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

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

Manifesto review 8 – health and Sinn Féin

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.

Manifesto review 7 – health and Fine Gael

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!


Manifesto review 6 – health and the Labour Party

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.

Manifesto review 5 – health and the Green Party

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.