After four years as Health Minister Micheál Martin is keeping mum about whether he wants to stay at Hawkins House or move on in the Autumn reshuffle, writes our health correspondent Eithne Donnellan.
The smell of freshly peeled oranges filled the Minister's office. He had just had his afternoon snack when I entered shortly after 4 p.m. last Thursday. There was no coffee, no chocolate bickies. Just bottled water and a basket of fresh fruit on the table.
But the stock of bottled water was running low. I wondered whether he would order more or leave the order till after the summer in case he ended up leaving the Department of Health and his successor might prefer fizzy drinks, wine or even beer? He laughed before giving the standard refrain he's been trotting out for days now about it being a matter for the Taoiseach to decide who goes where in the Autumn reshuffle.
But doesn't he want to remain in health. Apart from being a role model in healthy eating for the Irish public wouldn't he, if he left, miss seeing all the reforms he has been championing for some time now put into effect. He laughs again.
"You are trying new angles are you? A new way of asking that question. It's a matter for the Taoiseach to decide on that. It wouldn't be appropriate for me publicly to indicate one way or the other my own views on it at this stage as that would be perceived to be influencing the Taoiseach in one direction or another. I obviously will discuss it with the Taoiseach and it's a matter for the Taoiseach to decide then," he says.
He's not going to the Galway Races this week, where lots of bargaining may go on in the Fianna Fáil tent, so will he loose out? "You mean there will be no posts left by the time the Galway races are over?," he chuckles. "Ah no, I think the Taoiseach is experienced enough and tough enough not to be taken in by that or by whatever protestations are made".
One post at the Cabinet tablet that is definitely vacant is that of Finance Minister. Would he like that seat? I'm afraid the reply is the same. It's a matter for the Taoiseach.
Despite all the talk of friction between himself and Charlie McCreevy he says they had a good personal relationship and he will miss him when he goes to Brussels. He was "a bit surprised" by his selection as Ireland's next EU commissioner but believes the "bold move" will benefit Ireland and Europe.
If he himself stays in health any longer, I suggest, political pundits predict his chances of ever leading Fianna Fáil will be damaged. "People have suggested that its politically damaging and I'm not commenting on what commentators say about leadership or whatever because its not an issue at the moment. I mean Bertie Ahern has great resilience and a great appetite for the job and he's clearly going to lead us into the next general election and well beyond it so its not something that features on my horizon. But just to say that in terms of health being politically damaging, that is often the perception. I think we have to be careful that we don't sort of designate the health department as a department where no politician dare go. That is one of the worries I have," he says.
It's a department his predecessor Brian Cowen compared to Angola. Is it that bad or worse? "Brian is forever saying that was a joke," he contends. "It's a very very challenging portfolio. There's not a day goes by when something doesn't happen and it's a huge battle between maintaining a strategic focus in what you're doing and also having to engage in fire brigade activity on an ongoing basis. And that's what probably makes it a uniquely challenging portfolio. You also have a range of specialist interests, a huge number of people involved in different bodies and agencies, so ... its complex, and to get things moving is a slower process than other areas of public administration and service and people outside don't normally understand that.
"But it is also a very enriching portfolio. One learns an enormous amount about health and other areas but also you do come across great practitioners - we have great quality clinicians in this country. We should never forget that. So it's not all bad. There are a lot of pluses in this area as well."
But for all the pluses, the negatives dominated the recent local elections. There was the controversy over the reforms and what they would hold for smaller hospitals, A&E overcrowding and elderly patients spending days on trolleys, new healthcare facilities lying idle, the failure to honour promises to extend medical card eligibility and to end waiting lists once and for all, and unease in some quarters about the smoking ban.
So does he accept blame for Fianna Fáil's poor showing? "Not at all." There were, he said, post mortems at a number of parliamentary party meetings and it was agreed the reason for the result was "multifactorial". He stressed that in some areas "where all the heat was" over the Hanly report Fianna Fáil councillors managed to hold their seats. "I think definitely Hanly was used shamelessly by the opposition parties at the local elections to try and bolster their own position."
He accepted the A&E situation in Dublin continued to be problematic and may have affected the vote. "You can't blame one issue... you can't say health is a problem in one constituency and not a problem in another. There are organisational political issues that are internal to the party that we have to face up to. Some areas delivered. Some areas simply did not deliver in any shape or form and we need to face up to that. In my own area in Cork for example we lost one seat in the city and it was an excellent result given the storm that was blowing against us. In Kildare in Charlie McCreevy's constituency we gained a seat."
He concedes that in some areas too smokers were not happy with the smoking ban on smoking in pubs. But he stressed the vast majority of people were in favour of the ban. "Now some TDs said it was an issue that they got on the doorstep but the degree to which they could measure that as people voting on it is marginal," he said.
"If we were to reverse the ban now there would be an electoral backlash," he believes.
Isn't it contradictory though, given the ban, for the State to hold €24 million of shares in tobacco companies through the National Pensions Reserve Fund. "Personally I would prefer if we didn't invest in tobacco shares obviously but I did agree with the Cabinet and the Government agreed when we set up the pension fund that it would have to divorce itself from the investment decisions that the investors were going to take on behalf of the fund. In other words you can't have political interference on an ongoing basis in a fund such as that".
Apart from the smoking ban, the last year has seen significant controversy over health service reform and the implications of the Hanly report in particular for A&E units in smaller hospitals, which the report suggested should become minor injury units with limited opening hours. Communities with smaller hospitals are not impressed.
But the changes, which should be well underway by now, are nowhere in sight. The Minister says progress has been so slow it is "frustrating" but he points out it is due to consultants not engaging in the implementation of the Hanly plan in the mid western and east coast area health board regions, where it was to be piloted. The consultants are not co-operating as part of their campaign of action against the introduction without agreement of a new State insurance scheme to cover malpractice.
Their industrial action has also prevented work starting on the development of a plan to reorganise hospitals in other regions. This so-called Hanly II plan was due for publication after the local elections.
Mr Martin now believes it will be the end of the year before the row over the new insurance scheme for consultants will be solved, before the "i's are dotted and the t's are crossed".
"I've been unhappy with the industrial action. I don't think its justified. You have a situation where the government has actually intervened in a situation where one of the existing medical defence bodies, the Medical Defence Union (MDU), has indicated its not in a position to cover consultants' historic liabilities. The government is acting as a bone fide broker here as far as I'm concerned. We've been asked to pick up the entire tab... we've made it clear we have obligations to the taxpayer. Discussions are ongoing with the MDU."
The MDU has claimed it does not have funds to meet the estimated €400 million cost of historic liabilities of Irish obstetricians it insured over the years. The Department of Health is currently examining the MDU's books to see how much of the liabilities it could meet. It is inevitable that the State will have to pick up some of the tab. Given the progress made he hopes the consultants will reconsider their action now. But consultants claim that until a deal is done there is uncertainty over their cover for past liabilities and they would face financial ruin if they had to meet the cost of claims themselves.
Mr Martin stressed that while work on the major aspects of the implementation of Hanly was slow, groundwork was taking place behind the scenes. Advanced training courses have been arranged for September for Emergency Medical Technicians and a statutory instrument to allow them administer drugs in certain emergency situations is almost ready.
The structural reforms, in terms of the abolition of health boards and the setting up of a health service executive to take over the day to day running of the health service from the Department, is well underway, he insists. "The Hanly reforms were always going to be a bit more medium term. By definition they have a 10 year time frame".
Agreement has however, he confirms, been reached with the Department of Finance on the opening of the €400 million worth of health care facilities which have controversially been lying idle for some time. But he's not sure when he will have funds to lower the threshold for medical card eligibility.
Then there are the overflowing A&E units, some of which the Taoiseach conceded in the Dáil recently were "fairly disastrous". Part of the problem, said the Minister, is a lack of continuing care beds for patients who are ready for discharge from the major Dublin hospitals.
He said money given to the Southern Health Board (SHB) and the Eastern Regional Health Authority (ERHA) to provide care in the community for these patients last year freed up 330 beds but they were now full again. "I think its going to need sustained investment on the nursing home side. It also requires the development of home care packages... because of the funding constraints of the last three years we haven't really been in a position to develop such a programme".
He stresses significant improvements in A&Es can be made at hospital level though better organisation. "My own view is that some stories have emerged that shouldn't happen. The idea of there not being enough trolleys when you go into a hospital - that should never happen with the level of investment that is going in now. Using ambulances and stretchers in the car park, in my view that's not acceptable. With the level of money going in it should be possible to organise yourself to avoid that happening."
There are plans, he reveals, for the provision of some 850 community nursing unit beds in the SHB and ERHA areas, the regions with the biggest gaps, through public private partnership. The plan is at design stage and the beds should come onstream in about two years, he said.
The Minister rejects the notion that spending on health goes into a black hole. "My argument has always been that health will need investment and reform. It's not just one. I would argue that we have got huge returns on the investments we have made by the way. You see it in cardiology, you see it in cancer, you see it in the fact that we had 1 million discharges last year, a nearly 25 per cent increase on what we had in 1997," he said.
"Of course you can argue we've an awful lot to do but the bottom line is internationally... because of the ageing process, because of the expenditure on technology, medical devices, new therapies, new drugs, health expenditure is on an upward curve. The real challenge going forward is how do we as a society, particularly as we age, pay for that. The uncomfortable reality is expectations are higher, demands are greater, and the ageing process is all adding to it ... some people like to think we can sort it all out by value for money. Well we can't."