Mary Harney is celebrating (if that is the correct word) five years in “Angola” , presiding over the minefield that is the Department of Health and Children.
While it may seem like only yesterday that Ms Harney entered Hawkins House, she is in fact now the second longest-serving Health Minister since a separate health department was established in 1947.
So how will history judge her? The old cliche is, of course that all political careers end in failure. Given the Obama-level of expectation that surrounded her entrance into Hawkins House in September 2004, Mary Harney’s tenure will ultimately be seen as a failure, albeit an honourable one.
Mary Harney projects an impressive image. She has considerable political courage; she is a skilled orator and media performer who can speak on practically any subject without notes or prompts from advisers.
She usually does not baulk at facing hostile audiences, and there has been much hostility for her to face during her ministry.
However, for all her apparent accessibility and “common touch” communications skills, as Sara Burke remarked in her recent book on the health service: Irish Apartheid, there is a certain amount of orchestration or media management to her public appearances.
She has given few if any lengthy ‘sit down” interviews on her policies or record to journalists, certainly not in the print media. She has a tendency to deal in soundbites rather than detailed explanations of her policy. She, and her advisers, appear careful at picking which conferences she attends.
She firmly rejects accusations that she is an idealogue but claims she is merely a pragmatist trying to find the best way to make the service more efficient, and if this means using the private sector then so be it. Her critics would say that inherent in her policy is a distrust of the public sector and a lack of confidence in its structures or staffing to deliver the goods.
Health service workers, and this is also a criticism made of Brendan Drumm, claim she has not directly engaged sufficiently with the people working with the system in her quest to change things. The Minister would perhaps feel that many in the system are too resistant to change and that the system needs to reflect consumer rather than staff needs.
Harney has a habit in speeches or at press briefings at recounting what a person she encountered recently said to her about the health service. Surprisingly, this soothsayer invariably expresses opinions at one with those of the Minister.
Her critics, however, say she does not listen to enough people, or to the right people.
Mary Harney came to the Department of Health with a reputation for getting difficult things done. She has had some success, but her can-do reputation has taken a considerable denting over the past five years.
At a recent Oireachtas Health Committee, pressed on various issues by her Fine Gael counterpart James Reilly, the Minister retorted: “I am just telling Deputy Reilly the facts. The problem with Deputy Reilly is he is against everything and for nothing.”
This in effect sums up Harney’s style of ministry.
She projects an image of not being afraid to take on vested interests or to make decisions that may be politically controversial. She believes, and is probably correct, that Fine Gael or Labour would flinch at tackling some of the contentious issues she has grappled with.
However, when they eventually return to power, they may have no choice but to follow much of the Harney agenda.
In truth, the Minister has had mixed success in taking on interest groups. She has faced down opposition from pharmacists, nurses and opponents to hospital “reconfiguration". She has reduced fees paid to health professionals on State contracts.
She is credited with “taking on” hospital consultants and pushing through a new contract. However, whether handing them over huge pay increases during a recession and only implementing limited restrictions on private practice amounts to “taking them on” is open to debate. Consultants say that many of them were already working the extra hours provided for in the new contract.
She has failed to preside over a much–needed reformation and streamlining of the HSE. At best, she appears to view the health executive behemoth as a necessary evil that she has been lumbered with.
Spin vs reality
As Irish politicians go, and despite the criticism of the health services, Mary Harney still has a reasonably positive public image.
She had had failures as health minister, but in many cases has proven to be tough and reforming. Some of her positive achievements are often lost amidst the undoubtedly significant A&E crisis and cancer scandal headlines.
She has endured many controversies and scandals, from the Travers report on nursing home charges and the departure of the then Secretary General of her Department early in her reign, to the many cancer misdiagnosis scandals, to the more recent cack-handed handling of the over 70s medical card issue.
Flouting claims that she no longer has a political mandate, she has even survived the demise of her own party and premature reports of her own demise as health minister. She could even survive as Minister well into next year and perhaps beyond, depending on the durability of the most unpopular Government in the history of the State.
Yet despite her best efforts, it would seem that improving our beleaguered health system to the extent she initially promised has proven beyond her; or else it is going to take far longer than five years to reform the unreformable.
Despite assurances from the Minister and Brendan Drumm that services are improving and are being reformed, the perception of the person on the 46A bus would still be that five years on the system is still dysfunctional, hard to access, inequitable and unwieldy.
And, with the recent collapse of the economy and the Government finances, many would feel the service may further deteriorate rather than improve.
Mary Harney often appears to be in charge of a health service that has a split personality - the real service of trolley waits, waiting lists, dirty hospitals, infection, insufficient community care, worries about safety, and the inefficient behemoth of the HSE.
Then we have the "virtual" all-singing all-dancing all-spinning reformed health service that Mary Harney, Brendan Drumm and others insist is coming to fruition, but that the person in the street can find little evidence of to date.
And then there's the HSE...
Our health service is still a lumbering, bureaucratic, vested-interest-infested monster that it notoriously difficult to reform. Its unpopularity is reflected perhaps in the lack of any sense of pride in or ownership of the system by staff or indeed service users.
Harney’s presiding over the creation of the HSE in January 2005 without it shedding its excess administrative fat or making sure it had the structures to run services efficiently didn’t help matters, although the decision to set up the HSE predated her taking the Health portfolio.
Her Department has devolved most of its functions to the HSE, but at various time during her tenure to date, particularly during the cancer scandals, the Minister did not really know what was going on within the health executive.
And then there's the A&E crisis...
Mary Harney back in late 2004, promised, among other things, to sort out the A&E crisis "within months". By 2006 she was calling the A&E crisis a ’national emergency’ and today, the HSE admits that it has not achieved even its own modest targets for A&E improvement. This will probably go down as the major failure of the Harney years.
Despite some improvements, many large hospitals are in an almost constant state of emergency department pressure.
The promised extra acute hospital beds have not materialised and the existing stock is being reduced. Around 1,500 beds currently supposed to be available within the system are not available due to delayed discharges, and cutbacks.
We are told we have too many acute beds as it is and the system is being reformed in order to give people more care closer to home in the community - a laudable aim.
However, while small steps are being taken in this direction, “real time” hospital capacity problems continue.
New primary and community care services are beginning to be put on the ground to replace some hospital services, but at a very slow rate. A recent Department of Finance submission to An Bord Snip provided food for thought on the Minister’s policies in this area.
It said the delivery of new primary care terms and health and social care networks in the community are essential to the delivery of integrated healthcare and “is an essential prerequisite to freeing up resources in the hospital sector.”
The report pointed out that the Department and HSE were well behind the target for new primary care teams previously set in the Primary Care Strategy in 2001.
The report also warned on the false economy of seeking to make savings on the roll-out of primary care teams. The report pointed to substantial unmet needs in terms of emergency department developments, new facilities for primary care teams and residential care beds for the elderly.
This commentary on Mary Harney’s health policy, it should be noted, comes not from the usual opposition or vested interest suspects, but a Government department.
Perhaps the “big idea” most associated with Mary Harney is the co-located hospitals plan.
This policy, launched in 2005, appeared to be a sensible solution at the time to free up public beds, Much of the criticism of the plan was incoherent and vested interest- based. Harney appeared to be on to a winner here, with the economy flourishing and tax breaks abounding.
Chickens have come home to roost on this, as co-location appears to have been badly damaged on the rocks of the recession, providing grist to the mill for critics of Harney’s love affair with the private sector.
In the meantime, major hospitals still have too few beds available.
While the numbers waiting for procedures in public hospitals have dropped on the Minister’s watch, this has mainly been achieved in the private sector through the NTPF, a PD invention. And these waiting lists are still fairly long - 18,000 are waiting over three months for in-patient and day procedures.
The fact that many public patients still have to wait for years for an outpatient appointment is a major blot on the Minister and the HSE’s copybook.
While the the NTPF's inroads into operation waiting lists are welcome, it does not say much for the public health system that it must rely on the private sector to provide basic treatments to patients; not to mention that consultants can be paid twice for the same patient under the NTPF system.
Fine Gael, in a recent health policy document, said consultants are being restricted for budgetary reasons from carrying out additional operations in the public sector and then they can under the NTPF operate on the same patients in a parallel private system funded by the State. It said it will abolish the NTPF if they are elected to Government.
Mary Harney, however, would claim that it is cheaper to provide additional procedures through the private sector in this way. Fine Gael, however, says the NTPF introduces huge distortions to the system.
Some reform successes
While the Minister’s reform efforts have to date had a limited impact on the development of more efficient hospital services, reform has actually been her best subject over the past five years.
She introduced better regulation of doctors and other professions; set up an independent safety body, set up the Fair Deal scheme for nursing home care funding and brought in GP visit medical cards.
She helped push through a revamp of hospital cancer care, but this was speeded up only after breast cancer diagnosis scandals emerged. She got consultants to accept a badly-needed new contract, but at an expensive cost in terms of salaries and with a yet to be proven dividend in terms of a consultant-provided service and equality of access.
While consultants have agreed to change their work practices, such changes have yet to extend to many other staff groups in the hospital services.
Harney is the first Minister to finally bite the bullet of closing down acute services in smaller rural hospitals, often in the teeth of fierce opposition.
While there are still concerns on this score about capacity and resourcing of the hospitals to where services have moved, there is general agreement that the reorganisation policy makes sense from a patient safety perspective, although it still has a long way to go.
Harney has presided over numerous cancer misdiagnosis scandals, all of them revealing severe defects in the way hospitals and the HSE are run. The independent safety body HIQA has more or less admitted that smaller hospitals are not safe. The Minister has taken some initiatives on patient safety, but the public remains very concerned about safety and that hospital reorganisation may be done on cost-cutting rather than safety grounds.
Hanrey’s record on preventive health has been mixed - while she expanded breast screening and introduced the long overdue cervical screening programme, a deficit in this area was the u-turn on the cervical cancer vaccine programme late last year.
Overall, Mary Harney scores better in terms of performance than her predecessors of recent years, although to be honest the competition here is not very stiff.
Given the Minister’s high standards and reforming zeal, her five-year record can be deemed above average, but only just.
Her biggest failure has been in making no real improvement in the areas of the service that the public would most frequently experience and in failing to tackle equity problems in the system. The Susie Long case will be identified with the Harney years almost as much as the co-location controversy.
On assuming office in September 2004, Mary Harney said the one thing she wanted for this country was to have a health service that is accessible to every citizen, regardless of their wealth. This presumably does not include the public patients in Co. Kerry having to wait six years for an ENT appointment.
Despite her valiant efforts, after five years in the job, Mary Harney has not fulfilled her mission statement.
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