A brave new dawn of Irish healthcare is imminent but the definitive model for reform and operation has yet to be finalised. Maev-Ann Wren reports
Dedicated they may be but the staff of the health service are also suspicious, rumour mongering and paranoid.
They have an excuse. They are about to go through unparalleled change, driven by an organisation, the interim Health Service Executive (HSE), whose board has five members with expertise in business or finance, one lawyer, two members with experience of health service administration, and only one nurse and one doctor, both of whom hold academic posts.
Maureen Gaffney, psychologist and chair of the National Economic and Social Forum, is perhaps the vox populi on the board.
Rumours thrive on uncertainty and it is easier to list what is unknown about the HSE than what is known.
Unknown: where it will be located, who will head it, what its powers will be, how it will relate to the Department of Health, where it will draw the boundaries for four new administrative regions, and how it will encompass the many health and social care agencies which it must absorb?
This new body will centralise the administration of the health service for the first time in the history of this State but in one of the absurdities perpetrated by the current Government, the HSE is itself to be decentralised. Seven months before it formally takes over the health service, not its board nor its small staff nor the applicants for its chief executive post knows where the Government will locate it.
The HSE will assume responsibility for a service employing some 100,000 people, accounting for 25 per cent of Government spending and of intimate concern to every citizen. Run by 11 health boards with elected members from local councils and health professions, the service has been a battleground divided into myriad camps - consultants, GPs, care workers, nurses, health board administrators, Department of Health officials, competing hospital managements. It tolerates quasi-independent empires yet funds them from the Exchequer - voluntary hospitals, the Byzantine world of charitable organisations.
In the brave new dawn of 2005, a single entity headed by a single legally accountable individual (the HSE's chief executive) will run health and its associated social services.
The HSE will plan how funds are spent, allocate them, insist that independent empires receive prior approval before they spend State funds, decide which hospitals undertake which functions, implement the Hanly Report.
Insofar as it is accountable to the people for its actions, it will be at arm's length. Its chairman will answer to the Minister for Health, who appoints and can remove him and his board. The Department of Health must agree its annual service plans. Local representatives will be able to meet its executives but their veto is gone.
Correction - this appears to be how the HSE will operate. Any of these statements may prove untrue because so much remains undecided.
There is "no definitive model" to determine how the HSE will operate, explains Tom Ward, author of a guide for members of State boards. So it is critical that the legislation empowering the HSE is clear on areas of authority and reporting arrangements.
"Otherwise the people involved will end up having to second-guess the wishes of the Minister and the civil servants."
How to reconcile the tension between empowering the HSE and ensuring democratic accountability?
Kevin Kelly, executive chairman of the interim HSE, observes that "while we must be accountable we have to be given the authority to empower people right through the system to deliver".
How does that work in practice?
"This is the critical power struggle. Does the Department hand over power to an entity to go and implement Hanly without reference to the political system? That has to be clarified in the legislation. It has to define the Department's role and the HSE's role," stresses an experienced health board administrator.
In an internal document seen by The Irish Times and dated last February, the Department of Finance expressed "major concerns" about "lack of clarity" and "confusion" in Department of Health thinking about "the policy-executive" split. Although the HSE was envisaged as an executive body with the Department of Health retaining responsibility for policy, Health had recommended that the National Hospitals Office of the HSE "should oversee the public-private mix". This, Finance dissented, was "clearly a high level policy issue" and "not a matter for one pillar of the executive".
The hand of Finance has seldom lain so heavily on the Department of Health. On the national steering committee overseeing the health reforms and chaired by Kevin Kelly, sits David Doyle, second secretary general in Finance, and Dermot McCarthy, secretary general to the Government, alongside Michael Kelly, secretary general of the Department of Health. Subtle struggles are going on to determine the shape of the health service.
Finance and the McCreevy/Harney coterie in the Cabinet appear to believe that administrative reform can save money, while the Minister for Health becomes ever more outspoken about the need to raise tax to fund the service. It is no secret that there have been strains in relations between the Department of Health and the interim board, one of whose members, Prof Niamh Brennan, has publicly stated that health board chief executives and Department of Health officials lack the skills to bring health service change.
Labour Party deputy leader Liz McManus has questioned whether it is appropriate for the executive chairman to come from outside the health sector.
"Kevin Kelly is a banker. Look at what's been happening in banks in recent days. Why should we have faith in giving the health services to some one who has no experience of the health service?"
Before his banking career, Kelly worked as an accountant, spent six years in the 1980s as the court-appointed administrator of the PMPA, the State's largest motor insurer, and later moved to the food industry. Of his period in PMPA he observes that although he had never worked in insurance before, he had achieved results "by working with the people in the company who were deeply committed to making sure it survived".
Self-effacing and soft-spoken, widely respected in his PMPA role, now defending a subsequent employer AIB (see panel), at 62 years of age, Kelly's every sparing word is pored over by health sector employees and watchers. Under Kelly, the interim team of staff seconded from within the service is analysing "patient journeys", how patients experience the system.
Three tenets must govern reform, Kelly says: "To improve life for patients and clients; create a more productive and better working environment for staff; and deliver value for money for the Government."
Before the Joint Oireachtas Committee on Health last April, Kelly provided some comfort for sceptics fearful that the HSE might have a narrow view of its role.
He described reform of primary care as "more significant" than acute care and in response to questioning from Liz McManus about "apartheid" between public and private patients, expressed agreement "with the Deputy's sentiments". He had earlier outlined that the HSE intended to be represented on the team renegotiating the consultants' contract.
Advocates for a broader view of healthcare remain anxious. Should not the HSE's goal be to improve health rather than care, a much wider dispensation which could empower its executives to challenge the inequality and deprivation which feed ill-health? How will it give voice to the disappearing public health organisations which have played that role?
Why not a statutory mandate to promote and protect health, reduce health inequalities and ensure equity of access to care?
It's early days in a huge experiment in Irish Government.