Manifesto review – the lessons

I’ve now written eight short pieces on the health manifesto’s from each party. Each is linked to from the table below, as are the corresponding manifestos, if you want to read them. This has been an enlightening experience. Niamh Griffin, the Irish Mail on Sunday health correspondent, spurred me on to finish reviewing the manifestos, by asking me to contribute short notes to a piece which will, I think, appear tomorrow (Sunday Feb 21st). The blog posts are the long versions!

Two things strike me very forcibly. First, there is already a high degree of consensus on two propositions :-

  1. The Irish health care system is unfair, and needs to move to universal care, equally accessible to all.
  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, whether it be for under 18’s now (FG, Labour, Social Democrats), for everyone, but to be phased in over (SF, Labour), or vaguer plans in the future (FF), most of the parties support the idea. They are much hazier about what it means, how to do it, and how to pay for it.

What is being missed out? Several parties (FG, Sinn Féin, and People before Profit) want to abolish HSE. They believe, I think, that HSE cannot be fixed, and that no change can be made in Irish health services while it continues. I can understand why people are intensely frustrated by HSE. I am often driven wild by its latest messes, but it is the only game in town. If we choose to remove it, it will take a minimum of three years before the health system settles down enough to make any further changes. If you doubt this, look at the NHS. The biggest weakness of the NHS is the endless reorganizations which have crippled it. It’s easy to re-draw an organization chart – any idiot can do it, and several have. The hard bit is changing what happens in clinical encounters. This is the bit of the health service where the patient meets the clinician. This is also the bit which matters.

A second common error, and one which afflicts all the parties, though some less than others, is the continued obsession with hospitals, and hospital beds. It’s not that hospitals do not matter. Of course they do, and they have a vital role in any health care system. However, in Ireland, the balance between care in hospitals, and care in general practice, is wrong. Too much is being done in acute hospitals, and far too little activity, and far too little money goes into general practice. This is part of the reason for the long waiting lists, the queues in A/E, and the ludicrously high bed occupancy rates in our hospitals. We do need some more investment in our hospitals, but we need a lot more investment in general practice. This will take several years at least.

Many of the parties support the idea of giving GPs further access to test, x-rays, ultrasound, and so on, as well as moving more minor surgery into general practice. The capacity to take on more work in General Practice is somewhere between limited, and non-existent. There are far too few training posts in Ireland (full disclosure, I was involved in a plan to bring ACRRRM, an  Australian training body for GPs, to Ireland, but we did not succeed). There are also not nearly enough staff (nurses and other health professionals)  in most general practices to take on the necessary support roles for GPs. It will take a lot of time, and a great deal of political effort, to fix this.

There is also a fundamental confusion between primary care and general practice. In Ireland, when you ask people about primary care services, the only most people use is general practice. There are other bits of primary care, and, for historical reasons, these are now quite separate administratively from general practice. In most countries, primary care is much better integrated than in Ireland, and the managerial tangle is a serious obstacle to progress. GPs are, almost all, small business owners, or employees of small businesses, with relatively few staff, often 1 nurse per 2 GPs, and a secretary. Most nurses now working in the community are public health nurses, employed by HSE, and reporting, ultimately, to one of nine community health organizations. Home helps, community physiotherapists and occupational therapists, all fall into the same structure.  There are also separate mental health structures, with psychiatric nurses, psychologists, and psychiatrists working in their own silo. This all works better than it should, mostly because of personal links between professionals, but it is often very clunky.

Primary care teams were meant to fix this. The idea was that the GPs, public health nurses, and the other health professionals, would meet regularly, and work together to meet many of the needs of their local population. By and large, they have not worked. With some exceptions, their impact on health care has been limited. The key deficit is, I think, one of governance. Who exactly, is responsible for patient care? At the moment, this problem is bypassed, because many of the interactions are short

Blog postLink to manifestoDirect link to files
Renua IrelandManifesto textRenua Ireland
Social DemocratsManifesto textSocial Democrats
Fianna FáilManifesto textFianna Fáil
AAA - PBPManifesto textAAA-PBP
Green PartyManifesto textGreen Party
Labour PartyManifesto textLabour Party
Fine GaelManifesto textFine Gael
Sinn FéinSinn FéinManifesto textSinn Féin
This entry was posted in Health.

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