No way to start health revolution

Though you wouldn't know it from the amount of media attention given to the issue, the biggest single change in the governance of the State since Irish independence is currently taking place.

In a little over a fortnight, the running of the health system will be handed over to the new Health Service Executive. The delivery of the most important public service is being transformed. A quarter of all State spending - €11 billion - is at stake. The new body will become the largest employer in the State, with direct or indirect responsibility for almost 100,000 workers. And it is an astonishing mess.

Mired in confusion, riddled with uncertainties and lacking any notion of democratic accountability, the process of establishing the HSE is a disgrace.

This ought to be a good news story. No rational analyst would disagree with the scrapping of the madly fragmented system of running the medical services through 10 health boards and one regional authority. The idea of establishing a single management body with the power to co-ordinate services and to insist on high standards and equal provision enjoys huge goodwill. All the main political parties support it in principle. The unions representing the doctors, nurses, administrators and other health professionals, all think it's a great idea. There has also been plenty of time to get it right. In those circumstances, the fumbling of this opportunity is the gravest possible indictment of governmental incompetence.

Early last year, the Department of Health published a consultants report on the process of establishing the HSE. It emphasised a few obvious but vital aspects of the process.

One was the overwhelming need to secure and maintain the support of health service users and staff, professional groups, politicians and the general public. It particularly emphasised that "the engagement of staff and their representatives to support and participate in the implementation of successful organisational change is critical." A second was that "the appointment of a c.e.o. to lead the change must be a priority". A third was that "the first task" of the management team "will be developing a high-level project plan.

The core programme team and workstream project managers will need to conduct detailed programme and workstream planning in advance of any implementation."

What have we ended up with? There is no c.e.o., just the interim appointment of Kevin Kelly, whose previous career at Allied Irish Bank does not inspire confidence in a culture of accounta- bility. (AIB is in fact a big presence at the HEA, with Donal de Buitléir, who featured heavily at the DIRT inquiry on the board, and Hugh Cawley, a former general manager of the bank, heading the HSE's change management team.)

The failure to engage with health workers has led to threats of industrial action. GPs work on contracts with individual health boards which are going out of business but have had virtually no contact with the HSE. Community welfare officers, who are employed by the health boards, were apparently forgotten in the drafting of the Health Bill which establishes the HSE. And not only is there no "detailed programme" of work drawn up by the HSE, there is not even a clear set of stated goals.

This kind of mess is the reason we have a parliament. With the legislation for the HSE being processed through the Oireachtas, the checks and balances of a healthy democracy would kick in. In fact, the legislative process has been a charade.

Representations from professional, voluntary and patient groups have been ignored in the stampede to get the legislation through before January 1st. The word "patient" appeared once in the original text of the Health Bill, which has been pushed through so quickly and with so little opportunity for scrutiny that the TDs literally don't know what they're doing.

In last week's debate, the Fine Gael spokesman Liam Twomey confessed at one stage that "we have no clear idea as to whether our amendments have been taken on board . . . we have had insufficient time to read the amendments". The Labour spokeswoman Liz McManus said: "At this stage I am so befuddled I have no idea how the Bill will end up given all the changes. It is like a serial in a women's magazine. Each month there is a new version and a new chapter."

Even the Minister introducing the legislation, Mary Harney, seemed to be all at sea. In one crucial area - the accountability of the HSE to the Oireachtas - she accepted a Fine Gael amendment, incorporated it into the revised text of the Bill, then amended the revised Bill to take it out again. The text now says that the c.e.o. of the HSE can, if summoned by the Oireachtas Joint Health Committee, send any of his or her employees instead. Mary Harney assured the House that "the c.e.o. will not nominate any old flunkey to come before an Oireachtas committee."

Asked how she could say this when the Bill allows the c.e.o. to do precisely that, she replied: "We do not have flunkeys working in the health service." This pathetic charade is the way the biggest change in public governance in the history of the State is being implemented. It is both dangerous and disgraceful and it should be stopped now.