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July 22, 2014

Up the down escalator

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Dr Muiris Houston

Fresh from the Health Service Reform conference hosted by the think-tank TASC, Dr Muiris Houston analyses the Government’s record in year one and the potential pitfalls ahead.

After years of failed health reform, the Coalition Government assumed power with radical plans to shake up our health service. One year after taking up office, what has it achieved?

In a passionate defence of his plans, the Minister for Health Dr James Reilly has argued that progress is achievable in poor economic circumstances, citing the successful major reform of the NHS in Britain immediately after the Second World War. Speaking at a conference organised by the think-tank TASC, the Adelaide Hospital Society and the Jesuit Centre for Faith and Justice recently, Dr Reilly claimed reform was already working; thanks to his Department’s Special Delivery Unit, emergency department waiting times have been reduced and the number of ‘same-day’ surgical operations have increased.

But others voiced their concerns about the reform details, many of which are based on recent changes in the Dutch health system. Described by Richard Layte of the ESRI as a health economist’s dream because of its complexity, the Irish health service is dominated by different models of hospital care and a significantly underdeveloped primary care sector. In contrast, the Netherlands has one of the best-developed primary care systems in the world, giving it a solid base for reform.

Trinity College Dublin lecturer Steve Thomas likened the task facing Dr Reilly and his colleagues as “going up the down escalator”. He voiced concerns about elements of Universal Health Insurance (UHI), the lynchpin of the Government’s health plans; specifically that the population of the Republic is too small to support multiple health insurers. And the conference heard of concerns that the UHI model may unravel due to rapidly increasing costs once the current recession is over.

The myth that competition has been the key to cost containment in the Netherlands has obscured a crucial reality. Healthcare systems in Europe, Canada, Japan, and beyond rely on regulation of prices, co-ordinated payment, budgets, and in some cases limits on selected expensive medical technologies to contain health spending. So system-wide regulation of spending, rather than competition among insurers, is the key to controlling costs.

Dr Kieke Okma of New York University spoke of the lessons to be learned from international experience. If the Government wishes to follow the Dutch model, she believes it needs to be aware of the gap between policy intentions and outcomes. Advocates of the Dutch system had argued that competition among private insurers would reduce healthcare spending, enhance consumer choice, and improve the quality of care and the health system’s responsiveness to patients.

Before 2006, the Netherlands had a mixed health insurance system, with more than 60 per cent of the population covered by mandatory social insurance, administered by non-profit sick funds. The remaining population had private insurance, voluntarily purchased.

However, since 2006, Dutch healthcare expenditure has outpaced inflation, with the total cost of health insurance for Dutch families rising by over 40 per cent. The numbers who change provider each year is small and the Dutch experience suggests that in spite of expectations, the regulatory role of government in healthcare has expanded rather than diminished.

Minister of State with Responsibility for Primary Care Róisín Shortall was refreshingly honest in naming a number of outstanding deficiencies in our health system

Health budgets
A recent analysis of the Dutch experience, published online in the British Medical Journal, warned of the “unintended” consequences of personal health budgets, a key element of Fine Gael’s health manifesto prior to last year’s general election. Prof Martin McKee, Professor of European Public Health at the London School of Hygiene and Tropical Medicine, and colleagues from the Netherlands say that “unless the lessons of the Dutch experience are learnt, the unintended and negative consequences will outnumber the positive, empowering role of personal budgets”.

Minister of State with Responsibility for Primary Care Róisín Shortall was refreshingly honest in naming a number of outstanding deficiencies in our health system.

Surprisingly, there is still no separate primary care budget within the HSE. And despite its plethora of national directorates, there is no national director of primary care in the health service. When added to the paltry development of functioning primary care teams and so few primary care centres, it is clear that much fundamental structural development is needed.

It is amazing to hear everyone speak about how central primary care will be to rejuvenating the health service while at the same time glossing over how poorly developed the sector is here. And no-one seems to be arguing that to transform primary care will take a chunk of money — a transformation that must take place before universal health insurance can become a reality.

While progress on health reform is being made, it is vital that Government listens to the many voices of experience out there. We simply cannot allow another botched operation that produced the HSE white elephant to be carried out.