Monday 16 September 2019

Time to go back to basics after Universal Health Insurance blunder

Some 28,000 people wait more than six months for in-patient hospital admission; 80,000 people have been placed on trolleys because of a lack of hospital beds (Stock image)
Some 28,000 people wait more than six months for in-patient hospital admission; 80,000 people have been placed on trolleys because of a lack of hospital beds (Stock image)
Ivan Yates

Ivan Yates

I've told you so - ad nauseum, on umpteen occasions over the past six years. Universal Health Insurance (UHI) was a utopian pipe dream that could never work in Ireland.

It was a hopelessly flawed policy option, adopted by Fine Gael and Labour without proper research or understanding of the health service structures and services. Enda Kenny and Eamon Gilmore failed, both in government and in opposition, to stress-test the fundamental dynamics of cost or viability.

Even now, they are flailing around. Looking to a Canadian - rather than a Dutch - model of universal health reveals a limited understanding beyond the basic, negative cost implications put forward by the ESRI and KPMG.

Real damage can be done by taking an ideological approach to public healthcare provision. A singular state delivery model demands that everyone becomes a public patient. UHI is equally defective because it's based on the ideology that everyone becomes a private patient through mandatory health insurance. It all stems from a basic, incorrect assumption that a two-tier approach is what's really wrong in the first place. I would argue that choice and competition always achieve optimal results for consumers - and it's no different for patients.

UHI is wrong for us on a number of grounds. For one, so much healthcare pretty much constitutes an uninsurable risk - the exact costs of long-term residential care for the elderly and the disabled, or the mental health services, are hard to affix exact costs to.

Our private health insurance market of VHI, Laya, Glo and Aviva (now exiting the market, leaving only three players) do not appear to have been capable of driving cost efficiencies in state-run facilities, whereas they would reap huge profits in a captive market scenario. Some 97,000 HSE employees could not be readily re-employed by seven quangos. For example, some staff, like ambulance crews, can't be simply assigned centrally; a new regulatory industry of compulsory insurance to oversee UHI would only create another layer of unnecessary bureaucracy.

Even so, the Government still hasn't had the good grace to give UHI a decent burial. Vague notions of 'universality', that can somehow remove the inequities of unequal access to services, still hang in the air.

In primary care, politicians grabbed the populist bits of the policy where they could garner votes - starting with under-sixes, then over 70s, to be followed by under 18s, eventually everyone would get free GP care. Nationalising professional GPs as state employees will result in emigration and waiting times to see a doctor.

This policy is socially unjust - allowing the wealthiest families a taxpayer subsidy, while failing to allocate scarce resources for those who cannot afford to pay. We need to increase primary care expenditure from 3pc to an international norm of 10pc of total health spending to relieve pressure on hospitals, especially for diagnostic services. Developing a national infrastructure of primary care teams is different to free care for all. It's analogous to the difference between proper nutrition and lollipop politics.

The problem of waiting lists has been exacerbated by the political misadventure of UHI, threatening dislocation and disruption. We are left with more than 10,000 people waiting longer than a year for an outpatient appointment.

Some 28,000 people wait more than six months for in-patient hospital admission; 80,000 people have been placed on trolleys because of a lack of hospital beds.

The solution to more immediate access for treatment is extra capacity and a more efficient utilisation of beds. Hospital equipment can lie idle at weekends. We fail to implement a seven-day week work roster for employment contracts and work practices.

Funding for hospitals should be based on output - i.e. finance per treatment means a league table of accountability for elective treatments.

This rewards management and clinicians who achieve greater bed efficiency through shorter stays, streamlined discharges and day care treatments. It's bizarre that we still don't have electronic patient charts/records, resulting in the multiple repetition of expensive diagnostic tests. These modern management practices are the game changers for reduced waiting lists, not whether the hospital is private or publicly owned.

In 2013, we spent €19.2bn on healthcare, adding together taxpayer funds (73pc) and private healthcare insurance revenue. There are limits to public funding because of fiscal budgetary discipline. To increase capacity, we must attract investment from all sources into Irish healthcare. Non-governmental investment leads to higher standards of excellence in facilities and personnel. The cornerstone of policy should be a dual hybrid system. Demonising 'two-tier' health services got us into this current rudderless, leaderless mess.

A fundamental freedom of society is choice. If individuals or families opt to spend their own money on private education or extra hospital services, they should be free to do so - without taxpayer subsidy - provided it doesn't affect adequate minimum standards of public services. Policies that led to 250,000 people exiting voluntary private health insurance severely damaged quality, and the level of State healthcare and the total revenue for the entire health service was reduced.

Lifetime community rating (surcharging those over 34 for not taking out insurance) enticed 75,000 people. All measures that increase health expenditures increase capacity. Ideological rows about co-located hospitals and tax relief abolition for private health insurance actually result in restricting investment in health, undermining everyone's quality of care.

What should fill the policy lacuna following UHI abandonment? Firstly, acceptance that the HSE is here to stay. Its job is to provide minimal public health services with clear protocols of patient safety, along with using its purchasing power and scale to tackle vested interests, driving cost reductions and greater efficiency.

Secondly, complementary and parallel incentives to secure a thriving twin private health service that attracts the best clinicians, diagnostic equipment and future research.

We don't need to reinvent the wheel to ensure decent standards of healthcare.

Investment and insistence on efficiency are the hallmark of world-class standards.

Irish Independent

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