This will be quick. The AAA/PBP health policy is short. The one line summary from their manifesto is

• Creation of a National Health Service free to all at the point of access, with greater investment in all areas including mental health, and the promotion of alternative treatments over prescribing medications

The full version is only slightly longer. They do propose reducing health inequalities by reducing wealth inequalities, which is a good idea, and would have some effect. They plan to abolish HSE, and replace it with ‘democratically elected Community Health Councils and an Independent Agency of Public Health Promotion that works with a responsible and accountable Department of Health’. This is not a good idea – abolishing HSE would paralyse health care change in Ireland for a minimum of three years.

They suggest building more primary care centres, which would be run by public servants. They do not mention general practice once. Like almost everyone else they want to remove prescription charges, although they are not clear about which ones – medical card, or all charges. There is a heavy focus on mental health, which is welcome, including making non-drug therapy more widely available, and a commitment to implement Vision for Change.

There are no costs, and no details given about the implementation of these policies. All in all a pretty poor effort. It may be more a negotiating position than a serious policy.

Fianna Fáil have published their manifesto. I’m going to concentrate on both the strengths, and what I see as the weaknesses of their health care proposals. The title given to this section of their manifesto is telling. ‘Support a publicly funded health care system’ is what it says, and that is pretty much what you get. The presentation is a bit scrappy with 32 promises, some very general, such as ‘Reform the Health Budget’,  ‘Expand GP Care’ and ‘Improve the Health Service Executive’, and some very specific, such as ‘Increase funding for the Fair Deal scheme’, ‘Recruit an extra 500 Consultants’, ‘ Employ 4,000 more nursing staff’ and ‘Hire an additional 50 dental surgeons’.

There are some definite swipes at the current Government, notably ‘Reduce scheduled waiting times to the international standard of six months by re-activating the National Treatment Purchase Fund’. Translated this means moving resources to provide care in the private sector, so reducing waiting times, by restoring one of their pet schemes, from an earlier FF/PD government.

There are many positive features – for example the commitment to barring privatization of existing service providers, including hospital groups, and the health insurance function. For HSE, they are committed to making it work better, although there are some weasel words about removing under-performing managers to posts more commensurate with their capabilities’, whereas what is needed is the courage to lose some of these people. There is a strong, and welcome emphasis on primary care, community care and General practice, with items like ‘ Rebalance the Health budget towards Primary Care’, ‘ Boost Community Pharmacists’ and ‘Support General Practise’. They propose recruiting an extra 250 GPs by 2021, which is, at least, a start.

There are some nods to public health and disease prevention ‘ Establish an Office of Alcohol Control’, although this is silent o n reducing the overall intake of alcohol, ‘Make Smoking History’, which builds on Micheál Martin’s greatest achievement when he was Minister for Health, and ‘Promote Healthy Living and fight obesity’ which includes a personal favourite of mine – a sugar tax.

There are some innovative ideas. They propose to ‘ Establish a new National Mental Health Authority’ on the lines of the Road Safety Authority, to improve mental health, and reduce the toll of suicide. They also commit to finishing the implementation of ‘A Vision for Change‘, which would be a very welcome development. It’s not clear whether the 2,700 extra staff they propose to hire here are already included in the various others announcements of extra staff elsewhere in the manifesto. I’ve asked for clarification on this and will update when I get it. They propose improving care for those affected by cancer and dementia, and they commit to establishing proper neuro-rehabilitation services. All of these are welcome.

Taken all-in-all there are good parts, and some good ideas, but there is no trace of an overall vision. Much of it harks back to the past, for example refurbishing HSE, and re-establishing the NTPF. They want the service we have now, but with some of the rough bits smoothed. These are not bad ideas in themselves, but they would leave all the (expensive) perverse incentives in our health-care system firmly in place. We would still have a  very unfair two-tier system, and it would still be hospital focused. General practice is, at least, acknowledged, but I’m not sure that tits central role in modern health-care is understood. The phrase ‘universal access’ occurs only once in their manifesto (p 24), and there it refers to ‘universal access’ to fast and reliable broadband! These policies will not fix our problems.

I’ve now had time to read the Social Democrat’s health policy in their manifesto. Their overall goal is to create an Irish NHS, a single tier, comprehensive health care system, largely free at the point of use. This is a sensible, clearly described goal, which would improve health care in Ireland. The British NHS is not perfect, but it is a lot better than the Irish system, and a lot cheaper too. This forms part of their strategy to reduce the costs of living in Ireland.

There are three sections, one on acute healthcare, one on mental health, and one on disability services. Health care for older people is discussed as part of a broader section on support for older people.

The acute services section is labelled ‘BUILD AN IRISH NHS’. Ironically most of the text talks about hospitals, trolley waits, ambulances, waiting lists for surgery, travel for procedures. There is a stated aim to have a community care focus in the system, but it is not clear what this would mean. The practical measures listed include supporting staff, by, for example, encouraging the recruitment of GP’s and nurses, building more primary care centres; improving access by, among others, formal resource allocation methods, wider access to free GP care, aggressive health promotion, reducing administrative costs, and aligning hospital group borders and community health office borders; improve service delivery by setting up minor injury units, improved access to diagnostics technology both for A/E and for GP’s, and getting 5 chronic disease management programs running.

They also say ‘Implementation is as important as policy in health reform’ , with which I agree strongly! To support implementation, they will set up a long-term vision for health care, with staff and patients; work across all of government; make health service data more open, and remove perverse incentives. They also suggest reducing prescription charges for GMS users, in the first section of the manifesto.

All of this is laudable, and some of it may well be achievable. The idea of settling on a clear vision for the service is appealing, although more detail about how this is to be done would be welcome. It is still too hospital focused, and I do not think they quite get the scale of the resources required to resource general practice properly. There isn’t a clear commitment to free GP care, nor to the level of resources in general practice needed for this. Reducing administrative costs sells well to the public, but would probably prevent any effective change. As I never tire of saying the health services have too many administrators, but not nearly enough managers.

Under the heading ‘EMPOWER THOSE WITH DISABILITIES’ there is a strong and positive discussion of the issues for people with disabilities. The core of their policy is to ratify the UN Convention on the Rights of Persons with Disabilities, which would be very welcome. Other policies include supporting people with disabilities in living independently, in finding and keeping work, and in staying out of poverty. They don’t discuss the individualization of payments, where the disabled person, and not the service supporting them, gets state funding, and their vision does not really cover problems like high rates of imprisonment for people with intellectual disability, but the remainder would be a welcome new focus on disability care.

For older people, they suggest expanding the Fair Deal scheme to over home care packages, increasing access to medical cards for older people, and improving the benefits to carers of their PRSI contributions. Reducing prescription charge would also benefit older people significantly.

Under ‘SUPPORT MENTAL HEALTH’ they call for full implementation and resourcing of Vision for Change, the (very good) 2006 mental health strategy. They will expand services to detect difficulties in infancy, and to improve the mental health of school children. They will increase resources for suicide prevention, and support the much wider use of non-drug therapies for mental health problems. Additional ring-fenced resources will be set up for some high risk or marginalised groups, including young parents, Travellers, and asylum seekers. They will require a much greater emphasis on effective care for people with a ‘dual diagnosis’ – addiction and a specific mental health problem.

Overall, this is a reasonable policy. It’s not clear how much it would cost, which is a huge omission, but I think a process starting with developing a common vision for services, and with a focus on community care, might get us somewhere. At least implementation is discussed, which is unusual in political manifestos. There is no discussion of the need to fix the culture of HSE, nor of the need to improve accountability. There is not enough thought given to general practice, a blind spot shared with the Department of Health. Some of the proposals would not work – notably reducing health service administration, and aligning community health services to hospital group boundaries. However, all in all, this is a policy with many positive features.

I’ve just finished reviewing Renua’s health policy. I plan to review the health policies in each party’s manifesto as these become available. I’m fairly familiar both with the Irish system, and the health care systems in other developed countries, which gives me some basis for comparison.

My take is that the Irish health system is actually improving – it’s much better run than five years ago, and much more transparent about what it is doing, and what it is not doing, but there is still a lot of work to do. For me, the big challenges facing it are three :-

• a steadily rising number of older people (about 20,000 extra people over 65 each year). These people are pretty healthy, but they do place extra demand on health care.
• it was built to provide acute care, both in hospitals and in general practice, but most of the need is now for long-term care for chronic illness.
• it is expensive, and not meeting our needs right now. Fixing this, will cost a lot of money, certainly at least another billion euros a year, just to stand still. Changing the system to meet these needs more efficiently will also be expensive, but is probably more sustainable.

The bulk of the costs go to two groups, a small number of people in long-term institutional care, and a rather larger number of people affected by more than one long-term illness. The health service is not coping with these needs. This is partly because of resources, with large budget cuts from 2008 to 2014, and effectively flat budgets since; and partly due to the model of care we have, which is still heavily focussed on acute hospitals, and leaves general practice and primary care starved of resources.

Renua’s summary of their health policy is this :- ‘Healthcare must protect patients and treat them with respect. We will re-focus the health system on realistic and deliverable targets. We will deliver multi-disciplinary primary care, relieving pressure on acute hospitals and ensuring greater access to the care patients urgently need’.

All of this is eminently reasonable, but the details behind it matter. They do propose a patient centred health service, ‘shaped and designed around the increasing participation of citizens in the management of their health’, but give few details of how this is to be done. They also want to deploy electronic health records, which has to be a good idea.

They have one really good idea – a National Health Forum, where a vision for our future health services would be produced. Tony O’Brien, in a recent interview on the Sunday Business Post, lamented the lack of a common national vision for health care in Ireland, and such a Forum might allow one to develop. The forum would develop, and maintain, a rolling 20 year needs assessment for healthcare (necessarily broad brush and high level), and develop plans for the use of ICT and health care management. Such a body, providing it was taken seriously by the Civil Service, and the Minister, could be very valuable.

There is also one huge hole, which is the source of funding, and the route by which funding reaches health care providers. This is not discussed anywhere, and it’s an enormous omission from any serious health policy.

For acute hospitals, they propose establishing the Hospital Trusts properly, which is a good idea, and encouraging both competition between them and ‘deep specialisation’ for elective work. Neither of these has a reasonable evidence base. Competition between hospitals does not contribute to positive outcomes for patients, and encourages various exotic games, including the shifting of high cost patients. There is good evidence that volume and outcomes are linked for many procedures, but there is a big risk, that the volume of simple cases will be taken by some providers, leaving others to deal with all the complex, costly cases. This can seriously destabilise healthcare.

In general practice, they propose much greater use of GP services, which is good idea. However, some of the pieces of this seem poorly though out, for example, hiring doctors to assist GP’s (why not more nurses who do this already. and are trained?) ; putting consultants in the community, a move for which there is no evidence; and deploying a range of mobile clinics providing different services.

For people with mental health difficulties, many of their objectives are good, but again, there is little specific detail about how these will be reached. Recovery is not mentioned, nor is mental health advocacy, both very important parts of mental health systems.

For older people, they advocate more access to home care, and access to care in supported housing, with less emphasis on long-term institutional care than at present.

Oddly enough, two of the longest sections of the policy, are one on self-insurance against medial negligence, the scheme used in Denmark, and one on a healthcare professional indemnity Act. Both are interesting, but they seem unbalanced, and perhaps out of place in a manifesto.

Overall, it is clear that their hearts are, more or less, in the right place. There is a welcome emphasis on GP’s, preventive care, mental health, and on primary care. There is a complete lack of detail on funding, payment mechanisms, and the overall resources, which is worrying!