ANALYSIS:This latest initiative may well be the Minister's last chance to effect real reform in the health service, writes Sara Burke.
MARY HARNEY rejects charges of a U-turn and "botched reform" of the Health Service Executive (HSE), while Brendan Drumm insists the proposed changes in management structures and devolution of powers to the regions does "not signal a change in direction".
However, the news that the health services are returning to regional structures and that the central pillars of the HSE are to be dismembered and amalgamated seems an extraordinary reversal of vital decisions made under Harney's leadership less than four years ago.
This volte face may be the Minister's last chance to effect reform in health.
Up until the end of 2004, 11 health boards provided healthcare services in Ireland, alongside a gamut of other health agencies and more than a dozen voluntary hospitals.
Everyone agreed that changes were needed: the politicians who sat on the health boards had too much power, there was inconsistency across regions, and hospital and health board budgets ran out of control every year.
Mary Harney became Minister for Health just four months before the HSE was set up, amalgamating the roles of more than 40 health agencies into a new, much-heralded unified structure. Ambitious to reform the health services, she rushed through the legislation to establish the HSE amidst warnings from staff, management and unions that there was not enough clarity on the new structures and roles. They wanted more detail on the biggest public sector reform in the history of the State.
The establishment of the unified health service in the form of the HSE was flawed from the outset. It was insufficiently planned, lacked effective leadership and suffered immediately from a huge loss of organisational knowledge when many of the former health board chief executives left. It became an increasingly centralised, unaccountable body.
Under its structures, doctors, nurses, and service managers who previously had autonomy over local decisions have to get clearance from a plethora of managers in Dublin for day-to-day decisions about minor service developments.
The HSE was established on January 1st, 2005, with two central service "pillars" - the National Hospitals Office, and Primary, Community and Continuing Care. Chief executive officer Brendan Drumm has championed the "Transformation Programme", intended to transform the health service so that patients experience a seamless service from GPs, hospitals and community care. No-one could disagree with such aspirations. But the structures that Drumm inherited, with the two pillars separating care between hospitals and the community, worked against them. Within a year of operation, HSE staff and their unions were talking openly about the difficulty in getting decisions made. There was growing criticism of the control and command culture operated from Dublin, and complaints that the excess of centralised management was stagnating key decisions on patient care.
HSE senior management was so busy "transforming" the service that the concerns identified by staff and patients were neither heard nor addressed.
A year ago, Drumm commissioned McKinsey management consultants to look at the appropriate organisational structure required for the HSE. The consultants have recommended the restructuring of management, the merging of the hospital and community pillars and the devolution of more local decision-making.
It took the cancer misdiagnoses of nine women in Portlaoise to make Harney write to the chairman of the HSE board asking him whether "the deficiencies identified in Portlaoise had wider application". Former Dublin city manager John Fitzgerald, who was appointed by the HSE board to examine the handling of the cancer misdiagnoses, found there were systemic failings in HSE management and governance.
In 2004, the new HSE was promised as a more integrated, effective and accountable health service. Three and a half years on, this clearly has not happened.
The 2001 health strategy promised "that no public patient will wait longer than three months for treatment following referral from an out-patient department by the end of 2004". Figures published in the National Treatment Purchase Fund's 2007 annual report last month showed there were still 21,470 patients waiting for more than three months, with 2,155 public patients waiting more than one year for surgery.
The Primary Care Strategy, published in 2001, promised 600 new teams across the country. By 2006, 10 teams were in place. The 2006 social partnership agreement Towards 2016 committed to introducing 100 primary care teams per annum. The HSE says 87 (not the 200 to 300 as promised) teams are now fully operational. A recent RTÉ Primetime Investigates programme on the HSE found that just 16 per cent of these 87 teams were fully operational.
Undertakings made by the HSE and the Minister in response to crises are consistently broken: targets set for waiting times in emergency departments have not been met; no nursing home is independently inspected; the mental health strategy A Vision for Change is not being implemented; communities see their local hospital services being "downgraded" without the enhancement of community services; wards are being closed and staff are not being replaced - yet HSE management insists there are no cutbacks in frontline services.
For the current restructuring to succeed the mistakes made in the establishment of the HSE must not be repeated. Promises should not be made that cannot be delivered. The change must be well planned and executed. There must be clear and simple structures, communication and lines of accountability that staff, management and members of the public can easily understand.
There needs to be strong leadership and clarity of roles between the Department of Health and the HSE. Staff and patients need to have trust in HSE management and the Minister. Frontline workers and local managers need to be involved in and responsible for decisions and budgets which affect their patients and services.
But the establishment of the HSE has been just the first of four key reforms driven by Mary Harney during her tenure in the Department of Health.
The second was the plan to co-locate private hospitals in the grounds of public hospitals. Announced in June 2005 as the solution to bed shortages in the public hospital system, Harney said co-location "will create new beds for public patients in the fastest and most cost-effective way in the next five years", promising an extra 1,000 beds by freeing up beds in public hospitals and replacing them with 1,000 co-located private beds. Three years on from its announcement, five (not the eight or 10 envisaged) co-located hospitals are in the pipeline, with planning permission granted for just one. Not a sod has been turned and there is not a chance of an additional co-located bed in place within the five-year timeframe.
Another major reform initiated by Harney was the Fair Deal. Announcing it in December 2006, she claimed "it will make residential nursing home care for older people accessible, affordable and anxiety-free". Under the Fair Deal anyone in need of nursing home care would pay 80 per cent of their disposable income towards costs and could be charged up to 15 per cent of the value of their home and assets after their death. Its introduction last January was delayed due to uncertainty over its legality, and the cutbacks announced by the Government this week brought final confirmation that there will be no Fair Deal in 2008.
Mary Harney's other much-publicised reform is the hospital consultants' contract. And while a deal seems imminent, Harney's claims that it will end the two-tier system are widely refuted.
Mary Harney's Midas touch is no more. She is a Minister without a party or, at best, a party without a following. She has been abandoned by her Government partners to single-handedly crack the chestnut that is health service reform.
It would seem that HSE restructuring is a last ditch attempt to salvage her only realised hallmark of health reform and the fiasco of her stewardship - the unaccountable, overly-bureaucratic, unresponsive HSE.
Sara Burke is a journalist and health policy analyst. sarabur@gmail.com