Cassandra Voices

Tag: Ireland’s dysfunctional health system

  • Vaccine Passports “Inherently Illiberal”

    On October 5th of this year, Minister for Health Stephen Donnelly spoke before the Dáil during a debate to extend the legal framework for restrictions in the State – the sunset clause of the Health Amendments (Covid-19) Act 2021 – for three months. He stated that there was no intention to extend the restrictions beyond October 22nd, but that they wished to keep the legal framework in place in case of the need for further restrictions or lockdowns.

    This was clearly a lie, or ignorance on an unforgiveable scale. It cannot be both.

    In the interim, hospitalisations related to COVID-19 have steadily climbed, and the wheel of fear and dread has begun to turn again, quickly gathering pace.

    Thankfully, the government are attempting to turn the tide by extending the need for the Covid certification pass to theatre and cinemagoers, as well as banning nativity plays and playdates, thus surely halting the inevitable pressure that is being mounted on our health system.

    Inherently Illiberal

    I must state from the outset that I am vehemently against the concept of a vaccine passport or vaccine mandates. I believe them to be inherently illiberal and it pains me to see the willingness with which we have adopted them into our society.

    I acknowledge that when an issue produces such a visceral response, there is an increased likelihood that my reasoning may be faulty. Having read Daniel Kahnemann’s Thinking, Fast and Slow , I recognise that instinct and emotion can often cloud clear judgement. Hence, I have attempted to examine the principal arguments for and against vaccine passports in the context of the coronavirus pandemic to see if I can or will come to a different conclusion.

    I take COVID-19 extremely seriously and witness the impact of the pandemic on the patients that I meet every day. This relates not just to actual illness but to the myriad other issues, both medical and non-medical that the past twenty-two months have created for them.

    I support vaccination but not forced inoculation in the same way that I support appropriate medical treatment, not forced care. I worry that unnecessary interventions will create long-term sequalae that cannot be predicted, in the same way that inappropriate prescribing of medications does.

    Preventing the Spread?

    The most obvious argument in favour of vaccine certification is that it should prevent the spread of disease in an enclosed area. The certificate will work to protect both vaccinated and unvaccinated from contracting and spreading the disease and reducing the burden on the hospital system.

    Unfortunately, there is absolutely no evidence that this is the case. Vaccinated citizens have been readily demonstrated to be able to contract and transmit the virus in the exact same manner as an unvaccinated person.

    A recent Lancet study demonstrated that vaccination reduced the risk of Delta variant infection and accelerated viral clearance. This is great news, demonstrating that vaccines are effective. However, fully vaccinated individuals with breakthrough infections had peak viral load similar to unvaccinated cases, and could efficiently transmit infection in household settings, including to fully vaccinated contacts.[i]

    If vaccinated and unvaccinated persons are equally capable of transmitting a virus, why do we insist on segregation and marginalisation of a significant minority of our population?

    Pandemic of the Unvaccinated?

    The second argument commonly encountered is that it is the segment of the population who are unvaccinated by choice who are creating the ICU and hospital bed capacity issues.

    As of November 17th 52% of patients are unvaccinated, with a significant percentage of this population also immunocompromised. According to Minister Donnelly, 98% of the vaccinated ICU patients are immunocompromised. On this basis, there is a strong likelihood that a significant proportion of the unvaccinated cohort are not unvaccinated by choice but because they are too unwell to receive the vaccine.

    This is speculative on my part but is worth considering, and requires refutation.

    Another argument advanced is that full participation in society is not free and requires solidarity on the part of the individual citizen: Thus, “Play your part. Protect yourself. Protect others” is a common slogan.

    David Robert Grimes wrote an essay recently for The Guardian, comparing smallpox vaccine mandates in the early 1900’s to today’s issues. Of course, he neglected to mention that there was no vaccine passports in use at the time for participating in normal life, and provides no justification for them other than that they represent a mark of ‘solidarity.’

    He also states that participation in society is not free, and that freedom comes at a cost, which is somewhat paradoxical. There is an expectation of brotherhood in society. However, if brotherhood is coerced against someone’s will, it is difficult to define it so.

    I have not seen any evidence that prominent politicians during the smallpox era demanded that unvaccinated people should be banned from supermarkets and public transport. Does this evoke the spirit of fraternité?

    Finally, although never explicitly stated in Ireland, vaccine certification is certainly an effective measure to improve uptake of a vaccine.

    Whether one defines this as a nudge, gentle encouragement or coercion is a different argument. When I asked the Irish College of General Practitioners their position on the implementation of this system, they replied that ‘these people (the unvaccinated) may particularly benefit from national interventions to promote vaccination and limit the spread of COVID-19’.

    This statement is certainly open to interpretation. Undoubtedly, it has been effective in ensuring increased take-up of the vaccine in young adults – young people who may not have bothered otherwise with brother- and sisterhood.

    In a Machiavellian sense, this is the only true and potentially justifiable reason for a vaccine passport to be introduced in a civilised society. I cannot see another. Unfortunately, even 100% vaccination uptake, as in Gibraltar, has not resulted in the resolution of pandemic issues, with rising case numbers among the vaccinated causing all large Christmas activities to be cancelled.

    At this point in the pandemic, the above justification in Ireland no longer holds water. Ireland has one of the highest vaccination rates in the world, with 93% of the eligible adult population fully vaccinated.

    One should therefore assume that the remaining 7% of the ‘non-cooperating’ population are much more likely to consider a certification system coercive and will exacerbate their own fears of over-intervention by the State and unwelcome intrusion into their private lives.

    Someone who argues that this is for the benefit of the unvaccinated in protecting them from society does not do so in good faith. If someone does not wish to be inoculated at this point, there is more than a strong possibility that they do not wish to take up the kind offer of a jab.

    A certification system hence is more likely to have the inverse effect of its presumed benign intention. It is more likely to convince them further that the State wishes to harm and to segregate them against their wishes from a society that has already, by and large, shunned them.

    State of Distrust

    There has been no attempt to understand any of the multiple reasons why people do not wish to receive this vaccine. Distrust of the State, distrust of the pharmaceutical industry, distrust of the healthcare industry, anecdotal reports of adverse effects and concerns regarding under-reporting, the list is varied. The consistent link between all these issues/concerns is that of distrust.

    Many papers have been written on the subject of discussing vaccine hesitancy as a doctor with a patient. All suggest addressing hesitancy with compassion and understanding as decision-making around vaccination entails a complex mix of cultural, psychosocial, spiritual, political, and cognitive factors.[ii]

    Reasons for vaccine hesitancy fit into three categories: lack of confidence (in effectiveness, safety, the system, or policy makers), complacency (perceived low risk of acquiring VPDs), and lack of convenience (in the availability, accessibility, and appeal of immunization services, including time, place, language, and cultural contexts).

    All suggest addressing the patient’s concerns carefully, discussing with openness and honesty any potential side-effects as well as advocating the benefits, such as they are.

    Has any of this been done at any point during the pandemic with the vaccine hesitant? Vaccine passports are not a tool to advocate for immunisation in a humane and empathic manner and it is equally certain that the most effective way of fomenting further distrust is to patronise people for their ‘stupidity’ in doubting the effectiveness of a medical intervention, while downplaying the potential for any side-effects and then to mandate the intervention as a necessity for full participation in normal society, such as it is.

    Scapegoating

    Instead of focusing on and congratulating the 94% of the eligible adult population who have been vaccinated, we have decided to scapegoat and segregate the dirty few who have not complied with government directives.

    As a reminder, segregation has never been an attractive or effective feature of a functioning society. I make no lazy comparison to Nazi Germany, but rather suggest that people consider the State’s recent attitudes to same-sex relationships.

    It should not be forgotten that homosexuality was only decriminalised in Ireland in 1993. That was a horrible and unjust law, horridly intruding into the lives of normal people. Same-sex marriage was legalised six short years ago in 2015.

    Can any sane person reasonably make the case that it was legitimate or more importantly, healthy for a society to deny that two private citizens who love each other should be allowed to spend their lives together in a loving, equal relationship? That it was reasonable that same-sex marriage was such a danger to society that it had to remain illegal in the twenty-first century?

    By this logic, are the unvaccinated so lethally unclean that it is worth intentionally re-dividing society? That it is worth every citizen who wishes to eat in a restaurant having to demonstrate by law a private medical decision to a waiter that has no interest and no business in knowing same?

    The State is not a benign entity and is capable of dreadful, discriminatory decisions that have long-lasting impacts of the fabric of the country that we live in. Our long history of governmental corruption, cronyism and cover-ups at the cost to its people did not magically disappeared at the onset of a pandemic to be replaced by a wonderful, altruistic body guided by love and the rights of the individual.

    Marginalisation

    We should also consider the demographics of some of the people who do not wish to be vaccinated. People with lower levels of household income and those living in disadvantaged areas are demonstrably associated with increased likelihood of vaccine resistance and hesitancy.

    A recent survey also demonstrated that BAME people are a minimum of 25% less likely to take up the offer of the Covid vaccine.

    It is regularly reported that lockdowns and prolonged periods of state-imposed restrictions have had the most demonstrably negative effects on the exact population groups who are also hesitant to receive the vaccine.

    Therefore, we have managed to punish and further marginalise the very people who have suffered the most throughout this pandemic and will likely suffer the most in the years of anticipated turmoil ahead.

    This is not to denigrate the many wonderful, intelligent people who quite rightly question the manner in which they feel their country is being governed and directed but to highlight the unnecessary dual suffering that many people will encounter in the months and years ahead.

    In any other time, scepticism and resistance to dictates targeting minorities would be celebrated, not scorned. We should hold our leaders to a high standard at all times, not allow them easy opportunities for deflection from their own failings and label almost everything that does not agree with State narrative as “misinformation.”

    Again, instead of trying to understand why people do not wish to be injected with a treatment that they consider dangerous and unproven, and to try to convince in a humane and empathic manner, we have instead chosen to demonise and make them the culprits for the current issues that the hospital system faces in Ireland.

    Do we wish to follow the example of Singapore and begin charging patients who become ill and are unvaccinated by choice? Do we wish to follow the lead of Australia and send our citizens to quarantine camps against their wishes? Do we wish to follow the lead of Austria and lockdown the unvaccinated, and now mandate vaccines for the whole population?

    Why are these questions not being asked and answer by the opposition political parties in Ireland? Liberalism is defined as a political and social philosophy that promotes individual rights, civil liberties, democracy, and free enterprise and is supposed to be the cornerstone of left-wing politics.

    The presumed left, including Sinn Fein, Labour, the Social Democrats, People before Profit, have been pathetic in their lack of any attempt to hold the State to account. A strong opposition is the cornerstone of democracy, and it is not present currently in Ireland.

    Image (c) Daniele Idini.

    Public Health Department

    I have discussed vaccine certification with the local public health department in relation to the management of this pandemic. The doctor that I spoke to readily admitted that there is no medical indication for the use of vaccine certification and was shocked at the extension of the recent legislation in October.

    Hence, my surprise at the recent declarations by Colm Henry and Ina Kelly, president of the IMO, that the public should walk out of pubs or restaurants that are not asking for Covid 19 digital certificates.

    There remains no evidence whatsoever that vaccine certification has made any improvement to the management of the COVID-19 pandemic in any country that it has been used.

    An Israeli paper examining the effects of their ‘Green Pass’ concluded that apart from the coercive effects of increasing vaccine uptake[iii], there is no evidence that the use of a passport system reduces morbidity loads on a population.

    To repeat, there is no public health evidence for the intentional segregation of society. None. Zero. Nada. Zilch.

    Anyone who argues that there is should be immediately dismissed as a fool. However, if you wish to look at the data, the HSPC have kindly provided information on COVID-19 outbreaks in the Republic of Ireland.

    In May of 2021, there had been a grand total of two outbreaks attributed to hairdressers/personal grooming services. By November, there are now twenty-two recorded. In May, there were ten outbreaks attributed to public houses. By November, there have been forty more.

    Does anyone truly believe that presenting a piece of paper at the door achieves anything when the holder continues to have the potential to be highly infectious? There is no evidence that it improves either your safety or the safety of others.

    Image (c) Daniele Idini

    Misdirected Indication

    There has also been a recent effort to blame the unvaccinated for various sad occurrences that have occurred because of the lack of capacity in the HSE. Thus, it was reported that a transplant operation was cancelled because unvaccinated patients occupied ICU beds and the procedure was unable to go ahead.

    Blaming the unvaccinated for this is completely disingenuous and abdicates responsibility for decades of poor management. The reader should know that Ireland does not have a good reputation in the transplant world. We are currently 18th out of 24 countries in Europe, below Lithuania and Estonia in terms of organ transplantation per million people.

    In 2015, Dr David Hickey, the transplant surgeon described in the Irish Independent that he was the only pancreatic transplant surgeon in the State. Despite multiple offers to the HSE to mentor two people to take over his role, nothing was done. The pancreatic transplant program was then moved to another hospital setting, against advice and without consultation. At the time, no transplants, despite their life-saving nature, took place over a nine-month period.

    To consider that the people ‘clogging up the ICU’s’ are responsible for historically well-recognised governmental and state body failures is malicious.

    The 2019 Euro Health Consumer Index places Ireland in last position, below Albania, North Macedonia, Latvia and Romania, countries all with their own issues, in terms of outpatient hospital waiting lists.

    Ireland has the lowest rate of hospital consultants in the EU18, a fact heavily bemoaned by the Irish Medical Organisation. Shortages of GPs, shortages of nursing and allied health professionals, overcrowded emergency departments and public health failures have been reliable sources of outrage and headlines over the course of the past twenty years.

    Fortunately, there is now a perfect fall guy in the shape of an unvaccinated person to take the ire of the populace.

    The unvaccinated are at fault for five-year orthopaedic waiting lists, the unvaccinated are responsible for spiralling chronic diseases in an increasingly obese and unhealthy society. The unvaccinated are responsible for the lack of clinical staff living and working in this country.

    It would be laughable were it not for the real human cost of such misdirected indignation and hatred.

    If we are to blame the individual for the failings of the system, we should apply this logic to the others who place a heavier burden on the health system. The obese, the alcoholics, the smokers, the poor should all feel our wrath at the impact they place upon our hospitals. Perhaps an obesity cert would be an incentive for them to lose weight or keep them out of restaurants? That can only have positive results.

    Chaotic Interference

    Continuing along this path of chaotic interference in people’s lives will have iatrogenic consequences. Professor Helen Townsend, director of the Self-Harm Research Group in the University of Nottingham, has described the likely severe long-term consequences of lockdowns and that these have never been accounted for in policy making19.

    Has any consideration been given to the societal impacts of intentionally separating the ‘dirty dissenters’ from the rest of the country? If there is no public health evidence for overwhelming benefit, how can we justify such an enormous departure from normality?

    The ethical implications of these decisions have clearly not been fully considered, if at all. It should be noted that the National Public Health Emergency Team does not have any bioethical or legal representation, an amazing fact considering the enormous decisions that have been made on the basis of their recommendations over the course of the past twenty months.

    The Irish Council for Civil Liberties has repeatedly requested that such a representative should join NPHET, but this has been ignored. The ICCL, for what it is worth, has also stated their strong opposition to a domestic vaccine passport, stating that the system is discriminatory and has been developed without any meaningful consideration of human rights.

    And yet still we persist and tolerate further encroachment into both our and our children’s lives. 50,000 people can go to a football match in the Aviva stadium, the CEO of the HSE can drink and rub shoulders with sporting royalty indoors without a mask, yet we think it is appropriate that nine-year-old children should be masked and instructed not to attend nativity plays.

    190,000 children are currently living in poverty in Ireland, yet this is not a crisis worth addressing in the mainstream media. Instead, it is recommended to avoid playdates and sleepovers while Gary Barlow croons to thousands in the 3 Arena. It is preposterous and the antithesis of public health. It causes me great shame as a doctor that these measures are being carried out in the name of my profession.

    I am unable to convince myself that a system of vaccine certification is a reasonable or ethical idea in an essentially fully vaccinated adult population for a virus that is transmissible regardless of your vaccination status.

    Image (c) Daniele Idini.

    A Thought Experiment

    If you remain convinced that it is, I would like to propose a final thought experiment. Consider a politician or government that you dislike or fear. Consider your reaction if they were to have introduced a vaccine passport over the course of the past six months.

    Would you agree with segregation of society if Donal Trump suggested it? Would you clap wholeheartedly if Vladimir Putin encouraged marginalisation of a minority of people who have not broken any laws? Would you dismiss civil rights concerns if Bolsanaro was championing minority-blaming and hatred?

    If you would agree to all these questions, I would congratulate you on your single-minded conviction and realise that I will never convince you – as is assumed to be the case with all ‘anti-vaxxers’, a derogatory term that I despise.

    Coercion and essentially forced vaccination signifies a complete failure of scientific and public health messaging. My sympathies lie with the people who are not currently welcome to participate in society on the basis of one personal decision which has not broken any law.

    They have been stripped of their constitutional rights without seemingly without any recourse to due process. That should give anyone reason to pause and reflect. Without acknowledging it, we have become a country that has slipped, almost overnight, into an enduring state of fear and intolerance. I worry for the future and the country that my children will inhabit.

    [i] Anika Singanayagam, PhD et al, ‘Community transmission and viral load kinetics of the SARS-CoV-2 delta (B.1.617.2) variant in vaccinated and unvaccinated individuals in the UK: a prospective, longitudinal, cohort study’, The Lancet, October 29, 2021,  https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(21)00648-4/fulltext

    [ii] Shixin (Cindy) Shen and Vinita Dubey, ‘Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents’, The College of Family Physicians of Canada, 2019 Mar; 65(3): 175–181. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6515949/

    [iii] Ruth Waitzburg, ‘The Israeli Experience with the “Green Pass” Policy Highlights Issues to Be Considered by Policymakers in Other Countries,’ November 2021, International Journal of Environmental Research and Public Health, 18(21):11212. https://www.researchgate.net/publication/355819969_The_Israeli_Experience_with_the_Green_Pass_Policy_Highlights_Issues_to_Be_Considered_by_Policymakers_in_Other_Countries

  • Chay Bowes: HSE Perpetuating Dysfunction

    In the controversy surrounding the leaking of a confidential document by then Taoiseach Leo Varadkar last year, a key point has been missed regarding whistleblower Chay Bowes’s motivations. As an insider and former head of the VHI Homecare division Bowes gained significant insights into the operation of the Irish health system, especially the HSE. This interview probes into the obstacles he faced in attempting to deliver an effective model of community care away from overcrowded hospitals. He argues the HSE perpetuates dysfunction to the benefit of the private system.

    Innovator

    Chay Bowes first interfaced with medicine through the Irish Army Medical Corps in 1988. This stoked a passion for healthcare which led him to take up a job as a phlebotomist, where he encountered an older generation of hospitals, such as St James’s, where he worked with elderly patients in the country’s public health system.

    This experience coloured his view of the health system as it evolved to become, as he puts it, ‘more focused on financial outcome rather than patient outcome,’ and led him to set up his own company, focused on clinical work in people’s homes.

    He had found that general hospitals tended to be ‘Victorian constructs, where we put all the sick people who are susceptible to infections, so that they can mix with other sick people.’ He concluded ‘that much of what happens in the hospitals doesn’t really need to happen there, and a huge volume of those patients could be treated at home in a cheaper and safer holistic fashion.’

    After the dismantling of small, community hospitals Bowes observed ‘pressure building on the larger general hospitals to become the catchall for all kinds of diseases and complexities,’ and that this ‘contributed to the ongoing perpetual dysfunction which is today what we call the HSE.’

    Taking out a bank loan, he purchased a van to move around the nursing homes, taking blood samples. By that stage he had observed thousands of elderly arriving into hospital in taxis and ambulances for routine blood samples. There they were catching flus and colds, so he said to himself: “why don’t I develop a system to treat those people out in the community?” This was back in 2004-2005, but he was told that’s not how things are done.

    Undeterred, he decided to take an extended leave of absence from the hospital to set up a service doing these blood tests in the community, which proved very successful. The only limitation was that he was working alone.

    At that point, he expanded his service to give vaccinations in the community too and took on a few employees. The first company evolved into another, leading to a contract with the HSE in 2007 worth €14 million. That business was focused on patients with chronic obstructive pulmonary disease and chest diseases. Its rationale was to keep various types of patients in the community, who were repeatedly being admitted to hospital with lung diseases.

    ‘So, they didn’t go into a hospital, where people tend to get sicker, particularly those with lung diseases. It also helped these patients,’ he says, ‘that their social networks were intact.’ Soon there were two hundred working for the company.

    Resuscitation room bed after a trauma intervention.

    Tara Healthcare

    At that point he brought Dr. Gerry McElvaney on board, ‘a really patient focused guy,’ he says, ‘who was highly intelligent and super-committed to doing things differently.’

    Together, they pushed forward with what became Tara Healthcare. When patients were surveyed, he says, ‘ninety-eight percent preferred to remain in the community under our scheme rather than go into hospital: all the data was saying that this was a much safer.’ It was also cheaper to deliver, and the patients’ families were delighted to remain with their loved ones.’

    He argues that they had created a perfect example of how a community-based scheme could be delivered cheaper with better patient outcomes, and where staff were really happy too, as they could get out of the acute hospitals.

    However, he encountered, ‘an incredible level of scepticism around innovation in Irish healthcare.’ In one case, he says, there was a hospital in Dublin, which ‘wouldn’t send patients to this new service, because they didn’t like our medical director because he came from another hospital group. Professional rivalry is rife in Irish Medicine, sometimes to the detriment of patients.’

    HSE Logic

    Time and again he was met with the perverse HSE logic of ‘it’s doing really well, so let’s shut it down and send all these patients back into the hospital.’

    The HSE’s reaction to the Financial Crisis of 2008 was just like its dysfunctional approach to COVID-19 he argues. They closed his operation down because hospitals ‘which were in perpetual crisis wanted us to move this service into their area.’ A senior HSE figure told him directly that ‘“what you’ve done in Dublin is almost too good. Everyone’s going to want it. They’re going to want it in Galway. They’re going to want it in Limerick” So, they wouldn’t fund it because they were already funding the dysfunction.’

    Acute beds per capita in Ireland, March, 2020. Source: https://twitter.com/kevcunningham/status/1245060194356379648/photo/1

    Essentially, Bowes argues:

    The agency funds the dysfunction to a certain level of service with tens of billions of euros. And when something outside of the system comes along and demonstrates efficacy, financial viability, and good patient outcomes, that’s irrelevant because they still have to fund the dysfunction. It’s like trying to repair an airliner in mid-air – you don’t want to land because it could expose the rottenness of the system.

    So, we sent the patients back to hospital, further highlighting the dysfunction of the HSE at the time. They had to pay us a penalty for terminating the contract prematurely, which cost them more than running it for the subsequent two years.

    Working for the HSE he found innovation was met with suspicion: ‘the hospitals want to hold onto patients because without patients occupying beds, they can’t justify their budgets.’

    And because budgets are pinned to occupancy and the size of the facility, hospitals seemed slow to manage overcrowding at the cost of lesser funding.

    Fair Deal?

    He argues that we should ‘evolve to a place where we simply don’t treat people with certain uncomplicated infections in hospitals, like in Canada and Australia.’

    Now, he says, the only fast track for vulnerable patients is into a state or private nursing home, which is excessively expensive, ‘or their home is taken from them in what the government very cynically calls a Fair Deal:

    someone works all their life, pays taxes, builds a home for their family, and contributes to the state and to society. But when they get ill, go into a nursing home or require dignified care the state wants to take their home from them to pay for that care.

    Moreover, despite earning huge praise from patients, peers and when he presented the scheme to the NHS in the UK, he found the HSE ‘were always finding fault with what we were doing.’

    ‘I became used to that,’ he says ‘and very quickly realized the only thing the Irish public system does very well is perpetual dysfunction. It manages to procure massive budgets from the State, and despite this consistently overspends,’ despite ‘terrible outcomes for patients.’

    He suggests that it takes ‘a concerted effort to continually do health as badly as we do in Ireland’, a system of public health, ‘with such huge budgets for such a small population.’

    He says it is important to question why, given a very small and young population, ‘half of that population pays out of pocket expenses, approaching €2 billion, for private health insurance.’ He reckons this is ‘to protect ourselves from the dysfunction of the public system.’

    Knock, Knock

    ‘It’s a very simple problem,’ he says, ‘too many of the same actors are involved in the public and private systems.’ The analogy he uses is of two separate doorways in a clinic: the public and the private:

    You knock on the public door, and say, “Look, doc, I’ve got a terrible hip. It’s really hurting me. And he goes: “Yeah, you need a relatively simple, hip replacement, but it’s going to be probably three, three and-a-half years, because the system is overloaded.”

    But the doctor adds unless of course you’ve got health insurance. So you say, “OK, I’ll go and get health insurance.” But by this stage you are too old to avail of this. But what are you going to do now, as your hip is only going to get worse?

    You’ve been to the first door, where you met the doctor in the public system about the hip, who we’ll refer to as Dr Jim. Then you go ten feet down the corridor and knock on the door. “Who’s there? Why it’s Dr Jim again!’” And you say “Hey, Dr Jim, you just told me that you couldn’t fix my hip for three years.” and he responds: “not exactly. I can fix it if you pay me via your insurer.”

    In a country of five million people, we have almost one million people waiting for care of one sort or another in a public system, which is one of the best funded systems in the developed world.

    And, Bowes says, ‘it just so happens that the man running the show, Paul Reid, has no specific health care experience, for example. The UK’s NHS employs around 1.4 million people to serve a population of nearly 67 million. Its CEO Simon Stevens is paid €210,000 a year, while Ireland’s HSE employs around 102,000 people with a population of only 4.9 million, Reid is astoundingly paid over €426,000 a year.’

    We have hundreds of people who work for the agency on long term sick leave. The dysfunction runs into every fractional part, IT, training, resourcing, recruitment, and services. The dysfunction is almost at a cellular level. But again, we are consistently told that we can’t land the jumbo jet to fix it, because if we do that, what will happen?

    COVID-19

    When COVID-19 landed, Bowes says, ‘with the stroke of a pen, we bought up every single private bed in the State. This occurred despite people saying since the foundation of the State, “Oh, you know, you can’t publicize the private, it would never work, but it was done overnight because the will existed.’

    Health policy in Ireland, he says, reflects:

    the laissez faire attitude of a class of people who are running the medical system, advising the agency and the legal system. They of course all have health insurance. I don’t know anybody who served on the board of the VHI or any doctor working in the system who doesn’t have private healthcare. I myself have to admit that I took out private health insurance purely because I know how difficult it is to access care via the public system. It’s sad but true and I am lucky enough to be able to pay, unlike more than 50% of the most needy In our society who cannot.

    ‘Irish People’ he says are dying ‘for the lack of basic diagnostic care.

    Bowes muses on how: ‘The further up the pyramid you go around a health product in Ireland, the less you hear about the patients. And when you get to the board level, patient outcomes are in some way superfluous to the real issues, which are profit and the market.’ He argues that there ‘isn’t a single private provider in the country here’ which ‘isn’t preoccupied with profit.’

    He says:

    We’re happy to ostensibly starve a public system and propagate a private system which is absolutely predatory on the dysfunction in the public system. And in many, many cases, the people providing the care in the public system also have been or currently are providing care in the private system.

    That’s our medieval, dysfunction and immoral system. It’s actually, and I don’t use this term lightly, an apartheid system. We have a segregated, apartheid system in health care. It simply isn’t based on needs of the patients. Ok, obviously, if someone’s at death’s door, they’re going to get seen, but I’m talking about this grinding dysfunction, where both sides are nodding to each other as they pass each other in the night, knowing that it’s so wrong. It’s so wrong. There are super doctors out there, super surgeons, super nurses and staff operating in the health system. It’s definitely a case of lions being led by donkeys.

    Staffing

    Bowes muses ‘I have no problem with doctors wanting to make a decent living. You’ve got to pay people appropriately. But now we’re flooding the system with locums from overseas who are often poorly trained and have poor English and patient interaction skills .’

    And points to another ‘incredible dysfunction, which is again, state sponsored.’

    We train more doctors than any other country of our size in the world, but we export them to Australia, New Zealand and the UK. It costs the state a significant amount to train these guys, and then they can just catch a plane to Bondi Beach. Of course, we can’t force people to work here – no more that we can force a health care worker to take a vaccine – but there are ways to incentivize the system, and develop better methods of training doctors, because we still use the archaic Leaving Cert as the basis for deciding who we train as doctors.

    He also wonders:

    How is it that while we train more doctors than anyone else that we are importing more doctors and nurses than anyone else? Countries like the Philippines, India and others are being bled of their precious nursing and medical staff to come to Ireland to look after our sick. There’s something wrong, right? But in the Irish system nothing changes. No wants to take on the vested interests. No one wants to take on the big personalities in health care and medicine. The political nexus between medicine, law and politics in Ireland is so tight because of insular practices and local allegiances trumping national welfare with some of the biggest political donors and influencers being waist deep in the sector.

    He wonders ‘Who’s going to challenge the vested interests and speak out for vulnerable patients? The CEO of the HSE? Absolutely not. The past CEOs of the HSE seem to be only good at one thing, which is saying, “We’re trying…” But they walk out at the end of the end of their contracts with a big pension and usually into guess where? Yes, you guessed it, the private sector.’

    He reveals how ‘a former CEO of the agency said to my face that he was the most powerless man in the health system.’

    Image (c) Daniele Idini

    Dysfunction Funds Profit

    Bowes wonders:

    How can you operate a business with a hundred and twenty thousand employees and seem to be powerless to sack people for not delivering, or in many cases simply doing their job wrong? Where’s the accountability in that system?

    And looking back on the foundation of the HSE in 2005 he wonders:

    How can you amalgamate numerous health boards which are operating as satellites into a single “dynamic entity” and nobody loses their job? Not one manager is made redundant. Not one of them is even sanctioned.

    How can a health system pay out tens and tens of millions in malpractice claims for egregious malpractice and incompetence in both governance and clinical care? For essentially killing women who are pregnant by denying them an abortion? By condemning young women to terrible life ending illness by failing to diagnose their cancers? How can you pay out these tens and tens of millions again and again, year after year, and nobody is sanctioned for it? How does that work?

    It works because the dysfunction funds profit, and that profit is harvested by vulture funds, by private hospitals and private investors, by their legal advisors, some of whom don’t even pay taxes in this country, and who pays the price? The citizens that languish on public waiting lists accruing ill-health because they can’t pay for treatment. The man with the simple requirement for treatment, he’s invisible to the system, he is superfluous to the profit motive.

    The poor he says have no bargaining power because:

    the bargaining power is money and influence, and the people who have the influence to change the system are receiving huge salaries to manage and essentially perpetuate dysfunction. Again, the private system predates on the mismanagement of the public system. If it functioned there would be no need for a private system, right? Therefore, you have to wonder, who does the current dysfunction benefit? It’s an easy one: the private providers. But nobody who is of the machine is working against it. No one in Leinster House is saying to the CEO of the HSE: “What are you doing for your four hundred grand? We’ve got less intensive care beds per capita than Lithuania or Latvia. Two years into a pandemic, we still don’t have a dedicated COVID hospital which is just insane.

    Apparatchiks of a state system who’ve worked, like Paul Reid in state jobs are seen as a safe bet. They’re nominated in as managers, managers of dysfunction, gatekeepers for their political sponsors and marked for future cushy roles on the private side of the wall.

    Image (c) Daniele Idini.

    Perpetual Crisis

    He adds that ‘things like this mysterious and much vaunted “Cyber Attack”, which apparently “destroyed the abilities of the system” seem to be a perfect excuse to deflect from the internal failures of HSE management and external incompetence of its political masters.’

    Bowes says: ’what I know, and anyone that has worked in the system knows, is that there was and is no viable system to attack.’ The HSE have ruminated for decades on the implantation of an electronic patient record: they have spent millions evaluating, re-evaluating, procrastinating, and failing to implement a viable solution.

    Months after this “Attack”, you’re still running Windows 1998. Somebody needs to be held accountable.

    But, he says: ‘the Minister doesn’t talk to the to the HSE, the relationships between the “Three Masters” of Health are utterly flawed, the Department of Health is cumbersome and cautious, the HSE is a lumbering leviathan with no real direction other than self-preservation, and the Minister is preoccupied with surviving a potentially career ending stint in the mire of the Irish Health system.’

    Consider this, with such a huge annual Health budget and such poor outcomes for patients alongside such terrible value for money, the dysfunction and paying for it becomes central to the rational of the organisation. They actually need this dysfunction. Without the dysfunction, they’d be screwed because there would be an open accounting of what we’re doing in a system which is delivering horrendous results.

    He also criticises Stephen Donnelly’s policy of giving more money to the National Treatment Purchase Fund, which sends public patient overseas for treatment, arguing that ‘this is not the same as a really equitable national health system where everybody gets treated on the basis of need.’

    He says that people could argue that in a free-market economy if someone wants to purchase health insurance it’s up to them: ‘However, that’s different to paying almost half a million a year to a CEO to perpetuate a dysfunctional system.’

    He says the HSE is only interested in crises, ‘in things like COVID’ and saying ‘but COVID is why the system is screwed, or we’re dealing with the cyber attack, which has caused this perpetual dysfunction, which is, you know, all entirely untrue.’

    His conclusion is ‘the managers, architects and political apologists for the segregated and morally bankrupt system have done an exceptional job of screwing the Irish people out of their tax dollar and their rights to health and dignity. I’m not sure they are capable of doing anything else. It’s time to demolish and rebuild.’

    Featured Image by Gareth Curtis