“Time  to  put  equal  access  to  healthcare  on  a  legal  footing”    Irish  Times,  27th  February  2012    By  Oliver  O’Connor      The  Government  has  a  mandate  to  provide  universal  health  insurance.    The  prime  motivation  is  to  create  equal  access  to  health  services  through  a  single-­‐tier  system,  however  defined.    The  change  will  be  immensely  complex.    It  is  accepted  this  is  a  two-­‐term  task,  so  it  could  be  2021  before  it  is  in  place.    For  this  year,  a  White  Paper  is  promised.    A  person  without  health  insurance  –especially  someone  who  has  recently  had  to  cancel  their  policy  -­‐  might  well  ask,  can  any  assurance  be  given  about  equal  access  to  healthcare  before  2021?      How  can  they  be  sure  they  won’t  be  in  a  slow-­‐moving  queue  while  insured  people  get  seen  faster,  perhaps  even  in  the  same  hospital?        Here’s  one  step  that  can  be  taken  now.    A  Health  Equal  Status  Act  could  be  introduced  to  bring  the  timing  and  quality  of  publicly-­‐funded  healthcare  under  the  scope  of  equality  and  anti-­‐discrimination  legislation.      The  Equal  Status  Act,  2000  already  prohibits  discrimination  on  the  grounds  of  gender,  marital  status,  family  status,  sexual  orientation,  religion,  age,  disability,  race  and  membership  of  the  traveller  community.    A  Health  Equal  Status  Act  would  add  one  more  ground  for  non-­‐discrimination,  in  respect  of  public  hospital  care:    public  or  private  status.        We  would  think  it  preposterous  if  a  person  attending  a  public  hospital  were  admitted  more  slowly  based  on  their  race  or  gender,  or  any  of  those  grounds  for  discrimination.    The  Equality  Tribunal  would  rightly  find  against  the  hospital  or  doctor  in  favour  of  the  complainant.    It  has  already  found  against  public  heath  services  on  grounds  of  disability,  for  example.    

The  Equal  Status  Act  already  allows  for  clinical  judgment  to  prioritise  patients.    There  is  no  need  interfere  with  that.    This  proposal  is  only  about  discrimination  between  people  with  health  insurance  (or  are  willing  to  pay  privately)  and  those  without.    It  would  say  a  public  patient  can’t  be  discriminated  against  in  access  to  publicly-­‐funded  health  services  just  because  they  are  a  public  patient.    There  should  be  equality  between  patients  of  the  same  medical  status.      Access  should  be  based  on  clinical  need.      It  sounds  simple,  but  it  does  not  yet  exist  in  law.      Successive  governments  have  favoured  equity  of  access  to  healthcare  through  wider  public  provision  alongside,  awkwardly  at  times,  the  consultant  contract.  Public  hospital  care  was  extended  to  all  the  population,  universally,  through  a  

social  partnership  agreement  in  the  early  1990s.    The  pre-­‐existing  right  of  consultants  to  earn  fees  from  private  practice  in  public  hospitals  was  continued.    There  have  been  variations  and  developments  since,  notably  in  the  2008  contract,  where  access  to  outpatient  diagnostics  is  to  be  on  common,  ‘one  for  all’  basis  and  optional  ‘public  only’  contracts  were  introduced.    Most  consultants  in  public  hospitals  have  a  contractual  right  to  carry  out  private  practice,  up  to  limits  of  20%  or  30%  of  patients.      But  even  when  this  is  adhered  to,  it  is  not  possible  to  assure  any  individual  public  patient  that  their  waiting  time  has  not  been  longer  than  that  of  a  private  patient  with  the  same  medical  condition.    If  the  patient  claimed  that  it  was  longer,  and  if  even  if  that  were  proven,  they  would  still  have  no  grounds  for  complaint,  so  long  as  the  consultant  was  within  the  20%  or  30%  ratio.      The  consultants’  right  to  private  practice  is  not  a  right  to  earn  fees  by  means  of  discrimination  in  offering  faster  access  to  insured  patients.    It  was  neither  sought  nor  granted  on  that  basis.    It  is  simply  a  right  to  treat  a  proportion  of  private  patients  and  earn  fees  in  so  doing.    In  any  event,  the  2008  consultant  contract  is  subject  to  statute  law,  which  can  change.    A  statute  requiring  the  contractual  right  to  private  practice  in  a  public  hospital  to  be  exercised  subject  to  non-­‐discrimination  would  not  interfere  with  their  ability  to  earn  fees  or  to  treat  20%  or  30%  private  patients.    Private  practice  would  continue  but  without  discrimination  as  regards  timing  of  access.    One  would  think  that  most  consultants  would  have  no  objection  to  this.        What  it  would  mean,  however,  is  that  both  public  hospitals  and  consultants,  who  would  continue  to  make  admission  decisions  and  prioritise  the  clinical  care  of  patients,  would  have  to  put  in  place  administrative  systems  to  make  sure  they  could  demonstrate,  if  challenged  in  an  equality  case,  that  they  had  admitted  patients  in  a  non-­‐discriminatory  way,  as  between  people  with  insurance  and  without  it.      The  hospital  and  consultant  would  have  to  be  blind  to  the  public  or  private  status  of  the  patient  in  making  clinical  prioritisation  and  appointment  decisions.    The  grounds  for  complaint  of  discrimination  would  have  to  be  tightly  defined,  and  the  importance  of  compliance  taken  very  seriously  by  both  hospitals  and  consultants,  to  avoid  scarce  resources  for  health  being  diverted  into  paying  multiple  claims  for  compensation.    The  converse  of  consultants  having  autonomy  in  clinical  prioritisation  of  patients  would  be  a  personal  responsibility  to  do  so  in  a  non-­‐discriminatory  way.    Some  will  describe  this  as  a  ‘common  waiting  list’.    Unfortunately,  this  communicates  negativity  and  poor  performance.    No-­‐one  talks  about  a  common  waiting  list  at  GP  surgeries,  as  between  medical  card  and  other  patients.    People  don’t  complain  much  about  being  on  a  waiting  list  for  private  care,  but  unless  it  is  instant,  there  is  by  definition  a  queue,  a  ‘waiting  list’.    Basically,  a  ‘common  waiting  list’  is  not  a  useful  way  to  describe  what  should  be  a  responsive,  quality  and  fair  service.        

   This  proposal  is  limited  to  publicly-­‐funded  healthcare.    If  the  State  in  future  purchases  care  for  public  patients  from  private  hospitals  under  a  Money  Follows  the  Patient  system,  which  is  also  on  the  Government’s  agenda,  one  would  expect  all  patients  of  private  hospitals  to  be  treated  equally,  irrespective  of  who  was  paying  for  them.    No  private  hospital  would  object.        Going  beyond  that,  laws  should  respect  an  individual’s  freedom  to  seek  out  and  purchase  healthcare  for  oneself  beyond,  or  separate  to,  public  healthcare.    Even  in  the  United  Kingdom,  with  the  NHS  tradition,  15  per  cent  of  the  population  are  covered  by  private  health  insurance  in  a  £5bn  market.    The  NHS  is  single  tier,  but  this  does  not  prevent  people  from  purchasing  private  health  insurance,  even  for  hospital  care  available  on  the  NHS.    Private  hospitals  in  the  UK  are  not  obliged  to  treat  NHS  patients,  but  do  so  if  the  NHS  pays.    For  Ireland  at  present,  a  short  Health  Equal  Status  Act  would  provide  assurance  to  public  patients  that  the  public  health  system  was  fair.      It  would  pave  the  way  for  equity  under  Money  Follows  the  Patient,  and  deliver  some  of  the  desired  benefits  in  advance  of  the  complex  change  towards  universal  health  insurance.      ENDS        Oliver  O’Connor  is  an  independent  consultant  in  health  finance  and  economics.    He  was  Special  Adviser  to  the  Minister  for  Health  from  2004-­‐2010.