Cliff Taylor: Setting up HSE does not look so clever now

There are two big domestic policy challenges facing the Government. It is not in direct control of either. In health, it is relying on the Health Service Executive, an organisation whose structures are back under the microscope after the cervical cancer scandal. And in housing, the Government is trying to push the local authorities and the private sector to get more built, an exercise akin to herding cats.

When your political skin depends on it, it must be a worry when you don't control the levers that actually make things happen – or don't make them happen. For the Ministers for Health and for Housing, Simon Harris and Eoghan Murphy, it provides a particular challenge. Even if they get over the hurdles of getting Government agreement to do something, and get the money to do it, they then face a third job of making sure it happens.

Agencies and local government – and a reliance on the private sector to deliver – are part of a complex democracy, of course. Sometimes they can be useful, politically. Since it came into operation in 2005, the HSE has taken a lot of the flak for deficiencies in the health service, providing something of a shield for the minister of the day. But diffused responsibility can come back to bite the government of the day too because, ultimately, the minister carries the can.

Since it came into operation in 2005, the HSE has taken a lot of the flak for deficiencies in the health service

The latest controversy has shone a light again on the HSE's structures and processes – or lack of them – and its culture and its strained relationship with the Department of Health. And how an organisation handles controversy is surely a sign of its abilities to manage complex and difficult things. With billions more due to go into the health service and a major reform programme planned, can the HSE deliver?

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More bureaucracy

The classic response to something that does not work in the world of Irish government and bureaucracy is to set up another agency, arm or office. And the new proposals to reform the health service – Sláintecare – drawn up last year by an Oireachtas committee involve a new “programme office”. An announcement is expected shortly on the establishment of this office, the appointment of an executive director and a plan for what happens next. A HSE board is also to be appointed – yes, currently it hasn’t got one. Earlier plans to abolish the agency have been forgotten.

The central idea of the report – a universal single-tier health system – requires major reform. It will involve, on the committee’s view, a special €3 billion transition fund plus €2.8 billion in additional spending over 10 years, and on some other estimates a lot more. It will involve hand-to-hand combat with interest groups like consultants. It will be messy and complex.

There will now be four people in the middle of the mix here – the Minister for Health, the department’s secretary general, the head of the HSE and the Sláintecare executive director. Add in a new HSE chairperson perhaps. Who will be responsible for what? Can this turn into an effective team to drive change, or will it be an exercise in finger-pointing if it all runs into the sand?

Politically, more control is being taken back into the department. The Sláintecare boss will report to the department’s secretary general – but will need to get the HSE to do what is needed. As the agency and the department have been warning factions for years, this will be no easy job.

If Simon Harris has some direct control of the health ball, his colleague Eoghan Murphy is left relying largely on local authorities and the private sector to deliver more housing. The latest figures, showing house prices continuing to rise and rents exceeding Celtic Tiger peaks by 23 per cent, reveal the extent of the crisis. The only answer is increasing supply – and while house and apartment building is picking up, it is from a very low base

Difficult interventions

The Government is left grappling with local authority planning systems, a lack of serviced land in some areas and a private sector where capacity was wiped out during the crash and is only slowly rebuilding. Interventions are inevitably difficult. Assisting homebuyers helps those involved, but risks pushing up prices. And controlling rent increases in many areas helps sitting tenants, but is clearly a factor in cutting supply and thus pushing up prices for others. Just 3,100 houses were on the market to rent nationwide in April, according to the latest Daft.ie survey.

Interventions are inevitably difficult. Assisting homebuyers helps those involved, but risks pushing up prices

Here, too, the Government is trying to take back some control. The new National Planning Framework promises more top-down guidelines and rules for planners – aimed at speeding development and increasing urban density – and a new agency to develop State land. But while the building of social housing is to be ramped up, State and local authorities only have so much capacity. Murphy remains reliant on the private sector.

For the first time in a decade, we have some additional cash to spend, though of course in areas like health there is never enough. The challenge now is implementation – getting stuff done – or, in the case of housing, getting others to do it.

When the political system set up the HSE in 2005, it may have appeared like a masterstroke to create a firewall to take the flak. But the government of the day ultimately takes the heat when things go wrong – or when things do not happen. And this one must now try to drive through a major reform of an organisation and system which successive governments have struggled to manage. The department, having outsourced health in 2005, is now trying to grab the ball back. But the Government must still rely on the HSE to deliver the change. What goes around comes around.