A central Health Service Executive should take over the day-to-day running of the State's health service, according to the Prospectus report.
Under it there should be a National Hospitals Office, to take responsibility for the running of all publicly funded hospitals, and four regional management structures, supported by local health offices. These new structures will replace the State's existing 11 health boards.
The report said the Department of Health should also be restructured, and it should concentrate more on policy than the day-to-day running of the health service.
Furthermore, it recommended a reduction in the number of stand-alone health service agencies, from 58 to 27.
Apart from the abolition of health boards, including the Eastern Regional Health Authority, it said the Hospital Trust Board and the Board for the Employment of the Blind should be disbanded.
Its recommendations also mean that agencies such as the Health Service Employers' Agency (HSEA), Comhairle na nOspidéal, the Office for Health Management, and the National Breast Screening Board will no longer exist in their present format. The functions of these and several other agencies, it said, should be subsumed into the new Health Service Executive.
The report said that it was "striking" that of the 58 agencies included in the audit, almost half had been established in the past 10 years. "This is a doubling of the number of agencies established in the preceding 45 years," it said.
Their establishment had often been "a system response to a particular crisis or pressing public concern" and resulted in duplication and "a lack of pooling of experience and know-how". They had been established "as a part-solution rather than a more radical full solution" to problems.
"Most critically, it has led to an almost unmanageable mix of agenda-setting institutions with a strong individual with a strong individual focus but often lacking a broad policy context," it added.
Apart from fragmented structures, the audit found that boundaries of accountability were not always clearly defined in the health service. It was unclear, for example, where formal accountability for the levels of spending under the General Medical Service (GMS) or medical card scheme lay, it said.
Furthermore, it said, nobody was monitoring the quality of care provided by health boards and there was inadequate evaluation of the performance of individual health agencies.
It said it was essential that clinicians be "within the direct accountability line".
Referring to current structures, it said tensions between local representation, decision-making and the delivery of national and regional strategic objectives were hindering decision-making.
"Currently the health boards, the ERHA and the area health boards operate under a legislative requirement that public representation on the boards shall exceed the total number of other members on the board. This ensures that elected representatives form the board majority grouping and that all areas covered by the board are adequately represented through a formal democratic process. However, the negative effects of this arrangement include:
Predominance of local area concerns over regional interests.
Competition between representatives on the basis of locality or professional background rather than objective need.
Reluctance to accept evidence-based information or recommendation where it is locally unpopular, e.g., location of acute services.
Focus on operational and short-term issues over strategic issues.
Furthermore, it called for the setting up of a National Shared Services Centre and the strengthening of quality assurance and information through the establishment of a Health Information and Quality Authority.
In addition, it urged that mechanisms be developed to increase consumer involvement in decision-making and service delivery.
It said there was a need to quantify more clearly the outcomes anticipated from resources put into the service.
"There has been considerable debate about the impact of the increasing numbers of managers and administrators in the health system, on the level and quality of services. There is a perception that despite additional management resources the management capability of the system has not improved.
"While this issue was not central to the audit it emerged as a recurring theme during our high-level consultation. Senior management in the health system have repeatedly pointed out that the over 70 per cent of the new staff approved since 1999 and categorised as clerical/administrative staff, are in fact involved in front-line delivery. This serves to highlight the point that simply adding more people to the existing organisation may not in itself solve the difficulties presenting. Measures need to be taken to ensure maximum value from additional resources."
The purpose of the audit was to devise a plan to ensure clear lines of accountability between each part of the system and remove overlaps or duplications between organisations.
It said the transfer of executive functions from the Department of Health to the Health Service Executive will clearly separate the policy from the executive role in the health system.
"This will allow both functions to operate more effectively. Confusion around these functions has led to gaps in critical policy areas and to blurring around executive responsibility. All too often those gaps result in the Department being pulled into fire-fighting or operational issues."
It warned, however, that the challenges associated with undertaking the large-scale reforms recommended were considerable. "Sustained leadership from the highest levels and co-ordinated effort from all agencies involved will be required to effect the changes required," it said.