What a pity. What a pity when this State is wealthy enough to fund equal access to quality healthcare that this Government can look 10 years into the future and envisage the continuation of the two-tier system.
What a pity that a health strategy, worked on by so many dedicated people and offering plenty of good ideas and some quite brave ones, should retain at its heart the same flaw which lies at the heart of our inherited system.
Equity is no more than an aspiration in this strategy document entitled "Quality and Fairness". A "key message" of the document is summarised as: "Access to services to be more equitable - the perceived two-tier aspect of health care to be eliminated." Access is either equitable or not. "More equitable" should perhaps be translated as "less unfair".
How will this work? How will the service become more equitable if it is to retain the distinction between public and private patients in public State-funded hospitals?
The Tβnaiste, Ms Harney, unveiled a central aspect of the strategy: to ensure that "the large gap that has opened up between waiting times for public and private patients will be a thing of the past". This is the Progressive Democrats' recent proposal for a treatment purchase fund which will buy treatment in private hospitals or abroad for patients on the public waiting lists.
The proposal has a populist simplicity. By the end of 2002 no adult would wait for more than 12 months for treatment after their referral from an outpatient department, no child more than six. By the end of 2004, no public patients would wait more than three months, it was announced yesterday.
Significantly, however, both the Tβnaiste and the strategy document describe this latter objective as a "target" rather than a treatment guarantee.
"It will be a major challenge to meet. But it is absolutely right to set this standard," Ms Harney said.
This is not equity. Public patients can wait years to see a consultant before they are ever referred for treatment or counted as "waiting". Last June, Waterford Labour TD Mr Brian O'Shea raised the case in the Dβil of a 12-year-old boy with breathing difficulties who had been waiting to see a consultant for five years. Such a patient would be seen privately within weeks. The treatment purchase fund has no role to play for those whose condition has not even been assessed.
What about the quality of care which public patients receive? Under the present system private patients receive the personal care of consultants while public patients are frequently treated by junior doctors. Will this change? Not as a consequence of the strategy. Any change will depend on the outcome of negotiations on a new common contract for hospital consultants.
The strategy document states that "greater equity for public patients will be sought in a revised contract for hospital consultants".
"It will be proposed that newly appointed consultants would work exclusively for public patients for a specified number of years. This would mean that consultants would concentrate on treating public patients in the early years of their contract" but could develop private practice at a later stage, the strategy states.
At present, the majority of consultants who staff private hospitals are also paid a salary to work for an unmonitored 33 hours a week in public hospitals. A late draft of the health strategy reported in The Irish Times in October made the point that consultants' contracts covered "the hours committed to public hospitals and not the hours committed to public patients". This reference is absent in the published document.
The Government White Paper on private health insurance highlighted the risk that consultants would favour private patients because they are paid fees for each private patient on top of their public salary. Unless the consultants' contract is changed, the treatment purchase fund now offers an increased incentive for public hospital consultants to devote less time to working for public patients in public hospitals and more time to the private sector where they may now receive additional fees to treat both public and private patients.
Many consultants are unhappy with the current two-tier system. At a strategy meeting of consultants in the Irish Medical Organisation earlier this month there were calls for a special salary rate for consultants who wanted to focus on public work. A Fine Gael special health conference in Ennis 10 days ago heard an impassioned plea from a consultant who declared himself "fed up to the teeth" with our system which regarded private patients as "superior".
At his press conference yesterday, the Minister for Health, Mr Martin, said he did not underestimate the "significant challenge" that contract negotiations with the medical organisations would pose.
The Minister side-stepped questioning on why he had not introduced a common waiting list for public and private patients by stating that he intended to eliminate waiting lists. This would be achieved in a variety of ways such as by increasing bed capacity and the number of consultants.
Public patients will benefit by the allocation to their care of all the 3,000 planned additional acute hospital beds. A suggestion that private patients' elective admissions may be deferred in hospitals which fail to achieve public patients' target waiting times is brave in an election year.
What are the other good ideas in this strategy? It recognises that past under-spending has caused under-capacity in the healthcare system and sets out a long-term strategy to remedy it.
"This is the first time any strategy or Government has gone on record as saying that," a delighted Mr Donal O'Shea, chief executive of the Eastern Regional Health Authority, said yesterday.
Mr O'Shea, who has highlighted the pressing needs for extra beds in the eastern region, anticipates that he will be able to fund extra public beds and purchase care for public patients from the private sector.
Extra facilities for the elderly and for caring for people at home would reduce pressures on acute hospitals.
The new National Hospitals Agency will take problematic decisions about regional health services away from the health boards and advise the Minister on their location.
The Minister yesterday acknowledged that the ultimate decisions would be his but suggested that only a brave Minister would refuse the advice of his new agency.
The primary care document to be revealed in detail tomorrow promises to be far-reaching and may bring the Minister into further conflict with the medical profession.
The bottom line is funding, however. Not until the Budget will it be revealed how many more low-income families may qualify for medical cards.
The strategy document puts a price tag of £10 billion on the planned developments, of which £6 billion is for capital spending. In 10 years' time current spending would need to have risen by £4 billion annually to fund the new developments. This is on top of funding increases to maintain existing services which will cost £5.7 billion next year.
The strategy dismisses Opposition proposals for an insurance-funded health system. But with the Minister for Finance's continuing scepticism about funding healthcare and the strategy's failure to confront inequity, the Opposition's proposals will continue to be guaranteed a hearing in the run-up to the election.