Lyndon Johnson reportedly remarked that Gerald Ford – then a congressman, later president – was "so dumb that he can't walk and chew gum at the same time". This is an accurate diagnosis of what ails Irish government.
Governments have to be able to function simultaneously at two different speeds: crisis management and structural reform. The resignations of Laura Magahy, executive director of the Sláintecare programme to reshape the health service, and Prof Tom Keane, chairman of the Sláintecare Advisory Council, show all too clearly that our system can walk or it can chew gum. But it can't do both.
Sláintecare is not just an exercise in bureaucratic restructuring. It is supposed to fix a problem that has been corroding the Republic for decades: a health system that is both grossly unfair and deeply inefficient.
Last year, we spent €20 billion on the health system. Yet we have almost a million people waiting to be treated or assessed by a consultant. Nearly 200,000 people have been waiting longer than 18 months for an outpatient appointment.
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Only some of this can be explained by the pandemic and the cyberattack on the Health Service Executive. This is an underlying condition. A bad system is kept alive with ever more frequent transfusions of money. But it is never cured.
Aside from the toll of human misery, this failure is woefully debilitating for Irish democracy. It has created a political variant of chronic fatigue syndrome, a sense of futility that makes ministers believe, deep down, that since large-scale reform is impossible, it is safer to keep muddling along.
It seems clear that Keane has quit the Sláintecare project out of sheer frustration. The Government has used the pandemic as an excuse not to move ahead with a key part of the project: the devolution of the HSE’s power to six regional health bodies.
Pandemic vs politics
But the excuse is nonsense. The pandemic was well under way when the Government was formed last year. It nonetheless committed itself to these changes. The programme for government says that “We must now bring forward detailed proposals on the six new regional health areas to deliver local services for patients.”
Ministers believe, deep down, that since large-scale reform is impossible, it is safer to keep muddling along
The real problem is not the pandemic but the politics. Crisis management is fine – the system is oddly comfortable with a semi-permanent state of emergency. But structural change demands two things that have been absent for decades: fierce political will and a clear sense of what needs to be done.
Since the 1990s, health policy has consisted largely of making changes, undoing them and then undoing the undoing.
We had a regional structure: the old health board system. We abolished that and centralised everything in the HSE. Now we’re supposed to be going back to it.
Fine Gael, in 2011, decided that it would be a good idea to abolish the board that oversaw the HSE. James Reilly, as minister, scrapped it, "to create greater integration at the top of the health service between the Department [of Health] and the HSE."
Fast forward six years, and another minister for health from the very same party, Simon Harris, announces that he is bringing forward a smashing new idea for structural reform: the creation of a HSE board.
Harris also announced in 2017 that “a leaner national” HSE would be “complemented by more devolved, responsive and integrated entities at regional level”. Fast forward (or rather slow forward) four years and it is exactly the unwillingness to create these regional entities that has led to the current Sláintecare debacle.
Crisis vs structure
On the one hand, the policy of the elected government – and the consensus across the political system that supports Sláintecare – is that regionalisation is crucial to the integration of the hospital system with community care. But on the other hand, Paul Reid, who runs the HSE, told the Business Post last year that "if we are considering what to prioritise, then the regionalisation should not be up there". Stephen Donnelly, as Minister, seems to agree.
Implementing structural reform is not the priority. Crisis management is. As always, the urgent crowds out the necessary
In other words, implementing the structural reform that the Government itself proposes is not a priority. Crisis management is. As always, the urgent crowds out the necessary.
This is, though, Micheál Martin’s chance to save himself from oblivion. If he wants to be remembered for more than steering his party gently towards irrelevance, he should beg Tom Keane to come back and invest him and his committee with the full authority of the Taoiseach’s department.
On Friday, the Taoiseach, responding to suggestions that he do this, said his office did not have the “bandwidth to run a health service”. But this is utterly disingenuous. Nobody is asking him to run the service. What he has to do, rather, is to give those who are charged with reforming it the power to override all the institutional inertia in the HSE and the Department of Health.
Those with long memories will recall that it is almost exactly 20 years since Martin, then minister for health, was humiliated when Charlie McCreevy, who was minister for finance, contemptuously dismissed his plans to reform the health system.
If he does not want to preside over yet another failed strategy, he needs simultaneously to walk the walk and chew out those who get in the way.