The uneasy coexistence between public and private hospital care in Ireland has been highlighted by the current row between St Vincent's Healthcare Group and the HSE over the fact that many of its public hospital consultants are allegedly in breach of their contracts by working in the adjacent St Vincent's Private Hospital.
Basically, the HSE is saying consultants based at St Vincent's public hospital who hold contracts that only entitle them them to private practice in the public hospital in which they work, should not be working in the adjacent St Vincent's Private Hospital.
St Vincent's, for its part, claims they are entitled to do so as technically, it's all the one hospital group, on the one campus and under the same management structure.
HSE Director General Tony O'Brien has expressed concern about this alleged breach of private practice rules.
That well known commentator, 'a cynic', as he/she pores over the contractual complexity of this row, might be tempted to say pass the smelling salts and the corporate law textbooks.
The ordinary punter, meanwhile, will remain baffled and perhaps largely oblivious to the real issue here.
For this is the wrong row about the wrong thing
If the HSE was to have its way (and perhaps legally and technically it may be in the right); practically, it would have the effect of forcing around 80 consultants who are currently practising in the private hospital to do all their private work in the public hospital.
This could have a serious effect on services at St Vincent's Private Hospital.
But worse, it would mean that an even greater volume of consultant's private work would be carried out at St Vincent's public than is currently the case.
This leads us, TS Eliott like, to the overwhelming question, which is - never mind consultants working privately in an 'off-site' private hospital, why is private medicine allowed in a public hospital in the first place? They are, after all public hospitals.
There are two key iniquities in the Irish hospital system.
Firstly, there is the fact that those who can afford the more expensive insurance policies can bypass the public system and can get seen quicker, be guaranteed consultant-provided care and reside in in more comfortable circumstances in private hospitals.
Meanwhile public patients and privately insured people who cannot afford cover for stand-alone private hospitals, must suffer the slings and arrows of the public system.
The fact that private medicine receives indirect subsidisation from the State, through for example, tax relief on insurance premia which subsidises insurance costs, and through private hospitals doing public waiting list work, makes these situation even more iniquitous.
What is even more unfair than the above, however and is in fact a downright scam, is that public and private medicine co-exist in public hospitals.
The existence of private and public care within the same institution implies that there is a two-tier system within that hospital, which obviously would be wrong and is usually not the case. But even to imply that such a concept potentially exists by having this public-private designation in public hospitals, even if there is no overt discrimination, is simply wrong.
The official line is that two-tier access to care in public hospitals no longer exists. The policy now, we are told, is to ensure that there is no discrimination in public hospitals of in favour of private patients attending them in terms of levels of care, or access to and waiting for most services. So private patients in public hospitals cannot 'queue-skip'.
As regards a consultant-provided service, anecdotal evidence will inform you that a 'private' patient in a public hospital is just as likely (or as unlikely), to be seen by the treating consultant, as opposed to a junior, as a public patient.
Perhaps, you might justifiably believe, a private patient in a public institution will get slightly more luxurious or comfortable accommodation. Well, no, not really.
There are very few single designated private rooms in public hospitals, and semi-private wards largely don't seem much different to public wards in most hospitals in terms of bed numbers or facilities.
This leads us, then, to the other overwhelming question. Exactly what are the patients who fork out their hard-earned cash for an insurance policy for private care a public hospital actually getting in return? Remember, they would be entitled to access these hospitals anyway without holding any insurance cover.
The answer is, very little. Such an insurance policy will cover the €75 per day charge for non-medical card patients in public hospitals, which is something, one supposes, but not a whole lot for your money. And one must ask why there is such a charge in a public hospital in the first place.
This, however, will give us a clue as to why private medicine still exists in public hospitals - it's all about income generation. For the consultants, who will get private fees on top of their public salary, and for hospitals, who rely more and more nowadays on private accommodation as a source of badly-needed revenue.
And to make things worse, a recent legislative change by Health Minister James Reilly means that unlike before, a private patient, who through lack of available private or semi-private accommodation, might be placed in a public bed, can now be charged, through their health insurer, as a private patient.
Charged extra for for getting absolutely nothing extra.
And this new law, as it increases the amount that has to be forked out by insurers, has helped push premia up even further.
And then there's the fact that private patients in public hospitals are paying twice for their care - through their taxes and their insurance premia, and are getting nothing extra in return.
At every juncture, the patient is the sucker.
However, at least with private care in private hospitals, the two systems are ostensibly separated and the patient is getting something extra for their money.
Healthcare nowadays is not always about healthcare. It's most of the time about budgets, income and the relentless bottom line.
St Vincent's, judging by its deft manoeuvring with the Dail Public Accounts Committee and the HSE, has not exactly been the poster boy recently for transparency and public policy compliance.
However, in arguing for the retention of the right of its consultants to practice in its private hospital, it may hold the moral and practical higher ground over the HSE on this occasion.
Under the current iniquitous mess that is our public-private healthcare coexistence, allowing the St Vincent's consultants retain their right to private practice in the private hospital would be the lesser of two evils.
Better than more consultants returning to the public hospital and continuing to perpetuate the State-sponsored sleight-of-hand that is private healthcare in public institutions.
In the meantime, we await with bated breath the emergence of equality, liberty, and fraternity under James Reilly's universal health insurance plans.
Whatever people's qualms about it, any system that would essentially remove the money-grabbing public-private distinction and give everyone equal access to basic care can't be all bad.
HSE ultimatum on private practice
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