Health Service Executive (Financial Matters) Bill

[Speaking in the Seanad during Second Stage of the Health Service Executive (Financial Matters) Bill 2013]

This is obviously an important way-station in the process of health care reform and, as such, I support it. We were in a situation whereby a largely unanswerable bureaucracy had been given the outsourced job of operations management of the health service, with a rather loose level of political control for the most macro of macro questions. This brings the military back under civilian control, so to speak, and it is welcome, but it is a way station.

If I understand the model of universal social insurance that I hope will be implemented, it will be a small step between the HSE and where we are with this, a little piddling micro-step compared to the massive journey we have to make to get to the status of a truly social-insurance-based model.

In such a model, the Government’s role will be regulatory. Its role will be to ensure that the insurance mechanisms are in place, to ensure a degree of redistribution of resources between people who are better off and those who are worse off, which is necessary to make a health insurance system work, to ensure the system is socially responsive and efficient, and to ensure that a mandatory insurance deduction of a fixed percentage will be made against the entire income of every person in the State. That means that people who have a large income will pay much more than those who have a smaller income, but at the end will walk away with the same insurance instrument in order that they can go to the same hospitals and the same doctors. It will not be legally acceptable for any institution to cherry-pick and say it will take only people with a certain type of insurance. I hope there will be – as in countries such as Israel, which has an advanced version of this model – a basket of basic services. If one goes to the insurance market, insurers must provide certain services. There is no negotiation on them, and those drugs, procedures, treatments and diagnostic tests are covered completely.

While the State will assume a major regulatory role, the corollary is that it will lose its management role entirely. The system will not be owned exclusively and managed by the State and State actors. I hope that in the new dispensation most of the actors will be not-for-profit insurance companies and not-for-profit hospitals, but they will not necessarily be owned by the State. If somebody sets up a very efficient private operation, perhaps run by a university or a charity, or even run on a for-profit basis – sometimes they get it right – the only thing that will be mandated of it is that every citizen can walk up to the door, wave his or her insurance instrument and say, “I want to be your patient. I am supposed to be the patient of the State hospital down the street.” That has to be the nature of the level playing field.

I sometimes misunderstand the types of reform that are taking place towards the goal of universal insurance. I must avail of this opportunity, as I do not get to speak to the Minister too often, so please forgive me if I take this as a high-end private consultation for the next several minutes.

Some of the reforms which have taken place do not appear to be reforms that are configuring the system towards that kind of insurance model. Instead, they look as though they are configuring it towards an internal-market version of the NHS, which is a system under which the State still owns everything, runs everything and sets national contracts for all employees. Under that system, every health care worker is an employee of the State.

The only aspect of the principle that money follows the patient in the NHS is that there are different groups, such as fund-holding GPs, which can determine where within the NHS a patient can go. It is a different model and I hope that we are not aiming for it. While the term “Dutch model” is frequently used, the Minister will realise that when he entered into coalition with his partners in the Labour Party, the synthetic model which emerged from both parties’ laudable health policies resembles to a much greater extent the German model. It is the “Deutsch”, not the “Dutch”.

In 120 years time, I hope people refer to the “Reilly model” of health care the way they now refer to the “Bismarck model”. The Minister is right that we have an opportunity to do something entirely new here.

….. It was not named after the ship. It was named after the Iron Chancellor who in 1885 introduced what has become the longest, most durable, most successful, most resilient and most admired health system of any country. It is a system based on social solidarity, social democracy and treatment according to need not ability to pay. It is a system based not on the state running everything but on the state ensuring that there is a level playing field for everybody who comes into it. It is the model we need to emulate.

I ask the Minister to look critically at some of the way-station reforms which have been made in terms of things like hospital groups and national contracts and understand that the ultimate logic of where we are going with this is that many of the way stations will be obsolete and anachronistic. In the new dispensation, one may have very different kinds of doctors working. There may be doctors who are entirely private but take patients coming with their insurance instruments who would currently be called public patients. There will hopefully be doctors – I would love to be one if the opportunity arose – who are employees of a medical school and real professors unlike the situation we have now where we have nearly no one in that role. We may have some doctors who elect to work part-time in Government hospitals while others elect to work in partnerships with for-profit clinics. There will be different models available. What everyone will have is the same freely negotiable insurance cover. One can pick and choose the kind of doctor or hospital one wants to go to. In this system, large State-run hospital groups may not find themselves in a favourable competitive environment. The notion of having fixed national contracts for all doctors as if they all had the same unitary employer may not be feasible.

I wish the Minister well with his reforms. I am hopeful and confident that he will be in the chair he is in now to see through those reforms for the most part during the term of the current Government. It is potentially historic for our health service if these reforms come to pass. I ask the Minister not to waver, to keep pushing and to avoid being taken captive by the Civil Service.

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