Still no resolution on James’ site for NPH

I’ve been reading the submission from Connolly for Kids to the Oireachtas Health Committee. The submission is here, and the covering letter is here. My own views on the location of the NPH have changed little over the last few years. I wrote about Colocation, colocation, colocation in 2012, and I think the analysis there is still sound. For me, (a former paediatrics trainee, before going to public health), the most important feature is a maternity hospital adjoining the children’s hospital. Adjoining means accessible by corridor without going outside. Colocation with an adult hospital is not useless, but is much less useful than the Department of Health have suggested.

Given this perspective, I always thought the Mater site was complete non-starter. It was never going to be possible to fit the maternity service, nor a reasonably sized children’s hospital onto that site. After this decision was reversed on planning grounds, there was a challenging site selection process. I was involved, working on the proposal to locate the NPH beside the Coombe hospital, however, in the end the St James’ site was chosen. This was a much better choice than the Mater. It is a bigger site, more open, with better public transport, and a bit less traffic.

Unfortunately, as time has gone by, the weaknesses of that site are becoming more obvious. There is no immediate plan to bring in a maternity service, and it looks as if the NPH will, quite effectively, prevent any future major site developments for the adult hospital. St James’ is one of the biggest, and most important acute hospitals in the country, but large parts of it need to be rebuilt to meet modern service needs. Losing this opportunity would be a very high price for the NPH.

The other big issue is parking. Acute paediatric hospitals require much more parking that adult hospitals of the same size, because most of their patients arrive by car. This will not change. There is no prospect of parents of sick children bringing them in on the Luas, not by rail to Heuston station. It is already hard to park on the James’ site, and indeed the NPH build has already significantly reduced the number of parking spaces there.

It is true that Connolly does not have anything like the range of specialist services on the St James’ site, but this is not of great practical importance. The old model, under which some very hard-working adult specialists also did a bit of paediatric work on the side, is gone – almost all care is provided by fully trained paediatric specialists. Connolly could very rapidly be developed to meet a wider range of clinical needs, and this is probably necessary whether or not the NPH goes there. For example, if we ever do decide to build a national trauma centre, Connolly would be a far better choice than either James’ or Beaumont.

All in all, I agree with Connolly for Kids that Connolly would be a better site than James’ and would provide for a better and more affordable NPH. I hope the Oireachtas Health Committee will consider reviewing this decision.

Sitting as an Independent in the Seanad

Sean Melly, one of my respected rivals for the Seanad, has made two appearances in the Irish Times recently. One is an attack on me and three of the candidates running for the NUI panel. The attack is on the basis that we are all associated with Fine Gael, in different ways, and hence unable to serve as ‘independent’ candidates. This is reported by Miriam Lord, under the heading ‘Seanad university seats and a different independence‘. Lord, one of our more acute journalists, writes ‘Melly, who is an independent Independent, is deeply unimpressed. “Candidates need to be honest and political parties should not compromise the integrity of the Seanad,” he says. “The independence of the Upper House must be maintained and its original function rescued and preserved.”’

I agree, though I think reform, rather than restoration, is required. The Seanad does pretty much what Fianna Fail designed it to do – as little as possible. This is no longer acceptable.

I am a Fine Gael member, though not exactly a well-hidden one, see my Twitter account, Facebook Page, or my LinkedIn profile, if you doubt this. It seems odd to suggest that aspiring politicians ought not be interested in politics, and one legitimate way of showing this is to be a member of a party. Being a senator is a political position and having some experience of politics might well be an asset. Certainly, knowing how to work with politicians, and civil servants is essential, if you hope to get anything done.

So why am I  member of Fine Gael, rather than any other party? I am, like most Irish people, fairly centrist. I believe that States have a big role in providing good quality services, and high levels of personal protection to all residents. These include, health care, education, transport, housing, and direct protection (Gardaí etc.). This has to be paid for. I support progressive taxes, where people, like me, on high incomes pay much more than those on lower incomes. I believe that social solidarity matters, and that we need a more equal, and more just society. Fine Gael is not a perfect party, nor are our leadership perfect, but, for me, it tries to go in the right direction.

I agree with Sean that it is important for the Seanad to build on the independence of its members. I do not think that it would help me to work effectively in the Seanad, were I to join a parliamentary party, and I believe it might hinder me. If you know me personally, you may think that I am not well suited to taking a party whip!

There are more impediments to independence than party membership. I have fully declared all my personal and family financial interests, as well as my values, and my religious, and political views. including my latest P60, and my SIPO declarations. Anyone who wishes may inspect these, and draw whatever conclusions you wish.

I mentioned that Sean had appeared twice in the Irish Times recently. The second time was a story here, on February 15th of this year, which I suggest you read, and then consider what else independence might mean, and what else might affect the independence of a politician.

PSEU questions for Seanad candidates

The PSEU have asked three questions of each Seanad candidate.

It was a good opportunity to think carefully about my own values and priorities. My background is that I am a medical doctor, trained in child heath, and a public health specialist. I am a political and a social activist. My key values are equity, social justice and transparency. I have worked for many years with communities affected by environmental problems, and with people with autism or intellectual disability. I am a member of FG, but, if elected, I will be an independent, and will not take the party whip,

1) What will you do to restore the cuts to Public Servants’ pay?

Public sector workers salaries (including mine) were sharply reduced as a result of our economic collapse. While the reported recent growth rates may well not be sustained, there is little doubt that our economy is improving. I feel that Ireland could and should begin to restore these cuts. For me, the priority ought to be restoring cuts to those in lower salaries first, as this will have the greatest economic impact for any given investment.

2) What are your priorities for investment in public services?

In order these are :-

Housing. Ireland has a crisis of homelessness. The health, social, educational and economic consequences of this are very well known, and we cannot afford them. We need a rapid program of social housung cobstruction.

Education. We spend too little on education, especially in deprived and marginalised communities. This has life long bad effects. Education is our best investment in the future. We need a focused strategy of investment, and reform, in education all the way from pre-school, to third level or apprenticeship.

Health. We have a very costly health service (public and private). Our health service is not what it could be, nor is it very responsive. I think we need to reorient our services in three ways. First to a patient centred service; second to a GP/primary care focused service; third to an integrated care service for people with chronic disease. This change will require investment, but it will be worth it if we do it right.

Older people. The number of older people in Ireland will rise rapidly over the next decade. This is, of course, cause for celebration. At the same time, it is a challenge which we need to meet. Our goal should be healthy, active and productive aging. There is a lot of knowledge and good practice in Ireland. This needs to be spread and implemented better.

3) Why should members of the PSEU vote for you?

I will be an effective and accessible voice in the Seanad if elected. I know how the Irish political system, civil service and HSE work, and how to work with them. I also understand how to work with community groups.

I feel that Ireland should have more universally accessible services, including education, health care, and social care. These will need to be paid for if that is what we want. I have a record of working and achieving change, both in higher education and in health care. I will bring this experience to the Seanad.

I am a life-long trade union member, and have served as a branch official, and an executive member, at various times. I was one of the leaders of the 1987 doctors strike in Ireland. I strongly support union rights, including a right, where necessary, to industrial action. I know a fair bit about industrial relations, and the importance of maintaining good communication between management and staff.




Governments doing their jobs are not ‘nanny states’

The IEA, under the guise of the European Policy Information Centre, which operates from the IEA offices in London, has published the first Nanny State Index, described as ‘a league table of the worst places in the European Union to eat, drink, smoke and vape‘.

As you might expect, if you know the IEA, good (low scores) means unregulated, and bad (high scores) means regulated. The highest scores go to Finland, Sweden the UK, and Ireland, in that order. I’m quite proud of that. I believe that states have a role in protecting their citizens from the damage caused by unrestricted marketing of unhealthy behaviours and lifestyles. As many of the costs fall back on the state, there is a perfectly respectable economic argument for this as well.

There is a press campaign, so that journalists, and sub-editors, across Anglophone Europe at least, can cut and paste headlines. Oddly enough, for a project reportedly produced with six partners, and seven collaborators, in other countries, only one, the Visio Institute in Slovenia, now has a report of the index on their website that I can see.

Countries do well on this index by not regulating and not taxing alcohol, tobacco, e-cigarettes, and soft-drinks. The details of the scoring are complex, but quite well explained on the site. The overall scores are plotted against life expectancy, on a page headed ‘analysis‘, and no obvious correlation is shown. No statistics are shown either, and there is no account taken of wealth, the dominant factor in life expectancy, nor of changes over time. This isn’t a very credible analysis. As for references, apparently real men ‘don’t need no stinking references’. Frank de Vocht has done a proper analysis of this, and finds a modest effect, of about five weeks of life per person for every one point increase in the alcohol and tobacco components of the index.

Moving on, what is all this about? EPICENTRE, the coordinating body for the initiative, provides no  information on its funding on its own site. A spokesperson has confirmed that EPICENTRE, is 100% funded by the IEA. In turn, the IEA are coy about their funding, in fact a spokesperson today said they did not disclose the names of their private donors, and would neither confirm nor deny that they still received funding from the tobacco industry. It’s known that they did in the past, and in an index of transparency for leading UK think tanks, the IEA comes out close to the bottom.

My belief, subject to refutation, is that the IEA acts to support the interests of those who pay for it, by arguing against regulation on health grounds. The price of accepting their advice would be many extra deaths, many ruined lives, and higher profits for their corporate funders. This would be another good example of private profits and public costs. I do not think we should pay this.

My own interests, as an academic, and an aspiring politician, are a matter of public record, I fail to see why the IEA should be allowed to hide its conflicts of interest behind a veil of obscurity.

Incidentally it is reported that the UK Charity Commission is now reviewing the IEA, specifically asking ‘whether IEA is sufficiently transparent about the sources of funding for key political activities, and whether some of its controversial political activities are within its charitable objects’, which I would commend.

V0011830 An old wet nurse; symbolising France as nanny-state and publ Credit: Wellcome Library, London. Wellcome Images An old wet nurse; symbolising France as nanny-state and public health provider. Colour photomechanical reproduction of a lithograph by N. Dorville, 1901. 1901 By: Noël DorvillePublished: - Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0

Remembering all the dead of 1916

The photograph below may baffle at first, because it is both familiar and unfamiliar. It is, of course, the First Dáil, meeting in the Mansion House in 1919, but it is not the usual photograph, reproduced many times since, it is one belonging to my late grandmother, Julia. Many of the faces will be familiar, deValera, sitting in centre of the front row, Arthur Griffith beside him, and many others. The man standing behind Dev, to the right as you look at it, in a natty coat with a velvet collar will not be so familiar, but it is my grandfather, Michael Staines.


Here’s another photograph of him, from a few years earlier.




The uniform may look strange too, I believe it to be his Irish volunteers uniform. We don’t know when this was taken, but it may well have been only a few weeks before the rising of Easter 1916.

It’s now the vigil of Easter Sunday and in a few hours I will stand outside the GPO to commemorate his actions and those of the other, but of course the word matters – the other what? Heroes, terrorists, freedom-fighters, murderers, patriots, an endless spiral of antonyms, which may say more about the writers than the reality. The rising happened and I think it changed the path of our history both for good and for ill.

In 1916 my grandfather fought in the GPO. Among other actions he brought weapons, cut the telegraph lines, shot at people, raised a flag, and eventually carried the wounded James Conolly out. Three of his brothers fought with him. A fourth died fighting in the Royal Navy later in World War 1. In 2016, in a world he would hardly have recognized, I will stand and watch a parade go by. In many ways he contributed to the world I live in, as a fighter both in the War of Independence and the Civil War (Free State), as a TD, as the founder of the guards, as an alderman, and as a senator.

I think we need to remember what happened as truly as we can. When I went to Trinity in 1978, I found one item that intrigued me, tucked away on a wall insude the Nassau strret side of Trinity. It was a memorial plaque to a young man, a liitle older than I who had died there in 1916. Such plaques were and are common around Dublin. What made this one different was that this young man was a British soldier Pte. Arthur Smith a Hussar from Hexham. I felt then, and still feel that this was the right thing to do. Would my grandfather have approved? I have no idea, but he died sixty years ago.

There is an association, called the Relatives of 1916, who have taken umbrage at the proposal to list all of those who died in the Rising and afterwards in Glasnevin cemetery. Leaving aside the question of how this group can speak for all of us, without asking us first, I think they are wrong, just as the activists from Misneach who scribbled on John Redmond’s banner  in College Green were wrong.

No one owns the Easter rising. No one owns the dead. There were no first class and second class deaths in 1916, so let us remember them all equally.

Repeal the 8th?

I’ve been approached by two groups, the Pro-Life campaign, and the RepealEight campaign. Both requested me to indicate my views on the 8th amendment, specifically whether I am for it or against it, from the pro-life campaign, and whether I would support a referendum on the amendment, from RepealEight. This is a key issue for many people.

My own views, which  may not be popular with either side, are not simple, in that I favour repealing the 8th amendment, but oppose unrestricted abortion. I do not claim that I am right, but this is where I am starting from.

Some background first. I’m a doctor, and started my working life as a paediatrician. I spent several years working in the Coombe hospital, mostly caring for very sick premature babies, and a range of babies with congenital anomalies and chromosomal problems. I’m a man, I’ve never been, and never will be pregnant, so I don’t have that experience, but I have seen many mothers with critically ill and dying babies. I have a bit more experience than most people of both the tragedies and the joys of birth. I now work in public health, and a good deal of my recent work has been on intellectual disability, specifically my work with Special Olympics Ireland, and on autism.

In 1983, I was in my final year in medical school, when the 8th amendment was brought in. The purpose of this amendment was to prohibit any legislation regulating abortion in Ireland. Abortion, was, and is, illegal under the 1861 Offences against the Person Act. At the time, my father, a solicitor, and many other lawyers, including Alan Shatter, argued that the effect of the amendment would be to bring in a right to abortion, under the constitution. This subsequently turned out to be correct. Truthfully, I cannot now remember how I voted in 1983. I do remember watching SPUC in action, and later their trying to use the courts to muzzle people. At the time, I disliked them, – they did little to protect any child, born or unborn.

So, now, I think the 8th amendment was a bad idea. Abortion ought to be the subject of legislation, not an item in the constitution. Placing it in the constitution let the Oireacthas off the hook. There will be, almost certainly, be a vote to repeal it, and it will almost certainly fall. Both of these I support.

The hard question is what ought to replace it. At the moment, in the UK, abortion is available on demand. My view is that once a woman is pregnant there are two sets of rights involved – hers, and the baby’s. I also believe that rights impose duties, both on individuals and on the wider society. If they do not, they are vacuous. I do not believe that any right, of anyone, trumps all others in every circumstance. Managing rights, and the conflict of rights, is hard. I also appreciate, very clearly, that I am not ever going to be in the situation of being pregnant and not wanting to be.

What about unwanted pregnancy? I said earlier that I disliked SPUC. This was because for all their rhetoric about protecting babies, they did little to support women who found pregnancy difficult. Women can and do find themselves in bad situations, often because of poverty, which are made much worse by pregnancy. For me, the right social response is to support the woman, not terminate the pregnancy. I accept that others disagree, but having cared for a baby born at 22 weeks, and seen her parents interacting with a child who was going to live for less than an hour, I believe strongly that babies have rights, both in-utero, and after delivery. As a country, we have obligations to vindicate these rights, but also to balance these with the rights of the mother. This may not be easy, but there is no guarantee that a serious rights based approach will be easy.

In other countries, many babies affected by congenital anomalies, and chromosomal anomalies are terminated, purely because of their condition. I am unalterably opposed to selective termination based on gender, race, anatomy, or chromosome count. I take a firm rights based approach to disability, and this includes a right to live. Please try to imagine what people with Down syndrome think of quasi-routine termination of babies with trisomy 21, or better yet, ask someone.

What about fatal foetal anomalies? By far the commonest of these is anencephaly. This is a condition in which the brain fails to form. Such babies miscarry, or die  very shortly after birth, and are now usually diagnosed on the first routine ultrasound in pregnancy. I do not see any realistic objection to termination in such a case if that is the mother’s choice. Other conditions are proposed, as ‘fatal foetal anomalies’, for example Edward’s syndrome (trisomy 18) and Patau’s syndrome (trisomy 13). Many children affected by these two disorders die within the first year of life, but some do not. I do not believe that these, and the many similar disorders, are in the same category as anencephaly.

Are there difficult cases? Of course. The tragic death of Savita Halappanavar is a good example. I said earlier that it is hard to balance the rights of mother and baby. This may show what can happen when you fail to do do the work of finding the correct balance (there were several distinct issues in her care, besides her pregnancy). For me, (bearing in mind that I am not an obstetrician), a reasonable treatment for a woman in her condition might have been a termination. What about another tragedy – a woman raped, and pregnant, as in the X case? I try not be a hypocrite. If my daughter were in that situation, I would ensure that, if she so chose, she could have a termination. I’m well-paid, well-educated, and well-connected. I would have no difficulty arranging for this. I don’t see that I can argue that other women should be denied this.

I think we need comprehensive, but quite restrictive, legislation on abortion. I respect most of those who disagree with me, on both sides. I admire the courage of James Reilly and the Fine Gael/Labour government bringing in the Protection of Life During Pregnancy Act 2013. This Act is, literally, tied in knots by the constitution. It needs to be un-knotted.  If the Oireachtas does not do it, I think the courts will, perhaps following the very recent judgement in Northern Ireland.

Evictions in Tyrrelstown

Listening to Morning Ireland this morning, and reading Kitty Holland’s excellent article in the Irish Times made my blood boil. Briefly 60 or more families in Tyrrelstown are going to be legally evicted over the next four months by Goldman Sachs. The reason is that a Goldman Sachs linked investment fund, Beltany Property Finance, wishes to sell the houses. As many as 208 families in total may be evicted in this one estate. All of this is legal.

I’m no lawyer, but the relevant Act is the Residential Tenancies Act 2004. The relevant bit is Section 34 ‘Grounds for termination by landlord’. Under this landlords may terminate tenancies on several grounds. One, Ground 3 i the table in that section is this :-

‘The landlord intends, within 3 months after the termination of the tenancy under this section, to enter into an enforceable agreement for the transfer to another, for full consideration, of the whole of his or her interest in the dwelling or the property containing the dwelling’.

I assume this is the basis for the termination of tenancies here (but again, I am no lawyer, so if you know better, let me know).

There is little rental property available in Dublin. This morning on there were 2 properties to rent in Tyrrelstown,and only 400 properties anywhere in Dublin at under €1,500 a month. The odds are that most of these families will have to move, and many will not be able to find accommodation at a price they can pay. The effect of these lawful actions will be to render a large number of families homeless.

The scandal of homelessness in Dublin has been obvious for three years. The roots go back a lot longer, to the crash, to a poor quality, and corrupt, planning system, to greedy and feckless developers, to the decision of local authorities not to bother with social housing, and to our appallingly lax laws on tenancy rights.  The response from the Department of the Environment today, that the tenants should use the PRTB to delay eviction,  is best described as embarrassing. Clearly the civil service, Minister Kelly, and the Department will continue to sit on their hands, and close their eyes tightly. It is time to act.

Although we have yet to form a Government, the Oireahctas is still there. If our politicians could focus on something other than Irish Water, and various combinations of coalitions, they could pass a quick amendment to the Act, giving tenants the right to continue a tenancy even if a property is sold. This is already the norm in commercial property here, and it is usual in residential property lettings in most other developed countries. Anyone up for this? It would be a very constructive way to commemorate 1916.


Politics, politicians, and political activism

There was a fascinating interview on the Marian Finucane show on RTE radio yesterday, with Gino Kenny, the newly elected People before Profit TD. Mr. Kenny, an interesting and thoughtful man, was asked how he felt about being a politician. He was quite clear in his response, he was not a politician, he was a political activist, and in any event he would never be a ‘career politician’.

This made me think. I’m not, yet, an elected politician, although if my Seanad campaign succeeds, I hope to be. I usually describe myself as a doctor, an academic and an activist. Asked for more detail, I will say that I am both a political activist, as a Fine Gael supporter, and a trade union activist; and a social activist, as much of my research, and much of my work outside the academic world, is concerned with supporting people who are working to make their lives better.

Politicians are not especially trusted, although they may be more trusted than journalists, they are much less trusted than academics, or ‘people like me’. Perhaps this is what Deputy Kenny is getting at when he rejects the label of politician, but embraces that of political activist.

Why am I an activist? I grew up in a politically aware and active family, and I was educated by the Jesuits. In both settings, there was a strong emphasis on doing what you could for your community and for others. My mother, Nuala, was very active on our community council, and my late father, Michael, was active in Fine Gael, working with the late Mark Clinton in particular.

I went to school in a fee-paying school, Belvedere, which backed onto the Hardwicke St flats in the North inner-city. No-one in my school could fail to notice the poverty, and the lack of opportunity, for those who grew up around us. Many people from the school, and the wider Jesuit community, notably Fr. Peter McVerry, were, and are, very involved in community work.

I’m a doctor, and I chose a branch of my profession, public health, which is centrally concerned with issues like poverty, justice, housing, diet, exercise, disability, social inequality, environmental justice, and access to education and healthcare. For me, moving into electoral politics, is a very logical continuation of my own work.

Why am I not running as a Fine Gael candidate? I support quite a lot of what the outgoing Government did, in particular, the necessary, and brutal cuts in expenditure, while maintaining social welfare rates, and the tax rises and the pension levy. I think salary cuts to high earning public servants, like myself, could have, and should have, been deeper.

I opposed two of their policies strongly, both publicly and privately. The first was their failure to deal with the housing crisis. NAMA should have been required to build some social housing. Tenants should have been given a right of tenure, even if a property is sold. This should still be done.

The second was the rise in child poverty. I’m not stupid. I was well aware that large cuts in public spending would hurt poorer people, more than wealthier people. I did not, and do not, believe that Ireland had any choice. Having just read Kevin Cardiff’s book on the financial crisis I am more sure of that than before. However, I also believe that some more targeted measures, such as maintaining support for school assistants, breakfast clubs and the like, and some low-cost innovations, for example targeted support for childcare for those seeking to return to work, would have made a difference.

Why run as an Independent, and why not take a party whip? Simply, if I have the honour of being elected, in the TCD constituency, to the Seanad, I can be more effective as an independent. I can do a better job, both of representing Trinity, and of advocating for progressive change, outside a political party.

Tallying in Irish general elections

The media occasionally give the idea that tallymen (and the media always write about tallymen) are a breed apart, able to look at  a box of votes and tell you how many number 1’s are in it for each candidate While this would be a useful skill, it is entirely mythical. Tallys, or tally marks, are just an old system of counting. They have been in use, probably, for many millennia. In the vote counts in Irish election, the ‘tally’ is a running total of the votes cast in each ballot box. These are collected by volunteers whose legal role is to check the validity of the ballots.

Back up a step. When you vote in Ireland, you put your ballot paper into a box. Each box covers a certain area on the ground, maybe one housing estate, a few streets, several townlands, or even an entire village. The very first step in a count, is to take that box, inspect the seal, and open it, pouring the ballot papers onto a table. The papers are then removed one-by-one from the pile, placed face upwards on the table, and the total number of votes in that box is counted.

When they are placed face up on the table, the tally people look at each ballot to check two things. Is it a valid ballot, and for whom was the first preference vote cast on that ballot? Typically the tally people have a sheet, laid out in the same order as the ballot paper, with a table printed on it. A tally (or to be exact, a tally mark, a vertical stroke) is put beside the name of the candidate who got that vote. At the end of the process, hopefully, there is one tally for every vote in the box, and you know, quite accurately, where the first preference votes have gone from that box. Pooling these counts together for a constituency gives the tally for that constituency. These are accurate estimates of the first preference votes.

Finally, the count staff bundle the votes, usually into piles of 100 votes, held together with rubber bands. Then the bundles of votes from different boxes are mixed, and the count proper begins.

All of this has two effects, first there is a public, widely reported preliminary count. Second many kinds of wholesale ballot rigging become impossible or very very difficult. Irish elections are not perfect, but they are democratic, and the count reflects, very accurately indeed, how the Irish people have chosen to vote.


Refocusing healthcare resources – moving resources into primary care and general practice

I’m talking this morning at the National Health Summit in Dublin. I’m in a session on ‘fixing A/E services’ after Liam Doran from the INMO, talking about the ED crisis, and Mark Aiello from the NHS, talking about the role of pharmacists in A/E care.

The basic question I’m covering is this :-

Will Primary Care finally get the investment it needs to keep people out of hospital?

Every party has a piece on health in their manifestos. Many promise a lot of extra cash for the health services. I’m not sure this is either possible, or a good idea, and I doubt if the money is being spent in the right areas. We all know that he Irish health service has problems. Many of these have been widely reported in the media. Stories tend to focus on trolley counts, waiting lists, costs for drugs, excessive numbers of managers, and poor care. There is some coverage of rising levels of overweight and obesity, and our big problems with alcohol and drug use and abuse. There is much less coverage of some of the other causes of rising health care costs, notably new treatments for diseases, and the costs of care for people with chronic diseases, like diabetes, arthritis, chronic bronchitis, depression and heart failure.

The costs of the service itself are also a source of concern. The state spends about €13 billion, and the public spends about another €5.3 billion on health care costs, one way and another, each year. New figures from the CSO, which came out in December, show that we spend a higher proportion of our national income, 10.2% of GDP, and 12.4% of GNP (which is a better measure of the size of the Irish economy), than almost any other EU country. Over the last few years the proportion of care paid for ‘out of pocket’ has risen sharply, raising costs for individuals and families who need care. It would be very hard to argue that we get a correspondingly good health service for this very large investment. It will also be very hard to get additional money for it.

Why have we got the expensive service we have? Our services developed over a long period of time, and grew organically. After World War Two, when many EU countries restructured health services, we did not. The British got the NHS, we got little or nothing until the health act of 1970. This has left a system which is full of perverse incentives. We have, largely, free hospital care for outpatients, but quite expensive primary care.

Most health care, by far, is self-care, or care by family members. Most of the rest, the more visible piece, happens in general practice, where there are about 27 million visits a year. Unfortunately, the GP contract (the medical card) was designed to cover acute illness, and not the long-term care for people with chronic diseases. There is very good evidence that the long term relationship between the GP and their patient brings big benefits to the care of such chronic diseases, and especially to care for people with several such diseases. This group of patients is where most health care spending goes.

The problem in Ireland is resources. Irish general practice is seriously underfunded compared with similar countries. While GP’s have the ability to lead, coordinate and give care for people with long-term illness, They do not have the resources. There are too few GPs and not enough money, for GPs and their staff. GPs have also lost a lot of their state income n the last five years. Will resources be made available?

There’s an election on. I’ve gone over the manifestos of all the parties to find an answer to this question. There are a lot of common features in the manifestos. Most agree on two things :-

  1. The Irish health care system is unfair, and needs to move to universal care, equally accessible to all (except for Fianna Fáil).

  2. The system needs to focus more on primary care than at present.

There is also wide agreement on a number of more specific policies. Most parties intend to reduce or abolish prescription charges. This is good, because these charges discourage the use of essential medicines. Taxes on sugary drinks are popular, as are a range of public health measures, on alcohol, smoking, and promoting physical activity, especially in the young. Drug policy is more divisive, ranging from more Garda work to prevent the sale of drugs (FG) to a health based approach to drug policy (Green Party). However, every single party wants a wide range of public health policies and measures to tackle major health problems.

Free GP care is also popular, and most of the parties support the idea in some form. They are much hazier about what it means, how to do it, and how to pay for it.

What is missing? Several parties (FG, Sinn Féin, and People before Profit) want to abolish HSE. I understand why, but the price of abolition will be to halt change in healthcare for at least three years. The NHS -has suffered greatly from this over the years. Organization structure is secondary, what matters is changing what happens when the patient meets the clinician.

The parties, the media and the electorate remain obsessed with hospitals, and hospital beds. Hospitals do matter. In Ireland, I think the balance between care in hospitals, and care in general practice, is wrong. Too much is done in acute hospitals, and far too little in general practice. This is one part of the problem in the hospitals. We need some more investment in hospitals, but a lot more in general practice. GPs will benefit from more access to diagnostics, but there is almost no capacity to take on more work, be that free care for more people, or more care for chronic illness.

If action is not taken, as time goes by the services will be further and further stretched. The number of older people is rising steadily. While more are quite healthy, the need for healthcare will rise steadily over the next decade or so. Failure to meet this need, will cause much unnecessary suffering and death. We’ve tried building a hospital centred service, and it has not worked well. To meet rising demand I think we will need to move to community based services, and the heart of these is general practice.

What can be done? There are some very good models, backed by evidence, to support the further development of general practice. HSE are just beginning to move some chronic disease care ito GPs, starting with diabetes care, but more people will be needed to deal with this. More GPs are needed, both to increase capacity, and to cover for retirement, and more training places. Well trained nurses working with GPs, can provide good quality care. Bringing the clinical staff working for HSE in the community, public health nurses, physiotherapists, and others, much closer to the actual individual practices would be very desirable. The idea is achieve integrated care, led by general practice, but linking in to the hospitals, and the other community services.

This means moving resources from other parts of the service to general practice. Given the very high overall spend on health care here, I do not see that we can reasonably make a case for much more money. Between 1997 and 2008 the health care budget rocketed, but I do not believe that health care improved greatly. None of the political parties have acknowledged these problems in their manifesto, and several propose very large increases in health care budgets. Some increases will be needed, but we need more effective plans to ensure that the increased resources are not wasted.

My slides are here