When the summer gives way to the autumn in a few weeks, and the giddiness in Fine Gael over a few bouncey opinion polls subsides (as it will), health will once again elbow itself onto the political agenda. Why do we know this? Because it always does. And health will continue to be a political headache for the Taoiseach and his Government, with the enduring potential to derail it.
You’ll hear a lot about Sláintecare, the model for the future of the health service in the all-party report published more than year ago. Public hat-tipping to the plan by Ministers is matched by private scepticism that many of the proposed reforms are neither feasible or desirable.
Sláintecare might not have been given the last rites yet, but it’s in pretty ropey condition in the intensive care unit.
A gamey attempt by Simon Harris to secure dedicated funding for its reforms in recent months failed in the face of stony-faced resistance from Minister for Finance Paschal Donohoe, firmly backed by the Taoiseach.
Perhaps understandably the centre of Government is resistant to the idea that there should be a regular health budget, and then a budget for health reform and then – because this is inevitable – another budget to pay for the annual health overspending.
Any additional resources for Sláintecare reforms will now be decided as part of the regular budgetary process.
Also on the agenda for the autumn: the nurses are spoiling for a fight over pay. Waiting lists continue to grow. The fallout from the cervical care scandals will continue as the condition of some of the women affected deteriorates. Desperate personal stories out of war-zone emergency services will proliferate.
There is a view in Government that most people think the health system is a basket case but they don’t really think any politician can fix it – and that this neutralises health as a political issue. I think that’s incomplete. It ignores the fact that politicians can make a case for reform – and Sláintecare offers politicians the opportunity to do that. And it ignores the political damage that health can inflict on an incumbent government.
At present Harris’s simultaneously brave and deft handling of the abortion referendum is insulating him from criticism about the state of the service over which he ultimately presides. The insulation will be buffed up when he brings the legislation to the Oireachtas in the autumn. But it will not last. Time passes, and politics dwells in the present, looking to the future. Past achievements are a wasting asset; political capital does not last.
The truth is that there is something approaching fatalism about the health service at the top of Government. There are few people who believe health can be “fixed”.
The Taoiseach, with both a foot soldier’s combat experience and the bird’s eye view of a former general , knows the archipelago of competing and conflicting interests that is the Irish health system better than most. He is in the fatalist gang.
He wonders why – indeed, he does so publicly – Ireland’s health system spends more money for poorer outcomes than almost any other comparable country. He realises that the system will gobble more and more money.
The question that senior politicians in the Government tend to ask themselves about the health system is not “what can we do to fix it?” but rather “how can we stop it costing us the election?”
At what seemed to me to be a reinvigorated MacGill Summer School this week, one of the better sessions was on the health system.
The best presentation was given by Sunday Business Post journalist Susan Mitchell, who carefully dissected many of the failings of the system, and where responsibility for them lay: with politicians (who always prioritise the short-term), with staff (who prioritise their own interests) and with patients, a group which nobody ever blames for anything. As Mitchell pointed out, almost half a million appointments every year are unfulfilled by patients who don't bother turning up.
It’s not true that nobody knows what to do about health. In fact, there is a high degree of consensus on many of the things that have to be done such as extending primary care, changing work practices, centralising some services and so on.
But the problem is that very few of these things can be done without cost, and none of them can be done without upsetting someone. In some cases they can’t be done without upsetting a lot of people.
And it’s true that some highly successful reforms in the past, such as centralising cancer services, were fiercely resisted by medics, politicians and the public.
Stephen Donnelly, the Fianna Fáil health spokesman who also presented in Glenties, told about how during votes on that cancer strategy (introduced when Mary Harney was health minister and FF was in government) some TDs were afraid of being physically assaulted in Leinster House by angry protesters. (Mind you, I think Donnelly would admit that Fianna Fáil might not be above resisting reform for political advantage).
The success of Harney’s cancer reforms demonstrates the need for political leadership. But not just political will – also political craft and guile. Interest groups have to be brought on board, budgets stretched and people convinced. Deals need to be cut, compromises brokered, arms twisted, solutions sold. These are quintessentially the skills of the politician.
There is a common view that politics needs to be taken out of health. “Put Michael O’Leary in charge of it all” is a dinner party trope.
But actually what health needs is more politics, not less. But it needs to be politics pursued in the public interest. That requires people to think beyond the next election. There’s little sign of that right now.