YES says Gerard Bury. Private medicine can not be compared withpublic healthcare
The private healthcare industry in Ireland exploits and undermines the public health sector. But for its role, Ireland's healthcare structures might be a great deal better.
Private healthcare in Ireland is not a lean and efficient model to be explored and expanded. It is a highly selective, commercial enterprise devoted to selecting the least troublesome and most profitable healthcare interventions, without making any contribution to the broader health structures within which it exists.
The private health insurance industry benefits from many elements of the healthcare system, but makes little contribution in return, with the partial exceptions of psychiatry, obstetrics, and general practice which contribute significantly to education and training and provide limited data on their clinical activities.
The doctors, nurses and other professionals who work in private medicine have received virtually all of their undergraduate education and postgraduate training in the public sector. Conversely, almost none of our private hospitals trains nurses or doctors at undergraduate or postgraduate level.
Almost all public hospitals provide postgraduate training for doctors. These hospitals are repeatedly assessed by external bodies for accreditation purposes and must demonstrate high standards of practice. A handful of intern and initial specialist training posts exist in private hospitals - paltry by comparison with at least 2,000 medical training posts in the public sector.
The private hospital industry provides no data to the national Hospital In-Patient Enquiry system (HIPE), publishes no independent workload data, and protects its right to privacy on the grounds of commercial secrecy. The private hospital sector participates minimally in clinical audit, professional scrutiny, or external review.
While individual practitioners may achieve high standards whether they work in the public or private sector, it seems inevitable that private industry - without a culture of scrutiny - will succumb to the temptation to use financial parameters as the driving force for activity.
And the health insurance industry carefully selects the problems it deals with - most are episodic, interventional and costly. This approach maximises income but minimises outlay. The industry minimises the number of contacts between doctors and patients but maximises the numbers of diagnostic tests and surgical procedures.
"Case mix" is the mechanism used in the public sector to balance the types of work carried out by individual hospitals. This ensures a fair distribution of the burden of acute and chronic healthcare and of appropriate resources. Private hospitals are not subject to case mix.
Private medicine has escaped any responsibility for the problems of its clients which are not amenable to elective, planned - and costly - interventions. Examples include chronic illnesses, poorly defined presentations, or acute illness. If public hospitals were allowed operate on the same basis, they too would be models of organisation and calm - however, much real need would be unmet.
The public sector provides sophisticated care in areas which private healthcare deems too expensive, such as transplant surgery. Private healthcare does not support long-term nursing care or even extended hospitalisation for illness.
Apart from occasional TV or radio campaigns - which often have a subtle self-promotional context - the health insurance industry makes no contribution to prevention and health promotion. The burden of the complex public health medicine system falls on the public sector.
Private healthcare does not provide emergency care. For example, while coronary artery bypass grafting and angioplasty are promoted by the industry, thrombolysis (clot-busting therapy) for heart attack is not. Round-the-clock facilities to quickly diagnose and treat heart attacks are expensive to the provider - and therefore left to the public sector. A private healthcare industry which disowns responsibility for emergency medicine and acute medical care must ultimately subvert a public hospital system which struggles to meet the needs of an entire population. It does so by creating the illusion that these are comparable systems, one of which deals effectively and quickly with its consumers' needs, whereas the other is plagued by delay and inefficiency. However, like is not being compared with like.
Private medicine has been allowed to disown all responsibility for emergencies and acute care of the seriously ill, while at the same time drawing off the sophisticated interventions which often result from acute illnesses.
In the public sector, the critical mass of elective work which might allow regional public hospitals to function effectively may not be reached because of "cherrypicking" by the private sector. With 30-50 per cent more elective procedures, might some of our smaller hospitals now have a brighter future?
Public hospitals struggle to deal with acute emergencies, acute or chronic exacerbations of illness, the socially displaced and a considerable number of perceived health problems which could be better dealt with given more resources.
What contribution, then, should the health insurance industry be asked to make immediately?
It should contribute 10 per cent of its income for undergraduate and postgraduate training of health professionals. Health insurance organisations must provide a significant number of training places for medicine, nursing and other relevant professions.
It should engage with acute care. Private hospitals should meet case mix standards. The case mix profile should be analogous to that of adjacent general hospitals.
It must commit itself to the collection and submission of standardised data for publication.
Private hospitals should face accreditation by the Irish Health Services Accreditation Board.
In the long term, healthcare professionals should opt to work in either the public or private sectors. Currently, senior doctors may invidiously appear to reduce access to public services (through waiting lists) while at the same time making the same services available in the private sector to their own benefit. Such an obvious conflict of interest is incompatible with acceptable professional and commercial practice.
The examples above illustrate a wider range of issues which must be addressed urgently. The initial actions suggested are merely the first steps in correcting a situation, which if uncorrected, will continue to undermine efforts to provide the healthcare system which Ireland needs.