There’s only room for short-termism in health politics
Published 06/06/2015 | 02:30
If you fail to plan, you are planning to fail. Benjamin Franklin's quote aptly describes current Irish health policy. There's an identity crisis in our national health services. At every level of clinical care, intrinsic confusion exists as to the ultimate model of delivering treatment. Contradictions also abound as to the fundamentals of health policy. Fine Gael and Labour's Programme for Government promised Universal Health Insurance (UHI) by 2019 to end 'two-tier' health care, whereby public patients received a lesser, slower service and private patients could queue-jump into fast-track quality treatment. The idea was to achieve equality of access through uniform health cover, with the State paying premiums for those who couldn't afford it.
Eventually, a White Paper established guesstimate costs to be €920 per person - a couple with two children facing additional annual stealth tax of €3,680. But there were no answers as to who employs 97,000 health staff when the HSE was abolished. UHI would exclude mental health/disability services, ambulance network, long-stay residential care and other unspecified core facilities.
Leo Varadkar ditched these UHI commitments, after James Reilly's removal. The proposals were long-fingered and quietly shelved in the face of Department of Finance/Public Expenditure scepticism. Yet its ultimate abandonment creates new problems. What will replace it? A mix of public and private healthcare, or what?
The only concrete decision is the introduction of Lifetime Community Rating for private health insurance. This created annual incremental 2pc surcharges for people over 34 years who hadn't personal private cover. State policy is to ensure two million people have private insurance; while two million medical card holders are entitled to virtually everything free. But seemingly it's not State policy to have a dual system of public and private healthcare delivery. The principles behind universal free GP care is the effective nationalisation into State employment of every GP. Starting with those over 70 years and under six years, everyone is to be eligible for free care - eliminating private patients and revenue.
At hospital level, there's no clarity on the future of private hospitals. Currently we have 20 independent hospitals, accounting for 28pc of the overall acute hospital sector. This includes 2,500 out of 21,000 available hospital beds; 400,000 out of two million in-patient treatments. Facilities such as Bon Secours, Blackrock Clinic, Mater Private, St Vincent's Private Hospital, Hermitage, Sports Clinic Santry and Beacon hospital - they account for a gross €1bn of health expenditures (including €250m for consultants' private work) from health insurers. An ad hoc stop-go policy exists as regards the National Treatment Purchase Fund. When waiting lists become intolerable for public patients, tranches of treatments are tendered, without annual continuity.
HSE bosses and public health trade unions oppose fund diversion through outsourcing, as it takes from total fixed cost annual expenditures to public facilities. This approach has logic; based on adoption of the British model, where the NHS is the sole uniform provider of monopoly health services, free to all, funded through direct central taxation. This means every hospital consultant works exclusively in the public sector - no private patients, no extra revenue beyond State contracts of employment. If we're heading in that direction, why would we still want two million people to take out private health insurance cover? It's no coincidence that 400 hospital consultant posts remain unfilled when there's no clarity as to what the future holds for top clinicians.
Health debates focus on the politics of the latest crisis: thus we saw an extra 2015 budget bailout of €680m; there were Hiqa systemic criticisms of maternity hospitals; the Fair Deal funding crisis, with patient contributions of €234 per week from 22,000 participants while average costs exceed €1,000 per week, yet a comprehensive review report is still awaited since 2012; trolley crises of routinely more than 400 patients in emergency departments without a bed; patient safety concerns with 400,000 people awaiting outpatient appointments, with further 67,000 queuing for surgery admissions - some waiting 15 months; and the highest drug prices in Europe.
Population growth pressures (4.6 to 5.2 million) are set to exacerbate the post-austerity period; which meant Department of Health/HSE cutbacks of €3bn or 20pc and reduction of 10,000 employees. Sadly, the politics of health excludes long-term vision, and amounts to fighting bush fires.
Mary Harney proposed, back in 2005, a national "co-location" hospital plan. The idea was to convert 1,000 private beds in public hospitals into public facilities; while attracting external commercial investment into providing extra capacity of adjoining solely private hospital sites. This would've been an instant quick fix of more public beds. Sites were chosen at Beaumont, Cork University, Limerick, St James's, Sligo and Waterford. James Reilly made his reputation in opposing this blueprint on ideological, ethical and practical grounds. Now we've neither sufficient public nor private hospital investment to meet patient needs. Instead we've a policy lacuna, devoid of clear-cut long-term thinking or hybrid model options. We don't even know if the proposed seven consolidated hospital groups will become nationalised unit trusts.
Fianna Fáil's recent health policy proposes populist measures such as the abolition of the €2.50 prescription charge, reducing thresholds for Drug Payment Schemes to €120 a month, 5,000 extra homecare packages, 500 additional therapists. However, there is no over-arching template.
Kathleen Lynch and Labour don't articulate a health structure beyond a need to restore resources ahead of this year's €13.5bn. Meanwhile, Leo Varadkar can't wait to get out of Health and into Finance. His priority is mere stabilisation.
Enda doesn't want to hear of health issues on doorsteps after the medical card fiasco last year.
The future of private medicine in Ireland remains a mystery. Combinations of world-class excellence in clinical standards and adequate public treatment capacity require a considered two-tier approach, with equitable access. Sadly politicians don't think beyond the next election.