Apartheid nature of our health system must end
This article appeared in the Irish Times on Saturday 27 June 2009
ANALYSIS: The Irish healthcare system is unique in Europe in that private care is given in public facilities and those with money can queue jump and obtain earlier and better treatment, writes SARA BURKE .
IN THE decade when we had most, when the economy was booming, when we quadrupled our spending on public health services, Ireland’s political leaders failed spectacularly to reform the fundamental injustice that is at the core of the Irish health system.
For the past 10 years, an awful lot of time, energy and money went into “reforming” and restructuring the health services, nonetheless politicians and health planners choose to retain the two-tiered system of public hospital care, which gives private patients privileges over public patients.
History has taught us clearly that inequality is core to the Irish model of healthcare. It has also showed us that our unique, complicated, unfair system of care results in unequal experiences and outcomes for different sections of the population, benefiting those with more money over those with less.
There have been many recent developments in Irish health services: the establishment of the HSE; the reconfiguration of hospital services; an increased emphasis on primary care (in rhetoric, if not in action); the new, expensive consultants contract; the silent but very momentous privatisation of many aspects of the public health care system.
All these were introduced while allowing the apartheid nature of public hospital care to persist. Put simply, if you can afford to pay privately, you can get into public hospitals quicker than public patients and you may then receive treatment more quickly. Also, if you are a private patient, you are guaranteed consultant provided care and may be in a single or semi-private room.
If you are a public patient, you are more likely to be cared for by a junior doctor and to stay in a multi-bed ward.
While all European healthcare systems have aspects of public and private care, what is unique to Ireland is that we provide the private care in the public hospital system and the cost of the care of those private patients (who are allowed to skip the queue ahead of public patients) is largely subsidised by public money. Not only does it not make any sense, it is simply wrong.
Healthcare services are often privatised under the auspices of reducing cost. Interestingly, there is an increasing body of international evidence showing that private, for-profit healthcare is not more efficient, and often it can be more expensive, because of high administration costs and the need to reap profits. There is no evidence of better quality health outcomes for patients treated by private providers and in many instances the opposite is found.
There have been various attempts to provide a level playing field for public and private patients in Irish public hospitals: limiting private beds in the public hospital to 20 per cent of the total; the new consultants contract and the introduction of a common waiting list.
However, these measures fail to address the core inequality. As long as doctors and hospitals are paid differently for public and private patients, as long as the two-tier system remains, private patients will continue to be privileged over public patients.
Only when we decide to have a one-tiered, universal public health system, where access is solely determined by need, not ability to pay, will we have a level playing field for all Irish citizens.
In the early years of the 21st century, ministers of health were busy publishing strategy after strategy for reform, mandarins in the Department of Health were preoccupied with decisions as where to draw geographical boundaries, private management consultancy firms were making recommendations on reorganising health services. Simultaneously, a swift and hushed privatisation of key aspects of the public health system was being led from the highest ministerial offices in the land.
Two small changes to the Finance Acts in 2001 and 2002 by then minister Charlie McCreevy incentivised and gave tax breaks for for-profit hospitals and nursing homes. In 2002, the National Treatment Purchase Fund was established.
In 2005, Minister for Health Mary Harney heralded the co-location project. Under co-location, developers are to build private for-profit hospitals on the grounds of public hospitals and supposedly free up 1,000 public hospital beds. In 2008, the future of the primary care strategy became dependent on public-private partnerships to build the primary care centres promised since 2001.
The unannounced, undebated changes to the Finance Act mean that eight years on in 2009, two out of every three nursing home beds are in the private sector, while one in three hospitals beds are in the private sector. In 1998, there were two private for-profit hospitals in Ireland. In 2008, there were 18 private for-profit hospitals and healthcare institutions with many more in the pipeline (although their viability now must be questionable). The vast majority of these private sector beds are now in the for-profit sector.
In 2008, the budget allocated to the National Treatment Purchase Fund was €100 million. This buys private care for public patients mostly in for-profit private hospitals (rather than attempting to resolve the causes of the delays in the public hospitals in the first place). During the last decade, large parts of less visible health services have shifted over to private, profitable providers. These include cleaning, catering, security, car parking, laboratory testing, to name but a few.
This seismic shift of care to the private sector has happened in an unplanned, unregulated and unmonitored way. Four years after the Primetime Investigates programme which exposed the institutional abuse older people resident in a private nursing home in north county Dublin, not one nursing home is independently inspected. The Health Information and Quality Authority (HIQA) which was set up to ensure standards and quality in the health system does not have a remit over private hospitals or other private healthcare institutions.
While public health structures, most notably the HSE and acute public hospitals are being centralised, in direct contrast to public health policy, Government incentivised private healthcare facilities to open up all over the country, irrespective of need or local public provision. Care in private healthcare institutions may be of a high standard but the simple fact is that we do not know because no State institution scrutinises them.
At its most benign, this increased, unplanned, unregulated privatisation of healthcare can be considered hugely irresponsible of our political leaders. At its most insidious, it could be considered sabotage of the very public health system they are meant to lead.
On a more positive note, we are living in extraordinary economic, political and social times. The heyday of the free market may have passed. The virtues of profit are being questioned. In times of less, principles of solidarity and fairness may carry more heed.
In healthcare, big choices need to be made. We can continue down the road we are on – of an increasingly divisive, privatised, two-tiered provision of healthcare which favours private patients over public patients. Or we can say stop, lets undo the damage done. And as citizens and patients we can demand and plan for the universal, quality, public health system to which we are all entitled. The choice is ours.
Sara Burke is a freelance journalist and health policy analyst. She is the author of Irish Apartheid – Healthcare Inequality in Ireland which was published this week by New Island. http://www.saraburke.com
© 2009 The Irish Times