Michael Harty (Clare, Independent) | Oireachtas source

I thank Dr. Keegan and Dr. de Buitléir. I would like to make some comments. Most members of the joint committee sat on the Committee on the Future of Healthcare, which produced the Sláintecare report. The fundamental principle we were trying to introduce as part of the efforts to move private practice out of public hospitals was that preferential treatment would not be given to patients with private health insurance. It was suggested as a strategy that there should be a common waiting list for private or public patients with no preferential treatment. The idea was that people should be treated on the basis of need and not on the basis of whether they are insured.

When we looked at other countries, we learned that Ireland is an outlier in this regard. In other countries where there is private health insurance, supplementary insurance gives people additional access to services but not additional access to public services. In France, for example, one can have top-up insurance if one wishes. It allows one to access private facilities, but it does not give one any preferential treatment in the public system. Everybody in Ireland is essentially entitled to free public care in a public hospital, regardless of insurance status, with the caveat of paying €800 a year, or €80 a day for ten days. If someone with private health insurance ends up in a public hospital, that is bonanza money for the hospital. It is almost an accident that the person who has ended up in the public hospital has health insurance. The perverse incentive that arises in these circumstances has been outlined. The hospital wants to maximise the insurance income and the insurance company wants to minimise the amount of money it pays out. In fact, it is accidental money that comes in the door of the hospital, most likely through accident and emergency admissions.

It must be impossible to police the 20% private work that is allowed in a type B contract. If there are not many private hospitals in an area, as is the case in the mid-west, the percentage of people with private health insurance who are treated in the hospital can increase to 40%. We cannot refuse people treatment because they have private health insurance. We have to look after them.

If there is to be a public-only contract, medical indemnity insurance will cover public-only contract work. My understanding is that if one has a type B contract, a proportion of one's medical indemnity insurance is not covered through the public purse. I presume that consultants with public contracts who choose to do private work outside their 39-hour contracts will have to take out additional medical indemnity insurance to cover their private work. At the moment, they are probably getting an advantage because their public-paid medical indemnity insurance is covering much of their private practice.

We have discussed the cost of inpatient cover. A substantial amount of private practice takes place in our public hospitals. Private facilities are used for diagnostics. A consultant who carries out a private clinic in a public hospital has access to all the public facilities to carry out his diagnostic tests and his follow-up work, at no cost to the insurance company and at no cost to himself as a practitioner. I ask Dr. Keegan and Dr. de Buitléir to comment on that.

We discussed the provision of elective-only hospitals in the context of Sláintecare. As a result of capacity constraints, most people who are admitted to hospital come through accident and emergency departments. This involves urgent work. Elective work is being pushed out of public hospitals because they do not have the capacity to cope. Most of the work that is being carried out in public hospitals now is emergency care, urgent cancer care or perhaps some elective day-care procedures. More and more, the work in our public hospitals is urgent work. Unless we provide elective-only hospitals, we will never clear our waiting lists for elective work. I ask the witnesses to comment on these issues.