Michael Clifford: Is one-tier health system here to stay?

ON Monday, August 26, 2019, a government-commissioned report was published with minimum fanfare, writes Michael Clifford..

There were no flashing cameras, no smiling ministers, none of the usual props of spin.

The timing of the publication ensured that there would be precious few opposition politicians or public figures available to comment on it. The report had been completed nine months earlier.

Everything suggests that the Government was waiting for a time to slip it out unnoticed, and when better to do so than a Monday morning in lazy August?

The report examined how to remove private patients and consultants from public hospitals.

The group that compiled it was chaired by former HSE board member Donal de Buitléir. Its task was to put meat on the bones of the Sláintecare report, which advocates a single-tier health system and is accepted across the political spectrum.

Dr De Buitléir recommended that “the Government should send a clear signal, through legislation, that, from a specific date in the future, no private activity in public hospitals will be permitted”.

This would ensure that public patients receive the full benefit of the public system. Equity of access would move much closer under such a regime.

Citizens’ health concerns would be met based on need rather than ability to pay.

The report stated that the cost of removing private work would be about €6.5bn and would take 10 years.

The timing and circumstances of the publication of the De Buitléir report reflected an absence of political will in government to implement Sláintecare with any urgency.

Reshaping the health service will cost a lot of money. It will involve taking on powerful, vested interests. It will be messy, protracted, and full of political headaches.

In another lifetime, when politicians were given space and time to think big, maybe somebody would have stepped up to take it on and build their own political legacy. Right now, in the current environment, few, if any, could be bothered with what might be regarded as an exhausting political gamble.

Yet, last month, in response to the coronavirus emergency, the Government implemented a form of Sláintecare. There was no resistance, no gamble, no hassle.

It threw a few bob at the 19 private hospitals and flattened the two-tier health system into one. Private healthcare was temporarily nationalised.

Access to the health system in a time of coronavirus is now exclusively according to need, rather than the ability to pay.

Why? Because, unlike politics, the virus moves at a frightening speed. It attacks and it can kill within weeks.

There is no time to long-finger the reshaping of the health service, because lives are at stake in the here and now.

In a two-tiered system, discrimination can be hidden, over the years and decades, in long waiting lists and slow diagnoses.

Patients at the end of queues suffer in quiet desperation, while those who can afford it — roughly half the population — access the service nearly immediately.

Everybody knows the system is unequal, but the political culture and the half who have health insurance tolerate it rather than face upheaval.

Now, the biggest upheaval the State has ever known, health-wise, is upon us. So, suddenly, a one-tier health system can be done with consummate ease.

The change is temporary, but the swiftness and smoothness with which it was effected has led many to ask: Why not in the long term?

Certainly, it would cost money. The private system exists to generate profit and would require generous compensation. There would be upheaval for all concerned. But why not?

Health is replete with vested interests. Getting all on board, once the white heat of an emergency passes, would not be easy.

Take the most powerful of all the interests: The consultants. Currently, consultants of a range of disciplines are being selfless with their expertise. They are leading the battle to preserve life in the face of the virus.

Along with many other people who are providing essential services at the moment, they are being afforded heightened respect.

But a group of consultants also objected strongly to the temporary change. Private consultants, who earn considerably more than their colleagues in the public system, objected to the emergency conditions in which they are expected to work, where needed.

They said they would have to cancel appointments in private clinics.

For the consultants, this was an attack on ‘continuity of care’.

Yet the same rules were temporarily put in place for consultants in the public system. Many of them have been redeployed to meet the demands of the emergency.

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They have had to innovate, grab a consultation by phone, juggle the needs of the emergency with the needs of their own patients. Why couldn’t the consultants with private patients do the same? Why couldn’t they, where possible, simply engage in phone consultations in deference to the emergency? Maybe flatten down the fee a little?

There is a reality here. Hospital consultants are properly respected for the work they do. But long years of study and the acquisition of expertise do not elevate them to the pantheon of saints.

They are as susceptible to the lure of money as the next woman or man. Their objections to a single-tier system are many, but include the reality that they would earn less.

If the going gets tough in any attempts at deep reform, then whether consultants in private practice are overpaid on the back of an inequitable system will have to be addressed.

There is another reality on the other side of the public/private divide.

Patients are treated more quickly and more efficiently in the private system. The difference is down to the infrastructure around the delivery of health in the public sphere.

The shortcomings in this respect are certainly a factor in pushing some consultants towards an exclusively private practice.

The current restrictions started on Friday, March 27. They mandate that everyone should stay at home, only leaving to:
• Shop for essential food and household goods;
• Attend medical appointments, collect medicine or other health products;
• Care for children, older people or other vulnerable people - this excludes social family visits;
• Exercise outdoors - within 2kms of your home and only with members of your own household, keeping 2 metres distance between you and other people
• Travel to work if you provide an essential service - be sure to practice physical distancing

Reform has to include an overhaul of work practices in the public system, even if it means breaking from the norms of the public sector.

A single-tier system cannot mean that private health must be lowered to the standard of delivery in public health.

The floor of what is acceptable must be raised to ensure that everybody gets not just equal access, but as good a health service as is possible.

Since the onslaught of the virus, there have been many voices saying ‘now is the time to make the change’. Realistically, that won’t happen immediately. But this temporary arrangement has shown that it can happen and it must surely have brought closer the day when it will.

The current emergency has demonstrated that the easy option of long-fingering change can’t be tolerated any more.

Tiptoeing, over the course of a decade, to the land promised in Sláintecare might have sufficed before the world was shattered by coronavirus.

It simply won’t do from here on in.