One of the most striking theatre productions I have ever witnessed was a riotous Polish play called Birthrate, the highlight of the 1981 Dublin Theatre Festival. Starting with a stage set resembling a train compartment, all was sweetness and light as the first few passengers entered, ceding place politely to a mother and baby. However, as more and more passengers piled in, tempers began to fray and civility eroded, to the point where the baby and the mother became the first to be ejected through the window.
This metaphor for what happens to the vulnerable at times of pressure is very relevant to what happens in society at large, particularly for older people. The terrifying Francis report from Mid Staffordshire demonstrated vividly how older people became early victims of poor leadership and standards in the NHS, very belatedly recognised canaries in the coal mine.
Across the Irish Sea, a new and unhappy phenomenon is arising for older people in a mixed private and public healthcare system. A somewhat messy and porous border separates the two systems, with public and private beds in public and voluntary hospitals, as well as exclusively private hospitals which provide elective care in the main. There is much less discussion within the profession than might be desirable about the impact of the system on professional practice, with the few studies available (from general practice) showing differing treatment patterns for public and private patients . The aspiration of the current government is for a system of universal coverage, based on the Dutch model, but few are holding their breath.
In the meantime, almost one in two of the population holds private health insurance: up until recent years a system of community rating was in place, whereby people would pay a flat rate throughout their life, a form of intergenerational solidarity. However, an onslaught by a series of aggressive private insurance companies laid siege to the principle, and its defence by the Irish government, initially robust, has faltered to the point that a number of companies now offer rates for younger families which severely stretch community rating in the spirit, if not in the letter of the law.
Due to this, the larger insurance companies are now under significant pressure, with more stress on the way due a government plan to make every bed in the public system available for charging to private patients. A first sign of the dysfunctional response is an increasing tendency for the private insurance companies to query, and not pay for, lengths of stay associated with mostly older patients with complex disease and increased care needs.
Winding back the clock, the insurance companies are retreating to a Victorian model of acute illness, whereby the patient comes in with a single acute illness, is treated and discharged. Those were days! As we all should now know, multi-morbidity and loss of function are the rule rather than the exception in modern healthcare, and “acute take” in general hospitals would be more accurately described as “subacute on chronic take.”
Through this ruse, the insurance companies are abbreviating or delaying payment. If they don’t pay up, the public and voluntary hospitals suffer as private income is an important aspect of their revenues, and worryingly some hospitals are making moves to remove predominantly older people prematurely from private care to public care.
There is a series of injustices associated with this trend. Older people, through community rating when it worked, paid for the care of those in generations ahead of them in their time. Their care, particularly in the last year of life, costs less per head than that for younger people, a form of subsidy that they are providing. The cost to the hospital is on a “per day” basis, so they are supporting the younger people more likely statistically to be receiving high tech services. Finally, it is a negation of modern healthcare to impose outdated and simplistic funding paradigms on a major group – older people – that we could be completely unimaginable in cancer or cardiac care.
In the private hospitals as well, there are different pressures on older people. The private hospitals have increasingly negotiated a set payment for certain illnesses: treat in less days, the hospital gains, treat in more days, the hospital loses. Worryingly, I am aware of a number of cases where older people in private hospitals have been told after a relatively short stay, and while still unwell, that their insurance ‘has run out’. From the outside this looks like a cynical exercise of keeping the surplus if the patient is treated in less time, and avoiding the charge if it takes more time.
For those immersed in NHS culture – and I spent four happy years working in the NHS – there may be little sympathy for anything to do with private medicine. However, the Irish people have voted for this system, and if the system needs to be changed, a cynical short-changing of older people does not seem to be a good way of going about it.
In addition, the principle that doctors and nurses should defend patients is universal across systems. What is worrying about both in the Francis Report and what is happening to older people with private insurance in Irish hospitals, is the mute acquiescence of some senior doctors and nurses in these dubious practices.
Whether facing inappropriate demands in the private sector or through the rigidities of dysfunctional management in public systems, we need to articulate better the ethical and professional imperative of defending appropriate care in the face of organizational antipathy.
Theodore Roszak, the celebrated historian of counter-culture, wrote of the need for”a nobler economics that is not afraid to discuss spirit and conscience, moral purpose and the meaning of life“. We should not be afraid to demand the same of healthcare economics and the moral agency of doctors and nurses.
Desmond O’Neill is a consultant physician in geriatric and stroke medicine in Dublin, and is a member of the external advisory panel of the age friendly university initiative.