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.

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

Sinn Féin have not one, but two relevant documents. The first is their 58 page manifesto , and the second is their 82 page health policy, Better4Health, from late last year. Both are covered here.

Better4Health starts with ‘Universal Health Care, not Universal Health Insurance, is the solution’, which is now pretty much common ground amongst all the parties except Fianna Fáil. A huge amount of work was done on costing these proposals, but ran into some challenges .My favourite is this ‘Our costing development work was further frustrated by the staggering deficit of data held centrally by either the Department of Health or the HSE. On a number of occasions, they simply would not, or could not, provide the basic data required to determine what we are currently delivering for our spending. This in itself is of serious concern.’

Their analysis of overall health expenditure is spot on. We spend quite a lot, and we do not get a reasonable return from this expenditure. Their solution, which is to spend a lot more, does not seem obviously reasonable, or indeed likely to work at all.

In detail, they divide their solutions up under three headings – Equality, Capacity and Funding. They will hire 6,600 more staff, almost all in hospitals, remove prescription charges, and provide free GP care for all on a phased basis. As far as I can see almost none of the extra staff will be actually working in general practice, which is a major omission. They plan only 200 more practice nurses, which is a drop in the ocean, and an extra 40 trainees a year, which will not keep up with retirements.

They will bring in taxes on sugary drinks, minimum unit prices for alcohol, and more resources for drug treatment. They will also regulate food marketing. They have some good ideas in mental health, including specific suicide prevention actions, more resources for children’s mental health, and better access to counselling in primary care.

Overall,this is a policy which identifies problems, and some solutions, but fails to fund some of the key actions. For example, under managing chronic disease, they suggest hiring more consultants, care plans for people with asthma, and screening for coeliac disease. This is a rag-bag of ill thought out ideas, and will not address the huge challenges facing our health services in dealing with long-term illness. There are good ideas here, and the overall goal – universal health care, is worth reaching for. They have put a lot of work in, perhaps more than any other party, but they have missed the mark.

Full disclosure – I’m a Fine Gael member. I’m not very impressed with the health policies in their manifesto, as you will see, but I support them, partly because I approve  of the way they pulled our economy back from the edge from 2011 onwards.

Fine Gael’s manifesto is out. It’s a 140 page tome, with a long section on health policy. Like Fianna Fáil they talk about health in four headings, and an appendix with detailed costs. Unlike Fianna Fáil, they have been much more systematic in what they cover. Their overall message is that they have a ‘plan for Universal Healthcare – for access to quality preventative, primary, curative, rehabilitative and end-of-life healthcare that is timely and affordable for everyone’. This is very comprehensive, and ambitious. I’m not going to list every item, but will focus on some highlights and comment on these.

More Resources and Staff and Better Infrastructure for Health Services

They plan to increase health spending steadily, all going well, over th next five years. They will hire 4,400 more staff, although few of these seem to be in community services, and very few in general practice. They will encourage HSE to work with the private sector to roll out a decent health IT system, including electronic health records. Renua is the only other party to suggest this critical piece of investment. In 2017, there will be a capital review and a bed capacity review, which will guide hospital bed numbers. Both of these are sorely needed. They still plan for a competitive private health insurance market, which would be nice, but would not be a priority for me. Their plan is to fix the health care system, as outlined in the next section, come up with a better funding model, and then move to universal health care.

 Health Reform Programme

They still plan to abolish HSE. This is  really really bad idea. Having worked there, part time for two years, I quite understand why they feel like this, but it is still a bad idea. It is is not possible to simultaneously abolish HSE, and reform the delivery of health care. HSE itself is far from perfect, though it is improving, but abolishing it will freeze all health service change for at least three years. Making hospital groups work (this is at all, not better)  is not a bad idea, although this should have been done two years ago. The notion of keeping the voluntary hospital boards, and setting up hospital group boards, is entirely incoherent, and a recipe for chaos. Reducing drug costs, and limiting prescription charges are good ideas. They suggest an expanded role of nurses in hospitals, which I approve of, but say little about nurses in primary care. A stronger system of performance management for hospitals might be a good idea, although there is little mention of clinical governance. They mention open disclosure, that is telling patients about errors, which I strongly support.

A Decisive Shift Towards Primary and Community Care

For primary care, Fine Gael propose more primary care centers, supports for general practice, including more training places, and a wider range of services, as well as more chronic disease management,  in general practice. Where it falls down, with a bang, is in the idea of setting up multi-disciplinary teams in the primary care centers, with no mention of the GPs. Clinical governance is essential for primary care, and most of it, in my view, needs to come from the GPs. They plan free GP care for those under 18, which I believe is not feasible without quite a lot more GPs and a lot more staff in general practice. No serious budget for this is suggested anywhere.

Mental health gets its own subsection. There’s a lot of detail, but key pieces are more resources, more of a focus on prevention,and early intervention, with a number of specific programs identified, including the Jigsaw program, and some of the community based programs developed with Genio over the last few years.

Improving the Health and Well-being of the Nation

Key proposals here are the new Alcohol bill, a sugar tax, further reductions in smoking, an expanded vaccination program, and support for physical activity, obesity prevention and sexual health, and and a ‘Fit for Work’ program (to support people with illness and disability in working). I don’t like one phrase ‘to consider additional measures to tackle excess alcohol consumption and misuse’ which comes straight from the drinks industry. (What we need is a reduction in overall consumption too). They also undertake to support a range of clinical initiatives, cancer care, the national maternity strategy, dementia care, rehabilitation, and palliative care. These are, mostly, sensible suggestions, and I would support them, by and large.

Overall, there are good ideas here, but also some impressively bad ones. It is far too hospital focused. In fairness, so are many Irish people, and much of the Irish media, but it is still a mistake. There is too much emphasis on changing institutions and organizations, and little sign that they realize that the hard bit, and the important bit, is changing what people actually do on the ground. There are ambitious plans for general practice, with no real resources behind them. Could do better!

Labour’s manifesto covers health in a section labeled ‘Standing Up for Families & Communities’ which gives a clear idea of the context. The health section is called ‘A New National Community Health Service’. The idea is to have a single tier system with free access to care from GP to hospital. There will be a Minister with specific responsibility for this work. Like Renua, they suggest setting up a National Health Forum to ‘ develop a shared approach and understanding on the future challenges’ for our health services, which seems a good idea.

They plan to recruit 5,500 more staff, and lower the current charges for prescriptions, both  the GMS and on the drug prescribing scheme. Free GP care will come in over five years, along with community based chronic disease programs, to be delivered by GP’s, nurses, and others. No mention is made of the governance of these programs. This would require 1,428 more GP’s. I’ve no idea where this eerily specific number comes from, but this is in addition to the 5,500 other staff they plan to recruit.

They will improve access to dental health services, and bring in the National Maternity Strategy. Both of these seem very good ideas. For mental health, they want to focus on early intervention, especially for young people. They will provide access to counseling services, and better treatment for those with so-called ‘dual diagnosis’ – drug or alcohol addiction, and a serious mental illness, a much neglected group of patients.

For hospitals, they plan 1500 extra beds, to improve access, and reduce A/E wait times and waiting lists. They will also move to activity based funding – Money Follows the Patient, and and a new, much tougher system of financial and managerial accountability.

They support a sugar tax, and tighter controls on food marketing, with much better food labeling. They will bring in mother and baby clinics, to do what is left unspecified, and increase support for physical activity in children.

Almost no details of costs are given, apart from a total of €2.975 billion. This isn’t broken down in any way, but may well be in roughly the right ballpark. There is no real discussion of health management, or ways of improving health care delivery.

These polices are well focused. I am fairly sure that only a very large increase in activity and resources in general practice, primary care and community care, can untie the knots in our health services. However, there is a lack of serious thought about what these services might look like, how much they might cost, and who would provide the necessary clinical governance for them. My own view, for what it is worth, is that this can only be done by GP’s, but in any event, someone has to do it. I doubt we can afford a large increase in both hospital resources and general practice resources. They do not consider widening the roles of practice nurses either, but there is compelling evidence that, working with GP’s, these professionals can provide expanded good quality care for many people with long-term chronic disease.

The Green party manifesto has some good ideas on health. The ‘social affairs’ part of their manifesto is headed ‘Efficiency in Everything we do’, and it’s not a bad summary. Their key idea is ‘to develop patient-centred care, to prevent problems before they occur, and to create a world class health care system that is cheaper and more efficient’. This is laudably clear. Do they outline a credible path?

In part yes, but also in part no. One interesting thing about reading a stack of manifestos is that you get an idea of whether the people who wrote them are actually familiar with modern health care delivery or not. The Green Party fails on this. Ideas such as advanced public health nurses, providing care at home; paramedics going to homes, and keeping people out of hospital; combined physical and mental health polyclinics; do not suggest a strong grasp of what modern health care is about. There is also very little on social care, little on care for the elderly, nothing on chronic disease, little on general practice, and no suggestion of removing drug co-payments.

They plan to replace HSE with Community Health Organizations, ‘which will include a balance of community and patient participation advised by health care professionals. This is possible, but would be very disruptive. They have some good ideas on disability, but surprisingly do not suggest individual care budgets. They also support a sugar tax, which I welcome, better food labelling, and limits on marketing of food to children – the ‘Sydney principles‘.

Their most innovative ideas are on health care financing and funding –  They want a single-tier health system, funded largely from general taxation. They support multi-annual budgeting, Activity Based Costing and blended Capitation Schemes, to encourage efficient use of resources. These are really good, really radical (by Irish public sector standards anyway) ideas, which could make a big difference.

They say little about general practice, apart from suggesting  more investment in services to allow for ‘minor procedures and specialist services’ to take place outside of hospitals. This kind of misses the point.

Overall, they have some good ideas, and a plausible vision. They show little sign of knowing much about the detail of providing modern health care, and there are no detailed costs. They suggest €625m over five years, which I think could only cover a fraction of their aims.  Some of the financial changes proposed could have a big effect on the quality of financial management within the sector, and these are very welcome.