Ministers are generally careful when picking their fights and are always mindful of their political ‘legacy’. While political opponents will often ridicule Government initiatives in simplistic, black-and-white terms, Ministers themselves are notoriously reluctant to run with any new initiative without first weighing the costs and benefits carefully, both in political and in policy terms.

A ministerial legacy is built on many things: initiative; imagination; intuition; a willingness to take calculated political risks; an ability to get the civil and public service to break new ground based on new thinking; and an inner drive to ensure that their time in office counts for something. The electoral cycle also plays a part, as do events that threaten a government before ministers can cement their legacy.

With little more than a handful of sitting days left in the 29th Dáil, the Minister for Health, Mary Harney, will take comfort from the fact that she has succeeded in avoiding scrapes and events, thus keeping a free hand to steer health reform ably, if slowly.

In the weeks left to her, she will obviously want to put a permanent, personal stamp on her recent initiatives. Among them are the policy for hospital co-location, as well as new legislation for reforming the regulation of the medical profession, and contract talks with hospital consultants.

Key issue settled

Although the talks will probably have to run past the election, a key issue has already been settled in advance of the poll– there will be a new contract for consultants in the public system, and a timetable and timeframe for its introduction has been agreed in the event that the talks fail.

The Medical Practitioners Bill is broadly in line with the measures outlined in the Heads. There are important and welcome clarifications as to the general policy directions which the Minister may give the Medical Council, and on the circumstances in which some or all of its members may be removed from office. But there is no sign of a retreat from the move to put a non-medical majority on the council and the Fitness to Practice Committee.

It appears also that the controversial Government policy to allow private hospitals onto public hospital lands is now reaching its endgame. Minister Harney will be acutely aware that health policy, historically, is more noteworthy for continuity than change, and that if contracts can be signed by mid-April, they are unlikely to be torn up by any future Government.

Unfortunately, the debate about co-location has been dominated by the costs of the tax breaks rather than the benefits the scheme can bring to public and private patients alike. If Ireland did not have a mixed health system, we would have intolerable and interminable queues for services, as a public system, which was denied vital funding until the good times began a decade ago, buckled under pressure from all comers.

Co-location may well be the most practical response, given that the majority appear content to buy cheap private health insurance which is certain to cover them when things go wrong, rather than pay more in taxes to build up a public system that could still fail them just when they need it.

In this sense, Government policy is nothing more than the logical outcome of preferences clearly expressed and choices freely made by the majority. The acid test of co-location is as it always has been — whether and how well it releases beds that were hijacked for private fee income, while delivering extra resources and equitable access to public hospital care.

Opponents predicate their case on the view that the public sector should be the funder, provider and regulator of all health services, since a profit-motivated private sector cannot be trusted to do other than cherry pick the healthiest patients. But why not refocus the total effort, so that public and private hospitals are required, in legally binding contracts, to deliver the same range of high-quality care to all patients?

If the main opposition parties believe co-location is wrong in principle, they need to outline clearly how, in government, they will reform and ramp up the public procurement process, so that hospital infrastructure will be delivered as quickly as can be by the private sector. Otherwise, they may find themselves in a position of trying to explain to irate voters why they softened them with tax cuts but stuffed them on choice of hospital.

Vigorous approach

Despite her initial enthusiasm, even exuberance, that she could sort out deep problems within a short time, Ms Harney may take credit for bringing a vigorous, rigourous, practical approach to bear on tough issues.

She has picked her fights well. In the weeks ahead, she will consolidate her legacy. There are many who won’t agree with all or any of it, but they will remember her for trying hard to set a new direction.