The 'Good News' - A More Just Health System

on Saturday, 05 July 2003. Posted in Issue 41 For Richer for Poorer: Three Issues of Fairness?, 2001

Seamus O'Gorman SJ, researcher at the CFJ and part-time theology lecturer at Milltown Institute asks some searching questions about our commitment to a fair health system.

1. Introduction: the promise of good news for the sick

'Go and tell John what you hear and see: the blind receive their sight, the lame walk, the lepers are cleansed, the deaf hear, the dead are raised, and the poor have the good news brought to them'. Mt 11:5


It is unacceptable that people\'s access to basic health care should be determined by their income

For Christians one problem we have when we try to look at issues in the light of the gospel, is that the world of the gospel is in very many ways a different world to ours. So much has changed. Yet for thousands of people around Ireland today the good news they most desperately long for is strikingly similar to what people were looking for then. People suffering from illness, or those who care for them want good news: that their turn has come, that the wait is over, that there is a bed for them, that they finally have an appointment with a consultant. This means that there is an end to fear and anxiety, that there is a space where their precious and vital needs may be responded to. They want to hear that the joy of health will not be kept from them forever.

Being sick is often a great isolator. It cuts people off. It can sow real doubt about the meaning of our lives, the value of our relationships and the possibility of recovery, of getting back to normal. In Jesus\' time sickness often had associations with sin. In our time for many people it more often has another stigma attached to it. Those who fall ill, and cannot access the healing care which does exist, when the neighbour across the road can, are doubly ill. The mystery of sickness already raises piercing questions, but the society and nation they have been told they belong to leaves them with another question: is your life worth the same as others?

In one way, one of the most striking dimensions of the ongoing debate about the Irish health system is the widespread verbal consensus on the desirability of a more equitable system. In the recently published strategy document, Quality and Fairness: A Health System for You The Department of Health cites equity, along with quality, accountability and people centeredness as core principles underlying its current health strategy. It is encouraging that so many people seem to agree that it is unacceptable that people\'s access to and receiving of basic health care should be determined by their income. There are few people arguing publicly that it is fair that money should enable you to jump the queue or that a certain level of income should buy you an acceptable standard of health care as against an unacceptable standard. At some basic level there does seem to be a consensus that access to health care is a human right, and as such should be available to all.

This is encouraging, but it does raise two fundamental questions for Irish society in relation to health services, which we wish to consider in this article. If it is true, why have we had a system of health care that in fact treats people so inequitably? Sample cases raise questions about what kind of a society we are creating, where: a diabetic man must wait for six months for an eye operation during which time his doctor tells him he may lose his eyesight, while if he were a private patient there would be no wait; where a child with severe breathing difficulties has to wait five years for an appointment with a specialist; where an elderly lady with gangrene in both feet, who is no longer capable of minding herself, has to wait six weeks for a bed. The fact that we have an inequitable system is admitted in the Department\'s document that clearly states "The Strategy must address the \'two tier\' element of hospital treatment where public patients frequently do not have fair access to elective treatment." The inequity was also recognised in the statements of political leaders at its launch, with the Taoiseach stating \'There are too many people who have to wait too long for vital treatment\'

The second and more important question is what kind of things need to happen so that the commitment to reforming the health system will lead to the actual delivery of a more just system?

2. The causes of injustice in the Irish health system

i) An intention failure
ii) A systemic failure
iii) Distorting incentives

i) An intention failure?

out patience

When you try to answer why we have such an unjust system, at first it is hard not to think that it is something of a mystery. Otherwise it is difficult to understand why so many good intentions - recorded in so many reports - can produce such negative outcomes.

After all the health care system is constituted by a number of key actors all of whom have the good of the patients as a primary concern. No one takes any joy in the failure of the system. The greatest heat that is generated in the debate about health care reform seems to arise when different groups feel themselves targeted as the main culprit in explaining the injustice of the system. Having your basic good faith questioned when you are doing your best to survive in a chaotic and poorly performing system is difficult to accept. For example hospital consultants clearly resent being identified as the major obstacle to the development of a more just system. Other possible scapegoats are the increasing numbers of people who take out private insurance and in effect pay to be treated before people who cannot afford to pay. The hospitals themselves seem to support injustice by permitting disproportionate access to beds by private patients. In the same way we can sense the politicians of the day becoming increasingly defensive when the fingers are pointed at them.

To get at why, as a nation we have produced such an unjust health system and why we seem to tolerate it, we can of course spend long hours speculating about the level of commitment or real intentions of the key actors to adequate care for all. The present outcome does raise the question how high a priority it has been for any group. There is a danger however, that limiting the analysis of our health system to this kind of approach will leave us trapped in the present rather than allowing us to make the situation better. By analysing society in a way which only identifies the real conflicts between people, and which hones in on how people pursue their own interests we may fail to discover better possibilities. The more important challenge is to find a way of understanding the failure of the Irish health system that opens real and identifiable possibilities where people can co-operate for a better future. Rather than foster the paralysis of mutual suspicion and antagonism which bad faith presumptions so easily nourish do we need to encourage the creativity which trust can bring.

ii) A Systemic Failure?

One step in doing this might be to begin to think of the problem of the Irish health system as a more systemic or structural one. At present the Irish health system is systemically unjust. By that we mean that what the system of health care produces is more unjust than what any of the key actors intend it to produce. The administrators, doctors, nurses, insurers, privately insured, and politicians do not aim to produce such an unfair system. The injustice committed against those who cannot afford to buy health care is greater than the injustice intended by any group or individual.

For some, renaming - or re-imaging - the problem in this way will be of no value. From our point of view one of the advantages we see is that it could create a different and potentially more productive space for exploring the failures of the health system.
To some extent, such a systemic analysis is already widely accepted in relation to the recent history of the health service. We can now see more clearly the disastrous impact that the cutbacks in health spending in the 1980s had on our capacity to deliver health care now. We also know that it is the poor who suffer most and who are most vulnerable to shocks. Policies had an impact on poor people in Irish society beyond the deliberate intention of any person or group. No one sat down and said let\'s create a health system that favours the rich and ignores the less well off.

iii) Distorting incentives

The same is largely true of the way in which key elements of the Irish health system continue to interact. It is not clear that any one group really wants it to be this way. Yet we can only begin to understand, and more to face, why it persistently works this way if we have the personal and collective integrity to identify the building blocks of what can rightly, if somewhat emotively, be called an apartheid system. Key to this is looking at the way in which various incentives operate and interact to build up such an unfair system. Some of these include that:

Citizens have an incentive to buy private health insurance if the public health care service is slow and of low quality

Hospitals have an incentive to let more private patients in than agreed, if they are better paid for them

Consultants too have incentives to treat private patients if they are paid more for them

Politicians have incentives to address the medical system with a view to votes

The present way in which many of the incentives that shape the system work ensures that many people have reasons for doing things that combine to create and sustain the unjust system. One of the great difficulties is that no one easily sees that what they are doing plays a part in furthering medical apartheid. Crucially there is no-one with the power or ability to coordinate to ensure that what various groups do is at a minimum constrained by attending to the overall impact of what they do on the most vulnerable.

Far from being chaotic, what holds the system in place, and what means that we have a more unjust system than most of us seem to want is that from within the limits of our perspectives as key actors we behave rationally. Each individual within the above groups, and each group follow the logic of attending to their own interests as the present system allows them to be organised.

It further complicates the issue that not only do we act rationally, but that, even further, from within the limits of our own perspective we act reasonably. If the health system is seen to have been chronically under resourced, and to be in a general state of chaos people are naturally less trusting of how it will work for them. Buying private health insurance and so access to better health care then seems a reasonable thing to do if you can afford it. It increases your control over access to essential services. However, while the direct intent of such an option is understandable, it also has the indirect effect of reducing social and political pressure for the provision of a more adequate public health system, upon which those on lower income will be dependent. In addition to diluting the social pressure for a more adequate system for all society, it should also be remembered that there is the added injustice that these benefits are bought without paying adequately for them, as private health insurance does not cover the real costs of private patient\'s care within the public health system. In effect the state is paying a state subsidised benefit only to those who can afford to be insured.

Again providing some advantage to those who pay more is a reasonable thing for hospitals and consultants to do. For hospitals, the extra income they receive allows increased budgetary flexibility and in some cases funds new development; for consultants it provides compensation for the extraordinary pressures they feel they bear within the current system. In the case of consultants there is the added difficulty that the gains they can make from working with private patients mean that it is in their interests not to be accountable for the time they are contracted to deal with public patients. So once more the effective incentives divert key participants in the health system from directing their efforts towards making the system more just. In contrast, up to now, there have been few effective incentives to ensure that the system does not discriminate against those - the poor - who are most need a system that would discriminate not on the basis of finance but of need.

3. The future: creating the system society wants

i) Develop a Positive Vision of a Just System
ii) Become People more committed to a Just system
iii) Align the incentive system with a commitment to equity
iv) Clarify whether equity is for sale

BMW: Buy Medical Welfare

If we see the injustice in the Irish health system as systemic, what could give us hope that these injustices will be effectively tackled by the emerging health care strategy? The increased funding promised - though not guaranteed - is certainly one key element, and is to be welcomed. Without more expenditure it is clear that we will not have the staff - nurses, physiotherapists, therapists, doctors - or facilities to provide adequate service for everybody. Improving capacity however, is only one part of making the system more equitable. It is not a sufficient condition. For this to be achieved we suggest that progress will be needed in the following directions: the development of a positive vision of a just health system; that we become a more just society; that incentives are aligned with the pursuit of justice; clarify whether equity is for sale.

i) Develop a Positive Vision of a Just System

At the end of all the struggles amongst the different players in the Irish health scene, in some way the system we get is the one we want as a society. Other countries with different values and priorities produce very different systems. The general social consensus works to produce a more equitable outcome. We will only achieve a more equitable system if more people across different sectors work towards making it a reality and win society\'s support for a different kind of system.

It is vital that as a society we develop a positive vision of what an adequate and equitable health service would mean. In this regard there is much to welcome in the health strategy in terms of its valuable contribution to offering a vision for the future. In particular the efforts which were made to consult widely and to think out where health care in Ireland needs to go over the next ten years deserve credit. There are many good ideas across a wide range of areas that offer hope of a better service over the years to come. Such a vision, if it wins sufficient support could ground a real and sufficiently widespread commitment to progress, and a store of willingness to take the necessary decisions.

What still remains to be seen is whether the vision of justice proposed in the document measures up to the standard of justice we demand as a society. The foundations for such a standard and developing consensus could possibly be forged from the reservoirs of compassion which are created from the shocking and universal human experience of being confronted with the illness of those we love. Would we not rage to find that the system fails those we most love? Could we choose to apply that concern to those who are deprived of care for the meanest of reasons? After all, it could be your partner, your mother or your child: in justice does it matter so much that it is not? If we developed a more widespread conviction about a basic justice we demand from the health services perhaps then we could move beyond a nominal consensus to something we would really be committed to implementing. It is all too easy to be cynical and to give up on the hope of a better society. Yet recent Irish history, particularly in relation to the development of the peace process gives us an inspiring example of how positive visions of the future can release energies to solve apparently insoluble problems. The lessons they teach about the importance of forging a consensus through a real process of ongoing dialogue in society can and need to be applied to health care.

The healthy - and those of us who can afford to protect our health - need to break out of the false and somewhat embarrassing security of such a position. Christian faith asks us to take great risks: the risks of opening our eyes and hearts, of stopping and allowing our priorities be disturbed as long as there are people being marginalized. Each of us and each of the groups to which we belong can press ahead towards our goal. But one of the great challenges and invitations of Christian faith is to let our vision of life and our personal and socio-political goals be modified through the compassion we feel for those in great need.

In the gospel the Good Samaritan\'s willingness not to just trundle on where he was headed made all the difference. We need to remember that it is possible to have a system of care for those attacked by ill health whereby the 80,000 + people who work in it provide a standard of service that respects the dignity and equality of all people. Within such a system all could derive a legitimate satisfaction from their combined professional contribution. We have the resources in this country to fund a system that provides adequate service so that people do not suffer unnecessarily. As Irish society we could choose to consign to the past a way of allocating resources which ignores the damage done to the health of the most vulnerable when the powerful compete.

ii) Become People more committed to a Just system

Another advantage in thinking of the injustice of Irish health care access as truly a systemic problem is that it makes us realise that it is very difficult to turn around a system that has such injustice built into it. Undoing systemic injustice will not be achieved by random, piecemeal reforms. It will require honest and ongoing reflection on the part of all who shape the system with a view to identifying various dimensions of how they affect, create or sustain that system. If society produces the system, then getting a better system is society\'s responsibility. As long as groups, social classes and key actors concentrate only on the benefits to themselves of actions, it is more than likely that the overall system will not develop in ways which protect the innocent victims in the battle over the allocation of health resources. From a Christian perspective there is a special burden of responsibility on those for whom the system works reasonably well. For example, are key players with real power to shape policy and the 1.5 million people with VHI willing to make the leap of imagination required to see whether they would be content with the level of changes being proposed if it were they who could not afford private insurance.

The immediate reaction of the VHI to the government\'s strategy is illuminating in this light. They point out the likely unworkability and unacceptability for their members of their being refused a place in hospital if hospitals fail to meet the new targets for waiting lists on public patients. While our society works in a way so that some people\'s rights will be vigorously protected questions remain to be answered. For instance, why has there been relatively little reaction to the suggested solution that public patients should be \'exported\' overseas or to private hospitals within Ireland. In the very short run such a step may solve a problem, and may even be a preferred solution for those without a real choice, but - given the inevitable doubt about the ongoing funding of such an initiative and its level along with all the discomfort of travelling for care - would it really be the preferred solution of a society committed to not discriminating?

Above we suggested that certain actions can be rational and reasonable. Yet if we wish to see a more just society we also have to examine their reasonability not just from the point of view of self-interest or personal entitlement, but also of the system and of the overall good of society and within that of the most vulnerable. Will we achieve a more just system if we do not become a people with a greater real commitment to justice? Good strategies and worthwhile plans can be proposed, but in the end very little will be achieved if we are not becoming a more just people. Being more just people is not exhausted by our immediate and private interactions with others. It requires that we take time to think about and work out the overall impact of our behaviour and choices on the creation of a more just society and most immediately on a more just health system. A more just system will only be produced when more people, however they are involved with the system, demand a system where the only legitimate form of discrimination within the public health system is on the basis of need. To continue to choose otherwise is to support injustice.

iii) Align the incentive system with a commitment to equity

A society committed to a more just system would take care to ensure that the way in which incentives combine supports behaviour that contributes towards such a system. At one level incentives can be thought of in purely financial terms. Yet it is likely that very many dedicated people working in the health service would be strongly motivated by seeing that their efforts were part of creating a system they can believe in. A firm commitment that the system will not allow discrimination on the basis of income for essential services would itself be an incentive for many who participate in it.

At a more detailed level it seems desirable that:

Private patients should not be able to access services within the public hospital system more quickly on the basis of their insurance

Hospitals should not have an incentive to make beds more readily available for private patients than public patients

Consultants should not be able to get their patients to skip queues in public hospitals, nor should they be paid in such a way that they give more time to private patients during their time working for the public

There are more technical questions about how each of these incentives can best be shifted. Possibilities worth considering include: establishing one queue so that private patients can no longer skip ; paying hospitals the same for treating private or public patients; enforcing the cap on numbers of private patients treated in public beds; making consultants account for the hours they put into their public practice. The real difficulty however is not so much imagining aligning incentives with the commitment to a more just health system but having the social consensus to do so.

iv) Clarify whether equity is for sale

When we look at the debates over health in the wider context of Irish society, it is striking to note a divergence between the increased concern about inequities - particularly in access to health care. This seems to exist alongside a more general readiness to see Ireland become an increasingly unequal society. Throughout Irish society we seem to accommodate ourselves almost unquestioningly to the position that money buys advantage. Allowances may be made for the complex historical origins of our public and private mix. It may have some beneficial impacts on the standards of the overall system. According to Quality and Fairness, \'the current mix of public and private beds in the public hospital system is intended to ensure that the public and private sectors can share resources, clinical knowledge, skills and technology.\' Yet despite this much of the rationale underlying the support the private system receives seems to be that people are willing to pay for it because they do not trust the public system to provide quality of care, which includes making care accessible within a reasonable time period.

To achieve justice we need to question the principle that money buys advantage, even in relation to essential services. It would mean saying that there are certain goods, such as basic health care, which should be allocated by some other means. Without facing this question we have little chance of developing towards a society that is capable of valuing needs which are not only backed by money. If everything is for sale then being poor will mean having poorer health. The issue of providing fairer access to health care is only one issue within a range of many issues where our commitment as a society to the principles of justice and equity is played out.

4. Conclusion: the promise of justice

Many - perhaps most of us - struggle when faced with are also asked such questions: tough questions. In our interactions with others, now and again we are faced with the question about the kind of a person we really are. In our lives as citizens - as people with a vote -we What kind of people are we really? To stop and think out how our lives, the choices we make, either add to or fail to reduce the burden of pain and suffering in other lives is not easy. The failures of the health system confront us as a society with the toughest of questions both about our past, but most especially about the kind of future we are creating. Will we continue to accommodate ourselves to a situation where access to health care is determined by level of income? Do we limit our attentions to making the best of a bad situation for ourselves? Or will we seek to transform the situation so that protection for the worse off is adequate? The choices are ours.

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Working Notes is a journal published by the Jesuit Centre for Faith and Justice. The journal focuses on social, economic and theological analysis of Irish society. It has been produced since 1987.