What next for health?
As Leo Varadkar begins a testing time as Minister, eolas considers the pressing issues in health and his approach to policy.
James Reilly’s three-year tenure in health has widely been seen as a time of turmoil. Leo Varadkar has less than two years to improve the system before voters make their judgement.
This can be a thankless task at the best of times – Brian Cowen made his Angola comments as the Celtic Tiger took off – and like justice tends to break rather than make political careers. Cowen, in fairness, proved to be one of the most successful ‘survivors’ and Varadkar will be hoping that his own high ambitions are not thwarted by the sense of crisis in health.
Two live issues stand out: money and medical cards.
It’s almost certain that the HSE will overspend its budget this year with the supplement coming from social welfare. Patient campaign groups also want to link medical card eligibility with chronic conditions – an emotive idea which could imply that some groups of patients are more entitled to care than others. The issue has at least been postponed until a review report comes out in September.
Universal health insurance (UHI) remains the Government’s key long-term policy. The public consultation – carried out in April and May – will be followed up by a commission to estimate costs. Its report is due to be presented to the Government in early 2015.
Alongside that, legislation would split the HSE into a ‘health commissioning agency’ and a set of providers i.e. hospital trusts and community bodies. The ‘patient safety agency’ and the existing Healthcare Pricing Office will act as regulators. Introducing free GP care for all by 2016 would prepare for the full implementation of UHI by 2019 but this depends heavily on finances.
The Government’s vision for social care envisages a single funding source, a single care assessment framework, robust governance and accountability, and a greater emphasis on individualised budgeting.
Despite mental health being stated as a priority, funding for those services has fallen by almost a quarter since 2009 – a position made worse by underspends. Mental Health Reform warns that action is long overdue and stagnation will put more people at risk.
With its young age structure, Ireland does not face the same demands for older people’s care as other Western European countries but needs to plan for projected ageing over the coming decades. Strategies are in place for carers and palliative care but a national dementia strategy has been delayed since last year.
The Healthy Ireland strategy (see pages 68-69) aims to increase the proportion of people who are healthy at all stages of life, reduce health inequalities, and protect the public from threats to their health and well-being.
A ban on under-18s using sunbeds started on 21 July. Other legislative priorities for 2014 and 2015 include plain packaging for tobacco products, banning smoking in cars with children present, and implementing the EU Tobacco Products Directive. Minister Reilly called on all food service businesses to display the calorie content of food and drinks offered on their menus. This will be accompanied by a national plan to increase physical activity, to be published later this year.
Alcohol policy aims include minimum unit pricing, structural separation of alcohol from other products in mixed trading outlets, health labelling, and tighter regulation of advertising, marketing and sports sponsorship. Details on implementing the policy were published last October but the proposed Public Health (Alcohol) Bill has not yet been introduced.
The National Drugs Strategy covers 2009-2016 and has five themes: supply reduction, prevention, treatment, rehabilitation and research. Ireland is also the British-Irish Council’s lead administration for tackling the misuse of alcohol and drugs.
Health protection policy includes a three-year project to draw up a new oral health policy, which is to be completed in 2015. A national sexual health strategy, though, has been delayed since early 2013 and is needed to help the growing number of people living with HIV and AIDS.
Direction
Despite its reputation for inaction, the department did publish three significant policy documents just before the summer recess: a national rare disease plan, an evidence review of standardised tobacco packaging, and a framework agreement for the new GP contract.
As Minister, Varadkar has welcomed the passage of legislation allowing for free primary care for children aged under six and also announced the Medical Practitioners (Amendment) Bill, to ensure adequate indemnity insurance. He has also called for elective day surgery to become the default option for more surgical procedures as it should increase the number of operations.
His first policy speech after the reshuffle, at the MacGill Summer School, majored on trust and politics rather than health. Politicians, he suggested, show that they do not trust the people when they make “undeliverable” promises in opposition only to fall short in government.
Varadkar also questioned the notion that the financial crisis eroded faith in the democratic process. Instead, the public wanted politicians “to prove that they still deserved their trust” and more participation by citizens in that process was needed.
Trust in politicians “should never be uncritical and it should always be earned” and sometimes trust needed to be shaken in order to “cut through the fog of dishonesty and distortions.”
Most people, he acknowledged, are not particularly interested in the mechanics of politics: “They want a secure job, decent take-home pay and quality public services for the taxes they pay.”
He was “honoured” to be asked to serve as Minister for Health “even though the challenge is enormous and daunting.” Varadkar could not help but resurrect the Angola analogy, quipping that that it was maybe “considerably easier” to be that country’s President than to hold this portfolio in Ireland.
Budgets
The Department of Health has been allocated a net budget of €223 million for 2014. The largest single block is grant funding (€67 million), mostly for research and drug purchasing.
The separate HSE budget totals €12 billion, which is mainly sub-divided between the HSE regions (€6.5 billion) and primary care reimbursement (€2.4 billion). Administration counts for a relatively small sum (€110 million) in the context of the overall budget.
Some of the smaller health budget ‘accounts’ have been set up to support groups affected by policy failures. €15 million per year is allocated for people who contracted hepatitis C from blood transfusions while €745,000 compensates people with thalidomide-related disabilities.
