Important qualitative measures risk being cut out of the healthcare equation, writes Prof Orla Hardiman.
Irish people aspire to the provision of a health service that is equitable and accessible, and there is a growing perception that the disappointing performance in health over the past few years, despite increased investment, is due to bad management, vested interests and a general waste of resources.
There is no doubt that reform is required to reflect the changing demographics and evolving health problems of an ageing population. Our public health service does not serve the needs of our citizens as it should. This is not because of a "black hole", but because we are working at the limits of our capacity within a system that has been seriously underfunded in the past, and that was originally designed for a smaller population with different types of health problems.
The complex problems in our public health system have been compounded by administrative changes that have yet to consolidate. The HSE, comprising a combination of the former regional health boards and other bodies, is still evolving and currently functions as an opaque and labyrinthine bureaucracy. Add to this the enforced public service employment ceiling, which effectively prohibits new recruitment within the sector, and the portrayal of public hospitals by the media as dangerous and unhygienic, and we have all the ingredients for a major crisis of confidence.
Most healthcare professionals, working under tremendous pressure at the front line in an often hostile environment, feel misunderstood, disconnected and alienated from the management process which they feel should be supporting them.
And yet despite the difficulties with access experienced by patients and healthcare professionals alike, the overall quality of clinical service within the public health system remains of a very high standard.
It is not surprising that under these circumstances there has been a serious loss of confidence in the public health sector in Ireland. The private sector is marketed as being cleaner, more efficient, more "user friendly" and more accessible to those who can afford to pay. As a result, there has been a move towards the purchase of private health insurance in the belief that healthcare needs can be met by the private sector, comfortably bypassing the perceived chaos within the public system.
But while it is true that private health insurance can speed up access to services, there is no evidence that the private sector can deliver superior clinical care across the entire spectrum of health - indeed there is considerable international evidence to suggest that the quality of clinical care is generally better and more cost-effective in public not-for-profit hospitals.
The loss of confidence and breakdown of trust within the public sector is now extremely serious. Attempts by clinicians to emphasise the need to protect the quality of clinical care within the public sector are now seen as a cynical expression of vested interests. The resulting exclusion of those with clinical expertise from the management process within the HSE means that important qualitative measures that are clinically driven are at grave risk of being cut out of the healthcare equation.
This shift towards exclusive quantitative financial-based measurement is reflected in the view that the HSE takes of its role in delivering care. Rather than a healthcare provider, the HSE now views itself as a purchaser of healthcare services.
As there is an effective embargo on public sector employment, the HSE can justifiably purchase clinical services from the myriad of new "for-profit" providers within the private sector, if the price is right. There is an obvious benefit to the HSE as it can avoid taking on the added risks and burdens of extra public sector salaries, and it can avoid issues of clinical governance and accountability by shifting the responsibility on to the franchised agency. In this scenario, there appears to be little appetite within the HSE to establish a meaningful dialogue around qualitative measures such as clinical excellence.
This repositioning of the HSE has occurred in the context of an overall shift in health policy towards "for profit" privatisation. Generous tax breaks have been provided to encourage the development of private hospitals. Yet there has been little debate, and no White Paper that outlines the risks and benefits of an expanded role for for-profit private medicine to our society and its citizens.
Furthermore, for-profit healthcare differs from the relatively uncomplicated non-emergency care in a not-for-profit setting provided by the religious orders in the past. For-profit healthcare has a corporate structure and ethos. There is a primary responsibility to investors and shareholders. In a for-profit environment, healthcare is measured in terms of a pre-defined and expected clinical outcome, from which a profit margin can be generated. The juxtaposing of a financial incentive against a defined clinical outcome has a clear potential to put quality at risk.
However, from the perspective of the HSE this conflict does not seem to register. The track record to date of purchasing from the private sector has been poor. We need to look no further than the scandal of the Leas Cross private nursing home, and the recent outsourcing of cervical smear screening to a laboratory in the US that uses a different grading system. This led to serious difficulties in clinical interpretation by general practitioners counselling their patients. The qualitative implications of this outsourcing had not been anticipated in advance by the HSE.
The downgrading of qualitative clinical metrics, coupled with the introduction of for-profit privatisation, raises legitimate concerns about the entire future of our public service. First, there is the very real worry that public funds will be used to purchase expensive for-profit private healthcare instead of building capacity within the public sector. The introduction of Hospital in the Home and co-located for-profit private hospitals are good examples. Starved of necessary funding, the quality of care within the public system will inevitably deteriorate.
Second, the introduction of for-profit healthcare will increase costs for users. Private patients are required to pay the full economic cost of private care, which will include a profit margin, accounting, marketing and administration charges. While this may reflect a policy of a low-tax environment (to shift the cost from the public purse to the private individual), it is likely that, over time, a scenario similar to that in the US will prevail, in which those without health insurance are inadequately treated, and those with insurance will pay exorbitantly high premiums for care .
Third, in the absence of clear processes of clinical and financial accountability, the qualitative clinical metric will be further devalued in a for-profit environment.
Irish people want a choice, and the private sector is equipped to offer alternative treatment with better hotel facilities for some types of illness. But the private sector must grow in the context of a robust and well developed public system that is equitable and quality-driven, and the imperative for clinical excellence must be actively sustained.
Both the public and private sectors must be encouraged to establish meaningful outcome measures for clinical activity so that metrics incorporating "value for money" include a qualitative component that is equally valued. In order to achieve this, the HSE must take responsibility for the quality of what it purchases, be it public or private.
And because qualitative metrics require clinical expertise, the HSE must engage with healthcare professionals and patient advocates to develop appropriate outcome measures that reflect the totality of healthcare in all its complexities.
Prof Orla Hardiman is a consultant neurologist at Beaumont Hospital, Dublin.