OPINION: Reform of hospitals a challenge

WHILE it sounds good in theory, the Sláintecare plan’s worthy ambition to remove private health care activity from public hospitals will be easier said than done and could prove a lot more costly to achieve than anticipated. The analysis of this in the report of an independent review group chaired by Dr Donal de Buitléir crunched the numbers and it will take millions upon millions to effect the complete separation of public and private hospital care, mainly because of the way in which the current system has developed over the years with the vast majority of consultants being able to do lucrative private work alongside their public healthcare obligations in acute public hospitals.

Dr de Buitléar, who is the acting director-general of the Institute of International and European Affairs, and a former member of the board of the Health Service Executive (HSE), recommends that public hospitals should be exclusively used for the treatment of public patients. This is the way it is done in most other countries where timely access to public health care is prioritised based on medical need rather than ability to pay and it is obvious that Ireland needs to bite the bullet and start working towards such a system, even if unravelling the current one will prove costly.

There is no point in putting it off much longer but in doing so, we need to get away from just throwing money at the health service, as heretofore, and ensure that the new set-up will provide value for money. Taking private care out of public hospitals, according to the report, will result in an annual loss of revenue of €600million to these hospitals, which will have to be made up some other way.

The biggest logistical problem will be with consultants’ contracts, as only a tiny fraction of them (169 out of more than 2,500) are on contracts that preclude them from doing private work in public hospitals. This means that the vast majority, who are allowed give private care to patients in public hospitals, would need to agree to change their contracts and this would involve hefty compensation.

Inevitably, not all would want to go into public health practice and would prefer to develop their private practices and, therefore, would be lost to the public healthcare system. They would still have to be compensated if their contracts are being terminated and it may not be easy to replace them given the recruitment and retention issues the HSE has had to cope with in recent years.

The de Buitléar report also recommends that all new consultants’ contracts for public hospitals would preclude private work. Just how attractive that would prove for such highly-qualified medical professionals remains to be seen, given that there are so many vacancies in our health system at the moment.

The report also recommends that the treatment of private patients in public hospitals should no longer be happening by the conclusion of the Sláintecare plan’s 10-year implementation period. This seems hugely ambition, especially given the difficulties that are likely to be encountered in unravelling the deeply-rooted practices in the way the two-tier system is currently operated, the number of contracts that need to be terminated or renegotiated, and the amount of financial compensation that will be needed.

At the moment, people who can afford to – or because they are afraid not to – have taken out private health insurance to ensure they won’t have to go on long public waiting lists for treatment if they need it. Most will switch away from it only when there is a reduction in waiting lists, which will take time, if they feel that medical need has trumped ability to access healthcare in a timely fashion.

This will have a knock-on effect on the private hospitals – through probably not for a very long time yet – and only if the necessary resources in terms of medical personnel and state-of-the-art equipment are invested in the public hospitals over the coming decade. This, theoretically, could level the playing field in terms of the availability of consultants in the public sector as their basic remuneration is on a par with that offered for similar roles in other countries.

But, it is not just about money; working conditions – which can be quite stressful given the shortages in staffing – are another bugbear for consultants. According to the Irish Medical Organisation (IMO), Ireland has the lowest rate of medical specialists per capita in the EU, with over 520 consultant posts currently not filled, and it contends that that there is no evidence that capacity will improve or that waiting lists will be alleviated by removing private care from public hospitals.

Having commissioned and received the report from the independent review group chaired by Dr de Buitléar, Minister for Health Simon Harris needs to seriously consider and act decisively on its recommendations, putting improved patient care and better value for taxpayers’ money at the top of his reform agenda to do away with our grossly unfair two-tier health system. This will provide a stern test of the government’s political will, but needs to be tackled once and for all.