Public Private System

Everyone keeps harping on about the health service and how the government can go about improving the situation. But what no one seems to recognise is that we have a two-tier public-private system which significantly affects the system. Under the present arrangement 80% of the beds in acute hospitals may be designated as public while 20% may be private. It is estimated that the current ratio of private to public beds in public hospitals is being exceeded, with too many patients in public hospitals been designated private. This would raise the question of how this bed ratio affects the public waiting lists and the overcrowding in A&E. One could assume that if we did not have this two-tier system that at least 20% more beds could be made available and thus reduce many of the problems.

A report by Comhairle na nOspideal found that some consultants protect their beds by delaying discharge in order to insure bed availability for their incoming patients. This report found that delays in discharges usually happen over weekends, or other times when consultants were absent. It estimates that nearly two thirds of consultants currently have contracts that entitle them to treat private patients in the public hospital were they work. In the public system they are contracted and are paid on a salary basis, in the private system they are paid on a per patient basis. Figures from 2001 show that having a private practice, in affect doubles a consultant’s salary. Even without a private practice they are the highest paid in EU. So consultants are rewarded hugely to attend to private patients and it is questionable if this is at the expense of the public patients and the public hospital waiting lists. One commentator, Sean Conroy, put it succinctly: “If a publican paid her barman by the hour for covering the bar and by the drink for covering the lounge, it would be hard to get served in the bar”.

Consultants’ daily work is been divided in this two-tier system, and one could come to the conclusion that this is impacting negatively on the public system. Many consultants want to discharge their own patients. If they are absent there will be delays in discharge and causing more blocked beds. The Irish Nurses Organisation recently announced emergency measures to tackle the A&E problem. One of these has been the provision of additional ward rounds (at least three per day) to ensure a speedy discharge. Within the current two-tier system this may be virtually impossible for many consultants to do.

Consultants’ absence may also affect the A&E department directly. Eight out of ten times patients in A&E are seen by junior doctors. These doctors may be inexperienced, and are more likely to give substandard care over a longer period of time causing further delays. The government’s health strategy proposes a programme for improving A&E departments by appointing more A&E consultants and to designating a member of staff to liaise with patients awaiting treatment. Mary Harney remarked recently that consultants would have to change their working hours because patients often ended up staying in A&E overnight, because there was no consultant on duty after 6pm until 8 or 9 am the following morning.
The two-tier system offers unequal access for unequal care. These inequalities cause patients to wait longer to see consultants and to get treatments. During the waiting period the patient’s condition may worsen and inevitably present with more complex problems at a later stage. One radical solution would be to abolish the unequal two-tier health system. Canadians take enormous pride in their state-funded medical system. Many provinces have an outright ban on private health care. Since 1972 every Canadian has been covered by national health insurance for medical and hospital needs. This system could be possible in Ireland with the cooperation of the medical profession. Such a system could be feasible in Ireland. The funding could come from tax or introducing a compulsory insurance system. Maev-Ann Wren, author of Unhealthy State: Anatomy of a Sick Society believes that this would be a realistic solution, by banning private practices in public hospital and investing in public care so that the majority would opt to be treated in a one-tier public hospital by salaried consultants. She also warns against the risk of insufficient investment, which may cause doctors and patients to take flight into the private system and leave the two-tier system dominant. Unfortunately this government shows no signs of veering to a one-teir system and celebrates in the collaboration of public and private.