OPINION:Public patients needto be reassured that they won't be stuck in a queue while insured people get seen faster
THE GOVERNMENT has a mandate to provide universal health insurance. The prime motivation is to create equal access to health services through a single-tier system, however defined. The change will be immensely complex. It is accepted this is a two-term task, so it could be 2021 before it is in place. For this year, a White Paper is promised.
A person without health insurance – especially someone who has recently had to cancel their policy – might well ask, can any assurance be given about equal access to healthcare before 2021? How can they be sure they won’t be in a slow-moving queue while insured people get seen faster, perhaps even in the same hospital?
Here’s one step that can be taken now.
A health equal status act could be introduced to bring the timing and quality of publicly funded healthcare under the scope of equality and anti-discrimination legislation.
The Equal Status Act (2000) already prohibits discrimination on the grounds of gender, marital status, family status, sexual orientation, religion, age, disability, race and membership of the Traveller community.
A health equal status act would add one more ground for non-discrimination, in respect of public hospital care: public or private status.
We would think it preposterous if a person attending a public hospital were admitted more slowly based on their race or gender. The Equality Tribunal would rightly find against the hospital or doctor in favour of the complainant. It has already found against public heath services on grounds of disability, for example.
The Equal Status Act already allows for clinical judgment to prioritise patients. There is no need to interfere with that. This proposal is only about discrimination between people who have health insurance (or are willing to pay privately) and those without. It would say a public patient can’t be discriminated against in access to publicly funded health services just because they are a public patient. Access should be based on clinical need. It sounds simple, but it does not yet exist in law.
Successive governments have favoured equity of access to healthcare through wider public provision alongside, awkwardly at times, the consultant contract. Public hospital care was extended to all the population, universally, through a social partnership agreement in the early 1990s. The pre-existing right of consultants to earn fees from private practice in public hospitals was continued. There have been variations and developments since, notably in the 2008 contract, where access to outpatient diagnostics is to be on common, “one for all” basis and optional “public only” contracts were introduced.
Most consultants in public hospitals have a contractual right to carry out private practice, up to limits of 20 or 30 per cent of patients. But even when this is adhered to, it is not possible to assure any individual public patient that their waiting time has not been longer than that of a private patient with the same medical condition. If the patient claimed it was longer, and if even if that were proven, they would still have no grounds for complaint, so long as the consultant was within the 20 per cent or 30 per cent ratio.
The consultants’ right to private practice is not a right to earn fees by means of discrimination. In any event, the 2008 consultant contract is subject to statute law, which can change. A statute requiring the contractual right to private practice in a public hospital to be exercised subject to non-discrimination would not interfere with their ability to earn fees or to treat 20 or 30 per cent private patients. Private practice would continue but without discrimination as regards timing of access.
What it would mean, however, is that public hospitals and consultants, who would continue to make admission decisions and prioritise the clinical care of patients, would have to put in place administrative systems to make sure they could demonstrate that they had admitted patients in a non-discriminatory way.
The grounds for complaint of discrimination would have to be tightly defined, and the importance of compliance taken very seriously by both hospitals and consultants, to avoid scarce resources for health being diverted into paying multiple claims for compensation. The converse of consultants having autonomy in clinical prioritisation of patients would be a personal responsibility to do so in a non-discriminatory way.
Some will describe this as a “common waiting list”. Unfortunately, this communicates negativity and poor performance. No one talks about a common waiting list at GP surgeries, as between medical card and other patients. People don’t complain much about being on a waiting list for private care, but unless it is instant, there is by definition a queue, a waiting list. Basically, a common waiting list is not a useful way to describe what should be a responsive, quality and fair service.
This proposal is limited to publicly funded healthcare. If the State in future purchases care for public patients from private hospitals under a money-follows-the-patient system, which is also on the Government’s agenda, one would expect all patients of private hospitals to be treated equally, irrespective of who was paying for them. No private hospital would object.
Going beyond that, laws should respect an individual’s freedom to seek out and purchase healthcare for oneself beyond, or separate to, public healthcare. Even in the UK, with the NHS tradition, 15 per cent of the population are covered by private health insurance in a £5 billion market. The NHS is single tier, but this does not prevent people from purchasing private health insurance, even for hospital care available on the NHS. Private hospitals in the UK are not obliged to treat NHS patients, but do so if the NHS pays.
For Ireland at present, a short health equal status act would provide assurance to public patients that the public health system was fair. It would pave the way for equity under money-follows-the-patient, and deliver some of the desired benefits in advance of the complex change towards universal health insurance.
Oliver O’Connor is an independent consultant in health finance and economics. He was special adviser to the minister for health from 2004-2010