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Opinion: 'There are consequences to paying for all the most expensive new drugs'

We need to radically improve waiting times for treatment rather than focus on buying all the most expensive drugs, writes Dr Anthony O’Connor.

WE FREQUENTLY HEAR talk of a “two-tier” system of healthcare in this country being the root of a lot of problems.

The reality is that to call what we have a two-tier system is a gross underestimate.

There are at least two tiers in most countries I know of but here in Ireland, there are at least five tiers.

We have people with medical cards, then we have people whose circumstances do not qualify them for a medical card but don’t have private health insurance either.

Another group have private insurance that doesn’t cover them for private hospitals. The next tier consists of people whose insurance allows them limited access to private hospitals. Then finally you reach tier 1 – those who have unfettered access to private hospitals.

In the interests of full disclosure, I am a consultant who works full-time in a public hospital. I do not practice in a private hospital.

I am committed to providing high-quality public health care, but I do not believe – as some seem to – that private hospitals are intrinsically disordered or evil.

On the contrary, they are an important part of our nation’s healthcare infrastructure. The facilities are generally modern and comfortable.

For many conditions, the hospitals and the dedicated professionals that work in them provide an excellent standard of care to patients, and in almost all cases that care is timely.

Whether those who possess a higher degree of ideological purity like it or not, private hospitals are here to stay.

What they are not, however, is a substitute for public healthcare. They serve a radically different purpose.

Many citizens will never give up their private health insurance.

From where we are now, even with a strong wind it is difficult to envisage how we could match the standard of public access to healthcare enjoyed under the NHS or in Sweden in the short-term.

That notwithstanding, in many parts of the UK up to 15-20% of people have private health cover and in Sweden, 20% of hospital care and 30% of primary care is provided by private companies.

It is therefore long beyond time for those of us in the public sector to move beyond the shibboleths so beloved of commentators and politicians of the two-tier system and instead concentrate on what we want a reformed public service to look like.

To my mind at least this is one where patients would have a reasonable wait time. I’d say six weeks for routine and two weeks for urgent care. 

Where that care would be safe, effective and compassionate and for the Exchequer to fund treatments that have been proven to be substantially effective on a fair basis.

A lot of attention recently has been focussed on the decision made by the VHI to fund a particular expensive new chemotherapy agent in private hospitals that is not available in public ones.

This is an unwelcome development, but equally, it is one that must be taken in context.

The fundamental difference between the private and public sector in Irish healthcare is that we have a public sector that is charged with looking after people from the cradle to the grave, and a private sector that doesn’t have to and doesn’t want to.

The private sector should not apologise for this. They are entitled and required to be financially solvent and make a profit for their shareholders.

But what it does mean is that in many cases private providers do not engage in many complicated, expensive and difficult aspects of healthcare such as stroke, long-term home care and rehabilitation.

Stroke care, in particular, has been a story of sustained improvement in most Irish public hospitals in recent times with a 25% reduction in deaths between 2008 and 2015.

Should we sacrifice some of this in order to pay for every single one of the most expensive chemotherapy drugs?

This could be interpreted as pitting one set of patients against another, but it is not.

Nearly half of all stroke patients will be cancer patients too at some point in their lifetime and it is inconceivable that there is a family in the country that has been touched by stroke that has not also been touched by cancer.

The people who get cancer are the same people who get heart attacks, Crohn’s Disease, bipolar disorder, have children and like me – fall off their bicycles and nearly kill themselves.

Their treatment is delivered in the same places and paid for by the same people. Their interests, therefore, are basically the same.

We can pretend that there’s some sort of artificial divide between them, and as doctors, patients and advocates make our case for our particular disease or organ, or we can accept that in a public system we must provide good care for citizens from the maternity hospital to the hospice.

The public hospital has to be there for everyone, always.

It is a reductionist view to suggest that because of a decision not to fund a particular drug that cancer care is somehow inferior in the public sector than the private sector.

Cutting edge chemotherapy agents are a part of the tapestry of care but they are not a panacea either.

Evidence published in the British Medical Journal suggests that of the 48 new cancer drugs introduced in Europe between 2009 and 2013 the median benefit in terms of increased length of life was 11 weeks.

There are other equally important features of our cancer care in public hospitals such as our cohort of excellent cancer nurse specialists who provide invaluable expertise and support to patients and families.

These posts do exist in the private sector with similarly talented people occupying them but not to the same degree.  

Should the state reduce the number of nurse specialists for patients with cancer to a number comparable to that offered by the private sector in order to pay for a particular new drug offered by the VHI?

Or maybe the state should reduce the number of doctors in postgraduate training in the cancer services? Would that serve the greater good?

Private medicine simply doesn’t bear the same costs and can make decisions on drug budgets accordingly.

If we put all our eggs in the basket of paying for all the most expensive new drugs, we must recognise that there are consequences to this.

What is far more important is to operate a public sector that delivers sustainable, fair, low-cost, timely, good enough care to the citizen at all points of their life. This is not happening at the moment.

Nor is it likely to happen if we use access to every possible new drug as a benchmark of success.

Medicine is difficult. Planning it on a fair and sustainable basis is even harder.

Dr Anthony O’Connor MD, MRCPI is a Consultant Gastroenterologist at Tallaght Hospital.


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