Casting the Public Hospitals Adrift
Guest Blog Post by Marie O'Connor
First you cast the public hospitals adrift, then you turn them into business entities. That's the idea, anyway, behind the formation of the new hospital trusts. The Hanly Report has been resuscitated, this time in the guise of the hospital trusts report, which lays the foundation for the privatisation of our public hospital services. Under Universal Health Insurance (UHI), "the distinction between public and private health care will diminish" (page 62). Public hospitals will no longer be public: they will be "independent". Even the ambulance services are to become a trust, denationalised, like the maternity services, to enable them to be "configured to complement the hospital groups". For configuration, read reconfiguration.
The newly published report is short on detail: each hospital group, soon to become a trust - there are only six of them - will provide "a maternity service". That leaves a wide margin for manoeuvre. Maternity units in Cavan and Drogheda could close. The hospital trusts report commits only to maintaining maternity units in Tralee, Letterkenny and Wexford, so the future of the rest, including those in Portlaoise, Mullingar, Kilkenny, Clonmel, Ballinasloe, Castlebar and even Sligo, will depend on the new boards being created. These interim boards will decide on the cuts and closures within each hospital group, so the Government will no longer have to take the flak. Pure genius.
Nowhere does the report acknowledge that people have a right to accessible hospital services. The struggle of communities to maintain local hospitals is described on page 50 under the heading "Emotion", not equity. Smaller hospitals, we are assured, will provide more services, not less, but the history of Monaghan General Hospital shows otherwise. Ireland has one of the lowest allocations of acute hospitals per head of population in the European Union, and we are now preparing to slash and burn even further: children under five will not be seen in a local injuries unit.
All staff, clinical and non clinical, will be appointed to these hospital groups. With a further 4,000 jobs to go in the HSE, the new structures will pave the way for redeployment - and redundancies, presumably. There is a strong emphasis on "international" inputs. Hospital trust CEOs will be appointed through "open international competition" and each trust will be expected to tag onto a hospital "of international repute" and to "health service systems" overseas. My guess is these systems will be located in the US.
The new hospital landscape is called "managed competition". Hospitals will be "like private enterprises", cutting corners in the name of profit, presumably, to be reinvested in the enterprise. Creating an internal market, splitting the purchaser (still the State, mostly) from the provider (so-called not for profit hospitals), as Thatcher did in England in the 1980s, will lead to a massive increase in bureaucracy, which is the last thing our health service needs. Trusts can buy services as well as provide them, and private hospitals are hoping for a share of the cake.
UHI is modeled on the Dutch system, which has strong parallels with US-style managed care, where tens of millions are uninsured. Holland’s two-tier health system has been abolished––and replaced by a three-tier health system, where half a million people are either uninsured or in arrears. Under UHI, everyone will be legally required to take out private health insurance, but the cost of this has more than doubled in the last seven years. Bringing in the Dutch system, a gravy train for doctors, won't help. Premiums in Holland rose by over 40 per cent in the first five years of the new system. Household health insurance costs on average €4,and 500- €5,500 annually: the basic package costs over €1,200 per person, with employers deducting a further 7 per cent (up to a ceiling of €2,200) at source and the State dipping into social welfare payments. On top of all of this insurance-related extortion, people have to pay out of pocket for certain items and the standard basket of healthcare is so inadequate that anyone who can afford it takes out top up insurance. The pressure to drive down costs has also driven down quality, as it often does in for profit systems.
The government will now pay for services over which it has little or no control, and this loss of autonomy will extend to many hospitals. The biggest hospitals will rule: smaller hospitals may be managed directly by bigger ones. Clinical staff will also lose out to the managerial class. The new corporatised system is one where managers have "complete control of over the production of services" and "liquidation is the ultimate consequence of not remaining in budget" (page 47).
Cost control is widely acknowledged to be one of the main weaknesses of the Dutch system. That system, just seven years old, is untried and untested. More than 50 per cent of hospitals in the Netherlands were facing bankruptcy in 2011, five years after the introduction of universal health insurance.
So why are we doing this?