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Harney prognosis not good
Sunday, October 26, 2008 By Aileen O’Meara
The ill-judged proposal to drop the over-70s medical card may finally unravel the career of a minister who is no stranger to controversial decisions.

This weekend, few people around the country will remember September 2004 and the warm welcome Mary Harney received on taking over at the helm as Minister for Health, in the cabinet reshuffle of the Fianna Fáil-Progressive Democrats coalition.

Most people will instead recall her worried expression at last Tuesday morning’s hastily-convened press conference in Government Buildings to announce the climbdown on the over-70s medical card. Her expression reflected the huge stresses of pulling a government back from the brink over a decision of her making.

Her Fianna Fáil colleagues are now barely able to conceal their disapproval of her handling of this debacle, and her political reputation as an experienced minister and reformer has been shattered. There is widespread belief that her days as Minister for Health are numbered.

Harney is being held responsible for the biggest wave of public anger seen in this country since the 1970s, an anger needlessly created by ill-judged comments and an arrogant assumption that elderly people would accept being forced to go through a maze of bureaucratic means-testing procedures to access health services.

Her argument that the GP-only card (a measure that has become mired in needless bureaucratic delays for low-income families) or an annual cash payment would be a sufficient replacement for universal access to a range of health services and medicines only made people angrier.

A little over four years ago, as Tánaiste and leader of the Progressive Democrats, she had high public approval ratings, and a strong reputation as a doer - just the person needed to take the new health reforms by the scruff of the neck and make them work. She followed a Fianna Fáil minister characterised more for setting up task forces and reviews than making the hard decisions.

Harney was seen as someone who would take on the vested interests in the health services, use her considerable intellect to help shape the new structures, and work tirelessly to ensure that the vast amount of public money being poured into the health services would be better spent.

While she wasn’t exactly someone who supported the partnership mode l and brought the trade unions along with her, there was always Bertie Ahern there to rein in her more economically liberal PD tendencies.

Perhaps her newer cabinet colleagues - without the Bertie influence - had forgotten an incident from the 1990s which showed the Harney capacity for getting into self-destructive political battles, one that had clear parallels with last week’s medical card debacle.

In the May 1997 general election campaign, as PD leader, she damaged her party’s popularity by proposing to cut payments to single parents to encourage them to live at home.

The plan was angrily received and Harney was depicted as harsh and uncaring, with little insight into how low-income families coped.

Fianna Fáil, her coalition partners, distanced themselves from the plan as fast as they could. Harney was described as being on a ‘‘political suicide mission’’. The party returned with just four seats, losing Michael McDowell in the process, but got back into a Fianna Fáil-led coalition.

As leader, though, while her political party was criticised for lacking compassion, nobody ever said she was not passionate about politics and reform.

In October 2004, she told the Dáil in her first major speech as health minister: ‘‘The one thing I want for the country I love is to have a health service that is accessible to every citizen, regardless of their wealth.”

Coming from an ordinary background herself, and despite the image of the Progressive Democrats as a party of the rich, Harney has always said her chief motivation in politics has been to make systems more equitable.

Four years ago, most of the public acknowledged and respected that passion for fairness and equity. In the early months of her ministry, her visits to hospitals and health centres were greeted with warmth and enthusiasm by managers, workers and patients alike.

She brought this thinking to her ‘‘big idea’’, introduced before she took over in Health. The National Treatment Purchase Fund took those on long waiting lists for public hospitals and gave them private treatment from public funds. It worked, even if it meant that some consultants were being paid twice to do their job.

It also brought much needed funds into the private hospital sector and ensured that her bigger vision of competition in the health services got off the ground while she planned her next big idea: co-located hospitals.

Again, she used her argument for equity of access to debate the merits of the controversial plan - backed with very generous tax reliefs – to build private hospitals on the grounds of public hospitals. She argued that this would free 1,000 public beds being used by private patients while public patients languished on the waiting lists.

This big idea has taken a lot longer than her original optimistic projections, and the credit crunch could well put paid to several of the proposed private hospitals, reliant on bank loans to be built.

A more equitable system of paying for nursing home care for the dependent elderly was also at the heart of her radical ‘fair deal’ proposals.

These plans - which were delayed as much by a lukewarm response from her Fianna Fáil coalition partners as by legal and constitutional issues - propose that the state recoup up to 15 per cent from the equity released by the sale of the family home to help pay for long-term nursing home care for the elderly.

Ironically, the bill to introduce the fair deal - and to help many elderly and their families struggling to meet high fees - may now be scuppered by a government rocked to the core by the political damage created by an ill-judged and poorly planned proposal to make another elderly-related health service more equitable: the over-70s medical card.

The argument at the centre of the proposal to abolish universal access to free healthcare for the over-70s is that the current system is inequitable.

Thanks to the deal agreed by her predecessor, Micheál Martin, the Irish Medical Organisation (IMO)’s members who stood to lose their substantial fee income from private patients were given a capitation fee four times that of ‘‘ordinary’’ medical card holders to ensure their support.

It created considerable resentment among family doctors, while also made it considerably more difficult for lower income areas to attract GPs to work there.

Even before it was agreed, the IMO’s own leadership was against it, including the former chairman of its GP committee, Dr James Reilly.

Even last December, in an interview with this newspaper as Fine Gael’s health spokesman, Reilly continued to oppose the measure.

‘‘Should Tony O’Reilly have a medical card?” he asked in that interview. ‘‘We have limited resources, and they should be prioritised for those in greatest need. I don’t think it should be a case of who deserves it, but who needs it.” In the same interview, he defended his position as a negotiator of the deal.

‘‘I represented doctors: I got the best deal I could for my members,” he said. ‘‘But I did point out at the time that it was inappropriate prioritisation, and what I meant by that was I didn’t want 70-year-old millionaires getting a medical card, when Johnny who is on two inhalers, and his dad is on 15 grand a year, doesn’t have it.”

However, there was no opposition support for Harney when she announced that, as one of the measures to cut health spending, the over-70s card was to go.

During her tenure over the past four years, Harney had ample time to abolish this entitlement, but used the opportunity of the dire budgetary situation to take action. It was the poor execution of the plan that led to its demise.

‘‘They had weeks to prepare their ground, to tell people how much doctors were earning and how high the incomes of some of the over-70s were, in the so-called ‘gold coast’ areas,” said one close observer.

‘‘Yet they never prepared the ground for the backlash. And they generated a lot of mistrust by telling people they had to be means-tested.

‘‘Anyone who has ever had to apply for a means-tested medical card or a GP card knows how long it takes and how difficult it is.”

The vital argument in favour of reforming the GMS - the massive and growing drugs costs - was lost in the political emotion of the past week (see below).

The aftershocks from last week’s political earthquake continue to be felt. With the political party she spent much of her life building now gone, it is only a matter of time before Harney herself departs the political stage and leaves the political landmines in the ‘state of Angola’, as the health services are known, to explode in someone else’s face.

Drugs spend drove medical card decision
The unsustainable increase in the cost and amount of drugs being dispensed to medical card holders was at the centre of the decision to end universal access to free healthcare for the over-70s.

In the decade to 2006, the cost per item in the General Medical Services (GMS) scheme doubled. The drugs bill for medical card holders on various schemes administered under the GMS accounted for €1.84 billion – or 15 per cent of healthcare expenditure – in 2006.

Unplanned increases in GMS payments account for most of the €66 million financial deficit recorded by the Primary, Community and Continuing Care (PCCC) division of the Health Service Executive (HSE) last July.

Year-on-year, Ireland has seen among the highest increases in drugs expenditure in Europe. That is why health minister Mary Harney, instead of increasing income thresholds for medical cards in the past few years, opted for the GP-visit card for low-income families, as this did not include coverage for drugs costs.

The Department of Health is still insisting it can make savings of €100 million from the altered over-70s scheme, despite retaining most of the recipients.

The savings will now be directed at lowering the higher capitation fee for doctors, and at a more rigorous system of prescribing by doctors.

Ireland has one of the lowest prescribing rates for generic drugs, just 7 per cent of total expenditure, and the anticipated €300 million savings from the 2006 agreement between the HSE and the Irish Pharmaceutical Healthcare Association, which allows for a 35 per cent reduction in drugs prices, has not yet been delivered.

Dr Michael Barry, of the National Centre for Pharmacoeconomics in Dublin, said these savings would only happen if ‘‘monitoring’’ took place.

Barry is one of the advisers chosen by the government to draw up a plan to keep a lid on rising costs, as the numbers eligible for the medical card continue to rise in line with increased unemployment rates.

A review of eligibility rules for medical cards and other health services is continuing in the Department of Health.

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