For patients, the risks of the Minister for Health's announcement of 1,000 beds in new investor-owned for-profit hospitals - Public Private Partnerships (PPPs) that are massively subsidised by the taxpayer - is a more costly, inferior and inequitable health service, writes John Barton
As a consultant physician, the Minister expects me to practise evidence-based medicine and it is reasonable for the public and those who work in the health service to expect the Minister's health policies to be based similarly.
The Minister's proposal is not evidence-based, it will not meet the public need and is likely to result in a "rip-off" health service.
American, UK and Australian experience shows that for the State, the risks of involving the private sector in PPPs would appear greater than the rewards.
US research consistently shows that investor-owned for-profit hospitals result, not alone in more costly healthcare, but also in inferior care. The most recent research on quality in healthcare, published in the New England Journal of Medicine in July, yet again shows that investor-owned hospitals provide poorer quality care.
Ms Harney also states that the provision of these beds will cost substantially less than if the State provided them. The cost for the public purse, she says, will be only 42 per cent of the total cost. I am not a financier, but the 58 per cent cost for the investors will be returned in profit at the expense of sick people.
Investment promoters are suggesting that every €75,000 invested will yield a profit of €62,760. The authors of a report for the Netherlands board for hospital provision state that PPPs in hospital provision have not proved a universal success, as there has been too great an emphasis on cost efficiency - profit making - at the expense of improved patient care.
The authors refer to the Private Finance Initiative in the UK. Under this, the private sector finances, designs and builds hospitals and runs non-clinical services. Professor of health policy and health services research at University College London, Allyson Pollock has now shown that the costs of PFI will be greater than if the British government had borrowed the money itself. There are now plans for major changes in PPP policy there, with a greater emphasis on meeting the needs of patients.
In Australia the public-private partnership model has been even more trusting of the private sector than in the UK, as the sector was required to build the hospital, own it and operate all services including patient care, and then transfer the facilities to the state at the end of a certain period.
The Australian senate recently reported that there was no evidence that PPPs had consistently delivered better value for public patients than the public sector itself. The report stated that in some cases, PPPs had been detrimental to government and the public, as care for the elderly and chronically ill had been less than desired.
There have been rare PPP successes, attributed mainly to union collaboration with the change, coupled with excellent human resource skills management. However, based on the predominantly negative findings, Australia is now moving away from this form of PPP. There is now a sharper focus on ensuring that patient needs are met in an equitable fashion.
Despite the international evidence on costs and quality in healthcare, it is, nonetheless, possible that in the Irish context, quality of care may not be compromised in these for-profit hospitals, as they will be sharing with the on-site public hospital one of the key human resources required for quality healthcare - consultant doctors.
The problem with this approach, however, is that it may have an effect on the quality of care for public patients in the public hospital. Our current hospital system is quite similar to the Australian one, in that we have a public hospital system - treating private and public patients - working in parallel with a private hospital system. This is predominantly staffed by salaried public hospital consultants, who receive fees from Government subsidised private patients [insured by VHI, Bupa, Vivas and others].
It is an egregious system that provides doctors with perverse incentives to give quicker access to care for the privately insured wealthier sections of society. The Minister's proposals will augment this system.
The international evidence to support such a system is also lacking. In fact, the evidence strongly suggests an adverse effect on care for public patients in public hospitals. The Minister and her backers claim that her proposal will take pressure off our public hospitals. The Canadian Health Services Research Foundation in Ottawa, Ontario, has described claims like those made by the Minister in this context as mythical.
Moreover, professor of political science at the University of Toronto, Carolyn Hughes Tuohy, has published a report on the effect of private finance on public healthcare systems in five OECD countries last year. She concluded that "there is no ground for believing that the existence of a privately insured sector parallel to the public sector reduces overall waiting lists or times for public patients". She goes on to state that "it appears that private alternatives are not the solution".What private alternatives do is to "cream off" the less complicated cases. It is also likely that these new private hospitals will not significantly change the situation in our accident and emergency departments as private and public patients with emergency conditions will still have to go to the public hospital.
The Minister says that these private for-profit hospitals have an obligation to offer 20 per cent of their capacity for public patients and will be used by the State to treat public patients on waiting lists using the National Treatment Purchase Fund.
Stephen Duckett, professor of health policy in La Trobe University, Melbourne, published research last February showing that more privately provided care means longer waiting times for public patients in Australia. His study also included private sector treatments of public patients under contract to the state, similar to that of our own National Treatment Purchase Fund.
"Contracted activity thus appears to act more like private activity than public activity," he concluded. He recommends that the more simple and effective solution for public patient waiting lists is to increase activity in the public hospital rather than attempt the more complex "trickle down" private sector solution, which our Minister for Health has now proposed.
A major study of surgical waiting lists and their management published by the OECD in 2003 refers to the potential adverse effects of a parallel private hospital system in countries where consultants are in short supply, as currently applies in Ireland, and where doctors are allowed to pursue private practice in a parallel private hospital system.
Mary Harney's desire to have the private sector involved in hospital provision seems, as the report for the Dutch hospital board states about PPPs, to be driven more "by ideological persuasion" than a pressing need to involve the private sector.
It was the last Thatcher government in the 1980s and the liberal centre-right governments in Australia in the 1990s that initiated PPPs in healthcare.
So why is the Government going down this road? One possible answer is suggested by Jane Hall, professor of health economics in Sydney's University of Technology, and Alan Maynard, professor of health economics at the University of York in Britain.
In a paper published in the British Medical Journal in February, dealing with recent health policy reforms in Australia, they surmise that "creating cost inflation and greater inequity in healthcare pays politically". The re-election of Tony Blair, who continued Margaret Thatcher's PPP policies, and John Howard's Liberal Conservative Government in Australia, seems to bear this out. From my perspective, the research suggests that it is a case of politics before health; private hospital developers, profits and private patients first, the taxpayer and public patients second.
John Barton is consultant physician/cardiologist in Portiuncula Hospital, Ballinasloe, and chairman of the Health Services Action Group.