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Free Marketeering in Health

category national | anti-capitalism | opinion/analysis author Friday January 23, 2009 14:25author by Marie O'Connor - Health Services Action Group Report this post to the editors

Dressing the Government's privatisation agenda in the robes of centralisation

Privatisation is at the heart of the Government's so-called 'reform programme' in health. Now cloaked by the current economic crisis, the present 'slash and burn' approach to public health services, has been in preparation since the mid-90s. 'Transformation' is a code for marketisation.

The closures recently announced by the Health Service Executive (HSE) in the Mid-West belong to a script first written by a firm of Bolton accountants for the North-East in 2006.

Trapped in its own language, HSE continues to parrot the same worn-out clichés of 'patient safety', 'clinical risk', 'unsustainable' and 'key stakeholders'. Teamwork, which has, according to itself, masterminded a number of PPPs in the British NHS, is apparently being paid millions to regurgitate itself in Ireland. Author of a report on the North-East that recommended the closure of all five public hospitals in the region, Teamwork co-authored the recent report on the Mid-West, and is shortly expected to unveil its blueprint for the South.

A small army of public relations strategists has been employed to sell the Government's privatisation programme. PA, for example, a company that has also laid the ground for extensive bed cutting in public hospitals in Ireland, has been represented by MRPA Kinman (now MKC) whose Chairman, Brian Geoghegan, is married to the Minister for Health.

Strategies, too, are similar. Surgeons have been chosen to 'lead' the HSE's Decimation Programme in both the North-East and the Mid-West.

HSE is preparing to close five publicly-funded hospital in the Mid-West, three general hospitals (Ennis, Nenagh and St John's) and two 'stand alone' specialty hospitals (orthopaedics in Croom and maternity in Limerick City).

The writing has been on the wall for a long time. These closures were overtly recommended by the Hanly Report in 2003. These were the very regions selected as pilots for the Government's new 'burn and slash' approach. Fully implementing Hanly will close around 40 of our public hospitals, as well as countless inpatient psychiatric hospitals.

Last January the PA Report spelt out the monstrous scale of the Government's bed cutting ambitions: 40 per cent of Ireland's public patient beds are set to close by 2014. These closures, the Government hopes, will ensure the viability of those private for profit hospitals that have been sprouting up around the country, like ragwort, in recent years.

Public hospital closures are central to the Government's privatisation policy. As the cancer strategy––in preparation since 1995–– shows, centralisation is a proxy for cutting the public health service. Looking to the for profit sector is at the core of Government health policy. This policy has been embedded in health policy documents for over a decade.

US models of 'disease management' have now been adopted in Ireland, as part of HSE's Decimation Programme. Services for Ireland's
leading diseases are being outsourced in the name of 'excellence'.

Public hospitals are being hollowed out from within: taxpayers' money, until now earmarked for cancer, will soon be available to American
health care giants, some with a background in fraud, such as UPMC (described by Bertie as 'our friends' when he opened their Whitworth Clinic in Waterford).

Many of these for profit entities are far smaller than the public hospitals whose services have been stripped from them on so-called 'quality of care' grounds. Beacon Hospital, for example, opened with just 26 beds. Today, Monaghan General, with 50 beds–– a hospital with one of the best coronary care services in the country––is on the point of closing. Only last week, HSE's 'reform' programme reportedly endangered the lives of two patients there.

The 'critical mass' requirement appears to be little more than a neat device designed to shut public services. Public hospital cancer service
that do not have high volumes of patients are being closed by the HSE, while private for profit hospitals with equally low, or lower, patient
numbers are given fat contracts by the same Executive.

Ireland's health services are being restructured to facilitate privatisation. Services that are known to be profitable are being moved out of the public system into the for profit sector. These giant money spinners include elective or planned care, radiology, pathology, and chronic

Their funding is being removed from public hospitals and given to new HSE 'business units' to control and manage. Services for heart disease, stroke and diabetes are among those scheduled for commercialisation under the banner of 'centres of excellence'.

Cancer, that most high-profile of all chronic diseases, has long been selected to lead the way, and breast cancer, that most publicised of all cancers, has been chosen to spearhead the mass closures. Centralising cancer surgery serves corporate interests, as it facilitates the collection of patient tissue for company R&D. Those shouting loudest for public cancer service closures in Ireland include the Irish Cancer Society (ICS) and Europa Donna. As much as 87 per cent of Europa Donna's funding comes from the pharmaceutical sector. ICS's pharma funding as a proportion of its overall income remains unknown.

These disease 'networks' or business units will operate from cradle to grave, across community, hospital, continuing care and even hospice settings. With power being transferred to these new unaccountable entities, public hospitals will over time lose their ability to control the key services they currently provide.

The effect of this radical restructuring of the country's health system is likely to be disastrous, as the recent closure of public hospital cytology services shows. Radiologists have reported that the laboratory tender was rigged to favour Quest, another American company with a background in fraud in the US. Laboratory specialists say HSE bureaucracy prevented some public hospitals from 'competing'.

Public hospitals are unlikely to be able to compete with for profit entities on price for disease contracts. Unlike most private hospitals, which rely on public sector poaching to run their consultant-led services, public hospitals employ 24/7 medical staff. Hospitals need patients. If these institutions lose their core business, their survival as public hospitals is likely to be threatened in the longer term. This has already happened in other health care systems.

These Government policies place patients, particularly the less well off, at risk: hospital A&E and maternity services that used to be accessible will become two hours' drive for some, while many outpatient services that used to be free, such as physio, are likely to become fee-paying. (If the new centre in Ranelagh is any indication, the much-vaunted primary care centres are likely to charge all but medical card holders.) Meanwhile, a new bill is preparation which, like the 'Unfair Deal' for the elderly, is widely expected to cut people's entitlements to free medical care. Quality of patient care is also likely to be compromised: American research shows that care in for profit hospitals is of inferior quality, despite costing government substantially more, than care in not for profit settings.

Discussions have already been held with health unions on 'flexibility'. Nurses, for example, will be expected to rotate across the full spectrum of community, hospital, nursing home and hospice settings. The nursing shortage in Ireland, already acute, will intensify if many choose to leave
rather than work under agency-style conditions.

Not a scintilla of evidence has been produced by the Government, the HSE or the Department of Health in support of the new privatisation
programme. There is no good evidence for centralising the common cancers, for example, nor for centralising routine surgery. But as the Quest contract for women's smear tests shows, commercial interests, not quality of care, has become the driver.

author by Enid O'Dowdpublication date Sat Jan 24, 2009 13:08author email enidodowd at gmail dot comauthor address author phone Report this post to the editors

Marie on your beautifully written piece.

You refer to primary care teams. These are a key part of Minister Harney's health strategy. It sounds reasonable. You have excellent health services at local level so small health problems are dealt with, don't become big ones requiring (expensive) hospital beds. Who could disagree with that? As we know the Minister has been closing hospital beds before the primary care teams are in place and has been critisised for that but nobody has looked at who can access these primary care teams and what if anything they offer that wasn't there before.

There has been a HSE primary care team in Ranelagh where I live for about a year but I only found out it was there late last year. it seems Minister Harney officially opened it early in 2008 but I saw no coverage. Surely the HSE PR people should generate publicity for any new primary care team?

Teams includes nurses, a physiotherapist, an occupational therapist, a social worker, home support services, participating GPs and administrative staff, and residents living in the area can ‘self-refer to any member of the team.

I asked the Ranelagh team who can access the services they provide other than medical card holders and was referred to the HSE. After a number of days making phone calls and sending emails I received the official statement below made to me in my capacity as journalist for local paper Town&Village -

HSE reply to Town&Village

‘The current Transformation Programme envisages fully integrated health service delivery across the full spectrum of Primary Community and Continuing care (PCCC) and hospitals. The focus of PCCC services going forward is founded on the development of Primary Care Teams (PCT) and Health and Social Care Networks (HSCNs). It is intended that there would be a whole population approach to enrolment with PCTs.

Pending the development of a new Statutory Framework which will outline clear statutory provision on eligibility, a decision has been requested from the Department of Health and Children in relation to the prioritisation of access to primary care services on an interim basis.

Pending this decision and in order to ensure services are provided in an equitable manner and not impact on a person’s entitlements under the existing eligibility framework, it is has been decided that the current access arrangements to core front line primary care services in operation locally should continue. In general, access to these services is currently largely prioritized on the basis of medical criteria.’

End of HSE statement

Clear as mud!

The one thing that is clear about the teams is that the 'participating GPs' charge their normal fees to non medical card holders. So what is new?

In theory, physiotherapy services are free in hospital outpatient departments but you wont get an appointment without a GP referral letter (GP visit costs €50-€60) and even with the letter it can take weeks to get an appointment even though you may be in a lot of pain. THE HSE primary care leaflet says patients can 'self refer' to any member of the team - which appears to mean that you can go directly to the team physio - but the HSE statement doesn't seem to mean that!

Interestingly, a private physio practice has just moved into the building occupied by the Ranelagh primary care team. Why would they do that, if the team physio will see non medical card patients?

I sent the HSE statement to John Murray presenter of RTE radio's the Business for consideration for their anti jargon campaign and he featured it earlier this month.

I contacted the Department of Health who explained that legislation is in the pipeline (but with no timeframe) to bring together and clarify accessibility to health services.

So currently we have a limbo situation - HSE staff in the teams have no practical guidelines as to the eligibility of non medical card holders which is very unfair to them. I was assured on the phone by a HSE official that non medical card holders would not be 'means tested' by the teams.

It seems to me that until we have the new legislation which given the Ministers track record may seek to reduce existing rights the primary care teams will be required to keep a low profile in case - shock horror - non medical card holders try to access them. A friend told me this week how a woman trying to access the very recent primary care team in Ringsend was refused because she 'lived on the wrong side of the road.'

It would be interesting to know how much rent (and what lease commitment) the HSE is paying for the rooms the primary care team has in the 'Ranelagh Medical Centre' in Sandford Road Ranelagh. This is a renovated building where there used to be a garage. Other tenants include private physiotherapists, dentist, chemist and optician. The landlord is Centric Health who I understand are renting premises to a number of other HSE primary care teams.

On a different note, Marie refers to the 'nursing shortage in Ireland'.

The problem is that having increased nurse training places by 50% about 10 years ago to deal with the then shortage of nurses, the government now refuses to employ these Irish trained nurses. The majority of 2008 nursing graduates do not have jobs. They may well take the emigration route, particularly as the private health sector prefers nurses with some post qualification experience and will not want to invest in their professional development.

The Minister is determined to reduce numbers employed in the HSE yet late late last year she advertised for three more senior managers at salaries of
€194, 264 pa (incidentally, salary not mentioned in the advertisement but available if you looked up the website reference). Counting the cost of their pensions and other benefits, the cost of these three 'managers' won't leave much change out of €1 million pa.

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