The HSE is still delivering too much of the wrong things

Many problems were inherited by the HSE and continue to affect service provision today

The Minister for Health, Simon Harris, wants to change the structure of the Health Service Executive (HSE). These changes will give back regional control to hospitals and community services. In fact, it sounds like a return to the old health board model.

This is a really bad idea. Yes, the HSE is not working well and needs reform, but structural changes will not solve the problems.

When the HSE was established in 2005 the problems it inherited from the old health boards were the same as they are now, if not worse. They are the same as were identified in a 1966 White Paper, "The Health Services and their Further Development." The problems are the same as were identified in 1945 by the then chief medical officer Dr James Deeny.

The White Paper noted that “health services must facilitate the care and treatment of patients in their own homes”, and “it must be a prime object of policy to ensure that there is no avoidable use or unnecessarily prolonged occupancy of acute hospital beds”.


Deeny noted that “existing services are largely curative” with little emphasis on prevention. More than 70 years later services are still largely curative.

Other problems that have been identified through surveys and hundreds of workshops over the last 40 years include: poor communication between managers and front-line workers; an “us and them” mentality; too many management layers; and unknown outcomes apart from cancer and cardiovascular disease. In addition public expectations are too high.


These problems were inherited by the HSE and continue to affect the provision of services to this day. The structural changes envisaged by the Minister will not make things any better.

The old regional health board model created additional problems. Each board did its own thing without reference to population health need. The choices about which services to develop were often based on whims, personal preferences or political pressure.

Some boards developed older people’s services, others funded mental health, and a few put resources into children’s health. For example, in 1978 the Western Health Board decided it would develop its prevention strategy and was the only board to employ properly qualified health education officers.

When the HSE was established some areas had enough, say, speech therapists and physiotherapists, while other areas had almost none. Giving back regional control will encourage local managers to indulge their whims. Politicians will be more likely to pressurise these managers.

The HSE was supposed to solve the problems, including the geographical unevenness of services. Services were supposed to be developed based on a population health approach. This means planning for the whole population of 4,757,976. A majority of people are well most of the time, and about one in eight wait for hospital services.

Kept well

A population health approach starts with health, not sickness, and means that the well population are kept well. The term encompasses planning for a living wage, educational attainment, and eliminating health inequalities. This did not happen. In fact, the concept of planning health services based on population need never got off the ground in the HSE A new department of population health was set up which quickly became defunct because of internal wrangling and resistance from professional power-bases.

A population health approach involves intensive efforts to promote health and prevent disease. In Europe only 3 per cent of healthcare expenditure is allocated to prevention, with some countries spending as little as 1 per cent. The HSE allocates just 1.6 per cent of its €14 billion budget on health and wellbeing.

Almost half the budget (€6 billion) is spent on acute hospitals, including the so-called voluntary hospitals, whose boards would prefer to just take the money and have nothing more to do with the HSE. Only 7 per cent of the HSE budget is spent on primary care.

Prescribed items

The HSE is trying hard. It is succeeding in several areas. There are now better outcomes for cancer care, cardiovascular disease and stroke treatment. But this is not good enough. The HSE is still delivering too much of the wrong things such as more than eight million prescribed items per year.

A paradigm or “world view” shift from illness to wellness is required, not structural changes. In fairness to the Minister, he recognises the need to progress the Healthy Ireland agenda and to change the model of care from illness to wellness. He intends to fully implement the Healthy Ireland: a Framework for Improved Health and Wellbeing.

How he will manage to do it is another story.