Wading into the debate on the public-takeover of our private hospitals.

It cannot and should not be simplified into a #keepthecontract V #cancelthecontract dynamic
It is a luxurious fallacy to believe that ‘money follows the patient’ alone will incentivise efficiencies.

Firstly, we should remind ourselves how the private system leverages itself and benefits enormously from the State:
The public system is the workhorse of acute medicine/ surgery
The public system is the primary provider of complex social

care (in hospitals)
The public system always provides 365 24/7 care
The public system looks after the sickest of our patients (e.g. think of the initial COVID19 surge, our ICU capacity, and where this burden would have fallen)
The public system remains open on bank

holidays, public days and over Christmas
The State provides tax breaks to the developers of private hospitals
The State makes it tax efficient for persons who can afford private insurance (= inequality)
The State’s outpatient waiting-list-controller takes patients off

public lists and transfers them to private lists- benefiting private consultants and private hospitals
The State trains medical students; trains NCHDs and supports them through until they then work in the private sector (which is increasingly the case)
The public system

supports the MDT input for procedures performed in public hospitals.
The State often covers some of the indemnity risk incurred by the private sector
The ‘negative’ press of public ‘scandals’ and inefficiencies creates the ‘Risk Society’ which scares many into taking out

health insurance (declaration: I do not have health insurance).

It is not just one way traffic. Of course, the public system also benefits from the private system (payers and providers):
Private payers pay into the public hospital (up to 16% of the cases in the public system

are privately financed)
Public consultants receive a top up in salary from private payers (especially procedurists)
The argument that private care ‘keeps the pressure off the public system' has merit.

So the two systems overlap, but it is not symbiotic, with one party in this relationship disproportionately benefiting. Rather than mutualism, this is harmful competition. The gain to private hospitals, also brings large incomes to providers- & to consultants- and needs to be

factored before any #cancelthecontract discussion happens.

On #moneyfollowsthepatient, re-imagined by @ProfJohnCrown, I do not dispute the inefficiencies, poor governance and frustrations felt by public healthcare workers (I'd write a thesis on my own peeves with the HSE).

The call for a ‘money follows the patient system’, is one which will transactionalise healthcare further. It symbolises the commodification of healthcare, risks promoting any practice above ‘care’. The clue is in the title- money is mentioned first, then patient. It can enshrine

perverse incentives. More healthcare, but not better healthcare. More tests, more procedures, more marketing- yet disincentivising the time of the generalist.

The biggest story in #COVID19- and it is telling that is the 'unspoken' issue amongst medics- is how much of the previous care in all healthcare settings was not necessary settings- but especially in private hospitals.

We all know this to be the case.

Cross-discipline referrals that are not needed. Admissions that were not necessary. Tests that were not beneficial. The private outpatient reviews paid in cash that could be performed in General Practice, if it was resourced. Remember that this is what ‘money follows the

patient’ looks like and it isn’t always pretty.

We desperately need a lens shone on #overmedicalisation in the Irish system- as it harms the overtreated and those who cannot access healthcare. Money Follows the Patient will invariable supercharge #toomuchmedicine.

If #cancelthecontract means going backwards, with some patients waiting years and others weeks, I think we can be more ambitious.
If #moneyfollowsthepatient means more of any healthcare, above continuity, trust and relationships, I think we can be more ambitious.

And unsurprisingly, I think that the values underpinning @slaintecare , are what can deliver a more equal healthcare system. Fortunately every political party believes in this and I think that is the direction we should go. #slaintecare