Comment: Equity and efficiency within the health service remain ambitions rather than realities, despite higher spending, argues Miriam Wiley
Published by the Department of Health and Children in 2001, Quality and Fairness: A Health System for You committed future health system development to being based on the guiding principles of equity, quality, people-centredness and accountability.
While much attention of late has focused on the reorganisation of the health system, ensuring that policy and commitment stays concentrated on achieving these objectives remains critical, if some of the most basic problems within the health system are to be addressed.
While each statement of health strategy over the past two decades has highlighted the importance of equity and efficiency, any review of recent developments shows that, despite the much higher spending, these objectives remain an ambition rather than a reality.
Concerns about efficiency and accountability have been raised by a number of sources, including the Brennan Commission and the recent report of the Comptroller and Auditor General. While the commitment to a quality health service is to be welcomed, problems such as MRSA and other hospital-acquired infection indicate weaknesses within the system.
The quality issues are also raised by data from the National Cancer Registry showing geographical variations in health outcomes for specific conditions.
In welcoming the agreement on making "doctor-only" medical cards available to 200,000 people, concerns about equity remain. Reports published by the Institute for Public Health, for example, have identified socio-economic differentials in mortality rates.
The report on Health Services and the National Anti-Poverty Strategy highlights the relationship between poverty, disadvantage and bad health experiences which suggest a need for the poor and the disadvantaged to have better access to certain health services.
Research from the ESRI that shows private patients have better access to public hospitals than public patients raises questions about how policies aimed at improving equity are being pursued.
The fact that close to half the Irish population now have private health insurance has to be taken into account when designing policies to achieve the principles of the health strategy. International experience in addressing these challenges may prove useful.
In particular, the experience in Australia may have some parallels for Ireland. In reviewing this experience in a recent article in the British Medical Journal, Jane Hall and Alan Maynard report on the take-up of private health insurance by 45 per cent of Australians in the context of a universal, publicly funded health system.
They found that the strategy of subsidising insurance premiums was expensive, inflation of premiums was high and pressure on public hospitals did not decrease despite the increase in the numbers with private health insurance. The authors conclude that the Australian policies aimed at engineering a major expansion of private healthcare insurance "create increased fiscal burdens for government, increase inequality in funding care, and have no observable effects on efficiency".
Last January the Health Services Executive (HSE) assumed managerial, executive and budgetary responsibility for the health system while the Department of Health and Children (DoH&C) retained responsibility for health policy development. To fulfil these responsibilities, (gross) funding of just under €11 billion was voted for the HSE in 2005 while the allocation for the DoH&C for this year for (gross) current expenditure was €381 million.
Historically, we have been accustomed in Ireland to health policy commitments being reinforced by funding commitments. The main budget holder for health service funding (the HSE) is now separate from the agency (the DoH&C) with responsibility for health policy development. It now seems timely to ask how health policy can be given "bite" in the new structure.
While the HSE states in its first service plan that Quality and Fairness: A Health System for You provides the policy framework for service development and delivery, the distribution of functions within the reorganised health system would suggest differences in how the HSE and the DoH&C pursue their respective work programmes.
Given the budgetary responsibility assigned to the HSE, and the fact that the chief executive officer of the HSE is now the accounting officer for the health services, the HSE would be expected to take the lead role in ensuring efficiency and accountability in the deployment of public funds.
The relevant levers to pursue these goals include budgets, service level agreements with hospitals and monitoring expenditure and service delivery. The key health issues for policy development concern who gets access to what services, and how can we ensure equity in access to appropriate and effective care.
Given the shift in financial resources to the HSE, if the DoH&C is to give this policy framework the required "bite", it will be necessary for it in future to make greater use of the levers of regulation and legislation to ensure implementation of the policies to achieve equity within a quality health system in Ireland.
Miriam Wiley is a research professor at the Economic & Social Research Institute (ESRI).