IT IS always better to face up to problems than to carry on regardless and pretend that everything is fine. To the extent that it represents at least a tacit acknowledgment that the current structures of the Health Service Executive (HSE) are overly bureaucratic, centralised and opaque, the plan to devolve day-to-day responsibility to regional managers is welcome.
It might be too much to expect any politician to accept that such a shift is, in fact, an admission of failure. It is not surprising to hear the Minister for Health Mary Harney deny that the new policy is a U-turn. But when she tells RTÉ that the changes are being made because "we want to make sure that the appropriate organisation structures are in place", one has to ask why appropriate structures are only being devised four years after the HSE was established.
The point of asking such a question is not to engage in a sterile blame game. The public is rightly more interested in the restoration of confidence in the health system now than in the errors of the past. The inability to own up to those mistakes does, however, highlight one of the key requirements for that restoration of confidence: accountability. The shift back to a system of multiple healthcare regions is to some extent a return to the broad shape of the old health board system. There was a great deal wrong with that old system, but it had at least the virtue of having formal structures of local accountability. Ms Harney removed those structures without putting others in their place.
No reform is likely to succeed unless it restores and enhances a culture of accountability within the health services. Unless people know that they have to answer for what they do (and indeed that they know, as many in HSE management do not, what their own jobs are), there can be no clarity and no efficiency. There is a real danger that the new structures could in fact give even more scope for buck-passing, with the Minister referring questions to national HSE management and national managers referring them down the line to regional executives. This danger is enhanced by what seems a crucial confusion on the role of the Department of Health. If, in the new structures, the HSE nationally looks after policy and the regional managers implement it, where does that leave the department, which is supposed to be setting policy?
This is not an abstract question. The biggest deficit in the system is leadership and vision. No system can function efficiently unless it knows where it is supposed to be going. The integrated strategy published by Micheál Martin when he was minister was supposed to be the road map for the future of Irish healthcare. It has effectively been torn up. While there have been worthwhile individual initiatives, no real long-term strategy currently exists. Unless a culture of accountability is restored at the top and the political leadership can inject the necessary vision, structural changes in the HSE can make only a limited difference.