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FG and Labour, at your health service

THE dominant theme of the last week of the election campaign is the Elizabeth Taylor/Richard Burton impersonation being performed by Fine Gael and Labour.

Historically their on-off romance has been characterised by bursts of apparently profound and very public mutual hostility, punctuated by equally public and emotional hatchet-burying reconciliations. The fact that there is an outside chance of a Fine Gael single-party government wooing multiple independents (the bachelor-playing-the-field option) has increased the temperature of the courtship, with Labour going to great pains to remind the electorate of the steadying influence of a committed monogamous relationship with a wise, dependable partner.

The key question facing us is whether the two parties can make their marriage work for five years, and I have been asked to commentate on the compatibility of their health reform policies.

In fact, the major challenge facing the potential newlyweds is not incompatibility but the fact that the dowry house that Bertie and the Brians bequeathed them is in negative equity.

The awful irony of our current predicament is that it is very likely that we will finally get a reform-minded Minister for Health, whose freedom of action will be severely constrained by the desperate financial situation. The decision of the outgoing Government to give a "foreign aid donation" of 100 per cent of our gross domestic product to speculators (remember how proud we were that we were giving 0.7 per cent to provide food and water to some of the poorest people on the planet) raises the real possibility that every bit of progressive public policy in the manifestos will have to be shelved, as we dig deeper and deeper to meet our newly adopted obligations to Roman Abramovich and others who thought Irish banks were a good investment.

Those commentators who told us in 2007 to ignore trivia such as ethics in government and to return the administration which had stuffed our mouths with money have a lot to answer for.

Health reform is a core policy of both Fine Gael and Labour. Both have proposed radical reform of the system of health funding -- reforms which I believe would go a long way to addressing the core problems of our unfair, inefficient and mediocre health system. The policies are well thought out and subtly different, but would each introduce the same new dynamic into public health care?

The core of the reforms of both parties lies in the system of health funding. From my own point of view it is likely that both sets of reforms will reduce my income, so my espousal of the reformist cause does not come from financial self-interest. The status quo designed by generations of Fianna Fail and Progressive Democrat health ministers would suit my personal financial agenda just fine.

The public hospital system at present is a bit like a restaurant where the management is given a delivery of food for the freezer on January 1, just barely enough to last a year until another freezer truck arrives. All of the potential diners contribute up front to the cost of the truck load, but then don't pay when they are served.

If more people come for food, there is a danger the freezer will be empty before year's end, so the management tries to discourage additional diners from coming by closing sections of the restaurant ("we are short staffed", or "that section is being decorated"). Soon there are queues. The staff will be discouraged from developing tasty new dishes as this will just attract more customers. Similarly they will discourage speedy service. The well-off will soon tire of the queues and the bad food and will go to other restaurants where they pay as they eat. Incidentally, some of the staff in these alternative eateries are moonlighting from their day job in the other restaurant -- and get tips for good service.

The health system works like this restaurant, and as a result it is inefficient and mediocre. Get the money in January, make it last a year. Having too few X-ray scanners or operating theatres keeps costs down, as it keeps people sitting in hospital beds or on waiting lists and costing less while they wait for treatment.

Of course, the rational way to supply food in the restaurant, or treatment to patients, is to match supply with demand.

More customers come for the food, then more food is delivered, and sold. This is what happens in the private health system.

The food and service are better, but it is obviously unfair.

Under the Fine Gael and Labour models the hospital that attracts most patients gets most money. The restaurant doesn't get paid until the food is served. The essential element of social solidarity is, however, maintained in that the food is still free at the time you get it.

Everyone pays up front (insurance contributions) so that everyone has access to the restaurant when they are hungry.

The wealthy pay more for the same access. Everyone eats at the same table. This type of system breeds efficiency and quality, but is a little more expensive. The challenge facing Pappa James Reilly and Mamma Jan O'Sullivan as they attempt to bring everyone into the new family restaurant is that by undertaking the private debts of Fianna Fails banking buddies, we may all be stuck in the soup kitchen.

Professor John Crown is a consultant oncologist

Sunday Independent