In terms of the range, imagination and costedness of progressive health policies, Sinn Féin is in front, though Fianna Fáil’s is scrupulously budgeted for and the Social Democrats’ most orthodox. By Michael Smith All of Ireland’s political parties have signed up to Sláintecare which should be implemented by the end of 2028. That’s the key background to their manifestos which show variations and detail on what is now the template. Apart from Solidarity which has an appealingly short health manifesto including secularisation of hospitals and nationalisation of all private health and pharmaceutical enterprises, differences in policy are therefore largely about how the parties would prioritise elements of Sláintecare. Though in fact Sláintecare does itself lay out a timetabling of priorities. This means there is an anomaly between many parties’ support for Sláintecare up to 2029 including its timetable, and budget; and their proposals of separate interim timetables and budgets during the next, five-year, term of government. Presumably, if they frontload expenditure into the first five years when Sláintecare envisages a longer rollout, then there will be less expenditure in the second five years. Otherwise, the parties are implicitly disassociating from what they have all agreed as the central planks in their health policies. Extra expenditure during the term of the next government will have to come from the €11bn ‘fiscal space’ over five years projected by the Department of Finance and accepted by most parties. Beyond this, the parties have tacked on special pet projects. But these are likely to be compromised by coalition or partnership negotiations. Past performance is something of a guide to future performance so it is worth looking at the history of parties, particularly Fine Gael and Fianna Fáil, in drawing and implementing health policy in the State. Implementation of health policy will be largely determined by Sláintecare with the parties’ longstanding ideologies a guide, especially on immediate funding and their indulgence of some pet projects though not necessarily the ones listed in manifestos. On Health Policy Village cautions caveat emptor; there is every possibility there will be little change. This guide synopsises parties’ policies. If transposition results in any mistakes Village would be pleased to correct them. Because there is such overlap the most instructive thing we can do is highlight original and different approaches, in bold. History of Health policy in Ireland In the second half of the 1940s, after it was instigated in the UK, a National Health Service was promoted by Fianna Fáil and even made it as far as a White Paper. But Ireland never got a single-tier health service, at first because of medical-profession lobbying supported by the Fine Gael Opposition, then because of-church opposition, and then because of medical-profession lobbying and revised Fianna Fáil ideology. Donogh O’Malley, the hero of free secondary education, was against ‘socialised medicine’ when Minister for Health (1965-6): “those who could pay should pay”. The two-tier, medical-card, system of access to hospital care is a construct of Fianna Fáil governments, albeit never seriously challenged by any other party in government. With no vision for the health system, Fianna Fáil threw money at healthcare in the late 1970s only to cut back savagely in the late 1980s. Between 1986 and 1993 over a third (5500) of beds were cut nationally. The health budget quadrupled from under €4 bn in 1998 to over €15bn in 2008, largely playing catchup after Haughey-era cuts; and to €17.8bn in 2020. 2000 beds were cut in 2009 under Fianna Fáil/Greens/PDs but Fine Gael have put back around 900 since 2011. In the last government HSE staffing increased by 8,868 to 119,126 by the end of last year. HSE management/administration employees increased by 2,042, an extra 328 consultants were appointed and there were 2,008 more nurses, according to Department of Health figures. Because of the shortage of hospital beds, the average hospital stay in Ireland at 6.2 days is much shorter than the OECD average of 8.2 days; and Ireland hospitalises far fewer patients, at 139 per 1,000 of the population annually, compared with an OECD average of 169. Fianna Fáil, under Finance Minister Charlie McCreevy (1997-2004), gave generous tax breaks to developers to build private nursing homes and hospitals: although it was government policy to have fewer, bigger, safer acute hospitals, another arm of government was giving away public money to build small, profitable, unregulated hospitals anywhere they decided, totally contradicting the policy. In 2001 it gave and in 2008 it took away, un-means-tested medical cards for over-70-year-olds, recently reinstated by Fine Gael, the government then had to negotiate a very bad deal with GPs who (led by James Reilly who later finished up as a bad Minister for Health) squeezed the pips. As a result, GPs were paid three times the rate for looking after richer over-70s than those who already had medical cards. This skewed GP services so that doctors were paid more to provide care to those who needed it least. The establishment of the HSE is the biggest public-sector reform in Irish history. Prepared by Mícheál Martin but executed by Mary Harney it was badly planned, leaderless for its first seven months, without structures, a clear plan for redeployment of staff who’d been organised on a county level, or a vision specifically to provide universal, quality care. There have been numerous attempts to reform but without any real transformation. The renegotiation of the consultants’ contract a decade ago was a lost and expensive opportunity at enormous expense to reform the Irish health system but it is only very recent and exorbitant proposals to pay €250,000 – twice what Britain’s NHS pays – to consultants to practise only publicly are something of a start. A White Paper on Universal Health Insurance was published in 2014 with a report on the potential costs of the White Paper model published in November 2015. The debate was always too much about the cost of this rather than on how a focus on insurance might actually serve the presumed goal of universal healthcare. In the