OPINION:It is time to admit that the Health Service Executive is a failed experiment and is now a barrier to reform. Use the budget to scrap it and start patient and doctor-led reform writes Muiris Houston
FINANCIAL CONSTRAINTS represent an opportunity as much as a threat to our health system, Prof Brendan Drumm, chief executive of the Health Service Executive (HSE), said last weekend. With health service spending for 2009 set to take a major hit in Tuesday's budget, now is an opportune time to state unequivocally: the HSE represents a failed experiment in health service reform.
Saddled with a bloated and ineffectual bureaucracy, characterised by over-centralised decision making, the HSE has become a barrier to improving the health service at the point where it matters most: meeting the needs of individual patients.
Speaking to doctors at the Irish Hospital Consultants Association (IHCA), Prof Drumm seemed to acknowledge this: "The two most important criteria that the public will use to judge our success will be safety and patient experience. Then the only question is: are the public health services safer and are services revolving around my needs?"
Despite some isolated improvements in the last three years it is obvious the health service is neither safe nor more focused on the needs of patients.
Confidence in the system's safety has been severely dented by concerns over cancer misdiagnosis, while many patients with chronic illness and disability struggle with the system's continuing tendency to revolve around its own needs and not those of patients.
So what direction do we now follow along the apparently interminable road of health service reform? We could soldier on with HSE Mark 2, but the HSE moniker is so tainted with failure that not even the most skilled cosmetic surgeon could retrieve its reputation.
A name change must reflect a genuine restructuring of the system. Other health systems have been here before: both the NHS in Britain and the health service in New Zealand have had to undertake U-turns when initial reforms did not work out.
New Zealand is a country with both a population and geographic challenges similar to ours. In 1999, reforms introduced almost a decade earlier had to be reversed. Interestingly, the country went back to a system of devolving responsibility for health care to district health boards. It now has 22 district health boards (DHBs), who receive their funding directly from the department of health.
The DHBs run public hospitals and public health nursing services as well as health promotion activities such as the national cervical screening programme.
Why did New Zealand's initial efforts to centralise the health system under a purchaser/provider model fail? It suffered from a mismatch between the complexity of reforms and the system's inability to manage and implement these reforms. A key problem was the ability of senior managers to "manage down" the changes so as to align the managerial agenda with the stance of health professionals.
One option available to our Government in these straitened financial times is to slice a percentage crudely off the top of next year's health budget. This would be the easiest option and in purely financial terms, the most successful approach. But it would be bad for patients and would surely exacerbate existing health inequalities.
An alternative is to use the "opportunity" of decreased funding to drive a second wave of health service reform. Seemingly counterintuitive, this is a chance to trim unnecessary fat from the system, while acknowledging the reality of a failed HSE. How might this be achieved?
•The HSE is absolute proof that a "top-down" approach to healthcare reform does not work. Change must be led by patients and frontline professionals.
•The Department of Health must come out of its self-imposed purdah. It has largely failed to fulfil its planning brief following the creation of the HSE. It needs to step up to the plate and drive this second wave of health service reform.
•The forthcoming health service redundancy programme must have strings attached. Without caveats, it will simply encourage the 1,000 best managers to leave. The package will need to promote redeployment to facilitate the next wave of reform. It must reward productivity and initiative.
•Ban the use of management consultants. McKinsey and Co have just received €1 million for advice on how to dismantle the HSE. Ask frontline staff instead, many of whom have worked in health systems abroad. Put the money saved into frontline care.
•A revamped health service must adopt an incremental approach to change. By identifying and delivering small gains of tangible benefit to patients it will generate goodwill and re-establish credibility.
•We have unique geographic factors in the Republic that render the UK model of one general hospital per 500,000 people unworkable here. A network of 20-25 general hospitals across the State, each serving a population of 200,000-250,000 would create the foundation for an accessible and responsive hospital system.
•Without going back to the original health board structure, create autonomous health units of a size that can respond to the changing needs of local populations. Devolve strict budgets to these units and encourage rapid decision-making by local managers.
The HSE experiment has failed. Starting with next week's budget, it is time to try again.
• Dr Muiris Houstonis Medical Correspondent of The Irish Times