A litany of failed public-private collaboration in health

The Galway Clinic opened its doors in June 2004

The Galway Clinic opened its doors in June 2004. It is the first hospital to avail of the tax incentives introduced in the Finance Act, 2001, under which 20 per cent of the beds were made available for public patients.

The clinic introduced radio-therapy, cardiac surgery and PET/CT scanning to the west for the first time. Eighteen months later it is interesting to review the early stages of operation of the facility and to evaluate the concept of public-private partnership in the health environment.

This will also serve as a useful parameter for other proposed private/ independent hospitals planned.

The €100 million Galway Clinic is a 101-bed facility, privately funded, and represents the single largest investment in independent healthcare since the foundation of the State. It is the only private hospital developed in the past 20 years.

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The medical services in the west, like much of the other infrastructure, had been sadly neglected. Patients regularly had to travel to the east coast for treatment.

This was particularly the case with cancer patients, where no radiotherapy facilities existed. Patients referred for treatment had frequently to wait for up to 10 weeks to begin their therapy. Their treatment took approximately 10 to 15 minutes each day.

The Galway Clinic thus opened opportunities for collaboration between the public and private/independent sectors.

During the planning, construction, commissioning and early operational stages, numerous attempts were made to collaborate with the chief executive officer of the Western Health Board, before its subsequent incorporation into the HSE.

After 10 unsuccessful phone calls, contact was finally made, but a blank refusal to meet was proffered. It is interesting that over a six-year period I have never succeeded in meeting the chief executive of the health board. Was this a foretaste for collaboration in the future?

Despite this setback, very satisfactory lines of communication have been established with many public servants in the west. Let us look at the results of collaboration under the following six headings, for which we offered services.

National Treatment Purchase Fund:

Any public patient waiting for more than three months for surgery can avail of this service. The Galway Clinic has a surgical capacity of approximately 16,000 patient operations a year. With half of its beds offered for public work, it thus had a capacity to undertake 8,000 procedures each year, or 12,000 over the 18-month period, for publicly insured patients.

In the first month no referrals took place. A gradually increasing stream of patients were referred over the following 13 months, most for outpatient procedures.

Over this period an average of 150 patients were treated each month. In total to December 2005, 2,504 patients were treated. They occupied approximately 7 per cent of the beds or a third of the statutory beds allocated for such work, but only one in seven of the beds available under our community hospital initiative.

By September 2005 the purchase fund appeared to run out of money. Thus minimal work was undertaken in the last two months of 2005. What surprised me greatly was the low referral rate considering the national waiting lists, and the difficulty encountered by the administrative staff at the Galway Clinic to obtain such work.

In this period, more than 200 patients each month were referred to England by the treatment purchase fund for surgery which could have been performed in Galway. Orthopaedic patients awaiting hip and knee replacement have the longest waiting times in the west, averaging one to two years.

Only seven patients were referred from the Galway region for hip and knee arthroplasties. No patient was referred from the public service for cardiac surgery, and all such patients travelled past the entrance to the Galway Clinic en route to Dublin. They continue to do so.

Radiotherapy:

This service began in September 2004. The public service was not available until spring 2005. During this eight-month period, 64 patients were referred for treatment. Hundreds more, again, passed the door en route to St Luke's hospital in Dublin, with a 10-week delay in many cases before receiving treatment. This extraordinary reluctance to refer patients for cancer care has been the most worrying aspect of this project.

Following representation from Government, we offered to treat all patients from the northwest who required radiotherapy. A proposal was submitted (on invitation) and an offer made to treat all patients with no delay and to provide accommodation if required locally.

The same medical radiotherapist covering the northwest would supervise their treatment and follow their progress on return home to ensure continuity of care.

Two weeks after submission of this proposal, the Minister for Health announced that later this year such patients would be referred to Belfast, despite the availability of services in Galway.

Diagnostic services:

Public patients in the west are among the longest awaiting diagnostic tests. Routine scans such as CT and MR, ultrasound tests and mammography, frequently have waiting times of up to nine months.

Can you imagine the anxiety awaiting a mammogram after referral by a doctor? An offer was made to eliminate all waiting times for diagnostic procedures; indeed this offer has been repeated on a number of occasions. The possibility of a service largely on demand has never been accepted. With huge capacity for all diagnostic imaging modalities, only a handful of patients have been referred.

Trolleys:

The A&E departments at UCHG, Castlebar, Roscommon and Portiuncula hospitals have similar problems to the rest of the State, with some patients spending days on trolleys. Fifty per cent on average of these patients carry private insurance and, at no cost to the Exchequer, could be transferred to a private hospital bed, if available. Despite repeated offers, not a single patient has been transferred over the 18-month period.

BreastCheck:

This was rolled out in 1999 in Dublin with a promise for services in the remainder of the State as soon as possible. Offers have been made to the executive of BreastCheck that the Galway Clinic would run and operate such service until the Government managed to spend €12 million of taxpayers' money to roll out this service in the west.

The Galway Clinic has also offered to run this service indefinitely at a considerable saving to the taxpayer. A world-class breast facility is in situ, with mammography, biopsy facilities, breast-trained radiographers, a specialist full-time breast radiologist, histopathologists and facilities for the most up-to-date treatment with surgery, chemotherapy and radiotherapy.

It is one of only two facilities in the State to shortly offer full radiotherapy planning on its PET/CT scanner to ensure the optimum delivery of radiation therapy. This facility is currently only available in 20 centres in the US and will become the gold standard in years to come.

Discussions are continuing with the executives of BreastCheck. The Galway Clinic, however, provides a similar type of service to the community in the west with private insurance.

Outpatient initiatives:

It was identified at an early date that the main waiting lists in the west are for assessment by a consultant in the first instance, ie a rheumatology consultation, five years; or a routine dermatology appointment in Roscommon, currently up to nine years.

The major success in PPP initiatives has been in a pilot study of 473 patients awaiting a general surgical consultation, some for up to seven years. This group has been seen, investigated and surgery undertaken over a 10-week period.

The same initiative could be applied over a broad spectrum of disciplines. This litany of failed collaboration augurs poorly for PPPs in the future.

Fortunately, the Galway Clinic has been privileged to care for 16,000 patients in the first 18 months of operation, but the concept of up to 50 per cent of these patients being from the less fortunate members of the community has not materialised.

It has not served the entire community as a community hospital, as envisaged. For those patients, publicly funded from the time they enter the hospital, their treatment is identical to those carrying private insurance, and we can proudly state that it is a true demonstration of a one-tier level of service.

Almost €200 million in unused funds was handed back to the Exchequer in the past year by the Department of Health, which suggests that a shortage of funds is not a problem. Does this history suggest an emergency brain scan for the health service to confirm brain death?

James M. Sheehan FRCSI is a founder of the Blackrock and Galway Clinics