Where to now for health?
University College Cork’s Brian Turner reflects on the current status of Ireland’s health system and ponders how the new Government will be able to improve the situation.
As the Fine Gael-Labour Government leaves office after five years, Ireland’s health system is once again a major issue in the election. So how healthy is the health system, how did the outgoing Government fare and what can the next Government do to improve matters?
When it took office in 2011, the outgoing Government unveiled the most radical health reform proposals in the history of State. These included giving every resident free-at-the-point-of-use GP services, separating the HSE’s purchasing and provision functions, introducing a money-follows-the-patient (MFTP) reimbursement system and, finally, introducing universal health insurance (UHI), though that it did acknowledge this final element would require a second term.
While some progress has been made on some proposals, others remain a long way from being realised. To be fair, economic factors and austerity presented significant challenges, and any government would have struggled to push the health system forward under such circumstances, but even in better times the plans would have been ambitious.
Progress
The plan to roll out ‘free’ GP care ran into trouble early on, with legal difficulties being cited for abandoning the first stage, which was due to see it extended to those with long-term illnesses. As the curtain falls on the Government’s term, GP Visit cards have been extended to those aged under-6 and 70 or over who did not already have a medical card or GP Visit card. A proposal to extend this further to those aged under-12 is subject to negotiations on a new GP contract, which looks like it may not be straightforward.
Some progress has also been made on separating the purchasing and provision functions. Hospital Groups have been established as a first step towards independent hospital trusts. The implementation of MFTP has been slower than anticipated but is in progress. However, UHI now appears to have been abandoned, at least the proposed multi-purchaser model, although further research has been commissioned into alternative models. Talk has now switched from universal health insurance to universal health care.
In the meantime, lifetime community rating, involving late-entry loadings for those who put off purchasing private health insurance (PHI) until they are aged 35 or over, was introduced in May 2015. This was an effort to stabilise the market, which had seen not only a contraction in overall numbers but, more worryingly, a worsening age profile as younger consumers discontinued cover in greater numbers. Furthermore, State subsidisation of PHI was reduced with the capping of premiums subject to tax relief in 2013 and the application of charges for privately insured patients using all beds in public hospitals in 2014 (previously insurers were only charged if such patients were treated in private beds).
In addition to the drop in the number of people covered by PHI, the years of austerity also saw a sharp increase in the numbers of people with medical cards, although both trends have begun to unwind recently. As a result, more people are now reliant on the public system than before the economic crisis. Despite this, both spending and headcount were cut significantly. While there is evidence that the HSE was able to do more with less in the early years of the crisis, it was not able to continue this trend and we have seen increases in waiting lists and hospital overcrowding as a result.
Next steps
So what should (or indeed can) the incoming Government do to improve the Irish health system? In the first instance, expectations need to be managed. The kind of meaningful reform that most health manifestos propose will take far longer than one, or even two, terms of office. For that reason, some kind of consensus needs to prevail, to avoid changes in direction concurrent with electoral cycles. A national health forum should be established to elicit what kind of health system the Irish people want, how we want to pay for it, and crucially how much we are willing to pay for it.
Notwithstanding new figures, based on the System of Health Accounts, that show Ireland spending a relatively high share of Gross National Income on health, it is clear that more funding will be needed to reduce the financial burden on people visiting GPs, to provide more doctors, nurses and hospital beds, and to improve health outcomes for an ageing population.
It should also be borne in mind that the underfunding of the health system in the 1980s and 1990s has never fully been unwound. For example, the number of acute hospital beds in Ireland is around one sixth lower than it was in 1980, despite a one third increase in the overall population and a two thirds increase in the over-65 population over the same period. While there is an emphasis on reducing reliance on hospital treatment in favour of primary, community and continuing care, and while much of the treatment in hospitals has moved from inpatient to day care settings, we are still under-resourced in terms of bed numbers compared with the international average.
Rather than try to change the funding mechanism, the focus of the next Government(s) should be to reduce the overlap between the public and private funding and delivery mechanisms, which underlies many of the flaws in the Irish health system. While it is not unusual to have a mix of public and private funding and delivery – indeed, despite the ideological attraction of a single-tier health system, it is hard to think of any European country that has such a system – Ireland is unusual in the degree to which the two overlap, to the detriment of public patients in hospitals in particular.
The current system, whereby public hospitals and consultants who have private practice rights are paid largely on a fixed basis for treating public patients but on a fee-for-service basis for treating private patients, creates incentives to prioritise the latter, particularly in the context of reduced budgets and salary cuts.
One way to remove such incentives is to ensure that public hospitals are for public patients (bearing in mind that those with PHI still have a right to be treated as public patients). However, doing so will require contract renegotiations with consultants and increased funding to public hospitals to compensate for reduced private income and higher public patient throughput.
Improving the public health system will remove a major driver of demand for PHI, which is a lack of confidence in the public hospital system, and should lead naturally to a more equitable system. However, this will require significant ongoing investment. Politicians and the electorate need to accept this and have an honest debate about whether there is a collective willingness to pursue this objective.
