It won't be a pretty sight. Fine Gael's health spokesman Dr James Reilly admits that if, as is probably likely, he becomes Health Minister after the next election, he won't be able to please all of the people all of the time.
"I know there will be blood on the floor and I know some of it will be mine, but I relish the prospect of being health minister."
The challenge has frequently been thrown down to Fine Gael that its healthcare vision will become quickly unstuck once hit hits the rocks of fiscal reality, the mire of industrial relations, the tribalism of local politics and the strength-sapping dysfunctionality of the HSE.
Health Minister Mary Harney, under pressure from Dr Reilly at an Oireachtas Committee meeting last year, accused him of being "against everything and for nothing."
The accusation, to many, carried a ring of truth, but James Reilly says Fine Gael is very much for a number of things, and has a detailed plan to reform every aspect of the health system and how it delivers care to patients.
And James Reilly says he will not shirk from taking on vested interests, although he prefers to call them "stakeholders".
Fine Gael's FairCare policy offers universal health insurance in a system to be run by private insurance companies, at , apparently, no additional cost to the taxpayer.
There will be free GP care; less emphasis on hospital care and an end to waiting lists, among other things. The two-tier system of access will end, according to Fine Gael.
James Reilly admits that the party will have to sell the scheme to the public. It is, in places, confusing and there is some lack of clarity about the funding methods and operational details. It will, however, be a key plank of Fine Gael's manifesto, when as expected, it enters Government in the next two years.
"Under FairCare, we will make public hospitals more efficient and work practices will have to change."
"I believe in consultation, conciliation and cooperation, but I won't shy away from confrontation of that is the only remaining option. If there is some group that believes their rights exceed those of the Irish people they will find themselves in a very cold and lonely place."
The official line about Mary Harney's lengthy reign as Health Minister is that she has had some successes in attempting to reform the system. James Reilly agrees that she has made some progress, for example, cervical cancer vaccination and the Fair Deal scheme, but she has failed in key areas.
"The biggest blemish on her record is the private hospital co-location programme - it was a fiasco and literally delivered nothing. Her 10-point A&E plan was completely ineffective. Four years after she declared the ED situation a national emergency we still have around 300 people on trolleys practically every day."
He says Fine Gael will not be proposing spending more money on the health system, but will spend the existing €20 billion that goes on private and public healthcare in a better way.
Dr Reilly believes current health policy has transmogrified into a "slash and burn" process of premature reform and savage cuts.
"It's outrageous for the Minister or the HSE to suggest there will be any improvement in capacity or service quality in light of the cutbacks that have already been implemented and further cutbacks to come."
"I am angered by the suggestion, as would be any emergency medicine consultant, that you can reduce emergency admissions by 33,000 in a single year. The inference of this is that people have been admitted unnecessarily but I would utterly reject that."
James Reilly says the Minister is a "past master" (mistress?) of giving with one hand and taking away with the other. "The Fair Deal scheme freed up some beds at Beaumont and then the hospital was almost immediately forced to cut beds."
"Facilities are being closed down, being told that they do not meet standards and they must close, having deliberately been run down. We have seen in the past how they undermine smaller hospitals with a very simple formula - starve them of resources, make them unsafe, commission a report and then use that report to justify closure."
Doesn't this border a bit on a conspiracy theory? There are surely genuine safety and resource issues at play here.
"Yes, those issues exist, but I don't accept centralisation for every service. It makes sense to centralise some specialist services for which a particular volume of work in one centre is required for staff to be competent, but I do not accept the general thrust of centralisation policy."
"If you look at what is happening in Scotland, which has similar demographics and geography to Ireland, they are starting to open smaller hospitals again."
He rejects claims by some consultants that the A&E relocation in the mid-west has been successful.
"I challenge anyone to go down to Limerick and ask patients about A&E services and how long people have to wait on trolleys. I believe things are worse. Emergency services in Beaumont were already in a bad way but will be made worse when further beds are closed."
Asked how Fine Gael would do things differently, given the imperatives of resource management and safety, Dr Reilly says the party's policy is to reduce demand on hospitals by developing primary care.
While this would seem very similar to the Government's policy, on paper anyway, Dr Reilly says that is the problem with it - lip service is paid to it but is not properly implemented.
"When we say developing primary care, we mean developing it properly. I want to see a real system of groups of GPs working effectively with nurses, physios and other community healthcare staff. The bigger centres would have x-ray, ultrasound, MRI etc. with easy access for patients. We will also put in place a chronic illness programmes and through our National Body Test we will pick up chronic illness early. The HSE has plans for chronic illness programmes but nothing has materialised."
"We will reduce the patient flow into hospitals, stop cancelling operations so that people do not become emergency cases, and make better use of existing nursing home/long-term care capacity."
"We spend roughly the same on our healthcare as Holland. They have an excellent system and we have a terrible one. The money is there, but there is waste in a range of areas. When the HSE was set up there were 13 "grade eight" admin staff, but now there are 716. There is huge waste in hospitals, with people needing tests kept in far too long."
James Reilly claims official figures for admin staff in the HSE give the total as 17,500, but another report put it at nearer 49,000. "The truth is probably somewhere in between."
But will eliminating waste and slimming down admin numbers free up enough funding to do what needs to be done?
"Let's put it this way. Within the envelope we have for health at the moment we have enough money to do what is required to transform the service."
The driving force in the FairCare scheme, he says, is that "the money will follow the patient". In other words, rather than being given block grants at the start of every year, hospitals and healthcare providers will be paid according to the amount of procedures, tests etc, they perform.
"When Holland brought this system it made a 10% saving on hospital care - we would save €560 million a year on hospital care under the Fine Gael plan."
"The way hospitals are run now, when the money runs out the patient suffers. The current system provides no incentives for efficiency or productivity. With money following the patient, you get transparency, efficiency and a patient-centred service."
He says consultants frequently ask how it is that they can operate on as many patients in a private hospital on a Saturday as they treat in an entire week in a public hospital.
Essentially, the Fine Gael system will be based around how private hospitals currently operate, through being paid per item of service mostly by private insurers, who will pay a key part in running the Fair Deal scheme.
The Fine Gael plans say the current admin systems in health - the HSE and the private insurance system, will become one, run by the insurance companies. Under the new system, most people, depending on income, will pay into the insurance scheme, either on a totally or partially state-subsidised basis, depending on income.
Which poses the question-what's to stop this system mimicking the pre-Obama US model which served mainly to line the pockets of the insurance companies, hospitals and doctors, to the detriment of healthcare provision?
James Reilly,however, stresses that the Fine Gael plan will have a rigorous monitoring function designed to avoid abuses.
He puts nearly all the deficiencies in the system down to the lack of a proper management and leadership ethos.
"I get calls all the time from irate surgeons who come in to do their lists and find that they cannot treat all the patients on the list because of the lack of an available bed, anaesthetist or ICU nurse etc."
"I do not blame the porters for the situation that arose in Limerick where parents had to wheel their daughter in themselves for an appendix operation. I blame management for creating an ethos within the workplace that allowed that to happen."
Waiting lists will, it is promised, become a thing of the past under the Fine Gael plan.
"We will set up a special delivery unit answerable to the Minister, going in to each hospital, giving them a target and checking every week to ensure progress is being made. In Northern Ireland they used such a system and cleared 57,000 people off their lists at a cost of £36 million."
"We are spending nearly €100 million on the NTPF and we are making little progress. Outpatient waiting lists may be running at over 200,000."
Under the Fine Gael plan, the NTPF would be abolished and the money used to fund the special delivery unit on waiting lists.
James Reilly says Fine Gael has no ideological problems with private hospitals, whether "for-profit" or not. 'We do however, have a major problem with co-located hospitals."
He says while it will not be necessary to "reinvent the wheel" to bring in the FairCare system, he admits it will take time to bed in-over the life of two Governments, presumably both Fine Gael-led. Universal health insurance and free GP care, he says, would kick in in year five.
He admits that staff contracts, including those of hospital consultants, would have to be renegotiated, despite having only recently gone through a tortuous renegotiation process. Dr Reilly stresses that renegotiating staff contracts that may only recently have been changed, although tedious, will be worth it to achieve the ultimate goal of a fairer system.
"It will take two terms to bed in but people will see measurable improvements. Nobody will pay more than they pay now."
Fine Gael plans to set up a new patient safety body.
"HIQA has itself acknowledged that it cannot be a patient advocacy body and that is what is needed."
"We have seen from the Tallaght scandal that the days of taking at face value what any hospital says are over. There has to be proper monitoring and third-party verification when incidents like that occur."
James Reilly says his mission is "to turn this horrible, self-serving system into a patient-centred service. We have good doctors, nurses, other health staff, and administrators. What we need is leadership."
View Fine Gael's FairCare policy here
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