Going public with private concerns.
The surge in Covid-19 cases never materialised, and the State’s effective nationalising of private hospitals has come into sharp focus, writes Catherine Shanahan.
The State’s commandeering of private hospitals, at a time when the Italian experience of Covid-19 was weighing heavily on our minds, seemed like the only option to ward off the onslaught on the public hospital system that early modelling had predicted.
From the general public’s perspective, there was a collective “phew” that we now had access to c200 extra ventilators and c2,000 additional hospital beds, many designed for sole occupancy, ideal for those in need of isolation.
From an ideological viewpoint, it appeared to flatten our two-tier public/private system into a single tier overnight, with those most in need of treatment prioritised.
Given the unpredictable and ostensibly terrifying nature of what we were facing, there were no real voices of dissent.
Instead of having to assemble field hospitals with great urgency, as done in other countries, we had 19 largely state-of-the-art facilities ready to go at a moment’s notice.
Job done.
A month on, it hasn’t quite panned out as planned. It hasn’t panned out because thankfully, the surge didn’t come. But neither has it panned out very well for hospital consultants who work exclusively in these private hospitals.
And if their predictions are correct, it will pan out very badly indeed, not just for themselves, but for the taxpayer, who is paying €115m a month for the privilege of commandeering largely empty private hospitals - as of yesterday, three-quarters of beds were empty - and for the patients of these consultants who now find that their expensive private health insurance policies - their only guarantee of timely treatment - are not worth the paper that they’re written on.
“The HSE says we can now see public patients only, so what happens to the 2.2m people with private health insurance? They’re now in limbo. They must go to the back of the public waiting lists,” says Stephen Frohlich, consultant in anaesthesia and intensive care medicine, with commitments at the Beacon Hospital, Blackrock Clinic, and the Hermitage Clinic in Dublin and Aut Even in Kilkenny.
Dr Frohlich is one of the c450 consultants in full-time private practice who have chosen not to sign up to the Type A public practice-only contracts offered by the HSE under the deal with private hospitals. Like many of his colleagues, he is incensed at the “unilateral” nature of the agreement, which involved no consultation with the doctors themselves.
“We now find ourselves unable to treat our own patients, which is extremely frustrating and also damaging for them. Many consultants have thousands of patients on their books with no ability now to treat them. Where do we send them? The care pathway for them doesn’t exist.”
The agreement pays no heed to the complex infrastructure around treating patients, says Dr Frohlich says — the referral from the GP, the outpatient consultant appointment, potential tests and scans, and inpatient procedures and subsequent follow-up.
With hundreds of thousands of patients of these private consultants at various stages in this process, who will ultimately be responsible for their treatment and outcomes under this deal? And do our data laws even facilitate the sharing of patient information with different doctors?
The experience of Dubliner Rob O’Brien, a patient with a progressive lung condition who spoke on RTÉ’s Today with Seán O’Rourke show yesterday, is an example of what patients with private health insurance can expect in the current crisis.
Mr O’Brien, 60, has been under the care of the same consultant for 18 years at the Bon Secours Hospital in Glasnevin. “He knew my case, he knew what worked for me and what didn’t,” said Mr O’Brien. “I was due to undergo a procedure in mid March but all procedures were cancelled. I can’t access my consultant.”
He doesn’t know where to go from here, he said. He’s on an antibiotic and is hoping it will work to clear up a current chest infection. He does not want to have to go to an emergency department. “I’m scared a lot,” he said.
Professor Eric Masterson, a consultant orthopaedic surgeon at the Bon Secours, Limerick, says none of the 20 full-time private consultants at the hospital has signed up to the HSE deal. It’s also his understanding that none of the full-time private consultants in the 120-bed Galway Clinic has signed up.
Prof Masterson says most of his colleagues — including himself for 21 years — were “previously employees of the HSE and experienced a level of dissatisfaction that caused them to leave and would be reluctant to return”.
Prof Masterson had 70 patients booked in for hip and knee surgery, who are now “in limbo”. He has not signed up to the HSE contract; he is opposed to its potential for redeployment and hours and duties that are not fixed, as well as being unable to care for his own patients, he says. Asked what he is doing at the moment, he says: “I am gardening. I have worked all the hours God gave me all of my adult life and all I can do now is put on my gardening pants in the morning.” Prof Masterson says the HSE was “correct to plan for the surge but it hasn’t materialised and there is no value for money in what they are doing”.
On Monday, 27 of the 50 beds at Bon Secours Limerick were empty, says Prof Masterson. On the same day, 200 of 300 beds at the Bon Secours Hospital in Cork were empty. This is the hospital where the highest number of full-time private consultants - about 60 - have signed up to the HSE deal. Unlike their Dublin colleagues, most of them have a private practice at a single site.
Consultant cardiologist Crochan O’Sullivan has signed up the deal — a salary of c€160,000 — but says he’s losing about €4,000 a month because he is still paying for his outpatient rooms and secretarial staff. If he hadn’t signed up, he would have been unable to carry out some “time-critical” procedures on some of his patients, because he would have had no insurance cover.
As a temporary State employee, he is covered by the State’s clinical indemnity scheme, but this is being extended on a week-by-week basis, he says, adding that management at Bon Secours in Cork has made an informal offer to help them out where they are incurring losses “on a case-by-case basis”.
Ian Kelly, a consultant orthopaedic surgeon in UPMC Whitfield, a Waterford Clinic, says they are all “appalled by the deal”.
“I see 2,000 to 3,000 patients per annum and do c800 surgeries. If I was to sign a Type A contract, I couldn’t decide who I would see or where I would go. I could be told to go to University Hospital Waterford and do trauma [surgery] for the next three days, so I couldn’t look after my own patients. At the moment, I am looking after them free of charge.”
Michael O’Keefe, a consultant ophthalmologist in the Mater Private, Dublin, says the only way they can see private patients now, if they don’t sign up to the contract, is to do so free of charge.
“But if they need procedures, they must go on the public list.”
Like many of his colleagues, he believes the HSE could have offered a more flexible contract that would have allowed some private practice to continue and would have got more sign-up.
More than 230 consultants have joined the Independent Medical and Dental Consultants of Ireland, a lobby group calling for more flexibility in the contract. The general belief among them is that the State has made the deal and will now press ahead with making maximum use of the private hospitals to tackle public waiting lists.
The group says the deal is not just costing €115m a month, but that the State is also paying private consultants’ salaries when they sign up. A senior figure said the hospitals had been generating revenue in excess of €30m per month, another loss to the exchequer.
He said consultants would be happy to get half the salary of a public consultant if they were allowed a 50/50 split in terms of public/private practice. Or a 70/30 split - just allow them return to treating their private patients.
Dr Frohlich says the State should have looked at the UK approach where they paid for private hospitals on a not-for-profit basis, “but in the event the NHS didn’t need them, they could continue on with routine and urgent insured cases”.
He is not alone in questioning how the HSE is continuing to advertise posts in public hospitals that allow doctors to also treat private patients in the public system, while banning private practice in private clinics. “There are people in the HSE who will tell you privately that this is a shit storm,” says Dr Frohlich. “But no one has the political balls to say this is a disaster.”