Paying for GP appointments won’t save the NHS. Just look at Ireland
OPINION: The two-tier system praised by the British right is a crumbling deathtrap with long waits and bed shortages
According to politicians, journalists and even exasperated frontline workers, the NHS is trembling on its last legs. Soul-searching, unsentimental reform and new thinking are, we are being told, required to resuscitate the health service and prevent its total collapse, just as nurses go on strike for livable working conditions and thousands die from emergency department delays alone. Being pumped out at a steady clip are an assortment of half-baked solutions for this crisis, one that was created in large part by the same austerian Tories who claim to have all of the answers.
Last month, Sajid Javid, the former secretary of state for health and social care, sang the praises of fees for GP and hospital visits. “Take Ireland,” he wrote of the country’s two-tier system, “where some people are entitled to free healthcare through the public system, based on household income.” He took stock of Germany, home to a typical European social insurance model, as well as the £20 GP fees in Norway and Sweden. In particularly effusive terms, he hailed the Irish Health Service Executive (HSE), giving the example of what he ludicrously calls a “nominal” €75 fee, payable by most in Ireland for a visit to an injury unit.
To combat NHS dysfunction, an NHS.2 should, in Javid’s judgement, involve a “contributory principle to complement public financing”. Such a system, he claims, gives one control over demand, redirecting it to “more efficient methods of supply”.
Means-tested fees in Ireland, however, have created a scenario in which low- and middle-income earners were found to be five times more likely to forgo a primary care appointment than their wealthier counterparts. But demand for medical care has not simply evaporated into thin air – many people in Ireland neglect and de-prioritise their health, or take out costly private insurance to jump the queue for certain treatments.
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Just under half (47.5%) of the Irish population have private health insurance, one of the highest levels of take-up in Europe, and premiums – which are soaring across the board – cost individual adult policyholders an average of €1,412, according to one price comparison site. As one might expect, the privately insured receive preferential treatment and superior services to less affluent sections of Irish society, most of whom endure extreme waiting lists and much-hated out-of-pocket expenses.
Just before Christmas, The Times analysed the Irish system generally and GP fees specifically, finding widespread disapproval of the two-tier hybrid among patients and academics. Since the Irish model is occasionally singled out for emulation by English observers, it is worth discussing why.
Far from being an answer to the multi-pronged crises afflicting the NHS, Ireland’s health service is a crumbling deathtrap with a unique set of historical circumstances rooted in a reactionary cross-generation alliance between the state, the Church and a well-heeled doctor-consultant class. In 1951, at its zenith, this bloc forced out health minister Noel Browne, who, awe-struck by the immediate successes of a young NHS, proposed a measure to make healthcare services free for mothers and children up to the age of 16.
But the great irony in suggestions that the NHS ought to be more like the HSE is that Irish healthcare is, at least on paper and in rhetoric, undergoing a gradual process of universalisation, particularly with regard to GP fees.
One of the distinguishing marks of the Irish healthcare service is that it, put simply, doesn't work
While free GP care is offered to young children and the recipients of means-tested medical cards, last year’s budget revealed a plan to extend this to cover an additional 400,000 people, including all six and seven-year-olds and those on or below the ‘median income level’.
After decades of being burdened with unaffordability and not becoming equal beneficiaries to an epochal leap in living standards between the 1990s and the 2010s, many in Ireland seemed to desire a radical overhaul of the healthcare system. In 2011, a disastrous Labour-Fine Gael coalition, which was brought to power partly on a commitment to reform healthcare, became the first government in Irish history to commit to a universal, single-tiered health service (even if it failed utterly to do so).
One of the distinguishing marks of the Irish healthcare service is that it, put simply, doesn't work. Waiting lists for vital services are, in many cases, as long as in the UK, hospital bed availability is dire, and GP and other services are chronically understaffed. If this all feels familiar, it's because it is. This is all despite the fact that the Irish state actually spends more on healthcare per person than the UK.
The cross-party blueprint for the future of Irish healthcare, Sláintecare, which remains largely undelivered since it was unveiled in 2017, recognises the need to move toward equitable access and abolish the two-tiered structure. Meanwhile, Sinn Féin, which is currently on track to lead the next government in the South in 2025 while sitting as the largest party in the North, is promising a €1.2bn all-Ireland National Health Service.
The UK already has the outlines of a two-tier system, disguised by free primary services
Just as Tory MPs fawn over the two-tier status quo in Ireland and Labour preaches the gospel of fiscal discipline, moderates and even neoliberal doctrine-reliant centre-right parties in Ireland accept that a universalist model – or, rather, a more universalist model – is the future.
The contradiction does not concern Sajid Javid. But it would be foolish not to recognise that the UK, especially England, already has the outlines of a two-tier system, relatively well disguised by free primary services. Privatisation and outsourcing have filtered throughout the NHS for decades. Former Labour prime minister Gordon Brown, who wrote recently about the real existential dangers of Javid’s intervention, failed to mention his role as a key figurehead in a New Labour project that ramped up the presence of private mechanisms in the NHS, chiefly through the widespread use of Private Finance Initiatives (PFI) to fund healthcare projects.
A stark Lancet study published in 2022 found that in areas with increased levels of outsourcing of healthcare, more people die of treatable conditions. At one level, allusions to Ireland and other European models are a simple political strategy: making ‘innovative’ policy proposals for political gain. At another, however, they are part of a wider historical context of swingeing austerity and creeping privatisation and outsourcing, a pattern of wilful neglect that lays the foundations – and provides the justifications – for a two-tier system.
The grave issues relating to underfunding, staffing, bureaucracy and inefficient private-led services aside, the NHS still delivers on what the HSE so grievously fails: equal access to healthcare for all. “The Americanisation of the NHS is not something waiting for us in a post-Brexit future,” warned John Furse, a writer who researches the influence of US health policy on the UK, in 2019. “It is already in full swing.” While American shareholder interests and American-style business imperatives now course through the veins and arteries of the NHS, we should equally resist comparisons to the Irish system, since any Irishisation of the NHS spells doom for the health service's founding principles.
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