ANALYSIS:FG's ambitious focus on primary care addresses a fatal flaw in the HSE's way of doing things, writes DR MUIRIS HOUSTON
IT IS obvious that considerable thought has gone into Fine Gael’s FairCare proposals for health service reform. They rely heavily on the recently reformed service in the Netherlands. But can going Dutch really fix our chronically sick health system?
Since January 1st, 2006, the Netherlands has had a single statutory health insurance scheme for all its residents. It has three main features: long-term nursing care; what it calls “care with a view to a cure”; and a facility for individuals to take out supplementary insurance.
A key element is that private companies provide most healthcare but with strict regulation provided by government.
The Dutch Health Insurance Act provides the same level of cover that existed under the previous fragmented system: a combination of health fund insurance, social health insurance for employees, people receiving state benefits and people aged 65 and older. The system is funded through a combination of a nominal premium paid by everyone over 18, income-related premiums and public funds.
Drug prescribing is covered by dividing medications into groups, with the maximum reimbursement set on the basis of the average price of the medicines in each group. Someone can choose a more expensive medicine but must pay the difference.
Because the Irish system differs radically from the Dutch system, Fine Gael proposes three phases of health service reform. It says it will first broaden primary care and set performance targets for hospitals. The plan borrows from Northern Ireland by proposing a special delivery unit to ensure hospital waiting lists are sharply cut. In year three it will introduce a system whereby “money follows the patient”, who will be seen as a source of income rather than a cost. At the same time, the National Treatment Purchase Fund will be ended.
Year five will see the introduction of the Dutch model of universal health insurance (UHI), with mandatory health insurance chosen from a range of providers. It will be overseen by a UHI commission established early in the lifetime of a Fine Gael government.
Under UHI, everyone will receive free GP care with premiums either paid for or subsidised by the State. The cost will be no higher than present private health insurance premiums, with the State paying the total insurance costs of children and those with medical cards. Some 75 per cent of UHI funding will come from taxation.
Dr James Reilly, Fine Gael’s health spokesman, made much of the proposed system’s lack of discrimination. He promised strict community rating under UHI and a much strengthened primary care system. The HSE will have a much smaller role, although initially it will lose just 5,000 administrative staff.
He also predicted that smaller hospitals will do well under UHI. However, this aspect of reform will have to be squared with a commitment to improved patient safety, which for certain specialities is clearly linked to size and patient volume.
The implementation of FairCare will not cost any additional money to run hospitals, Fine Gael claims. It predicts efficiencies of 10 per cent from the change process itself. And it says the expansion of primary care will be mainly funded by the private sector.
The success or otherwise of Fine Gael’s plans will be decided on how it times its plans for the expansion of primary-care centres. A fatal flaw in the HSE’s way of doing things has been its failure to build up primary-care teams before attempting to decant patients from the hospital system. Unlike the Netherlands or Northern Ireland, we do not have fully functioning patient-centred primary-care teams. To attempt this degree of reform will require an element of “transformation” funding, the bulk of which should go into the early development of primary care. Without this, the plan will not have a safety net and could quickly lose the confidence of the public. Corporations, a fraction of the size of the HSE, would not attempt significant change without specific funding for the transition process.
On the plus side, Fine Gael’s plan is a graduated one with a total timeframe of 10 years. And both Enda Kenny and James Reilly were at pains to emphasise they are prepared to modify the reform package as it progresses.
The notion of being able to see a consultant and have a colonoscopy performed in a primary-care centre is attractive, as is the availability of post-hospital care in the same location. The stated aim to treat psychiatric illness just like any other is a laudable aim.
However, the FairCare proposals would be better off without gimmicks such as a National Body Test for which there seems little evidence of effectiveness. While it may pick up certain illnesses at an early stage, it has a significant downside of creating a group of “worried well” who will face unnecessary further testing and anxiety.
For those who may be understandably allergic to healthcare reform after the failed experiment that is the HSE and co-location, convincing them of the value of further health system change may be difficult.
However, there may be some solace to be had from the Netherlands. Earlier attempts at reform such as the Dekker plan and the Simons plan failed for a variety of reasons. What price FairCare succeeding where others have failed? Fine Gael aims to have the Republic in the top three for healthcare quality in Europe and in the European top five on a value-for-money basis at the end of 10 years. FairCare cannot be faulted on ambition. Whether it succeeds in putting health at the centre of the next general election campaign remains to be seen. Its ultimate test will depend on the electorate returning a Fine Gael-led government.
Dr Muiris Houston is medical correspondent of
The Irish Times