The Citizen: Issue 2
Author: Marie O’Connor
This article is based on the talk given by the author at the Ireland Institute on 18 November 2008. The papers from this series of public meetings, Society and Economy – What Kind of Ireland Do We Want?, will be published in 2009 by the Ireland Institute.
Two weeks ago, I was in Pittsburgh, Pennsylvania, looking up at the city’s tallest tower, sixty-six floors high. Across it blazed the letters: UPMC – University of Pittsburgh Medical Centre. Technically a not-for-profit corporation, UPMC dominates not only the Pittsburgh skyline but also the Pennsylvania health landscape. UPMC owns every hospital except two in Pittsburgh, controls the University of Pittsburgh medical faculty, and has a large private health insurance company: other links in the chain include four hundred doctors’ offices, long-term care facilities, and numerous for-profit subsidiaries.
UPMC has been trading in Ireland since 2006. It runs two cancer centres and the Beacon Hospital; and in partnership with the Beacon Medical Group, it is poised to run three co-located hospitals and a maternity hospital planned for south County Dublin. Despite having paid almost $20 million in fraud fines to the US Justice Department, the hospital chain is in receipt of lucrative contracts from the government.1
UPMC represents the new approach to health care in Ireland, where even medical trainers have become major players in the commercial world. Take the Royal College of Surgeons in Ireland (RCSI), which had a turnover of €1 million in 2006.2 Recently described as ‘an entrepreneurial rapid-response unit worth €500 million’, RCSI is now a global brand that owns a private hospital and ‘health oasis’ in Bahrain, a medical school in Penang, Malaysia (with UCD), and a string of educational centres in Africa.3 Thanks to our legislators, the College now enjoys the powers of a modern corporation, empowered to go into partnership with the pharmaceutical industry and to manufacture and sell drugs tax-free.4 RCSI also has its own property development company, Keating Investments, run by two of its executives. Its Dublin properties are among the most valuable in the city. Yet, as a ‘charitable body’, it is immune from property and other taxes and exempt, at least until now, from the need to make financial returns.5 Despite these exemptions and immunities, the College does little to alleviate Ireland’s shortage of doctors: three-quarters of its graduates work overseas. But, its Court of Patrons does include a number of Ireland’s billionaires, whose commercial projects enriched each other for the common good during the boom.
The commercialisation of health services is a worldwide phenomenon. During the 1990s, pressure built up to open public services to international trade. From 1990 to 1997, foreign direct investment in heath care in the US rose tenfold, marginally increasing competition in a crowded private sector.6 US health care companies began to look to other countries to boost their flagging revenues, especially those, such as Ireland, that offered tax schemes tailored to their needs. When the General Agreement on Trade in Services (GATS) was signed in 1995, just one in four member countries opened their health services to competition.7 But, Article 1.3 of the Agreement said that the right to exempt public services from market forces did not apply if a service was provided on a ‘commercial basis’ or if it was supplied ‘in competition with one or more service suppliers’.
Health services in Ireland are well established on a commercial basis. Instead of a stand-alone public hospital system, we have a public-private mix. Private non-profit institutions (referred to, confusingly, as ‘public voluntary’ hospitals), such as the Mater, Beaumont, St. James’s, and St. Vincent’s, wield considerable power. One of the problems with having such a powerful private non-profit hospital sector is the ease with which private non-profit can be converted into private for-profit. The nuns once ran a non-profit hospital system, but in recent years, nuns have joined the ranks of property developers, investors, and doctors who make money from the aged, the sick, and the dying. Take the Sisters of St. John of God, for example – they sold their hospital in Kilkenny, Aut Even, as a going concern to a for-profit company that included cardiologist John Clarke.8
Ireland has never succeeded in developing a real public health service. Beds in both public and private non-profit hospitals were gifted to medical consultants for their private practice in 1953. Since 1970, these hospitals have been allowed to charge private health insurers. These beds, as a result, came to be regarded as moneymakers. Private non-profit hospitals are joined at the hip to public hospitals, like Siamese twins. Staffing is one of the main joints. Hospital consultants hold posts that straddle the public and private sectors: these cross-over positions, paid for by taxpayers, account for one appointment in every three.9 Another vital organ shared by the private sector with the public is the so-called ‘common contract’. As many as ninety per cent of our hospital consultants are paid by the public purse, yet two in every five are entitled to work off-site in private practice.10 This contract enables private for-profit corporations to poach senior doctors from the public system, staffing their hospitals at no cost to themselves.
Public patients are now being treated by a variety of ‘providers’, including domestic and overseas companies. These investor-owned corporations mark a sea change, where the owners are no longer the managers and where patient care may have to take second place to turning a profit.
Research on for-profit health care is negative: health services run for profit are less safe and cost more to provide. Death rates are higher in for-profit institutions. The profit motive leads to overtesting and overtreatment, increasing the risks for patients.11 Private cosmetic surgery clinics have proved particularly problematic in Ireland. One of the biggest, Advanced Cosmetic Surgery, was recently wound up after being bought as a going concern by British building firm Artisan. Advanced ran into difficulties following the death of a woman who had received gastric banding. At least seventeen other legal actions against the clinic are pending. Deficiencies have also been found in the private for-profit nursing home sector here: inspectors have complained of, among other things, low staffing levels and poor hygiene.
Private sector involvement in health care has intensified over the past decade. Thanks to the government’s neo-liberal health policy, we now face a future where medical services funded by taxpayers will increasingly be provided by for-profit operators. New roles are being given to the for-profit sector despite international evidence testifying to the risks to both patient safety and the public purse. These roles include providing beds for public patients (under co-location), carrying out medical procedures (under contract to the state), and implementing that golden formula: design, build, maintain, and operate health facilities.
This sea change has been accomplished in a variety of ways, not least through taxation policies. Nursing homes superseded golf courses as the investment of choice during the boom. Fianna Fáil introduced tax breaks for building or refurbishing non-profit nursing homes and hospitals in 2001. The following year, these concessions were extended to for-profits. By October 2004, there were 427 private nursing homes in Ireland, with over 16,000 beds.12 One nursing home chain in the south, Golden Meadows, described its main business as ‘real estate management’.
Within months of the 2002 Finance Act becoming law, a major US hospital chain that was still in the process of paying fraud fines to the US Government attempted to enter the Irish market. That company, HCA, went on to pay a total of $1.7 billion to the US Justice Department to settle insurance fraud issues.13 Allegations of physician bribery were not resolved, however.14 Over 400 HCA hospitals were named in the settlement. The hospital chain also pleaded guilty to criminal charges. It was the biggest health care swindle in US history, in an industry mired in corruption. HCA’s successor company, Triad, began to trade in Ireland in 2006, in partnership with UPMC and the Beacon Medical Group. Triad ran the Beacon Hospital in Sandyford, Dublin, until 2007, when the facility was taken over by UPMC.
Another milestone in privatisation was the setting up of the National Treatment Purchase Fund (NTPF) in 2002. Designed to outsource clinical services to the private for-profit sector, the NTPF offers the perfect complement to the tax breaks introduced by Fianna Fáil for investor-owned hospitals. The fund treats relatively small numbers of public patients who have been waiting for more than three months for certain medical procedures. In 2006, the fund treated just under 17,000 inpatients and over 7,000 outpatients, at a cost to the taxpayer of €79 million.15 Most patients had minor surgery, with cataracts, tonsils, and/or adenoids topping the list. In this Alice-in-Wonderland scheme, some consultants have been paid twice to treat their public patients, with taxpayers ‘billed’ twice for their services.
Patient services are also being outsourced by the Health Service Executive. How much is being spent on these contracts? What are the terms and conditions? We do not know – there is no transparency, no accountability.
First designed for road-building, public-private partnerships (PPPs) are now used for hospitals and schools. That most lucrative of privatisation formulas, ‘design, build, finance, and operate’, has now been adopted in relation to cancer care. In 2005, the Minister announced the building of six oncology units at a capital cost to the public purse of over €400 million, most of it funded through PPPs. A year later, according to Anne Counihan, then CEO of the National Development Finance Agency, the capital cost of these radiotherapy centres had jumped to €550 million, plus €72 million annually in running costs.16 Although overruns are common in PPPs, the national media failed to notice.
General practitioner services in Ireland now look set to be corporatised: PPPs are also being used to build the new primary-care centres. We ‘went to the market and let the market decide’, a HSE bureaucrat proudly told a private health care conference in Santry’s Plaza Hotel in 2008.
But, the most significant public-private partnership in health in the history of the state is undoubtedly co-location, the grafting of private for-profit entities onto publicly funded hospitals. Eight hospitals, including many of our largest and most prominent teaching institutions, are currently scheduled for co-location.17 particularly invidious form of privatisation, co-location is designed to embed the private sector with the public service, stripping the parent hospital of its most valuable assets (staff and patients), while, at the same time, ‘sharing’ its technology and other resources. Developers – if they can persuade the banks to fund them – will see nearly half the cost of building offset in tax write-offs; taxpayers will forfeit around half a billion euro for hospitals they will never own; and the co-located entities will be staffed, courtesy of taxpayers, by publicly employed medical consultants, while a steady stream of public patients, re-routed from the public system, will ensure both corporate profits and private fees.
Private health insurance also acts as a potent growth promoter of for-profit medicine, with subscriptions attracting generous tax relief. Co-location, however, will require privately insured patients to be treated in the co-located entity. (But, how many Vhi and other subscribers know that they will no longer be able to use their private health insurance in the adjoining public hospital?)
The government’s policy of privatisation, implemented through tax incentives, outsourcing, and public-private partnerships, has been remarkably successful. Private for-profit hospitals are shooting up all over the country, uncontrolled, like ragwort. If the ten co-located hospitals and thirteen tax-fuelled investor-owned entities are built here as planned, around half of all our acute hospital beds (excluding long-stay and psychiatric beds), could soon be for profit, in one form or another.18
Public service closures are essential to privatisation. Nurturing for-profit companies requires public sector pruning. For example, a recent report commissioned by the HSE envisages cutting public-patient beds in Ireland from 12,778 to 7,990 by 2014.19 Nationally, this represents a total bed loss of 4,788.
We are now facing the biggest closure of beds and services since the public hospital asset-stripping programme of Fianna Fáil in the 1980s. Our public health system is being stripped out by stealth, under the banner of ‘reform’. Government bed-cutting programmes have been dressed in various guises, such as ‘centralisation’. But, centralisation in this context is an untried and untested experiment predicated on mass hospital closures. No country in the developed world has eliminated its tier of second level hospitals as Ireland, with one of the lowest bed-to-head-of-population ratios in the European Union, now proposes to do. Moreover, the oft-repeated claim that primary, community, and emergency services can safely replace hospital inpatient care is without foundation: not a shred of evidence exists to support this myth.
Public relations have taken the place of evidence. Implementing such deeply unpopular programmes requires massive spending on spin, with firms hired (at a daily rate of around €1,500) to devise strategies to minimise resistance to hospital, ward, and bed closures. These tactics have resulted in positive coverage from a largely uninformed media: the hollow rhetoric of ‘centres of excellence’ has yet to be pierced.
Business plays an important role in the marketisation project here, as it does in England. Personal relationships are believed to influence political decisions and policy-making to a considerable degree in Ireland.20 Actors from the private sector, who may reasonably be expected to represent private sector interests, are being given leading roles in health policy-making. The group that produced the Hanly Report in 2003, for example, was chaired by a prominent businessman, David Hanly.21 Repeatedly flagged in the national media as an ‘independent’ chairman, his company, Parc, ran a private hospital in Baghdad.
The Hanly Report offered a new rationale for the privatisation programme popularly known as ‘reform’. Fully implementing Hanly will effectively close around forty of our fifty-three acute public hospitals. (All hospitals that survive the coming purges will have for-profit entities umbilically or otherwise attached to them.) Hanly proposed a population threshold of up to five hundred thousand for a ‘viable’ in-hospital A & E unit. Implementing that yardstick in Ireland will require each hospital A & E to serve an area of 2,300 square miles.22
Central to the accomplishment of the HSE’s so-called ‘transformation programme’ is the privatisation of public administration. A veritable army of private consultancy firms has been deployed to this end. Teamwork, a Bolton accountancy firm that played a leading role in devising public-private partnerships in the British National Health Service (NHS), is one of the main architects of the privatisation of our health service. The company has been retained by the HSE since at least 2006 to ‘advise’ on the restructuring of the health system. In the North-East, for example, Teamwork proposed that all five public hospitals in the region should close, in effect, in the interests of ‘patient safety’ and be replaced by a new regional hospital at an unspecified location. New builds like this offer almost unlimited commercial opportunities.
The decision on the location of the planned new hospital was outsourced to yet another private consultancy firm, the Health Partnership. The firm has two principals, one of whom, Noel Daly, is a former CEO of An Bord Altranais and former member of Comhairle na n-Ospidéal. The Health Partnership has a strategic partnership with UPMC, the US hospital chain, and has advised on at least seven developer-led health care projects in Ireland. Entrusting a sensitive decision like this to a company with such a strong profile in the private sector raises the possibility of conflict of interests. Moreover, private interests are facilitated by the existence of a revolving door between the public and the private sector. A similar conflict of interests arises in relation to consultancy firms who work for both the public and the private sectors. Or, prominent actors in public policy-making may be simply related to industry leaders in the private sector. The forum that developed the cancer strategy, for example, was chaired by Professor Paul Redmond of Cork University Hospital, a brother of Beacon Medical Group founder and director Dr. Mark Redmond. I am not suggesting a conflict of interests: in a society as small as Ireland, such close connections may be expected.
Teamwork’s 2006 report on the North-East has been adopted as a ‘template’ by the HSE for the restructuring of the entire health service. Our public health system is being hollowed out and replaced with an internal market in which health services will be traded just like any other commodity. Private health care corporations have long reaped huge profits in planned care, radiology, pathology, and chronic diseases.23 Teamwork divided the health services along these lines, breaking them down into various segments, or niche markets, dubbed ‘clinical networks’.24 New disease entities have been created through the amalgamation of primary or community care, hospital care, and continuing care. This bundling will enable all services for chronic diseases, such as cancer, to be sold as ‘integrated’ packages on the open market. The Teamwork template will see high-cost and unprofitable services, such as A & E and intensive care, being left to publicly funded hospitals to provide. Other services and other segments will be outsourced.
Public hospital services are being radically restructured to provide a foundation for privatisation. Profitable areas of health care, such as pathology, are being removed from public hospital control: private medical laboratories have been described as ‘money machines’. One segment of laboratory testing has already been put to market, even before the publication of Teamwork’s unpublished report on pathology, which reportedly proposes mass closures and wholesale privatisation.25 That report is now imminent.
American models of ‘chronic disease management’ are now in use in Ireland, despite being untried and untested. Ireland’s leading diseases, such as heart, stroke, and diabetes, have been selected for commercialisation.26 Services for other diseases, such as asthma, chronic bronchitis, and musculoskeletal conditions, may also be put to market.27 Cancer has been chosen to lead the way in implementing the new ‘chronic disease management strategy’.
Cancer services are now being removed from public hospital control. The new specialist breast cancer centres, for example, will be ‘separate entities’, outside the management of public hospitals. The ‘national cancer control programme’ headed by Tom Keane has been described as ‘a separate business unit within the HSE’.28 All public monies hitherto expended on cancer care are to be made available to this unit: one of its main functions is to create ‘competition’. The new internal market or state auction for cancer services will force publicly funded hospitals to bid against private for-profit entities. The national cancer strategy explicitly provides for state contracts to be given to private-sector ‘providers’.29 Public monies previously earmarked for public hospitals will now be available to corporate providers. Many, if not all, of these for-profit facilities are significantly smaller than some of the public hospitals whose cancer services are being withdrawn. The new cancer business-unit will control many aspects of service provision, including the appointment of medical consultants. It will also own and manage the six radiation oncology centres to be built through public-private partnerships. Depending on how it is structured, the new cancer entity may also be free to enter into commercial contracts and to establish joint ventures with private for-profit companies, including pharmaceutical corporations, such as the RCSI.
Corporate influence over health care policy-making is a global phenomenon. In Ireland, around half of all patient groups are funded by industry. Patient groups, such as Europa Donna Ireland, a breast cancer advocacy group, are among those who have campaigned hardest for the closure of public cancer services. These groups are funded by pharmaceutical companies. For example, as much as 86 per cent of the funding of Europa Donna’s parent company in Europe comes from drug companies.30 Breast cancer has been chosen to spearhead the privatisation of cancer care in Ireland.
Another disquieting aspect of the cancer strategy is the marked emphasis on drug trials. Centralising cancer surgery, for example, serves commercial R & D. Anything removed during an operation can legally be put to commercial use. Genes are the building blocks of the biotech industry: DNA is the new gold. Pharmaceuticals, biopharmaceuticals, devices, and diagnostics were worth over $52 billion in exports from Ireland in 2005. UPMC has announced plans to establish a biomedical research and biotechnology centre here with state aid. Ireland’s gene pool is more homogeneous than most, making it particularly attractive to gene hunters. By 2005, 18 per cent of the entire human genome had been patented: two-thirds of these genes were in private hands.
The cancer strategy may be seen as yet another stratagem for the closure of public hospital services, a formula to terminate cancer care in twenty-five publicly funded hospitals. Even medium-sized hospitals, such as Tralee, are being forced to discontinue breast cancer surgery on the alleged grounds that they lack the requisite patient numbers. Yet, corporate providers, such as UPMC, have been able to announce the opening of breast cancer surgery in a context, presumably, of zero volumes. Opening the UPMC cancer facility at Beacon in Sandyford, the Minister for Health welcomed the hospital’s vaunted link with the Hillman Centre in Pittsburgh (also owned by UPMC). With Ministerial approval, actual patient numbers (too few, presumably, to meet HSE criteria) could evidently be boosted by virtual patient numbers through telemedicine, but only in the private sector.
Patients and communities will bear the cost of the government’s privatisation programme in health care. The cancer strategy, for example, offered new evidence of a growing disconnect between national health policy and community health needs. Geographic inequality has been intensified. The plan disregarded the North-West, ignoring the fact that over a million people live north of a line from Dublin to Galway and giving Dublin (once again) the lion’s share.31 Only sustained public pressure from voluntary groups, such as Co-operating for Cancer Care North-West, prevented Letterkenny Hospital from losing its services.32 The cancer forum cut public cancer care to just eight hospitals (unlike the O’Higgins Report, which had proposed fourteen), with four going to the big four private non-profit hospitals in Dublin and four to the rest of the country.33 Co-located private entities are planned for five of the eight hospitals: St. James’s (Synchrony/Capio); Beaumont (Beacon Medical Group/UPMC); Cork (Beacon Medical Group/UPMC); Limerick (Beacon Medical Group/UPMC); and Waterford (Peleton Consortium).
But, the robotic centralisation of cancer care is not in patients’ interests. For example, a regional study of cancer sufferers in Scotland cited one 84-year-old who described having to make a one-way seven-and-a-half hour journey by ambulance from Stranraer to Edinburgh for radiotherapy. As much as 13 per cent of cancer patients’ remaining time on earth was spent travelling to and from hospitals, the researchers established.34
More widely, health ‘reform’ will leave hundreds of thousands of people two hours’ drive or more from hospital inpatient care, at increased risk of death or permanent disability, due to the mass closure of A & E and maternity units. Patients also risk being out of pocket. The rules governing health eligibility are currently being rewritten. The shift from hospital to community care is likely to bring new charges. General practitioner services have never been free, except to medical card holders, and the new corporate primary care centres are likely to charge for services once provided free of charge to public hospital outpatients.
Public hospitals now face destabilisation and downgrading. Implementing the cancer and chronic-disease strategies will fragment and disintegrate existing public hospital services, not least by removing their principal sources of business.
Patients will soon see a depleted public hospital system. For example, terminating cancer surgery in publicly funded hospitals will jeopardise the quality of care in other departments, including A & E. Surgeons will be unable to operate on a patient presenting in casualty with a bowel obstruction, for instance, lest it be cancerous. Instead of having surgery locally, that patient will now be required to travel to a centre approved for cancer surgery, although he or she may not suffer from cancer. Moreover, if surgeons are unwilling to work in such a difficult environment, public sector hospitals will be unable to attract (or retain) high quality staff, and quality of patient care will suffer.
Patient safety issues have already emerged in relation to pathology services. Cervical cancer testing has been withdrawn from all public hospitals and outsourced to Quest Diagnostics, a laboratory giant in the US. General practitioners and laboratory scientists here have expressed strong reservations about the quality of American laboratory testing and its incompatibility with Irish screening practices. The Finnish experience shows that outsourcing has led to delays in accessing test results, while the inability of clinicians to consult remote laboratory personnel has also contributed to a drop in the quality of care.
The National Cancer Screening Service awarded the contract to the US firm in 2008, following reports in the Irish media that the company had repeatedly been fined under the False Claims Act. From 1996 to 2004, Quest paid over $150 million to the US Justice Department to settle allegations that they (among others) had billed government insurers for medically unnecessary tests and overcharged for cancer blood testing.35
The viability of our public health services is in jeopardy. For example, outsourcing cervical smear testing has had a disastrous effect on our public laboratory services. Around sixty scientists have been redeployed as a result. Laboratories at St. Luke’s Hospital and the Royal College of Surgeons in Dublin were among the first to close. Quest may now look forward to a monopoly on cervical cancer testing: no Irish laboratory will have the capaci36
The ‘smart economy’ requires human guinea-pigs. But, meeting the needs of the biotech industry raises wider issues of patient health and safety. While patients are promised access to leading-edge drugs, animal-to-human testing is extremely hazardous. Stem cell research has been oversold. Of the almost seven hundred gene therapy trials approved in the US, not one has yet resulted in drugs approved for use in patients there or in Europe.37 When they do reach the market, new therapies may be risky and/or unaffordable. Many of the new generation cancer drugs, such as Avastin, are highly toxic, and most, if not all, are prohibitively expensive. Moreover, industry-sponsored research tends to draw pro-industry conclusions, potentially endangering patients.38 So, while the new medical-academic-industrial complex serves corporate and other interests, the benefits to patients and communities are less evident.
Sweeping claims have been made for centralisation: that larger volumes lead to better outcomes; that the new specialist breast cancer clinics will offer increased survival prospects to sufferers. But, no data have been produced to support these assertions. No good evidence exists for centralising care for the common cancers. Scientific evidence for the claim that larger volumes of surgery lead to better outcomes for patients is lacking, except in the case of a very small number of highly complex procedures.39 A recent large-scale study published in the British Medical Journal found no relationship between the number of surgical procedures performed and survival rates for that particular operation.40 Death rates were unrelated to volumes.
Health ‘reform’ is synonymous with privatisation. It is driven not by evidence but by ideology: belief in a model that has failed spectacularly in recent months, the market model. Privatisation requires the closure of public services. Strategic management has produced reports (such as Hanly and Teamwork) and devised tactics (such as the cancer and chronic disease stratagems), all seamlessly dovetailed to secure public service cuts. These closures create business opportunities for powerful interests that serve commercial needs, not patient welfare.
Our health system is being recast in an American mould. We are witnessing a massive experiment driven not by science but by greed. This re-engineering is integral to government strategies, North and South, embedding health with business and industry with medicine via hospitals and universities, in blind pursuit of a flawed paradigm, economic growth at any cost.
The walls of the public health system are being pulled down from within. Cost cutting is now being used to drive centralisation, and centralisation, as we have seen, is a Trojan Horse crammed with private for-profit soldiers.
1 In 2002, UPMC paid over $2 million in settlements under the False Claims Act for unlawfully charging government insurers for heart surgery involving experimental stents and catheters not approved by the Food and Drug Administration. Insurance fraud, not patient safety, was reportedly the issue. UPMC had previously paid $17 million to the US Justice Department in 1998 to settle Medicare and Medicaid fraud allegations. See: United States Department of Justice, Health Care Fraud Report Fiscal Year 1998, available online at http://www.usdoj.gov/dag/pubdoc/health98.htm. See also: http://www.patientstogether.com/tellMyStory.asp?aid=226; and Brian C. Elmer (Crowell & Moring LLP), False Claims Act Settlements, Simple List, available online at http://220.127.116.11/search?q=cache:CaoAygMuIqQJ:www.crowell.com/pdf/2000-2006_FCA-Settlements.pdf.
13 United States Department of Justice, The Department of Health and Human Services and The Department of Justice Health Care, Fraud and Abuse Control Program Annual Report, Fiscal Year 2001, (April 2002), available online at http://www.usdoj.gov/dag/pubdoc/hipaa01fe19.htm; and Department of Health and Human Services and The Department of Justice Health Care, Fraud and Abuse Control Program Annual Report, Fiscal Year 2003, (December 2004), available online at http://www.usdoj.gov/dag/pubdoc/hcfacreport2003.htm. See also: http://www.patientstogether.com/tellMyStory.asp?aid=226.
15 National Treatment Purchase Fund, Treating People Faster, (2008), available online at http://www.ntpf.ie/news/NTPF%20Ann.Report%202006.pdf.
17 Mary Harney TD, Minister for Health and Children, Dail Debates, 9 July 2008, available online at http://historical-debates.oireachtas.ie/D/0659/D.0659.200807090121.html.
19 PA Consulting, Hospital Bed Capacity Review: A Preferred Health System in Ireland to 2020 – Detailed Report, (Dublin: Health Service Executive 2007), p. 150, available online at http://www.hse.ie/eng/Publications/Hospitals/PA_Consulting_Report_-_A_Preferred_Health_System.pdf.
20 Transparency International Ireland, National Integrity Systems, Transparency International Country Study, Ireland 2009, (2009), p. 16. The report found high levels of legal or lawful corruption, with decisions influenced to an undue degree by personal relationships, patronage, political favours, and political donations. Available online at http://www.transparency.ie/Files/NIS_Full_Report_Ireland_2009.pdf.
22 Catherine McNamara, The Hanly Report: A Critique, (2004), p. 10, available online at http://www.saveourhospital.com.
23 Jerry Mansmann, speaking at ‘The Business of Health’ conference, held at the Berkeley Court Hotel, Dublin, 5 April 2006, cited in O’Connor, op. cit., pp. 202–5. Planned surgery, diagnostics, cancer, and chronic diseases are the areas to target, according to the Nations Healthcare CEO. The transnational health care corporation has formed a strategic alliance with UPMC.
26 Department of Health and Children, Tackling Chronic Disease: A Policy Framework for the Management of Chronic Diseases, (2008), available online at http://www.dohc.ie/publications/pdf/tackling_chronic_disease.pdf?direct=1.
28 Maureen Brown, Health Manager Journal, 11 February 2008, available online at http://www.hmi.ie/NewsArticles/feb_8_tom_keane_interview.pdf.
29 National Cancer Forum, A Strategy for Cancer Control in Ireland, (2006), available online at http://www.hse.ie/eng/Publications/Public_Health_/National_Cancer_Control_Strategy.pdf.
30 The German board of Europa Donna stepped down in May 2008. A pharmaceutical industry funding level of 86 per cent, the board said, compromises the integrity of the parent group. The European Parliamentary Group on Breast Cancer has also stopped working with Europa Donna for the same reason. See http://www.wecf.eu/english/articles/2008/05/board-europadonna.php.
33 Bernadette O’Keefe, Niall O’Higgins, Anne O’Doherty, Development of Services for Symptomatic Breast Disease: Report of the Sub-Group to the National Cancer Forum, (Dublin: Department of Health and Children 2000), available online at http://www.dohc.ie/publications/symptomatic_breastdisease.html.
34 A. G. Baird et al., ‘Centralisation of cancer services in rural areas has disadvantages’, British Medical Journal, No. 320, (2000), p. 717, quoted in I. J. Mungall, ‘Trend towards Centralisation of Hospital Services, and its Effect on Access to Care for Rural and Remote Communities in the UK’, Rural and Remote Health, No. 5, (2005), p. 390.
35 Quest Diagnostics was fined $11.35 million in 2004 to settle allegations that the company had charged government insurers for medically unnecessary tests. In 2001, Quest paid $352,926 in connection with insurance fraud, plus $122,144 to Medicare. Quest previously paid over $13 million on behalf of the Nichols Institute, which it bought in 1994, for routinely billing insurers for medically unnecessary tests. See The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report For Fiscal Year 2001, (April 2002), available online at http://www.usdoj.gov/dag/pubdoc/hipaa01fe19.htm. In 2001, Corning (now known as Quest Diagnostics) paid $1 million to settle allegations of overcharging for cancer blood tests. See online at http://www.taf.org/publications/PDF/jan02qr.pdf. Corning had previously paid $6.8 million in 1998 to resolve allegations that it had billed Medicare for laboratory tests not ordered by a physician. See Health Care Fraud Report Fiscal Year 1998, available online at http://www.usdoj.gov/dag/pubdoc/health98.htm. In addition, in January of that year, four former executives of Damon (later known as Corning) were indicted on federal criminal charges of conspiring to defraud Medicare. In October 1996, in a related plea, Damon pleaded guilty to conspiracy to defraud Medicare and was fined by the US Government. See Annual Report of the Attorney General and the Secretary Detailing Expenditures and Revenues under the Health Care Fraud and Abuse Control Program for Fiscal Year 1998, available online at http://www.usdoj.gov/dag/pubdoc/98hipaa_ar.htm. The $119 million paid by Damon included a fine of $35.3 million, the largest criminal fine ever recovered in a health fraud prosecution. Damon was also barred from participating in Medicare and other government health programs. See US Department of Justice, Health Care Fraud Report Fiscal Year 1997, available online at http://www.usdoj.gov/dag/pubdoc/health97.htm.
36 Shane Phelan, Irish Independent, 8 September 2008, available online at http://www.independent.ie/national-news/cervical-smear-contract-forces—top-labs-to-shut-1471401.html
38 Justin E. Bekelman, Yan Li, and Gary P. Gross, ‘Scope and Impact of Financial Conflicts of Interest in Biomedical Research: A Systematic Review’, Journal of the American Medical Association, 13 March 2009, available online at http://jama.ama-assn.org/cgi/reprint/289/4/454.pdf.
40 David R. Urbach and Nancy N. Baxter, ‘Does it Matter What a Hospital is “High Volume” for? Specificity of Hospital Volume – Outcome Associations for Surgical Procedures: Analysis of Administrative Data’, British Medical Journal, 12 March 2004, available online at http://www.bmj.com/cgi/content/abstract/bmj.38030.642963.AEv1.