Competition in Primary HealthCare in Ireland:More and Bettter Services for Less Money

heard on the radio that a paper is going the rounds of HSE ……

simply stop issuing medical cards ….. [i.e. let them die]

cut more hours from the home help and carers budgets [i.e. let them die]

I cannot believe that this madness is continuing ….. and that a few billion will be paid out to unsecured bondholders before XMAS …

Maybe we should give that essay to the Troika, and say this is fulfilment of the MoU Q3, 2011 requirement to introduce legislation to deal with the supply of GPs, competition etc .

Before there are any changes to the health service south of the border in the direction of reducing private sector provision of health care, which seems to be what the left-wing ideologues in the media and academia want, there should be a thorough investigation of why the almost entirely public health service north of the border is lagging so far behind its counterpart south of the border in reducing mortality rates.

Since 1996, mortality rates have fallen on average by well over twice as much south of the border as north of the border. Before a ‘socialist’ health service is introduced south of the border, there should be an investigation as to why. I have calculated the falls in mortality rates north and south of the border for 10 age-groups between 1996 and 2010 (figures from NISRA for the north and CSO from the south):

note: – indicates fall , + indicates rise

age-group 0- 4: north -0.5% , south -37.2%

age-group 5-14: north -10.2% , south -44.1%

age-group 15-24: north +9.6% , south -28.6%

age-group 25-34: north -4.8% , south -35.3%

age-group 35-44: north +5.5% , south -20.5%

age-group 45-54: north -7.4% , south -28.7%

age-group 55-64: north -27.8% , south -39.9%

age-group 65-74: north -36.5% , south -45.3%

age-group 75-84: north -31.3% , south -37.3%

age-group 85 plus: north -6.4% , south -29.3%

A considerable body of opinion is of the view that, when people are given more responsibility for obtaining their own health care, they make better choices and may look after their health better. These figures seem to bear that out.

Of course, factors such as climate and diet also affect outcomes. However, to be perfectly frank about it, I have never noticed much difference in the climate or dietary habits as between Tyrone/Fermanagh and Longford/Westmeath. So, the explanation is more likely to lie in the different systems of healthcare provision.

Some competent health statistician, such as Brendan Walsh or Seamus Coffey, should be invited to investigate the diverging mortality trends on either side of the border before left-wing ideologues dismantle the part-private part-public health service south of the border and replace it with an entirely public health service, such as now exists north of the border, but which is failing dismally in comparison.

I know next to nothing about the workings of our health service…… – but when you introduce competion into any utility or indeed any company and it somehow becomes more “efficient” – it creates a surplus that must be recycled – ( In the past a rich doctor buys a grandiose house , employs a builder , a nanny for his kids etc. etc.)

Remember efficiency & productivity are two very different things.
If this company or that is externally owned the profit surplus will leak out of the country.

I am reminded of the old brewery industry vs the new brewery industry – the drinks are still consumed domestically but the shareholders are now outside the country or at least anonymous and very little labour is involved in its manufacture – on the other side the advantage is better quality beer in the main although a tad antiseptic.

Who gets the surplus ?
This is the most profound question of the globalised age – the service / product providers are outside all poltical control.
This may have its obvious advantages but it makes the idea of community & politics completly redundant.

@JtO
Life expectancy at birth for males is 76.8 years in RoI and 76.7 years in NI.

Life expectancy at birth is 81.6 years for females in RoI and 81.3 years in NI.

The RoI figures are for the 2005-07 period and are estimated by the CSO. The NI figures are for the 2007-09 period and are estimated by the ONS.

But life expectancy is beside the point – UHI is not about outcomes it’s about dealing with inequity in access. I’m sure you would agree that there are serious problems with socioeconomic inequities in access to healthcare in the Republic.

Seriously? Have you seen how much money gets spent per capita in the US? And have you seen the worse health outcomes?

And this is presented as a serious paper? Does the phrase “free market” remove all sense of reason from political leaders? Critical thinking just grinds to a halt the moment “competition” is a possibility.

How much shopping around for ambulance prices and cardiologist price/outcome ratios will you do if you’re having a heart attack on a street corner? How many doctors do you want to chat with about your hemeroids in order to get the best price? This stuff isn’t like going out and trying on shoes. Get a freaking clues people.

@David O’Donnell

It sounds like madness that won’t even save money in the short term, but it’ll save money in one budget while busting another, and for the manager whose budget is reduced, that’s the right outcome.

@Sarah Carey
See page 37 for the survival data.

This post, the paper highlighted and some of the comments on this thread reveal various aspects of the current malaise in the body economic and politic.

First, the paper that has been selected for the post. Is it, perhaps, an attempt to draw attention to an aspect of this ‘internal devaluation’ that is talked about much in the abstract, but rarely, if ever, considered in terms of the detailed policy and regulatory reforms that will be required? The paper is quite specific “..[excessive costs and under-utilisation of primary healthcare].. in turn can increase Ireland’s overall health expenditure and contribute to a higher cost of living in Ireland and thus lower competitiveness.” The timidity of the academics to even talk about these issues – not to mind employing their publicly-funded knowledge and competence to engage in these issues – is a dereliction of duty and responsibility – but, perhaps, perfectly understandable.

Secondly, the ‘political’ context. It appears that, when the Troika arrived last November, the then Government – or, more likely, the senior levels of the government machine behind it – had begun to develop a broad programme of structural reform. The Croke Park deal, irrespective of its pros and cons, addressed broad public sector issues; the state asset review (with a focus on the semi-states) had been kicked off in the previous July; some consideration was being given to labour market reforms; a knee-jerk reaction to reduce the number of quangos collided with a desire to, some how, re-empower the Competition Authority and dela with consumer protection and representation; and the legal, medical and pharmacy professions were to be subject to some structural and regulatory reform.

Given its fully justified focus on fiscal sustainability, bank sector restructuring and financial regulation, it appears that the Troika broadly accepted this programme of ‘structural reform’ and it was adopted in the subsequent – and frequently revised – MoU. And we’ve seen ‘progress’ on a number of fronts in a politically balanced manner that attempts to reconcile FG’s promotion of the private sector urges with the more statist urges of Labour and the ICTU. But, while it may generate some benefits, it is all being advanced in a manner fundamentally determined by the top levels of the government machine to ensure a re-establishment of the pre-crash power and economic relationships. Although there are major fights ging on behind the scenes and the post-crash ‘settlement’ will differ in a number of respects from the pre-crash one, the desire to return to some form of ‘business-as-usual’ is overwhelming. The result will be a long drawn-out painful economic recovery for the vast majority of citizens who are not a party to these power and economic relationships.

Thridly, and, perhaps, most importantly the naive presumption in the paper – and typical of much of mainstream economics – that competition in primary health care is beneficial at all times and in all places. The idea that full retail competition is the only means of generating efficient outcomes in health, education, social welfare (and in the provision of utility services) seems to have taken hold among most politicians, policy-makers, regulators, academics and researchers and not argumeent will be brooked. Those who question it are immediately characterised as ante-deluvian, unrestrucrured Marxists and/or haters of personal liberty and free enterprise.

There is no recognition of the huge search, information and switching costs imposed on ordinary citizens. It is simply not good enough to label these services – in particular, primary medical services – as ‘credence goods’ and trust that regulation and ‘professionalism’ will minimise damage to the public. Irrespective any consideration of ‘rights’ to the universal provision of primary health care and education services, there is a strong case that competition in these areas should be ‘for the market’, rather than ‘in the market’. And there is an even stronger case for more democratic control and acocuntability at the local or regional level of the funding and provision of these services. There is ample scope for competition in the market to provide the specialist and secondary sevices commisioned by primary care providers.

But such alternatives are never given serious consideration because those who capture rents in the existing supply chain determine the policy agenda and ultimately finance the research. Once again, ordinanry citizens lose out.

@Paul Hunt

I agree with a lot of what you said, but I think the criticism of the author of the paper is a bit harsh. She works for the Competition Authority. It’s not her job to set health policy, just to comment on competition when a market exists. There is an enormous market in primary health care in Ireland at the moment. The list of goods and services that are offered by competing providers is endless. Flu shots is the classic example. The variation in price is incredible and there is a clear market failure here because of the extent to which entry is controlled and GPs manipulate information asymetry. I think the author of the paper does us a service by pointing these things out. Now it us up to others to propose an alternative. I’d agree with you that competition for the market of a service such as flu shots makes much more sense than the current system and when we have UHI that is exactly what we should be going for.

@Paul Hunt

The programme for government promises “A White Paper on Financing UHI will be published early in the Government’s first term and will review cost-effective pricing and funding mechanisms for care and care to be covered under UHI.” Presumably this will have to at least consider competition for aspects of the market in primary care.

Re secondary care “Insurers will negotiate directly with hospitals to help control costs and encourage innovation in the delivery of care.” Seems to imply at least some purchaser-provider split and the beginnings of a fight for value.

The White Paper will be interesting, no timetable for publication yet. Expect a fierce rearguard action and deliberate muddying of the waters from the day of publication onwards.

@Sarah Carey
“Can’t get to see one for all the not-sick people in the surgeries. Charges do have benefits.”

There is data on this and many other aspects of primary care in the NHS. Satisfaction with primary care in the NHS is very high. Satisfaction is often a poor indicator because it is too global. But when you get down to specific issues like waiting times the NHS does well. 71% of the general public report getting a GP appointment within 2 days. The fact that it is not 100% is not necessarily a sign of failure – to some unknown extent it reflects an active approach to managing need with lower priority cases asked to wait longer. Of course we have no idea what the stats are for Ireland because our doctors still have a feudal attitude to patient information. But rest assured there are plenty of GP practices in Ireland, usually in the poorest areas, where getting to see your GP within 2 days is not guaranteed.

UHI is not “universal free care” it is just another form of insurance. You will pay a premium just like under any form of insurance. There will be an insurance company. You will get a package of care, some things included, some things not. The main intention is not to improve health outcomes for the population as a whole but to reduce inequities in access for people from different socioeconomic groups. Not the poorest in society either – they have fairly good access already. It’s for those just above the income thresholds for medical cards, the upper working classes and lower middle classes.

On your larger point about the general complaining about the health system I think it’s very simple. If you have to rely on the ‘free’ bit of the system the care you receive is very average. Long watiing times, rude staff, general incompetence. Don’t take my word for it – it’s what the HSE thinks:

http://www.hse.ie/eng/staff/Healthstat/overall/hsopitalresults.html

It’s not all bad – there are pockets of quality across the country (James’s is an excellent hospital imo). And there are some things we are doing much better across the country than say 20 years ago, cancer being the stand out.

If you go private the care is more timely and people are nicer to you. I don’t know if the care you receive is any better – as I say the Irish medical fraternity don’t like nosey parkers asking about outcomes.

@Kevin Walsh
Apologies, I thought you were talking about the original post not the medical cards issue.

I don’t believe anyone is being arbitrarily denied a medical card at the moment or is likely to do so in the future. The process of applying for a medical card is centralised and the income guidelines are very clear. Maybe there is a discussion document going round the HSE about changing the income guidelines but I haven’t heard of anything.

@Sarah Carey

Maternity care in Ireland is a very mixed bag. The actual process of giving birth could be a more humane experience. Some of the units are a bit too gung-ho when it comes to inducing women and there is still too much suspicion of alternative models of care for low-risk women. But the whole package of ante- and post-natal care is good and free, and the mortality outcomes are superb. I don’t know anything about acute paediatrics. I would say that A&E care in general is a lot better than it used to be with some obvious exceptions (Tallaght).

Regarding patient experience, the HSE and the doctors and nurses only have themselves to blame if anecdote trumps evidence. They’ve shown no interest in getting any serious analysis of patient experience in Ireland off the ground. Until they take this seriously and start measuring and publishing data we all have to rely on anecdote. My own anecdotes would turn your hair white. Some of the things that are still going on in psychiatric facilities or residential care units are straight out of a horror film.