Simon Harris’s announcement on Wednesday of the establishment of six new health regions is significant. It follows 26 months after the publication of Sláintecare, the final report of the Oireachtas Committee on the Future of Healthcare, which specified the need for “the establishment of regional bodies that will be accountable for implementing integrated care”.
This 2017 Sláintecare report recommendation was based on international evidence that, in order to provide integrated health and social care services with a focus on prevention, early intervention, care at the least complex level, as close as possible to people’s home, some form of autonomous regional structures were necessary to allocate resources and to ensure good governance and accountability. A “one budget, one system” approach.
The plan is that these new health regions will be allocated resources on the basis of population health needs
The 2017 Sláintecare report did not specify how many or where these regions should be, but stated the need for further work “to identify how alignment (of existing services) can be best achieved with minimal disruption to key structures”. This week’s announcements are the result of a public consultation as well as lots of technical work based on population data, by the HSE and the Department of Health, on how best to structure the new regions.
The plan is that these new health regions will be allocated resources on the basis of population health needs. In other words, regions with higher levels of sickness will to get more money and staff to meet people’s needs.
The new regional areas are not a retrograde step to the old health boards. They are very different animals. The old boards were funded directly by the Department of Finance via the Department of Health, with boards composed of elected representatives, ministerial nominees and health professionals, allowing for local fiefdoms not necessarily meeting local needs.
Fragmented
Then and now, funding of the vast majority of health and social services was fragmented, based on historical allocations, with a little more or less each year. Funding services based on population health needs is potentially a game-changer as it will allow funding and staff to respond to local issues such as deprivation, and the differing needs of rural and urban communities.
Central to the proposed regional resource allocation model will be the involvement of clinicians, especially from the public health profession, who are trained to plan, design and deliver preventive health policies and interventions. This, combined with devolved, accountable governance structures and sustainable mechanisms to meaningfully engage staff and residents, should enable the better planning and delivery of healthcare for the people of Ireland.
On Thursday, there were 59 people on trolleys in University Hospital Limerick. In theory the new integrated structures would enable health service leaders (clinicians and managers) in the mid-west free up a similar number of beds via faster access to home care packages, rehabilitation beds and other services, ultimately providing better care to whoever needs it.
In the long term, it incentivises the regions to invest in prevention and early intervention so that the vast majority of chronic care needs can be met in a community setting, often led by a nurse or an allied health professional, avoiding unnecessary (and expensive) hospital care.
Mistakes have been made in the past by restructuring without actually reforming, most notably in the formation of the HSE. It is much easier to draw lines and reorganise than to change the culture and ethos of the health system. And while line-drawing is important, it will have little effect unless time, attention and resources are applied to designing and introducing a system that meets the needs of the population.
Carefully implemented
In order for the new integrated health regions to work, they need to be carefully implemented. Their success will be hindered or helped by clarity on their respective roles and relationships with a lean, reformed national HSE centre and the Department of Health. And, crucially, the structural reforms need to take place alongside the myriad of other health system reforms detailed in the 2017 Sláintecare report.
There is a chronic shortage of doctors, but many other healthcare professionals are also needed to provide earlier, better, quality, timely care
The Sláintecare report outlined a €3 billion transition fund and the additional €380 million to €465 million required each year to provide universal access to care over a decade. Investment in e-health is central to delivering integrated care, yet we remain a laggard in terms of introducing electronic patient records and IT systems to deliver modern, effective healthcare. There is a chronic shortage of doctors, but many other healthcare professionals are also needed to provide earlier, better, quality, timely care. Critical to universal access is legislating for an entitlement to care, yet the Government remains silent on this matter. Donal de Buitléir and his independent review group have done their work examining the impact of removing private practice from public hospitals. This was due to be completed by September 2018 but it has not yet gone to Cabinet.
The new health regions, if well executed, can be pivotal to Irish health system reform, but they are not the cure-all. The thorny issues intrinsic to our current system of not having the volume or breadth of services to meet existing need, and inequality in access to care, will persist unless other Sláintecare reform measures are also pursued with courage and vision by our political leaders.
Dr Sara Burke is a research fellow in the Centre for Health Policy and Management, Trinity College Dublin. She co-ordinated the academic team which provided technical support to the Oireachtas Committee on the Future of Healthcare in 2017