THE ISSUES surrounding the Government's controversial plan to develop co-located hospitals were articulated at length and in some detail during the second of the 2009 Pfizer Health Debates in association with The Irish Timesat University College Cork last week.
The debate on the motion that This house agrees that hospital co-location is neither financially viable nor ethically soundwas chaired by Irish Timescolumnist and assistant editor Fintan O'Toole and attracted an invited audience of more than 100 people.
Proposing the motion, chairman of the Irish Medical Organisation GP Committee, Dr Ronan Boland, said that having worked in Cork public hospitals for three years, he was well aware of what distinguished them from private hospitals.
Public hospitals do not have the luxury of closing their doors when the last bed is full and they operate a full functioning emergency department which is open to all “from the very ill and not so very ill to the very drunk, the very stoned and sometimes just the plain bad”, he said.
“If you get a heart attack or a brain haemorrhage or perforated ulcer in this country, the care you receive will be of a uniformly high standard irrespective of whether you are rich or poor, insured or uninsured,” he said.
Where the real gap in Irish healthcare emerges is in the area of elective care where those with private health insurance can get seen faster compared with those relying on public healthcare where they can wait up to two and a half years for an appointment with an orthopaedic consultant, he said.
And he warned that while the co-location advocates argue the co-located hospital will have the same case mix as the public hospitals, such assurances should be treated with caution as evidenced by the regular breaching of a 20 per cent cap on private beds in public hospitals.
Dr Boland said that worsening economic circumstances and rising health insurance premia may mean fewer people will avail of co-located hospitals but even if they are financially successful, “they will copperfasten healthcare apartheid in Ireland for another 50 years”.
Beacon Medical Group (BMG) chief executive Michael Cullen, whose company is involved in building co-located facilities, said Ireland currently has 20 per cent less beds than the OECD average and the situation is set to worsen as the number of over-60s doubles by 2020.
BMG’s three proposed co-located facilities will be capable of treating 30,000 inpatients and 48,000 day patients per annum, substantially relieving the pressure on public services and they will cater for the same case mix as in public hospitals, he said.
The State will gain not just through the freeing up of public beds occupied by private patients in public hospitals but also through obtaining substantial rent and a percentage of revenues while the proposal will also inject €800 million into the local economies, he claimed.
Mr Cullen said the State was not the most efficient provider of healthcare and said the last three public hospitals to be built in Ireland took on average 19 years to build and open from initial launch compared with just three years for Beacon’s first hospital.
Co-location critics cite the profit motive as the reason why they believe the private sector will provide a poor quality service that will somehow leave patients shortchanged but healthcare is not a get-rich-quick industry and there will rarely be super profits as reinvestment is vital, he said.
“These co-located hospitals will pay HSE rates of pay and charge payers, ie the insurers such as VHI and HSE, costs plus an appropriate margin which will in turn generate profits which will allow borrowing repayments and reinvestment,” said Mr Cullen.
Seconding the motion, consultant at Nenagh General Hospital, Dr Christine O’Malley, said co-location was “the jewel in the crown” of the Government’s reform programme which will change the system from 90 per cent public hospital care, 10 per cent private care, to approximately 50:50.
Co-located hospitals will be legally obligated to take the same case mix as public hospitals including insured patients from AE so that means a full trauma service even if they haven’t the staff available, she maintained.
However, she said that the co-located hospital has a major “get-out clause” in that it is not required to take “high complexity cases” and she suggested that most AE cases would fit within this term.
If the private hospital does employ more doctors, costs will soar and it will not be financially viable as the health insurers do not pay extra for emergencies and if they did, health insurance would have to skyrocket to US levels, she warned.
Dr O’Malley also questioned who will regulate the co-located hospitals with many private hospitals using international accreditation agents such as JCI but JCI says the number of doctors staffing a hospital by night are a matter for national regulation and Ireland doesn’t have any regulations in this area.
In future, HIQA,will indeed license all hospitals but it has been instructed to license public hospitals first which will take a few years so the licensing of private hospitals will take even longer to achieve, said Dr O’Malley.
However, UCC economist Brian Turner argued that public patients will gain from co-location through the provision of 1,000 extra beds while private patients will lose through having to pay higher private health insurance premiums.
He said the Irish public health system still hasn’t recovered from cutbacks in the 1980s when public bed capacity in the early 1980s peaked at about 17,500-18,000 beds before being reduced to its current level of about 12,500 beds in public hospitals. Of these, some 2,000 beds or 12 per cent are private beds and co-location will lead to a freeing up of these, a reduction in the number of private beds in public hospitals by 40 per cent and an increase in the number of public beds available for public patients by about 10 per cent, he said.
Mr Turner said that just over 50 per cent of people in Ireland have private health insurance with some 20 per cent of beds in public hospitals being given over to private patients even though private health insurance accounts for just about 8 per cent of total health spending in Ireland.
Co-location seeks to address that imbalance and will lead to a greater match between what people are paying privately and what they are receiving privately, said Mr Turner, adding that co-location was a pragmatic and immediate means of providing extra public beds.
“If co-location goes ahead, we will have 1,000 extra public beds – this represents an increase of nearly 10 per cent in the public bed stock – this is the only realistic source of public beds in the foreseeable future,” he said.
Following a vote which saw the motion passed, Mr O’Toole said while it was clearly a highly polarising issue, it seemed there were two areas of common ground – a recognition that the state system had failed to deliver sufficient care and that Ireland has a two-tier health system.
The debate also highlighted the urgent need for clarity on the issue as there currently seems to be a paralysis in relation to public health policy and in particular hospital policy which means nothing is being done to address what are life and death issues, he said.