In times of great cynicism with our political leaders, it’s hard to believe that politics matter. In these times of greater economic pessimism, it’s even harder to believe that politics can bring about a better society or even a better health system, particularly as our macro- economic and fiscal decisions are largely beyond our control.
However, it is inconvertible that the new Government that took up office on 9 March 2011 means that there is substantial change ahead for the Irish health system – if the parties in government manage to deliver on their commitments.
So what difference will election 2011 have on the users of the Irish health system? From a health perspective it is safe to say that for the first time in the history of this state, election 2011 means an end to the unequal, two-tiered system of health care is in reach.
The newly adopted Programme for Government called ‘Government for National Recovery 2011-2016’ has “committed to developing a universal, single-tier health system, which guarantees access to medical care, based on need, not income”. This is good news for everyone. If, when and how this ‘guarantee’ to universal access to health care can be achieved is not so certain.
Both Fine Gael and the Labour Party campaigned for the election proposing different versions of universal health insurance (UHI). Despite the title of universal health insurance, in fact under both models, two-thirds to three-quarters of all health care will still be funded by the tax system, even after 2016.
Access to health care
Under the new Government’s plan, all citizens will be entitled to universal access to health care by 2016. Everyone will have to have insurance. Those with medical cards will have their insurance paid for by the state. Those who currently have private health insurance would pay no more than they currently do but will get more for it e.g. free GP care and those who currently have neither private health insurance nor medical cards will be subsidised by the state. However, the Programme for Government does not specify how much, if anything, this group will have to contribute towards their UHI.
Fine Gael, originally published its ‘FairCare’ proposals in April 2009, but have never produced the details they promised on how exactly they would achieve universal coverage. Four days before the election they produced an additional 28 pages which did not provide much more detail than before but did outline some changes of mind, crucially delaying the provision of GP care without charge and having the VHI as a public insurer. Central to the delivery of universal insurance is the detail of the proposed model which Fine Gael have never provided.
Two weeks in advance of the election, Labour published a detailed, 100-page policy document called ‘Fair Health Care’, despite 10 years of campaigning for universal health insurance. This included comprehensive costings with a timetable for its introduction plus clarity on the model proposed.
Labour’s policy proposed that everybody would be entitled to GP care without charge by 2014. Labour, using the last Government’s expert group report, costed this measure at €389 million and specified where they would make savings elsewhere to fund this move. This increase in numbers of GPs, nurses and primary health care professionals is now included in the Programme for Government.
So too is Labour’s proposal for staged access to GP care, with those now on the long-term illness scheme getting free GP care by 2012 and those on the high-tech drugs scheme getting it by 2013. But significantly the Programme for Government does not specify free GP care for all by 2014. Instead, it commits that “subsidised care will be extended to all in the next phase” and “access to care without fees will be extended to all in the final phase” but crucially does not give a date for this. Fine Gael won that battle by delaying everyone access to ‘free’ GP care, presumably on the basis of cost implications.
The Programme for Government commits to negotiating a new GP contract. GPs will be paid primarily through capitation, registration with a GP will be compulsory and there will be a strong focus on the management of chronic conditions in the community.
Universal health insurance
There will be universal hospital coverage from 2016 onwards. Under this scheme, every citizen will be entitled to the same package of services. According to the Programme for Government: “The universal health insurance system will be designed according to the European principle of social solidarity: access will be according to need and payment will be according to ability to pay. The principle of social solidarity will underpin all relevant legislation.”
The VHI will be kept in public ownership so that there is a public insurance option in the UHI system. A hospital insurance fund will subsidise or pay insurance premia for those who are on lower incomes, it will oversee a reformed system of risk equalisation and community rating and “control health care costs for which central control is most effective.” The fund, with the Minister for Health, will decide on the make-up of the UHI package. Hospitals and clinics providing care under UHI will not be allowed to sell faster access to anything covered by UHI.
A hospital care purchase agency, which will combine with the National Treatment Purchase Fund and the HSE’s purchasing function, will buy care for uninsured patients during the transition period. A Universal Health Insurance Act will be legislated for in the first term in office.
The structure and detail of the UHI proposals are closely in line with Labour’s proposals with a stronger state input, leaving less to the vagaries of the market.
Public hospitals will become independent not-for-profit hospital trusts which will negotiate with insurers who will purchase care.
The HSE will cease to exist but in reality most people who now work in the HSE will continue to do so just under a different employer, either an independent hospital trust, the integrated care services at local level, the hospital insurance fund or the Department of Health. Critically, there is no number named on how many staff will come out of the health system. In fact more will be added, for example in primary care. Again, this was a clear victory for Labour. Fine Gael’s plans to divide services in ‘care’ and ‘cure’ has been abandoned.
The programme also commits to a much stronger role for the department and Minister of Health alongside an increase in transparency and accountability. It clearly specifies the need for better resourcing of mental health services, a stronger focus on primary care, reducing waiting times and providing quality services as near as possible to people’s home.
A special delivery unit will be established in the Department of Health to reduce waiting lists and upgrade IT capabilities and a patient safety authority will set up which will incorporate the HIQA. Both of these were Fine Gael ‘wins’ in the negotiations as they are clearly based on their proposals.
The new Government commits to cut consultants’ pay under a new hospital consultants’ contract and to abandon the policy of co-locating private hospitals on the grounds of public hospitals.
Despite both parties’ campaigning for the election on the basis of abolishing the recently introduced prescription charges for medica
l card holders, there is no mention of this in their joint plan.
Vital to what actually happens is the new Minister for Health. James Reilly has been firmly rewarded for his loyalty to Enda Kenny in the leadership heave last year; he is now in the highest health post. While the seven pages on health in the Programme for Government are more Labour than Fine Gael, they are a compromise of both parties’ proposals, and ultimately it is the Minister that will call the shots and decide on the detail.
Only time can tell the extent and the success of the change that lies ahead for the Irish health system, but the indicators are we are moving in the right direction. However, failure to improve our dire economic situation could mean more difficult, rather than rosier times ahead for the users and staff of the health services.