Few tears shed over move to abolish friendless HSE


ANALYSIS:When the executive is replaced, responsibility for the €13.7bn budget will again rest with the Department of Health, writes MARTIN WALL

THE HEALTH Service Executive is probably the most unloved organisation to emerge within the Irish public service. And under plans announced yesterday by Minister for Health James Reilly it will formally cease to exist in 2014 – less than a decade after it was established.

Originally, there was considerable merit to the concept that underpinned the HSE. A national organisation could move the health service away from the control of local vested interests that dominated under the regional health board system.

Former minister for health Mary Harney argued that rationalisation of breast cancer services into regional centres of excellence could never have been achieved under the health boards as local politics, both medical and party political, would not have allowed it.

However the implementation of the HSE project was highly questionable from the start.

The government of the day refused to put in place any measure for staff rationalisation – such as the voluntary redundancy scheme that eventually emerged in 2010 – when bringing together 11 different health boards. The government also agreed a deal with the trade unions guaranteeing terms and conditions for staff.

As the HSE came together there was widespread grade drift as the number of personnel in senior positions escalated.

While there were some successes, financial difficulties were never far away; a situation not helped by the organisation having more than 50 different financial systems.

There was also a distinct lack of openness and transparency. Meetings for the old health boards were held in public but the HSE board, appointed by Harney, met and made crucial decisions affecting thousands of people in private.

In the Dáil TDs lost the power to ask the minister parliamentary questions directly about local health issues. Such questions were passed to the HSE to answer. The answers, when they emerged, were not placed on the Dáil record.

The new system of health service administration announced by Reilly is a very different model.

While the HSE was always at arm’s length from the minister and Department of Health – a move which cynics at the time of its establishment considered to be deliberate to create a firebreak between the inevitable controversies in the health service and the political system – it is now to be centralised. The minister for health will have far more direct, hands-on authority in the future.

The executive is to be run by a system of directorates – each responsible for specific areas such as primary care, mental health, hospitals etc. Each will be headed by a director. The new directorate will be chaired by a director general who, in the first instance, will be appointed by the Minister for Health.

The Government has argued that on occasions in the past funds allocated to one area of the health service ended up being used for something else. The principle behind the new reforms is that there will be far greater clarity in tracking the budget.

The new legislation allows the Minister to issue directions to the HSE on the implementation of policies and objectives. The Minister will also be able to specify priorities which it must follow in preparing its service plan for the year.

However, crucially, responsibility for spending the €13.7 billion budget – the vote as it is known – is to be taken back from the HSE and given once again to the secretary general of the department.

Groups of hospitals are to be established as independent trusts. The HSE will be replaced by an integrated care agency.

However, the directorate system is only transitional in nature. It will remain in place for two or three years pending the Government’s ultimate move to a system of universal health insurance. Reilly said the old system had been “self-serving rather than patient centred” and that his reforms were aimed at addressing this complaint.

However, questions remain concerning how the proposed system will work in practice.

The Minister indicated that the directors would be appointed following a competition from within the health service.

However, section 16 A of the explanatory memorandum published yesterday stated that only existing Health Service Executive national directors will be considered for these positions – a development which, if true, will undoubtedly lead to accusations he is merely shuffling deckchairs.

There is also a general lack of clarity about how the new integrated care agency – with its separate purchaser and provider arrangements for healthcare – will operate in practice.

The most pressing questions remain about how the Government’s proposed system of universal health insurance will work in practice. Moreover, given that it will be mandatory, how much it will cost for individuals.

Earlier this year the Minister appointed a group to develop detailed proposals for the implementation of universal health insurance and it will not be until this reports that some of the key answers are likely to emerge.

Martin Wall is Industry Correspondent

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