The size of queues in A&E units will show whether the hospital beds initiative announced yesterday is a success, writes Dr Muiris Houston, Medical Correspondent
Yesterday's announcement of a new strategic initiative by Minister for Health Mary Harney represents the latest attempt to tackle the chronic shortage of public hospital beds in the State.
Significantly, this 3,000 bed shortage goes back at least 20 years. It was created by her predecessors, Barry Desmond and Rory O'Hanlon, in the cash-strapped 1980's and is notable for the failure of all ministers since then to rectify a worsening situation.
Ms Harney's immediate predecessor attempted to reverse the decline by adding some beds directly into the public system. According to figures published yesterday, Micheál Martin succeeded in adding just under 300 beds between 2001 and 2004. The Tánaiste has now decided to tackle the issue by largely excluding private beds from our public hospitals.
Until now, each major acute hospital in the State had a quota of private and semi-private beds. Those with private insurance cover were admitted to these beds, usually located at the end of corridors leading to the main public wards in the hospital. They were looked after by consultants as private patients; in return for nursing care and the "hotel" aspects of health care, the hospital was entitled to bill the VHI or other health insurer.
What is now proposed is the decanting of these beds from the public hospital. They will now be made available in a new stand-alone private facility built on the grounds of the existing hospital. The former private and semi-private beds become public ones, thus "creating" additional public beds in our existing hospitals.
It is a neat trick potentially offering a quick and a cost-effective solution to the shortage in the system. Private developers are renowned for their ability to complete projects like this quickly. They are also skilled in achieving value for money through the kind of flexible and innovative thinking that is often absent where public funds are concerned. But even the Tánaiste recognises that it will take time to deliver the total number of beds. She has opted for a five year timescale, indicating that anyone who thinks the overcrowding in an accident and emergency department will be resolved by next winter is in for a rude awakening.
However, where a new private hospital is built, the public patients in that region stand to gain access to the private facility. It will be open to the Health Service Executive (HSE) to purchase operations, investigations and other treatments from the private hospital using public money. This can be done either directly or through the existing mechanism of the National Treatment Purchase Fund.
In theory, both the purchasing arrangement and the freeing up of more public beds should help the inequity that has plagued the public health services for years. However, for those who advocate a free market approach to healthcare, the change also offers opportunities. It will allow the HSE to invite tenders from the established public hospital and its neighbouring private facility for specific services, thus creating the kind of direct regional competition that should drive down costs.
This major policy initiative also has implications for the consultants' common contract. With talks due to begin on its renegotiation, it will put pressure on the Government side to increase the number of category 1 consultants. This contract allows for public practice on a public hospital site only and is held by 61 per cent of consultants at present.
Ms Harney's move will also have a significant impact on the VHI. It will be expected to pay full market rates for beds it previously paid for at a lower rate. And it may also help explain the recent Government decision on risk equalisation which so upset the board of the VHI. Nor is the move budget-neutral for the Exchequer. The income previously generated by public hospitals from the VHI and other insurers will disappear. Either additional funding is provided to make up this shortfall or previous service levels will not be sustainable.
The Tánaiste's plans are based on the work of Prospectus management consultants.
Although not published yesterday, its report provided the Department of Health with strategic advice on the policy implications of the decision.
At a practical level it also drew up an assessment framework against which proposals from private operators would be benchmarked. This framework will oblige contractors to supply a clean statement of need for each private development; it will examine competing bids for value for money aspects, including a wide ranging risk assessment; governance issues, in particular how the adjoining public and private hospitals share responsibility for quality failures; and the framework will assess quality aspects as laid down by the Health Information and Quality Authority.
The success or otherwise of this initiative will largely depend on how well the public interest is protected. If there are problems at a local level, then the status and representation of the existing hospital will be damaged. Should the strategy fail to ensure public patient access to the new facility, then there will be no health or social gain associated with it.
Ms Harney has significantly changed the landscape of hospital care in the Republic. Her plans offer opportunities as well as pitfalls. Despite the nuances and angles that will occupy the minds of health economists over the coming days, the crude measure of the success of her initiative will be whether it removes the lengthy queues in our hospital accident and emergency departments.