Where is she?
Right now it’s damn hard to know where Mary Harney is or what she is up to. Did the Minister for Health quietly step down from office and Government forgot to tell anyone? Is she burrowing away behind the scenes struggling to ensure a legacy in health? Or is she, as the political rumour mill has it, busy trying to secure a plum job in Europe, replacing her fellow neo-liberal, Charlie McCreevy? Minister Harney is nowhere to be seen. But that is hardly surprising. Mary Harney is a Minister without a party, running out of time to deliver the health reform she set out to accomplish.
What’s she done?
So what has Mary achieved in her four-and-a-half-year tenure in health? The HSE was established three months into her stewardship with the aim of providing a unified, accountable, quality health service. Although the HSE was devised under Mícheál Martin, Harney executed its introduction. The Health Act was rushed through the Dáil in winter 2004 amidst warnings that it was too hasty. The act got rid of the 11 health boards, setting up four larger regions and three main pillars to the HSE – the National Hospitals Office, Primary Community and Continuing Care, and Shared Services. Four years on from its establishment, the very architecture of the HSE has been dismantled. Shared Services disappeared off the organisational map in 2007 without explanation, while the hospital and primary and community sections are currently being merged. New regional structures, closer in size to that of the old health boards, are about to be announced. Unions, staff and patients describe a health system in 2009 that is over centralised, devoid of leadership, where decision- making is stymied, and staff morale at an all time low. Government is about to introduce a redundancy plan to get rid of superfluous administrators and managers whose roles were duplicated instead of rationalised when the HSE was established, over four years ago.
The HSE’s budget has increased but not sufficiently to meet the needs of a growing, ageing population, alongside the escalating costs of medical care. To live within its budget, as required by law, the HSE is embarking on “cost-cutting” initiatives. Public patients bear the brunt of these cuts.
Funding of some services has increased significantly under Harney, in particular of services for older people and people with disabilities. But these services were coming from such a low base, that unless this investment is maintained, any progress will quickly be undone.
Where has she failed?
Other areas where much needed development was promised – 3,000 more public hospital beds; 2,000 new consultants; 600 primary care teams; 100s of multi-disciplinary mental health teams; many more long stay public beds for older people – have all been woefully slow to materialise. Instead of championing the greatest reform that is required in the health system – ending the two-tier system of care, Mary Harney has beavered away escalating the unequal provision of hospital care in Ireland.
The consultants’ contract is at the heart of the inequity in Irish healthcare. Mary Harney vowed she would deliver a new contract. And she has. Many streetwise commentators thought that if anyone had the fortitude to take on the muscle of consultants it was Harney. Yet negotiations ran from 2003 to the end of 2008. The deal is hardly revolutionary and some of the detail is still being worked out. Under the new deal, consultants are required to work 37 (instead of 33) hours a week. Their work will be monitored and the majority, who will still be allowed to practise privately, will have their private practice limited to 20 or 30% of their total workload. Consultants may be asked to work evenings and weekends, a common waiting list will be introduced for all patients, and for the first time consultants will be accountable to a clinical director who will be appointed from among the current consultants’ ranks and get an additional €50,000. Harney’s deal pays Irish consultants €220,000-€250,000 a year, a multiple of what other European consultants’ salaries. Starting salaries are three times those of British consultants. The OECD pointed out in their review of Irish public services last year before the higher wages were agreed, Irish “consultants’ annual income is 50% higher than in France and 80% higher than in Germany”. This does not include private income, which for many is substantial. And most importantly, the new contract allows the bulk of consultants to practise privately, albeit under more regulated conditions. Under the new contract, incentives are still in place for consultants and hospitals to favour private patients who will therefore continue to skip the queue for access and treatment in Irish public hospitals. The new “deal” may, as Mary Harney claims, tilt hospital care more in favour of the public patient, but it is very expensive and still not does offer equal treatment for public and private patients on the basis of need. It is very hard to see how even a fraction of the 2,000 promised consultants will be hired at such high rates in a time of budgetary restraint.
Another of Minister Harney’s bouquet projects is “co-location”. The plan is to deliver 1,000 additional public hospital beds by freeing up private beds in public hospitals. Incentivised by tax breaks, the private for-profit health sector, was expected to build 11 “co-located” private hospitals on the grounds of public hospitals. Nearly four years on from their announcement, six “co-located” hospitals are works in progress but not one sod has been turned. The HSE Service Plan hastily published the week before Christmas, after it was leaked to the media, stated that co-location plans will progress “subject to satisfactory banking arrangements”. On January 9th , Jim Power, economist with Friends First, said that “there had to be serious questions about co-location proceeding in the current environment”. If it does proceed it will institutionalise forprofit private health care into the public health system, exacerbating our already unfair system of hospital care.
Cancer care: a rare success
One area where progress is being made is in the area of cancer care, though the U-turn on the cervical cancer vaccine last November can only be viewed as misjudged short-termism. Ireland currently has one of the lowest rates of survival in cancer across Europe. Last year’s cancer scandals exposed a series of misdiagnoses and sub-standard cancer diagnosis and treatment. Until 2007, cancer care was provided in 30 hospitals around the country, many treating few cases. International best practice deems that effective cancer care is best provided in fewer specialist centres where patient volume is higher. Under the leadership of cancer chief Professor Tom Keane, stridently supported by Mary Harney and HSE CEO Brendan Drumm, by the end of this year, all patients will qualify for “optimum” care in one of the eight cancer centres. While there are still some bastions of resistance and battles over the location of theses centres – there are four in Dublin and not one north of Galway or Dublin – the war seems to have been won.
A similar approach is being taken to all hospital services in the “reconfiguration” of hospitals around the country. Depressingly, many Irish governments have attempted to pull this off before, and failed. Recommendations from the 1936 Hospital Commission Report, 1968 Fitzgerald Report and 2003 Hanly Report were never effected.
The HSE’s ‘Transformation Programme’ is premised in the provision of most health in the community. In parallel, some hospital services such as Emergency Departments, intensive care, complex surgery and treatment, are to be centralised under the auspices of patient safety. Communities are resistant, they do not want to lose their local hospital. They are right. Easier access is swapped for quality care and patient safety. So which is better – faster access to below standard care or slower access to higher quality care? Certainly, building up primary and community services as well as investing in more specialised, higher quality, centralised hospitals is not a cheaper option. In times of constraining budgets like now, something has to give. People do not trust the HSE or the minister. Typically promises have been broken and “reconfiguration” is used to close or downgrade existing services without beefing up the replacement services. A text-book case of this is the North East of the country.
Harney’s legacy should have been a unified, effective HSE; the improvement of quality and standards in health care, particularly cancer care; and the reconfiguration of hospitals to ensure excellence. More likely, Harney will be remembered for conceding to consultants, privatisating health care, accentuating an already divisive, two-tier system of hospital care, and failing to provide quality care for all, on the basis of need. Despite years of plenty, the jury is just about still out. But not for long.