How can we provide social and equitable health care for all if "for profit" nitiatives become an increasing part of our health service? asks Orla Hardiman
The 2006 Euro Health Consumer Index published last week reports Ireland as having one of the worst health services in Europe. One of the factors that contributes to our ranking of 24 out of 25 countries is our collective ambivalence about our public service.
In Ireland, we struggle with how best to provide high quality health service at a reasonable price and in an equitable manner, yet we have not enunciated clear policies as to how to achieve this. Do we follow Boston or Berlin or, in the case of the health survey, Paris?
At present, we seem to be veering towards Boston. We encourage privately-funded health care that can then be harnessed to support the beleaguered public health services. This is evidenced by the inception, funding and publicising of the successes of the National Treatment Purchase Fund.
However, it is also a widely held view among health practitioners that the treatment purchase fund is an expensive solution to a problem that should be tackled by direct investment within the public sector.
The treatment purchase fund provides funding for public operations within the private sector, but many of the doctors involved also work in the public sector, and could have performed these operations in the public hospital if resources had been made available.
Instead they receive extra remuneration to perform these operations in the private sector.
People with non-surgical problems (comprising up to 80 per cent of all A&E admissions) are not eligible for services within the treatment purchase fund.
In Boston, healthcare is privately funded by "for profit" healthcare agencies. In Ireland there is a view that the Department of Health is willing to facilitate and promote the introduction of large "for profit" health care conglomerates which will collaborate and compete with the public health system, often using the same clinicians who are employed within the public sector.
There seems to be little concern that such an initiative exacerbates the existing conflicts of interest within the medical profession, and reduces the quality of care provided within the public system, while financially rewarding those with public contracts who are also engaged with new clinics and hospitals.
"For profit" initiatives are now being openly discussed by some senior clinicians holding public consultant contracts. The Beacon Clinic in Sandyford in Dublin is being held as a potentially successful example of a private sector initiative, which is also planning to draw public patients by contracting with the public sector.
There may be some short-term merit to such a partnership, but the introduction of "for profit" ventures into a system that is organised along a model of providing social and equitable health care for all seems incongruous. Incorporating such a partnership into an overall plan that integrates the totality of care within our health service would be very difficult.
Ambivalence about how we should conduct the business of health care has been a feature of public policy for many years.
Ambivalence leads to misinformation. Rumours that the Department of Health may concede policy initiatives to the private sector are very damaging to the public health sector. There are major and justifiable concerns that partnership with "for profit" groups will lead to a decline in the ability of the public sector to provide high quality care. Clinicians with both public and private contracts will be conflicted. Public funding will be diverted towards the private partner, and integration of care between hospital and community services will suffer.
Treatments not having a "procedure" component will be devalued, as has been the case with the treatment purchase fund.
Ambivalence facilitates an environment whereby enterprising and entrepreneurial public hospital clinicians seek to capitalise on a situation of uncertainty and low morale within the public sector to justify their contracts with the private sector while retaining public contracts.
Ambivalence leads to frustrations within the public sector. Such frustrations drive people to acts of desperation in the belief that there is little alternative. The Irish hospital system is genuinely disorganised, inefficient and plagued by multiple layers of "street level bureaucracy" which make existing funding initiatives very difficult to implement in a streamlined way. These difficulties serve as justification for some to seek to utilise fully facilities in the private sector while retaining public sector contracts.
In Ireland, the tradition has been that health policy follows existing practice, rather than the other way around. We have been traditionally ambivalent about our health care.
Unless we seek to regulate the growth of "for profit" health care initiatives in some way, they will become part of the structure of our service, to the ultimate detriment of the health of the Irish population. As a matter of urgency, we must enunciate in clear terms how we want our health service to develop.
Our primary objective must be the provision of integrated care for all of our citizens.
If we are to facilitate the entry of multinational "for profit" health conglomerates into the provision of our health services, we must ask some hard questions:
- To what extent is the current health administration aware of the conflicts that engaging in private initiatives create for publicly funded consultants?
- Is there a policy shift that accepts "for profit" centres as part of the Irish medical landscape?
- Are we open to doing business with private multinational "for profit" health organisations, and if so, under what terms?
- Is there a strategic policy document that discusses the possible merits and pitfalls of such an engagement?
- To what extent will the rights of all Irish citizens to an effective and integrated health service be ensured, and how will such initiatives fit into future health strategy?
The Irish population is increasingly comfortably off, sophisticated and well educated. The Irish healthcare system should reflect this and provide a high quality equitable and accessible service for all.
"For profit" healthcare represents a radical departure from previously held policies, and the long-term implications of accepting such a shift must be carefully analysed. In the absence of well defined policy on the growing role of the "for profit" sector in Irish health care, our health services will continue to under-provide in comparison to our European peers.
Orla Hardiman is a consultant neurologist at Beaumont Hospital