No, Minister: is there a cure for all the ills of James Reilly's department?

Róisín Shorthall's sudden resignation leaves James Reilly the last man standing in the Department of Health. How has he managed to ruffle so many feathers in just 18 months?

‘DOH” READ the sign behind James Reilly one day last week as he made yet another television appearance explaining his decision to site two primary-care centres in his constituency.

The sign outside the office of the Minister for Health was an appropriate reminder of the three-letter word Homer Simpson uses when he realises he has done something foolish.

The Department of Health has had many “Doh!” moments in recent decades; the results of successive scandals over the treatment of patients. Along the way, the enormous difficulties of managing a huge health system riven by conflicting interests have damaged or shortened the careers of many of the politicians appointed to head it.

This week, the health jinx claimed yet another political scalp, as Minister of State Róisín Shortall packed her bags at short notice after running out of road in a lengthy dispute with Reilly.

His tenure looks far from certain, not just because of the continuing fallout from the row with a Labour colleague but also because of the enormous challenges in managing a shrinking health budget. A Government that switched into reverse at the first sign of protest over the availability of cancer drugs or home-help hours, to take two recent examples of relatively small-cost savings, is faced with cutting a whopping €2 billion off spending by 2014.

“Angola” is the overused nickname coined by a former minister, Brian Cowen, to describe a department historically given to infighting at the highest levels and to civil wars between vested interests, as well as the potential for landmines that can surprise the most sure-footed of politicians.

Still, the epithet is being dragged out again now to describe Dr Reilly’s 18-month tenure at the top of the department’s home in Hawkins House, an ugly office block on Hawkins Street in Dublin. Shortall’s departure is only the latest in a long line from the health service since the deputy leader of Fine Gael assumed office with big ideas.

Since March 2011, we have seen the exit of the HSE chairman, the HSE board, the VHI chairman, the VHI chief executive, the secretary general of the department and, most significantly, the chief executive of the HSE, Cathal Magee. Under Reilly’s tenure, the holders of all the biggest State jobs in health have left, leaving the Minister as virtually the last man standing. He therefore enjoys unparalleled freedom to implement his proposals, provided he can find the money.

Reilly can be brusque and unpredictable and sometimes hot-headed, and he has been depicted as a boor in the political debate of the past week, but it would be wrong to say he is unpopular in his department. Sources say he is well liked by his officials, with whom he enjoys a more relaxed rapport than existed when Mary Harney was minister.

Shortall, by contrast, was not universally popular with her staff, according to insiders who have suffered her impatience.

WHAT HASN’T GONE down well is Reilly’s importation of so many new faces, some on the staff and others on expensive consultancy contracts. This coterie of aides has become known as the “cabal”, and operates as a department within a department. A handful of senior appointees now pull the strings at the top of the organisation; notably the secretary general, Ambrose McLoughlin, the first outsider to be appointed to the post, and Tony O’Brien, the deputy chief executive. A former head of the Irish Family Planning Association who has risen through the ranks since joining the civil service, O’Brien is now effectively running the HSE and is charged with overseeing its reintegration into the department.

The Minister’s preference for appointing people directly, in favour of open competition, contravenes stated Government policy and rankles with some.

Reilly has also engaged a variety of consultants to help deal with the most pressing problems in the health service, notably the waiting lists for patients and the continuing inability to stay within budget. A new special delivery unit was set up to tackle the waiting list. Dr Martin Connor, who achieved success in this area in Northern Ireland, is the head of this unit and has been paid €370,000 since last year, despite working an 80 per cent contract and spending much of his time in the US, but he has achieved a 20 per cent drop in the numbers on trolleys.

Yet the need for a new approach was well founded. In 2010, a draft report prepared for the last Government’s civil-service reform programme was deeply critical of a department that, after all, was no longer responsible for running the health service since the HSE opened its doors in 2005.

It found that some staff had “little or nothing to do”, while their colleagues were overwhelmed with work. The report described a department frequently “under siege”, that spent much time fighting fires ignited by repeated controversies. Staff morale was low, sick leave was high and senior management and the rest of staff were “out of step”.

“The department as a whole has had limited success in marshalling the vested interests in the health sector and also suffers from a negative media image,” was another finding that still rings true. These findings are supported by some of those who worked with the department in the recent past. “There are many good people in Hawkins House, but what’s lacking are the quality of management and the breadth of qualifications and experience that are needed to oversee the running of a €13 billion health service,” says a former adviser who was engaged during Harney’s term in office.

Another source is critical of the “endless” time officials have to spend answering questions from TDs, or referring them to the HSE.

DESPITE THE current row, much has improved in the health service over the past five years. Waiting lists have been cut. Fewer staff are looking after more patients. Consultants and other high-earners are working more flexibly. Health crises, such as the bird-flu pandemic, that arise from time to time have been dealt with. There are fewer cases of misdiagnosis and none of the blood scandals that were so prevalent a decade ago.

The dispute between Reilly and Shortall differs from previous controversies over health issues.

This is essentially a policy row, with tinges of personality differences. It’s intensely political, and runs along the fault line of private-sector versus public-sector tensions within the Coalition.

These tensions were foreshadowed during Shortall’s much-quoted Dáil speech last week, when she asked who would bear the burden of the health cuts coming down the line. “Do we increase prescription charges for medical-card patients, for example, or instead reduce the drugs bill? Do we cut public health nurses, or instead collect money owed by insurance companies? Do we cut home-help services, or instead impose a cap on consultants’ pay?”

In the recent past, lawyers have tried to reform the justice system, but Reilly is the first doctor minister for health in some decades to attempt to cure the ills of the health service.

Being an insider brings obvious advantages such as an understanding of the issues and familiarity with the main players, but also brings drawbacks such as the danger of preset notions and perceptions of bias.

He is also a businessman with substantial interests in the medical area, which has brought its own difficulties.

Many of the disputes between the two politicians erupted over issues relating to doctors, for example a disagreement over the fee payable to GPs for administering the winter-flu vaccine, or the issues around staff and the provision of centres for primary care. As a former president of the Irish Medical Organisation, Reilly knows all about negotiating, but he has yet to go head-to-head with the IMO’s current leadership.

Meanwhile, the deal he trumpeted with hospital consultants at the end of last week’s talks is a long way from crossing the finishing line.

In contrast to Shortall, who could be over-punctilious at times, he emerges as a man of broad brushstrokes, a politician not terribly interested in the details of his proposals, only the outcome.

It seems likely now that his Cabinet colleagues, while they approved of his proposal, were not apprised of the details. But since a number of them stood to gain from the primary-care centres proposed for their own constituencies, they were probably disinclined to complain.

It’s worth noting, too, that the Government stimulus package that contained the announcement of 35 primary-care centres last July also included two major road projects in the Wexford constituency of Minister for Public Enterprise Brendan Howlin.

The affair, by encouraging perceptions of the same old clientelist politics that dogged Fianna Fáil, has damaged the Government enormously. But with swingeing cuts on the way in December’s budget, we may end up looking back on it fondly as an amusing diversion.