South east stand off symptomatic of public private mix
On Thursday’s Morning Ireland programme, there was a very public stand-off between the HSE and Whitfield Cancer Centre (run by UPMC) in a row over radiotherapy services in the south east. UPMC threatened to withdraw radiotherapy services for cancer patients in the South East from 1 May next. This spat was a very public manifestation of the mess that is Ireland’s public and private mix of healthcare. In a statement issued later in the day, both sides said they were back in discussions with the hope of “resolving outstanding contractual issues”. So what was this all about? It is an unusual way to do business to have to go on the national airwaves to express disgruntlement with a contractual process and at the same time threaten to withdraw services for cancer patients. Especially when agreement now seems imminent. At the heart of this issue is money. And poor communications.
Since 2007, Whitfield Cancer Centre, which is a privately for profit facility in Waterford beside Whitfield hospital, has been contracted by the HSE to provide radiotherapy treatment for people in the south east. And the row is over how much the HSE will pay them for providing that service. Up to 2007, cancer patients from the South East had to travel to Dublin or Cork for treatment. So getting radiotherapy treatment in the Whitfield Cancer Centre has greatly improved the quality of life of cancer patients from the south east.
Radiotherapy treatment usually takes just a short time – 10/20 minutes or so – and often on consecutive days for a number of weeks so having to travel for 4 to 6 hours for 10 minutes treatment was very inconvenient. Public patients have to travel up til then as there are no public radiotherapy facilities in the south east. Whitfield saw the gap in the market and moved there. Whitfield was the first location for UPMC – University of Pittsburgh Medical Centre – in Ireland. UPMC is also the majority stakeholder in Beacon Hospital.
Whitfield main work is radiotherapy and last year it provided it to about 800 patients, 3/4 s of whom were public patients, whom the HSE pays Whitfield to treat. There are two main types of radiotherapy – the older, conventional beam therapy and a newer, more sensitive IMRT – Intensity Modulated Radio Therapy – which is usually used to treat more sensitive areas, such as the pancreas, brain, neck etc..
The row seems messy and dirty and what actually was going on depends who you ask, but it does seem that there have been poor relations between HSE and Whitfield, and allegations of delayed payments to Whitfield from the HSE. But essentially, this stand off was down to money. The conventional treatment costs about €200 a dose but there is disagreement between the sides as to how much should be paid for the more high tech IMRT. And agreement has not been reached on that.
UPMC is an American company, operating in a country where healthcare is largely for profit driven. Radiology is one of the most profitable aspects of healthcare. Its start up costs are high but once you have the right machines and people in place, it can be very profitable. What an American for-profit hospital would charge for IMRT is very different to what a French or Canadian hospital charges where there is no profit to be made.
The HSE don’t want to pay double or more than the price of the conventional treatment for this newer, more high tech treatment and is looking for the best value for public money so that more patients can be treated whereas Whitfield Cancer Centre is looking for what it expected to get (which apparently was more than double the conventional rate). Up to now this was not specified in the service agreements, but a deal was done on all payments up to December 2009. The issue now is what the HSE will pay for treatments from 1 January this year.
The HSE contract is important to Whitfield. Given that over 75% of the patients treated are public patients then 75% of its income comes from public money. There are plans to build a public radiotherapy facility in Waterford, but they will not be in place til 2014.
What is most interesting about this story is it demonstrates the complexity and competing interests of the public and private mix of care in Ireland. Since 2000, there have been a raft of reports from expert groups and independent advisors on how many public radiotherapy facilities there should be in Ireland and where they should be. The first report in 2003 had no facilities in south east, mid west and north west and after much protest, the government agreed to provide services in Waterford and Limerick. The original plan was that all units would be completed by 2011 but now the timeline is that they will not be in place until 2014.
Putting radiotherapy services in place in Ireland was very slow between 2000 and 2005. Since 2005 Mary Harney and subsequently since 2007 Tom Keane speeded up the roll out of radiotherapy treatment. Two more units will open this year in St James and Beaumont, the one in Waterford is planned to be in place by 2014.
But its been slow and in the meantime private facilities have opened. Many of these private facilities (although not Whitfield Cancer Centre) were built with private developers using government tax breaks. So on one hand, government was planning to develop public facilities but while this took time, the government was also giving tax breaks to private developers to build private hospitals where private radiotherapy treatment is provided. As a result, we will have an over supply of radiotherapy facilities in Ireland.
In the meantime, cancer patients are being used as pawns in a stand off between the HSE and private providers – another fine mess…