An architect of health reform…

She is one of the better known faces on the Labour front bench. An award-winning novelist and qualified architect, Liz McManus was formerly a stalwart of Democratic Left, instrumental in building up a substantial left-wing political base in Wicklow during the 1980s. Still a TD for the region, Ms McManus is now part of the new-look Labour seeking, under Ruairi Quinn, to hold the balance of power at the next General Election.

While she holds the health portfolio within Labour, she recognises that the best she could hope for is a junior ministerial role in a coalition government. She is viewed as having performed quite well as Minister for Housing during the Rainbow Coalition, although the legacy from successive governments is now a massive housing crisis.

She is straight-talking yet canny and somehow managed while in government to avoid the opprobrium that has since been directed at her replacement, Bobby Molloy. With health, once again she has again been granted a 'no-win' portfolio. However, given that she is married to the Bray-based GP John McManus, she is able to bring a wealth of knowledge of the health service to her current role.

Liz McManus, Labour's Health Spokesperson

Rather than playing the election game by waiting to see what the big two parties intended to propose, Liz McManus decided to spark debate on crucial health issues. Her discussion document, 'Curing Our Ills' appeared last year and has proposed a universal health insurance model. The Fine Gael health proposals that emerged recently bear more than a passing resemblance to McManus's discussion document.

She says that while there is great interest and need among the public for health and information on health, there are serious problems in the system in delivering that care and information.

"People are fascinated with health", she says. "Being married to a doctor, as a couple we cannot go anywhere without someone telling John or me the most intimate details of their last hospital procedure".

While many GPs have been vocal against political proposals to expand the General Medical Service system, Dr John McManus seems not to be one of them. While Fianna Fail attempts to raise the proportion of the population with medical cards to the 40% agreed with doctors in the GMS contract, Fine Gael has already expressed a desire to extend that to 60% and beyond. Liz McManus and Labour, however, want to introduce free GP care for all, effectively making family doctors employees of the state.

"When you walk in the door to see your GP, the system should not be governed on whether you can afford to pay", she says. "We are out of step with the vast majority of EU countries in that the ability to pay determines whether you access your family doctor or not. It is so anachronistic. That is why the Labour Party is committed to free GP care for everybody, while keeping the drugs schemes in place".

Free healthcare for all has been a long held belief of the Left in many countries and underpinned the Bevan plan in Britain that introduced the NHS. If primary care would become free under a Labour administration, why not hospital care too?

"We looked at abolishing private insurance and allowing everybody to have a public service" Liz McManus explains. "But that would be like the NHS in Britain, which would be levelling down. We saw that it would create all sorts of problems. Whatever you think of health insurance, up until now it has been delivering to the public".

In fact, private insurance lies at the heart of the Labour proposals, which have been the subject of public meetings around the country for nearly a year now. While GP care is seen as so successful that it can be incorporated into the state system, hospital services, according to Labour have become so problematic that only the private sector can help sort this area out.

Labour envisages a system wherein the public would be insured by the state through private health insurers for basic health provision. The richer elements of society could choose to receive more comprehensive care by buying themselves further insurance.

Ireland's Left - seeking free GP care for all in Ireland.

"The first thing I would want to do is to start the process of delivering an insurance based system", she explains. "Whether you can afford to pay or not, your hospital care and family doctor care should be covered by insurance. There's a lot of work to be done as to how that insurance can be delivered".

According to Ms McManus when you look at surveys done on, for example VHI subscribers, you find they are happy with the service they get. "They get quality care when they need it. When you make an insurance system universal, you need checks and balances to make sure that the insurers do not have inordinate power in the way that, in my view, the Department of Health currently has. The regulatory authority is so important. It has already been set up under legislation, unfortunately with no doctors or patients representatives on it".

The Health Insurance Authority was established in the Health Insurance Act of 1994, but members were only appointed in March this year. The authority features an actuary, an accountant, an economist, a maths professor and the chief executive of the pensions board. The widespread introduction of private insurers into a central role in healthcare provision obviously requires more checks and balances than this authority is likely to provide, Labour argues. Liz McManus envisages legislation that would mark out the territory within which insurers would operate.

"Insurers should not be able to own hospitals", she insists. "There is a difficulty in giving insurers that power. It is a conflict of interest. However, it doesn't really matter whether a hospital is publicly owned or privately owned as long as there is a capacity there. If someone needs to go to the Blackrock Clinic and they are poor, it shouldn't matter, because they will be insured. At the moment of course, unless you are a cardiac patient on the point of death, you don't get into the Blackrock Clinic unless you can pay for it".

Labour does acknowledge that no matter how drastic the change in the organisation of healthcare, the issue of capacity and the emotive subject of waiting lists will remain uppermost in the public eye. Despite the wish-list rhetoric of much of the 'Curing Our Ills' document, she is enough of a pragmatist to realise that Blackrock Clinic-style treatment for all is a pipe-dream.

"My own view is that whatever healthcare system you operate under, you are effectively talking about rationing or prioritisation", she admits. "Demand for healthcare always exceeds the capacity to deliver on those demands. You have to make sure that the prioritisation is as fair as it can be. The grand plan is to ensure that there is appropriate care for people when they need it".

It is a given that the standard of care offered in private hospitals in Ireland compares favourably with hospitals anywhere in the world. The problem is that our public hospitals are unable to provide a similar level of service. The reasons for this are well-documented - lack of funding, a lack of staff, low staff morale and a clogged up administrative system that leaves many waiting too long for much needed treatment. How does Liz McManus intend to improve Ireland's public hospitals?

"We need to build up partnerships within the hospitals so that everyone working there can feel part of the creation of quality care", she explains. "At the moment, it is too hierarchical and people are alienated. Morale is awful and nurses are leaving as a consequence. There is a problem with fragmentation. People aren't talking to each other and everything is in little boxes. Whether it is primary care being separated from acute hospital care, or even within the hospital care area, there are not enough connections being made. Partnership has to be built. It will take time, but if we don't do it, how can we deliver excellence?"

Labour is proposing to shift the emphasis and make the system more responsive to the patient. Where hospitals and doctors are more responsive to patient's needs, they should be rewarded. "There is currently a major disincentive for hospitals to go over their budget but at the same time patients are knocking on the doors trying to get in. The key to an insurance based system is opening up the possibility of more patients being cared for".

However, while all the major political parties agree that an insurance-based system offers the opportunity of improving efficiency in the hospital system, it cannot by itself improve the standards of care delivered to the patient. Liz McManus backs the introduction of accreditation for hospitals, but believes that the current proposal of a peer-accredited system is wrong for a small country like Ireland.

'All the major Dail parties seem agreed on an
insurance-based healthcare model'.

"I don't believe that the standards in hospitals are good enough, in terms of medical errors, in terms of hospital-acquired infections like MRSA, in terms of patient service, in terms of hygiene", she says. "At the moment the Department of Health is trying to encourage voluntary accreditation among hospitals which is good".

However, she says that Ireland need's international standards and international advice guiding the accreditation, not the peer group. The state has a role to play, and it should be separate and different from the role of the Medical Council, which is essentially doctors policing doctors.

"I want a genuinely independent system that will assist hospitals in the delivery of care. The last thing anybody needs or wants is 'Big Brother'. It's not that all hospitals are bad. We do have good quality hospital care, but there's just not enough of it. Other countries have done this - it's not as if we are trying to invent the wheel".

Liz McManus believes that the public shock at recent health scandals has jarred health administrators into a best-practice mentality at last. Because of the issues at the heart of the tribunals, she does not think that healthcare administrators will seriously object to the kind of monitoring and accreditation she is proposing.

"The Lindsay Tribunal is probably the most stark example of just how seriously deficient and deviant the system was in times past", she says. "Clearly haemophiliacs were very badly hurt and the public look on these events with absolute horror. They cannot believe that things could have been so bad and we have to learn from that. This tribunal must now be the yardstick - we have to measure everything by how seriously things can go wrong and Lindsay will teach us that".

Fine Gael has proposed the establishment of a health ombudsman to act in the role of public watchdog on the health service. Labour does not oppose the concept of a health ombudsman and the party has just proposed one to monitor the Gardai.

"A health ombudsman is not a bad idea", she says. "It's important though that there is more than simply that kind of investigation. The system should be responding to its own failures. The debate about healthcare here is very underdeveloped. We want to formalise the debate in a National Forum on Health, where all those involved can be in there and actually have a running assessment that feeds into policy".

This National Forum would be organised on a regional level and would include members of the public, as well as representatives from all the healthcare professions, the unions, hospital administrations and politicians. If such a think-tank were to play a role in formulating policy, what would the role of the Department of Health be?

"I do not think the Department needs to be in effect running hospitals. There's too much involvement at a very small scale that is holding back the development of the hospital system. The Department's research and assessment capacity is currently very limited, because its brief is just too wide".

Labour wants to bring about a radial overhaul of the hospital system that would encourage hospitals to have greater autonomy, with checks and balances in place to ensure that tragedies such as those currently featuring in tribunals do not arise in future. Liz McManus sees increasing current levels of staffing as crucial in bringing this about and wants to see more specialities moving to the regions.

"The consultants, through the Irish Hospital Consultants Association, have proposed 1,000 new posts", she says. "They have committed themselves and so we should see that reflected in government action. But 22 A&E consultants were due to be appointed under the Health Minister's winter illness initiative last October. These jobs have yet to be filled, either by temporary or permanent staff. We're now into April and the winter is over. The system is so slow that you cannot actually get that delivery through".

'Regardless of whether you are a private patient
or not, you should get the same standard
of high quality care when you need it'.

Everyone knows that the Irish healthcare system is short-staffed. The problem is in sourcing the doctors and nurses needed to provide the first-class healthcare service that everyone desires. The Health Service Employers Agency has already sponsored a number of foreign recruitment drives, leading to the employment of Indian junior hospital doctors and Filipino nurses in Dublin hospitals. While the ethics of headhunting medical staff from poorer countries remains questionable, even this source could not provide the extra staff needed. So, where will the staff come from?

"There are a lot of Irish born consultants who would like to come back to Ireland", Liz McManus believes. "The diaspora has a lot of medics in it. We could fill a lot more posts if we would simply open them up. We really need the system to be more responsive more quickly. The problem is that for years it has been a top-down system, with the Department of Health determining what the delivery of care will be".

She insists that hospital consultants have not come out against the Labour proposals. "They are always very good at fighting their corner, which I understand, but they haven't in principle filed any objection to what we are saying. I view consultants as part of the solution. If we keep treating them solely as a problem, we are not going to make much progress. Their delivery of care is crucial in determining how equality can be established".

Labour also want to see more specialists working outside of the capital. All the national specialties are currently based in Dublin, including heart transplantation at the Mater, neurosurgery and renal transplantation at Beaumont and liver transplantation at St Vincent's. She believes that some specialist care units should be regionalised in order to provide patients with the fast track to suitable treatment.

"One of the complaints I hear from the more outlying hospitals is that they are trying to get patients to referral centres in Dublin, but they don't have the swift access or fast track that they should have and patients are losing out as a consequence. We need to develop those linkages to tertiary care".

She says that perhaps the fact that so many consultants live in Dublin, "it means that everything ends up in Dublin and we are going to have to change this. A strategic approach means that all these specialist units should not have to end up in Dublin. Obviously value for money is a factor, but otherwise there is absolutely no reason why Galway and Cork could not be referral centres for some specialties".

Ms McManus sees the North-South connection as also being valuable in this context. "You can have centres that provide very advanced levels of care, though they may be on the other side of the border. It doesn't matter if we can help them provide the critical mass to develop that".

In any future government that Labour might be involved in, they would obviously end up the junior partner. Similarly, Labour frontbenchers understand that junior ministerial positions are the highest they can realistically hope to attain in government. For this reason it is interesting to hear Liz McManus express her interest in dedicating a junior minister at the Department of Health to health promotion.

"We are proposing having a junior minister solely responsible for health promotion", she explains. "We know people are smoking and drinking too much. We can see the effects of poverty and obesity. We have the facts, but we are not too clear on how to change the attitudes of people, the unhealthy ways they are responding to the Celtic Tiger. If you have a dedicated minister figuring out what works, you can develop programmes at health board level".

Health promotion is often seen as a 'happy face' role for the health minister. When hospitals are in crisis and healthcare workers threatening to strike, a new health promotion initiative always ensures that much-sought-after positive media coverage. Liz McManus argues that the current health minister has been particularly big on PR.

"Micheal Martin has been extremely good at managing the media, but the reality is that his anti-smoking Bill has yet to be published and he made the same promises 12 months ago. He's talking hard, but actually acting quite soft. I expect that this government will go out of office without making a huge impact on health promotion in this country. Health promotion is pretty incoherent at the moment".

There is a strong history of addiction in this country, she says: "But most importantly there are very powerful vested interests promoting drinking too much, smoking too much, eating too much. We have to grapple with all of this. It will be a major change if we can get people to really think about their health. We have a very intelligent population".

She recognises that the radical reform Labour proposes will not happen overnight. Nevertheless, she seems genuinely committed to assuming a health brief if Labour comes to power. Her concern is that the big two parties are not serious enough about the degree of reform the health service requires, nor the time it will take to deliver to the public.

"To transform the service as the Labour Party envisages will take a full term in office", she concedes. "This will not happen in the first year and I don't want anyone to have any illusions about that. This is turning the tanker around in deep water and that will take time".

For Labour, every patient should be treated on the basis of need, not on the basis of income. "Regardless of whether you are a private patient or not, you should get the same standard of high quality care when you need it".