Sláintecare Express

Slaintecare is supposed to be the all-party solution to the problems of our healthcare system. But will it turn out to be too complex to actually work? What if, rather than waiting for the HSE to be re-engineered, we found a way to give everybody who needs it access to Ireland’s existing private healthcare system?

Sláintecare was originally put forward in a report by an all-party Oireachtas committee. You can read a summary prepared in TCD. The core ambition is to provide fast, inexpensive or free care in the public system.

The Slaintecare Implementation Plan, presumably written by civil servants and management specialists, is a different sort of beast. It focuses on ten broad strategic moves to make our health system more unitary, monolithic and efficient, but it doesn’t really amount to a plan for delivering the specific changes sought by the Oireachtas Committee. The Plan is sketchy on how Sláintecare will actually achieve its ten-year ambition with no activities planned beyond 2021 . It depends on a major renegotiation of work practices and pay for hospital consultants amongst others. This in itself could be expected to take five years, judging by reactions to the report and the plan. It is easy to see that Slaintecare is likely to go off-track.

There is a more practical step that could immediately enhance our health system. I call it ‘Sláintecare Express’, because it would deliver the main benefit of Sláintecare, but much more quickly. It works as follows: we quite simply give uninsured people in Ireland access to the beds in private hospitals, with the cost covered by the government through tax or a compulsory insurance. For around 600 million euros per year we could pay for an additional 100,000 procedures to be carried out on public patients in the private hospitals. This would be adequate to clear waiting lists and keep them clear. The €600m works out at a cost of about 280 euros per year per person in the workforce (based on figures from the Health Insurance Authority  and statistics from Private Hospitals Association) . This is a tiny fraction of the Slaintecare proposals which would have yearly costs of €2.8 billion euros per year.

Making private hospital beds available to public patients would give quick relief on surgical waiting lists. But the real long-term benefit is that this would allow us to restructure our acute hospital system. The beds in private hospitals could be used for the so-called ‘routine’ elective procedures (things like endoscopies, hip replacements, cardiac procedures and scans), leaving the public hospitals with space free to focus on emergencies and the most difficult cases. Private hospitals and consultants working there would be paid on a per-procedure basis, just as the are today. Private hospitals are not tied into the restrictions of the HSE HR and pay system and so would be able to recruit more flexibly.

Would this solve all our health problems? Certainly not. Other solutions are needed to solve issues around mental health, social care, primary care (access to GPs and related facilities) and paying for drugs. But this would immediately put us on a path to address our most acute problem, getting people off waiting lists and into operating theatres for life-enhancing elective procedures, at a relatively low cost. It would also free up space in our busiest acute hospitals.

 

A Cold House: post-Brexit Northern Ireland

The biggest, most significant practical consequence of Brexit for Ireland has not really been talked about to date. That is, that for the first time, the London government will not be in a position to continue to underwrite the Northern Ireland economy. Northern Ireland is headed for a massive economic shock.

It works like this. Northern Ireland is deeply dependent on fiscal transfers (essentially payments of money) from the UK, in particular the financial service driven economies of the British south-east. There is a net transfer of £10 billion per year (£200 million per week) from the rest of the UK to Northern Ireland. NI has the highest public expenditure to person in the UK, and is highly dependent on public sector employment, much more than any other UK region. The Guardian put it in quite a stark graph:

The UK economy is in decline as a result of Brexit. Growth is slow and debt is high. How bad it gets will depend on how Brexit hits. Some say there is a full-on recession coming.

This will hit tax revenues in the UK. Getting more particular,  the IMF is talking about a major reduction in sales of financial services from the UK to the European Union. Financial services alone is said to account for 11 percent of UK government tax receipts. The loss of revenues to the City will be in the tens of billions of euros.  And financial services is clearly not the only sector that will be effected. Jaguar is moving operations from the UK to Slovakia, for example.

Even a few percentage points reduction in the UK tax take will have massive knock-on consequences for Northern Ireland.

London and Great Britain are going to face big economic and social problems of their own. Even the Brexit optimists agree there will be a period of upheaval. Britain is already in a major austerity program. It can’t take much more without severe political and social consequences. Northern Ireland will not be a priority if there is widespread disaffection (and maybe even riots) on the mainland.

As UK tax receipts fall, it is hard to see the axe not falling on Northern Ireland expenditure. If Northern Ireland’s subsidy per person is cut back so that it was in line with where the next biggest beneficiary is today (Wales) that would be a 20 percent cut, or a £40 million a week reduction to welfare, public employment and services like education and health. That would be a massive impact, far bigger than any benefits the DUP has gotten from its supply-and-confidence arrangement with the Conservative government.

Could Northern Ireland’s fragile political, economic and social framework really bear such a shock? Could it bear it in tandem with a cut in cross-border trade? What will all these unemployed Irish passport holders do, or where will they go? The impact of Brexit on Northern Ireland (and by extension Ireland) will be far more all-pervading than changes at the border.

‘Completion payment’ contracts – a structure to get Irish housing moving.

It’s interesting to dissect the Eamon Ryan’s article on the need for a new model for housing. Firstly, there is a sense of desperation, that we need to do something different. Secondly, Eamon and the Green Party recognises that social housing as we understand it is not the whole answer. The shortage of housing is not just something that is effecting the least well off. It effects people with pretty good incomes too. And thirdly, it recognises that there is something very broken about our whole housing market. Nothing near enough new accommodation is coming on-stream.

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Brexit leverage

The UK government is finding that it has very little leverage in negotiations with the EU over Brexit. What was Her Majesty’s Government’s plan, if there ever was one?

In retrospect, I think Teresa May and her cabinet were hoping that Ireland would be their leverage. Europe would accept a ‘back door’ for Britain into the Single Market in order to avoid startling the Northern Ireland horses.

This could never really work, for reasons that basically have nothing to do with the political situation in Ireland. European agricultural lobbies could never allow allow such a gaping hole in the border of the single market. And Ireland is just not anything like an important enough issue in the EU, population and votes-wise.

Having the DUP supporting Teresa May’s government made this ill-conceived idea completely impossible. The UK government was no longer a neutral actor, trying to get the best outcome for Northern Ireland. It now had a clearly partisan mission. This has made it impossible for the UK to blame the EU for the problems Brexit is causing in Ireland. The EU could now place the blame firmly at the feet of the British.

Three things that definitely won’t fix Dublin’s housing crisis.

The reason prices for accommodation inDublin are so high is very simple. here are more or less the same number of homes as there were ten years ago, but there are 10 percent more people. At the same time, the economy has moved from recession to growth. There is just more money around. As a result, prices go up.

The theory of supply and demand is that new demand should now come on-stream in response to the increase in prices. But that hasn’t happened. The reasons for this are many and they need to be addressed. But there are three things that won’t help.

1. Capping the price of accommodation. Capping the price of accommodation with some sort of rent freeze provides welcome relief to existing renters, but it doesn’t really help much for people who don’t have accommodation or who have to move because their family is growing. Accommodation availability has reached a record low. The fact that the rent is capped is not much good to you if you cannot find a place to rent.

2. Increasing standards, implementing regulations for landlords. There are many good reasons to increase standards and implement new regulations. An example would be a deposit protection scheme. It provides a benefit for tenants, certainly, but it also adds a new cost and a new bureaucratic barrier. In general, regulations make it less attractive to landlords to be in the market. This means that there will be less rental accommodation. (It might result in more property to be available to buy, but that is not much good to you if you need to rent.)

3. Increasing building regulations and planning requirements. Building regulations today are a lot higher than they were 10 years ago. There are sound environmental reasons to increase standards, but ultimately, this means that houses are more expensive to build and take longer to build. Take the case of the iRES development in Rockbrook. This was originally supposed to be 456 homes, but an analyst reckons that this will now be reduced by 40 homes. There will also be a couple of months delay for a new application to be submitted.

Diplomats: annoying but cheap.

People have always had high expectations of America for sure. And there is jealousy too. A lot of those expectations arise from the very good work the State Department has done around the world. It is a great pity to see that Tillerson plans to largely dismantle it. Diplomats are very annoying to politicians with their cosmopolitan lifestyles and expense accounts but they are cheap and effective compared to military action.

The forty-eight percent

The forty-eight percent in the UK have sufficient common cause that they could galvanize behind one political party in the forthcoming election. If that were to happen, the first-past-the-post system would not be kind to the two major parties.

Brits who opposed Brexit, who are reticent about it, or want a ‘soft’ brexit are now being asked to galvanise around a national platform. Their demand that the next government gets and takes the best deal for Britain is very attractive, and very hard to argue with.

Brexit is a story of disaffection. 52 percent of British voters are fundamentally unhappy with their lives or how they are governed. There are important reasons why this is the case.

But for now, these disaffected people are the people the government is depending on for support. This is obviously new territory for the Tory party. It is more familiar territory for Labour and Jeremy Corbyn in particular, but he has never had to compete with the Tories for these votes. I think this will get very scrappy. The traditional parties will show a very dark side of themselves. And can you really build a national consensus on the basis of disaffection alone?

And make no mistake, this is an election about Brexit and disaffection. There is no other issue on the table. Theresa May has said as much. It doesn’t really matter who the next prime minister is. What matters is what Britain’s new relationship with Europe will be, and how it will bring its own people in from the cold.

We can’t wait any longer: get homebuilding going in Ireland

Things are pretty bad. Two public servants are moving to Abu Dhabi, so they can afford to buy a home in Dublin. We spend tens of thousands of euros to educate and train people, then they have to go to a tax haven to be able to afford to even live in our country.

We have to provide housing, and quite a lot of it, and fast. We are not building anywhere near enough. The basic problem we face is that when all costs are taken into account, new homes are too expensive to provide without government support. It is cheaper to buy a house (even at high current prices) than to build a house. There are a number of reasons for this and we need to address them for sure.

But we also need to get homes built, starting now. We need to be thinking in terms of hundreds of thousands of new homes over the next few years.

On the sidelines, there is an ideological war going on about house-building. Should the houses be built by the private sector, or by the state? The problem is that nobody at all is building houses at the moment at any scale. It is unaffordable for everybody.

There is one good thing however: the country is awash with young people ready and willing to buy a house, and with a strong economy, many of them are creditworthy and have deposits ready.

Here is what I would do:

Firstly, a straight incentive – €15,000 for every bedroom in a new build completed in accordance with building regulations and occupied by 31 December 2019 in the case of a house and 31 December 2020 in the case of an apartment. (There would also have to be conditions to avoid subsidising houses already underway). The figure would go up to €20,000 where more than 100 units are provided on the same site.

Why €15,000? Well, because for a three-bed semi, that’s enough to cover the shortfall between the price of an existing house and a new house in Dublin. The cost overall for 25,000 homes would be over a billion euros, sure, but all of that would be recovered through VAT and PAYE from the increased economic activity.

Every year after 2019, the amount of the incentive could be reduced if it is no longer required.

Secondly a finance structure is needed. Prospective home purchasers should be encouraged to put down a deposit, now, on their future home. Rather than putting the deposit with the builder, they should place it with a government scheme which would provide a guarantee for the prospective purchaser that their deposit was safe. The government could then loan the value of the deposit to the developer, secured on the land.

The government would also guarantee to purchase the property if the original purchaser ‘fell through’ and didn’t go ahead with the purchase, and if a replacement purchaser couldn’t be found. If it did exercise this option, the government would get a small discount (say 7.5 percent).

But if the economy keeps storming on, that is unlikely to happen. And even if the economy weakens and the government has to buy the houses, the country is still going to need these new homes for the long-term. These will be modern, high-quality houses. The government can rent them for the short term, and rent them later on.

Now the builder has a rock-solid, guaranteed purchaser, rain, hail or shine. With this guarantee, the builder can go to the bank and borrow the money they need to actually build the complex.

This scheme is really designed with private housing built by private developers in mind. But it can work for local authorities too. They can use this funding mechanism to build social housing, or they can use it to build houses for resale.

It can also potentially be used by people who want to buy property to let it, though the structure would need to be tailored to avoid abuse.

Is this the full solution? No. We also need to address the problem of land costs. And to do that, we may ultimately need to replan our transport networks to open up new land. We may need more flexibility in the planning laws. But it provides for immediate action and will mobilise the talent and capital we have available already.

Combined with a plan to utilise vacant housing in the most sought after areas of the country, and perhaps some form of site value tax to incentivise use of vacant or underused land, this would put us well on the way to building hundreds of thousands of homes for our growing population.

Where soft power comes from.

The question came up in a discussion with RP Eddy on Facebook, why does Donald Trump, a master of brand and marketing if there ever was one, is so against building the international brand of the US, through ‘soft power’ of diplomacy and international relations.

The answer, I think, is that Donald Trump believes that America’s ‘soft power’ (its influence and ability to get things done where others can’t) derives from its latent ‘hard power’ (the fact that America keeps a powerful military on alert, worldwide). In fact, this is not true, and the reason for America’s influence is that the US is basically trustworthy in its international dealings and follows through on things it says it will do (it is far from completely trustworthy, but maybe 60 or 70 percent of the time, it carries through which is still a lot better than the international batting average. This is not because of moral superiority, by the way, but that the US has many resources to draw on, and considers its options and its actions quite carefully.)

If Trump, as president, believes American soft power mainly derives from military power, then as a new president, he has to demonstrate that power somewhere to prove that he is ready to use it.