HEAD2HEAD: Is the HSE working better than the old health boards?

YES says Professor Brendan Drumm, who maintains the HSE is tackling inconsistencies, delivering greater accountability and improving…

YESsays Professor Brendan Drumm,who maintains the HSE is tackling inconsistencies, delivering greater accountability and improving services.  NOsays Kevin Callinan,who believes that the rush to create the HSE has created confusion and demoralisation.

In 2005 the HSE took over from the 17 separate health boards and agencies that were responsible for providing the country's health and social care services. These boards and agencies had many different work practices, financial and staff management systems, facilities and priorities and, as a result, provided varying levels of service and results for patients and clients. While it is clearly unrealistic to expect that an integrated world-class health service could be fashioned from this highly complex and unconnected structure within two years, significant progress has been made and the enormous benefits of the HSE's unified approach are evident.

During January, the HSE treated 14 per cent more outpatients, 5 per cent more inpatients and carried out 8 per cent more day procedures than last year. The numbers waiting for admission from emergency departments have been reduced by up to 60 per cent, even though the number of people attending is increasing. An independent survey found that almost four out of five are satisfied with the service. Ninety per cent of people can now see a GP at night and at weekends. In north Dublin, for example, there are five fully-equipped treatment centres open every night and at weekends to provide urgent GP care, with virtually no waiting time. The service visits people at home if they are too ill to travel. Nationally almost 20,000 people a week use this service.

Five hundred primary care teams are being set up across the country to provide up to 90 per cent of the health and social care people will ever need from within their own communities, such as GP services, occupational therapy, physiotherapy, social work and so on. In addition to providing more services, more quickly, the HSE has met its budget two years in a row and its employment numbers are under control. This is a big change from the previous era of regular financial over-runs.

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As a national purchaser, the HSE is making additional savings for taxpayers. In areas such as pharmaceuticals, ambulances and insurance it will save more than €300 million over the next five years and expects further significant savings in areas such as legal services and property management. In the area of elder care, last year 5,400 more people received home care packages, which included public health nursing, home help, physiotherapy and occupational therapy, so they could stay in their own homes. We also provided long stay care for an additional 1,000 people and will provide another 800 places this year.

The HSE's unified approach has enabled these benefits to be delivered quickly and consistently across the country.

We are entering a new era in health and social care. Consistent measurement, accountability and control are now integral to the way we do business.

With this approach we can now see the parts of the health system that are delivering much better service, but receiving the same or less funding, than others. For example in some parts of the country, people stay in hospital longer for the same procedure than they do in others. Those who are committed to high performance welcome this level of scrutiny while those eager to maintain outdated practices resist it.

Our experience in addressing the difficulties in emergency departments proves that significant improvements do not happen by simply pouring more money on a problem. Sometimes this can be counterproductive and perpetuate bad practices. Funding must build on our strengths and starve inefficiency.

The HSE's greatest impact stems from its ability to make key decisions that are driven solely by what patients, clients and their families need. Ironically this is where we have experienced some of the greatest criticism. These include, for example, the decision to build the first single national specialist children's hospital. For decades, this decision had been side stepped. This project is now proceeding and we will have a world class children's hospital. It took the advent of the HSE to begin reconfiguring services in the north east region where we will have a new regional hospital supported by local hospitals, delivering high quality local services, and up to 40 primary care teams.

Past attempts to reconfigure many parts of the system to provide better and safer services have stalled due to conflicting interests. Creating a world-class health service, that is financially sustainable, will require some tough decisions for staff and the public. We cannot insist on doing things as they have been done in the past and at the same time demand that things change quickly. We cannot have it both ways. Thanks to the tremendous commitment and efforts of thousands of staff who are embracing change, many services have improved and will continue to get better. All of us who work for the health service must accept that our first and foremost responsibility is to be fully accountable to the public and this also requires significant change. Our four-year Transformation Programme will enable us achieve our ambition which is to provide easy access to services the public has confidence in and staff are proud to provide.

Prof Brendan Drumm is chief executive officer of the HSE
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NOThere are a lot of good things happening in our public health services and HSE staff are working hard to hold the service together and improve it. But the HSE has, predictably, become one of the barriers to real reform. I say "predictably" because it was predicted. In the weeks preceding the January 2005 abolition of the health boards, IMPACT was inundated with concerns from managers and clinicians about the readiness of the HSE to run a €14 billion-a-year "life or death" service with over 100,000 staff.

Most people accepted that the old health board system was faulty (although in hindsight, perhaps it wasn't as bad as all that). But the Government had convinced itself - and most media commentators - that getting rid of the boards would, immediately and of itself, solve most of the problems. It was an extraordinary situation where the people who use, deliver, and pay for health services through their taxes, were asked to believe that the only important thing was to establish the HSE and everything else would fall into place.

It was soon obvious that the HSE, and its growing band of expensive external advisors, had little understanding of how health services were managed, administered and delivered on the ground. No wonder. Neither they nor the Government attempted to ask the experienced people who did know, and who were expected to operate the new system. In the interests of accountability, service continuity and patient care - let alone the sanity of health workers - the trade unions called for the changes to be postponed until the practical details of service delivery had been worked out.

But a Government determined to meet its own political deadline drove through its rushed decision. Most of us who operate and use public health services have experienced the confusion and creeping demoralisation that followed.

It was not "all right on the night" and, unless there's a significant change of tack, it won't be all right. Health workers have shown themselves to be open to change - indeed they have been vocal advocates for real reform. Yet every single group of staff has expressed growing dissatisfaction with the way change is now being handled. There is a growing unease among hospital-based and community health professionals about the direction that health service delivery is taking.

There's dismay that costly and unaccountable external consultants - who know little and care less about public health provision - have been elevated to guru-status while experienced health professionals and managers are routinely ignored and sidelined. Far from speeding up service improvements, this has slowed the pace of reorganisation. If anything is to be salvaged from the administrative reforms, the HSE must begin to value the skills, experience and commitment of staff. And soon.

On the face of it, many of the frustrations I hear from staff support the caricature of top HSE management as bungling fools. I'm thinking of the community social worker who can't get a mobile phone or the manager who can't sanction maternity cover for a secretary without permission from Dublin.

But I don't buy this view. The real problems are rooted in Government decisions. The decision to hand total control to the HSE before it was ready (remember, it didn't even have a permanent CEO for the first eight months of its existence). The decision to cede budgetary control to an ill-prepared HSE from day one, in an attempt to distance Government from the shortcomings caused by decades of under funding and political timidity.

And, increasingly, the decision to rush through privatisation on the back of people's growing frustrations at the structures devised and implemented by Government itself just a couple of years ago.

The "arms-length" HSE helps politicians to propagate the phoney idea that they've done their bit by increasing spending, but others have failed to deliver. This approach gives comfort to those who wrongly say the public service is incapable of reform and that privatisation is the only solution.

And, while energy and effort is diverted into administrative changes that bring few benefits to service users, a weary public is being fed more outsourcing and privatisation, which seems to have become the main plank of Government health policy. It's an agenda that's likely to diminish service quality and widen the gap between the two tiers in our health system.

The Government's acceptance of ICTU's suggestion of a new partnership-based forum, involving all the appropriate unions, management and government, is welcome - not least because it brings elected politicians firmly back into the health reform frame. The unions instigated this initiative knowing that it would put the spotlight on the need to change certain working practices. We're willing and able to do that, so long as Government and the HSE are prepared to set aside some of their preconceived ideas and change tack. That is badly needed if we are to deliver a truly fair and high quality health system.

Kevin Callinan is national secretary for health and welfare at IMPACT trade union

Last week, we asked "Should alternative medicine be integrated into the health system?" Here is an edited selection of your comments

Yes: Alternative medicines such as natural, herbal medicines are very effective in treating many diseases. They are known to have no side-effects and are also less expensive. Many countries are successfully using alternative medicines in practice. I wonder why we are restricting ourselves to only one stream of medication. We should find all possible ways to treat suffering people, avoid queuing delays in hospitals. - Pushkar, Ireland

No: Pushkar should note that herbal medicines are often potent, do have side-effects and can dangerously interact with other medications. Having read Ruth Cloherty's article I consulted the website of the organisation she is referenced as directing. Much on it would concern me, but consider this one example. She offers a diploma in Clinical Iridology where this is claimed as an "invaluable tool (that) will help you to form a diagnosis" . . . Iridology is a nonsense that can diagnose nothing and has been systematically discredited. The course lasts five weekends over six months, costs €1,600 and releases "graduates" into society deluded that they can diagnose. This kind of reprehensible activity hardly lends credence or confidence to Ms Cloherty's plea that alternative practitioners can in any sense complement a scientifically-driven, evidence-based approach to health and medicine. - Paul O'Donoghue, Ireland

Yes: Conventional medicine looks at disease from a very narrow perspective. They believe symptoms are the disease itself rather than the body's expression of a disease. How often have people become sick after a shock/grief/change in weather and yet the symptoms are treated conventionally by pumping the patient with drugs/antibiotics! It's time we had a comprehensive choice in the type of healing we want, whether it be spiritual, energetic, chemical etc . . . It's time we looked at people individually. Find out their story, get the trigger point for their change in health, look at trends in their case history. - Mags Fitzgerald, Ireland

No: I couldn't agree more with Dr Brian Hughes's assessment of the need to keep alternative medicine (ie medicine that doesn't work but looks as if it does) out of our mainstream health services. We have worked for years to develop a health service committed to evidence-based practice. Alternative medicine seeks to have us embrace treatments on the basis of anecdote and testimonial. - Mike, Ireland

Yes: Alternative therapies, especially non-intrusive forms, should definitely be integrated into mainstream medicine in Ireland. I have witnessed first-hand here in the USA the beneficial effects of reiki on cancer patients (counteracting side-effects of chemo), and on diabetics' blood sugar levels. - Wendy Plumley, United States

No: It's good to finally see this debate. The media have allowed the alternative medicine industry to propagate false claims and squeeze money from an uninformed public. The Irish Times has been just as uncritical as every other media outlet. A recent Health Supplement printed without challenge the ridiculous claim that reiki is explained by quantum mechanics. Genuine science is unfortunately confined to a single weekly page. Alternative medicine is the greatest health rip-off in this country and yet The Irish Times is not covering it. - David H, Ireland

Yes: I continually use alternative medication. I got a serious infection some years ago. Only for alternative medicine I would not have cured it. I just hope that our health system allows this scheme to go through. - Margaret McGrath, Ireland

No: Integrating "complementary" and "alternative" medicine into our health system would be like integrating intelligent design into our education system. - Sean, Ireland

Yes: I have experienced the success of chiropractics. I had severe lower back pain and that has been a thing of the past. I know also that I have had no need of a doctor that thinks pills are the first answer. As I learned from chiropractics, pain is your body telling you there is something wrong. - David, US

Head2Head is edited by Fintan O'Toole

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