There is a madness at the heart of our healthcare system that contributes substantially to the unfairness in our hospital service, and the Government is committed to perpetuating it, writes Vincent Browne.
It concerns the most highly paid and most powerful lobby within the health system, the hospital consultants, and this is encapsulated in a contract they negotiated over 20 years ago, "the common contract for consultant medical staff". The issue has been debated a lot in this newspaper, particularly over the last few years, but it is relevant to return to it now with the continuing rumpus about the health system.
When the charitable (or voluntary) hospital service developed here in the 18th, 19th and early 20th centuries, a practice developed whereby specialist hospital consultants would treat public patients for free and, in return, would be allocated beds in these hospitals for their private fee-paying patients. It seemed a fair trade-off for those times.
Problems began when, in the 1920s, public hospitals were established by local authorities and senior hospital specialists were employed on a salaried basis but were also allocated a small number of beds to treat their private patients. The Health Act 1953 made matters much worse. It provided for the payment (out of the public purse) for consultants in the voluntary hospitals for treating public patients, while permitting them to engage in private practice as before, with the allocation of beds in these hospitals for the treatment of their private patients. The old fair trade-off between free treatment for public patients in return for the allocation of private beds was now gone.
And that madcap arrangement was extended into the public hospital system following the publication of the now infamous FitzGerald report of 1969 (infamous for it led to the establishment of the health boards).
Meanwhile the Voluntary Health Insurance Board had been established in 1957 and it enabled a sizeable (and wealthier) section of the population to afford private medical care, even though many of them were eligible for free care in public hospitals. The hospital consultants were on the pig's back, and they strapped themselves firmly onto its back through the negotiation of the common contract in 1981, which was renegotiated in 1991 and 1997.
It is no surprise to note that gradually the proportion of beds in public hospitals allocated to private patients crept up. In the early 1970s it was around 10 per cent; by the end of the 1980s it had doubled to over 20 per cent. In fact, the situation became even more bizarre for a category of patients who were entitled to free care in public hospitals but were fee-paying patients of the consultants. This latter arrangement was supposedly phased out from 1991, though it has been noted "in practice 30 per cent of elective procedures carried out in public hospitals are on private patients".
And to compound the absurdity, the practice has been to charge the private patients only half the cost of the public hospital services. A proposal was made some years ago to introduce a common waiting list, whereby people would be admitted to hospital on the basis of their medical needs, rather than on their ability to pay. There were obvious problems with this proposal, for, it was suggested, consultants would be the ones to determine the medical needs. However it had some merit, but got nowhere. So we have managed to devise an arrangement whereby the highly paid people who drive the public hospital system are incentivised to devote as much of their time as they can to look after their private patients, whether in the private beds in public hospitals or in private hospitals or in their private consulting rooms. (Minor curtailments have been introduced in the last 10 years but, for many consultants, this remains the case).
In addition, the State further subsidises inequity in the healthcare system by massively subventing the costs of private care in public hospitals and encourages the growth of this private healthcare through tax breaks for private health insurance. And we wonder why we have an unfair health system?
Ingenious arguments have been devised by the consultants, and by their consultants, to justify this - it helps to attract and retain consultants of the highest calibre; promotes efficiency and links between the two systems; represents an additional income stream for public hospitals. Yeah, right!
A medical consultant friend draws an analogy. What would we think of an arrangement whereby gardaí were permitted to engage in private security work as part of their normal duties, permitted (indeed encouraged) to set up separate consulting rooms, with plaques outside, and allowed to use the State's forensic and other facilities for work on behalf of private clients? We would think it was off the wall. So how come we don't think it is intolerable in the health system?
(In writing this column, I have relied heavily on the National Economic and Social Council Forum Report No 25: Equity of Access to Hospital Care).