Taking a scalpel to HSE

DESPITE a quadrupling of our health budget since 1997, Ireland is ranked 15th among European nations for the quality of its healthcare, and 24th in value terms.

All political parties agree that throwing money at the health service will not solve its inherent problems.

Earlier this month Fine Gael launched its FairCare health plan, setting out how it will abolish the Health Service Executive by 2016 and introduce a Universal Health Insurance (UHI) system.

Fine Gael’s policy is modelled on the Dutch system of Universal Health Insurance, under which all citizens are required to purchase private health insurance, with varying levels of subsidy available to those less able to contribute. The policy, which would effectively abolish the two-tier system, would be introduced on a phased basis, and would see the abolition of the HSE by 2014. Full implementation could take as long as ten years.

Under the Fine Gael system, hospitals will be paid for the number of patients they treat rather than giving block grants.

Furthermore, Fine Gael will introduce more affordable GP care by opening up contracts to all qualified doctors. Part of the plan would be to reduce waiting lists by establishing a special delivery unit which reports directly to the Minister.

Overall, a total reform of the health service is envisaged by the party. Changes will be made in three key phases:

n2011-14: Waiting lists will be slashed and a stronger primary care system built.

n2014: Block grants paid to hospitals will be replaced by a system based on the numbers of patients they treat, increasing productivity by up to 10 per cent.

n2016: A new UHI will be introduced to end the two-tier system of care.

According to Enda Kenny, FairCare represents the “most radical change in the health system since its establishment”.

The plan incorporates the best elements of the Dutch service, as well as the successful system in Northern Ireland that eliminated hospital waiting lists through the establishment of special delivery units.

“We have looked at the best systems around the world and are satisfied that a modified version of the famous Dutch health system is the plan we will implement.”

The party’s health spokesperson, Dr James Reilly insisted Fine Gael would “slash waiting lists” using the methods adopted in Northern Ireland.

“We will introduce a ‘money follows the patient’ budgeting system so that hospitals are paid for how many patients they treat. Patients will no longer be seen as ‘costs’ to the health service but as valuable resources. This will transform the system back to a service,” Dr Reilly said.

“What we have done is take what we see as the best elements of a number of systems, largely the Dutch service but also seeking to emulate the level of patient safety evident in Denmark, the achievements made in the North as well as the hospital trusts model in Britain.

“This will not happen overnight but we believe, within five years, we will have universal health insurance, free GP care and free drugs package for all but the highest earners. We are guided by the underlying principle of equity for all. It’s as simple as this: if you have food in your belly and a roof over your head, access to free health care and free education are the two things that will level the playing field towards a fairer society.”

Fine Gael, in power, plans to cut down waiting lists and “build a stronger primary care system” by 2014 before changing the way hospitals are paid for treating patients. The first phase also involves increasing the number of people who can access GPs instead of seeking hospital treatment.

The party will then begin the long-term project of introducing universal health insurance in 2016 to “end the two tier system of health”, according to Dr Reilly. He said this would mean everyone would have health insurance and the state would cover children, students, and people with medical cards and GP visit cards, while subsidising treatment for low income earners.

That’s how things are run in Holland. The Dutch health care system is privately run but with public regulation. Through a single legal framework set by the government, the system provides a social safety net and induces sharing of risks and costs across society.

In contrast to many other European systems, the Dutch system is based entirely on private insurers rather than a single payer or national system as in Britain. Yet the Dutch system is universal, has far superior rates of satisfaction with quality of care and access, and still costs less than what we pay for healthcare per capita.

The Health Insurance Act of 2006 was the culmination of several years of Dutch legislation and policy aimed at achieving universal health care.

Dutch health insurance changed dramatically in that year with the abolition of the sick fund insurance that had covered wage earners and their dependents for over 100 years.

In 2005, with surprisingly little political debate or public opposition, the Dutch Parliament passed a law introducing a new form of population- wide health insurance that replaced the former public and private health insurance systems. In essence, the law was similar to earlier proposals of the 1980s and 1990s that failed to gain lasting public and political support but it meant a further push towards privatisation of Dutch health insurance.

Since January 2006, all residents of the Netherlands had to take out health insurance with one of the 40 or so private insurers of their own choice. Insurers are required to accept each applicant at a community-rated premium regardless of pre-existing conditions. An insurance regulator ensures all basic policies have identical coverage rules so that no person is medically disadvantaged by his or her choice of insurer. The Dutch describe their system as “private health insurance with social conditions”.

To prevent loss of profitability from chronically-ill patients, they have a risk equalisation system so that rather than losing profits from recruiting sicker patients, insurance companies are compensated for providing service to those patients who need it most. Thus insurance companies have no incentive to deter high cost individuals from taking insurance and are compensated if they have to pay out more than a threshold.

And if a citizen wants to change companies, or buy additional insurance, they are free to. The government even runs a website allowing patients to comparison-shop among the different insurance companies and hospitals based upon their ratings for quality, outcomes and performance indicators.

The incentives are designed to provide excellent care to as many people as possible, cheaply and efficiently no matter what their health status.

Half of insurers’ income consists of the income-related contribution that employers withhold as earmarked taxation, channelled to insurers through a central fund under the authority of the tax department. For the remaining 50%, insured people pay a flat rate premium directly to their insurer and patients pay modest amounts of user fees. Low-income groups, almost 40% of the population — can apply for a Government subsidy.

Surveys show the Dutch are the least likely to think their system needs major reforms and have one of the best access rates with most patients being able to see a physician within the same day.

They also have shorter waiting for elective surgery along with the shortest A&E wait times. They are the least likely to avoid medical care or to fail to fill a prescription due to concerns over cost.

However, the system is not without its detractors. An analysis, by Professor Dr Fred van Eenennaam of Nyenrode Business School, reflects growing concern at the huge increase in costs over the past decade.

Accessibility, availability and quality have all been under pressure. Because of the aging population, concerns have grown about the increasing number of people who will need healthcare services in the future. Furthermore, more people will suffer from chronic problems such as diabetes along with cardiac and vascular diseases.