Paying for a swift alternative

New 'emergency' clinics are opening for those of us prepared to pay to avoid having to wait hours for treatment

THE NUMBER of private emergency medicine facilities was swelled in recent weeks by the opening of two new centres in Dublin.

While the Hermitage Medical Clinical Clinic in Lucan and the Xpress Med Urgent Care Centre in Smithfield are the latest additions, the reasons for the expansion are obvious to any recent visitor to a public accident and emergency department.

With half the population paying for private health insurance, many are willing to pay for a swift alternative to queuing for hours to X-ray a suspected sprained ankle or stitch a DIY injury.

Providers of private emergency medicine have clearly identified this disgruntled patient market, and are moving to meet demand.

This expansion of private emergency medicine has received a muted reception from some healthcare professionals, with GPs in particular conscious of the potential competition.

There have also been discontented murmurings about a further entrenchment of a two-tier health system based on ability to pay, and the fact that the private sector units predominantly provide services during business hours.

The type of services available can be split into two broad groups: emergency departments and minor injuries clinics.

In the first category, emergency departments are operated by the Hermitage Clinic in Lucan, Co Dublin; the Beacon in Sandyford, Co Dublin; and the Galway Clinic.

These offer treatment by an emergency consultant and access to a wide range of consultant specialists, diagnostics and can admit the more severely ill.

They do not accept HSE ambulances nor the most seriously injured patients such as car-crash victims. Most open 9am-7pm weekdays, with some opening at weekends to cater for sports injuries. A key selling point is that the medical care is consultant provided.

Despite new entrants coming into the market, it is not seen as immediately profitable. A Beacon Clinic spokeswoman said their "emergency department was never planned to make a profit, but rather to be an alternate access point for patients".

Mark Sheehan, business development manager of the Galway Clinic agrees, and frankly admits the emergency service is a loss leader.

"If you took our AE department as a standalone unit, it is loss-making. But we get a lot of admissions through this route."

Sheehan says about 160 patients a week present at the department with 30 per cent based on GP referrals. While patients are predominantly health insurance holders, Sheehan says the hospital will treat whoever comes through the door.

Sheehan rejects suggestions that private emergency departments lean on the nearest public AE by referring on more complicated or potentially costly patients.

"We are not embarrassed to say that from time to time we will need other expertise. We will send neurological cases to Dublin for example. But less than 3 per cent of our patients are referred on, and sometimes patients from UCHG come to us. We see it as a two-way street," he says.

Given the tight margins for private emergency departments, Sheehan identifies minor injuries clinics, the second category of private emergency medicine, as most likely to expand. "That business is all based on volume. You need a large volume of patients in a large catchment area with the right demographic profile," he says.

"In simple terms, minor injuries are more profitable, the sicker patients are less profitable. It is not our model but I see that model being developed."

Among the minor injuries units Sheehan refers to are the VHI Swiftcare clinics and the recently opened Xpress Med Urgent Care Centre in Smithfield, in the north of Dublin city.

Dave Shanahan is chief executive of Charter Medical Group, which developed the Smithfield clinic as a joint venture with Hibernian Insurance, the purchaser of Vivas Health.

"If you look at an average public AE, even a good day, around 60 per cent of the people in the waiting rooms don't really need to be there," says Shanahan.

"The patients are ambulant [can walk] and sub-acute, and can be dealt with more quickly in a more appropriate setting. I have heard the argument about cherry-picking patients but I don't agree with it."

Charter uses AE registrars or consultants to provide its service and Shanahan sees opportunities to expand the business model into every "large metropolitan area" in the State.

The Smithfield centre can treat up to 100 patients a day and Shanahan expects it will start to turn a profit in "around 18 months".

"Our service frees up capacity. If patients need an X-ray, a CT scan or a Dexa scan, there is no need for them to be in AE. AE units in Irish public hospitals weren't set up for minor sutures," says Shanahan.

While the private sector claims to be alleviating pressure on the public AEs, its impact is unclear.

According to the HSE, the number of patients presenting at public emergency departments last year rose by 3 per cent to 1.14 million, compared with 2006.

In volume terms, one of the largest providers of private minor injuries care in the State are the VHI Swiftcare clinics. Tim McKeown, head of diversified business at VHI, said the three Dublin centres at Balally, on the southside near Dundrum, DCU and Swords centres deal with an average of 1,100 patients a week.

In recent weeks, the company has expanded outside Dublin, and opened clinics in Waterford and Cork with a projected combined turnover of 500 patients a week.

VHI Swiftcare clinics are staffed by "urgent care" doctors, from Australia, South Africa and New Zealand where this care model is more established. The doctors are supplemented by consultants, particularly in orthopaedics, says McKeown.

"Our business model aims to be a national middle tier between GPs and acute hospitals. If someone hasn't got health insurance, then it's just like a GP, you get treated and you pay. We send details of their visit to their GP, so the family doctor has a record.

"The majority of presentations are breaks, sprains and minor lacerations. There are a high proportion of muscular skeletal injuries and about 50 per cent of our patients require an X-ray and 15 per cent turn out to be a fracture," McKeown says.

About 10 per cent of patients are referred by GPs, he says.

There is a strong seasonal element to the business, with McKeown saying bouncy castle and tag rugby injuries present in summer, and rugby players and ice-skaters in winter.

Depending on the success of the expansion, McKeown believes there is scope for three more VHI Swiftcare clinics but declined to identify locations.

With referrals, a central part of the business model, private emergency medicine providers all profess to having good working relationships with local GPs.

However, Irish Medical Organisation GP Committee chairman Dr Ronan Boland believes private emergency units run counter to the Government's intention of centralising services.

"It's a fragmentation of services, and it also would be fair to say doctors have huge concerns about the further development of a two-tier system whereby access to a range of services is purely on the basis of an ability to pay."

The Blackpool, Co Cork-based GP adds he can "scarcely conceive of an instance in which I would refer a patient to one of these clinics rather than to a public emergency department". He believes many private emergency units are treating patients who could be dealt with by a local GP or out-of-hours clinic and questions the competitive advantage afforded the private sector in being able to advertise.

"We must remember at all times that these centres are designed to make a profit. They are predominately targeted at affluent areas in our major cities. That is where the value and the volume comes in. They then set their criteria sufficiently tightly to exclude the messy, resource-intensive cases.

"I am also concerned about the extent to which patients are self-referring to these clinics. With a profit imperative there is an incentive to investigate more and use more diagnostics or investigations which a GP would not order."

While Boland does not welcome the growing presence of the private sector in emergency medicine, he admits it's filling a service gap.

"I would accept that a niche has arisen and that we have problems in AE with people inappropriately attending and having to wait inordinate amounts of time for relatively simple procedures."

Dr James Reilly, Fine Gael health spokesman, agrees that difficulties in public AEs have created a demand for an alternative.

"There is a market out there for private emergency services because people are deeply unhappy with the public service, notwithstanding the fact that people end up paying twice, through health insurance and tax, for the same service," says Reilly.

Reilly says the growth of private emergency medicine is also a reflection of the "present Government's ideological belief that people should use private healthcare providers".

The view of the HSE and the department on the expansion of this sector is difficult to discern.

Because no licensing for a private healthcare facility is required, they effectively have no route to object, nor any control over where clinics are located.

However, the fact that the Minister for Health, Ms Harney, formally opened the emergency department at the Hermitage Clinic recently suggests the Government is taking a benign view.

The view of the department and the HSE is important, because most operators of private emergency departments intimated they would welcome the opportunity to provide AE services under contract to the public service, in much the same basis as the National Treatment Purchase Fund.

Hermitage chief executive Eamonn FitzGerald says while HSE contract work is not a major part of the business plan, "there is an interest to provide services to the HSE".

He says until there is sufficient capacity in the public sector, it makes sense to look at the private hospitals.

"It should also be noted that because we share consultants with most of the acute hospitals in our area, it is the same clinical expertise."

He also stresses that the Hermitage discourages self-referrals.

Currently, the Health Information and Quality Authority (HIQA) has no statutory entitlement to investigate the private hospitals, but FitzGerald hopes this will change.

"We have met with HIQA and we are keen to work with them to develop safe, high-quality care in the independent sector."

Asked how he expects the emergency medicine market to develop, FitzGerald points to a universal health insurance model as the preferred option: "This would allow the money follow the patient.

"The patient, through their GP, can then determine how and where their needs can best be met."

What's on offer: check theprivate treatments available

All private emergency medicine providers have a detailed list of conditions they will and will not treat and patients should check with their planned service provider before presenting.

There are a number of broad similarities in the restrictions.

Most private emergency departments and clinics do not treat young children, usually defined as those under four years old, unless it is a minor injury, such as a cut or a sprain.

They also refuse to treat acute illnesses or psychiatric conditions.

Minor injury clinics will also usually not deal with pregnancy-related conditions.

While the private emergency departments can treat and admit patients and offer on-site surgical, medical, cardiology and orthopaedic specialists (among others) on site, they will not accept patients from ambulances.

Minor injuries clinics also tend to decline patients with chest pain or severe breathing difficulty, burns, loss of consciousness and serious head or neck injuries.

Private clinics: artificial market?

The underdevelopment of emergency departments in public hospitals has created an "artificial" market for providers of private minor injury clinics, according to a senior hospital consultant.

James Binchy, consultant in emergency medicine in University College Hospital Galway (UCHG) and honorary secretary of the Irish Association of Emergency Medicine, says despite the enthusiasm of the Minister for Health, Mary Harney, for private minor injury units, "all the international evidence show they make no impact on emergency department overcrowding".

"In the UK, overcrowding in emergency departments was solved without recourse to the private sector.

"In the US, Australia and New Zealand, where they have large numbers of these minor injuries and walk-in centres, they have made no impact on emergency department overcrowding at all."

Binchy is also concerned that there are simply not enough emergency medicine consultants to adequately staff the new units.

"The biggest issue is clinical governance.

"If it is a consultant-led system, they will have to be trained emergency consultants and there are only 51 or 52 of these in the country."

He says that private sector involvement in this sphere will also lead to a competition for key staff, many of which the public sector will have invested time and money in training.

"These centres will make no contribution to overcrowding.

"The majority of people in accident and emergency departments are elderly patients with co-morbidity and uninsured," he says.

Binchy conducts a number of private medical sessions at the Galway Clinic but says his interest is not in developing the private emergency department there.