There is general agreement that our current health system is not working for most of the people who use it or who work in it. There is also consensus that we need to have a very different system of care; where people are not denied access due to waiting lists, the cost of care or geographic location; that everyone in Ireland is entitled to equitable access to timely, quality, integrated healthcare.
For the first time ever, there is a national political consensus on a radical health reform plan which will deliver universal healthcare. This plan, Sláintecare, was published by the Oireachtas Committee on the Future of Healthcare last May. After six months of little action, there have been some positive noises from the Government on Sláintecare in the last while. That said, the official government response and implementation roadmap due before Christmas has not yet been published and deadlines such as appointing an implementation lead and team have been missed.
International literature on successful major health system reform shows that the slower the reform, the more time that vested interests have to mobilise and oppose reform.
It should come as no surprise then that various vested interest groups have sought to rubbish the costings and declare Sláintecare unfeasible in an attempt to avoid universal healthcare.
These vested interests include the highest-paid healthcare professionals. When the reforms are fully implemented, hospital consultants would lose what they currently earn in private income from treating private patients in public hospitals. Under Sláintecare, consultants will be able to practise and earn income from private care in private hospitals.
Interestingly, there is no data on how much private consultants earn from their private work in public hospitals. Neither is there any tracking of whether consultants meet their public hospital work commitments under the 2008 contract.
Fair and efficient
Removing private care from public hospitals is essential to providing a fair and efficient health system and delivering universal healthcare. Access cannot be universal in a system which provides preferential access to privately insured patients in public hospitals. Therefore Sláintecare recommends ending this.
The only publicly available financial data on private care in public hospitals is how much public hospitals get from private insurers. In 2016, the last full year of this data, public hospitals received €652 million from insurance companies. Sláintecare recommends phasing out private care in public hospitals over a five-year period from the second year of the plan, acknowledging that removing the embedded nature of private care in public hospitals is complex, requiring time and dependent on the replacement of the private insurance income in public hospitals with public money.
Sláintecare costs this on the best available data at €4.5 billion over the 10 years not the €6.6-€8 billion figures claimed by consultants. There is no data on how much private care in public hospitals actually costs hospitals outside of the insurance fees paid. But there could be additional savings when care costs are more than the daily rate currently paid. Ending private care in public hospitals will free up time and resources for at least 20 per cent more elective care for public patients in public hospitals.
But this is just one measure. Sláintecare is the sum of the whole and utterly dependent on many moving parts all going in the same direction – more and better prevention and public health, more diagnosis and treatment outside of hospital in primary and social care, and integrated accessible care provided where feasible without a cost barrier.
Hospital consultants also claimed that the €2.836 billion Sláintecare price tag is a “thoroughly misleading under-estimation”. We agree this figure is the estimated cumulative annual cost by year 10 and the total costs over the full 10 years is closer to €19.8 billion. However this is in the context of overall public funding to health being close to €200 billion for 10 years. So a €19.8 billion price tag over a decade is actually quite small in comparison to the total overall public funding during this time and a reasonable price tag for a single-tier system, designed to meet population health needs.
Transition fund
Many of these total costs are not new or additional costs, they are switched so that households won’t pay directly out of pocket for them but will pay through government financing, paid by tax and public insurance they themselves contribute to. This “switching” of funding accounts for about half of the initial costs of expansion of entitlements. Furthermore, Sláintecare proposes a transition fund to deal with a one-off investment. This is best practice internationally and indeed is now endorsed by the “King’s Fund” as a strategy for the National Health Service. The recommendation is not to fund this through normal budgetary means.
Quite simply it is fanciful to maintain the current system. It is not affordable not to implement Sláintecare. Many vested interests groups will oppose Sláintecare because they fear change and because they like and profit from the status quo.
Government needs to publish its response to Sláintecare, face off the vested interests and get on with the long, hard work of delivering major health system reform in the public interest.
Sara Burke and Steve Thomas, Centre for Health Policy, Trinity College Dublin, were part of the Trinity team which provides technical assistance to the Oireachtas Committee on the Future of Healthcare