Cabinet defiant on reforms

IT'S time to bite a few bullets. The Cabinet's top quartet were in defiant form yesterday as they promised delivery on the most radical reform of the health service in 30 years.

Backed up by two of the plethora of reports conducted into the current health system, the Government pledged to make tough decisions and put their credibility on the line.

The Brennan and Prospectus reports provide a damning indictment of management in the entire service but also the outdated system with a culture of a complete lack of financial accountability at its core.

The Taoiseach acknowledged that money alone is not going to reform the system, while the Tánaiste said the health service would be politically accountable, but it didn't need 263 health board members to do so.

Often criticised for his reservations over the billions of euro allocated to the health sector and how it was spent, Finance Minister Charlie McCreevy resisted the temptation to claim he was vindicated in his position all along.

However, he said clear accountability structures and financial management systems would be put in place:

"The reform programme being launched today is all about providing a better level of service to patients and better value for money to the taxpayer."

Putting in a quite impressive performance, Minister for Health Micheál Martin also touched on the hard medicine to be administered across the country, when he referred to plans to create a limited number of highly specialised centres of excellence:

"It is neither practical or realistic to suggest we can provide this within immediate reach of everyone's home. It's time we faced up to these issues.

"As a society, we need to achieve a consensus about the reality of achieving high-quality, safe care in a country of this size and population."

That is where the crunch will really come. Tough decisions must be made if the Government is to depoliticise the decision-making process of where services should be based and where hospitals should be closed or expanded in response to patient demand.

Although the Fianna Fáil backbenchers may be prepared to accept the abolition of the health boards without much rancour, when acute services are being centralised into a small number of locations, there will be more than just murmurings of discontent to deal with.

Indeed, at yesterday's meeting with his TDs and senators, Minister Martin appeared to be tetchy on the point raised about health boards being scrapped, looking as though he had been hearing too many rumblings on this matter.

The general acceptance permeating from the meeting that health boards are ineffective and inefficient is helped by the fact that the abolition of the dual mandate means TDs and senators will not be able to sit on health boards from next year anyway as they will no longer be sitting on the local council.

The desire to tackle the vested interests in the system also remains to be quantified. Although the Department of Health is to review the consultants' contract, which allows public consultants to treat private patients at their will, there is no guarantee this will bring about any substantial change in this practice.

Ministers McCreevy and Martin may have set differences aside to put forward a united front, but the issue of funding for the ambitious plans remains.

Yesterday's Health Service Reform Programme is heralded as the means by which the ambitious commitments of the National Health Strategy can be delivered.

Launched with even greater aplomb more than 18 months ago, the €13 billion price tag attached to the health strategy appears to remain too dear for Minister McCreevy's liking.

Minister McCreevy's infamous letter, sent just a week before the launch of the much vaunted health strategy, in November 14, 2001, has still not been revoked.

At that time he wrote:

"Dear Micheál,

"I understand that you are proceeding with the printing of the Health Strategy. You are well aware of my views in the matter, particularly in relation to the financing position.

"I wish to make it clear that initiatives contained in the Strategy involving expenditure implications for 2002 are included without my approval and carry no commitment on my part to the allocation of any particular sums to your Department in the Budget.

"This matter cannot be considered in isolation from the other priority competing demands which the Government currently face.

"I am copying this letter to the Taoiseach and the Tánaiste."

Nothing that was said yesterday suggests that this situation has changed. Yesterday the financial management structures desired by Mr McCreevy were promised and Mr Martin said the reforms will free up resources.

Aside from that, no extra funding is being promised. Only last week, the Department of Health warned that just to keep the head above water and deliver the same level of service next year, an extra €900 million will be required.

The Tánaiste and Minister for Finance are not going to assent to the minister for health's wish to see taxes raised to fund an improved health service.

The key term is value for money and Mr Martin is going to have to implement this latest plan in order to stretch every euro to the limit. And all in time for general election polling day in 2007.