Goretti Horgan explains how decades of underfunding and creeping privatisation has undermined the once treasured NHS.
During the COVID crisis, People before Profit and others initiated a campaign for an All-Ireland NHS. The reasoning was simple: Covid-19 plunged the health and social care systems, north and south of the border, into crisis. Even before the onset of the pandemic the governments in Dublin and Belfast accepted that the existing health services needed radical transformation to cope with increased demand for services. Both systems suffered from insufficient hospital bed capacity, too few intensive care beds (ICUs), too few hospital nurses and consultants and glaring structural defects accumulated over decades. Ireland has two expensively administered separate health services operating on a small island with a small population of just seven million inhabitants. The pandemic revealed each system as markedly inadequate.
In addition, the issue of the NHS has long been seen in the North as a stumbling block when it comes to reunification on the island. Every opinion poll or attitude survey with regards to a Border Poll shows healthcare and the future of the NHS to be the issue that most concerns the citizens in Northern Ireland in the case of the potential unification of the island. 92% of respondents to both the 2019 and 2020 Northern Ireland Life & Times (NILT) Surveys, for example, said that they valued, “The National Health Service, with healthcare free at the point of delivery”, “a lot”, with only 1% saying they did not value it, “at all”. There was no significant difference in responses from those declaring as Catholic, Protestant or of no religion while over half of respondents (52%) said that not having an NHS “would discourage me from voting for a united Ireland”, this figure included 45% of Catholics and 46% of those declaring no religion.
Since COVID, we have seen the health services on both sides of the border struggle to deal with the numbers of people needing medical care. Waiting lists are bad across the island but much worse in the North – about 900,000 on waiting lists in the 26 Counties (pop: c5 million) and about 500,000 in the Six (pop: c2 million). So, why is it that the NHS, so long the envy of people in the South, is failing patients now? The answer lies in years of neglect, underfunding and creeping privatisation.
The NHS in the North was established in 1948 at the same time as the NHS across Britain but with the difference that it is supposed to be an integrated health and social care service. Like in the South, there have been many re-organisations and restructurings to the NHS in NI. But these corporate restructurings rarely made much difference to patient care or to the working conditions of healthcare staff. The NHS in the North has escaped some of the worst privatisation seen in NHS services in England but a creeping privatisation in both health and social care has occurred over the last twenty years.
The two main ways in which this has happened is through the widespread use of agencies to provide nurses and other health care professionals and through use of the private health sector facilities. Hundreds of millions have been spent on agency staff by Health and Social Care Trusts. It was £280 in 2020-21 while the response to a written question from People Before Profit MLA Gerry Carroll revealed the “total agency spend” for 2022/23 was £394m! Many nurses and other health care staff choose to work for agencies because they pay better and there is more flexibility in relation to working hours. This contrasts with those employed directly by the NHS who are forced to work very long shifts and, until very recently, had not seen a real pay rise for over a decade. Secondly, the annual waiting list reduction strategy involves sending numbers of NHS patients to the private sector for treatment. In the five years to the start of COVID, £20 million a year was spent by the NHS in NI to buy care in the private sector; during COVID, that rose to £27 million. This gives poor value for money and diverts resources from core funding of the NHS.
There have been many elaborate plans to ‘reform’ or ‘restructure’ the health services, north and south of the border. But none of these proposals seem to go anywhere. For example, in the North, the Bengoa Report is the latest of a long line of reports on what needs to be done to save the NHS. While some of the proposals are eminently sensible – eg having regional centres across NI for particular specialisms, the report seems to envisage a greater role for the private sector within the NHS. Indeed, the British Medical Association has already expressed its concern that Bengoa’s proposals will lead to wholesale privatisation of the NHS in NI. For example, Bengoa advocates the introduction of ‘Accountable Care Organisations’. This was a concept that had to be withdrawn in England after a storm of political protest as these bodies were widely seen as vehicles for US private health care groups to take over whole swathes of the NHS. Additionally, proposals for greater use of the community and voluntary sector to provide some current statutory services are unacceptable to workers in the NHS.
In the South, Sláintecare as a set of policy reform proposals has been around as long as Bengoa has in the North. The final Sláintecare report elaborated a vision for a one-tiered universal healthcare system, comparable with the “Beveridge model” of the NHS. It identified specific aims including the phasing out of private care in public hospitals, eliminating charges for access to public hospital care, universal access to GP care without charge and reducing waiting lists for first outpatient department appointments and hospital treatment.
However, in the 2019 Sláintecare ‘Implementation Strategy’ proposals, the commitment to universal healthcare was qualified and now defined as, “healthcare which would not put people at risk of financial harm”, This in effect preserved the existing two-tier healthcare system. Since then, the concept of free and universal access has been eroded even further, with an assertion of the core importance of “choice in healthcare” – in other words, the preservation of the existing private health insurance industry and private medicine provision, rather than the integration of these into a unified national public health system.
So, North and South, then, ideological battles are currently being fought over how health and social care should be provided and paid for. Should it be a two-tier system where cash-strapped working-class people have to gamble with their health while the better off with subscriptions to insurance schemes are well looked after? Or should it be, as NHS architect Aneurin Bevan proposed, a health service where ‘the rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged’.
The truth is that, North and South, we don’t have healthcare systems so much as sickness systems. All of our health is undermined by high levels of inequality. Several reviews of the international evidence of health inequalities argue for an approach that puts broader socio-economic inequality and not just access to healthcare, at the heart of our approach to health. Studies show the, ‘pernicious effects that inequality has on societies: eroding trust, increasing anxiety and illness, (and) encouraging excessive consumption’. When it comes to each of eleven different health and social problems: physical health, mental health, drug abuse, education, imprisonment, obesity, social mobility, trust and community life, violence, teenage pregnancies, and child well-being, outcomes are significantly worse in countries with higher levels of social inequality.
If we are to have a truly healthy society then, we will have to do more than achieve a national health and social care service that covers the whole island ensuring free access to health and social care for all. We will also need to build a more equal society across the 32 Counties – an Ireland where no child grows up in poverty and deprivation, thereby restricting their opportunities to profit from education and robbing them of healthy years at the end of their lives. Such an Ireland of greater social equality, opportunity and social justice is one that all the citizens of NI – including those of Protestant background – are much more likely to want to embrace. It is also one within which Southerners may be less suspicious of their Northern neighbours – of all religions and none – and more willing to embrace the changes entailed in the unification process. Securing an All-Ireland NHS would be a good first step towards building this more equal and inclusive island.
