Keep Private Practice in Public Hospitals Nov 2, 2018 -
J. A. McNamara
The proposal in the Slaintecare Report to incrementally take private practice out of public hospitals needs to be very carefully considered and debated to avoid unintended consequences that could lead to a destabilisation of the Irish hospital system.
There is no denying that there are difficulties in the delivery of hospital care in Ireland in relation to shortcomings in the transparent management of waiting lists and public concern at the manner in which capacity to pay (either through insurance or self-paying) oftentimes results in speedier access to care. This is an injustice that can and needs to be addressed by for example (i) improved implementation of the provisions of the consultant contract, (ii) greater transparency, (iii) the creation of common waiting lists for specialties and (iv) increased accountability on the part of hospital executive and clinical leadership.
There are many reasons as to why the answer is not to take private practice out of public hospitals as a means of addressing these problems of access and accountability.
In the first instance we must decide on what type of hospital system we want in Ireland. Do we want a system that is based on collegiality as is characteristic of European models of healthcare, or do we want to have a system such as in the United States, that is largely (and increasingly) based on an ability to pay? Irish people are not innately discriminatory and I do not believe that implementing a model of access to hospitals that will discriminate on the basis of capacity to pay, such as is proposed in Slaintecare, reflects the values of Irish people.
One of the key characteristics of the Irish hospital system is the access that non-insured patients get to consultant opinion because of the mixed public / private system that we have in public hospitals. We should nurture this universal access to specialist opinion and actively advocate for those in society who cannot afford health insurance and who will be all the poorer in terms of access in the event of private practice being taken out of public hospitals and with it the best of our consultant staff.
At present, the Irish hospital system recruits the very best consultant staff and we must do everything to maintain this differentiator in the public interest and in the interest of developing services in our hospitals to a standard that the public deserve. There is a very real probability that, over time, a restriction to generate private income in public hospitals will result in the best doctors migrating to private hospitals. That would be a serious impediment to the capacity of the Irish hospital system to achieve its potential through international collaborations for clinical trials, research and the delivery of high quality, safe care as measured against peer hospitals internationally.
There is also the practical issue of the cost of such a decision to the taxpayer. Public hospitals in Ireland currently generate c. €600m annually in income from private practice and obviously this level of funding will need to be compensated by the exchequer. In addition, hospital consultants by and large have a reasonable expectation of generating a level of private practice and there is every likelihood that claims will be made by their representative bodies for either an option for a change of contract to allow greater access to private hospitals or for monetary compensation for loss of private practice, both of which would have serious implications for our public hospitals.
One of the issues that deserves very careful consideration is the risk of private hospitals selectively deciding, perhaps on the basis of potentially more lucrative funding streams, to focus on the delivery of certain specialist services in preference to others. In such circumstances, it will be left to government to support the development of less profitable services in public hospitals – a task that will be made all the more difficult when it will be ever more difficult to recruit consultants to hospitals that will not support private practice. We cannot, as a society, allow a situation develop in which planning for services such as stroke management, rehabilitation medicine and long term non-profitable services is left to the vagaries of a market in which financial profitability as determined by the market is the key driver.
The matter of advocacy for service development is a fundamental and essential requirement in the evolution of hospital services and it is essential that such advocacy is based on scientific data and international best practice. Advocacy is the responsibility of all professionals working in our public hospitals, but those who have experience of having worked in the best hospitals worldwide (as do many of our staff) have a particular perspective that challenges leadership at all levels to continually improve services to equate with the best hospitals internationally.
These are critically important issues that warrant reflection and discussion before the State embarks on a radical change in policy that has the potential to radically and adversely impact on the delivery of hospital services. The Minister has established a Working Group to review the proposals contained in the Slaintecare report and their deliberations will require wisdom and vision and their considered views will, in all likelihood, shape the hospital system in Ireland for decades to come.
Tony McNamara, Chief Executive Officer in the Cork University Group of Hospitals