Why is the health system in the Republic of Ireland so poor? One way to begin to answer this extremely complicated question might be to compare it with the health system in Northern Ireland, which, while being very far from perfect, is widely perceived as superior to its Southern counterpart. Certainly many thousands of people in the Southern border region see it like this, judging by the large numbers of Southerners (many of them with Northern accommodation addresses) who regularly use Northern GPs and hospital services.

Let’s go though some of the essential elements in what makes for a good health service and compare the performance of the two Irish jurisdictions. First, and most important, the North, in common with the rest of the UK, has free universal access to health care. It has a common waiting list for treatment in public hospitals (with a tiny if growing private sector), compared to the South’s fractured system, with 32% of people entitled to free treatment because they hold a medical card and the rest having to take out insurance to pay fees in public or private hospitals (fees which the largest insurer, the semi-state VHI, will raise by a whopping 10-45% on 1 February).

Then there is the North’s higher capacity to implement key reform initiatives because of this largely unified system. Thus in recent years the NI Department of Health, Social Services and Public Safety has overseen a significant reduction in hospital waiting times. In October 2010 over 82% of patients were either treated and discharged, or admitted to a ward, within four hours of their arrival in an Accident and Emergency Department in Northern hospitals(1). In contrast in the same month over 25% of patients in the Mater (Dublin), over 30% in Sligo Regional and 45% in Cork University hospitals had to wait 12-24 hours for admittance through A&E(2).

Primary care is better organised and funded in the North, with the provision of teams of GPs and allied health professionals (nurses, physiotherapists, chiropodists etc.) who offer free and lifelong care to people in local areas. In the South the nearly 70% of people who don’t have medical cards have to pay €50-75 before they even darken the local GP’s door.

Public health is a much higher priority in the North. The all-island Institute of Public Health in Ireland has consistently shown in its reports that there is a greater understanding of the relationship between social inequality and health in the Northern Ireland system. This has been greatly helped by NI Health Minister Michael McGimpsey’s stated determination to make overcoming health inequalities a top priority, in sharp contrast to Mary Harney’s policy of exacerbating the rich-poor divide by encouraging private hospitals to ‘co-locate’ beside public hospitals. Public health specialists in the Republic say that there was a high level of public health leadership there before it was stifled by the new bureaucracy of the Health Service Executive (HSE).

Morale in the health service is much better in the North. The constant revelations of inefficiencies – and worse – in the HSE must make it a difficult place to work. For example, the revelation last year of tens of thousands of unopened GP referral letters and unread x-rays at Tallaght Hospital shocked even the most hardened critic of the Republic’s sprawling health service delivery body.

Health-related social services are often equally poor in the South when compared to the North. One distressing example is the waiting lists for speech therapists. In May 2010 it was reported that more than 23,000 young people under 18 in the Republic were on waiting lists for speech and language therapy, with almost 4,000 of those waiting for between 12 months and two years(3). The equivalent figure in Northern Ireland (in January 2008) was 2,358. Specialists agree that early intervention is vital when treating young people with speech problems, who otherwise can be doomed to a lifetime of incapacity and marginalisation.

The explanation for the inferior Southern health system in the past was that the Republic was a poor country which simply could not afford the world-class National Health Service (NHS) that the UK boasted from the 1950s until recently. But during the period of massive – if temporary – increases in public funding brought about by the Celtic Tiger economic boom, this argument started to sound a little thin. Now, of course, it is back again with a vengeance.

In the meantime, David Cameron and his Health Secretary, Andrew Lansley, have decided to take the NHS in England down the decentralisation and part-privatisation road, with their surprising and extremely radical plan to give GPs command of 80% of the NHS budget and freedom to negotiate contracts with hospitals and other health service providers. The question is whether Scotland, Wales and Northern Ireland will be forced by financial pressures to follow this route, which has caused deep concern among doctors, nurses and patients.

For the final difference between the health systems in the two Irish jurisdictions is that Northerners, in common with the majority of people in the UK, are genuinely proud of the NHS, and are very anxious to protect what is left of it. For them, it is a classic example of a universal public service as a ‘public good’. In contrast, in the Republic the HSE is seen as a huge bureaucratic monster that exemplifies all that is wrong with public services in that state. In the end, perhaps that is the most significant difference of all.

Andy Pollak