Mary Harney, the new minister for health, does not have time on her side. Winter is upon us and so are the first crises of her administration: young children sent home on the day they were meant to receive life-saving operations, old people waiting on trolleys in accident and emergency units for days and, all around her, cries for more money and quick fixes.

She has the misfortune to be surrounded by a department of health that is, of course, part of the problem rather than part of the solution, and she will struggle to lay her hands on sound advice that diverges from the conventional wisdom of tinkering with the present system and pumping more money into it. The crises of the past two weeks have demonstrated — in microcosm — what is wrong with the health service, and why it needs to be torn down if it is to be transformed.

Harney’s objectives must be clear: her duty as minister for health is to ensure that everyone in the country, regardless of their wealth, has timely access to high-quality healthcare. That is the extent of her basic remit: it is not her responsibility to provide that healthcare, but it is her responsibility to ensure that it is adequately funded and efficiently provided. At present, it is neither.

Harney will be told that the fundamental problem with the Irish health service is that it is underfunded, even though spending on the health service has almost tripled in seven years. The extra funding, so the argument runs, is nowhere near adequate. If we want an effective health service, we have to be prepared to pay higher taxes and spend ever more.

It is an argument that does not stand up to scrutiny, but it is widely accepted and propagated. The truth is much more complex: some countries spend more than we do and get a better service; others spend significantly less and get a better service.

It should be obvious that the actual amount of money spent matters far less than the way in which it is spent, yet raw data is used as a stick with which to beat the minister.

The health service is a bloated bureaucracy: out of the 96,000 people it employs, just a third are nurses and about 7% are doctors. Managing the health service requires the full-time equivalent of nearly 16,000 administrators, and that’s not including the 14,000 caterers and gardeners and other “support” staff employed by the state. There are more clerical officers than doctors and their numbers have grown dramatically over the past four years.

All that bureaucracy has created a system in which decision-making is lost in a fog and has contributed to an information black hole: nobody has a clear picture of what is happening in individual hospitals, let alone across the whole system. It is chaotic, inefficient and designed to fail.

The trolley crisis revealed some of the basic flaws. Patients are marooned on trolleys because there are no available beds even though there are plenty of beds available in private nursing homes.

Why? In no particular order, the reasons seem to be as follows: private nursing homes are not seen to be an extension of hospital care, so the state will not pay the full cost of that care even though it is cheaper than that offered in a hospital; some patients need care that the private nursing homes cannot provide (though the nursing homes dispute that); hospitals are paid by the year, regardless of how many operations they perform, and since it’s cheaper to look after recovering patients than to operate on new ones, budget constraints encourage hospitals to block beds with cheaper patients.

Unblocking the system requires a few straightforward, though not necessarily simple, measures. Step-down care, whereby patients leave hospital after an operation and continue their recovery in a nursing home, has to be seen as an extension of their hospital treatment; and the bill must be met in full by the state or by the patients’ insurers.

It is cheaper than staying in hospital, so it makes sound economic sense for both.

In the short term, the Treatment Procurement Fund can acquire those beds. It has to make sense for the fund to enable treatment in Irish hospitals rather than exporting patients because of a lack of beds here. In the longer term, private nursing homes have to become a natural extension of hospital care, just as community care must be seen as a natural extension. They are both part of a patient’s treatment, and are more cost effective than using scarce and expensive hospital beds.

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