21st Century
Eligibility for Hospital
In 1991, a two-tier system of eligibility for hospital inpatient and outpatient services was introduced. It provided for category 1, medical card holders and category 2, all others.
The population is divided into category 1 and category 2. Category 1 comprises medical card holders and dependants who are entitled to all health services free of charge. This covers one-third of the population.
Category 2 covers the remainder of the population who are entitled to a more limited range of services free of charge.
People in Category 1 are entitled to free GP and hospital services in public wards of public and voluntary public hospitals. People in Category 2 are liable for GP fees but are entitled to free hospital services subject to an annual maximum charge of €1200, a maximum of 2010.
Health Funding
In 1989, the Commission on Health Funding favoured public funding as the principal method of funding the health service. On the basis of public funding, the choice was between general taxation and compulsory health insurance earmarked tax.
General taxation was favoured on the basis that the earmarked tax constituted general taxation in substance. It recommended the abolition of health contributions introduced in 1971. As of 2004, 85 per cent of health services were derived from the exchequer, with outpatient charges accounting for 10 per cent.-
In 2005, a proposal for the development of private hospitals with tax relief on the site of public hospitals in a number of locations was proposed in order to provide additional bed capacity. The purpose was to increase the number of private beds and free up private beds in public hospitals. The issue became controversial, and most of the projects were not completed.
National Health Strategy
National Health Strategy (Quality and Fairness – A Health System for You) was published in 2001. ‘Quality and Fairness’ set out the following four guiding principles, which highlighted the assessment that weaknesses in the system related to lack of coverage and equity of access:
- Universal coverage
- Solidarity in finance
- Equity in access and
- High-quality healthcare
The assessment put forward in ‘Quality and Fairness’ included, among others, that the future health service should clarify eligibility and entitlement to services, remove barriers to accessing services and that “[a]ccess to services [is] to be more equitable” where “ the perceived two-tier aspect of health care [is] to be eliminated”.
Many of the ‘system transformative’ actions set out in this National Health Strategy and in subsequent sector-specific health policies (“A Vision for Change” (2006) and “Healthy Ireland” (2013) have not been implemented. Reform that has taken place has centred on restructuring and reorganising the governance and delivery of health services.
Voluntary Health Insurance
The Voluntary Health Insurance Board was established by the Voluntary Health Insurance Act 1957. Category 2, eligibility persons with eligibility for subsidised hospital services, commonly take cover to provide private or semiprivate accommodation and private treatment in hospitals.
EU competition legislation required the introduction of competition into the private health insurance market. The Health Insurance Act 1994 ended the VHI monopoly. The British Union of Private Assurance commenced operating in 1997. By 2002 it had 300,000 subscribers. Its business was taken over by Quinn Insurance in 2007.
Aviva entered the market in 2004, was taken over by Hibernian Health in 2008, and became Hibernian Aviva. By 2009, VHI retained the largest market at 64 percent, followed by Quinn Healthcare (Liberty Mutual) at 22 percent and Hibernian Aviva Health at 10 percent.
Reform
A 1999 White Paper on Private Health Insurance provided for a programme of reform to include the transformation of VHI into a commercial semi-state agency and the retention of revised community-based ratings. The 1994 Act provided for risk equalisation to prevent insurers from targeting low-risk, relatively younger and healthier subscribers. The Health Insurance Authority was established by legislation in 2001.
A system of community rating applies. All age categories are charged the same premium irrespective of age. Risk equalization was recommended by the Health Insurance Authority and involves transfer payments between insurers to spread the cost of higher-risk older members.
In 2006, BUPA decided to withdraw from the Irish markets, leading to its acquisition by Quinn following a failed challenge to risk equalization. The BUPA appealed the High Court decision and the 2008 Supreme Court rule that the system of risky equalization was invalid because it had been based on an incorrect interpretation of the provision in the Health Insurance Act 1994.
In 2010, the government announced an intention to invest €200 million in VHI prior to putting it for sale by 2013. The purpose was to bring VHI’s reserves up to a level that would enable it to be authorised on objective financial services grounds. By 2008, over half the population had VHI cover, but this fell significantly following the financial crisis.
Hospital Services
In principle, all have had full access to hospital services since 1991. However, waiting lists for public patients have grown, and the private health insurance system is perceived to provide quicker access to hospital care.
The Health Strategy [2000] proposed the creation of 3,000 beds by 2011 designated for public patients. The proposed employment of additional consultants. It promised a waiting time of not more than 3 months. It proposed a treatment purchase fund for treatment from private hospitals and abroad.
The National Treatment Purchase Fund is an independent agency whose purpose is to reduce waiting times for public patients waiting for surgery. Public patients on the waiting list may contact the NTPFR or may be referred to it, which may source treatment. The NTPF has made a substantial difference in the waiting list, decreasing waiting time for surgery considerably.
Hospoital Consultant Contract
Under the 1997 hospital consultant’s contract, consultants were paid a salary for treating public patients of 33 hours per week. They could also charge fees to private patients.
In conjunction with the pre-designation of categorization in 1991, it was provided that private patients must generally be accommodated in designated private beds. 20 per cent of beds were to be designated private, although this percentage, in fact, increased. A report by the Controller and Auditor General noted that the 80-20 split was largely ignored to the detriment of public patients.
The new consultant’s contract was finalised in 2008. It provides for a longer working week and public-only type contracts, limits on private first and public practice and a common waiting list for diagnostic services, including laboratory and radiology services. It provided for restricted monitoring of private practice.
GMS Scheme
The choice of doctor schemes commenced under the GMS introduced in 1972. Until 1989, GMS doctors were paid a fee per consultation in accordance with the scale.
Under GMS, pharmacists who enter an agreement with the HSE are the primary suppliers of drugs to those eligible for GMS cards. The pharmacy recoups the cost of drugs from the HSE and is paid a dispensing fee. A prescription charge of 50 cents per item subject to a maximum of €10 per month per person of family was introduced in 2010.
In 1989 a capitation payment was introduced for each panel patient weighted to gender, age, geographic factors. There are agreements with 2500 doctors, 1500 pharmacies, 1200 dentists and 550 optometrists as of 2007. Most doctors attend to both public and eligible patients and “private” patients with variations in distribution.
Limited Eligibility
In 2001, eligibility for medical cards was extended to all persons over 70 years of age irrespective of means. The automatic entitlement was removed in 2009. However, after significant protests, 95 per cent of persons over 70 retained their medical card, with the remainder losing automatic entitlement.
A special medical card was introduced in 2005, providing for free GP service but not free drugs and medicine. The income level threshold for qualifications is 25 per cent above the standard medical card threshold.
The GP Visit Card was first introduced to enable access to GP care without charge for those whose income is below a certain threshold but above the Medical Card threshold.
Extension of GP Care
In the 2011 Programme for Government, the State committed to free GP care for all and the introduction of UHI in order ‘to develop a universal, single-tiered health service” guaranteeing access based on need and not on ability to pay. However, the planned single-tier health system with universal access had not come to fruition. The planned introduction of free GP care for all had similarly not been implemented.
However, on foot of the above policy prescriptions, ‘free’24 GP care for under 6s and some over 70s had been implemented since 2015.
Table 2 below provides a brief overview of development in respect of universal health care and in particular, extending coverage to children and those over 70s:
June 2015 Free GP care (via GP visit cards) for all children aged under 6 years of age, and all adults aged 70+ years was introduced. Health (General Practitioner Service) Act 2015
May 2016 The Government announced a commitment to an extension of free GP care to all those under 18 years of age. “Extending in phases, and subject to negotiation with GPs, we are committed to the introduction of free GP care to under 18s. This will require a substantial increase in GP numbers to support the additional workload”.25 Not applicable
June 2018 Act extending entitlement to GP visit cards to those in receipt of Carer’s Allowance and Carer’s Benefit (i.e. those who do not already qualify for a GP visit card or medical card on means or age grounds). Health (General Practitioner Service) Act 2018
July 2020 Bill proposes to extend free GP services on a phased basis for children up to the age of 13 and increase the eligibility threshold for medical cards for over 70s. Health (General Practitioner Service and Alteration of Criteria for Eligibility) Bill 2020
Interdisciplinary Primary Care
The Health Strategy proposed an interdisciplinary themed approach to primary care in Primary Care a National Direction in 2001. It proposed greater liaison between care providers and proposed that many hospital services could be provided in the community.
It proposed that primary care teams would comprise GPs, nurses, midwives, healthcare assistants, home helps, occupational therapists, social workers, and administrative personnel working together from a single centre. The purpose was to provide a one-stop shop to deal with 95 per cent of health needs. Each team would cover a population of 8,000 to 10,000 people.
There have been 10 pilot schemes since 2006. As of 2010, progress has been significantly less than expected, with only 222 teams of the 600 proposed teams. Half of these work were at an advanced functioning stage, which was defined as holding clinical team meetings to discuss and plan integrated care for clients while other teams had no GPs in place.
Hospital Rationalisation
In the 1980s, cutbacks in public expenditure forced rationalisation in the hospital sectors. A number of public, voluntary hospitals and smaller district hospitals were closed. Approximately 6,000 beds were removed between 1984 and 1993. Many closures occurred through the department-reducing Health Board, leaving no alternative but to close smaller hospitals.
The rationalisation of Dublin hospitals was undertaken at three major hospitals on the north side, Beaumont the Mater and James Connolly Memorial Hospital, and three on the south side, St. Vincent’s, St. James and Tallaght.
The Hanly Report 2003 considered the Working Time Directive in the context of hospital doctors. It recommended the employment of a larger number of consultants and revised working patterns. It recommended a consultant-provided hospital service instead of the existing consultant-led service.
The Hanly examined the Dublin and the Mid-Western areas. In 2009, the HSE proceeded with hospital services reconfiguration in the Midwest broadly along the lines in the Hanly report.
Children’s Hospital
The Children Health First report commissioned by the HSE and compiled by McKinney’s was published in 2006. It recommended that the State c could justify one world class children’s hospital which it indicated should be in Dublin adjacent to an adult hospital.
A task force in the Department of Health and HSE concluded that the project could be delivered most efficiently on the Mater side. The Boards of National Children’s Hospital, Tallaght and Crumlin Hospital expressed the view that the process was flawed and lacked transparency. Ultimately, it proceeded at St James’s Hospital.