FAR be it from me to understand the deep meanings behind the composition of a Fianna Fail Cabinet. The party reasons why person X gets job Y are a good deal more compelling, I'm sure that the reasons presented to the general public All the same, I find myself wondering about Brian Cowen getting Health. Or rather about Brian Cowen taking Health. He's a major Dail figure. He's as clever, apparently, as he is forceful. He will therefore have noticed that Health seems to get its holders into endless trouble, and yet never wins them a corresponding amount of credit.
Still, I hope he'll think of something better to do with the job than just boot out his predecessor's last-minute political appointees. This is a controversy of little or no importance to the general public: if you are going to have politicians on health boards just because they're politicians, it is a matter of indifference which party they belong to.
But it is a pity that which boys get which jobs seems to be the new Minister's mission statement. There are a lot of other things the Minister for Health might already have made a stir about.
He might have been seen to be pondering, for instance, the small item of news that 12 - which is the majority - of consultant respiratory physicians in the country have pulled out of the VHI "total cover" scheme. The VHI had, it seems, proposed that the fee for certain procedures should be reduced. The respiratory physicians are in dispute about that and they've left the VHI scheme.
Since this means that the VHI will pay them less for what they do - there's a bonus for being in the "total cover" scheme - the consultants will bill the customer so as to bring their fees up to the habitual level.
So, if you are unfortunate enough to have a problem with asthma or bronchitis or emphysema or the like, and you must attend one of those physicians, you will have to put your hand in your pocket.
Your VHI subscription won't cover the lot. You'll have to find, yourself, in the order of Pounds 100 a week.
The respiratory consultants, need I say, are absolutely within their rights. Few occupational groups just lie down and accept a diminution of their income. But this dispute raises a lot of the structural questions Brian Cowen might well address.
The pinnacles of the health service are occupied by the consultants. How are they to ensure that, insofar as outside agencies have an input into their affairs, they are treated fairly? How are we to be sure that they are treating us fairly?
THIS arises, too, in another dispute of the moment, the one between the consultants and the Department of Health about the conditions of the "common contract" between them. As you know, the majority of the consultants in the Republic make themselves available to do a certain amount of work paid for from public monies, and they also do as much as they can for private individuals who pay for themselves. You all know the two-tier system. If you can afford it, Mr X will see you now: if not, he'll see you when next there's a vacancy in his clinic.
You may be in such-and-such a bed in a hospital under whatever consultant comes your way: an identical bed, in the same hospital, built by the taxpayer and sub vented by the taxpayer, is Mr X's "private" bed.
The Department of Health is proposing that it should know some of the details of the professional life of consultants who are in public as well as private practice. The Department pays individual consultants between Pounds 53,000 and Pounds 65,000 a year for their public work, and that gives it some standing.
But the consultants are opposed to what they see as an outrageous intrusion, and one can see their point. On the other hand, the Department must have a reason for wanting to know more about the consultants' work patterns.
The status quo has served the Irish medical profession - or at least sectors of it - well. Our specialists are very, very good. And, as it happens, the possibilities open to them on the private side, coupled with the relative scarcity of consultants, means that some are very, very wealthy.
And why not? Under our capitalist system, people are entitled to make what money they can by charging for their expertise whatever the market will bear. But there is no market in health provision. The demand is unlimited. The specialists themselves in a sense do something to regulate the demand for their services by charging high fees. But they could charge higher. When it comes to medicine the market will bear anything. To me, that makes it not a market.
If any of us had an asthmatic child who needed the skills of a respiratory physician, we'd find the extra Pounds 100 on top of the VHI subscription. We'd find more or less anything. There is no alternative. There are no other respiratory physicians except the ones we've got. And you can't give up trying to be healthy and trying to stay alive. The public, rich and poor, are entirely in the hands of the medical specialists. And the specialists, neither better nor worse than any other group of people, are, whether they see it or not, primarily self- interested.
THIS makes the Minister for Health of unique importance in this society. He and his Department hold the ring. All of us, health professionals and ordinary people, need their very best offices. Health is also a most expensive Department. It will supervise the spending of Pounds 2,754 million, which is our money, this year. Are all of us - providers and consumers - getting value for that huge sum?
If not, what reforms are needed? Brian Cowen has the personal credentials to be a reforming Minister for Health. The constant difficulties with the consultants - the two disputes mentioned here are only two of the latest - suggest that the time is ripe for reform.
Can we hope that putting a Fianna Fail stamp on the health boards will satisfy the Minister's party appetites for the moment, and that he'll turn to the tasks which might write his name into the history book?