ANALYSIS:Honesty about the proposed cuts is needed to counter the track record of concealment from the public, writes MUIRIS HOUSTON
WITH MINISTER for Health James Reilly acknowledging that there will be continuing cuts to frontline health services following the budget, there needs to be complete transparency about where cuts are being made.
Unfortunately, the track record of the Department of Health and the HSE is one of concealment of the detail of cuts so that patients can find that a service available to a neighbour may be denied to them following some opaque and unannounced cutback.
It was ever thus. In what amounts to a failure of both politics and the public service there is a deep-rooted culture of not openly declaring curtailments until direct questions are asked by the media or by public representatives.
Recent examples include equivocation over nursing home supports, dental care for medical card holders, the availability of aids and appliances for people after strokes and other illnesses, and of course the especially iniquitous illegal charging of medical card holders for nursing home care in public facilities. Ombudsman Emily O’Reilly spoke about this when she gave the recent Doolin Memorial Lecture for the Irish Medical Organisation.
Noting the poor record of achieving goals set out in the area of health, she said: “One of our biggest difficulties to date has been a failure to implement health policy. Sustained failure to implement policy, especially where policy has been given the strength of law, is bad for those individuals who do not get their entitlements; but it is also bad for us as a society.”
Health policy regarding the provision of long-stay care for older people was given legal expression within the Health Act of 1970. It created a legal entitlement for people to be provided with “in-patient services”, including nursing home care. But as O’Reilly pointed out, between 1970 and 2009 that policy in very many cases was not implemented. “I am not in any way convinced that this long-running failure had anything to do with uncertainty in the law or with any confusion as to what the State’s commitment was.
“As evidenced by the complaints dealt with by my office, this was a wilful and knowing disregard for policy and more importantly for the law, on the part of the State’s health authorities”, she said.
Such blatant disregard for policy and the law, repeated to a greater or lesser degree in other instances, goes some way to explaining today’s bureaucratic culture around health. It also helps explain the incredible inertia and repeated failure to change when the health boards became the HSE in 2005.
With such a long-standing level of endemic frustration of policy implementation – one of which Sir Humphrey in Yes Minister would have been very proud – perhaps it was naive to believe meaningful change was possible.
The recent health budget announcement contained another depressing example of the mandarins’ dead hand. Reference pricing and generic substitution of drugs as a means of reducing the State’s massive drugs bill was first proposed by Mary Harney in her budget speech in 2009. “It is my intention to bring forward legislation on this subject during 2010 for the earliest possible implementation,” she said. Fast forward to last week’s budget statement by Minister of State at the Department of Health Róisín Shortall: “This (2012) legislation will introduce a system of reference pricing and generic substitution for drugs prescribed under the GMS(General Medical Services) and community drug schemes. These reforms will promote price competition among suppliers and ensure that lower prices are paid for these medicines resulting in significant savings for taxpayers and patients.”
If the “Yes Ministers” in the Department of Health were up to scratch, then this legislation would have been published before Harney left office and there would have been some definite savings figures to apply to the full year estimates for 2012. Even though the State is in the worst financial crisis in its history, the mandarins have been unable to progress the issue for two whole years.
All of which leads to the question: what model of healthcare should be adopted in the future? Whatever model is followed will reflect the kind of society we want to be. And a good place to start is to be mindful of the failures of the past.
A knee-jerk reaction would probably include privatisation of the health system. It is a road followed by the previous government with mixed results. But there is public ambivalence about the relationship with the public health system: on the one hand the HSE is subject to a great deal of criticism, while at the same time the public demonstrates openly its wish to hold on to existing hospitals, nursing homes and health centres.
The Ombudsman argues that the HSE and the health boards have not had a fair chance to deliver an acceptable public service. Her patience with the public health system is admirable, and consistent with her role as Ombudsman for the public service. But what she didn’t say but might have is: it is time that policymakers in the Department of Health replace their stifling modus operandi of the past with a commitment to openness.
Honesty about the specific nature of the present health service cuts would be a good starting point.
Dr Muiris Houston is Irish Timeshealth analyst