health Consumer Index 2016 (Health Consumer Powerhouse, 2017).

3. For whom a waiting time is available

4. https://www.hse.ie/eng/services/publications/corporate/hse-annual-report-and-financial-statements-2019.pdf 

5. http://www.irishtimes.com/news/health/public-patients-wait-up-to-25-times-longer-for-cancer-tests-1.2624303.

6. HSE, “Annual Report & Financial Statements 2019”, p. 78, https://www.hse.ie/eng/services/publications/corporate/hse-annual-report-and-financial-statements-2019.pdf 

7. According to the Sunday Business Post,  Ibid.

8. OECD. Health at a Glance 2019: OECD Indicators. Health at a Glance. OECD, 2019, p. 33 https://doi.org/10.1787/4dd50c09-en.

9. OECD. Health at a Glance 2019: OECD Indicators. Health at a Glance. OECD, 2019, p. 29 https://doi.org/10.1787/4dd50c09-en.

10. Charles Normand, “Funding Universal Health and Social Care in Ireland: Ageing, Dying, and Affordability,” 2015.

11. Pollock, Universal Health Care and the NHS: Discussion - Professor Alysson Pollock; Management of Chronic Care Illness: Discussion - Irish College of General Practitioners.

12. Ibid.

13. Source: Department of Public Expenditure & Reform Public Spending Database

14. PA Consulting. ‘Health Service Capacity Review 2018 Executive Report’. Department of Health, 2018. https://assets.gov.ie/10131/5bb5ff12463345bbac465aaf02a2333d.pdf. p. 3

15. https://www.irishexaminer.com/news/arid-30935020.html

16. https://doi.org/10.1787/4dd50c09-en.

17. quoted in Wren, Unhealthy State: Anatomy of a Sick Society, p. 74.

18. quoted in ibid., p. 99.

19. quoted in ibid.

20. quoted in ibid., p. 97.

21. quoted in ibid., p. 99.

22. Diarmaid Ferriter, “Diarmaid Ferriter: St Vincent’s Was Built with Public Money,” Irish Times, April 29, 2017.

23. http://www.thejournal.ie/religion-health-care-catholic-church-3360849-Apr2017/?utm_source=shortlink.

24. Wren, Unhealthy State: Anatomy of a Sick Society, p. 67.

25. Ibid, p. 284.

26. http://www.irishtimes.com/news/social-affairs/order-of-nuns-behind-tuam-home-runs-private-hospital-group-1.3000231.

27. Wren, Unhealthy State: Anatomy of a Sick Society, p. 133.

28. http://www.irishtimes.com/news/health/succession-rules-safeguard-catholic-ethos-of-church-s-health-service-assets-1.3067871. 

29. HSE, ‘HSE Annual Report and Financial Statements 2019’, 2020. p. 130.

30. http://www.ictu.ie/download/pdf/downsizingcommunitysector.pdf.

31. Amy Power, Dennis O’Connor, and Karena Walshe, “The Irish Not for Profit Sector Fundraising Performance Report 2015” (2into3, November 2015).

32. Patsy McGarry, “Irish Charity Sector Is Being Drained by Duplication,” Irish Times, July 11, 2016.

33. http://www.irishtimes.com/opinion/apartheid-nature-of-our-health-system-must-end-1.793197.

34. http://privatehospitals.ie/members/ 

35. http://privatehospitals.ie/overview/ 

36. Wren, Unhealthy State: Anatomy of a Sick Society, p. 281.

37. Revenue Commissioners, “Certain Property Based Tax Reliefs,” February 9, 2017.

38. Wren, Unhealthy State: Anatomy of a Sick Society, p. 282.

39. quoted & cited in ibid.

40. http://www.audgen.gov.ie/documents/annualreports/2004/Vol1Eng.pdf.

41. Based on Comptroller & Auditor General reports and NTPF Annual Reports and the fact that from 2002-2005, 56% of NTPF referrals were to private hospitals compared to at least 90% from 2006-2013. The NTPF was effectively suspended from 2014-2016.

42. Dr. Peter Boylan and Professor Louise Kenny, “National Maternity Strategy: Discussion,” Joint Committee on Health, January 19, 2017.

43. PHA, “€70M Commitment to National Treatment Purchase Fund Welcomed,” October 18, 2016, http://privatehospitals.ie/ntpfbudget/.

44. https://www.ntpf.ie/home/pdf/pressreleases/National%20Treatment%20Purchase%20Fund%20welcomes%20Budget%202019%20allocation.pdf

45. https://www.revenue.ie/en/corporate/documents/statistics/tax-expenditures/costs-tax-expenditures.pdf 

46. PHA, “Private Hospitals Association Submission to Oireachtas Committee on the Future of Healthcare,” p 6.

47. HIA, “Annual Report 2004,” 2005, 43, https://www.hia.ie/sites/default/files/annual-report-2004-en.pdf.

48. https://www.hia.ie/sites/default/files/I%20HIA%20Annual%20Report%202019%20Release%20I%2030%20July%202019%20FINAL.pdf  

49. HIA, “Annual Report 2004,” 2005, 43, https://www.hia.ie/sites/default/files/annual-report-2004-en.pdf.

50. Charlie Taylor, “Figures Show More People on Inpatient Health Insurance Plans,” Irish Times, May 27, 2017.

51. HIA, “Private Health Insurance Market Is Responding to Economic Recovery and Lifetime Community Rating - HIA,” May 3, 2017.

52. https://www.citizensinformation.ie/en/health/health_services/health_services_for_older_people/nursing_homes_support_scheme_1.html

53. HSE, “Annual Report & Financial Statements 2019,” p. 189. 

54. https://www.pbp.ie/the-roots-of-the-nursing-home-tragedy/ 

55. Nursing Homes Ireland, “About Nursing Homes Ireland,” accessed May 13, 2017, http://www.nhi.ie/index.php?p=about.

56. https://www.pbp.ie/the-roots-of-the-nursing-home-tragedy/

57. Maeve Sheehan, “Special Report: Investors Poised to Make Millions from Nursing Homes,” Sunday Independent, February 17, 2017.

58. Denis O’Brien owns the Beacon Hospital in Sandyford. Larry Goodman is the largest owner of private hospitals with shares in the Blackrock Clinic, Hermitage Medical Clinic in Lucan and the Galway Clinic.

59. Maev-Ann Wren and Sheelah Connolly, “Challenges in Achieving Universal Healthcare in Ireland” (ESRI, 2016), 2, https://www.esri.ie/pubs/BP201701.pdf; Sara Burke, “Opening Statement by Sara Burke,” October 5, 2016.

60. https://www.gov.ie/en/publication/f1bb64-health-in-ireland-key-trends-2019/ p. 53

61. Burke, “Opening Statement by Sara Burke,” p. 2.

62. WHO, World Health Report 2010 - Health Systems Financing: The Path to Universal Coverage, 2010, 5.

63. Ibid., 88; Aaron Rogan, “Don’t Sign Hospital Waivers, Patients Told,” Times Online, April 12, 2017, https://www.thetimes.co.uk/edition/ireland/dont-sign-hospital-waivers-patients-told-0jhfq5pth?CMP=TNLEmail_118918_1677711.

64. quoted in Martin Wall, “Rules Limiting Private Practice in Hospitals ‘a Farce’ – HSE Chief,” Irish Times, January 9, 2016.

65. OECD. ‘Assessing Private Practice In Public Hospitals’, October 2018. https://assets.gov.ie/26530/88ebd7ddd9e74b51ac5227a38927d5f9.pdf p.14.

66. In practice, private patients’ preferential access to public hospital beds is attenuated by the fact that the majority of public hospital admissions are for emergencies and public hospitals are so over-crowded they often have to cancel non-emergency/elective care. It’s a significant contributor to longer waiting lists for public patients for elective procedures however. 

67. https://www.hia.ie/sites/default/files/I%20HIA%20Annual%20Report%202019%20Release%20I%2030%20July%202019%20FINAL.pdf 

68. Department of Health. ‘Health in Ireland: Key Trends 2019’. December 2019. https://www.gov.ie/en/publication/f1bb64-health-in-ireland-key-trends-2019/ p. 51

69. Dr. Sara Burke, Committee on the Future of Healthcare, Inequality in Access to Health Care: Discussion, October 5th 2016 https://www.oireachtas.ie/en/debates/debate/committee_on_the_future_of_healthcare/2016-10-05/2/ 

70. https://www.citizensinformation.ie/en/health/health_services/gp_and_hospital_services/hospital_charges.html 

71. OECD. Health at a Glance 2019: OECD Indicators. Health at a Glance. OECD, 2019, p. 111 https://doi.org/10.1787/4dd50c09-en.

72. OECD. ‘Assessing Private Practice In Public Hospitals’, October 2018. https://assets.gov.ie/26530/88ebd7ddd9e74b51ac5227a38927d5f9.pdf. p. 27

73. Wren, Unhealthy State: Anatomy of a Sick Society, p. 17.

74. Ibid

75. Collins, Deirdre. ‘Health Workforce Consultant Pay and Skills Mix’, https://assets.gov.ie/25637/4757eb04a70b4836900ff250a5636783.pdf p. 15

76. Lawless, Jessica. ‘Budget 2019: Hospital Income - 2013-2017’, October 2018. http://www.budget.gov.ie/Budgets/2019/Documents/Hospital%20Income%20-%202013-2017.pdf. p. 2, 6. 

77. Maev-Ann Wren, Unhealthy State: Anatomy of a Sick Society (New Island Books, 2003).

78. IHCA, “IHCA Submission to the Oireachtas Committee on the Future of Healthcare: Ten Year Strategy and Health Policy,” August 26, 2016, p. 8.

79. IMO. ‘Irish Medical Organisation Submission to the Independent Review Group on Private Practice in Public Hospitals’, February 2018.

80. ICGP, “Management of Chronic Care Illness: Discussion,” Committee on the Future of Healthcare (2017). 

81. Quoted in Órla Ryan, “‘In a Utopian Society There Would Be Free GP Care. In Reality, We Can’t Do That,’” May 19, 2017.

82. Pollock, Universal Health Care and the NHS: Discussion - Professor Alysson Pollock; Management of Chronic Care Illness: Discussion - Irish College of General Practitioners.

83. PHA, Health Service Reform.

AnalysisDiana O'Dwyer16 November 2020healthcare, church

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