SHOCKS TO THE SYSTEM
The outcome of the 2019 UK election was a significant setback for the DUP and brought to an end the leverage it had influenced through the confidence and supply arrangement with the outgoing Tory government. It lost two seats, including that of its Westminster leader Nigel Dodds, who was defeated in North Belfast by John Finucane, a young lawyer and SF member.
Finucane – Lord Mayor of Belfast and a son of the solicitor Pat Finucane who was shot dead by loyalist and British agents in 1989 – benefitted from the SDLP’s decision not to contest the seat. In return, SF gave Claire Hanna of the SDLP a free run to take another DUP seat in South Belfast while Stephen Farry of the Alliance Party won in the wealthy, largely pro-union, North Down constituency previously represented by independent unionist, Sylvia Hermon.
The SF vote was down on its 2017 election result, and it lost its seat in Derry to Colum Eastwood of the SDLP, but the careful voting arrangement between the non-unionist parties meant that, for the first time, the two nationalist parties outnumbered the unionists at Westminster: the DUP returned with 8 seats, while SF had 7, SDLP 2 and Alliance 1. The outcome was even more significant as it meant that a critical target had been reached in the conditions required for the calling of a unity referendum. When the number of votes cast for nationalist candidates exceeded those for unionist candidates in a general election, in the minds of many people the British secretary of state was obliged to at least consider whether to call a referendum or border poll on unity.
A comfortable election victory for Boris Johnson meant that he was no longer shackled in the continuing Brexit negotiations by the twin burdens of the DUP and the extreme Brexiteers within his own party, including the European Research Group. The consequences for politics in the North and for the growing debate on a unity referendum were profound. The immediate effect was a resumption of efforts, led by Julian Smith and Simon Coveney, to restore the suspended devolved institutions at Stormont. After weeks of discussions, an agreement entitled ‘New Decade, New Approach’ was signed off by all five parties in the assembly. It included commitments on Irish language legislation, and health reforms that guaranteed pay parity for nurses and an action plan on hospital waiting times. It also promised movement to improve the management of the education and justice systems and enhanced accountability for the conduct of ministers, civil servants and special advisers at Stormont.
By mid-January 2020, DUP leader Arlene Foster and SF MLA Michelle O’Neill were installed as First and deputy First Minister respectively, with equal powers, in an executive that also included representatives of Alliance, the Ulster Unionist Party (UUP) and the SDLP.
A month later, a general election in the South had, arguably, even greater significance in relation to a potential unity referendum, when SF emerged with more votes than either Fianna Fáil (FF) or Fine Gael (FG). The result, which defied all pre-election predictions, saw SF take 24.53 per cent of the popular vote compared to 22.18 per cent for FF and 20.8 per cent for FG, with other parties trailing well behind. The history-making swing to SF left the party with 37 seats, fewer than FF with 38, and with FG at 35. The result was all the more remarkable given that, just eight months earlier, in May 2019, SF had lost almost half their council seats and most of their MEPs, following a disastrous performance in the local government and European Parliament elections. As a consequence of those poor results, the party had adopted a cautious approach in the general election and was reluctant to run more than one candidate in most constituencies. Had it adopted a dual-candidate strategy, the party could have returned up to a dozen more TDs as it topped the polls in several constituencies with more than two quotas.
The result sent shockwaves through the political establishment and, in particular, within FF which had, with a large degree of complacency, expected to take up to 60 seats in the election and to be in a position to govern with a smaller party and some of the wide selection of independents returned to Dáil Éireann. The party leadership had underestimated the damage to its independence and credibility from its close association with FG during four years of a confidence and supply arrangement. Equally, both parties had failed to grasp how the continuing crisis in the provision of housing to a whole generation of young voters, and the growth of precarious, low-paid work across wide sectors of the economy, had transformed traditional voting patterns.
The mobilisation of young people in the 2015 and 2018 referendums on marriage equality and reproductive rights for women had raised expectations of what could, and should be, attainable in a modern, European democracy. The creaking public health system, inadequate childcare provision and FG plans to increase the pension age were also factors in the decisions of huge swathes of voters to desert and punish the large centre-right parties that had dominated Irish politics for decades.
The prospect of a referendum and of Irish unity, while promoted by Sinn Féin during the election campaign, did not feature among the primary reasons voters subsequently gave as the motivation for their unprecedented support for the party, but the idea was endorsed by a sizeable number of voters in an exit poll on election day, 8 February 2020. Some 57 per cent of voters polled said they thought there should be referendums on Irish unity, North and South, within five years. The Ipsos MRBI poll commissioned by RTÉ, the Irish Times, TG4 and University College Dublin (UCD), revealed that 75 per cent of 18-to-24-year-olds and 62 per cent of 35-to-64-year-olds wanted a referendum within five years, falling to 47 per cent of over-65s, illustrating a distinct generational preference for unity, or at least a right to vote on it.
During the prolonged post-election discussions on government formation, the prospect of SF taking a prominent, if not leading, role simultaneously in administrations North and South weighed heavily on FF and FG. Both parties refused to enter discussions with SF, despite the similar numbers of seats won by each and the fact that at least two of the three parties would have to enter into a coalition in order to form a government.
Just weeks after the general election, another storm landed that was to have deep and lasting consequences, causing premature deaths among older people in care homes, overpowering the intensive care units (ICUs) of hospitals and stretching the already burdened health systems in both parts of the island.
Covid-19 fundamentally challenged the capacity of government and the public health service in both jurisdictions to protect the lives of citizens, as infections rapidly spread and large parts of the economy were closed down. The first confirmed case on the island was of a Belfast woman who had travelled home from Italy, the epicentre of the coronavirus outbreak in Europe, via Dublin airport.
By early March 2020, the hastily-assembled National Public Health Emergency Team (NPHET) in the South reported a doubling of cases within a week, bringing the total to 18, with another 4 cases in the North as the global figure neared 100,000.
On 12 March, as the first lockdown measures were adopted, Varadkar addressed the nation from Washington DC, where he was visiting President Donald Trump during the St Patrick’s Day celebrations. Varadkar remained as Taoiseach until a new government was agreed and appointed and, in this temporary, caretaker role, was now facing the most challenging period since he took office in June 2017. ‘We have not witnessed a pandemic of this nature in living memory,’ he said. ‘This is unchartered territory. We said we would take the right actions at the right time. We have to move now to have the greatest impact.’
Announcing a lockdown of schools, colleges, childcare and cultural institutions until 29 March, Varadkar also advised that indoor events of more than 100 people and outdoor gatherings of more than 500 should be cancelled. He said:
In the period ahead, the government will deploy all the resources we can muster, human and financial, to tackle this threat head-on. Those resources are extensive but not unlimited. Healthcare workers have been at the forefront of this crisis since it started. They will be at the frontline of the crisis in the time ahead. We must do all we can to help them, so they can help those who need help the most.
The escalating crisis from the Covid-19 virus dominated public discourse as the first lockdown was introduced, while the government announced a raft of financial supports for individuals laid off from their jobs and for businesses forced to close.
The crisis also disrupted the discussions about a referendum for a united Ireland and a series of public meetings planned by IF across the country was postponed indefinitely. Its work was also affected when Niall Murphy contracted Covid-19 during a visit to New York, where he had been invited by the Brehon Law Society to attend Irish American events during the St Patrick’s Day celebrations, and to discuss the emerging role of Ireland’s Future in the unity debate. On his return to Belfast, Murphy was diagnosed with life-threatening respiratory symptoms and placed in an induced coma for several weeks. In the middle of the night on 30 March 2020, his wife, Marie, was informed that his chances of survival were ‘50/50’. As with many other patients, he attributed his recovery to the care of nurses, doctors and other frontline staff, but he also criticised the inability of the National Health Service (NHS) in the North to cope with the public health crisis. SF leader Mary Lou McDonald, was on a nationwide tour, addressing large rallies in Cork, Dublin and Newry, to demand her party’s place at the table in government formation negotiations, when she was struck down in the early weeks of the Covid-19 crisis.
Notwithstanding the reassuring words of the Taoiseach in Washington, and the professional and scientific advice from the NPHET team led by Chief Medical Officer Tony Holohan, the weaknesses of the public health service in the South and its capacity to cope with an epidemic were quickly exposed. From the outset, the Health and Safety Executive (HSE) scrambled to get into the global market for ICU ventilators, testing kits and basic Personal Protection Equipment (PPE) for healthcare workers and the wider public. As the numbers of cases grew during the first surge, the years of successive cuts in the number of hospital, including ICU, beds and the failure to recruit sufficient nurses and doctors and other crucial frontline staff, came home to roost. The most vulnerable, elderly and sick people in nursing homes and other residential facilities, were the first hit as there was little or no protection in place to prevent the spread of the virus. Poorly ventilated and overcrowded care facilities hastened the spread. Many elderly people were infected when patients were released from hospital settings where the virus was on the rampage, into nursing homes without prior testing for Covid-19.
The cabinet decided not to activate its public emergency strategy, which would have deployed the resources of all the agencies of the state, including the health service, local authorities, government departments, gardaí and defence forces as set out in a report published in July 2017. Over 60 pages, the government report, entitled Strategic Emergency Management: National Structures and Framework, contained a detailed plan on how to respond to an unexpected crisis, including one caused by a pandemic. It recommended that the lead department, in this case the Department of Health, should immediately convene the National Emergency Co-ordination Group involving a ‘whole of government’ response to such an emergency.
Crucially, the government also failed to adopt an immediate policy of closing entry points to travellers from abroad. During March, almost 2,000 rugby supporters were permitted to land in Dublin from Northern Italy, the European epicentre of the Covid-19 crisis, where the coronavirus was already decimating its older population and overwhelming a modern and well-resourced health service. The supporters arrived in the city, even though the international game between Ireland and Italy that they had come to attend, had been cancelled due to the epidemic. Weeks later, hundreds of horse racing enthusiasts from Ireland mingled with many thousands attending the annual meeting at Cheltenham in a part of England already experiencing a rapid spread of infections from the virus. As case numbers soared, the government negotiated a €100 million a month deal to access privately-run hospitals and opened large step-down facilities for recovering patients and specially-commissioned mortuaries to cope with any overload of fatalities. Hundreds of thousands of patients on ever-growing waiting lists, including those awaiting treatment for chronic and life-threatening conditions, were unable to meet their consultants. Elderly residents of private care homes, many staffed by underpaid, undertrained and poorly-resourced workers, were dying at a rapid rate, while ICU units were almost overrun as numbers peaked between April and June.
Health and Social Care (HSC), the operator of the NHS in the North, was also overwhelmed as case numbers and deaths rose at a higher rate than in the South, and hospitals and healthcare workers struggled to cope with the pressure. A similar inability, or reluctance, in the North to curb the numbers of international arrivals intensified the spread of the virus, which was raging across the UK and stretching its NHS to the limit.
The failure, in both jurisdictions, to develop an efficient contact tracing system, which would have enabled the health services to track the source of individual infections and clusters of Covid-19 cases, severely hampered an effective response to the spread of the virus. While the numbers of deaths and cases in the North were significantly higher than in the South per head of population, the virus did not recognise borders, and it was evident that deeper co-operation was required between both administrations to delay and curtail its spread.
By the end of June, and as the first surge abated, the Health Protection Surveillance Centre (HPSC) in Dublin reported that there had been 1,475 confirmed Covid-19 related deaths and 25,462 cases in the Republic. In the North, there had been 551 deaths and 5,760 cases reported by the Northern Ireland Statistics and Research Agency (NISRA) at the end of June, as numbers of daily fatalities dropped to zero after the first lockdown. The scale of the crisis and the failure of the authorities, North and South, to agree measures to curb entry, or to enforce a strict testing and quarantining regime for those arriving at airports and seaports in order to stop the spread of the virus as other island nations had successfully done, was a matter of major public concern. The mounting death rates and the inability to seal off the country due to UK jurisdiction in the North, also led to speculation and debate as to the potential benefits of an all-island health service in the event of a unity referendum. The refusal of the main unionist parties to agree to any restrictions on entry from the UK, even as the virus killed many more in Britain than in any other country in Europe, was a significant factor in allowing its spread across the North and border counties during the first surge. This was the greatest public health emergency since the Spanish flu in 1918.
From the outset of the pandemic, Dr Gabriel Scally of Bristol University had called for an all-island response. Scally, a public health specialist, was born in 1954 in Belfast, where his father was a psychiatrist. As a child, Scally travelled each summer to Donegal where his father, who had previously been a GP, would cover as a locum for his uncle who, with his wife, ran a GP practice in Letterkenny. Scally’s annual holidays to Donegal ended because his father, coming from the universal free NHS culture, found it difficult to charge patients, while his uncle could not maintain his medical practice if he didn’t. It was Scally’s first insight into the contrast in public health provision on the island.
After attending secondary school in St Mary’s in Belfast, Scally went on to study medicine in Queen’s University in the city where he became active in student politics and served as a vice-president of the Union of Students in Ireland. His main interest was in public health and he spent two years training as a GP, including for a period in the village of Mullabawn close to Forkhill, in south Armagh at the height of the Troubles in the late 1970s.
On completing his degree, Scally did his post-graduate studies in public health in the School of Hygiene and Tropical Medicine in London and returned to work as a consultant in Belfast before his appointment as chief administrative medical officer of the Eastern Health and Social Services Board of Northern Ireland at the end of the 1980s. He subsequently took a position as a regional director of public health with the NHS in England, where he worked for 20 years.
Throughout his professional life, Scally has promoted the view that a universal health service, free at the point of use is the most effective, sensible and fair model of provision. ‘The evidence base is perfectly clear from around the world that if you wish to get a fully functioning health service that deals with people equally and fairly, the only sensible way of funding it is out of general taxation. And free to everyone at the point of use,’ he told this author in August 2020.
Before the arrival of Covid-19, Scally had carried out the investigation into the CervicalCheck scandal in the South and reported on the reasons so many women who developed cervical cancer had been provided with possible ‘false negative’ results following earlier smear tests for cancer. His report was widely recognised as a shocking and accurate portrayal of a dysfunctional service.
Scally was scathing at the lack of a coherent strategy to deal with the pandemic in either the Republic or the UK. He said he was the first to use the term ‘Zero-Covid’ as the most effective way to completely suppress the virus by making use of the advantage of living on an island. A member of Independent SAGE, a group of professionals in the UK with diverse medical expertise, Scally made an influential and effective intervention in the Covid-19 debate in both jurisdictions. He was among the first to call for an ‘all-island’ medical response, including a complete ban on foreign travel into Ireland:
We were on the verge of suppression both North, South and in Scotland, and the fact we didn’t fully suppress it was because we didn’t try hard enough. We didn’t put the resources into that goal. It’s very hard to achieve something when it’s not your goal. We’re mopping up the floor here in this place, but we haven’t fixed the hole in the roof.
Scally cited the failure to restrict arrivals from abroad at an earlier stage of the crisis as particularly negligent:
At the time, Britain and Ireland were in a minority of countries across the world which did not impose border restrictions. The reason voluminous air traffic stopped was not because of Britain and Ireland doing anything to stop people waltzing in with viruses. It was because other countries stopped them. I’ve always regarded that as a failure.
The Covid-19 experience reinforced Scally’s view that there should be a single, universal, health care system across the island of Ireland:
One of the key cornerstones of the World Health Organization’s international programme for development of health across the world is universal access. Achieving universal access across the island of Ireland is something that is a pretty fundamental building block, which is why I’ve been very pleased to see what is in Sláintecare.
Sláintecare, a 10-year plan for reform of the health services in the South, was agreed by the Oireachtas Committee on the Future of Healthcare in 2017. It proposed the establishment of a universal, single-tier health service, where patients are treated solely on the basis of health need. It also recommended that the health system should move ‘towards integrated primary and community care, consistent with the highest quality of patient safety in as short a time-frame as possible’. It proposed the decentralisation of health administration and suggested that the ambitious reform programme should be led by the Department of the Taoiseach.
The South was the only country in western Europe that did not provide universal coverage of primary care, a situation that Sláintecare aimed to alter. In the South, over half of the population pay €50 for a GP visit. Those who arrive at an A&E department without a referral letter from their GP are asked to pay €100. Two-thirds of the population spend almost €150 per month on prescription drugs, on top of payments they make for other medical services. Those on low incomes (almost one-third of the population) are entitled to medical cards that provide free primary and hospital care. In recent years, the numbers of those with medical cards or GP visit cards has risen to more than 45 per cent of the population. In April 2019, it was announced that by 2022, free GP care would be extended to all children under the age of 12. Sláintecare also envisaged a movement towards free, universal GP services, comparable to the current NHS in the North.
A key challenge to both services, however, has been the unacceptable and damaging waiting times for the most basic of treatments, as well as for the most urgent of life-threatening conditions. In 2019, over 800,000 people were on waiting lists in the public system in the South, a figure which has continued to rise due to restrictions caused by the Covid-19 crisis. (By September 2021, the number had risen to 900,000 people, according to data from the National Treatment Purchase Fund (NTPF).)
Those who can afford to pay, or who have voluntary health insurance, can avail of private hospitals and can also gain more rapid access for diagnosis and treatment in the public health system. By developing a contract for consultants to work exclusively in public hospitals, Sláintecare also challenges the influence of the private medical industry over the health service.
In June 2020, Scally spoke with Monaghan GP Ilona Duffy and the late Professor Jim Dornan, in a video broadcast organised by IF about the ongoing pandemic, the failure to develop an all-island response and its impact on border areas. ‘There is no point in having free ice cream for life if it takes a year to get a poke,’ he said in relation to excessive waiting lists in the North during the broadcast.
While private health care is not as pervasive or developed in the North, the underfunding of the NHS and the creeping privatisation of health provision has fostered inequality between those who can afford to avoid ever-lengthening waiting lists by accessing private treatment elsewhere – including in the South, the UK or in Europe – and those who cannot afford to do so. However, the free, universal access to primary, community and hospital care by the NHS remains a significant benefit for citizens in the North compared to those south of the border.
Scally said that the government’s role in taking over private hospital facilities – albeit at a cost of €100 million a month – to cope with the first surge of the Covid-19 crisis, was a form of nationalisation and an example of what is possible. Introducing a universal health service would require careful consideration and planning to meet the concerns of those who currently operate and use the private system, he argued:
Better commissioning and contracting of services shows how a universal system would make use of private facilities all the way through to a nationalisation programme. It was interesting to see how the government moved very rapidly to nationalise the hospitals, in a sense, for Covid-19. I think there are a series of layers to that. There is the ownership of private facilities by capital-based organisations, there are the interests of individual professionals in terms of their personal private practice and then there are the interests of the public who will worry that they will be giving up something that they hold dear, which is their ability to consult a doctor of their choice and get the treatment that they want at any time.
The pre-Covid public health service in the South costs almost €18 billion annually in public monies, while Northern Ireland Health and Social Services (commonly referred to as the NHS), requires about £8 billion each year. The North is the least resourced of the NHS regions across the UK and its deficiencies were highlighted when Covid-19 threatened to overwhelm hospitals and state-run care homes in the summer and autumn of 2020. In the South, the Covid crisis similarly challenged the health service and exposed its shortage of ICU and critical care beds as well as step-down facilities, and contributed to a tragic failure of supervision and protection for older people in nursing homes, as reported in the Irish Times in February 2021.
For Scally, the merging of the two services into a single universal health system in an all-Ireland scenario makes economic and political sense and would produce better economies of scale and outcomes for users. It is important, in his view, to concentrate highly specialised medical procedures and treatments but to have public health services available in every community. As he put it:
The diffusion of medical health technology has changed the map of what can be done locally and in terms of the specialisation of services required in order to get better outcomes. The island of Ireland, in my view, is a really good size for a very well structured, highly efficient health service in which to operate.
Where previously community care was based on the old health board system, with public health nurses and centres located in towns and villages across the country, the GP system is now the favoured method for bringing care closer to the patient, including in the Sláintecare proposals.
In the North, a 2016 report by Spanish consultant, Rafael Bengoa, envisaged a similar future for healthcare services. It also proposed a consolidation of specialised treatments in regional centres of excellence. At the same time, it argued that many other services could be provided closer to people’s homes, including in community-based GP centres, rather than in hospitals.
In both health systems, there is a movement towards multi-disciplinary teams, including pharmacists, mental health professionals, physiotherapists and social workers working with GPs to provide a more holistic approach to medical care. As with Sláintecare, the health service in the North, in the wake of the Bengoa report, adopted a policy of shifting care out of hospital and towards treatment of people in their neighbourhoods with a greater focus on illness prevention.
As a new wave of Covid-19 cases hit in the autumn of 2020, placing more pressure on the two health systems, Scally continued to publicly advocate for greater investment and resources in public health, including more public health doctors, in order to prevent the future recurrence of the devastation caused by the Covid-19 pandemic. He warned that a further surge, including of new variants, was likely and that an all-island response, including to inward travel, was essential to avoid many more preventable deaths. His advice was not always heeded. Neither was his view, shared by many other doctors and consultants, that a free, universal service built on the NHS model is the best fit for an all-island health service.
Professor John Crown, an oncologist at St Vincent’s University Hospital in Dublin and former independent senator, agreed during an interview with the author that an all-island health service providing for a population of over 7 million people would be ‘doable’, notwithstanding the current dysfunctional nature of both systems, North and South. Other countries have excellent models already in place by way of example:
I’m a believer in socialised medicine but I’m not a believer in socialised medicine where everything is run by the government. What the government has to do is ensure a level playing field, to ensure through legislation and regulation that everybody has mandatory access to healthcare, to ensure rich people pay more for it than poor people do and to make sure that what everybody gets in the end is an equal and high-quality service.
The British model, however, is just to make sure that everybody gets an equal service and forget about the quality. As a result, the NHS has extraordinarily long waiting lists, only surpassed by Ireland. It has a very low doctor–patient ratio and mediocre outcomes. It’s not a bad health system. It’s just not an excellent one.
The excellent ones are Germany, France, Holland, Belgium. These are systems where government mandates that you must have insurance in one way or another. It doesn’t own all the hospitals; it owns some of them. Under this model, people all have a universal social insurance entitlement which they can take at their choice to a government-run hospital, to a private hospital, to a university hospital, to a religious charity. Whatever it is, they take it where they want. The poor person would pay a whole lot less and the unemployed person would pay nothing for it.
Leaving aside the politics, an all-island health service would be sufficiently big with a population of seven million rather than just five million in the South to be very self-contained. People in Denmark, Norway or Sweden don’t ever have to leave those countries to get healthcare and we wouldn’t either. We’d be able to do everything, I would hope. We need fundamental reform in the system in the South. Trying to merge the two Frankensteins into one viable monster would be hard but not undoable.
Crown said that Sláintecare may succeed in taking private beds out of the public hospitals, but it will not eliminate the two-tier health system:
Sláintecare entrenches two-tier healthcare because it would be a totally separate public system and a totally separate private system. Under Sláintecare, the private system will thrive because people will leave the public system in droves. Private healthcare in Ireland is not only something some rarefied social elite have. Teachers, taxi drivers, guards, prison officers have private health insurance. It’s not like England where [it’s] only the top 10 per cent of the population that have it. What we call private insurance in Ireland is actually social insurance. It’s the same thing that they have in Canada, only there they call it National Social Insurance.
In the same interview, Crown was scathing about the failure of the health authorities to deal with the waiting lists which are heading towards the one million mark and claimed that it is not an aberration but a business model:
The Irish health system is not underfunded, it’s ‘malfunded’. It’s funded in a way that does not incentivise efficiency and equality. Instead, it incentivises inactivity because the hospital knows the patient on a waiting list does not cost anything. The patient costs the hospital no money until they come into the hospital and you start doing stuff to them. The waiting time is the business model of the system. The business model of the waiting list is to constrain the resource, make them wait.
It’s more fundamental than saying it’s somehow dysfunctional as a system. People have to decide; do they want the doctor who will try and get their treatment done relatively quickly and to a high quality, or do they want somebody who is being paid a salary who will say, ‘you can go on a list and wait for it’?
It is interesting that the people that make that model all have private insurance. All the HSE administrators, Department of Health civil servants, nearly all politicians have private health insurance. It doesn’t affect them, that’s part of the problem.
We’ve far too many small hospitals, far too many medical schools. A whole lot of things for historical reasons evolved in different ways and that’s just the reality of where we are. Trying to get them to act in concert and to have a critical concentration of resources is not a bad idea. For some things it is probably good, but it doesn’t again fix the fundamental problems which are access, inequality and waiting lists.
Crown also argued that the service in the South is well served by outstanding nurses, doctors and other healthcare professionals:
The problem is that they and their facilities are in such short supply that we prop up the bottom of most league tables for access to care. Waiting lists for tests, specialist appointments and operations are so long that in some cases the services effectively don’t exist. Treatment delayed is treatment denied. Despite repeated warnings that our intensive care capacity was deficient, it took a pandemic to get action from the Department of Health and the HSE.