Implementing Social Health Insurance in Ireland

This opinion piece was published in the Irish Times on Tuesday 12th February 2011.

Implementing Social Health Insurance in Ireland, a report of the workshop held on December 6th, 2010, will be published today by DCU. The report is edited by Prof Anthony Staines of the school of nursing in DCU which sponsored the workshop. Participants included Prof Peter Groenewegen of Nivel, the Netherlands Institute for Health Services Research; Prof Orla Hardiman of Beaumont Hospital; Dr Martin White of Nobber General Practice; Dr Steven Thomas of Trinity College Dublin; Dr Gerard Crotty from Tullamore; as well as Dr Davida De La Harpe, FPHM; Dr Michael Drumm, MMUH; Dr Maire O’Connor, FPHM; Dr Susan Smith, Inchicore Medical Centre; Dr Mary Rose Sweeney, DCU; and others

It seems likely the next government will be made up of Fine Gael and Labour. Both propose extensive changes to the health service and both propose to introduce universal health insurance.

Last weekend, Fine Gael published a detailed policy proposing to introduce a social health insurance scheme, modelled roughly on the system in the Netherlands. Labour has yet to publish its detailed policies.

In the Netherlands everyone is required to have health insurance, with the premium paid, or subsidised, by the state for people on low incomes. This provides free access on equal terms to primary care, ie GPs and related services, to prescriptions, to mental health services and to hospital care.

Like our own health insurers, they apply community rating, but unlike ours, they have a working system of risk equalisation. Long-term care is funded separately from other health services.

Can we really implement a social health insurance system in Ireland? A group of national and international experts, clinicians, managers, policy makers and others met in Dublin just before Christmas to consider this question. Some basic principles of care delivery were brought out at the conference.

Care needs to be patient centred, not determined by the needs of the institutions. Access to care must not depend on patients’ resources. A system which places a high priority on equity and social solidarity can be built and can be delivered within the existing budget. Such a system must have accountability, visibility of outcomes, resources and activity.

The first source of concern is the miserable track record of both the Health Service Executive (HSE) and the Department of Health in effecting change. Although there are some recent successes, most notably the partial reorganisation of cancer services, there are a lot more failures. Overcoming this will need political, managerial and clinical leadership, as well as substantial training and support for staff.

The leadership exists within HSE. Will it come out? Will managers and clinicians line up behind the sort of radical reform that is needed? The view of those of us who met before Christmas is that clinical leadership is essential, and will be forthcoming.

In primary care, including general practice, the main obstacle is overcoming decades of underinvestment without spending much money. It is possible to build up primary care relatively cheaply. There are large resources spent in the sector, but there is an absence of co-ordination between different professionals.

Providing shared spaces, meetings and common record systems will cost little, and should be helpful. Moving away from the present highly centralised model of primary care development, acknowledging that the best ideas for primary care development in each area will come from the people working there and supporting a more organic model of service development, more attuned to local needs, will help. This is all quite possible.

The acute hospital sector is of very variable quality and it is impossible to make any reasoned assessment of the performance of these organisations. Maurice Hayes’s recent report on Tallaght hospital, allegedly one of the better run facilities, does not make for comforting reading.

It ought to be possible to save money and get a more intelligent use of resources by merging hospitals into groups with a common management. The first steps on this path have already been taken. A much wider use of shared services is also essential, with, for example, a common purchasing agency for the whole sector.

It will be much harder to get the hospitals to refocus on servicing primary care. To take one example, there are several huge clinics for treating diabetes in Irish hospitals. These are very costly and most of these patients ought to be fully managed in general practice. There are a number of other examples of this kind of pointless gigantism. A revised hospital system would have many staff, doctors, nurses and others, who spent most of their time off the premises.

Long-term care is also a challenge. The question is: “Whose interests will prevail: those of the clients, or those of the institutions which seek to provide care for them?” At the moment the institutions are winning. It’s not at all clear that the Fair Deal nursing home funding policy is economically sustainable.

The nursing home sector grew rapidly, and in a completely unplanned way, thanks to careless tax breaks. It’s not clear that it meets the needs, or the reasonable desires, of elderly people to remain living in their own homes. The budget for home care for the frail elderly is under threat and this may lead to people being bumped into nursing homes who do not need to be there and do not wish to be there.

The same issue affects people with disabilities. A more reasonable model for both groups is to provide them with individual budgets and let them source the care they need, using their own judgement.

The final pieces of the jigsaw are the insurance companies and their regulators. It’s very doubtful if any of the current crop of health insurers have the skills and the capacity to take on the task of running a social health insurance system. The demands on the insurers are much tougher than in our current system, and so the new insurer will cost a lot more to run. In fact, it’s questionable whether there is room for more than one such insurance company in a small country of only 4.5 million people.

Equally, the regulator will need to change its role. Without very tight regulation, and very tough enforcement, a social health insurance system will fail.

A key question is who controls the basic package of services? This is the core compulsory insurance and will be the only cover held by most people. As such it is essential that it provides enough cover; that the quality of the care provided is closely monitored; and that the outcomes of care and other quality measures are made public.

To support all this, Ireland will need a modern health information infrastructure. There are several successful models of this, for example the free open-source Vista system used by the American Veterans’ Administration. Such a system could be in place in three to four years. It would both improve productivity in the system and provide the infrastructure for the health regulator to do its job.

All of this depends on leadership. Without political leadership, nothing at all will happen. Without leadership from clinicians (doctors, nurses and others), what happens will not work. Without leadership from managers in HSE and the Civil Service, what happens will not be sustainable.

Our view is that, if the necessary training and support are provided, Ireland could have a working social health insurance scheme in five years’ time. What are we waiting for?

More detail of our report, and a number of useful resources are found elsewhere on this website.

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