by Enid O'Dowd
Trading patients
But back to Hanly, which re-emerged out of the shadows in 2006, when accountants and others from Bolton in England were apparently given the job of rewriting the report. Teamwork took Hanly to the next level: privatisation. The firm produced a report that bare-facedly proposed to close all five public hospitals in the North-East, and replace them with a new regional hospital. (New builds offer almost unlimited commercial opportunities.) But there was more to come.
The document was a first step in creating an internal market, one where health services––and by extension, patients––would be traded just like any other commodity. Teamwork’s plan to radically restructure our health service went much further than any devised by Maggie Thatcher. Public hospitals were to be gutted from within, their profitable services hived off. Private health care corporations had long reaped huge profits in niche markets––providing services for people with chronic diseases, such as cancer, for example. Teamwork also identified other money spinners, such as radiology, pathology and planned care (this covers every imaginable non-emergency scan and many non-emergency operations). All are services of vital interest to those living with cancer; and all are to be divvied out to private companies, unless public hospitals can compete.
Teamwork’s 2006 report has since been used as a blueprint for the entire health system. The following year saw a second report from Teamwork that proposed to privatise public pathology services. Private labs are well known to be money-making machines. Although Teamwork’s 2007 report on pathology was never published, cervical cancer testing was subsequently withdrawn from all public hospitals and outsourced to Quest Diagnostics, one of the biggest private lab conglomerates in the US. Meanwhile, patient services are routinely outsourced by the HSE. How much is being spent on these contracts––what the terms and conditions are––we do not know. There is no transparency, no accountability. And Teamwork, one of the main architects of the privatisation of our health system, goes from strength to strength and region to region, earning enormous sums of money by dreaming up new ways of selling the closure of our public hospitals to a public that has been ill informed by the consensus media.
Cancer was chosen to spearhead the privatisation of services for chronic diseases. First out of the traps came the national cancer strategy, published by the Department of Health in 2006. The cancer forum proposed a role for the private sector in providing services and restricted to eight the number of public hospitals allowed to provide cancer care. This represented a 40 per cent cut in the public allocation recommended by an expert group just six years earlier. The new forum bestowed four of the eight cancer centres on some of Dublin’s biggest so-called voluntary hospitals, leaving just four for the rest of the country. Of the eight hospitals selected as specialist cancer centres, five were already designated for co-location with private for profit companies: St James’s (Synchrony Capio); Beaumont (UPMC Beacon); Cork University (UPMC Beacon); Limerick Regional (UPMC Beacon); and Waterford Regional (where co-location has stalled.)
Indeed, the cancer strategy could be seen as yet another device designed by the authorities to terminate cancer care in 25 publicly funded hospitals. Lowering the bar to eight meant that even medium-sized hospitals, such as those in Castlebar, Sligo and Tralee, would be forced to discontinue their cancer services. The reason? Patient numbers were too few.
It later transpired, however, that there was one rule for public hospitals and another for the private sector. Opening the UPMC cancer facility at the Beacon Hospital in May 2007, the Minister for Health welcomed the hospital’s vaunted link with UPMC’s Hillman Centre in Pittsburgh. Actual patients (then zero, presumably) could evidently be boosted by virtual patients: telemedicine could, with Ministerial approval, make the concept of minimum patient numbers redundant. But only in the private sector. Prohibited from linking with Galway University Hospital as part of a cancer network, Sligo General was forced to discontinue its breast cancer service two years later.
But if low volumes placed patients at risk, how could the Minister promote small private units and how could consultants who treated their private patients in them remain silent? And if small numbers did not matter, then small private hospitals posed no such danger to patients, so why were smaller public hospitals being closed, and how could doctors working in them acquiesce in such plans?
These contradictions were left hanging. Yet another blueprint for privatisation appeared in 2008, this time courtesy of the Department of Health. Of all the stratagems designed to outsource our health services, the 2008 chronic disease strategy is arguably the most far-reaching. In it, the Department proposed to introduce American ‘models’ of ‘chronic disease management’ that were so new as to be experimental. No good evidence existed to show that they worked well, or even that they worked at all. Ignoring the mountain of research, internationally, on the hazards of private health care, the Department proposed, in effect, that all services for particular diseases, such as cancer, heart, stroke and diabetes, should be put to market. Asthma, chronic bronchitis and musculoskeletal services were also mentioned.
The new business approach
Cancer was chosen to spearhead the new business approach. All services for cancer patients, be they primary/community, hospital or continuing care, are to be bundled together, and these bundles will form the basis of ‘integrated’ packages to be sold on the open market. Think telecom providers who bundle line rental, broadband, and a finite number of calls, all for a fixed sum, and you get the idea. No less than 20 ‘clinical programmes’ modelled along the lines of the cancer enterprise, and covering primary care, mental health, emergency services, surgery and outpatients, are due to be implemented here in 2011.
Private hospitals will be among the first to bid for these contracts. UPMC Beacon, for example, has long expressed an interest in developing such cross-over services. So public monies that, until now, have been earmarked for public hospitals will, in the not too distant future, go to private sector providers. Public hospital funding is now being radically restructured to enable this to happen. Meanwhile, costly and unprofitable services, such as A&E and intensive care, will be left to workhorse public hospitals to provide.
Behind the HSE spin of ‘integration’ lies the reality of a US-style health system. Implementing this American model will see cancer services, among others, removed from the control of public hospitals. This is the ‘restructuring’ that lies behind behind the rhetoric of ‘reconfiguration’. The new specialist breast cancer centres, for example, are to be separate entities, run independently of the public hospitals where they are located. Privatisation brings this kind of fragmentation. Despite its name, the ‘national cancer control programme’ is, in fact, a separate business unit within the HSE. One of its main functions is to create ‘competition’. All public monies hitherto expended on cancer care are to be made available to this unit: it also follows that all public monies hitherto allocated to public hospitals for cancer care are to be withdrawn. Those monies will only revert to those hospitals if their bids for patients succeed. State auctions for cancer services will force publicly funded hospitals to compete against private for profit entities. The cancer strategy explicitly provides for State contracts to be given to private sector suppliers. As we have seen, many, if not all, of these for profit facilities are significantly smaller than some of the public hospitals whose cancer services are being withdrawn.
The new entity will control many aspects of cancer care, including the appointment of medical consultants. It will also own and manage the six radiation oncology centres being built through PPPs. Moreover, depending on how it is structured, the cancer superboard may also be free to enter into commercial contracts and to establish joint ventures with private sector companies, including software developers, machine manufacturers and pharmaceutical corporations.
Volumes and outcomes
Sweeping claims have been made for centralisation, that larger volumes lead to better outcomes, that the n
ew specialist breast cancer clinics offer better survival prospects. But no hard data have been produced in support of these assertions. No good evidence exists for centralising care for the common cancers, for example. Scientific evidence for the claim that larger volumes of surgery lead to better outcomes is lacking, except in the case of a tiny number of extremely complex procedures. A recent large scale study published in the British Medical Journal found no relationship between the number of surgical procedures performed and survival rates for that particular operation: death rates were totally unrelated to patient numbers.
Behind the ‘Transformation’ Programme
If there is little or no evidence to support the so-called Transformation Programme, then why the drive towards centralisation and privatisation?
There is, first of all, that blind neo-liberal faith in the market, the belief that the private sector can do it better. Then there is the market itself. Business plays an important role in policymaking here, just as it does in other countries. Personal relationships have been shown to influence political decisions in Ireland to a considerable degree. Private interests are further facilitated by the revolving door that exists between the public and the private sectors. Many former heads of health boards lead private health care projects today. The revolving door also swings in the opposite direction. HSE Director of Quality and Clinical Care, Dr Barry White, for example, who is currently leading the establishment of the HSE’s new disease business units, is a former medical director of Synchrony, the company that was awarded the co-location contract at St James’s Hospital. How could he be opposed to privatisation? Alternatively, public policy makers may simply be related to captains of private industry. The forum that developed the cancer strategy, for example, was chaired by Professor Paul Redmond, of Cork University Hospital, a brother of Beacon Medical Group co-founder and medical director, Professor J Mark Redmond. While such close connections are only to be expected in a society as small as ours, they tend to give rise to conflict of interest queries.
Gene hunters
The new Decimation Programme also has its roots in big business. The growing influence of corporations in Ireland is a huge factor in the reshaping of our health system. Breast cancer was chosen to spearhead the termination of public cancer services in Ireland. One group that pushed for this was a breast cancer advocacy group, Europa Donna Ireland. As much as 86 per cent of its parent company’s income in Europe comes from drug companies. Whether or not medicine manufacturers had an active interest in funneling all cancer patients into a small number of large centres, Europa Donna Ireland campaigned long and hard for the closure of breast cancer services in public hospitals across Ireland.
Note the marked emphasis on drug trials in the cancer strategy. Was this in some way related to the strength of the drug industry in Ireland? Around half of all patient groups here are funded by pharmaceutical companies: most of these organisations tend not to disclose their funding.
Centralising cancer surgery serves the new R&D or research and development environment to a considerable degree. Anything removed during an operation can legally be put to commercial use. Genes are the building blocks of the biotechnology industry: DNA is the new gold. UPMC Beacon plans to establish a biomedical research and biotechnology centre here with State aid. Ireland’s gene pool is, or was, more homogeneous than most, making it particularly attractive to gene hunters. By 2005, 18 per cent of the entire human genome had been patented: two-thirds of these genes were in private hands.
The costs of privatisation
Patients, communities and society in general will bear the cost of the Government’s centralisation/privatisation programme in health. We are now facing the biggest closure of beds and services since the public hospital asset-stripping programme of the 1980s (also under a Fianna Fail government). Our public health system is being stripped out by stealth, under the banner of ‘reform’ so beloved of Thatcher. Government bed-cutting programmes have been dressed in various guises. But ‘moving care from the hospital to the community’ is an untried and untested experiment, a meaningless mantra that is designed to soothe in the face of mass hospital closures.
No country in the developed world has eliminated its tier of second level hospitals. Despite the fact that Ireland has one of the lowest hospital bed-to-head ratios in the industrialised world, the HSE is now working overtime to dismantle up to 40 of our 53 acute public hospitals. Official claims that primary, community and emergency services can safely replace hospital inpatient care are without foundation: not a shred of evidence exists to support this myth.
The Government’s health reform programme is one that sets at nought the lives of those living in non-urban areas. Hundreds of thousands of people, two hours’ drive or even more from hospital inpatient care, face significantly increased risks of death or permanent disability. Mass closures of A&E and intensive care units have just been proposed at the time of writing (20 September 2010) in the latest version of the Hanly Report. Hanly proposed a population of half a million as a minimum threshold for a ‘viable’ hospital casualty unit. It was an outlandish proposition. Implementing that yardstick in a population as small and dispersed as ours will leave each public hospital A&E ‘serving’ a geographic area of 2,300 square miles.
The cancer strategy offered new evidence of the growing disconnect between national health policy and community health needs. Other countries, such as The Netherlands, provide cancer services in what are called ‘peripheral’ hospitals. Not Ireland. Our population is nearly five times more dispersed than that of our nearest neighbour, Britain. Access to services depends on where you live. Geographic inequality has intensified in recent years. The cancer strategy disregarded the North-West, ignoring the fact that over a million people live north of a line from Dublin to Galway, and (once again) giving the capital the lion’s share. Only sustained public pressure from voluntary groups, such as Co-operating for Cancer Care North-West prevented Letterkenny Hospital from losing its cancer services.
The robotic centralisation of cancer care is not in patients’ interests. Those living with cancer spend an enormous amount of time and money travelling, both to access care, and to visit family and friends. A regional study of cancer sufferers in Scotland, for example, cited one 84-year-old lady, who described having to make a one way seven and a half hour journey by ambulance from Stranraer to Edinburgh for radiotherapy. As much as 13 per cent of cancer patients’ time was spent travelling to and from hospitals, the researchers concluded.
All patients, cancer and non-cancer, public and private, will lose out in the new US-style health care park. The viability of our public health system is in jeopardy. Outsourcing cervical smear testing, for example, has had a disastrous effect on our public laboratories. Around 60 scientists were redeployed as a result of the Quest contract. Labs in Dublin at St Luke’s and the Royal College of Surgeons were among the first to close. Since then, Quest has had its HSE contract renewed, and may now look forward to a monopoly on cervical cancer testing: no Irish lab will have the capacity to compete when that contract is put to market again.
Public hospitals now face destabilisation and downgrading from within. Implementing the cancer and chronic disease strategies will fragment and dis-integrate existing public hospital services, not least by removing their principal sources of business. Patients are already seeing a depleted and demoralised public hospital system.
Terminating cancer surgery, for example, jeopardises the quality of care in other hospital departments, particularly A&E. Surgeons in regional hospitals, such as Sligo General, now find themselves unable to operate on a patient presenting in casualty with a bowel obstruction, for example, lest that blockage be cancerous. Instead of having surgery locally, that patient, whilst not necessarily suffering from cancer, will be required to travel for two hours or more to a hospital approved for cancer surgery. And if surgeons are unwilling to work in such a difficult environment, as seems likely, even regional public hospitals will be unable to a
ttract (or retain) high quality staff, and quality of care will suffer.
Co-location carries its own hazards for all patients, public and private. It will probably result in medical consultants being less available to their public patients. Australian research shows that, in this parallel universe, public patients actually wait longer to see medical specialists. And those who believed they were buying choice with private health insurance may soon find that they have no option but to be treated in the co-located entities. Private patients, unless they are in need of intensive care, stand to lose the security of being treated privately in public hospitals that are co-located. The Minister has decreed that all such private patients must be treated in the new for profit wings. The Government now plans to bring in legislation forcing private insurers to cover these facilities.
The hazards of private health care
But private health care should carry a health warning. Private sector provision cannot always be relied upon. Private operators may simply up sticks, closing hospitals when they cease to be profitable and leaving communities high and dry. Private nursing home owners here have closed facilities without warning in recent years, leaving residents to fend for themselves. Or private providers may simply refuse to provide unless the price is right. UPMC’s second cancer centre at Waterford’s Whitfield Clinic was recently embroiled in a dispute with HSE over how much money it should be paid for radiotherapy services. The dispute was resolved when UPMC threatened to withdraw radiotherapy treatment from public cancer patients.
Private health care also carries other dangers. North American academics say the risks to patient safety are substantial. Research on for profit health care shows that health services run for profit are less safe: death rates are higher in for profit institutions. Costcutting is a major factor. But the need to turn a profit also leads to over-testing and over-treatment. Both of these scenarios increase the hazards for patients, as neither tests nor treatment are without risk.
