Researchers say private care in public hospitals institutionalises inequity

Disentangling and removing private care from public hospitals is essential to delivering universal healthcare in Ireland, researchers who advised the all-party committee that drew up the Sláintecare reforms have argued.

The Mapping the Pathways to Universal Healthcare team said the existence of private care in public hospitals institutionalised inequity in the public system.

“It means that people who can afford to pay privately or who have private health insurance can gain access to faster care in the public hospital system. This is particularly the case for access to out-patient appointments and elective care in public hospitals.”

The group said emergency departments were the one part of the public hospital system where money did not allow patients to skip the queue as in general those who presented there were treated solely on the basis of need.

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Mapping the Pathways to Universal Healthcare is a research project which was funded by the Health Research Board running from October 2014-October 2017. The team is led by Dr Steve Thomas, director of the centre for health policy and management at Trinity College Dublin. Academic and journalist Dr Sara Burke is the project co-ordinator. For six months to May 2017, the research team worked with the Oireachtas committee which produced the Sláintecare report.

There is no data to determine if the total cost of private care in public hospitals is fully covered by private fees

In a submission to the expert group examining the implications of the recommendation in the Sláintecare report to separate private care from public hospitals, the Pathways group said there was an economic incentive in the public hospital system to treat private patients. It said consultants and hospitals were paid a fee for every private patient seen and a capitation grant for all public patients no matter how many or how few were treated.

Wait longer

The group argued that the financial dependency of public hospitals on private insurance income resulted in poorer access and quality of care for public patients, who had to wait longer for care and receive less consultant-provided care as consultants were providing treatment for private patients on or off site.

“If one can afford to pay privately one can go see a consultant as a private out-patient, often in rooms on-site in the public hospital or off-site beside the public hospital, and then can be referred into the public hospital for care where the same consultant may also work. This allows people to skip the often-long waits for public out-patient appointments.”

The group said that although in theory there was a common waiting list for treatment in Irish public hospitals, “the incentives in place and the embedded nature of the public and private mix means, in effect, private patients are often privileged over public ones within the public hospital system”.

“For example, one is more likely to be seen by a consultant if one is a private patient, and more likely to be treated by a more junior doctor if a public patient.

Private fees

“While consultants are paid a fee for each private patient seen in a public hospital and hospitals are paid a set rate per night for treatment, there is no data to determine if the total cost of private care in public hospitals is fully covered by private fees.

“There is only data available to quantify the actual income received by hospitals from private insurance companies. There is no public record of the private income of publicly-paid consultants working in public hospitals.

Neither is there any tracking of whether consultants meet their public hospital work commitments under the 2008 contract. In December 2017, senior Department of Health officials acknowledged the absence of compliance with contracts, and the failure of the HSE to effectively monitor and enforce compliance."