No simple solutions on health equity and funding


OPINION:Recent proposals for a single tier, free at the point of delivery health service would not work, writes MARY HARNEY

THIS YEAR, the people of our country are providing €15.4 billion for public health services alone. It’s worth remembering that that figure is greater than the total annual exchequer take from income tax. In addition, people pay several billion euro for private health insurance, fees for GP visits and clinical services, and for drugs and other health expenditure.

But does it represent the best use of our resources? Many people now say that “money should follow the patient”. I say that “money should follow the patient’s best health”.

The critical question is how we use all resources, particularly public resources, to help people stay healthy and to get best outcomes for patients from healthcare. This means a much stronger role for preventive health measures, such as cancer screening, for primary care and for chronic illness management in the community.

It’s a critical question for all developed countries because the hospitalisation model of healthcare is financially unsustainable. Better use of limited resources is a common need across countries, whether they raise funds for health from general taxation, payroll levies for social insurance or compulsory private health insurance.

I invite people to recognise that it’s more important how money is spent than how it is raised from the public. My clear focus now is to achieve better health through better use of the limited resources. For this reason, I have set up a Resource Allocation Group of diverse experts, chaired by Prof Frances Ruane of the ESRI, to make practical recommendations to achieve a better allocation of resources. Their report is expected shortly. It will inform the next steps in this area.

It would be folly to allocate resources for unlimited or unnecessary interventions, tests, consultations and so on. In my view, this is a danger in the simple formula “money should follow the patient”. We would run out of money and we would not deliver the best results. We have all heard the consequences from other countries: high costs, high fee earnings for some, little health gain for most.

I also believe fundamentally that public health services should be provided on the basis of medical need. I believe that, where people choose to pay privately for certain health services, as they will in any system, this must not be at the expense of people who use public services in terms of their access to, or quality of, care. So the question is how to use resources best to achieve all health policy objectives, including that of equity of access. I suggest that the weakness in some new proposals is that there is a concentration on how to raise the money and not enough concentration on how it will be spent.

Proposals have been put forward, most recently by the Adelaide Society, to bundle all or nearly all public and private money spent on health into a special payroll-based health levy, which would more than replace income tax. These funds would all be given to a new State or semi-State Social Health Insurance Fund, to be then allocated to public and private healthcare providers. Broadly, this is social health insurance.

Alternatively, there is a very different proposal to make private health insurance compulsory for all, and channel perhaps €18 billion or more health spending through private health insurers (they currently manage about €2 billion).

We would need to see crucial details of how the various proposals would actually work. For example, we don’t see exactly who would pay more, the same, or less for healthcare, and by how much. I don’t believe that these proposals would mean that no one would feel any impact on their personal budget.

These ideas are often presented as delivering free GP, consultant and hospital care to all, with no apparent limits on either the number of GP/consultant appointments a person could make, or hospital treatments and diagnostic investigations provided to patients each year. All consultations and treatments would be available virtually immediately.

We have to seriously question promises that a new system of healthcare with limited resources can offer unlimited treatments, consultations or diagnostics, to be immediately available. Any social insurance fund that is obliged to pay for unlimited treatments with limited funds will simply go insolvent. Any private insurance fund will, too.

It is also suggested that either social insurance or compulsory private insurance would end “two-tier” aspects in health services. But it is accepted by advocates that these proposals would not end the right of people to be seen and treated by a consultant or doctor privately, either in a clinic or a private hospital. Unless we are prepared to ban people from paying to see, or be treated by, a doctor, then a pure one-tier health system is not on offer from anyone.

Our policy is equity of access to publicly-funded health services. We are open to using all providers who meet quality and value for money standards to contribute to public services.

The question is whether the results claimed for universal health insurance are achievable, and particularly by a major change in the way we fund health services from general taxation to social or compulsory insurance. It is widely accepted that that a transition to a full universal health insurance system could take up to 15 years to achieve. But would the disruption over a 10- to 15-year period be justified by realistically achievable goals?

I believe the goals of best health for the population, best outcomes for patients, and equity of access are achievable within our taxation-based funding system.

In any system, there will always be a limit on resources. In our system, that limit is set democratically by the Oireachtas each year. The critical thing to note about health funding in other countries with social or compulsory private health insurance is that they are supplemented by resources from general taxation.

For us, this would mean that the annual budget for healthcare would still be limited ultimately by a set amount voted by the Oireachtas. General taxation, and the exchequer, would remain the bedrock of public health funding.

Healthcare and health funding is complex. An open and honest debate is useful. It serves no purpose to put simplistic arguments either for or against particular proposals. There are no simple “solutions”.

No single method of raising funds from the people for health itself delivers the results we all want. The most important thing, I would suggest, is to use the resources we can actually generate for patients’ best health.

Mary Harney is Minister for Health