We need to ensure the vulnerable are not the first to suffer

Second Opinion:My most striking theatrical experience was undoubtedly a riotous Polish play called Birthrate, the highlight of the 1981 Dublin Theatre Festival.

Starting with a stage set resembling a train compartment, all was sweetness and light as the first few passengers entered, ceding place politely to a mother and baby. However, as more and more passengers piled in, tempers began to fray and civility eroded, to the point where the baby and the mother became the first to be ejected through the window.

That the vulnerable are the first to suffer when the going gets tough in real life as well was amply illustrated by a recent major scandal in the Mid-Staffordshire hospitals in the UK, where older people suffered disproportionately from poor care in a dysfunctional managerial system.

New threat

In cash-strapped Ireland, similar pressures are showing, with a new and unhappy threat arising for older people in our mixed private and public health system.

Almost one in two people hold private health insurance: until quite recently we had true community rating, whereby people paid a flat rate throughout their life, a form of intergenerational solidarity.

However, an onslaught by rapacious private insurance companies laid siege to the principle: the initially robust defence by the Government has faltered to the point that companies now offer rates for younger families which severely stretch the reality of community rating while preserving the letter of the law.

Due to this, the insurance companies are under significant pressure, with more stress on the way due to a Government plan to make every bed in the public system available for charging to private patients.

A first dysfunctional response is an increasing tendency for insurance companies to query, and not pay for, lengths of stay associated with mostly older patients with complex disease and increased care needs.

By abbreviating or delaying payment, the public and voluntary hospitals suffer as private income is an important aspect of their revenues. In turn, some hospitals are removing predominantly older people prematurely from private care to public care. A series of injustices is associated with this trend.

Older people, through community rating, paid for the care of those in generations ahead of them in their time.

Their care, particularly in the last year of life, costs less per head than that for younger people, a subsidy to younger generations.

The cost to the hospital is on a “per day” basis, again supporting younger people more likely to receive high-tech services.

Finally, it is a negation of modern healthcare to impose outdated and simplistic funding paradigms on a major group – older people – that would be completely unimaginable in cancer or cardiac care.

Under pressure

In private hospitals, different pressures apply to older people. These hospitals have increasingly negotiated a set payment for certain illnesses: treat in fewer days, the hospital gains; treat in more days, the hospital loses.

Worryingly, I am aware of a number of cases where older people in private hospitals have been told, after a relatively short stay and while still unwell, that their insurance “has run out”.

From the outside this looks like a sharp practice of keeping the surplus if the patient is treated in less time, and avoiding the charge if it takes more time.

At a time of severe financial crisis there may be little sympathy for anything to do with private medicine. However, the Irish people have voted for this system, and if the system needs to be changed, a cynical short-changing of older people is not a good starting place.

The key culprits in this shameful trend are the insurance companies and a complicit and knowing Department of Health. However, the mute acquiescence of senior doctors and nurses with these dubious practices towards older people is also unacceptable.

Whether facing inappropriate demands in the private sector or through the rigidities of management in public systems, we need to articulate better the ethical and professional imperative of defending appropriate care in the face of organisational antipathy.

The historian Theodore Roszak wrote of the need for “a nobler economics that is not afraid to discuss spirit and conscience, moral purpose and the meaning of life”. We should not be afraid to demand the same of healthcare economics and the moral agency of doctors and nurses.

A version of this column originally appeared as a BMJ blog

Prof Des O’Neill is a consultant in geriatric and stroke medicine