No major industry with a workforce of almost 100,000 would contemplate deep structural changes without a budget specifically earmarked for the process itself – apart from the HSE
MINISTER FOR Health James Reilly has brought forward another reforming Health Bill as he continues the road to achieving his overarching aim of “money follows the patient”. But with a projected health budget deficit of €500 million this year, will the latest reforms have any effect on imminent cuts to frontline services?
The stated aim of the Bill is to: make the Health Service Executive (HSE) more directly accountable to the Minister for Health; and to help prepare service delivery for the next phase of the health reform programme.
The biggest change is to create a directorate system with a Director General and directors of six specific areas. Significantly the legislation allows the Minister to increase the number of directors – a move that suggests some fluidity will be part of the imminent changes.
There is already a division of responsibilities at the head of the HSE. It’s not entirely clear from the Minister’s announcement how the existing structures will mesh with the new ones (see panel).
We know one national director, Dr Barry White, who heads up Clinical Strategy and Clinical Programmes, has already moved under the umbrella of the Department of Health. The National Cancer Control Programme is also heading in the same direction. Presumably, essential back-office divisions such as human resources, finance and communications will continue to function under their present heads. But what has yet to be spelled out is how the new and old will knit together.
There may be some clues hidden in the Minister’s statement which said “the Directorate will be accountable to the Minister for the performance of HSE functions – it will have to explain its decisions”.
Another indication of Dr Reilly’s wish to have more control of what is happening at the coalface comes further down the explanatory notes which observe that the new legislation “allows the Minister to issue directions to the HSE on the implementation of Ministerial and Government policies and objectives relating to HSE functions where the Minister believes that the HSE is not having sufficient regard to such objectives or policies in performing its functions”.
And there is a reference to establishing performance targets for the HSE in certain priority areas.
“For too long the treatment of patients in our health services has had to conform to the needs of the system,” said Dr Reilly at the announcement of the new legislation. “This new Directorate structure in the HSE will allow us to redesign the system to put the needs of the patient front and centre.”
Although a spokesman for the Minister has confirmed he had not based his new structure on any other health system, it shares some similarities with the National Health Service (NHS) in England. It too is in a major state of flux but has existing directorates in, among others, medicine, nursing, health improvement and protection and commissioning development.
It has the usual back-office directorates; the difference being that the NHS website makes it clear how the various boards and directorates relate to one another.
But as the NHS moves through a major change programme there is one glaring difference when compared with events here. It has set up a special transitional executive to manage the change process.
The NHS Transitional Executive Forum (NHS TEF) was established during the transition to “provide oversight of both NHS operational delivery and development of the NHS future system as part of the overall new governance arrangements for managing the total health and social care transition”. The plan is for the NHS TEF to cease to exist by the end of March 2013.
A lack of such defined planning for change has long been a weakness in the Irish health system. At no time since the new national strategy for health was published in 2001 have any of the many changes been visibly and accountably managed.
It’s a blind spot on the part of the Department of Health which has never seemed to appreciate the enormity or complexity of change management. No major industry with a workforce of almost 100,000 would ever contemplate changes of the magnitude the HSE has been through without a budget specifically earmarked for the process itself.
Ironically, the departing chief executive of the HSE, Cathal Magee, writing in the executive’s 2011 annual report, said it was notable that reform was costly and successful reform was best carried out in a stable environment to lead to sustainable platforms.
Structural change and managing the risk of such change in the current health services environment presented significant challenges, he said, adding that, “at a time of very considerable reductions in funding and resources, the risks associated with major structural change are multiplied”.
With insight like this, Mr Magee will be missed. Junior Minister for Health, Róisín Shortall, obviously appreciates his skills. The day he announced he was leaving the HSE, apart from acidly noting that the first she knew about it was from the media and not her senior minister, Ms Shortall said, “Cathal Magee’s departure is a significant blow to the health service and in this very challenging time of severe pressures, he will be badly missed.”
Another Magee observation from the annual report suggests that he “gets” the risks of so much change. “Governance needs to be at the heart of health sector reform. It is vitally important that as we move towards new operating models, that there is due diligence in the way we transition in order that patient safety is maintained,” he wrote. But he is out the door now, and as the HSE is dismantled, will not be replaced.
For patients, there is now a double jeopardy: the risk associated with structural change; and the risks inherent in trying to claw back in the region of €500 million between now and the end of December. Cuts made in a hurry inevitably hit frontline services for patients.
Earlier this month the Department of Health rejected HSE proposals to deal with the deficit by closing hospital beds and reducing elective treatments and operations.
Rather Secretary General Ambrose McLoughlin, in a letter to the HSE, noted elective activity was running ahead of that planned.
Pointing to management issues within the HSE’s primary care reimbursement service, he said, “We must seek to reduce the cost of each [medical] card, or at least control the cost of each card. The present rate of prescribing needs to be managed more cost-effectively.”
However much merit there is in refining prescribing practice, savings from this source will take a number of months to filter through. Unfortunately, in trying to cut a deficit of the magnitude it now faces, the department will eventually be forced to close beds and operating theatres. Secondary care costs much more than primary care per patient; high tech and expensive care will inevitably be cut in the absence of a supplementary health budget.
Sadly, the structural changes announced recently will have no effect on the immediate cuts in services patients can expect to see and feel. And cuts made in a hurry are potentially dangerous cuts that may threaten patient safety.
A visiting academic who is in Ireland on sabbatical offered the following view on structural change last week: “Structures are not the problem – you are tackling the wrong stuff. It’s your [health service] systems that need overhauling.” If he is right, then the reorganisation of the HSE, may, regrettably turn out to be “much ado about nothing”.
