Constantin Gurdgievsays YES, that co-location will benefit both public and private patients, while Fergus O'Ferrall says NO, that co-location will embed unfairness, cost more and undermine medical professionalism
YES: Constantin Gurdgiev says co-location will benefit both public and private patients
The acute shortage of beds in our hospitals simply cannot be addressed in a cost-effective manner without direct participation from the private sector. It might be a fine philosophical argument to say that healthcare is so morally paramount to any society that the State should deliver new beds at any cost. In reality, the State is the Irish taxpayer and taxpayers have limited resources and finite patience. During the last elections, not a single party delivered a viable and more efficient alternative to co-location as the means for freeing up existent facilities to allow for the admission of more patients.
It took the HSE a year and a half just to solicit bids from private investors. Given this abysmally low speed of our State bureaucracy, can anyone wonder why taxpayers have little belief in the public system? Our existent system of publicly-funded hospitals operates private wards which are off-limits for public patients. At the same time, in many cases private and semi-private patients are being forced by the lack of beds and basic lack of managerial competency to occupy public facilities. In effect, from the point of view of both types of patients, the current system does not supply reliable and accountable services. The result - a double standard of unfairness and inequity in our public wards.
The first arises because, despite the fact that public beds are subsidised by the State, some of these beds are not available to public patients. The inequity arises because private and semi-private patients, having paid twice for the same care through their taxes and medical insurance, are often given no premium over and above public patients in terms of treatment. This, in effect, is a form of double charging the patient - a classic example of income-based discrimination that would be unimaginable in the private sector.
The co-location system will resolve both problems by assuring that all public hospitals beds will be reserved exclusively for public patients. This is not about providing a lower level of care for public patients. The entire issue of improving public hospitals' standards of care can and should be addressed independently by the Government with no conflict with co-location policy.
Although the private-to-public bed ratio is typically 20 per cent, private activity in public hospitals today can take up nearly 40 per cent of public ward capacity. Such private case-loads effectively prevent improvements in the standards of care in public wards by simply crowding out investment, and professional and management capacity. Co-location will entirely remove these obstacles to delivering higher quality of services for public patients.
In terms of simply increasing the number of beds available to public patients, co-location will be able to free at least 20 per cent of existent beds capacity within public wards, plus all wards currently designated as private. Effectively, to deliver the same results via public investment would cost the exchequer in excess of €3 billion and would take at least five years - time that many patients awaiting treatment today simply do not have.
In addition, through supporting more direct competition between hospitals, co-location can allow for better and more efficient public purchasing of private service alternatives, as in the case of the National Treatment Purchase Fund. Effectively, the NTPF is yielding significant improvements in the quality and availability of services already. It also introduces much-needed competition into this State-monopolised sector, with a resultant reorientation of the health providers back towards the needs of patients.
However, the NTPF's scope to deliver much-needed services is severely restricted by the shortage of funding. Currently less than 2 per cent of public health spending goes to buy these vital and competitively supplied services. By reducing public services inefficiencies and freeing beds, personnel and management, co-location promises to deliver significant cost savings to public health providers.
Some of our politicians and commentators are very quick to label patients with private insurance as the rich folks out to get an unfair advantage. In reality more than half of the residents of this State hold private insurance. They include tens of thousands of families with modest means. Effectively it is the fear of substandard services and attitudes from the public hospitals that drives Irish middle class patients toward purchasing private insurance.
Ironically, far from being favoured by our healthcare system, private patients are often discriminated against in our leading hospitals. Take, for example, the case of cancer patients awaiting chemotherapy in St Vincent's Private Hospital, where waiting times for treatment are longer than in the public ward. In Beaumont, some neurological procedures (including those relating to treatment of multiple sclerosis and motor neuron disease) have longer private waiting lists, with public patients clearly at an advantage.
Overall, co-location will offer a possibility to resolve the problem of under-provision of services to those who pay more, while enhancing our society's ability to offer better care to those patients who cannot afford supplementary insurance. It is neither a "privatisation" of healthcare nor a pure form of market economics.
Dr Constantin Gurdgiev is economist and group editor, Business & Finance Publications
NO: Fergus O'Ferrall says co-location will embed unfairness, cost more and undermine medical professionalism
Ambrose Bierce in The Devil's Dictionary cynically defined politics as "the conduct of public affairs for private advantage". Co-located private hospitals may be defined as the conduct of healthcare for private advantage. Prof Brendan Drumm, chief executive of the Health Service Executive, consistently appears to distance the HSE from such hospitals. Last week he stated that once the public sites were handed over for the proper economic payments "it really has nothing to do with us . . ." Sadly, however, patients and taxpayers will have to live with the negative consequences of private co-located hospitals - as will, I believe, the HSE.
These proposed hospitals pose a range of significant threats to the Irish public healthcare system, including: embedding unequal and unfair treatment in respect of hospital care; raising health costs for taxpayers and patients; undermining medical professionalism and creating poorer health outcomes for patients.
Our current hospital system is unfair in that its "two-tier" structure gives quicker access and better care to those who use the private system. Co-located hospitals will further entrench this unjust system when, instead, we should be moving to end it by creating a unified hospital system providing universal access based on medical need, not income. This is commonplace in many European countries and is provided either through taxation or social health insurance.
Co-located private hospitals are the most expensive way to provide extra bed capacity. During the general election campaign it emerged that the tax breaks to private investors will cost the State about €500 million over seven years; the income lost to public hospitals will be about €700 million over the same period, giving an estimated total cost of €1.2 billion. Clearly, such loss of revenue has important implications for all of us - including the HSE.
In addition will come the ongoing cost to the taxpayer of funding the National Treatment Purchase Fund to "purchase" treatment for public patients from these co-located private hospitals. In effect, the proposed model is based on the premise that these private hospitals can rely on the fact that there will continue to be public patients for whom treatment will have to be purchased at an agreed price.
In other words, the model implicitly assumes that there will continue to be lengthy waiting lists for public patients: it will therefore act as an incentive to ensure that the public hospital capacity will not be adequately developed, since to do so would result in the disappearance of an assured stream of revenue for the private co-located hospitals. Complex cases and chronically ill patients will be left to the public hospital system as they are not profitable to treat.
Furthermore, private patients are to be asked to pay the full economic cost of their care in the co-located private hospital: this means an increase of 40 per cent, at least, in their current private health insurance. It is well established in healthcare research that private hospitals are more costly than not-for-profit hospitals. Hence, leading health economists such as Prof Dale Tussing are advising that it would be more cost-effective to invest in public hospitals where the kinds of beds required can be properly planned and integrated into our hospital system.
Co-located private hospitals will further the current perverse incentives provided for our doctors in our two-tier system. The Medical Council has issued a clear ethical warning to doctors who have a financial interest in a private hospital to which they refer patients: they have a duty to declare such an interest to patients. The council states: "Such doctors must take exceptional care to prevent their financial interests influencing their management of patients." It is significant that Dr John Hillary, outgoing president of the Medical Council, has stated that the co-location plans are "open to abuse".
Other highly respected doctors, such as Prof Ristéard Mulcahy, have warned publicly of the corrosive effect of for-profit medicine on doctors' professional ethos. The recent history of vast fraud and maladministration by investor-owned hospitals in the United States adds great weight to these concerns. Some of these investor-owned groups now operate in Ireland and, given the even less robust Irish system of regulation and clinical audit, the pitfalls for patients and temptations for doctors will be great indeed.
There is very worrying evidence in leading journals, such as the New England Journal of Medicine, that the outcomes of treatment in private for-profit hospitals compare unfavourably with those of not-for-profit hospitals. Why should for-profit medicine be different in Ireland?
Co-located private hospitals are based upon a myth that management of investor-owned private hospitals is by that very fact more efficient than management of the same activity by public hospitals. The myth lacks empirical support - indeed the research shows the very opposite. Why do we not base our hospital planning upon the best evidence available?
Dr Fergus O'Ferrall is director of The Adelaide Hospital Society and co-author of a policy paper, published jointly with the Jesuit Centre for Faith and Justice: The Irish Health Service - Vision, Values, Reality, which is available at www.adelaide.ie or www.cfj.ie
Last week, Mary O'Leary and Donal Buckley debated the question: do we need incinerators to solve Ireland's waste problem? Here is an edited version of some of your comments:
There is no question that incinerators, no matter how they are run, are extremely dangerous for human health and will have a negative impact on the environment, as well as on the emission of CO2 gases. The answer to the problem of waste is prevention, and that includes the polluter pays principle, ie, first helping businesses to change their ways so that they remove toxic and non-toxic waste materials from their products, and fining them if they do not. This is exactly what governments have been afraid to do due to the influence of big business and groups like Ibec, who are certainly not impartial in this debate. - Tadhg, Ireland
"Mary O'Leary says mass incineration is unsafe and wasteful and that there are viable alternatives" - so went the blurb on her article. Ms O'Leary then bleated on about reports that say we need to make room for other technologies, management of waste, reducing reusing and recycling. Then there is the use of all the cliches now associated with this area, ie, carbon footprints, CO2 emissions etc etc. I was waiting with anticipation to read of the viable alternatives and what they would do for our waste difficulties. Surprisingly - or maybe not - these alternatives were not outlined with any degree of clarity. A report recommended mechanical and biological treatments on a smaller scale! Is that it? It is not good enough to say no all the time and not offer a worked out alternative. - Eamon, Ireland
Incineration is dangerous; build an incinerator and you build a monster that needs to be fed. Part of the initial agreement is an agreement on the volume of waste to be produced; therefore you need to reach waste targets in order to fulfil indentures to the agreement. Effectively, they create an incentive to waste. Incinerators also create dioxins: even if they have filters on them there is no 100 per cent absence of risk that these will not be released in the environment. Dioxins are Group 1 carcinogens. The answer? Recycle more, produce less waste. - Mary Davey, Ireland
The countries we admire for their recycling and clean environments such as Sweden and Denmark also have incinerators. They don't stick their heads in the sand and claim everything can be recycled. What happens to all our waste from our hospitals? It is exported or dumped in some field illegally. To me a sign of a civilised country is one that can deal responsibly with all its waste. At the moment Ireland has a long way to go. - Irene, Ireland
The attitude of most people in this country to waste scares me, as they complain bitterly about the price of waste collection, yet these are the very same people that don't want incinerators. The days of landfill are coming to an end in this country, so while we should all strive to recycle as much as is humanly possible, there is always going to be waste that cannot be recycled. - "Fatboy Slim", Ireland
Yes, incinerators are required and are a necessary component of an integrated solution for Ireland's waste management issues. Britain, France, Belgium, Holland, Germany, Denmark, Finland, Austria, Switzerland, Sweden, Norway, Italy, Spain and Portugal all have municipal waste incineration as part of their waste management strategies. The World Health Organisation has recognised that modern incinerators, operating to the most exacting standards with state-of-the-art technology, pose no threat to human health. - Richard Coffey, Ireland
In response to Mary O'Leary: it is true that we cannot keep pumping extra tonnes of CO2 into the atmosphere. This is why Ireland needs to move away from landfill. Biodegradable waste when disposed of in landfill generates methane, which is a greenhouse gas 21 times stronger than CO2. In an incinerator, this waste generates CO2. According to the European Union and the International Panel for Climate Change (IPCC), CO2 emissions from biodegradable waste do not contribute to the greenhouse effect. This is because biodegradable waste is renewable. As such, overall greenhouse gas emissions from landfill are three times higher than emissions from incinerators. Incinerators are also extremely efficient at generating energy from waste. As most of this energy is renewable, it can make a positive contribution to greenhouse gas reduction by replacing energy from fossil fuels like coal and gas. - Jackie Keaney, Ireland
join the debate @ www.ireland.com/head2head