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 The fallacy of private health care efficiency

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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 1:05 pm

cactus flower wrote:
seinfeld wrote:
Auditor #9 wrote:

Seinfeld has just posted before me on co-location: I'm wondering if those systems in Canada and elsewhere may not for some reason apply in Ireland? Perhaps there is a geographic or infrastructural peculiarity to our country ... ?

Our peculiarity is that we are hugely invested in politically sensitive in-patient care.

ie

We have lots of County Hospitals into which people are admitted for all manner of procedures that in other countries are dealt with in primary care clinics.

We also have a God-culture amongst our consultants, who up until now have been very rigid in terms of their work practices, meaning that we have very narrow discharge windows.

All of this has led to huge pressure on our acute bed capacity, particularly when private patients are being admitted to public facilities because there isn't enough private capacity to accommodate them.

Co-location is a tactical response to that specific issue, not some sort of grand conspiracy on the part of Mary Harney and corporate Ireland.
Pax would prefer to see a massive overhaul of health funding and the development of a single tier system therein. I imagine most people would, but its not a short term solution, and may not be a solution at all, given that there is no evidence that Irish people would accept mandatory health insurance.

From what I have read a lot of people do see it as the thin end of the wedge of privatisation. I think I agree with them.

Private medical care is already pervasive in the health service. People have this notion that if they are in a bed in a public hospital that they are not using private medicine. If you are paying for your treatment with your health insurance you are using private medical care, which is what a majority of people are doing. The thin end of the wedge has passed right through, and did so years ago.

Co-location is not the start of privatisation; its a mechanism to ensure that private medicine doesn't impact unduely on the public system.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 1:34 pm

That doesn't answer any of my questions about the fragmentation of health service provision proposed by Harney or the cost that the public will incurr in paying for private profit made out of health care.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 2:06 pm

cactus flower wrote:
That doesn't answer any of my questions about the fragmentation of health service provision proposed by Harney or the cost that the public will incurr in paying for private profit made out of health care.

52% present of the adult population are already paying for private profit, and the other 48% are subsidising what their private insurance premia doesn't cover.

You seem determined to avoid the stark reality that the public system is being used for private practice; ie public patients are subsidising private patients.

What do you propose we do about that?
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 3:03 pm

Labour launched a HSE reform proposal document yesterday.



Document Here

Labour six steps are:

1. Establish clear lines of authority, responsibility and reporting within the HSE, with standard-setting at national level and as much day-to-day decision making devolved to local level as possible.

2.
Make the Minister for Health answerable to the public through the Dáil
for all aspects of Health Service policy and delivery, and make the
Secretary General of the Department the Accounting Officer for the HSE

3. Offer a voluntary early retirement, redundancy and re-deployment
scheme, as part of the rationalisation of management structures

4.
Give each hospital and each community care area autonomy to spend its
budget, allocated according to national norms. Require each hospital to
establish a management board

5. Accountability to the public
through Local and National Public Representatives should be at network
and community care area rather than regional level and regional
structures should be abolished.

6. Each hospital and community
care area should be required to establish a patient liaison programme
in accordance with recommendation 11 of the HIQA Report on Rebecca
O’Malley’s case.

What ye think.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 3:35 pm

EvotingMachine0197 wrote:

1. Establish clear lines of authority, responsibility and reporting within the HSE, with standard-setting at national level and as much day-to-day decision making devolved to local level as possible.

Sounds like management speak to me, and I don't believe in devolved management in health; what you end up with is political interference.

EvotingMachine0197 wrote:

2.
Make the Minister for Health answerable to the public through the Dáil
for all aspects of Health Service policy and delivery, and make the
Secretary General of the Department the Accounting Officer for the HSE
The Minister is answerable already, not sure how they propose to make the Minister more answerable. Good idea re. the Secretary General.

EvotingMachine0197 wrote:

3. Offer a voluntary early retirement, redundancy and re-deployment
scheme, as part of the rationalisation of management structures

The HSE are already doing this.

EvotingMachine0197 wrote:

4.
Give each hospital and each community care area autonomy to spend its
budget, allocated according to national norms. Require each hospital to
establish a management board

Again, I'd have fears that money allocated for resource A would be spent on resource B due to political pressure.

EvotingMachine0197 wrote:

5. Accountability to the public
through Local and National Public Representatives should be at network
and community care area rather than regional level and regional
structures should be abolished.

Local representatives are elected to hold their Local Authority to account, not the HSE. In general , local reps should be kept at arms length from decision making of any consequence.

EvotingMachine0197 wrote:

6. Each hospital and community
care area should be required to establish a patient liaison programme
in accordance with recommendation 11 of the HIQA Report on Rebecca
O’Malley’s case.

Good idea.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 4:18 pm

seinfeld wrote:
cactus flower wrote:
That doesn't answer any of my questions about the fragmentation of health service provision proposed by Harney or the cost that the public will incurr in paying for private profit made out of health care.

52% present of the adult population are already paying for private profit, and the other 48% are subsidising what their private insurance premia doesn't cover.

You seem determined to avoid the stark reality that the public system is being used for private practice; ie public patients are subsidising private patients.

What do you propose we do about that?

Sorry to quote myself from an earlier post at length, but I don't.


Quote :
Seinfeld, you obviously know a good bit about the health system. As an outsider / user neither the existing nor the proposed system makes sense to me.

We have always had a dual public / private system, have we not, with a good proportion of the private hospital side provided by Church run bodies. Consultants were free to sell their services to both public and private. The hospitals weren't organised in any planned way across the country but had evolved in a fairly ad hoc way to provide most services locally with some more specialised services provided in Dublin and Cork.

G.P.s are I think private operators who are compensated for treating people who can't afford to pay?

We seem all to be agreed that the present system in which half the population pay a private "top up" insurance that does not cover the full costs of treatment, with "private" patients being shoved up the queue and in some cases overtreated and public patients waiting years for consultant appointments and in some cases dying untreated is a scandal and a misuse of resources.

The other big problem we are being told is that consultants/treatment centres are too small in terms of patient numbers per annum and therefore don't reach the best possible level of expertise, and that patients also die for that reason.

I can't for the life of me see how in a small country splitting public from private consultants in different hospitals sitting next to each other, but with no shared expertise between the two, can possibly do anything but make the latter problem (lack of sufficient patient numbers in a particular field) much worse.

In some areas, say pancreatic care, we have no national centre of any description. There would be no sense in Ireland in having more than one centre. If we divide our consultants between two different systems we would be even further away from having one.

What reason does Mary Harney give for dividing the consultants up in this way? I think it is plain nuts.

You haven't replied to these questions Seinfeld, and I know you are under no obligation to, but it leaves me feeling that if one of MH's defenders can't explain the 'strategy' then there isn't one.

This thread is about the inefficiency of privatising health care. I would be very happy to exchange views with you on another thread about what is wrong with the present system.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 4:47 pm

cactus flower wrote:
seinfeld wrote:
cactus flower wrote:
That doesn't answer any of my questions about the fragmentation of health service provision proposed by Harney or the cost that the public will incurr in paying for private profit made out of health care.

52% present of the adult population are already paying for private profit, and the other 48% are subsidising what their private insurance premia doesn't cover.

You seem determined to avoid the stark reality that the public system is being used for private practice; ie public patients are subsidising private patients.

What do you propose we do about that?

Sorry to quote myself from an earlier post at length, but I don't.

Fine, you described the problem; you didn't suggest a solution. What I am saying is that we can't just go on acknowledging the problem; somebody need to do something.


cactus flower wrote:

You haven't replied to these questions Seinfeld

About splitting up the system and undermining critical mass? I did (previous page):

"Consultants will continue to do both private and public practice, and
the co-lo hospitals will constitute only a fraction of overall
capacity, but yes, it won't be the same as all consultants working in
public facilities and building up expertise through shared experience.

Nobody
is arguing that there are significant downsides to co-location. The
problem is that we have a very urgent acute capacity problem, that is
costing lives, and co-location is the just one of the solutions being
applied to address this."
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 4:57 pm

Auditor #9 wrote:
Thanks for those links Pax, no idea why I couldn't find those stats ages ago when I was getting involved in a HSE debate over on p.ie.

I wrote a giant reply there but I think I was rambling a bit .. I don't know if your world health chart link is linking or is it me but the google page entry #1 for those very words was this

http://www.whc.ki.se/index.php

which looks like it's linking for me anyway.

That link seems to be working for me. Although that index page is more Flashy!
http://www.whc.ki.se/index.php

Auditor #9 wrote:
Ye seem to be both in agreement that the HSE needs an overhaul anyway - is it possible to eject hundreds of consultants and bring in Polish and Pakistani ones instead as well as implement thousands of other cost-cutting measures I could think of given a bit of time and a small consultancy fee...

The consultants definitely seem to be a major part of the problem here. Are they?

Imho if the consultants get uppity with the introduction of say, a single-tier universal public system funded through taxation (the most efficient mechanism is via tax), then I'd have no problem getting doctors of an equivalent ability in from anywhere - Polish, Pakistani, Cuban even, etc. They'd all be more than happy to do it I'd imagine. Btw I'd fully expect them to get itchy as they seem to do it everywhere - i.e. they did in the UK when the apres-WWII Labour government started to build the NHS.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 5:30 pm

We seem to have missed each others posts. Embarassed
Have the consultant contracts been changed? Last time I was reading about them public/private consultants were to be completely separate.

That would have been a big step down by Mary Harney.

What would I do?

If I was given the job of organising a health system for Ireland I would stop advertising of alcohol and put the age for smoking and drinking up to 21.

I'd provide better health education at school - get people eating a better diet and better public sports and fitness facilities.

I would get a proper system of GP/medical surgeries up across the country and particularly improve services in the 'disadvantaged areas' so that fewer people go to A+E with minor complaints. There need to be a lot more GPs in Ireland, so that would mean change too. Caredoc systems out of hours across the country.

Encourage doctors not to supply unneccessary and ineffective drugs like
-antibiotics
-prozac
-cough linctuses and codeine based drugs

For the hospital system I would
-survey and evaluate the resources we already have in place (and I would include in that trained personnel - medical and administrative)
- look at best practice internationally
- have a needs assessment based on future projected needs for all types of hospital services
- building on the existing resources where possible, put in the services needed.
-allow for multi-annual budgeting in all areas.

Whether it was paid by a universal health insurance system or by general taxation would not be very important to me - although I think I have read that UHI achieves better services.

Having said all that, I've no expertise whatsoever in the health planning field and I am sure something much better could be done - but that would be my general drift, as you asked me.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 6:08 pm

cactus flower wrote:
We seem to have missed each others posts. Embarassed
Have the consultant contracts been changed? Last time I was reading about them public/private consultants were to be completely separate.

The new contract that was accepted by the IHCA last week creates 3 types of consultant:

1. Public Only
2. 20% private practice in public facilities
3. Negotiated private practice in public facilities

Type 3 is for uber-specialist consultants who work in parts of the country where there are no private hospitals.

Generally speaking, consultants will continue to see the same number of patients as before. The difference is that they'll be seeing a lot fewer private patients in public facilities.

You still have told me how you would address the specific short term issue of private patients using capacity in the public system.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 6:11 pm

Pax wrote:

Imho if the consultants get uppity with the introduction of say, a single-tier universal public system funded through taxation (the most efficient mechanism is via tax), then I'd have no problem getting doctors of an equivalent ability in from anywhere - Polish, Pakistani, Cuban even, etc. They'd all be more than happy to do it I'd imagine. Btw I'd fully expect them to get itchy as they seem to do it everywhere - i.e. they did in the UK when the apres-WWII Labour government started to build the NHS.

We already have lots of foreign consultants and the HSE are always looking for more. Don't be fooled into thinking that just because a consultant is from a different country that they are going to work for peanuts. There is a shortage of consultants worldwide, and these guys go where they get paid. A Polish consultant isn't going to work in public hospital in Ireland for €200k per annum if he can get €500k for half the work in a private hospital in Dubai.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 6:13 pm

seinfeld wrote:
cactus flower wrote:
We seem to have missed each others posts. Embarassed
Have the consultant contracts been changed? Last time I was reading about them public/private consultants were to be completely separate.

The new contract that was accepted by the IHCA last week creates 3 types of consultant:

1. Public Only
2. 20% private practice in public facilities
3. Negotiated private practice in public facilities

Type 3 is for uber-specialist consultants who work in parts of the country where there are no private hospitals.

Generally speaking, consultants will continue to see the same number of patients as before. The difference is that they'll be seeing a lot fewer private patients in public facilities.

You still have told me how you would address the specific short term issue of private patients using capacity in the public system.


What is the issue? A capacity issue or one of principle?
In terms of capacity, open closed wards and use beds far more efficiently. In terms of principle, co-location will not mean that private patients aren't treated in public hospitals in the short term.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 6:18 pm

You may have a better explanation, but the new contract seems to be designed mainly to drive a body of consultants into the arms of the private sector, in order to artificially support its early viability.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 6:33 pm

cactus flower wrote:
seinfeld wrote:
cactus flower wrote:
We seem to have missed each others posts. Embarassed
Have the consultant contracts been changed? Last time I was reading about them public/private consultants were to be completely separate.

The new contract that was accepted by the IHCA last week creates 3 types of consultant:

1. Public Only
2. 20% private practice in public facilities
3. Negotiated private practice in public facilities

Type 3 is for uber-specialist consultants who work in parts of the country where there are no private hospitals.

Generally speaking, consultants will continue to see the same number of patients as before. The difference is that they'll be seeing a lot fewer private patients in public facilities.

You still have told me how you would address the specific short term issue of private patients using capacity in the public system.


What is the issue? A capacity issue or one of principle?

The issue is that public patients cannot access public beds because private patients are sitting in them.

What needs to be done?
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 6:35 pm

cactus flower wrote:
You may have a better explanation, but the new contract seems to be designed mainly to drive a body of consultants into the arms of the private sector, in order to artificially support its early viability.

You're just looking for bogeymen.

How can the creation of a public-only consultant post be construed as an effort to drive consultants to the private sector?

There is nothing preventing consultants working in the private sector as things stand.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 7:00 pm

seinfeld wrote:
Pax wrote:

Imho if the consultants get uppity with the introduction of say, a single-tier universal public system funded through taxation (the most efficient mechanism is via tax), then I'd have no problem getting doctors of an equivalent ability in from anywhere - Polish, Pakistani, Cuban even, etc. They'd all be more than happy to do it I'd imagine. Btw I'd fully expect them to get itchy as they seem to do it everywhere - i.e. they did in the UK when the apres-WWII Labour government started to build the NHS.

We already have lots of foreign consultants and the HSE are always looking for more. Don't be fooled into thinking that just because a consultant is from a different country that they are going to work for peanuts. There is a shortage of consultants worldwide, and these guys go where they get paid. A Polish consultant isn't going to work in public hospital in Ireland for €200k per annum if he can get €500k for half the work in a private hospital in Dubai.

Hmm, I'm not so sure about that. The Venezuelans are certainly benefiting from Cuba's surplus of doctors and they're not earning an awful lot afaia. But not all consultants or doctors are entirely motivated by their wage packet size. Also, in the example of the introduction of the NHS I believe the doctors were partly bought out, but were mainly shamed into accepting the deal. There are other examples elsewhere in the development of public health systems.
And I believe the Canadians recently and successfully, used this threat against their consultants? ( although I can't remember where I read that last one or in what Canadian reform context)
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 7:04 pm

seinfeld wrote:
The issue is that public patients cannot access public beds because private patients are sitting in them.

What needs to be done?

Well, certainly not colocation. That's not a solution and only exacerbates the situation (as shown by similar elsewhere).
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 7:20 pm

seinfeld wrote:
cactus flower wrote:
You may have a better explanation, but the new contract seems to be designed mainly to drive a body of consultants into the arms of the private sector, in order to artificially support its early viability.

You're just looking for bogeymen.

How can the creation of a public-only consultant post be construed as an effort to drive consultants to the private sector?

There is nothing preventing consultants working in the private sector as things stand.

As it is clearly a bad idea to split them up this way from the point of view of the critical mass of patient numbers that should be seen by each consultant , why is it being done ? What is the rationale? I have never heard anyone explain the point. It is of no advantage to the public patient who just wants to be seen by someone.

The head of the HSE has repeatedly said there are too many beds. There are repeated closures of wards and underuse and misuse of beds. So how can the issue be a bed shortage? and if it is a bed shortage, the hospital should be extended in a rational way instead of using up the lands intended for expansion on a duplicate private facility.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 7:50 pm

cactus flower wrote:
seinfeld wrote:
cactus flower wrote:
You may have a better explanation, but the new contract seems to be designed mainly to drive a body of consultants into the arms of the private sector, in order to artificially support its early viability.

You're just looking for bogeymen.

How can the creation of a public-only consultant post be construed as an effort to drive consultants to the private sector?

There is nothing preventing consultants working in the private sector as things stand.

As it is clearly a bad idea to split them up this way from the point of view of the critical mass of patient numbers that should be seen by each consultant , why is it being done?

I'm sorry, you've lost me. What do mean 'split them up'?

Pretty much all consultants do private and public practice as things stand. They won't see fewer patients under the new contract; they'll just be limited in the number of private patients they can treat in public hospitals.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 7:51 pm

Pax wrote:
seinfeld wrote:
The issue is that public patients cannot access public beds because private patients are sitting in them.

What needs to be done?

Well, certainly not colocation. That's not a solution and only exacerbates the situation (as shown by similar elsewhere).

What then?

I've never heard an opponent of co-location actually answer this question.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 7:55 pm

Quote :
Seinfeld: 'm sorry, you've lost me. What do mean 'split them up'?

Pretty much all consultants do private and public practice as things stand. They won't see fewer patients under the new contract; they'll just be limited in the number of private patients they can treat in public hospitals.
seinfeld
Tool-Master's Apprentice Stage I

If some consultants are private and others public only then in any one centre the number of patients in each of their catchments is reduced. How does this help the Centres of Excellence project ?

It makes every sense to have a single pool of consultants in each region rather than subdividing them into these limited categories.
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PostSubject: Re: The fallacy of private health care efficiency   Fri May 23, 2008 11:32 pm

seinfeld wrote:
Pax wrote:
seinfeld wrote:
The issue is that public patients cannot access public beds because private patients are sitting in them.

What needs to be done?

Well, certainly not colocation. That's not a solution and only exacerbates the situation (as shown by similar elsewhere).

What then?

I've never heard an opponent of co-location actually answer this question.

You must have missed my posts earlier then where I said we should increase capacity directly within the public system, and how my longer-term ideal would be a single tier universal public system, ideally paid for by the most efficient method which is tax.

Tangent non-solutions like colocation get us nowhere on that road and are justifiably seen as a thin wedge towards the opposite direction.
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PostSubject: Re: The fallacy of private health care efficiency   Sat May 24, 2008 12:14 am

Pax wrote:
seinfeld wrote:
Pax wrote:
seinfeld wrote:
The issue is that public patients cannot access public beds because private patients are sitting in them.

What needs to be done?

Well, certainly not colocation. That's not a solution and only exacerbates the situation (as shown by similar elsewhere).

What then?

I've never heard an opponent of co-location actually answer this question.

You must have missed my posts earlier then where I said we should increase capacity directly within the public system.

Why should we be spending public money to provide capacity for private patients to jump the queue?

The problem is not that we have insufficient public capacity; the problem is that we have insufficient private capacity.
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PostSubject: Re: The fallacy of private health care efficiency   Sat May 24, 2008 12:30 am

seinfeld wrote:
Pax wrote:
seinfeld wrote:
Pax wrote:
seinfeld wrote:
The issue is that public patients cannot access public beds because private patients are sitting in them.

What needs to be done?

Well, certainly not colocation. That's not a solution and only exacerbates the situation (as shown by similar elsewhere).

What then?

I've never heard an opponent of co-location actually answer this question.

You must have missed my posts earlier then where I said we should increase capacity directly within the public system.

Why should we be spending public money to provide capacity for private patients to jump the queue?

The problem is not that we have insufficient public capacity; the problem is that we have insufficient private capacity.

That's another one of your non-sequiturs. The private for-profit capacity you propose is at the public expense. It will not free up public beds. It will not increase capacity. It will remove funding from public hospitals.
So why not spend it directly within the public system? Why not include VHI insurance funds to fund a public only, single-payer single tier system? If people want ancillary treatements within private facilities then they can pay them without public subsidy via private for-profit insurance if they want. You know, like they do in France.
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PostSubject: Re: The fallacy of private health care efficiency   Sat May 24, 2008 2:56 am

Pax wrote:
seinfeld wrote:
Pax wrote:
seinfeld wrote:
Pax wrote:
seinfeld wrote:
The issue is that public patients cannot access public beds because private patients are sitting in them.

What needs to be done?

Well, certainly not colocation. That's not a solution and only exacerbates the situation (as shown by similar elsewhere).

What then?

I've never heard an opponent of co-location actually answer this question.

You must have missed my posts earlier then where I said we should increase capacity directly within the public system.

Why should we be spending public money to provide capacity for private patients to jump the queue?

The problem is not that we have insufficient public capacity; the problem is that we have insufficient private capacity.

That's another one of your non-sequiturs. The private for-profit capacity you propose is at the public expense.

Using public beds for private patients is also at the public expense.

Pax wrote:

It will not free up public beds. It will not increase capacity.

Hmmm. A thousand extra beds in the system, that can be used by the HSE, will neither free up public beds or increase capacity?


Pax wrote:

Why not include VHI insurance funds to fund a public only, single-payer single tier system?

What?

Pax wrote:

If people want ancillary treatements within private facilities then they can pay them without public subsidy via private for-profit insurance if they want. You know, like they do in France.

Because the private facilities wouldn't exist if the incentives didn't exist.

You answer is to the connumdrum is still: increase public capacity, and my question is still: why should the public purse be financing capacity that is being used by private patients.
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