Mary Harney bows out of politics leaving mixed views about her legacy in relation to the Irish health system. MARESE MCDONAGHasked a number of commentators on health issues what her greatest achievements were as minister, what were the biggest failures of her tenure in health and what challenges should preoccupy her successor
DR DONAL O’SHEA, consultant endocrinologist and campaigner on obesity
Achievements: In the context of positive impact on health, it was something she did in another department. The smokeless fuel legislation she introduced while in the Department of the Environment had a huge impact, and within one year winter hospital admissions for chest infections were significantly down.
In Health, it would have to be her selfless commitment to driving reform of the health service in the face of constant pressure. She was an inspirationally hard-working minister who was motivated solely by improving the way healthcare was delivered in primary and secondary care.
Failures:Supporting and implementing the decision to site the National Children's Hospital in a completely unsuitable city centre location. It's a decision that should be revisited by the next Government – it represents all that was bad about the politics of the past 20 years.
From my perspective, the failure to lead the implementation of the 2005 obesity task force report was a big disappointment. That report addressed the biggest cause of preventable death in Ireland. Six years later, the report is still only partially implemented.
Challenges facing the new minister:At present we pour a huge percentage of the health budget into the last 48 hours of life, prolonging terminal illness when often the only beneficiary is the pharmaceutical industry. We are also prescribing extraordinarily expensive oncology medicines that prolong life by weeks (in certain patients only) without any data or evidence about impact on quality of life, while cardiac surgery is now not uncommon in the over 80s. These are really difficult moral and ethical issues – but the current situation is simply not sustainable, so addressing the whole issue of healthcare rationing is the nightmare that an incoming minister will have to face up to.
Transposing a universal system of healthcare over our current public/private system – which both likely new ministers are proposing – is an almost impossible task.
PROF BRENDAN DRUMM, first chief executive of HSE 2005-2010
Achievements:She had the courage to support fundamental changes, including those opposed by powerful vested interests who could influence the public's views. When we began at the HSE, we knew we had to make fundamental changes, a number of which would be very unpopular. Mary Harney supported these changes despite the sometimes intense pressure for her to take a softer stance.
One change under her watch was the decision to stop investing in more acute hospital beds in order to tackle access delays, and instead to get hospitals to operate more efficiently by providing daycare and community based primary care centres.
During her tenure, hospitals across the country were modernised to make all services including cancer services safer, and a new consultant contract was negotiated that would in future mean new consultants would work only in public hospitals. The remarkably high cost of drugs in Ireland was also reduced.
Her support for building the new children’s hospital has been critical and is something that I will personally always remember her for.
Failures:Some will point out the unacceptably long waits in some emergency departments. While there will always be spikes, because this is the nature of an on-demand service, it must be noted that the majority of hospitals have resolved this issue over the past five years. The major change during her tenure was that we stopped throwing money at the problem hoping it would make a difference.
Challenges: Resist simple solutions. They have not worked in the past but are always pushed by vested interests as the only quick fix solutions.
Be patient. You will be criticised for sticking with fundamental change because the pace of change can be frustrating for people. Being responsible for the health and welfare of a country is a huge responsibility and a genuine privilege. It cannot be a populist approach. It’s more important to improve the service than be popular.
JANETTE BYRNE, Patients Together
Achievements: I honestly struggled with this question big time. I find it difficult to pinpoint even one improvement. I would give her credit for starting the ball rolling on the consultants' contracts and the development of Hiqa.
Failures:I believe she has left a general trail of destruction. When she came in in 2004 our attitude was, "She is a new woman coming in – give her a break", but look what she has left behind. More people are lying on trolleys, operations are being cancelled and many wards have been closed.
Overcrowding in emergency departments is actually dangerous now in some hospitals, and conditions are unhygienic. Yet so much money has been spent producing 10-point plans and emergency plans and audits, all just to prove what the patients had been saying all along.
We trusted her, but as time went on all the promises and the nice words came to nothing, and now she has gone we see no light at the end of the tunnel.
Challenges: The system is in chaos, so her successor will have to start from scratch. The patients must be put at the heart of the system and the focus should be on the public health service. The battle between private and public healthcare must not continue. We need more step-down facilities and we need better watchdogs.
TIM O’HANRAHAN, consultant general surgeon, Sligo General Hospital
Achievements: I struggled to think of any unqualified success and, in fact, consulted with 25 consultant colleagues in Sligo General Hospital. Not one could come up with an achievement attributable to Ms Harney as Minister for Health. Some commentators have described the creation of cancer centres as one of the minister's successes, but the view from the northwest is that this has actually disimproved overall cancer care because of access difficulties.
Failures:I believe Mary Harney has exerted a destructive influence on the Irish healthcare system, probably due to her application of market force principles to the service. The removal of breast cancer services from Sligo is a good example of this. Patients must now make a 170-mile round trip to access a diagnostic service which previously existed in Sligo.
Co-location was another of Ms Harney’s disasters. The selection of Sligo as a site, for example, has stymied all other hospital developments here.
The former minister also failed to reform the dysfunctional body that is the HSE. The emergency department crisis is a telling example of that failure.
Challenges: Restoration of morale and confidence among the health service workforce. The other key challenge will be to restore credibility in the office of the minister by regaining control of and responsibility for the health service. This means either major reform of the HSE or, if not, its abolition.
JONATHAN IRWIN, Founder Jack & Jill Foundation
Achievements:I believe her great success was progressing the centres of excellence for cancer treatment. Earlier in her career, I think she deserved great credit for making Dublin smoke free.
Failures:I have no doubt that the gravest disappointment was that she did not win the unequal struggle with the HSE to effect real reform. I am a bit disappointed from our point of view at Jack and Jill that our funding actually went down during her term. At the moment we look after 287 children all over the country aged up to four years, but when children become older we cannot drop those families into a void. We have tried to convince the HSE that if we had responsibility for children aged up to six, we could actually save the State €42 million. It is very disappointing that they won't listen.
Challenges:The biggest challenge will be tackling the big blob that is the HSE. If you even walk into Hawkins House , it is like walking into an Eastern bloc building in the 1940s. It must be the most negative, ugliest building in the State. A new minister will have to tackle that negativity.
EAMON TIMMINS, Age Action Ireland
Achievements: The creation of the independent inspectorate for nursing homes, as part of the Health Information and Quality Authority, was a significant achievement. It established quality standards for the first time and the necessary enforcement, backed with real sanctions. The large investment in community care since 2007 has also had an impact on the lives of older people. Increases in home help hours and the introduction of homecare packages has helped many older people to remain in their own homes.
Failures:The decision to end the automatic entitlement to an over-70s medical card in 2008 was a major failure and a retrograde step when it came to protecting the health of older people. The income thresholds were only increased following backbench revolt and public protests, but the entitlement is gone.
The Nursing Home Support Act was also very damaging because, for the first time, it enables essential services for older people to be charged for in a completely different way than other health supports (including the charge on their family home after their death). In return, it does not meet all the costs of some nursing home residents, who face bills to pay from the 20 per cent of their income they are left with by the “Fair Deal” legislation.
Challenges: The greatest challenge will be how to restructure our health services to meet the needs of our ageing population. Our health services will need to focus on the management of longer term chronic illness, moving away from acute services and providing greater investment for community based services. The aim must be to help the maximum number of older people to remain living in their own homes. Quality standards and regulations will be needed, along with independent inspection and real sanctions for those who provide sub-standard services.
DR MEL BATES, Irish College of General Practitioners
Achievements: She introduced the "Fair Deal" scheme and she had the political will to see through the establishment of centres of excellence which are founded on evidence-based outcomes and a striving to the highest standards in cancer care.
Failures:She failed to properly engage with general practice and exploit its potential. She saw GPs as part of the problem rather than part of the solution. Her free market approach to healthcare and hospital co-location were based on flawed ideology.
Challenges:From a GP viewpoint, the main challenge will be to support the establishment of real primary care teams rather than virtual ones. Her successor must replace the GMS contract of the 1970s with a new one that supports improvements in prevention and management of chronic care in the community.
PAUL MURRAY, head of communications, Irish Hospice Foundation
Achievements: Mary Harney, as The Irish Timesonce aptly put it, was prepared to pick up the muddy ball and run with it. She left her mark, an intelligent one, as few health ministers have done. She routed opposition to her cancer programme, imaginatively corralling Tom Keane as czar. She brought some shape to the care of older people with the "Fair Deal" nursing home programme. After many years, too, she unveiled a new consultants' contract.
Importantly, for the near 30,000 people who die in Ireland each year, she supported hospice and palliative care, engaging with the need for better services and more hospice beds. She encouraged the five-year plan for hospice and palliative care, the Irish Hospice Foundation’s Hospice Friendly Hospitals Programme, its National Audit of End-of-Life Care in Hospitals, Quality Standards, the Design and Dignity programme, and the Forum on End of Life.
Failures: Unfortunately, her natural ease with private medicine exacerbated the advance of a two-tier health system. Her push for hospital co-location, the mess that is now private health insurance, and the near universal disquiet about public hospitals, their emergency departments, and (often) intolerable waiting times add to a worrisome brew. The test is, can Ireland be proud of its health system? The answer is no.
Challenges:The great challenge is to engender trust in the ability of the health service to deliver. It is to develop a health insurance system for all, based on ability to pay. Primary care is one key element, as is illness prevention.
The new minister will need to address why so many Irish doctors flee abroad, and the cost of drugs. S/he needs to ensure that the current hospital beds’ reconfiguration provides for more hospice care. The development of a proper national end-of-life care strategy, and equity in the provision of hospice care, would also add lustre to any ministerial career.
CONOR Mac LIAM, whose wife Susie Long died of bowel cancer in 2007 after waiting seven months for a colonoscopy, is a general election candidate for the Socialist Party/United Left Alliance in Carlow/Kilkenny
Achievements:I personally could not credit her with any achievement without qualification. She strove to erase the idea of healthcare as a social good and instead tried to turn hospitals into profit makers and suffering patients into a "market", thus imposing her own neo-liberal agenda upon our health service.
Failures:From the point of view of the public patient her tenure was not just a failure, it was a disaster. She presided over an era of privatisation; the facilitation of private medicine in public hospitals; and the subsidisation of private medicine from public funds. It became an apartheid system for public patients, leading inevitably to Susie's seven-month delay in diagnosis for bowel cancer, while a private patient was diagnosed within three days.
Challenges:The biggest challenge for her successor will be to repair a system so damaged by decades of neglect and under-funding. This would require a massive injection of resources. There is really no getting around this.
PAUL KELLY, founder of Console, a suicide bereavement and prevention service
Achievements: The major issue of suicide was firmly placed on the national agenda during Mary Harney's time at the helm in the Department of Health.While we still have a long way to go in tackling this critical health issue, the minister was responsible for monumental change, especially in terms of reducing the taboo associated with suicide.
She played an instrumental role in developing the Reach Out strategy to target the tragic reality of suicide in 2005, and during her time as Minister for Health, the Vision for Change Mental Health strategy was launched and both the Office for Disability and Mental Health and the National Office of Suicide Prevention was established.
Failures: The most glaring failure relates to the HSE which, as she leaves office, is in need of major reform. Failures in the area of health come down to the fundamental issue of funding, and no health minister can successfully meet the monumental requirements of the nation's health without the allocation of funds. It is very worrying for us that the budget for suicide prevention is just €5 million while €40 million is spent each year on preventing road deaths, even though more people die by suicide than in road traffic accidents.
Health is an area where there is no room for compromise; the health of the Irish people is essential to the health of our nation, and the Government must find a way of securing the funds, not just in the area of mental health but across the board.
Challenges:We firmly believe the issues of mental health and suicide are the most urgent health issues that need to be properly and cohesively targeted. Too many people, in particular young men, are losing their lives to suicide. The next minister must take a holistic approach to solving the issues that lead to this devastating end.