The inquest into the death of Savita Halapanavar in Galway University hospital found a number of lapses in care. According to expert witness obstetrician Dr Peter Boylan, these did not directly contribute to her death. One of the lapses of care identified was that her vital signs were not monitored every four hours in the days before her death.

Monitoring the four vital signs – pulse, temperature, blood pressure and respiratory function – is hospital policy for women like Savita, who was at risk of infection due to the rupturing of her membranes on Sunday, the day of her admission. There were particularly long gaps identified in monitoring her vital signs on Tuesday – the day before she became critically ill. Scientific literature shows that missing just one vital sign can be fatal.

Medical science is increasingly complex and one of the many challenges is how complex care can be managed by a myriad of different professionals simply and effectively. In this instance, how can one ensure that all vitals are monitored regularly when required? The answer is a check-list.

The use of checklists is an application of the knowledge of airline safety, which has been in use since the pilot’s checklist was developed during World War II, to medical care.

Mr Atul Gawande, a general surgeon and Harvard professor, has written a page-turning best seller on the application of checklists to surgical safety. Mr Gawande, Director of the WHO’s Global Challenge for Safer Surgical Care, writes about the reasons people fail. The first reason given is ignorance, the second is ineptitude, i.e. the knowledge exists but we fail to apply it.

In ‘The Checklist Manifesto: How to Get Things Right’, Mr Gawande observes how medicine has developed so much that ineptitude is now as much of a struggle as ignorance. “The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably. Knowledge has both saved us and burdened us,” he maintains.

Checklists are a way to make sure that we always apply the knowledge we have in the correct way. Their application to surgical outcomes over the last 12 years has been remarkable. Thousands, may-be hundreds of thousands, of lives have been saved, the rate of post-operative infection has been radically reduced, lengths of stay have been halved, and outcomes have been manifestly improved. Clinical studies have found that surgical deaths are reduced by 50 per cent and surgical complications are reduced by more than one-third when the surgical checklist is implemented.

Central to the success of the surgical checklist is that nurses are expected and empowered to point out to doctors when a checklist is not being adhered to. Hospital administrators have bought into them, literally, because check-lists have huge benefits on the bottom line. Yet, surgical checklists are a relatively new science – it is only since 2006 have medical journals begun to report on the success stories of surgical checklists.

In 2008, the WHO published the safe surgery checklist. This has been embraced in Ireland by the HSE, RCSI and other key groups such as the Irish Midwives and Nurses Organisation (IMNO). A survey in 2010 carried out by the IMNO found that 75 per cent of respondents said the safe surgery checklist was a part of operating room policy in their hospital, but only 50 per cent said that it has been implemented in its entirety.

Checklists work because they remind people what to do, as well as setting out the required minimum steps in any process. This in turn leads to more consistent and higher standards of care. However, all checklists, be they for vitals or for surgery, are only as good as their implementation. In times of greater pressures on fewer staff who are expected to provide more complex care, checklists are more necessary than ever.

It is time to ensure that basic systems such as the four-hour monitoring of vital signs and the safe surgical checklists are adhered to in all Irish hospitals. As Mr Gawande remarks, failure from ignorance is forgivable, but failure from ineptitude is not.

For more on surgical safety and related topics see www.gawande.com.

The launch of Ireland’s first ever public health policy ‘Healthy Ireland’ took place on 28 March, a month after it was originally meant to happen. Invites went out far and wide. The Taoiseach was meant to launch it. The Mansion House was bursting with ‘Healthy Ireland’ green logos and ministers wearing green ties. The spin machine was in full swing.

It made sense for the Taoiseach to launch ‘Healthy Ireland’. After all, any decent public health strategy requires a government-wide approach. Lessons from other countries tell us that the most senior political and cross government leadership is critical to achieving real improvements in health and reducing health inequalities.

It had been postponed a month previously because Jose Manuel Barroso, President of the European Commission, was in town. And on 28 March, at the last minute, there was a no show from Enda Kenny. He was in Waterford at the opening of a tapestry and the reannoucement of 200 jobs, which had been announced, but never materialised, four years previously. At least he was not opening a pub.

So the Taoiseach was missing, but so too were Michael Noonan, Brendan Howlin, Richard Bruton, Ruairi Quinn, Phil Hogan and Joan Burton. You can be sure that if the launch had gone ahead a month previously and Barroso had turned up that the Cabinet would have been out in force. And that would have been the strongest symbol of support from the highest European and Irish political leaders for Ireland’s return to the status of a healthy country.

Secretary General at the Department of Health, Ambrose McLoughlin, chaired what turned out to be a tedious non-event. There were nine or ten long, cliché ridden speeches, spanning over two hours and delivered to an ever-dwindling crowd.

What was meant to be Ireland’s first public health policy morphed into a framework for improved health and well-being 2013-2025. ‘Healthy Ireland’ has four overriding goals: improving everyone’s health; reducing health inequalities; protecting the public from threats to health; and creating an environment where every sector can play a part. It contains 64 actions. Many are woolly; some are aspirational. Critically, many are contrary to the policies of austerity currently being pursued by the Government.

Advocates of the policy have argued that if and when ‘Healthy Ireland’ is achieved: There will be one-quarter of a million more adults and children of healthy weight in 2025 than there is now; That by 2025, one more million people will be taking the right amount of daily fruit and vegetables and physical activity; Fewer young people will start smoking and overall there will be half a million less smokers; Children will stay longer in education; Health literacy among adults will be improved and fewer people will live in poverty.

Obviously, all of these would be a most welcome success by 2025. However, these are a rehash of many previous unachieved targets set as far back as the 2002 National Anti-Poverty Strategy. Most of the targets in the 2010 cardiovascular strategy and 2012 substance misuse strategy are restated in ‘Healthy Ireland’, but, critically, not one new target has been set. An ‘outcomes framework’ is promised by the end of 2013, where apparently ambitious and specific targets for improved health and reduced health inequalities will be set.

At the launch, Minister Reilly spoke with passion about the cost of obesity and alcohol misuse, and his plans to introduce logo free cigarette packs. He also articulated his desire to increase tax on cigarettes so that they became a euro each and to introduce a sugar tax. Minister of State for Primary Care Alex White and Minister for Children Frances Fitzgerald spoke about their determination to ban alcohol advertising of sporting events. James Reilly concurred, saying he would like to see the alcohol sponsorship ban in place by 2018, but admitting 2020 was probably more realistic.

However, Ministers Reilly, White and Fitzgerald do not have the support of their government colleagues. Fellow TDs have spoken out against the alcohol sponsorship ban, Cabinet rejected the sugar tax and if Noonan wanted more revenue from fags, he would have increased them already to a euro each in these desperate times.

The first of the 64 actions, a “Cabinet Committee on Social Policy chaired by the Taoiseach [which] will oversee and monitor the implementation of ‘Healthy Ireland’ is described as “probably the most important of them all”. However, the Taoiseach and other key senior ministers were notable merely in their absence. Maybe that is just pure optics. Yet, not walking the walk from the outset is a poor indicator of the Government’s commitment to really achieve a ‘Healthy Ireland’.

Minister Reilly’s reaction to a Sunday newspaper article was to order a review of HSE funding for SpunOut.ie. My column for the Medical Independent from 11 April wonders how this became news in the first place

The Sunday Independent ran a front page story on an advice article about threesomes that appeared on the SpunOut.ie website. It is one of more than 3,000 articles on sex, mental health, alcohol, drugs, education and employment on the SpunOut.ie website, which gives objective advice to 16- to 25-year-olds.

SpunOut.ie, according to itself, is dedicated to helping young people make informed decisions about things which may be happening in their lives. It is youth-led by a panel of 17 young people who determine the direction and focus of the organisation’s work. It has a staff of five which runs the website, edits all the material and empowers young people to participate. It gets €124,000 from the HSE to provide health information to young people. Much of the content is written by young people themselves, edited by a SpunOut editor and factchecked by an appropriate professional.

The article in question gave young people advice on the pros and cons of threesomes, all the time promoting safe sex and encouraging young people not to do anything they are not comfortable with. The page came across as approving of threesomes, which was objectionable to many. It has been edited since, appropriately toning down some of the more positive lines on threesomes. Mayo Fine Gael TD, Michelle Mulherin was outraged with the content and suggested SpunOut.ie should not be funded with public money.

Minister Reilly, in his wisdom, capitulated to the pressure, announcing a HSE review of SpunOut.ie’s funding the next day. So how on earth does a story like this get front page attention on the country’s best selling Sunday broadsheet? As far as this writer can work out – what happened was as follows. SpunOut.ie was launching its new website the week before the story ran. To mark the website launch, SpunOut ran a live show devised, produced and presented by young people in Croke Park that was broadcast online.

There was much tweeting and social media attention to the SpunOut live event, including tweets from this columnist who was lucky enough to be invited to the event (I was a board member of SpunOut.ie from 2009 to 2012). This was around the same time that the Sunday Independent journalist came across the ‘threesome’ webpage.

She then called Michelle Mulherin of ‘fornication’ fame for comment, which was then used as front page fodder.

This was the same journalist who, two weeks previously, had written an article entitled ‘Ireland’s most eligible bachelors – the names every girl should know’ to go along with their rich list. SpunOut.ie defended the article, saying they “believe in the ability of young people to make the right decision for themselves once they have access to quality and reliable information, such as the information provided by our website…. we do not promote threesomes, we arm young people with the facts about them”.

How on earth can the Minister not think that €124,000 is good value for providing such broad and extensive information, for young people by young people, especially if young people actually read it and engage with SpunOut.ie, which they do? Have a look at the HSE’s own yoursexualhealth.ie and you will see why young people go to SpunOut.ie in their droves.

SpunOut.ie was started in an attic in Donegal by a hugely innovative young person, Ruairi McKiernan, as a response to the failure of the State to meet young people’s health needs. It has blossomed and transformed since to meet the changing needs of young people. It has always had some health board/HSE funding as well as significant philanthropic funding. It reaches over one million users per year and has won every social media and social innovation award going.

Young people are bearing the brunt of much of the current economic crisis, with more than 30 per cent youth unemployment, high emigration and the stresses of youth exacerbated by the crisis.

Meanwhile, government continues to cut support to youth groups including SpunOut.ie. It would be a damn shame if Reilly used the ‘review’ as a way to withdraw funding to an organisation that is playing a critical role in informing and supporting young people, while the State continues to fail them.

Despite much public and political attention, there is still no decent explanation as to why the Irish pay more for prescription drugs, sometimes more than 20 times what other similar high income countries pay. Neither is there any reasonable, official explanation for why generic drugs in Ireland can be as expensive and sometimes even dearer than branded drugs.

Common sense or public interest does not prevail when it comes to drug costs in Ireland. The drugs budget escalated hugely during the boom. Between 2000 and 2008, the public drug budget tripled.

These increases can be explained. First of all, we were starting from a low base. In 2005, Ireland’s expenditure on drugs was the lowest in the then EU 15. Our growing and ageing population are also contributory factors. The greatest reasons for the escalating drugs budget was probably the greater availability of newer, more expensive drugs and increased volumes of prescribing. Also influencing the drugs budget in the mid-noughties was the introduction of medical cards for all over 70-year-olds in 2001. Older people are the more likely to be prescribed more drugs and often more expensive drugs. The withdrawal of universal medical cards for over 70-year-olds in 2008 will help to reverse that particular factor.

Initial figures just released for 2011 show that €1.8 billion was spent on drugs through the various public drug schemes – for those on medical cards, the long term illness, the high tech and the drug payment schemes.

The price paid by Irish people is determined by ‘deals’ agreed every three years between the government and the Irish Pharmaceutical Health Care Association (IPHA), the organsiation representing pharmaceutical companies in Ireland. Since 2006, government has been trying to bring down the high cost paid by the Irish public through the State drugs bill and individually out of our pockets through these ‘deals’.

Recent agreements (in 2006, 2009 and 2012) have sought to target the cost of drugs at different points where high prices are paid – ex-factory, wholesale and retail. In 2009, the spend on the public drugs budget was just under €2 billion, whereas the 2011 spend on the same schemes was €1.8 billion. These totals do not include the 60 per cent of the population that pay €144 for drugs every month. However, the deals have had some effect of bringing down the drugs bill, given that there are increasing amounts of items prescribed to a growing, ageing population.

So why is it that, despite efforts to drive down the cost of the drugs, that the Irish drugs spend in 2010 was the highest in the EU – 34 per cent above the average? And how is that a Sunday Business Post survey comparing the prices of the top 10 generics drugs in March 2013 shows we pay between eight to 24 times what our English neighbours do? These are extraordinary findings, given that English drug prices are more expensive than most other comparable high income countries. The same survey also showed that the price differentials had increased since last August, loading an additional burden on Irish pockets.

These excessive drug costs in Ireland are a direct result of shoddy deals done by the Department of Health, on behalf of the government, with the pharmaceutical sector. The high generic prices are because the government allowed generic companies to charge up to 98 per cent of the original branded drug. This has now been cut to 90 per cent. But it’s still eight to 24 times higher than what the English pay.

The Health (Pricing and Supply of Medical Goods) Bill 2012, originally initiated by Mary Harney in 2010, is slowly weaving its way thro-ugh the Houses of the Oireachtas. When enacted, this Bill will allow for substituting drug ingredients with generic or cheaper medicines. It offers the best potential for reducing our high drug costs.

Health officials are currently in negotiation with generic producers, hopefully achieving a better deal on the generics front and the National Task Force on Prescribing and Dispensing has also been established which, if effective, should lead to more efficient and effective prescribing and dispensing.

The most recent IPHA deal signed off by Minister Reilly last October will yield only €190 million in savings over three years when the cost of new drugs is taken into account. While new drugs are most welcome to those who benefit from them, recent political decisions allowing the cancer drug ipilimumab and CF drug Kalydeco show that even €190 million in savings is optimistic.

There is a possibility that the effect of the 2012 Health Bill will override such populist decision making. Here’s hoping.

The entire governance of our health system is being dismantled under the stewardship of minister James Reilly. He got rid of the old HSE board within months of coming into office – the board members actually stepped down and were replaced by those he personally picked from the senior ranks of HSE and Department of Health.

Having senior people from government departments or state agencies on the board another state agency is contrary to all good governance practices, where board members are meant to be independent, operating solely in the interest of its stakeholders (in this instance the people of Ireland), and not the HSE nor Department of Health. One of the inquiries after the 1980s blood scandal recommended not appointing senior state officials to state boards due to the myriad of conflicts of interest. James Reilly is ignoring all such wisdom.

Cathal McGee also stood down as HSE chief. We don’t know why, but it is reasonable to speculate that he was being sidelined by the new minister and he felt his position was untenable. Tony O’Brien was the chosen one by the minister, appointed HSE directorate designate last July. Ambrose McLoughlin was appointed secretary general of the Department of Health last April after going through a public appointments process, but ultimately it was a political call to decide who to appoint from the pool of three shortlisted for the post.

Currently, five new HSE directorate positions are being recruited – Acute Hospitals, Primary Care, Mental Health, Social Care, and Health and Well-Being – from the ‘wider health family’. In other words you have to already be working in the HSE, the Department of Health or another major health agency to go for the job. The Chief Finance Officer post is being advertised through open competition. Why there is an open appointment process for this one post and not the others is inexplicable. Surely some outside experience in these new posts would be a good thing.

Once again, the minister made two unilateral appointments without any competition. Laverne McGuinness,currently director of integrated services is to become chief operations officer and Liam Woods, who was the national director of finance, is to become director of shared services.

The Health Service Executive Governance Bill 2012 is currently being debated and is going through the Houses of the Oireachtas. This lays out the legislative basis for James Reilly’s plans for the health system, including abolishing the board of the HSE and replacing it with a directorate, which will be made up of the director general and six directors. It also enables the Department to have control of the entire health budget from January 2014 onwards.

Critically, what the minister is doing is getting rid of any accountability and governance structures that exist and replacing them with a coterie of his men – and they are mostly men – in effect creating a command and control structure for the minister and those around him without any checks and balances in place. Given that it is government policy to abolish the HSE in its entirety in 2014/15, this new structure stinks of charade.

Speaking in the Dáil debate on this Bill, Roisín Shortall pointed out that this might be acceptable if the Minister’s plans were related to principles, but as she said, “we know from bitter experience, however, that neither the minister nor his cabinet colleagues operate on the basis of transparency and prioritisation when it comes to health spending…it would be the height of folly and highly irresponsible for this House to give these wide ranging and unfettered powers to a minister whose track record already concerns us”.

Given our mistakes of the past – the jobs for the boys, absence of accountability and good governance – we must learn this time round. This government came to power with the promise of a more transparent, accountable and efficient public administration. Yet, James Reilly’s actions in health are completely contrary to what we were promised.

Roisín Shortall is fighting a lonely battle. There needs to be more scrutiny of this Bill before it is enacted. Is it too much to assume that other public representatives might take on this mantle or that our leaders in the health systems – doctors, nurses and managers might cry halt?

Last time major health service legislation was driven through without any real debate or amendments, the monster that is the HSE was created. Surely HSE mark II without any checks and balances is another retrograde step that needs to be stopped, before further damage is done.

As part of the Irish presidency, the health ministers of Europe will gather on 4 and 5 March in Dublin Castle for what is billed as ‘an informal meeting’. According to the official blurb, the meeting ‘presents an opportunity to explore some of the challenges in improving the health and wellbeing of EU citizens’. The agenda includes: childhood obesity; working towards smoke free environments; improved inter-sectoral working for health; children with complex developmental needs (including autism); patient safety, including the prevention and control of healthcare associated infections.

This strong public health dimension is welcome. While Ireland has a strong track record on smoking prevention due to the pioneering work-place smoking ban introduced in 2004, public health policy and measures have been largely ignored by Irish political and health service leaders. Despite the smoking ban, we rate amongst the top three highest smokers in Europe – 29 per cent of Irish people smoke, a rate surpassed only by Bulgaria (29.2 per cent) and Greece (31.9 per cent).

Effective prevention of obesity and smoking, as well as encouraging more smokers to quit and those too heavy to lose weight, could be the best way to lessen demand for health services. Reduced demand for health services is a definitive way of assisting us to deliver more care to more people with our declining health budget.

Ireland has a rotten track record on ‘inter-sectoral working for health’. Apart from the smoking ban, the only area where inter-sectoral working has been effective, in the interest of public health, is road safety. Interestingly, road safety was driven from a justice and law enforcement perspective, rather than a public health one.

Good inter-sectoral working would ensure that more children could walk to school due to safe walking, cycling paths and better public transport; it would make healthy food available in all communities, especially the most disadvantaged. Good inter-sectoral working is good for everyone’s health.

Ireland has never prioritised public health policy or the implementation of the narrow policies that exist. While there is much rhetoric about public health, there has been little action on it. A new public health policy has been promised for years. Now referred to as a ‘health and well-being framework’ its publication was guaranteed by this government by the end of 2012. There is still no sign of it.

The focus of European health ministers on children with complex developmental needs is good news for any parent or carer given the abysmal state of diagnosis and care services for these Irish children. Likewise, the spotlight on patient safety must be welcome. There has been recent attention and much needed action in the area of patient safety, including hospital infections, in Ireland over the last few years. However, much more needs to be done. A recent article in the New England Journal of Medicine shows one in four hospital patients are harmed by medical errors. No such Irish data exist.

The promotional blurb for the health ministers’ meeting also says that there will be a ‘working lunch, for heads of delegations only… to discuss the impact of the economic crisis on health systems and consideration of policy responses’. What will the Irish Minister James Reilly share with them? Will he tell them that the Irish people and health service have taken austerity on the chin, that it’s been hard, but we are doing it and ‘notwithstanding the difficult financial environment, examples of the very substantial progress’ are present. That’s what he told the health summit on the 13 February. The rest of his 2,000 word plus speech was the usual guff.

It is doubtful that Minister Reilly will explain that despite statements to the contrary, homehelp hours to those who need them most have been cut. Will he share with them the new ‘yellow pack’ terms and conditions for doctors and nurses which are a direct result of the economic crisis? Will he document the closed hospital wards and theatres and non appointment of primary care staff? Unlikely. But we will never know as the meeting is closed to mere mortals like you and me.

It is most improbable that Irish presidency of the EU will have any impact on Irish health policy, but if Minister Reilly was to listen and implement just one effective measure from our European neighbours, he might, just might, improve the health and well-being of Irish citizens.

Of these, 20,000 are expected to be over 70 years of age, as Budget 2013 reduced the threshold for eligibility from €700 a week to €600 a week for that specific age group. The other 20,000 who will lose them are under 70, who currently have to earn less than €186 a week to qualify, as well as meeting many other requirements.The HSE Service Plan tells us how 40,000 people will lose their medical cards in 2013, but what about the thousands of others who would have qualified in 2012 and won’t this year? Medical Independent column from 14 February 2014. The HSE Service Plan for 2013 details how 40,000 people who currently have medical cards will lose them in the year ahead. Medical Independent column from 14 February 2013. 

Of these, 20,000 are expected to be over 70 years of age, as Budget 2013 reduced the threshold for eligibility from €700 a week to €600 a week for that specific age group. The other 20,000 who will lose them are under 70, who currently have to earn less than €186 a week to qualify, as well as meeting many other requirements.The HSE Service Plan tells us how 40,000 people will lose their medical cards in 2013, but what about the thousands of others who would have qualified in 2012 and won’t this year? Medical Independent column from 14 February 2014. 

The HSE Service Plan for 2013 details how 40,000 people who currently have medical cards will lose them in the year ahead. Of these, 20,000 are expected to be over 70 years of age, as Budget 2013 reduced the threshold for eligibility from €700 a week to €600 a week for that specific age group. The other 20,000 who will lose them are under 70, who currently have to earn less than €186 a week to qualify, as well as meeting many other requirements.

There was no mention about having an even playing field between over and under 70-year-olds – a clear hangover from the terror that older people ensued on politicians when Mary Harney announced the withdrawal of medical cards from richer over 70-year-olds in October 2008. Marches on Dáil Eireann and protests in churches resulted in a series of u-turns which meant most over 70-year-olds kept their cards because you could earn up to a threshold of €700 a week. Also many older people who had higher incomes did not return their cards and have held on to them so as to gain free access to GPs and avail of prescription drugs at a minimal fee. The over 70-year-olds who will lose their full medical card, will get it replaced by a GP only card, so they will still have free access to GPs, but will now have to pay up to €144 a month for drugs.

For the under 70-year-olds, it’s not so clear what will happen. There was no mention of this in the Budget 2013 speech or in the Department of Health press release on same. However, queries to the Department of Health and responses to questions at the launch of the 2013 HSE Service Plan tell us a bit more.

The official response said “it is intended to tighten the rules relating to a person’s spending that is taken into account when carrying out the means test for medical card. These expenditures include home improvement loans, second home loans, a weekly allowance of €50 towards car depreciation and an 18 cent per kilometre travel to work allowance. It is also intended to include certain forms of income that are currently disregarded in the assessment process.”

Figure that out! Basically, they plan to make it harder to get medical cards. While this will hit hard on any of the 40,000 people who will lose it, it will hit even harder on those who are unable to get access to medical cards in 2013 despite their need and low income.

Anyone who has ever applied for a medical card or assisted someone to do so knows that vast amounts of personal and financial information are required, that cards are not given out easily or quickly. And yes we have higher amounts of people with medical cards than ever before.

As of 1 October 2012 (the most up-to-date figure at the time of writing) 1,838,603 were covered by medical cards. This is up by 144,540 from January 2012 when 1,694,063 people were covered. The increased growth is a direct result of the economic crisis as more people are unemployed and on low income and therefore eligible for medical cards.

We know from research carried out by the ESRI that medical cards are a progressive pro-poor measure which provides an essential safety net of access to GP care and medicines at a very low cost.

What the HSE 2013 Service Plan gently reveals is that there will be a net increase of just 60,000 medical cards in 2013. If the same amount of people need medical cards in 2013 as needed them in 2012, then 132,000 who would have got them in 2012 will not get them in 2013. This is a blatant example of rationing based on economic constraints. The latest troika report focussed on high consultant pay and over-paying for drugs, but it also mentioned the need to “tackle the unsustainable growth in medical cards”.

If the same amount of people need medical cards in 2013 as needed them in 2012, then 132,000 who would have got them in 2012 will not get them in 2013

There has been no public or political debate about the planned rationing of medical cards. In order to restrict eligibility, which is the plan, legislation is required. So as with all legislation going through the Department of Health, nothing will happen quickly. But as the legislation is being drafted and going through Dáil Eireann there is an opportunity to debate how a limited health budget should be rationed and whether 130,000 plus people on low income should be part of the austerity prey in 2013.

The latest troika review of Ireland puts health services and money health spending starkly in the firing line. The European Commissions’ Winter Review of Ireland’s Economic Adjustment Programme dated 19 December 2012 commends the Irish Government for making good progress by “putting fiscal policy back on a sustainable base”. In the next sentence, it raps some knuckles by stating that “much remains to be done including addressing new spending pressures in the health arena”.

It details how measures were unsuccessfully put in place last July to try to deal with health overspend and is critical that these were “only partly implemented, resulting in an estimated overrun of €370 million through November 2012”. By any standard, this is heavy-handed re-primanding by the troika – the European Commission, the International Monetary Fund and the European Central Bank – who are now our bankers and bosses in rela-ti-on to the health budget. Since December, the troika is taking a much more hands-on approach to health policy matters.

The Commission’s report rightly highlights the “delayed/failed implementation” of cost saving measures in health due to the slow passa-ge of legislation required to gi-ve them effect. It makes wide ranging recommendati-ons on how further savings can be achieved and cleverly bounces back to the Government their own intentions such as introducing “money follows the patient”, the enhancement of primary care, increased transparency and better cost control measures.

Quite bluntly, they say “while most indicators show Ireland close to average in terms of health outcomes, health spending… is relatively high, suggesting poor value for money”.

Between 1997 and 2007, Ireland’s healthcare spending increases outpaced all other OECD countries. In other words, we kept on spending more without improving our health status.

The mission report, as they call it, recommends that health spending should become part of the Government’s (i.e. the troika’s) high level goals so that it can be monitored and managed. Two specific areas of what they consider excessive spending are identified – “more could be done on the cost of pharmaceuticals” and “remuneration of medical staff should also be reviewed”.

They outline how we tripled our drugs spend between 2000 and 2008 and they use 2010 data to show that we have the highest spending on pharmaceuticals in the EU. They suggest potential drug savings (well beyond what Minister James Reilly has planned), focussing on a much greater use of lower cost generic drugs, reform of reference pricing i.e. having a larger set of countries in which the basket of drugs is priced, and shifting price from the average basket to the lowest, which is exactly what other troika countries have done. They also suggest monitoring and putting in place financial incentives to make sure doctors prescribe the most cost-effective alternatives.

On medical staff pay, the Commission uses OECD data to show how consultant pay is well above the EU average. They show how consultants’ pay is nearly four times the average wage and how the average consultants’ pay in Ireland is €181,000. In other troika countries such as Greece and Portugal, average specialty pay is €48,000 and €46,000, respectively.

This €181,000 figure takes into account the pay cuts implemented in 2010 but purely counts a consultant’s public income. Given that at least two-thirds of consultants ha-ve contracts which allow them to practise privately, €181,000 is a huge under-estimation of actual income, as private earnings can be a multiple of the public salary.

The Commission acknowledges the low numbers of consultants in Ireland and suggest “a comprehensive review of the market for medical staff”. In short, they are recommending having more less well paid consultants rather than fewer extremely high paid consultants, which is currently the case. They also note the 30 per cent cut in newly appointed specialists.

In a separate section on Croke Park, the troika stress the importance of vigilant monitoring of the implementation of public sector reform but interestingly, they cite the recent report that the WHO did for the Irish Department of Health that was slipped up on the Department of Health website in November. The WHO report warned that “additional savings through efficiency gains cannot be made within the required timeframe without damaging patient care unless high salaries and the high price of other inputs are seriously addressed”.

While it is clearly not in Ireland’s interest to have the troika’s grubby hands all over our health policy, if they manage to spur the Government into action that will reduce the price of the drugs bill and cut the excessive pay of consultants, their winter mission’s report is a welcome one.

If one looks at the bigger mental health picture, the arithmetic is not much prettier. There has been an €80 million reduction in the overall mental health budget between 2009 and 2012, when €707 million was allocated to it. There were 1,200 fewer mental health staff in November 2012 compared to March 2009.

The decline in the mental health budget and staffing levels could be explained in two ways. Firstly, the 2006 mental health policy A Vision for Change places a large emphasis on shifting people out of institutions, closing them down and providing more and better care in the community. This, in theory, requires fewer staff and resources. The second explanation is that cutting budgets and staffing is directly in line with the Government’s austerity policy.

While many long-term residents have been transferred out of those institutions, some remain, seven years after the policy’s publication. The most recent report of the Inspector of Mental Health spoke about residents in an institution in Wexford who were withdrawn, without stimulation, presenting maladaptive behaviours. He concluded that if these residents were living in an appropriate place with the correct therapies, they could live much better lives. That such places and therapeutic staff are still not available is a strong indicator of the failure to deliver on mental health reform.

Slow to change

And while hospitals and institutions have been closed, the corresponding development of community services has just not happened. One could explain this as unlucky, with the economic crisis looming at the time or one could conclude that mental health services are neither a political not public policy priority.

Commenting on the “slow and inconsistent” implemen-tation of A Vision for Change, the most recent report of the Independent Monitoring

Group of A Vision for Change, details how community mental health teams are “poorly populated with an estimated 1,500 vacant posts”. The report also highlights how the continued absence of a National Mental Health Service Directorate (and director) “with authority and control of resources” and a comprehensive, costed, time-lined implementation plan contribute to the “lack of coherency in the planning and development of community based services”.

The Fine Gael/Labour Programme for Government specified that they would ring fence an additional “€35 million annually… to develop community mental health teams and services as outlined in A Vision for Change”.

Minister Kathleen Lynch, the Minister under whose remit mental health falls, has repeatedly stated that €35 million was delivered in 2012 and that there will be a new, additional €35 million in 2013. Yet, when questioned on this, she has been unable to give a breakdown on how it was spent in 2012. When the Department of Health was asked for this breakdown, the question was referred to the HSE. The HSE was also unable to give a breakdown, but communications confirm that most of the €35 million was not spent in 2012 and was used to shore up spending in other areas.

Staffing

A key factor in not spending the €35 million in 2012 was the tactical delay in appointing the much-needed 414 new posts for mental health. By the end of December 2012, just 58 of those posts were in place, and another 54 posts filled but not yet in place. Whither the 306 other posts?

Extraordinarily, the HSE is unable to give a breakdown of what those posts were, even those already in place, as no such information is collated nationally.

From experience, we know that successful service reform can be delivered where there is determined political and clinical leadership, good management, sufficient and ring-fenced budgets, and staffing.

The post of first National Director for Mental Health is to be advertised shortly. If they can get the right person (preferably with international experience), and give mental health reform the political priority and resources it deserves, this Government has a chance to start saving lives not money. And it would be one sure way that it could show its word on this is for real.