Hospital consultants are hurting public patients
Public-private remuneration system has created perverse incentives for consultants
“The fact that consultants are paid a salary no matter how many or few public patients they treat, and a fee for each private patient, creates perverse incentives.”
The RTÉ Investigates programme Public v Private: the Battle for Care expertly portrayed the most insidious aspect of the Irish health system, whereby private patients are privileged at the expense of public patients within the Irish public hospital system.
This discrimination of public patients is a direct result of decades of purposeful government policy which facilitates private care in public hospitals. This disadvantaging of public patients is taking place in plain sight of the Health Service Executive, which pays the generous salaries of public-hospitals consultants while wilfully overlooking non-compliance with the consultants’ contract.
The vast majority of consultants who are publicly salaried staff in public hospitals have contracts which allow them to work up to a fifth of their time privately. While the national figures pan out at this 80/20 ratio of private and public work in public hospitals, Tuesday night’s programme exposed that 14 out of 47 acute hospitals persistently exceed the 20 per cent private limit. It also laid bare that even in hospitals where the overall limit is kept, a significant minority of consultants in certain specialities work well above the 20 per cent limit on site and that in some instances consultants publicly advertise their private work off-site even though this is contrary to their contracts.
Each of these issues adeptly depicted by RTÉ Investigates has a detrimental impact on public patients. Tens of thousands of public patients currently on our excessively long waiting lists for public hospital care could have been treated had the rules of private practice been adhered to.
The fact that consultants are paid a salary no matter how many or few public patients they treat, and a fee for each private patient, creates perverse incentives. Not only do private patients get privileged access to public-hospital care but this private care is subsidised by public money in the form of tax relief for private health insurance. The unorthodox public-private mix directly contributes to the high cost and poor access to care in the Irish public health system.
Since the programme, the Minister for Health and consultants’ representatives have said the vast majority of consultants work many more then their full hours in the public system and keep within the public private limit. HSE data never previously in the public domain show the agency knew about the poor compliance with the consultants’ contract and failed to act upon it. The fact that these figures have no longer been collected nationally since 2014 proves that no one authority has oversight over public-private compliance rates and strongly signifies that these are not important issues of concern for the Department of Health or the HSE.
The 2008 consultants’ contract was supposed to act in the public interest. Pay increases negotiated in the contract were meant to be in lieu of treating more public patients, through putting in place strict limits on their private work. This programmes proved a well-known but hard-to-show point that the consultants’ contract and broader government health policy which endorses the public-private mix actively work against the public interest – in this instance sick patients who require timely public-hospital care.
The end of consultants’ compliance monitoring coincided with a rule change in 2014, under the stewardship of the minister for health James Reilly, which allows public hospitals to bill all private patients, no matter what type of bed they were in. Up to then there was also a 80/20 bed designation in public hospitals as well as the 80/20 limit in consultants’ contracts. This rule change was to allow cash-strapped public hospitals earn more income from privately-insured patients. A knock-on impact of this move was to incentivise public hospitals to earn more income from patients with private insurance policies.
Official waiting-list figures show there has been no improvement in the waiting times for public-hospital diagnosis and treatment since 2014. These waiting times are unprecedented internationally and have reached record levels in recent years and months. It is no coincidence that some of the longest waiting times are in some of the most profitable areas of healthcare.
Nobody thinks it is a good idea to allow teachers to run private grind schools in our public schools, or private security firms in our Garda stations, through which publicly-salaried teachers and Garda could personally profit. How is it that it is perfectly acceptable to run private healthcare businesses in and out of our public hospitals to the detriment of public patients?
Tuesday’s RTÉ Investigates programme demonstrates the absence of strong and effective clinical governance and how the public-private mix in Irish public hospitals harms the care of public patients. The Government must delay no further and live up to its commitment to provide quality medical care on the basis of need, finally ridding the Irish health system of one of its most barbaric features.
Sara Burke is a health policy analyst at Trinity College Dublin